An incredibly confusing doctor’s appointment

I had imagined a lot of possibilities going into my HRT appointment, but I never imagined it going like this. Going into this appointment, I knew that I was going to have to discuss my estrogen dosage. Following my last appointment, three months ago, I had increased my estrogen dosage using my own stockpile (more on that here: The unresponsiveness of transgender healthcare). That change to my dosage will affect the blood test results, so I needed to be open about the change. The idea was that they would increased the prescribed dosage to meet my self-medicating dosage, but that wasn’t exactly what happened…

The appointment started as normal, I saw the nurse and then talked to the doctor for a little bit. Then I asked the doctor to increase my estradiol dosage and they said that we could discuss it after seeing the results of the blood test. This is the exact same thing they said 3 months ago and my results were bad then. So, at this point, I told them that I had been taking the higher dosage for 3 months already. And the doctor ignored me. They refused to acknowledge what I had said and kept going on like I hadn’t said anything. This was so flagrant, that I was worried that they hadn’t heard me. A little later in the conversation, my doctor mentioned that if my levels were good that we wouldn’t have to change my dosage. At this point, I reiterated that I had been taking a higher dosage and that any lab results would be the result of that, to which the doctor responded that they had heard me the first time. To top it all off, the doctor concluded the appointment by saying that we could increase the time between appointments since my dosage was stable. We had just spent 15 minutes discussing my desire to change my dosage and I had just told them that it had changed! I just don’t understand how any of this appointment made sense.

I have been criticized before for being too critical of my HRT provider (and perhaps I am), but not only do the events of my appointment make no sense, they are contrary to good practice. My HRT provider did not ask a single question about me increasing my dosage. How long have I been taking the higher dosage? Where did the estrogen come from to do so? Why did I raise it myself? They don’t know because they didn’t ask. They didn’t even tell me that I shouldn’t have raised it myself. Their actions also conflict with the WPATH standards that they claim to follow. WPATH’s “standards of care” stresses the importance of harm reduction strategies and encourages medication bridging. If a patient is self-medicating with hormones, the harm reduction approach encourages healthcare providers to provide a prescription to replace the DIY hormones. My provider didn’t just not replace my self-acquired hormones, they refused to even seriously acknowledge that I was taking them.

I am aware of my doctor’s motivation for being so cautious, but I don’t believe that it is rational. The primary issue that my doctor has repeatedly brought up is the increased risk of blood clots when estradiol levels exceed 300 pg/ml. This is a true statement, but I don’t think it is a valid concern. First, my estradiol levels have exceeded 150 pg/ml, so it is unlikely that an additional 2mg will increase it by such a vast margin. Second, estradiol levels far exceeding 300 pg/ml are common in cis women, and they don’t all die from blood clots. Normal levels for cis women are 30-400 pg/ml and it can be as high as 800 pg/ml during some parts of their cycle and still be normal. Third, the increased risk of blood clots from 300 pg/ml only raises the risk to be the same as cis women’s. There is no good argument for refusing to raise my dosage based on the risk of blood clots.

The other reason that they won’t raise my estrogen dosage is that they want me on spironolactone. Every time that I have requested an increase in my estrogen dosage, they have told me that they want to wait for another blood test before changing my dosage, and then immediately offered me spironolactone if I am interested. I have made it clear to them, I am not interested in spironolactone. Its side effects are well documented and quite negative. Besides, there is no reason that estrogen monotherapy wouldn’t get my levels correct if they would raise my dosage.

I don’t know what to do now. I am not going to stop taking the higher dosage. My hormone levels were not good at the lower level and my physical results have improved since raising it. I refuse to allow my transition to be held hostage by a medical institution that is unwilling to adapt and clings to outdated and incorrect orthodoxy. My therapist has suggested that I start looking into finding another HRT provider. I don’t disagree with their suggestion, but it isn’t that easy. I am not in or near a major city, so my options are quite limited. There is only one other physician that provides trans HRT in my area and they are not accepting new clients (and haven’t been for over a year). Unless they start accepting new patients, I am kinda stuck.

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