Waiting for the miracle of testosterone to truly kick in

On September 17, I went and had blood work done as part of the regular maintenance of hormone therapy. As usual, I requested a copy of the results and received those back yesterday. Judging from the numbers staring back at me, I felt as if I was looking at the lab results of an entirely different person. My name is at the top, and I’m listed as Sex: M, but my estradiol has shot through the roof, and my free testosterone has sunk. My DHEA-S has dropped to a level that’s lower than what my results showed pre-T. Hmm.

I picked up the phone and called the nurse at the doctor’s office. She was also perplexed and booked me a follow-up appointment for today. Then I called the endocrinologist’s office. The receptionist and the endo in the background kept referring to me as “she” but I let it slide because I was more interested in her thoughts about the results. She said it’s entirely normal for my body to be fighting the testosterone and that the lab results were not too surprising. I asked if the high estriadol would be why I am still bleeding (having started this past Monday, all over again, after being two weeks late and thinking this might finally be it, but nooooo…) and she agreed that would be in line with the results. Considering that she felt all this was normal, I asked if it was necessary that I go see my doctor for follow-up and she did think that was a good idea.

Now, my family doctor is very good but he doesn’t have experience with transmale health (beyond me.) Nevertheless, I thought I would bring him some questions and we could at least have a discussion, if only to let him know how thorough I am being with all this.

Q: Is FSH being tested?
A: No

Q: Is LH being tested? Is LH being adequately suppressed?
A: LH is not being tested, so we don’t know how well it’s being suppressed.

Q: Why is my estriadol level so high?
Note: 406 pmol/L. Normal range is <220 for men. For women, it’s: 110-184 mid-follicular; 550-1650 ovulatory peak; 550-845 mid-luteal.
A: Not really sure, probably what the endo suggested, that my body is reacting to testosterone by flooding with estrogen.

Q: Why has DHEA-S dropped to levels that are lower than pre-T?
Note: 3.9umol/L compared to 4.4 pre T, and 5.6 in June.
A: Same answer as above.

Q: Am I metabolizing testosterone into estrogen?
A: My doctor told me this wasn’t possible, but I informed him that it certainly is, via the aromatase enzyme. We don’t know if my body is doing this or not.

Q: What is the difference between “serum testosterone,” “bound testosterone,” “free testosterone,” and “trough testosterone?”
A: Serum (or “bioavailable”) is total level; bound is attached to proteins and is “unavailable”; free is serum level minus bound level and is considered “available” in the bloodstream; trough is the free T at it’s lowest point (ie. right before an injection.)

Q: Could the fluctuation in T levels as shown in my blood work be caused by my injection cycle?
A: Yes. When I had blood work done in June, it was 5 days after an injection, when my T level would have been peaking (41.5 pmol/L). When I had blood work last week, it was 2 days before an injection, when I would have had a low T level (14.2 pmol/L).

Q: When should I expect menstruation to (finally) cease?
Note: Medical Therapy & Health Maintenance for Transgender Men states that menstruation should stop within 5 months (p. 51). The VCH Trans Health documentation suggests that you speak with your doctor if it hasn’t stopped by 6 months. I will hit 6 months next week, BUT I also was started on just 50 mg / 2 weeks, where the suggested starting dose in these guides is 100-150 mg / 2 weeks.
A: Considering my low starting dose, my doctor suggested that I put my first three months out of my head, and in that light thinks that I should stop bleeding within the next 3 months.

Q: If I don’t stop bleeding, what would be the next course of action?
A: My doctor didn’t really have any ideas about what the next step would be, especially considering that we have just upped my dosage to 150 mg / 2 weeks. However, it’s most likely that I will eventually stop without further intervention. While I am not a fan of throwing drugs at a problem, I did present these ideas for discussion:

  1. Block aromatase with Armidex or Cytadren
  2. Block estrogen with anti-estrogenics such as Clomid or Tamoxifen
  3. Add progestin (medroxyprogesterone acetate) 5-10 mg

Those first two came from this interesting article at trans-health.com: How Much Is Too Much? The third idea came from Medical Therapy & Health Maintenance for Transgender Men, p. 51.

One idea came to mind to get more even lab results back: where I live, blood work is only done on Wednesdays. I can’t change when I have blood taken unless I go to a neighboring community, which represents a cash and time expenditure. I can however change my injection day back to Wednesdays (which is what it was originally, then got switched to Fridays when my semi-retired doctor moved my file to one of the other doctors at the office.) This means that I could schedule blood work smack in the middle of an injection cycle—after my peak but before the trough.

In the end, I was glad to have had the chance to have a good discussion with my doctor. He reminded me that clinical results are more important than the numbers on the lab reports, and while the changes are slow, they are coming. If I were to start this all over again, I would really put some questions to the endocrinologist who designed my treatment plan and find out more specifically why she starts her patients on such a low dose. While I can appreciate the idea of giving the body a chance to adjust to changes like this by easing in, I would also say that my dysphoria has increased with the slowness of the changes (which isn’t really a concern for the endo), and that has not been a positive experience. (Everyone who enjoys changing a tampon in the men’s room, raise your hands!)

So, the prescription is to wait it out. As Robert Hunter says, “All good things in all good time.” I think it’s about time I get that printed on a t-shirt!

UPDATE, November 21: It’s now been 61 days since the start of my last period. October was the first month I missed. I think I’m in the clear now! So, it took 7 months for cessation of menstruation. That’s quite a bit longer than the average. I imagine that if I’d started on a dose of 100mg/2 weeks instead of 50mg, I would have reached cessation earlier.

I know I’ve referenced that video before on Gender Outlaw. Maybe I should include “Waiting for a Miracle” here as well:

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