The HRT saga
It’s about time I finally write a timeline of how frustrating HRT has been over the years, because I’m tired of re-explaining it and just want something to point folks to whenever it comes up.
Short version: I have historically been done extremely dirty by the healthcare system when it comes to HRT access.
### 2004: DIY
Back in 2004 I was working at Ubisoft and did not feel safe in my situation, but I felt desperately like I needed to be on estradiol. So I took the DIY approach for a few months, doing 1mg/day imported from New Zealand.
This made me feel _so_ much better right away, but I was worried about clotting issues and decided to hold off for a while until I felt safer in my situation.
### 2011: San Francisco
I had been living in San Francisco for a few years and the pressure was building up again. I did not have access to doctors I felt safe talking to about HRT. There was one doctor I knew of who specialized in transgender medicine but he had a very long waitlist and didn’t accept my insurance. Eventually I managed to finagle different insurance which he did take, and made it through his waiting list.
He put me on 1mg/day of oral estradiol as well as a typical dose of spironolactone, but was incredibly acephobic to me, and dismissive of my nonbinary identity (which I referred to as “neutrois” at the time because I was still figuring shit out). I ended up not being able to tolerate the spironolactone and due to not being on an antiandrogen he didn’t want to raise my estradiol dose.
### 2012: Seattle
After I returned to Seattle I found a doctor who was willing to administer my HRT. I talked about my neutrois identity and how I leaned feminine. In my notes he wrote,
> [patient] considers himself gender-neutral and uses they/them pronouns.
Anyway. He kept me at 1mg/day.
### 2014
I got my orchiectomy. The surgeon who administered it almost canceled it because she thought I might regret it based on me asking offhandedly (during a pre-surgery panic attack and rumination cycle) if it’d be possible to harvest sperm from the testes post-removal. I had to plead with her to go through with it. Afterwards she was really surprised to learn that I was happy with the results.
I was still with the same doctor as in 2012, and he did not want to raise my dose even though I wasn’t getting the level of breast development I wanted.
Later that year I switched jobs, and due to the change in insurance and also finally clearing yet another doctor waiting list, ended up switching to a doctor who specialized in trans healthcare. She raised me to 2mg/day.
### 2017
After leaving that job to found a startup, I got my bottom surgery, which was supposed to be covered via the COBRA from the job, but it more or less wasn’t.
I switched to marketplace insurance. Except for some reason the Washington Healthplan Finder thing decided to put me on AppleCare due to no declared income even though I requested normal marketplace insurance, and they assigned me a county doctor that did not want to touch HRT. Then that insurance got canceled on me because I failed to provide proof of no income that they never requested from me (and how do you provide a lack of a paystub, anyway?), but I scrambled to get marketplace insurance with the same provider that I was on via COBRA before.
Then in November I had an embolism due to a blood clot in my leg, and the hematologist insisted I had to cease HRT immediately and forever. She was super cavalier about it and had an attitude that I was just taking it for funsies, or something. This led to the worst month of my life, but my doctor didn’t want to go against what the hematologist said.
A month later my doctor finally gave me a referral to a different hematologist, who said that of _course_ I needed to be on HRT and gave me the all-clear to go back on at 1mg/day to start with. No consideration was given to alternate modes of dosing.
Then my insurance provider left the public marketplace and I had to scramble to get new insurance, and I ended up on an HMO which meant I had to change doctors _again_.
This new doctor was _okay_ but he would not consider raising my dose past 1mg/day because of the clot risk. No consideration was given to other modes of dosing. My blood tests came back at 100pg/mL, which is borderline acceptable for post-transition maintenance. I still had no real breast development, and my doctor insisted that it was too late to get anything more through estradiol and if I wanted more breast tissue I should consider top surgery.
### 2020
I went back to working for someone else, and with this came a change in insurance. I ended up with a new doctor who fucking sucked; she prescribed mindfulness for everything, particularly my chronic pain.
I developed another DVT, which I caught before it threw a clot (but had to insist to my doctor that it felt like a clot and wasn’t “just” my fibromyalgia), and as a result of this started on blood thinners for life. Because of the clotting disorder, 1mg/day of estradiol was all I would ever get, at most, and even then I’d have to monitor things. I asked about going on transdermal or injections, and my doctor insisted that their clotting risks were just as bad as oral. She was also begrudging about even letting me stay on 1mg/day orally.
### 2021
I moved to a small town and changed doctors again. Things were okay, and my levels were being checked and were still holding steady at around 100pg/mL.
### 2022
My doctor decided that because of the clotting issues I should be switched to transdermal. Unfortunately, it was the lowest possible dose of transdermal. But my serum levels were holding steady for the time being.
He also insisted that my chronic pain was due to my high triglycerides which in turn were caused by my familial hypercholesteromia. We tried a bunch of options for reducing them to see if that would help but I couldn’t tolerate any of the medications that were available. He refused to try any other plan of attack and just blamed everything on my triglycerides.
Later that year, he burned out and disappeared. I was reassigned a nurse practitioner, who fucking sucked, and who blamed all of my problems on my weight, and without even talking to me decided that I needed to “stop eating fast food,” so I changed doctors again.
This new doctor was willing to learn about trans stuff but had absolutely no understanding of any of it (“But behind all that you’re still male, right?” as if I had just had drywall and spackle installed on top of my genitalia).
### 2023
Then she burned out and disappeared.
I was reassigned to another GP at the same clinic, who insisted that she could not treat me and also that it was irresponsible to get HRT from anyone other than an endocrinologist, but the endocrinologist she referred me to had a waiting list and wasn’t willing to take me on as a patient. The GP refused to even order blood work.
Meanwhile, Rite-Aid bought out the pharmacy I went to and shut it down.
I finally got on a cholesterol-reducing drug (Repatha, an injection) that worked well without side effects, and which also reduced my triglycerides. This made no difference to my chronic pain.
### 2024
I finally found a doctor who listed gender-affirming care as one of her specialties, and she was pretty good. But she just kept me on transdermal HRT, and my levels were still not being checked. She was also a few towns over and it was getting difficult for me to go that far due to fatigue and driving anxiety.
The clinic wanted to do all the labwork in-house but I preferred to get it done at the hospital near me since it was easier for me to get to, and both places were just going to Labcorp for all testing anyway, so why would it matter? So I insisted on the clinic just sending a labwork order to Labcorp.
Most of the essential stuff got checked, but they kept on conveniently forgetting to send over the order for estradiol.
Meanwhile, Rite-Aid stopped being able to fill prescriptions reliably, and I switched to Safeway.
### 2025
The clinic I was going to was opening a new branch in my town! But they weren’t sure when it was opening. And my doctor wasn’t going to practice out of that office, and she was also very busy and backlogged so it was difficult to get an appointment with her. She kept on sending orders for getting my estradiol checked. Those tests never ended up happening (while other tests did). Clinic staff would misgender me on the regular.
My fatigue and anxiety were getting worse and I ended up only using Lyft to get to the clinic, which made it quite an expensive ordeal. I was also having other slides in my overall quality of life, and according to my mood tracker, my last good day was sometime in July.
In November she transferred me over to another doctor at her clinic, who was brand new, enthusiastic about gender-affirming care, and was also going to be working part-time at the clinic in my own town, so that was a good reason to switch.
I was also finding that I was having a lot of symptoms that were consistent with very low hormone levels, and I finally got the stars to align and got my estradiol levels checked.
They were 31pg/mL, which is dangerously low, and it’s quite likely that they’d been at that level for quite some time, possibly contributing to my fatigue and pain issues, and definitely causing plenty of other problems for me.
My doctor doubled my transdermal dose, and ordered another test to take place a few months later.
It took a while for the updated transdermal dose to get filled by any pharmacies.
Meanwhile, Rite-Aid shut down completely, as did my town’s Walgreens, so suddenly the Safeway pharmacy became very difficult to deal with because of insufficient staff and very long lines. Prescriptions kept getting lost. So I switched to CVS mail-order for everything that I could, but CVS refused to fill my Repatha mail-order, so I still had to go to Safeway for that.
### 2026 so far
After being on the higher transdermal dose for a few months, I got my levels checked again. They went up — to 32pg/mL.
I finally discussed injections with my doctor and he agreed that it was worth a try, but also warned me of the clotting risk and how he’s only willing to do this thanks to informed consent. Because of some concerns regarding a potential peanut allergy, which in turn could translate to a potential castor oil allergy, he prescribed me estradiol cypionate, which is considerably more expensive (by many orders of magnitude) over estradiol valerate, but it also has some other advantages such as slower absorption and less of a serum level spike, so it seems like a good call.
Unfortunately, CVS mail-order will not fill that either, and they took their sweet fucking time letting me know about that. So that prescription was moved to Safeway. And it took forever to be filled, too, all the while I’m nearly out of my transdermal patches (ineffective as they are) and getting anxious.
Fortunately, Safeway finally managed to fill the prescription today, and I got the estradiol, the 18ga needles for dosing, and the 25ga needles for injecting.
Unfortunately, the doctor forgot to also transfer over the prescription for the syringes, so I have no way to actually inject it.
Fortunately, I was able to get in touch with Safeway’s pharmacist right before they closed and she said she’d put a note on my file to give me some syringes when I come in next time, so I’ll be picking them up sometime tomorrow, and I’ve also left a message with my doctor asking him to remember to prescribe the syringes too. (He also didn’t remember to transfer over the alcohol wipes but that’s something I can get OTC and which I already have a good supply of.)
Anyway, tomorrow I’ll hopefully be starting on my injections, which just so happens to be on another special trans-related anniversary… but more about that in a post scheduled to go live in a few hours.
My doctor is starting me at 0.2mg/week and then we’ll adjust based on how I respond to it. I already have labwork scheduled for two months from now, to get my levels measured at the end of my dosing cycle. I’m cautiously optimistic.
### Random thoughts
Healthcare is a complete mess right now, particularly in the Seattle area, and for all of the great experiences people have with being trans here, I’ve sure not had a good one in terms of medical access.
It’s understandable that doctors have been hesitant regarding clotting risks, but that caution needs to be balanced against other issues that also impact my quality of life. How much has my chronic pain and fatigue been affected by being basically menopausal for who knows how long?
And how long have my levels been this low?
Maybe I could have done a better job of advocating for myself and trying to get on injections earlier, because I’ve been super frustrated at my lack of breast development. I think that the doctor who told me that it was too late to develop further was misguided in his judgement. Or maybe he was using that as an excuse to avoid a clotting risk.
So many doctors (including my current one) are under the misapprehension that the clotting risk of injections is too high, and that it’s nearly as high as oral route, but the thing is that the clotting factors are primarily due to liver involvement, which _only_ happens in the oral route, not in injections. But unfortunately the amount of peer-reviewed research on this is minimal, because it’s in the intersection of “women’s issues” and “trans issues,” which are both _horribly_ under-studied.
Estradiol cypionate also only exists (at least in terms of marketing) as a medication because of the case made for it helping cis women through menopause, and it’s only indicated as a short-term relief in that capacity. Its use as transgender HRT is technically off-label, even though my understanding is that’s basically _all_ it’s used for, and of course in the current political climate, transgender HRT is the villain of the week.
Heck, a week ago there was an incident where a drunk and stoned person had a driving incident nearby, and the rumor that’s spreading is that she’s a trans woman and that she was raging because of being on “the wrong sex hormones,” and that is part of the overall narrative: that the “wrong hormones” (based solely on one’s birth sex) is Bad and that it causes Rage and Issues, when at least for me, the _testosterone_ was what was wrong for me, and estradiol helped my mood and sense of calm _immensely_. The lack of estradiol in my system for the past who-knows-how-long is probably a big part of why I’ve been so quick to anger for so long!
And how many of my interpersonal problems have been due to that? Who knows! But there’s been a few important bridges burnt that will be difficult, if not impossible, to repair, and the timeline certainly matches my theory of how long I’ve been in misery due to a lack of proper hormones.
I needed my levels to be checked a lot more frequently, and for that to happen I needed to have a medical system that gave even the tiniest shit about my well-being.
Going forward I seem to have that, at least. As long as my current doctor doesn’t also burn out and disappear.
And as long as my insurance doesn’t agree with the right-wing shitheads that HRT is the root of all evil and it must be stopped.
I think that last possibility is what scares me the most.
