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!
I haven’t had hrt yet and it sounds like you’re describing my life. I’m not functional at all, and I have no clue what to do to be functional. The only thing I can do is use discipline to play pretend, but then again that makes no sense because I don’t feel connected to my life. I just kinda manage a little at times because I don’t want to hurt the people around me.
Yeah, before HRT my life had two modes: stress and depressed. I preferred stress, it gave me agency and movement and made me feel alive. I think it’s part of why I became a workaholic, the stress of work became addictive and necessary to me.
I didn’t know how HRT would impact me, but I was shocked when I read about “biochemical dysphoria” in the Gender Dysphoria Bible. I became hopeful the HRT would help. The first two days after my first injection it wasn’t clear to me how I felt about estrogen, there were mixed feelings. By day 3 I think the testosterone was starting to get suppressed and I became euphoric and that’s the first time I would just lay there and feel delicious euphoria all over my body. I felt high, like I had taken drugs. It was delightful. I took that as a good sign.
I was surprised at how much estrogen changed my life. I have struggled to create stability with HRT, but in the periods where my hormones were right (I am guessing), I become much more able to handle everything. It suddenly became easy to do things that felt impossible before. I have a garage full of clutter that has built up to the point where I can barely get into my car anymore, and every time I need to drive out of the garage I have to move a bunch of items out of the way to make room. One day, just during breaks from my job (working from home), I was able to significantly clear out and organize the clutter. Something I wasn’t sure would ever happen.
I was suddenly finishing projects that I had sat on for years. It just became easier, more matter-of-fact, and less stressful. There was a kind of stress, but it didn’t take the same toll. Some when I would plan meals and go grocery shopping. Before HRT doing that would take up half of my day and would leave me completely drained afterwards, I would barely be able to put up groceries when I got home. Now with HRT I can feel the stress, but when I leave the store it doesn’t wreck me, I even have energy do other things after putting up the groceries.
Before HRT I could sleep 11 - 12 hours every night and still not feel that energetic. With HRT I sleep more like 6 - 8 hours and wake up rested and with more energy than before.
It is a huge change for me.
But my story shouldn’t set any expectations for anyone. I don’t think being trans is a monolith, and the causes of dysphoria which I believe are likely both social and biological in nature are probably multiple or quite complex. I have read a study which found a correlation between left interior parietal cortical thickness (Cth) and reported congruence with self and body (for both trans men and trans women, by the way - the Cth in cis controls different in the same ways from trans people regardless of whether they were trans men or women). The study compared baseline levels before HRT and after taking HRT, and what I found interesting was that some trans study participants after HRT actually had both thicker Cth and increased reported incongruence between self and body.
So while HRT is helpful in many, many cases, it’s not guaranteed that a person suffering from gender dysphoria will respond to HRT the same way as others. There might be more complicated mechanisms that explain this that we don’t understand yet. Some trans people don’t find HRT helpful and that’s OK. Some people try HRT and find it doesn’t make a big difference mentally, but they take it for the physical transformations.
My primary goal in taking HRT is to improve my mental health, above and beyond the transition.
I feel constant pressure to know whether the HRT is helping, to know whether I’m “really trans”, and so on - but ultimately even if the HRT didn’t work for me, that doesn’t necessarily invalidate my “transness”. So take my account with a grain of salt, it may or may not happen for others. Lots of people start HRT and experience more depression or anxiety (esp. if there are other things going on in your life that are creating stress or might cause that depression and anxiety, and transitioning is definitely a such an event for most people).
Whatever struggles you are having, I hope you find a way to cope and even overcome them! I ultimately transitioned and took transitioning seriously precisely because I was hurting the people around me by not doing so, I realized I needed to be more self-compassionate so that I could be a good person (whereas before I felt my welfare should come last, and I wasn’t sacrificing enough to be a good person). I can really relate to the struggle, and I’m so sorry you’re going through that.
Thanks for your story, I think I might show it to my gp in the hope of getting the signature I desperately need. Because it is exactly how I feel too.
Weeks ago I tried hrt from a friend for a month. It had a fundamental effect on my psyche. It was as if I was meditating but without any effort. From waking up to going to sleep, it was absolutely solid.
And once the end of the meds was in sight, I knew what was ahead of me. To get back in the cage and to forget the feeling of life. I remember it in an abstract way now, but sometimes I lose hope.
I just feel utterly dissociated, even worse than before, if that’s even possible. All I can do is wait and trust.
I wonder why your GP wouldn’t prescribe HRT … If you are in the U.S., you should be able to use informed consent and go to any Planned Parenthood to get HRT. I think it’s possible a therapist can also refer you to an endrocrinologist, though that’s less common these days (and I don’t know the details, whether the psychologist can refer you directly to the endo, or if it somehow still routes through your primary care, I don’t know).
Have you read the Gender Dysphoria Bible? It’s full of information and anecdotes like mine. Either way, you shouldn’t be in a position of arguing with your GP or pleading your case with testimonies like mine. Contemporary doctors should know better and will refer you to an endo based on self-reporting. It’s not that different than if you have depression and need anti-depressants, there is no test, and ultimately the doctor has to take seriously your self-reporting. Obviously transphobia throws a wrench in this theoretical case, but if you’re trans you should want to find a doctor that isn’t transphobic anyway, since you will need unbiased care during and after your transition as well.
If you really wanted evidence to present to your GP that trans care is effective, here are collected research findings published by Cornell which provides a summary and many, many studies which overwhelmingly conclude that gender affirming care is effective. Still, I don’t think you should be in a position of arguing or pleading this case with your doctor. I got a referral to my endo by calling my doctor’s office, speaking with the nurse and telling her I think I have gender dysphoria and want to see an endocrinologist. She spoke with the doctor and he agreed to refer me to the endo. I am his first trans-feminine patient, and the first trans patient he has referred to an endo, but I learned he has some trans-masculine patients that transitioned before seeing him.
Sometimes there are directories to find trans-friendly providers in your area. That’s how I found my endo, there was a guide where he was listed. If there is any local LGBTQ+ organization, connect with that community and even if there is no official directory, someone might be able to tell you which doctors are safe.
Good luck out there, I’m rooting for you! <3
Thanks for your support.
Unfortunately in this case I live in the Netherlands and we don’t have informed consent here. I’m required to see a psychologist and it can take 1 or 2 years before you even meet one, and it takes longer to actually get it. I personally know someone who has been waiting for 2 years now.
I don’t let it stop me. I’ve socially transitioned for well over a year now. And eventhough I am a responsible person I have a plan B which involves getting DIY hrt. I just hope this GP sees reason and allows me a safer way.
What bothers me most at the moment is that my depression has regressed back to non functional, and I am unsure about the future. All I can do is wait and not lose faith.
Ah, I don’t know much about the laws and the way healthcare works in the Netherlands. I’m in the States, and after the doctor referred me to the endo, my first appointment with the endo was scheduled two to three months away. It felt like a long time, and in that time having socially transitioned but having no HRT I suffered much more than before. It was like I was giving up all of my repression and previous coping strategies, and that left me rather exposed to the dysphoria, to the point of having strong suicidal ideation.
In retrospect, knowing how I responded to HRT, I regretted waiting and not trying DIY first. It was easy before seeing the endo to rationalize not taking the DIY route, as I wouldn’t have baseline blood tests showing my hormone levels before HRT. I also didn’t want to come across as non-cooperative or acting in bad faith with my doctors. But I sacrificed my well-being for that, in ways that makes no sense.
In the U.S. estradiol is not a controlled substance, even though you generally need a prescription to acquire it. You can order it online and have it shipped to your house, and the quality of some of the estradiol on the market is the same as what you get at the pharmacy here (obviously not all sources are equal). The issue is really money for most people.
I don’t know how you might react to HRT, or what situation trying DIY might put you in. However, I would completely understand taking the DIY route, and I wish I had taken my well-being more seriously. I know in the UK people often turn to DIY because it can shorten the timeline for getting HRT through the clinics there, I guess the clinic feels a pressure to engage in “harm reduction” and will waive some of the transphobic policies that require waiting arbitrarily long times before being given HRT.
Much luck to you, sister. I hope you are able to find a way to help yourself and feel better. <3
Thanks, that makes me feel a lot better.
Being a goody two shoes can definitely be detrimental. I’m gonna try to get her to at least give me the blood tests. Otherwise I’ll have to go the private way and it’s gonna be expensive. And I’m already drying up my friends enough.
Looks like people are saying the greymarket medication is more expensive in the UK than through official means (just like in the U.S. where insurance should bring down the cost of the medication), but private (which I assume means still going to a clinic and paying out of pocket) might be more expensive than greymarket DIY, just a thought if financial resources are tight. Basically this would mean just not seeing a doctor or getting blood tests privately, just sourcing the medication on the greymarket. Then when you do finally get access to the public healthcare you will have been self-medicating and they will be motivated to fast-track getting you the medication through official means (as a form of harm reduction). At least this is what I have heard can happen.
If you haven’t already, you might find Yes, You Are Trans Enough by Mia Violet interesting, it’s a memoir but she’s in the UK and talks about what it was like navigating the UK healthcare system. I found the book important at the very beginning of my transition to help me come to terms with being trans and accepting that.
Whenever I get dysphoric thoughts, I counteract them with euphoric thoughts, such as how happy I was when I started HRT or when I changed my name. I take pills and I still have days where I feel dysphoric and shitty although they are getting rarer.
I do get the dysphoric thoughts too about not being trans and that I’m actually just a man pretending to be a woman, but for me I think that’s part of religious trauma I have from being put in a sex separated catholic school program for most of my childhood. I think that understanding why you have dysphoric thoughts is a key part to figuring out how to conquer them. Society is very cisheteronormative, especially in rural and religious areas, which makes it easy to feel like there is something wrong with us being trans, when really there isn’t.
Idk how long it takes to work through those feelings of shame, doubt, and anxiety about who I am. I’ve been working at for years and I feel like I’ve made decent progress but sometimes bad old memories resurface and then dysphoria comes and hits me like a truck. I always use my technique of thinking of euphoric memories, which does help, although I don’t know how to make the dysphoric thoughts stop entirely.
I hope that you feel better soon! Dysphoria sucks ass.
Edit: I noticed that you recently started HRT and sometimes your brain adjusting to the new hormones can cause depression and such. I had issues like that as well until I reached about 6 months. Before that point I had a few days where I could hardly function and even exercise didn’t help.
Yes, I do think because I’m still only on month 3 of starting HRT that it seems like I slip back into testosterone production easily, and that seems to correlate with the mood issues. I have been careful and conservative with my estrogen doses until recently (I consider 5 mg EV injected every 4 days a rather large dose for that frequency).
I do live in an extremely conservative place, and I live in a city surrounded by rural areas and lots of people here come to the city to work their jobs but live in a rural place. I was raised here, and I have internalized a lot of transphobia. My father was also maybe repressed or closeted, we don’t know, but for whatever reason he was rather fragile about his masculinity and used violence to keep me from even doing normal gender exploring as a young child.
I think the dysphoria I feel in these gap periods seem to make it hard to connect with gender-euphoric thoughts, but I think it’s a good idea - maybe I can journal about all the times people have given me compliments or all the times I have been affirmed by people when I least expected it. The reality is that most people have been extremely supportive of me.
Thanks for the help!
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shoutout to the mods for removing that <3
