HRT Begins: Risk vs. Reward

How do I say hormones are life changing? How do I say I can already see a light at the end of the tunnel? How do I say I feel better than I have ever felt in my life? How do I say I am becoming complete again?

I honestly do not know how to express those things. I started hormone replacement therapy on Monday. It is the morning of Friday as I write this section and although I am going to sleep soon I already feel different. The doctor said not to expect anything for about a week. That makes me wonder if what I am feeling is just a Placebo Effect. On the other hand, the hormones might already starting to change my blood levels.

I need to draw a distinction between a few things at this point. First, there is a difference between “dosage” and “blood level.” The dosage of my medications can change in an instant as soon as we decide to change them. The dosage is how much medicine I am taking. Blood levels are how much testosterone and estrogen are in the blood stream. Blood levels change slowly, although the higher the dose, the faster they change. In addition, each dose will have a cap of how much it can change the blood levels from my body’s natural. If we wanted to rush the transition, we would up dosage of the medications. Likewise, if we wanted to slow the transition down, we would lower the dose.

There are four sets of risk. With each medication (there are two) there are risks of having too high of a dosage. With estrogen blood level, there are risks of it being too high. With testosterone blood level, there are risks of it being too low.

Next, I would like to talk about the specific medications that comprise my HRT. This is the most common combination for people who are MtF. I am also currently on the most common starting dose – It will be adjusted if needed as my blood levels change. The dosage I am on is a low-moderate dosage. It gives us the flexibility to move up (to moderate or high) or down (to low) depending on various factors. I am on two different medications.

Spironolactone (spir-ON-oh-LAK-tone) is a well-researched medication mainly used to reduce swelling and fluid retention in patients with congestive heart failure. Spiro (as transgender community calls it) is also effective in the treatment of high blood pressure. It also increases survival rates of people who have heart failure and need to go to the hospital. However, in the way it is useful to me is to be an anti-androgen. It reduces the secretion of the hormone aldosterone by the adrenal gland. That reduces testosterone in the blood stream. If I took just Spiro, some of the changes associated with this transition would happen. Like becoming less angry and my muscles starting to get smaller and weaker.

The issue with taking too much Spiro is that it is a diuretic. Almost everyone that takes Spiro has this side effect. The more you take the more the side effect. Other side effects of Spiro include diarrhea, dizziness, drowsiness, headache, nausea, or vomiting. There are other more severe side effects where it says call a doctor but none of the side effects is life endangering the worst one is irregular heartbeat. I can manage all the side effects if I am aware of my body, my feelings, and my surroundings. Keep in mind my blood levels of testosterone will also decrease that will produce the most “problematic” side effects. However, we will get into blood level effects a little later

The second medication I am on is Estradiol (ES-tra-DYE-ol.) Estradiol is a hormone replacement for women going through menopause. The idea in both cases for them, and for me, is to replace the estrogen that either their body does not produce or was never produced in the first place. It is in the treatment of metastatic breast cancers. This medication will add to the estrogen naturally occurring inside my body and will actually bring on a great deal of the changes associated with this transition. In women going through menopause, the goal is to bring the blood level up to what it usually is. For me, the goal is to bring the blood level up to that of a woman.

There are larger risks with Estradiol than with Spiro. Some of them are similar: dizziness, lightheadedness, headaches, nausea. In addition, Estradiol has its own as well. Bloating, increase/decreased interest in sex, breast tenderness. There are items that are under the heading “contact your doctor if:” mental/mood changes (i.e. severe depression or memory loss,) sudden severe headache, chest pain, trouble breathing, vision changes. As with Spiro, these risks go up with increased dosage and are quite rare. Interestingly enough a couple of these changes are exactly what we are trying to induce with the transition. The breast tenderness will be a sign that breast growth has started. The mental/mood changes are a normal part of the transition as well. While these do look scary, again, my doctor and I will manage them with careful vigilance. If any of them do happen, the Estradiol dosage and the transition will happen slower.

The doctor and I feel these dosages are safe and effective for me. They are between the Low and Moderate range for HRT. In addition, in regards to Estradiol there are also topical options as well as shots. I am currently taking pills and all the risks are higher with pills. So why take pills? The other options have less ability to change dose when dosage may need to change abruptly. The range of dose is also limited on some of the other options… Topical options (patches, creams, gels) can only give Low dosages. Shots can only give High dosages. In addition, an implant exists that is good for three months. However, the dosage is set during the entire time of an implant. I would have to wait the remainder of the three months before changing dose. I consider that (until we figure out what the right dose is for me) dangerous. To me, being observant and having the flexibility to make changes can offset most risks.

We all take risks every day, from the most mundane example, walking across a street, to the most dramatic example, heart, or brain surgery. The key to taking risks and not having consequences is being aware and mitigating that risk. For crossing the street being aware can be as simple as looking both ways and seeing who’s coming. Most pedestrians that are hit or almost get hit are fundamentally not aware while they are crossing the street. Remember, a car can kill you and is harder to stop than a person… It terms of mitigating the risk of crossing the street there are many things you can do; Cross when no cars are coming, no cars means less risk. Cross in a crosswalk, drivers know where crosswalks are and are going to be more aware for pedestrians in those places. Cross only when you have the right of way; if you have the right of way you are mitigating risk by doing what is expected. Your actions are safer when everyone around you can predict them.

By taking this medication, I am adding risk into my life, sure. However, the risk is worth the reward to me. In addition, I have the skills needed to ask the questions of my doctor and mitigate the risk. I will constantly be aware and on edge watching for side effects and issues with taking these medications. However, if all goes well, I will be on these medications for the rest of my life. I accept the fact that I will take these forever knowing that the effects of these medications will greatly improve my life. Almost as if, I took a daily medication for asthma or diabetes. My body did not generate the correct hormones for me to grow in a way that is consistent with my mind and spirit. At first, I tried to change my mind and spirit. That led to depression and pain. Now, I turn to medical science to change my body. To do that requires this medication to change the levels of testosterone and estrogen in my blood.

The blood levels are the reasons I am taking this path. For a look at the planned effects that the hormones will have on my body please see my post from early February entitled Puberty: Attempt Two. It is for those reasons that I take this path. Every one of the things listed in that post are the positives associated with taking hormones for me. I do not care about the medications themselves. They are just the only way for me to get the results I need. I do not care to take estrogen. In fact, if someone asked me 2 years ago if I would take estrogen in my life ever, I probably would have said no. I would have made the same response if someone asked if having testosterone was interfering with my life.

Managing blood levels is going to be a constant game of balance. If I find the right dosage to keep my blood level where I want, that would be amazing, finding that dosage is not hard. With any luck, that ideal dosage will be the starting dosage, who knows? The hard part is maintaining it. Something as small as changing to a vegetarian or vegan diet (even though I never plan to do that) can change the way your body processes and creates these hormones. Changing my diet could radically change my blood levels. Any change in lifestyle can cause the same effect. Getting more exercise, changing diet, changing amount of sleep, drinking more or less alcohol, smoking, any change of “lifestyle” can change how these hormones are processed. Even after we find the ideal dosage if I make a change in lifestyle I have to go in for testing to see if my dosage needs to change… For “natural” women, their body will slowly change production of estrogen to return their body to the correct blood level. I do not, and never will, have that benefit. My first (of many) blood level test will be a month after starting HRT. We shall see where this dosage takes me. We are aiming for the middle of each range of what is normal for a, to use my doctor’s words, female-bodied patient. From there we adjust dosages. Let the balancing act begin!

There is without a doubt a perfect balance. Let us talk about what happens if my hormones get out of acceptable ranges.

If testosterone gets too high and/or estrogen gets too low:

Since testosterone can never get higher than my natural and estrogen can never get lower then my natural the results from this are what I would call rollback. I return to the person I was before transition: Weak-willed, unsure of myself, overly angry, and disconnected from my emotions. I return to the man that I was even though some of the changes are permanent and will remain. I return, mentally, spiritually and emotionally to the man that I was.

If testosterone blood levels gets too low:

This situation is not dangerous but is what I would call unpleasant. Having low testosterone will result in many things. I will lose motivation, lack of sex drive, lack of interest in hobbies. I may return to a depressed mood. Overall fatigue or sleep disturbances.

If estrogen blood levels get too high:

This result is without a doubt the dangerous one. This is where I have to keep watch most closely. Keep in mind that even parts of the normal female range of estrogen will be dangerous for me. I was born a man therefore estrogen is in some ways a poison for me. Yes, I can transition but too much of a good thing will cause problems. I am changing my body so it will accept estrogen, as a part of itself, however too much will cause many problems. However many of them are just a judgment call. Becoming more emotional is good; however being overemotional is the first sign that I am getting too much estrogen. The biggest risk is an extremely high risk of breast cancer. I already have an increased risk because of biological family history but more in particular a type that feeds on higher levels of estrogen. I will have dramatically increased risk for blood clots, and other cardiovascular problems that may cause death. I will have increased risk for migraines, and a couple of other non-life threatening disorders. In addition, any of the above issues that happen will be too late to reverse once they have set in. Once they happen, it is far too late to reverse them. The goal is to keep the minimum level of estrogen in my blood to provide for a successful transition.

Therefore, I accept these risks. I will become the person I wish to become. I will be the person I have always seen in the Four Mirrors. At this point, I have been on Hormone Replacement Therapy for four days. I am already starting to feel like the person inside me is coming out. I am already becoming less angry, I am already sleeping better. I am already looking in the mirror and seeing less and less man and more and more woman. I am getting a much stronger appetite as if my body wants to start growing something that was not there before. I do not know how much of that has to do with the change of hormones and how much of that has to do with a Placebo Effect from actually starting HRT. I will be watching myself closely for signs of too much estrogen and too little testosterone. Please, I ask that everyone watch me too… For a while, we are not going to know exactly what my dosage should be. We can take informed guesses, but each person processes these hormones differently. Sometimes an external view is just the view I need.

This is the risk I take; this is the risk I take to bring myself to life. However, it is not just me. Society around me needs to bring me to life as well. My life as a woman no matter what my physical form, not matter what hormones are inside my body will remain a dream if people do not see me in the way I see myself. Fixing my hormones can only do so much. Fixing my mentality can only do so much. It is up to you all. I will do everything I can to be a woman as society defines it. However, I will never trash my personality; I will never trash my interests. I have lived a façade and a lie for many, many years. It is time to bring me to life.

I really did want to end this post on a happy note, but didn’t quite get there. It is time for bed but I want everyone to know that I am happier then I’ve ever been in my life. I feel like I can take on the world right now. While the physical transition has just begun, and I’m in for a fight of ups and downs but I will always get back up and get back on the street.

In fact, there is only one song with which to end this post…

2 thoughts on “HRT Begins: Risk vs. Reward”

  1. Very good job of explaining the medications, effects both desired and undesired. I am confident you will be able to identify issues and follow up with your physician. This paragraph worries me a bit, “Since testosterone can never get higher than my natural and estrogen can never get lower then my natural the results from this are what I would call rollback. I return to the person I was before transition: Weak-willed, unsure of myself, overly angry, and disconnected from my emotions. I return to the man that I was even though some of the changes are permanent and will remain. I return, mentally, spiritually and emotionally to the man that I was.” I don’t know all your history, I don’t see you as weak-willed that is for sure. I know the hormones have a lot to do with the man you were and the woman you are becoming. I believe that just the fact that you are going through the work it takes to transition, mentally and emotionally and that work started before the hormones, that if the levels were to return to your previous state you wouldn’t have to return to the man you were. I am not expressing this well. You have changed a lot as you have allowed “girl-mode” to surface and even without hormones, I think it will be harder and harder for the “boy-mode” to return. Just the way I am thinking at the moment. Also having been through the breast cancer and being the biological link that increases both your risk and your sisters risk, makes me sad. You and she will have to keep on top of the screenings and I will feel better knowing that you will be watched closely. I am glad you are feeling better. Love you bunches.

  2. Congratulations on this big step in your journey. Your post was so well written and informative. And although my daughter is on the same medications (spiro and Estradiol) I never knew how to pronounce them – so THANK YOU. You really should be a doctor, or a counselor when you grow up. You have a gift, and you are so well informed. Good luck to you as you proceed – one side affect of the E for my daughter (14) was laughter – which we hadn’t heard in a long, long time! (ps – you will need to come up with a name for your budding breasts. We call them “booblings” in our house! And they started budding after just 2 months on 1mg of E – so that’s very exciting)

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