ideal E levels.. there seems to be two trains of thought....

[alannanicole]

ok i seem to be seeing conflicting information out there that both drs and patients alike seem to have axcess to...

this is for MTF ladys out there..

what does your doctor use for a reference line approx 200 pg/ml serum levels or the other train of thought... 400-800 pg/ml

i m not asking for dosages just the test levels used by each respective dr... i m at an impasse with mine...

[arbon]

There is more then just two trains of thoughts. In the US it is very inconsistent. Who's right I have no idea.

200 is my current target, but I seem to bounce around a lot between 130 and 300 (and as high as >650). The doctor I am seeing now is very new to transsexual care, I'm his very first one so there is a learning curve for him. I provided him a lot of information and he has done research on his own. He is more comfortable with me being on the low side. Im okay with that right now. My previous doctor who has worked with a lot of trans women first told me the tested level did not matter its judged by how you are doing and feeling on it.

I have read various guidelines that can be found on the web and in those guidelines there is that same inconsistency.

[Michelle.M]

Well, there’s a bit more to it than that. Baseline level standards are developed by various entities, to include pharmaceutical companies, so although there is variation they are all within a consistent range.

My first doctor sent my samples to a lab that used this range standard (these are from my lab reports):

Adult Female:
Follicular phase 19.5 - 144.2
Midcycle 63.9 - 356.7
Luteal phase 55.8 - 214.2
Postmenopausal 0.0 - 32.2

My current doctor sends my samples to a lab that uses this range standard:

Adult Female:
Follicular phase 12.5 - 166.0
Ovulation phase 85.8 - 498.0
Luteal phase 43.8 - 211.0
Postmenopausal <6.0 - 54.7
Pregnancy
1st trimester 215.0 - >4300.0
Girls (1-10 years) 6.0 - 27.0
Roche ECLIA methodology

Numbers really don’t mean much. You can have really high numbers and still not have the body changes you’re hoping for.

The real question is what is your doctor trying to achieve? My E dosages have not changed in 2 and a half years, but my estradiol levels have due to a variety of factors - changes in T dosage, weight gain and loss, the cumulative effects of hormone treatments building up in my body, and after GRS it all went haywire so I am practically starting all over.

Discuss your doctor’s goals with him. In my case, both doctors were trying to help me achieve the desired body changes and still use the minimum dose needed to make that happen. I have known some girls whose bodies just didn’t respond well to estrogen treatments like most of us do and they needed orchiectomies to finally bring their E levels and body changes into line.

Wikipedia has a pretty good write-up, with links to definitions:

http://en.wikipedia.org/wiki/Estradiol

[LeaP]

The Endocrine Society's Clinical Practice Guideline for Endocrine Treatment of Transsexual Persons is as authoritative in the US as you will find. It calls (page 22) for serum estradiol level in MTFs to be "ideal levels, 200 pg/ml."

The goal should be as low a dose as needed. More is not better. You only have so many receptors.
Excess estrogen is excreted. If you are maintaining a reasonably steady average serum level, you are taking as much as your body can process.

[alannanicole]

i guess wht im refering to then nobody has really looked at.. the temple university press book transgender care where the drs published a chart reccomednding 2x the averge female level for pre op MtF

[LeaP]

"Average female level" is meaningless without more context. Serum estradiol levels vary greatly in different phases on the menstrual cycle. If a term like "average" is used, it usually is in reference to a particular phase (often the follicular phase) and in reference to a table of the values for that phase (different people use different reference material). Watch the units also. Pmol/l is not the same as pg/ml ! One is a normalized expression of mass, the other weight. ALWAYS consider the notation and frame of reference in addition to the values.

[alannanicole]

by 2X the average range of female i mean the published range of 75-450 Pg/ML and some drs are using a standard range of reatment to be 400--800 PG./ML others seem to be happy with 200 Pg/ML thus my issue...

in example my personal serum level is 204.. which my dr is happy with, however i am having huge set of symptomology that begins to disappear as higher levels are attained.. yet because the blood levels look good in here eyes she wont entertain the idea that at my current levels is way to low for my body to be in a favorable ballance.. thus our impasse.. and if we agreed that a 400-800 Pg/ML range was a better level to attain we rightly may find a point where the symptopmology disapears.. but if i as a patient and her as a dr are in disagreement of what is best road to follow then i am not getting the best care available in my mind.


i personally know several other MTF in my area and actually prior members here who are workig with drs that want to see a level in the 5-700 range and have a much better overall quality of life so that is why i asked the question to me it seems like some drs are working on a different set of baseline numbers than the rest of the country and if the higher numbers are the better way to go, then i feel its time for me to move on to a new dr that isnt using standards from a decade ago.. .

[LeaP]

What symptoms?

Also, are you on anti-androgens or progesterone?

The range you reference is the pre-ovulatory peak. I've never seen it used as a standard.

Some doctors prefer to use higher E levels to suppress T (hence the questions above).

[alannanicole]

long list but basically emotional issues, fatigue, and a few other things like migraines that will only subside with a higher than normal perscribed daily dosage level of estrogen. not fun having a migraine for 36 hours then as a last ditch effort because nothing was working and it ws continuing to get worse take double dose of E as a last attempt before going crazy and in 30 min its gone... every time.. not once... every time..

on t blockers T level is 27 and with in the last 18 mo only fluxuated 10 points.
progesterone levels are around 19 (waiting for the exact number and lab report ) but doc posted a memo saying what the stats were when she messged me they had come in and she was mailing them to me


maybe standard is wrong wording.. reference goal may be a better way of asking???

[TeresaL]

Could you please list documented online evidence of 2x the female levels of estradiol so we can read them on the websites which present them? Google is not my friend today. LOL

I keep finding that the dose of estrogen needed for the treatment of MtF patients is about 2–3 times the recommended doses for hormone replacement therapy in postmenopausal women. ... AND ...
... this is achieved by maintaining serum estradiol levels within the normal range for healthy premenopausal women (<200 pg/ml) and suppressing testosterone levels to those normally found in women (<55 ng/dl).

See
http://www.medscape.com/viewarticle/757128_3

Self medicating by increasing the dose above recommended PRESCRIBED amounts is not advised in the sites that I have perused. In view of that, where does your supporting advice for doubling premenopausal female levels come from? What website can we follow your train of thought?

[Angela Campbell]

Could be just some old information. A long time ago rather large doses of estrogen were used before they began using anti androgens. It is much safer now with the lower doses of estrogen.

Then again there is little standardization of treatment out there. Just in one town I have seen several different Doctors prescribing differently. Across the world there is a wild variance. I go with what my doctor prescribes because I think he knows what he is doing more than I do.

[LeaP]

It sounds to me like there might be some underlying medical problem. (And no, I don't mean transsexualism…)

Is the doctor prescribing the hormones an endocrinologist?

[danielleb]

Within the same clinic I switched doctors recently. At first I had a target of 200, then (not feeling right for many of the same reasons you stated) I started overdosing and came in just shy of 600, suddenly <400 became the new target. I transferred to the other doctors care and she was fine with around 400 (I'm at 470 now) and not trying to get me below. Most of the concern for me I think came from the very high dosage of pills required to reach those levels. I wish there was some type of evidence one way or the other, but for now looks like we remain poorly examined science experiments. I know I feel better taking more, as for femenizing effects, I had almost none after two years, so I'm really no longer hold it as a concern.

I know it became a real hassle just getting my meds with the first doctor. She would refill knowing I was taking double what she prescribed, but wouldn't write the prescription for what I was actually taking. Finding a new source for my meds it became an issue. Sounds like you need a change of doctors if you're at an impasse with yours. :)

[alannanicole]

transgender care was published by temple university in 1997 and revised in 2013 with the chart shown s posted in the wikipedia post shown in this link.. the basis for the increased estrogen levels is to cancel out the testosterone that antiandrogens cant.. if your pre-orchi that is... after orchi or SRS standard practice is same as female or slightly above.. after explaining the chart to my dr her goal is now 500-650 pg/ml because she misconverted a pmol/dl statment of 100-200 which is a 367-734 pg/ml level in her guidlines... someone forgot a conversion factor.... and took her a while to admit it..


http://en.wikipedia.org/wiki/Hormone_replacement_therapy_(male-to-female)


It sounds to me like there might be some underlying medical problem. (And no, I don't mean transsexualism…)

Is the doctor prescribing the hormones an endocrinologist?

not hardly... dr and i met 3 days ago nd solved our little argument... if still low wil be switchig to im injections in march... in 3 days feel completly different... nd so many of my issues are beginning to disappear.. flat out ws a hormone induced problem


and yes she is an endo..

[TeresaL]

The chart in that wicki page contradicts itself by providing a reference to a very well established source, which states less than 200 pg/ml for the blood serum level for estradiol levels.

if we follow the chart in ...

http://en.wikipedia.org/wiki/Hormone_replacement_therapy_(male-to-female)
,the note directly above the chart says;
"See the table below for all of the precise values they suggest.[61]"

[61] takes you directly to;
http://press.endocrine.org/doi/full/10.1210/jc.2009-0345
On that page find;

Measurement of serum estradiol levels can be used to monitor oral, transdermal, and im estradiol or its esters. Use of conjugated estrogens or synthetic estrogens cannot be monitored by blood tests. Serum estradiol should be maintained at the mean daily level for premenopausal women (<200 pg/ml), and the serum testosterone level should be in the female range (<55 ng/dl).

Something is not making sense.
What is it?

[LeaP]

I don't know ... Gianna Israel was a therapist, not a doctor, and with no credentials that I've been able to find. Her co-author was a psychiatrist, not an endocrinologist. The book also (pg 61) says that high levels of E may be counterproductive. "It is important for both physicians and clients to understand that more hormones do not necessarily mean better results. In fact, the opposite is often the case." It also describes levels over 400 pg/ml as "supratherapeutic" and that "no further increase in prescribed estrogen is warranted." Further, the statement is made that lower levels are safer.

Not so consistent. I think it is hard to draw a cogent conclusion about target levels from this book.

[alannanicole]

lower levels (below 200 pg/ml) make me suicidal... how is that safer... wanna argue that there lea.. regarding wikipedia, its editable and the chart was easier to get from there than it was scanning in an attachment from any one of my other publications i was not saying wikipedia is a safe reference, but the book was just revised and wikipedias data reflects the revision published in 2012/2013 thats all... so befire we get all fired up over a flagging of a link in the basis of argument i had a knock down drag out fight with my doc.. found her error, correction factored in her error, to match her labs information and units and agreed on a new plan... so as far as im concerned this thread is done or at least i am on it..

you really have to watch the units being referenced.. pmol/dl is a .3671 of a pg/ml and they seem to get confused ALOT!!! hell i had 4 doctors, 2 PCP, an Endo, and a therapist all look at my numbers and NONE of them caught the data error until i pulled up prior conversatioins

ironically 100-200 pmol/dl is 367-734 pg/ml so.... whats that say about actual lab units and theraputic levels...

i never assume another person is smarter than i am in my health care... I know Long before they do something is off and i am horrible at describing symptoms to doctors.. while they have more experiance .. i do know my body better and am not afraid to get into knock down drag out fights with my care givers to get things done my way so long as the data i m using to argue the point is known good safe to do argument points


ive had to argue the fact i was trans* the fact im dyslexic, the fact i have High Functioning Autism, the fact OTC pain killers do not have effectiveness in my body, but vicoden does, and many other points in my life.. why would i assume my doctors data was accurate if it was found to be stated earlier as a different level to me based on prior info and her having an inability to be comfortable with a given dosage level. i dont care what SHE is comfortable with.. i care what my body is comfortable with... and nothing more...

[BOBBI G.]

I don't understand all the numbers and I figure they will fill me in as I progress on the trip. They now have their "base line" test results and next month I have another series of test to adjust my prescriptions. Maybe at my next meeting I will find out a little bit more.

Bobbi

[TeresaL]

If you are a veteran, here are the stats for both testoserone and estrogen levels.
Home Phone Number: NA
Test Name: TESTOSTERONE
Result: Low
Units: ng/dL
Reference Range: (300-800)
Interpretation: Adult male: 300-800 ng/dL; Adult female:
25-100 ng/dL; Prepubertal: <100 ng/dL.
Performing Location: RICHARD L. ROUDEBUSH VAMC 1481 West 10th Street ,
INDIANAPOLIS, IN 46202-2803

Test Name: ESTRADIOL
Result: High
Units: pg/mL
Reference Range: ("<=39")
Interpretation: Reference Range: (Effective 12/5/2011 - )
Males: < or = 39 pg/mL
Females:
Follicular Phase: 19-144 pg/mL
Mid-Cycle: 64-357 pg/mL
Luteal Phase: 56-214 pg/mL
Post-menopausal: < or = 31 pg/mL

As ovulation approaches and the levels of estrogen increase, the influence of estrogen produced by the ovary signals the brain to release higher doses of LH (orange line). It is the surge of LH around mid-cycle that triggers the release of the egg from the follicle in the ovary, or ovulation. After this point, both FSH and LH play a less prominent role.

MtF do not ovulate, so peak mid cycle is not a factor.

Definition: Follicular Phase: The follicular phase begins on Day 1 of your menstrual cycle. Day 1 is by definition the day your period starts. The follicular phase ends when a hormone called luteinizing hormone peaks and ovulation occurs.
In the early follicular phase, after menstrual flow has ended, the lining of the uterus is at its most thin. Levels of estrogen and progesterone are at their lowest. Later in the follicular phase, proliferation (or thickening) of the uterine lining occurs. This thickened lining is preparing for a possible pregnancy. The follicular phase typically lasts about 14 days. The luteal phase begins when the follicular phase ends.

luteal phase
noun Physiology.
a stage of the menstrual cycle, lasting about two weeks, from ovulation to the beginning of the next menstrual flow.

Finally, from WPATH in regards to measuring estradiol levels....
In order to more rapidly predict the hormone dosages that will achieve clinical response, one can measure testosterone levels for suppression below the upper limit of the normal female range and estradiol levels within a premenopausal female range but well below supraphysiologic levels (Feldman & Safer, 2009; Hembree et al., 2009).
Page 194, Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7

[LeaP]

I'm not disputing your statement that you feel better at high levels. I am questioning why. High E levels, like low E levels, are associated with mood disruptions. Migraines have been associated with large *changes* in E levels. So I wonder why your endo isn't investigating, especially since his/her clinical practice guidelines call for lower levels. Do what you want - you obviously are - but passing things off on statements like you know best and know how you feel sounds, shall we say ... convenient?

My reference was to the book, not Wikipedia. My other reference was to the Endocrine Society's clinical practice guideline, where the recommended levels are consistently in pg/ml. What guideline document is your endo referencing? (the one with the units error)

[Ariamythe]

Alanna, if you're feeling suicidal, then the person you should be talking to is a therapist, not an endocrinologist.

I know you're hoping to get validating information to support your case to your doctor, but you're just not going to find it. The standard of care is NOT the Temple U guidelines, it's the WPATH SOC and they very deliberately do not make specific dosage or e-level recommendations. Plenty of papers do, and their recommendations vary widely; but the most standard practice is NOT to give supraphysiologic levels of e, as that can greatly increase risk of things like deep vein thrombosis and even liver toxicity.

If you don't trust your doctor's judgement, then you may want to find one you do trust. But if you're going to shop around until you find a doctor willing to give you what you want, you may find yourself without a doctor.

[TeresaL]

I wish I could press the "like" button on the last two posts.

We are all unique individuals, who's hormones must be regarded and treated differently. Your reactions to the chemicals are not the same as another MtF's. For example, I've never experienced a migraine, at 65yo, and am on FHT over a year. My dosage was the smallest blue pill for 6 months, then it was doubled because my doctor determined my development was not enough. Personally, I'm ok with that because my mental well-being is satisfied with the lower dosage. But I would like an hourglass figure. LOL

[Lilo]

I remember reading a scientific paper (sorry dont have the source) where breast growth outcome was compared for MTF TS at higher and lower E levels. What stuck with me was that growth was faster at higher levels but in the end the overall growth was larger for those at lower levels. If I remember or find the source I will post it. I personally take a very conservative approach (low but in the pre-menopause normal female range)

Found it.

Predictive markers for mammoplasty and a comparison of side effect profiles in transwomen taking various hormonal regimens.
Journal of clinical endocrinology and metabolism. Vol 97 issue 12 pg 4422 Dec 2012

It is a very interesting read. FYI, higher levels were consistently found in self-medicating TSs.