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how to cope mentally during gaps in HRT (lemmy.blahaj.zone)
submitted 8 months ago by dandelion@lemmy.blahaj.zone to c/mtf@lemmy.blahaj.zone
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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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[–] xilliah 5 points 8 months ago* (last edited 8 months ago) (1 children)

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.

[–] dandelion@lemmy.blahaj.zone 5 points 8 months ago (1 children)

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.

[–] xilliah 3 points 8 months ago* (last edited 8 months ago) (1 children)

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.

[–] dandelion@lemmy.blahaj.zone 1 points 8 months ago (1 children)

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

[–] xilliah 4 points 8 months ago (1 children)

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.

[–] dandelion@lemmy.blahaj.zone 3 points 8 months ago (1 children)

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

[–] xilliah 2 points 8 months ago (1 children)

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.

[–] dandelion@lemmy.blahaj.zone 2 points 8 months ago* (last edited 8 months ago) (1 children)

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.

[–] xilliah 3 points 8 months ago* (last edited 8 months ago) (1 children)

Well I can tell you that in the NL the official route is way more expensive, less predictable, slower, harder, dehumanizing and traumatizing. Even when it drove me to the point of suicide, they wouldn't let me stay in the hospital. I'd recommend against going this route to anybody.

DIY is the status quo, simple, convenient, respectful, cheap, and you get a whole year's worth. The only thing that really costs anything is the bloodwork. Learning how to be responsible with it costs less time and energy than all the paperwork.

For the official route, if I add up all costs, I am currently at well over 1500 usd, and I haven't seen a single blood test or pill yet.

Thanks for the book, but right now I just need to get my medication in order.

[–] dandelion@lemmy.blahaj.zone 2 points 7 months ago* (last edited 7 months ago) (1 children)

sorry, I think I might have gotten confused and forgot you were in NL, not in the UK 🤦‍♀️ oof

I hope you are able to get the medication you need, I'm sorry the system sucks so badly. :-(

[–] xilliah 2 points 7 months ago (1 children)

Thanks for your words! Actually yesterday I finally got some and today is my first day without full blown dissociation. And it's trans visibility day :)

I'll keep tinkering with the gendergp and Dutch pathways though.

[–] dandelion@lemmy.blahaj.zone 2 points 7 months ago (1 children)

woohoo! That's great news! Are you doing injections, and what dose did you decide to start with?

This is so exciting! 👏👏👏

[–] xilliah 2 points 7 months ago* (last edited 7 months ago) (1 children)

Yes and I still have to look that up. Posted an update.

[–] dandelion@lemmy.blahaj.zone 2 points 7 months ago

nice, I checked your update and posted there - thanks!

[–] Lumelore@lemmy.blahaj.zone 5 points 8 months ago* (last edited 8 months ago) (1 children)

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.

[–] dandelion@lemmy.blahaj.zone 2 points 8 months ago

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!

[–] IcedCoffeeBitch 2 points 8 months ago (1 children)

If it helps, it's unlikely you hit a vein with SubQ injections, especially if you did it at 45 degree and especially if your needle is short enough and you aren't hitting the muscle. So it's a bigger chance you didn't, and your E is fine, even if you got hurt. If you are with a doctor (or if you are on DIY then the doctor is yourself), talk with them about injecting more often (and maybe a higher dosage) just in case. For some people the ups and downs can cause mood swings and stuff. It's also important to know mood swings are not reliable as estrogen indicators, since they are influenced by many factors. A better though not completely reliable option is (cw sex and AMAB genital mention)

spoilercheck on the semen on your masturbation, and compare a few days after the injection visually to what you produce the day of the injection. It should remain consistent, most but not all people on good E levels produce a kinda transparent, white-ish watery fluid.
Obviously though, the best way is blood test. But not everyone has that option sadly.

[–] dandelion@lemmy.blahaj.zone 2 points 8 months ago (1 children)

I used a 1/2" needle at 90 degrees into my thigh. I think my thigh has been maybe losing fat? I injected for a couple months without much issue in my thighs, suddenly I've hit some kind of blood supply twice now in the past week or two, this time it bled significantly more and more forcefully, enough that I had to use my hands to prevent the blood from getting on everything, the blood covered my hands and I had to use a rag to clean it all up (the other time there was more like a few drips of blood, but not as forceful or copious).

I inject 5 mg EV every 4 days currently. I consider this dose / frequency enough normally, I've had a couple weeks of it working well for me. I do see an endo, but he is giving me a lot of autonomy to control my dose. I have had blood work twice, once before HRT and once after 2 months or so (before I started this new dose regimen).

Thanks for the semen tip, that is helpful. I have noticed much less semen, even no semen sometimes (esp. before this semi-failed injection). My bad mood seemed to correlate with semen coming back. There are other physiological signs along with the mental symptoms, like erections when I wake up in the morning, or body odor changes (my armpits smell spicier / worse).

It does seem like the depression is correlated with too little estrogen, but I haven't had an issue until this recent injection where the E didn't depot properly (maybe some of it ended up in the blood supply, maybe some of it ended up not in the muscle or fat, but in the skin layer, I don't know why it changed anything, I don't see any explanation as to why it would mess up the depot effect).

[–] IcedCoffeeBitch 2 points 8 months ago (1 children)

It’s worth noting that quantity of semen can vary throughout your progress in HRT. In my case I produced little to almost none around the first 4 months but now (6 months) my semen is in much more quantity but more diluted. That seems pretty normal according to what other trans people go through, in fact you might eventually notice more pre-cum. Some say it could be related to cis women’s lubrication and your body trying to replicate that.

I would incline to say, based on what you say, maybe you are experiencing too little estrogen, but hopefully you are aware that self diagnosing has the problem of confirmation bias and placebo, which is the reason I don’t put them that much weight into them.

My advice is three things: first, next time you inject make sure you have at least one or two inches of fat between your fingers, if you don’t use another area like your tummy. Probably use 45 degrees especially if you’re on the skinny side; besides, imho I don’t get why people that want SubQ inject in 90 degrees anyways, afaik there are no advantages to it and only risks hitting muscle instead, and IM can hit a blood vessel. Second, if you haven’t had issues before this incident then perhaps you have nothing to worry about but make sure to keep in mind your blood test. Third, if it’s an option for you perhaps consider getting estradiol cypionate, or even better enanthate? Those have a longer half life than valerate so they might make your levels more consistent and you could inject less often (people on cypionate commonly inject weekly, and on enanthate every 10 days or even every two weeks).

[–] dandelion@lemmy.blahaj.zone 2 points 8 months ago (1 children)

That makes sense, I have definitely seen an increase in pre-cum. It's surprising how natural all of this feels. It's a huge change, and I was worried when I started HRT how I would feel about all of this.

Thanks for evaluating my account, it does seem like too little estrogen if I had to guess, but I do hate the ambiguity (esp. when I'm in the midst of the dysphoria, when I become paranoid and increasingly susceptible to my internalized transphobia).

I think the advice about injecting at 45 degrees is helpful, I have been injecting at 90 degrees because my endo had a patient who injected too shallowly and now he drives home in his patients that you have to inject subq "deeply".

I wouldn't consider myself on the skinny side, but I admit I have a large build and I might have less fat in some places than I tend to think. It might be that I'm losing some fat around the thigh areas where I reliably had fattier deposits before.

Either way, the advice to inject in the tummy is exactly the conclusion I came to and that's where I injected last time. I have moderate to severe needle phobia and injecting into my thighs was much easier when I first started off, and injecting into the tummy was mentally fraught. Now it seems like it's more difficult but much more doable, I have learned to cope better with injections.

I would love to be taking a different ester like cypionate and esp. enanthate. I talked to my endo about it and he just shrugged and said that's a question for a pharmacist. He doesn't know any that offer other esters and I would have to find someone that would compound it for me. I'm based in the U.S., and I have one trans-fem friend who compounds their own estradiol enanthate. They bought some powder online and they mix it with oil and some preservative to make vials. I think the supplier is China, purchased on sketch websites. All based on Lena's guide.

It's sketch, but I would still consider doing it, esp. to guarantee long-term HRT supply, but with the current supply of EV from official sources I haven't been particularly motivated to take those risks and do all that research to double-check everything myself.

Do you have any advice on finding alternate esters?

[–] IcedCoffeeBitch 3 points 8 months ago (1 children)

Yeah if your insurance covers HRT then it might be for the best to stick with valerate until you find a pharmacy. Sadly I don’t have any tips for getting it officially. I do DIY so I buy EEn from Otokonoko. If you are here then I assume you would avoid using Reddit lol, but you might have a better chance if you ask in one of their subreddits.

Honestly I’ve never injected in thighs and find the tummy more reassuring lol, to me I barely feel it there. Ig people sometimes are built different ig

Regardless, glad I could help :3

[–] dandelion@lemmy.blahaj.zone 2 points 8 months ago

Thanks, good to know re Otokonoko, I think I had heard of that before. I see in the /r/TransDIY that they link to https://hrtcafe.net/, I had looked into DIY originally but was spooked about potential risks. If you don't mind me asking, what dose do you take of EEn and how frequently (and how do you inject, and where)? Looking at the injection simulator, and here's a screenshot of what I'm looking at, 15 mg EEn every 14 days gives a similar-ish pattern to my dose of 5 mg EV every 4 days. That dose of EEn seems to peak a bit higher and the trough is a bit lower than EV every 4 days, but a dose of 7 mg EEn every 7 days seems more stable overall.

I can't tell exactly, but I suspect because I'm only 3 months into HRT that the spikiness of EV is actually helping suppress the T more effectively than if I had a more stable and lower dose (for example, I noticed injecting between 3 and 4 mg EV every 3 days was not working well to stabilize my mood and effectively suppress T; it suppressed it to some extent, but not enough it seemed; only with 5 mg did it seem like I was having real relief, and at that point the question was how long that relief lasted before I needed another 5 mg injection).

I do think injecting into my belly has become easier, so I'm not too worried about it now (I've injected into my belly maybe the last three injections now); maybe it was just not the best place for me to start off injecting into (since I have such bad needle phobia).

Thanks for everything! <3