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@@ -322,7 +322,7 @@ Standard Adult Female Range: 0.8-3.1 nmol/L<br>
<h5 id="female-reference-ranges">Female Reference Ranges</h5>
<p>As a final consideration, it&rsquo;s worth looking at female reference ranges. A Google search will turn up many slightly varying results, but we&rsquo;d recommend <a href="https://www.hse.ie/eng/services/list/3/acutehospitals/hospitals/waterford/laboratoryservices/complex-reference-ranges.html">these values from the Irish Health Service Executive</a> as representative and reputable.</p>
<h5 id="our-recommendation">Our Recommendation</h5>
<p>Coming full circle we&rsquo;re happy to endorse the WPATH guidelines of 100-200 pg/mL (367-734 pmol/L) for Estradiol and &lt;50 ng/dL (1.73 nmol/L). They&rsquo;re known safe values in regards to broader health concerns, they clearly work given they&rsquo;re what we see in cis women, and after seeing hundreds of blood tests and helping many trans people over the years, it&rsquo;s clear to us that the overwhelming majority are happy with what they get from these levels in the long run. We would however add one caveat:</p>
<p>Coming full circle we&rsquo;re happy to endorse the WPATH guidelines of 100-200 pg/mL (367-734 pmol/L) for Estradiol and &lt;50 ng/dL (1.73 nmol/L) for Testosterone. They&rsquo;re known safe values in regards to broader health concerns, they clearly work given they&rsquo;re what we see in cis women, and after seeing hundreds of blood tests and helping many trans people over the years, it&rsquo;s clear to us that the overwhelming majority are happy with what they get from these levels in the long run. We would however add one caveat:</p>
<p>You should aim for the upper end of this range and not be scared to exceed it at peak. In patients using transdermal patches where the level is essentially a flat line, it&rsquo;s common to observe complaints of lethargy and low libido if the patient is sitting at the lower end of this spectrum, and then find those complaints are resolved when they titrate up to a higher dose. Rather than considering anywhere in that window the goal, treat it like an archery target where 200 pg/mL is the yellow center and 100 pg/mL is the edge of the target. If you hit the target it&rsquo;s a good enough shot, but you&rsquo;re always aiming for the center.</p>
<h2 id="antiandrogens">Anti-androgens (AAs)</h2>
<p>Most HRT regimens begin with the use of an antiandrogen (often known as a &ldquo;blocker&rdquo;) to suppress Androgens directly. It should be noted Estradiol alone functions as an AA by stimulating the Hypothalamus and slowing down the HPG axis. The amount required to achieve this varies wildly from person to person but it&rsquo;s important to note that if Estradiol alone achieves this, an AA is usually unnecessary.</p>
@@ -336,7 +336,7 @@ Standard Adult Female Range: 0.8-3.1 nmol/L<br>
<p>CPA is a widely used and extremely cheap synthetic progestin used exclusively for its potent effects as an AA, first introduced in 1973. It has been widely used in AFAB birth control pills, used successfully to treat a variety of conditions relating to excessive androgen levels in both AMAB and AFAB individuals, and in Androgen Deprivation Therapy (ADT) to treat Prostate Cancer.</p>
<p>As an AA, CPA functions by having a strong effect on the Hypothalamus, significantly reducing GnRH production and effectively shutting down the HPG axis.</p>
<p>In Feminising HRT CPA is widely used in Europe, Australia and Latin America, typically at doses of 12.5-25mg/day.</p>
<p>Though well tolerated, the primary side effects of CPA are mild depression, vitamin B12 deficiency, hepatotoxicity, increased prolactin levels and on rare occasions (less than 1 in 10,000) benign brain tumours. It is also worth noting that these side effects are mostly commonly found when used in ADT at significantly higher doses than the 12.5-25mg/day most commonly used in HRT.</p>
<p>Though well tolerated, the primary side effects of CPA are mild depression, vitamin B12 deficiency, hepatotoxicity, increased prolactin levels and on rare occasions benign brain tumours. It is also worth noting that these side effects are mostly commonly found when used in ADT at significantly higher doses than the 12.5-25mg/day most commonly used in HRT.</p>
<p>CPA is generally considered to be a safe and effective AA as part of an HRT regimen. When available it is generally considered a preferable alternative to Spironolactone due to its milder side effect profile.</p>
<h4 id="bicalutamide">Bicalutamide</h4>
<p>Bicalutamide is a Nonsteroidal antiandrogen (NSAA) first introduced in 1995. It is a derivative of Flutamide and appears on the World Health Organisation&rsquo;s list of Essential Medicines, the safest and most effective medicines needed in a health system. It is most widely used as monotherapy ADT to treat Prostate Cancer.</p>
@@ -390,5 +390,5 @@ DIYHRT.Market 2022-2023
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