how to cope mentally during gaps in HRT
how to cope mentally during gaps in HRT
I recently had an injection that seemed to go wrong (CW: blood, I inject EV subq and I hit something like a capillary, there was a lot of blood and it bruised badly afterwards). Within a couple days I felt unusually dysphoric as a result of what I assume was a failure for the oil to depot and slowly release over time.
I get these "dysphoric thoughts" that maybe the estrogen is causing the problems, that I don't have objective proof that I'm trans, etc. Lots of doubt, paranoia, and increasing amounts of anxiety and irrational fear (about transition, but also in general, e.g. thinking spiders are in my bed), and I start to experience depression and anhedonia (things aren't as pleasurable, everything feels pretty flat emotionally, I just feel "bad").
Of course when I inject again and it goes well, I feel much better and I forget about these problems.
I was just wondering if anyone has advice on how to deal with dysphoria when there are gaps in the HRT. Obviously in the long term, surgery will fix the hormone issue and I suspect that will fix this problem. Until then, though, I am stuck in a rather fragile place where I feel normal (even good, even amazing) when my estrogen levels are high and suppressing my testosterone. Any small slip in that and I barely function as a person.
Before HRT I would just do whatever I could to increase mental well-being:
- physical exertion (aerobic exercise, weightlifting, etc.)
- going outside and getting sunshine
- keeping up with hydration
- keeping good sleep hygiene (sleeping enough, going to sleep at the same times, etc.)
- meditation every day
But now it feels harder for me to "bootstrap" when there are gaps in HRT and my hormones aren't right, it's like I'm no longer used to how hard it was before.
Anyway - any tips or thoughts, would like to hear other's experiences.
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I used to have really bad mood swings that included lots of dysphoria. I made the soonest appointment with my doctor and brought this up to them. They changed the frequency of my injections to be closer together. This worked for me really well.
Alternatives could be different delivery methods like the patch or pills to help reduce the fluctuations in estradiol levels.
Stay strong girl friend 💜
Ah, that's definitely a good idea. My endo initially told me to inject 5 mg estradiol valerate every 10 days (I chose to inject subcutaneously). I couldn't last longer than 8 days, the dysphoria got so bad (I started to wonder how I possibly survived without HRT for so long, it really seems insane to me how I used to live).
I changed to every 5 days with 5 mg, but I kept lowering my dose (I was afraid of my endo forcing me onto a lower dose if my blood work showed too high E levels). I tried lower doses more frequently. All in all, lower doses were a mistake, I kept having a few days of horrible-ness in the trough. Eventually I went back to 5 mg every 5 days, and found around day 4 I started to feel weird, so to avoid issues I started injecting 5 mg every 4 days.
I know the half life is supposedly every 3.5 days, and I'm essentially relying on the estrogen to act as the anti-androgen (bicalutamide didn't seem to have any effect on my mood, positive or negative, so I stopped using it), so I'm intending such a high dose, I'm just not sure what those upper limits are or when I might be taking too much.
On the one hand, more frequent but a lower dose (even 4.6 mg) seems to have less of that anti-androgen effect that 5 mg has, and it feels less euphoric (mentally, I mean - estrogen sometimes feels like a recreational drug). On the other hand, less frequent doses means unevenness and potential troughs where things get dicey. I think as long as my injections don't fail (like when I injected into a vein or capillary), it seems like this dose / frequency works well enough for me. Still, it's a bit concerning that my basic functioning is so fragile, I wish I had better coping strategies.
For example, I wonder if anyone uses gel in conjunction with injections, or if anyone injects a partial dose when it seems like something didn't go right. I get the impression this just isn't as frequent of a problem, I've never heard that hitting a capillary caused such dysphoria as a result.
Another factor: I started HRT three months ago, so it could be that my body more easily slides back to testosterone right now and I just need to get over this initial transition to a new hormone regime.
Thanks for reading my post and for the suggestions! 🥰
I changed to every 5 days with 5 mg, but I kept lowering my dose (I was afraid of my endo forcing me onto a lower dose if my blood work showed too high E levels).
Something to think about in terms of your estradiol results is how long it's been since your last injection. I've had several providers tell me they don't care how long it's been since my last injection, they just want to see. I push back that and only let them draw when it's a true trough sample (e.g. I inject every 7 days, so I have blood drawn on that 7th day before I inject). This will give you (and your endo) a truer value to base your dosages/frequency on.
(bicalutamide didn't seem to have any effect on my mood, positive or negative, so I stopped using it)
I had a similar experience to bicalutamide, but I kept taking it up until my orchiectomy. I tried spironolactone, but I didn't like the results. If you're not in the US, ask your doctor about cyproterone acetate. That stuff made me feel levelheaded; sadly because I was self medicating I had to stop when I began seeing a professional.
Another factor: I started HRT three months ago, so it could be that my body more easily slides back to testosterone right now and I just need to get over this initial transition to a new hormone regime.
This definitely sounds true. Based on my experiences, the first several months had ups and downs (hormone-wise). When those lows hit you, talk to a therapist, hangout with a friend, do a mini-fashion show in your room, go for a hike. The lows will pass; things definitely get easier. 💜
I’ve had several providers tell me they don’t care how long it’s been since my last injection, they just want to see. I push back that and only let them draw when it’s a true trough sample (e.g. I inject every 7 days, so I have blood drawn on that 7th day before I inject). This will give you (and your endo) a truer value to base your dosages/frequency on.
Yes, this was a red-flag with my endo that flamed my anxieties about my blood levels being too high: he asked me to get tested mid-way between injections, not at trough. There seems to be a kind of community consensus (perhaps most emphatically expressed by Dr. Powers and his enthusiasts) that testing at trough is the only legitimate way to know what your levels are, so when my endo suggested I get tested mid-way between injection day and trough, I felt suspicious. I don't have the education or knowledge to parse claims by Dr. Powers on why blood drawn outside of trough is problematic, he seems to say that the information doctors really want is the amount of the hormone in tissue, and that the amount in the blood is misleading except at trough / nadir. However, I don't know how true that is; for example, I would suspect the blood-hormone levels continue a predictable decline regardless of how much of the hormone is in your tissue. Powers claims:
... the closest that the "blood" level will ever get to the "tissue" level (which is the thing we care about) is effectively right before your next scheduled dose.
It seems to me this is a highly contextual claim, and depending on how much and how frequently you inject, even at trough your blood levels might still be elevated in a way that doesn't give information about "tissue levels" (I don't know enough to even speculate about the relationship between blood and tissue levels, at trough or any other time).
For example, a large dose of estradiol valerate (EV) taken less frequently (like every 7 or 14 days) will give much, much more time for the EV to eliminate from the system. The half-life of EV is supposedly around 3.5 days (this might vary from person to person). So if you test at trough with an injection cycle of every 3.5 days, the blood levels necessarily will be elevated above "tissue levels" because the hormone is still releasing into the blood from the injection site.
All of this to say, I'm left a bit disoriented and unsure about what exactly to think. I don't trust my endo and his method, nor do I trust Dr. Powers and his explanation. I would like to educate myself significantly more so I can hopefully sort through some of this with a bit more competence.
Either way, I'm oriented to like drawing blood at trough (just before my next injection) for more pragmatic reasons: I seem to require higher doses to feel OK than the doctors want me to take, and trough is when my levels are lowest and are least likely to cause alarm for the doctor.
I had a similar experience to bicalutamide, but I kept taking it up until my orchiectomy. I tried spironolactone, but I didn’t like the results. If you’re not in the US, ask your doctor about cyproterone acetate. That stuff made me feel levelheaded; sadly because I was self medicating I had to stop when I began seeing a professional.
Good to know I'm not the only one. I don't know to what extent bicalutamide might have helped with anti-androgen effects on my body, but since my primary goal with HRT is mental well-being, I didn't think it was worth the risk or damage to my liver.
This definitely sounds true. Based on my experiences, the first several months had ups and downs (hormone-wise). When those lows hit you, talk to a therapist, hangout with a friend, do a mini-fashion show in your room, go for a hike. The lows will pass; things definitely get easier. 💜
Thank you so much, it's really helpful to hear this is others' experiences as well. I can get so perfectionistic and narrow-minded, obsessing about phenomenology and trying to track possible effects from my hormones day by day, hour by hour, in an attempt to notice pattens and orient what is best for me.
I do think when my hormones aren't right, life becomes unbearably bad. It's a strange thing to live so long and survive such difficult mental spaces, to emerge into a "normal" and healthy mental space with HRT that has now spoiled me. I feel more vulnerable and dependent on the HRT now for my mental well-being, and knowing how deterministic it all is can be demotivating. (Before HRT when I thought I was the problem, and to fix that problem I just needed to try harder to be healthy and happy. Now I know it's more biological and I feel much less in control, if that makes sense. The bad times are just going to be bad, and it's just a matter of hoping it comes at a time where I can accommodate that.)
Thanks for your kindness and help, I really appreciate it!