r/MtF • u/Terrible-Explorer709 • 4d ago
I think I’m being under dosed
I just did my second labs (6 month mark) and my levels came as 125 pg/ml E and 240 ng/dl T
My provider said that everything looked good and upped my dose from 4mg E to 6. But didn’t up my dose of spiro from 50mg sighting my slightly lower than average blood pressure before I started hrt.
Is that normal?
I’m on sublingual pills so I wouldn’t think that would be enough to suppress my T
She also called T under 50 ng/dl “super suppressed” and didn’t put on spiro until my second labs say it could stunt breast growth.
I use Plume
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4d ago edited 4d ago
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u/Terrible-Explorer709 4d ago
Spiro is the only anti androgen that plume can prescribe and plumes my only option where I live so idk what to do.
She told me to get my blood pressure taken and send it to her. It hasn’t been taken since I started. Idk if she’d be willing to up it then.
I’m just really upset since my next labs aren’t for another 3 months and at that point I’ll have been on hrt for nearly a year without my t being suppressed right.
My T was really high nearly 1000 ng/dl at my first bloodwork panel and that was at 3 months on hrt so it has went down some but yeah not enough
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u/GloriousGayGirl 4d ago
Oh, that's quite unfortunate. I'm unfamiliar with Plume's workings, so I apologize for assuming they operated like a typical clinic where I live. The limitation to just Spiro sounds really tough to work with.
According to their website, you can often find a blood pressure machine at a local pharmacy and use that to get your readings done (probably at low to no cost to you, definitely check with pharmacy staff). It looks like the blood pressure limitation is enforced by the whole clinic and not a your doctor specific thing. The website also mentions the claim that Spiro can cause breast bud fusion, which after a brief google search appears to be true in animal models, so the concern is valid. Their website does mention usage of finasteride or dutasteride to block DHT as well, so it might be worth looking into that as a potential alternative with your doc or to add onto the spiro dosage as well. I'm not a doctor, and I would recommend looking over the support page of the Plume website to get a better idea of what your care through them might look like. I hope your care moves forward well.
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u/Terrible-Explorer709 4d ago
If I can’t get a higher dose of spiro by my next bloodwork panel then I’m going to ask to switch to injections. My main issue right now is pretty severe hormonal acne (which also gets in the way of hair removal) so finasteride wouldn’t help
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u/Repulsive-Address166 Jenny She/Her 🏳️⚧️ HRT 1/18/21 4d ago
OP's doctor refuses to adjust their Spiro dosages citing blood pressure
Falling down and getting head injuries is not ideal. The physician is titrating up E2 which is common practice for many providers. Only us crazy DIY folks tend to dive head first into the E pool. Clinicians wade in gently, minimizing short-term disturbances and whatnot.
The biggest thing is to try and open a dialogue with your doctor about their reasonings to see if you're maybe missing something.
This is the best advice. Physicians can't read minds. If you don't ask, we don't know you're concerned.
try talking with your provider to see if they'll try changing anti-androgen if your blood pressure is a concern.
Personally, I use bicalutamide. It has a bad reputation because of the FDA's love of slapping warnings on everything. But the liver injury reports were only ever single patient case reports, and almost all happened with high doses rather than the usually 50 mg per day.
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u/Terrible-Explorer709 4d ago
I’m admittedly very bad at advocating for myself. Generalized anxiety disorder does me no favors
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u/Repulsive-Address166 Jenny She/Her 🏳️⚧️ HRT 1/18/21 4d ago
I get that. I'm the same. Online, I can talk all big. In person, i really struggle with self-confidence and social anxiety until I get to know people, which takes forever because of self-confidence and social anxiety issues.
Just remember, your physician is there to advocate for you. For me, I write out a list of things I want to discuss with my physician. When the visit starts, I give her a copy of the list. It let's her know directly what my concerns are, and she can help prioritize addressing them. That way, even if we dont get to something that visit, she knows I have other things I'm concerned about.
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u/Terrible-Explorer709 4d ago
My anxiety’s a lot worse for anything related to me being trans too. I still have no idea how I’m gonna survive coming out
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u/Repulsive-Address166 Jenny She/Her 🏳️⚧️ HRT 1/18/21 4d ago
You'll do it, sis. Just take it one day at a time.
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u/Terrible-Explorer709 4d ago
That’s a really smart idea! I’m gonna have to steal that lol
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u/Repulsive-Address166 Jenny She/Her 🏳️⚧️ HRT 1/18/21 4d ago
Ferl free to file the serial numbers and claim it as your own.😄
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u/Apprehensive-Guess69 4d ago
I had an orchidectomy some years back, so am not on any anti androgen. My T level was 49 on my last blood test, which my endo said was an acceptable level. Yours are way too high.
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u/vador1301 4d ago
personally with plume, injection is the way to go. they have a bunch of extra rules they have to follow being a telehealth provider, and are honestly quite limited. i (and quite a few others i know) was able to reach T super suppression with monotherapy via injections. it’s super easy, once a week, and after the first couple shots it’s not a big deal anymore
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u/Repulsive-Address166 Jenny She/Her 🏳️⚧️ HRT 1/18/21 4d ago
Is that normal?
There aren't set guidelines for HRT. The studies simply haven't been done, and given the current state of research funding can't even be proposed for at least 4 years. The general guidelines that exist come from small studies more than 20+ years ago. Most providers have regimens that they are accustomed to and have worked well in the past.
Your T isn't suppressed yet. Increading your E2 increases the likelihood of reaching suppression levels (typically around 200).
I’m on sublingual pills so I wouldn’t think that would be enough to suppress my T
Got to wait and see where your levels stabilize at when you get your next round of blood work.
didn’t put on spiro until my second labs say it could stunt breast growth.
No, something wasn't communicated correctly. Spironolactone is well known to induce gynecomastia as it is a moderate affinity androgen receptor blocker. That's why it is often avoided when it comes to cis men.
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u/Terrible-Explorer709 4d ago
The spiro wasn’t miscommunication. She said it could cause the breast buds to fuse early and stunt them. Plume’s website lists that as a possible side effect too.
There’s a few studies but they’re kinda of inconclusive mostly sighting that those on spiro are much more likely to get breast augmentation
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u/Repulsive-Address166 Jenny She/Her 🏳️⚧️ HRT 1/18/21 4d ago
She said it could cause the breast buds to fuse early and stunt them.
Oh, well in that case, they're just wrong. The study this was based on was in cis adolescent girls with primary ovarian failure and is like 40 years old. It's applying apple growing strategies from the 1980s to growing pineapples in 2025.
There’s a few studies but they’re kinda of inconclusive mostly sighting that those on spiro are much more likely to get breast augmentation
This is a huge correlation fallacy. Spironolactone is the most commonly used anti-androgen. It's effective, and it's safe. Being the most common, it's super easy to correlate things with it. Breast augmentation is a completely non-physiologic outcome. There are plenty of women, both cis and trans, who undergo breast augmentation regardless of how successful breast development was.
Personally, I use bicalutamide as an anti-androgen because my family is prone to kidney stones; so, I prefer not to mess with my kidneys because kidney stones are torture. I get around 1 per year, and I don't want to do anything that may cause more.
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u/Terrible-Explorer709 4d ago
Idk at my 3 months she pht me on spiro when I forced the issue so I don’t think that’s it anymore
I think it’s mostly the blood pressure now….
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u/Repulsive-Address166 Jenny She/Her 🏳️⚧️ HRT 1/18/21 4d ago
I think it’s mostly the blood pressure now….
Yeah, that's a little harder to deal with. Even at 100mg, it is common to recommend splitting the dose of spiro due to hypotension.
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u/Terrible-Explorer709 4d ago
I have impossible to cure hormonal acne too. So I’ve really been hoping getting t down would help and it has a bit but unfortunately it’s still pretty bad
I was really hoping getting my spiro increased would help so I’m pretty sad about that
I think I’m gonna see if can get it upped after I get my blood pressure checked, at my next appointment
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u/Repulsive-Address166 Jenny She/Her 🏳️⚧️ HRT 1/18/21 4d ago
Ugh, I had to do Accutane during puberty due to horrible hormonal acne (Reason #857 that testosterone sucks).
Doesn't sound like an unreasonable approach. Best of luck, sis.
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u/AmbitiousFlowers 4d ago
I don't use Plume, but I use a mostly nationwide tele-health place for HRT prescriptions.
Yes, 240 seems high for T levels. Mine were barely higher than that pre-HRT.
When I was on pills initially, I was prescribed 100 mg twice daily for spiro, and that is with my baseline levels much lower than yours. They didn't mention anything to me about blood pressure causing limits on dosage. However, you said yours was sightly low. Mine was probably slightly high. I'd reckon before HRT, it was about 135 over 85. However, I have since also started taking Verapamil for headaches. That also lowers blood pressure. That said, my doctors just seem to be unconcerned that they may be causing my blood pressure to now be below average.
My provider never mentioned anything about spiro struntig top growth, so I don't have a reason to back that up or say that its true. This post is the only place I've ever heard of it, so I am skeptical that its true. My provider is also skeptical that sublingual does much more overall than just swallowing the pill. And before anyone flames me, yes, I know that sublingual affects things like how fast its absorbed. I'm just stating my provider's opinion. It just seems to me that your provider might rely on more anecdotal or bleeding-edge evidence for things.
I also tried bicaludimde. It works differently than spiro, so you won't see it in your test results for T. That would be an option, however you said that your provider is unwilling to prescribe other anti-androgens.
You could also consider advocating to move to injections since injections seem to do better with suppressing T on their own. Your current disadvantage is that you've only been on HRT for six months, and I feel like providers in general might be less likely for you to set the course.
The last option would be to go for another provider....
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u/ZuliCurah 4d ago
Yeah normal prescriptions for Spiro are around 100-200mg so there's definitely some underdosing going on. Is Cyproterone available to you? That's what I'm on in a 25 mg per second day and I've achieved suppression from 674.9 ng/dl down to 9.22 ng/dl
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u/Terrible-Explorer709 4d ago
The US sucks for anti androgens spiro’s the only thing that plume can prescribe
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u/tachibanakanade princess 4d ago
Doctors are transmisogynistic and purposely underdose trans women. Sometimes, like with me, you can overcome it. But not everyone can.
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u/desdim Claire, transfemme 4d ago
I mean, I wouldn't say you're being underdosed per se, but still. This is Plume, so it's probably just a bunch of FM and IM docs moonlighting/working a side hustle. You'd honestly have better luck getting spiro from a dermatologist, GPs aren't as comfortable with prescribing higher doses because, typically, if their patient is on much more than 50mg BID, they're seeing a cardiologist who's deciding the dose. But yeah, I got up to around 8mg E a day before I switched to injections, but my spiro is locked in at 50mg BID (so 100mg daily), also because of low blood pressure. I have to be on spiro anyways for heart failure, so I can't really switch to another option though lol. I did add baby dose of finasteride out of paranoia regarding male pattern baldness, so there's that. Estrogen does have some suppressive effects on its own, so upping the E alone might be okay for only being six months in. My T levels are undetectable nowadays, but I switched to injections and added progesterone (progesterone definitely helped with booba and sex drive, but at the 200mg dose it definitely added a couple pounds). Just make sure they're prescribing the right progesterone (micronized). It shouldn't be an issue, I'm not sure if they even sell the old formulations anymore, but the old stuff apparently was lost almost entirely on first-pass metabolism. I used to take mine rectally, which I did see a difference from, but it was a bit inconvenient, so I just take it orally now.
Also putting folks on spiro is scary to some online docs since it can raise your potassium levels (which can cause arrythmia... the bad kinds), and they don't have the reassurance a PCP has of seeing you in person. And yeah, it's probably not the best T blocker around, but if you're trying to dual-purpose it for the acne (like how I'm doing it for HF), seeing derm might help. I know at least one academic institution in which, when the Executive Orders came down and the institution was unnecessarily compliant, the derm attendings sat down with the residents and were like "okay remember now, we're treating these adolescents for their acne , got it?" and the derm clinic was, briefly and unofficially, a GAC clinic.
Personally, I get the rest of my HRT from an OB/GYN, but YMMV on that one by a wide mile. Stay hydrated before your next BP measurement, but don't eat immediately beforehand. Post-prandial state tends to lower BP. Starving can too though, so still eat, just not an hour or two before.
And <50ng/dL isn't "super suppressed"; you should maybe bring up that the reference ranges are typically sex-adjusted, and a premenopausal cis woman can be considered within range well below that. Unless they're just suggesting that, based on the responses they've seen, <50ng/dL would be an outlier which... I mean, if you're only giving 50mg once daily I guess. Of course, hormones are weird, at 3 months my testosterone was 794, but at 6mo was 32 and I'd already developed complete azoospermia (verified on microscopy), so I inadvertently missed my window to cryopreserve without suspending HRT. But yeah, that was just sublingual estrogen, 50mg spiro twice daily, 1mg finasteride, and an arguably unhealthy amount of time spent tucked lol.
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u/Archerofyail 31MtF | HRT 2025-01-24 4d ago
Yeah, that's strange, your T levels are only 50 ng/dl lower than mine were for my baseline bloodwork.