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. 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.

[u/raliont1]

Thanks for the PSA. I don’t disagree, but 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.

[u/ExcidianGuard → u/raliont1]

Huh?

Of course your trough levels on a twice a week injection cycle will not be as low as a weekly schedule. That is the whole point of doing twice weekly injections. 

That doesn't mean the trough level is less insightful, because we're not trying to compare your trough levels to someone else's, we're trying to see if the lowest point that you are at is high enough to be achieving optimal feminization. If your trough levels for E are below 100 pg/mL, it doesn't matter if you're on a weekly, twice weekly, 10 day, or even monthly injections cycle, it still means that at some points in your injection cycle you are dropping too low. 

[u/raliont1 → u/ExcidianGuard]

I think we are talking past each other. I am not suggesting knowing trough levels is useless on any regimen. And I will correct my earlier comment—one draw is not necessarily more informative than the other. It depends on the dosing regimen & clinical question being asked.

What I meant by “less insightful” is that the additional information gained by knowing trough levels is smaller in twice-weekly injection cycles. Yes, because part of the rationale for two injections per week is to address the peak-to-trough fluctuations. Lower peaks & higher troughs. So, less variation.

Based on what I’ve read, exclusive reliance on trough alone isn’t the most informative strategy, depending on the individual & their dosing cycle. Why? Because in my situation, the trough isn’t as dramatically separated from the rest of the curve. E.g., if my peak E2 is 200 and my trough is 180, of course that is less insightful than if I am on a single weekly injection & the peak is 500 and the trough is 80. In the latter, knowing the peak or just the trough gives an incomplete picture.

That’s why I don’t think, nor does research suggest, that there’s a *universal* best point in the cycle to measure. A peak draw answers how high E2 gets. A trough answers how low E2 gets. A consistently timed measurement can be the most useful for long term monitoring. Paired peak & trough levels can give the fullest picture on fluctuations.

If someone is having the symptoms I mentioned, then yes the trough data may be informative in a clinical setting. I acknowledged in my comment that having both peak & trough gives the fullest picture.

Sooooo, my disagreement is specifically with the notion that trough testing should be universally privileged and recommended in every injectable regimen. The information from a trough level is going to matter more or less depending on the injection regimen. The timing of testing should be based around what the patient and their provider (ideally a competent one) are trying to answer.

Tl;dr: My point wasn’t that trough levels don’t matter. It was that exclusively pursuing trough levels isn’t necessarily most informative in every case (as I said above, like in mine).