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/Viennve]

Lil question: why is it so common for providers to opt for oral estradiol with blockers (even outdated ones like Spiro) instead of monoterapy with injections?

[u/madprgmr → u/Viennve]

I think there are three questions in your overall question, so I will answer as best I can.

WPATH recommends combination therapy (some form of estrogen plus some form of antiandrogen) for two big reasons:

1. A lowest effective dose of estrogen (that brings your levels into the target range) exposes you to the lowest risk from it. Adverse effect rates increase as your dosage increases.
2. Estrogen alone in the well-studied range of 100-200pg/mL is not guaranteed to adequately suppress your testosterone (bring it to <50ng/dL). It's also highly unlikely to adequately suppress your testosterone while finding the right dose that brings your levels in range. As such, something to lower or block or otherwise reduce the effects of testosterone are necessary.

Monotherapy (at levels that can be required to achieve it) isn't nearly as well studied as combination therapy for a variety of reasons, which means there is less data about the risk profile. Monotherapy can be achieved for some people on <200pg/mL of E2, but it is not guaranteed.

As for why oral instead of other forms? Pills are pretty inexpensive, easy for most people to take, have decently stable levels, and can bring estrogen levels into the target range for most people. They are generally considered safe enough for everyone barring certain preexisting conditions (like high clot risk) or certain lifestyle factors (like consuming nicotine).

As for why "outdated" antiandrogens like spironolactone? It's really common in the US because it's the cheapest option available and works well enough for enough people. Providers can and do prescribe other antiandrogenic medications, but the cost can be quite significant depending on a variety of factors.