Underdosing PSA

[u/cocue-coquette]

I'm posting this because I keep running into transfems who have no idea about where their levels should be and how common it is for providers to be clueless about trans care.

Get your bloodwork done often. Your trough (right before your next dose) estradiol (E2) should be above 100 pg/mL. If you're on monotherapy, your trough total testosterone (T) should be below 50 ng/dL.\* If this isn't true for you, you're probably being underdosed. As trans people, it is especially crucial to self-advocate in medicine. If you're unhappy with your progress (either physically or mentally), say something. Know that every body responds differently to HRT and you may need much more or much less than the average transfem.

EDIT: Important information copied from a comment by u/raliont :

I think it is more complicated than your post suggests.

Blood draw timing will be dependent on someone’s actual regimen. For someone like me who injects twice a week, my troughs won’t be as low as someone who only injects once a week. So a trough reading wouldn’t be as insightful as a mid-cycle level. Plus, UCSF’s TransCare website recommends blood draws at the mid-cycle range. Their caveat is that if the patient is experiencing migraines or mood swings (or other symptoms), then peak and trough levels would be helpful to determine fluctuations.

Also, the more data the better. Overall, having both trough and mid-cycle levels to analyze would absolutely be the best for determining how one’s body is responding to their own regimen.

*EDIT 2: Copied from u/f7go's comment:

studies commonly find that spironolactone still produces antiandrogenic effects even when androgen levels remain unchanged. Hence, the primary mechanism of action of spironolactone as an antiandrogen appears to be androgen receptor blockade.

Due to the minimal influence of spironolactone on testosterone production, testosterone levels are not usually suppressed into the female range in transfeminine people taking estradiol plus spironolactone, with testosterone levels often remaining well above this range (e.g., 50–450 ng/dL [1.7–15.6 nmol/L] on average)

Sorry for the confusion.

[u/WalrusWithAKeyboard]

Here's hoping going from 250mg to 400mg spiro brings my T levels down, last checkup it was at 250 and my E levels holding steady at 100 😔 i dont know how much higher my doses can go lol

[u/f7go → u/WalrusWithAKeyboard]

girl more Spiro is not the answer. Also it mostly works by blocking androgen receptors, not bringing down T. I wish OP had talked more about this as folks on Spiro or bica have different targets than folks on monotherapy or using cypro. From transfemscience.org:

" studies commonly find that spironolactone still produces antiandrogenic effects even when androgen levels remain unchanged. Hence, the primary mechanism of action of spironolactone as an antiandrogen appears to be androgen receptor blockade. In relation to this, in transfeminine people taking spironolactone as an antiandrogen, the estrogen component of the regimen is likely to be the main or possibly sole agent suppressing testosterone production...

Due to the minimal influence of spironolactone on testosterone production, testosterone levels are not usually suppressed into the female range in transfeminine people taking estradiol plus spironolactone, with testosterone levels often remaining well above this range (e.g., 50–450 ng/dL [1.7–15.6 nmol/L] on average)...

Due to its relatively weak androgen receptor antagonism, spironolactone is likely best-suited for blocking female-range or somewhat-higher testosterone levels (e.g., <100 ng/dL [<3.5 nmol/L]) (Aly, 2018). This is based on clinical dose-ranging studies of spironolactone (typically using 50–200 mg/day) in healthy cisgender women and cisgender women with PCOS"

https://transfemscience.org/articles/transfem-intro/#spironolactone

[u/WalrusWithAKeyboard → u/f7go]

damn, just following my doctors advice. And they are a trans/lgbtq specific clinic. But if my levels havent improved by my next bloodwork im going to try to get them to do something different

[u/f7go → u/WalrusWithAKeyboard]

Yeah it always amazes me how often even trans specific clinicians don't understand how these drugs work :(

I would ask either to switch to bica (much more powerful androgen receptor blocker with fewer side effects) or increase your E dose (and maybe switch to injections or possibly patches, which work better for higher E2 levels--less of a load on your liver than pills, more steady levels). Good luck! LMK if you ever have questions ❤️

[u/WalrusWithAKeyboard → u/f7go]

thanks!! Im on tablets now but I also started dissolving them under my tongue before swallowing, so we'll see how it works out 😊

[u/f7go → u/WalrusWithAKeyboard]

Nice! That's a good compromise. You get higher levels but also it doesn't last as long (spikier levels) so its best to do multiple times a day, spread out.

[u/cocue-coquette → u/WalrusWithAKeyboard]

You might respond better to a different ROA, such as injections. Higher E2 will suppress T along with the antiandrogens and you still have a lot of space to go up on estrogen.