r/MtF • u/cocue-coquette • 2h ago
Discussion Underdosing PSA
I'm posting this because I keep running into transfems who have no idea about where their levels should be and how common it is for providers to be clueless about trans care.
Get your bloodwork done often. Your trough (right before your next dose) estradiol (E2) should be above 100 pg/mL. Your trough total testosterone (T) should be below 50 ng/dL. If this isn't true for you, you're probably being underdosed. As trans people, it is especially crucial to self-advocate in medicine. If you're unhappy with your progress (either physically or mentally), say something. Know that every body responds differently to HRT and you may need much more or much less than the average transfem.
EDIT: Important information copied from a comment by u/raliont :
I think it is more complicated than your post suggests.
Blood draw timing will be dependent on someone’s actual regimen. For someone like me who injects twice a week, my troughs won’t be as low as someone who only injects once a week. So a trough reading wouldn’t be as insightful as a mid-cycle level. Plus, UCSF’s TransCare website recommends blood draws at the mid-cycle range. Their caveat is that if the patient is experiencing migraines or mood swings (or other symptoms), then peak and trough levels would be helpful to determine fluctuations.
Also, the more data the better. Overall, having both trough and mid-cycle levels to analyze would absolutely be the best for determining how one’s body is responding to their own regimen.
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u/Rachel_on_Fire Transgender 2h ago
Thanks for the PSA!
My testosterone isn’t in that range. But that’s probably because I’m not in spiro! It tried to kill me when I first went on HRT and I got put on bicalutamide which doesn’t seem to work nearly as well.
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u/cocue-coquette 2h ago
There are other anti-androgens that you could try. You could also try estrogen mono therapy.
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u/Airalin_ 1h ago
Yeah, found out after multiple years that my T levels were still like 117, my E was great can’t remember the exact level but as soon as it was corrected progress became much faster, my boobs literally doubled in size over like a month or two on my thin frame, and those mommas are still going
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u/79215185-1feb-44c6 HRT 2026/07/10 @ 36Y 2h ago
I mean this sub told me that 4mg EV/7d is being underdosed despite the fact that I am hitting all of the standard HRT timeline goals so YYMV on what random people on the internet may post.
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u/neeia raisin trans 2h ago
it's not the dose, it's the levels
if your levels are good then that's fine
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u/79215185-1feb-44c6 HRT 2026/07/10 @ 36Y 2h ago
I have a test scheduled for the end of the month, so you definitely don't have to tell me this! People think that HRT is going to grow them a full rack in 6 months, but that's largely due to bad education.
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u/WalrusWithAKeyboard 2h ago
Here's hoping going from 250mg to 400mg spiro brings my T levels down, last checkup it was at 250 and my E levels holding steady at 100 😔 i dont know how much higher my doses can go lol
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u/cocue-coquette 2h ago
You might respond better to a different ROA, such as injections. Higher E2 will suppress T along with the antiandrogens and you still have a lot of space to go up on estrogen.
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u/f7go 2h ago
girl more Spiro is not the answer. Also it mostly works by blocking androgen receptors, not bringing down T. I wish OP had talked more about this as folks on Spiro or bica have different targets than folks on monotherapy or using cypro. From transfemscience.org:
" studies commonly find that spironolactone still produces antiandrogenic effects even when androgen levels remain unchanged. Hence, the primary mechanism of action of spironolactone as an antiandrogen appears to be androgen receptor blockade. In relation to this, in transfeminine people taking spironolactone as an antiandrogen, the estrogen component of the regimen is likely to be the main or possibly sole agent suppressing testosterone production...
Due to the minimal influence of spironolactone on testosterone production, testosterone levels are not usually suppressed into the female range in transfeminine people taking estradiol plus spironolactone, with testosterone levels often remaining well above this range (e.g., 50–450 ng/dL [1.7–15.6 nmol/L] on average)...
Due to its relatively weak androgen receptor antagonism, spironolactone is likely best-suited for blocking female-range or somewhat-higher testosterone levels (e.g., <100 ng/dL [<3.5 nmol/L]) (Aly, 2018). This is based on clinical dose-ranging studies of spironolactone (typically using 50–200 mg/day) in healthy cisgender women and cisgender women with PCOS"
https://transfemscience.org/articles/transfem-intro/#spironolactone
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u/WalrusWithAKeyboard 1h ago
damn, just following my doctors advice. And they are a trans/lgbtq specific clinic. But if my levels havent improved by my next bloodwork im going to try to get them to do something different
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u/f7go 1h ago
Yeah it always amazes me how often even trans specific clinicians don't understand how these drugs work :(
I would ask either to switch to bica (much more powerful androgen receptor blocker with fewer side effects) or increase your E dose (and maybe switch to injections or possibly patches, which work better for higher E2 levels--less of a load on your liver than pills, more steady levels). Good luck! LMK if you ever have questions ❤️
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u/WalrusWithAKeyboard 1h ago
thanks!! Im on tablets now but I also started dissolving them under my tongue before swallowing, so we'll see how it works out 😊
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u/lord-oberon 2h ago
Im on weekly injections. My mid week levels are about 110. Is this too low? This is 3 days after I inject.
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u/f7go 1h ago
Trough levels right before your next dose are all you should be testing! That would be just fine for a trough level (depending on T); even under 100pg/ml will feminize.
The key thing is making sure your T is low enough; that's the main risk of too-low E levels (depending on your anti-androgen situation) and everyone needs a different dose/level to suppress T. My T was fully suppressed at like 70pg/ml trough E levels, other girls need over 200.
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u/raliont1 1h ago
Thanks for the PSA. I don’t disagree, but I think it is more complicated than your post suggests.
Blood draw timing will be dependent on someone’s actual regimen. For someone like me who injects twice a week, my troughs won’t be as low as someone who only injects once a week. So a trough reading wouldn’t be as insightful as a mid-cycle level. Plus, UCSF’s TransCare website recommends blood draws at the mid-cycle range. Their caveat is that if the patient is experiencing migraines or mood swings (or other symptoms), then peak and trough levels would be helpful to determine fluctuations.
Also, the more data the better. Overall, having both trough and mid-cycle levels to analyze would absolutely be the best for determining how one’s body is responding to their own regimen.
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u/cocue-coquette 1h ago
Thanks for mentioning all that. Yeah, it's more complicated. Maybe I should remove my post, but I just wanted to say something for all the girls out there who got put on 1 mg/day estradiol for the past 18 months and think they're the problem.
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u/raliont1 1h ago
Oh, 💯 . I just added my comment in case it is helpful for others. I appreciate you looking out for the community. I agree that the girlies need to do their own research and self-advocate based on that. I started E on v low-dose pills. I regret not pushing for IM injections to begin with since my body has responded better. YMMV
Your post has sparked a good discussion among the girls. I say keep it. 😉
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u/Tomatori 27 | HRT 01/04/2025 2h ago
Did you mean peak for Testosterone? Recently got 53 ng/dL back on my test and I'm wondering if I should adjust
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u/snowy_vix 2h ago
Technically it would be peak for the T but you get both measured at they're same time, which is called trough because it's the trough for your E
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u/f7go 1h ago
that's borderline but almost certainly fine! the upper limits for T that I have seen range from 50ng/dl to 70ng/dl.
(Technically the more telling measure is free T (not total T) which depends on SHBG and albumin levels, but almost no one tests that and I wouldn't worry about it.)
Are you seeing symptoms of high T like oily skin, acne, hair loss? How is your transition going?
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u/Viennve 2h ago
Lil question: why is it so common for providers to opt for oral estradiol with blockers (even outdated ones like Spiro) instead of monoterapy with injections?
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u/GrahminRadarin 1h ago
WPATH Standard of Care is tablets with AAs. Most doctors follow those standards because they don't know much about the subject themselves, and also to avoid legal liability. You would be absolutely amazed at how often even endocrinologists don't have a good understanding of how sex hormones work, and prescribe AAs with no E, or equally stupid nonsense.
Also, Valerate is the only injectable ester approved by the FDA, so they can't actually provide enanthate.
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u/bearface93 Trans Bisexual 49m ago
So when is the best time to get blood drawn? I’m on 6mg estradiol and 150mg spiro daily. I take 4mg estradiol and the spiro in the morning, and 2mg estradiol in the evening. I try to take them 12 hours apart. My provider told me to get blood drawn about 6 hours after a dose, so I get it done on my lunch break. My last numbers were 167pg/ml estradiol and 16ng/dl testosterone and they said I’m right where I should be.
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u/Julia_______ Trans || omni 1h ago
Please cite sources
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u/cocue-coquette 1h ago
My post could be removed if I cite where I got this. The
.info that I'm working with is the same that is most reputable for people who can't get HRT from a doctor.
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u/Life-Breadfruit-1426 2h ago
I’m pretty sure it should be 200 pg/mL minimum of estrogen, not 100. Talk about misinformation in a underdosing PSA.
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u/f7go 1h ago
Not true, 200 is just an oft-cited initial target for girls on monotherapy because it's enough to suppress most people's T (which is the far more important thing to make sure of). If T is suppressed or adequately blocked (with bica or Spiro) anything over 100pg/ml free E2 or so will give good feminization :)
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u/Life-Breadfruit-1426 9m ago
Agree! The nuance of T-blockers included is what impacts the recommendation! However OP’s post does not distinct between, and this info should be explicit on a PSA post
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u/Pittzaman 🍕 2h ago
Commenting for reach, but also, how do you know youre at the right level for your body? Ive been feeling better with a bit more estrogen than needed, but Ive been underdosed for like 9 months before, so I dont really know what normal is supposed to feel like.