A common question which many trans women ask, is what their estrogen levels should ideally be. They have often asked for a higher dose from their prescribing doctor, and been told no, there are too many risks, and that their current level is within the normal ranges. The maximum pmol/L cited by doctors is often 200 or 250. However, this is against best practise.
The National Guidelines for Gender Affirming Healthcare (2019) recommends a pmol/L level of up to 500, but also emphasise that dosage decisions should be led by the patient.
The Endocrine Society Clinical Practice Guideline (2017) recommends 100 to 200 pg/mL – which translates as 367.09 pmol/L to 734.19 pmol/L.
Informed Consent
If an adult is on a dose resulting in a lower pmol/L than the above, they should be given a higher dose if desired, unless there are sound medical reasons to keep their dose lower.
A sound medical reason may include hormone sensitive cancers or other medical conditions that are not well controlled. If liver and kidney concerns are the reason, these can be minimised by switching from oral estrogen to patches, gel, or cream, as these bypass the liver and kidneys. It is also possible for your prescribing doctor to advocate for estrogen implants (such as those available in Australia) to be made available in NZ through Pharmac.
If a patient is being told no repeatedly without what they consider to be a legitimate medical reason, they have the right ask in writing:
“I am not seeing results and would like to increase my estrogen dose. Please tell me if this is possible, and if not; what is the medical reason?”
They may also wish to add that the national guidelines recommend up to 500 pmol/L, and the endocrinology society guidelines recommend between 367.09 and 734.19 pmol/L.
If there are sound medical reasons for keeping the patients dose lower, the clinician then has the opportunity to write these down in a way that the patient can understand. It also gives them the opportunity to make sure they understand the risks and best practise, before writing it down, to ensure they won’t be found to be wrong later.
GMA would like to acknowledge the enormous amount of work being done by trans people, advocates, and healthcare workers to bring gender affirming healthcare in Aotearoa up to standard. We also wish to acknowledge that there is still bias, negligence, and malpractice from some healthcare providers, and that this can have a devastating impact on their patients’ lives.
If you are a trans person struggling to navigate the healthcare system, please get in touch with us as we may be able to assist you in finding out what your options are.
Sources
- National Guidelines for Gender Affirming Healthcare (2019)., Jeannie Oliphant, Jaimie Veale, Joe Macdonald, Richard Carroll, Rachel Johnson, Mo Harte, Cathy Stephenson, Jemima Bullock, David Cole, Patrick Manning. https://www.nzma.org.nz/journal-articles/guidelines-for-gender-affirming-healthcare-for-gender-diverse-and-transgender-children-young-people-and-adults-in-aotearoa-new-zealand
- Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline (2017)., Wylie C Hembree, Peggy T Cohen-Kettenis, Louis Gooren, Sabine E Hannema,Walter J Meyer, M Hassan Murad, Stephen M Rosenthal, Joshua D Safer,Vin Tangpricha, Guy G T’Sjoen. https://academic.oup.com/jcem/article/102/11/3869/4157558
- pg/mL to pmol/L converter http://www.endmemo.com/medical/unitconvert/Estradiol.php
