Hormone Availability

[Guest Katharsys]

(Spurred by Bettypooh's issues with Inhouse)

When I was laying out the groundwork to restart hormone therapy, I of course looked at possibly going through Inhouse Pharmacy. Getting the hormones I need for my transition, without going through either the hoops, or the expense, of the doctor was a tempting option - especially since HRT and anything TG is specifically excluded from my health insurance. Then I did the math. On average, my hormone therapy from Inhouse would run me approximately $130+ a month, and I realized that there has to be a better option. That got me wondering if it would be worth it to offset the expense of the non-script hormones by going through the traditional medical system and WPATH recommendations. What I found surprised me.

All of this information is based on the usual dosages for MtF hormone regimen as reported in The Journal of Clinical Endocrinology & Metabolism:

Ethinyl estradiol 100 μg/d or conjugated equine estrogen 2.5 mg/d.

Transdermal once >40 yr old. Adjust to suppress total testosterone to <25 ng/dl. If estrogen doses reach twice above recommendations, add spironolactone, cyproterone acetate, or GnRH agonists to minimize estrogen requirement.

Eva Moore, Amy Wisniewski and Adrian Dobs

Departments of Medicine and Pediatrics, The Johns Hopkins School of Medicine, Baltimore, Maryland

It was then that I started looking at prices that are available on the web - and that is when I ran across the Walmart reduced cost prescription plans (PDF). On that list is the following:

30 Day Supply:

(On the $4 list)

Estradiol 0.5mg tab

(Ed: This dosage is equivalent to 500 μg Ethinyl estradiol, so the dosage will need to be split - thus making a 30 day dose really a 60 day amount.)

Spironolactone 25mg tab

(Ed: This dosage will need to be multiplied by 4, as the recommended dosage is 100 mg/d - $16 monthly)

(On the $9 list)

Finasteride 5mg

(ED: A

nti-androgen

in place of the GnRH agonists)

OPTIONAL Progestrone:

($4)

Medroxyprogesterone Acetate 5mg tab

Total Monthly Cost: $33 USD

A similar regimine from Inhouse for the month would cost you approximately $139 - a difference of $106 a month. Let's put this savings into the context of paying out of your own pocket to get a doctors script for this treatment.

As most people who know me know, I live at the confluence of the Mississippi and Ohio rivers area - essentially where Southern Illinois, Missouri and Kentucky kiss each other - so it is not necessarily the most "liberal" or have the most open mindset. Resources available at low or no-cost for TG individuals are unknown in this area. That said, I will give my current out-of-pocket examples.

My therapist is a little pricier than the norm - but that is because they use the funds to subsidize for people who don't have insurance to allow for a sliding scale. But worst case scenerio here is paying full face value of $90 a session. I am having to go for a total of 5 sessions to get my letter, making a grand total of $450. Some therapists may require less sessions - ask your local TG support groups for resource recommendations. On a side note, if you are already taking "black-market" hormones for treatment, your therapist might be willing to write you a letter in as little as two sessions since you are already demonstrating one of the key prongs to WPATH standards.

I will have to go to at least two sessions with the physician at approximately $140 per visit, plus lab fees of $200. This brings the running total up to $930. Once again through your local TG support groups, you may be able to find a doctor or clinic that works on a sliding scale to provide lower costs that what I have quoted.

While this may sound outrageous, a total initial outlay of $930, you have to look at the fact that this amount will be recouped within the first year of hormone treatment in the savings from the Walmart listing! In addition, you now no longer have to worry about import regulations. Yes, despite what they say on the website - it is illegal to import prescription drugs into the US. "Whether for personal use or not, importing prescription medication into the United States is technically illegal."- US FDA. Additionally, you need to remember that HRT dosing is a dangerous business. Estrogen has been linked almost conclusively with increased risks of Strokes, Pulmonary Embolisms and Heart Attack arising from an increased risk of DVT. Being under a doctor's care during HRT can help to reduce these risks. The doctor will be able to determine from lab testing what the best dosage is to achieve the best results with minimum risk.

While I know that for many TGs, the desire to just get started makes the use of internet pharmacies an attractive option - as you don't have the daunting up-front cost of getting going. But in the long run you end up paying more, and by the end of the first year, you will have paid out $300 more than you would have otherwise - and $1500 by the end of the second year, $2,700 by year three, etc. Think about what you could have bought with that additional $300! Something else to consider here - many therapists and clinics will allow you to make payments. Usually, they will want you paid in full in 180 days - but that breaks down to $155 a month for 6 months. Just a little more than what you are paying now...

Just food for thought.

*Edited to correct a some numbers there - my initial estimate of cost for me included estrogen gel, pushing the monthly cost over $200.

[WallaWalla]

100mg of spiro is low, and 500ug of estrogen is ultra low.

When I was still in full swing of HRT I took 4mg of estradiol + 150mg of spironolactone a day. It cost 10.99 a month for estrogen and something like 25 dollars for the spiro, don't recall exactly. Got it from Walgreen's, the prices were quite suitable if you pay the like $20 a year to join the prescription plan.

I advise pretty much everybody to start ordering off the internet THEN see a therapist, especially if you have tried to see a therapist and they dicked around about it. If I hadn't of taken things into my own hands I probably wouldn't have started until several years later, christ knows how badly that would have fucked up my life, probably wouldn't pass seemlessly if I hadn't taken some personal initiative.

[Guest Katharsys]

The old dosage regimens required higher levels of estrogen intake, which is what it sounds like you were following Walla. However, the estrogen levels can be much lower when using dual anti-androgen medications or a GnRH angonist. I will grant that some people will need higher or lower dosages - which would affect the pricing scheme somewhat. The doses I quoted are the average listed in the linked professional endocrinology journal article - and if they don't understand how hormones affect the body, well then they are in the wrong line of work.

While I won't challenge anyone choice to "self-medicate" when starting transition, I will argue the fact that a doctor will be able to understand the interactions of the medication better than any lay person will. The idea is to maximize the effects of the hormones while minimizing the dosage to avoid harmful effects to the body. While self-dosing may help overcoming bias in terms of getting a letter, research in finding a TG friendly therapist works equally as well.

On a slightly different rant - the latest trend is the idea of "informed consent" in allowing the hormones to be prescribed. While that is fine and helps those who are wanting to transition, you run the risk of coming across people who have too much money and no clue. Therapy is a must, at least to have one person to actually poke your brain. We have a few people on here, well at least one that I know of, who probably should never have transitioned and therapy - good therapy - could have caught that.

*edited for slight grammatical corrections and clarity

[Guest Katharsys]

my estimate with inhouse runs me at $45~ per month which, assuming you hold ANY type of job, is plenty cheap. We may be on different HRT plans though. I have a basic spiro + oral estro plan.

spiro: $109 for enough to last me 5 monthes

estro: $120 for enough to last me 5 monthes

-$5 loyalty discount

224/5 = 44.8 per month.

45 x 12 = 540 (my first years worth of hormones, this i can afford)

33 x 12 = 396 + 930 = 1326 (this i cant afford)

sure the cost becomes less over time, and i plan to eventually see psychiatrists, but it will have to wait until i can afford it, and until such a time that i can, i plan to continue doing what i can to fix my body. I have multiple people fairly knowledgeable in the field assisting me, im not doing this blind. But i refuse to let more "boy" infect my body, just because of somebody elses regulations.

See, you are judging two separate regimens here - four drugs against your two. If you were to do just the Spiro and Estrogen from Walmart, your cost would be only $20 a month - half of what you are paying now. With that, let's see the cost:

$20 x 12 = $240 - that is a savings once again of $300 annually. Essentially, that makes the doctor visits a one time cost of $630 out of pocket over what you would have spent. But don't just look at the first year - you will have to be taking hormones for the rest of your life, whether you go for the surgery or not - and this is an annualized savings. By the end of your 5th year, you will have saved a total of (not counting the first year, since we are using that to offset the doctor costs) a total of $1,200. And just remember, the $930 is a worst-case scenario - you may end up doing much better than that if you can get access to a clinic with a sliding scale or able to defer the costs if they allow you to make payments. In the end though, it isn't about the costs, it is about your health.

I will grant that a cursory breakdown just now on Spiro comparing Walmart v. Inhouse - Inhouse comes on top by about $.70 per month - negligible difference. Estrogens however, Walmart has them beat by between $12 and $18 depending on which estradol you use. However, note that with the two medicine dosing, you will have to take a higher dose of estrogen to get the effects you are looking for - this will also raise your costs and risks. It doesn't take much estrogen if you can properly suppress the T levels in the body.

[WallaWalla]

Finasteride only blocks the conversion of testosterone to dihydrotestosterone.It's worthless for anything other than preventing hair loss or coarse hair growth, and even then it might hurt more than it helps. It doesn't reduce overall serum testosterone levels As a matter of fact, finasteride can INCREASE serum testosterone levels in those who have low testosterone counts: http://cat.inist.fr/?aModele=afficheN&cpsidt=15249285. GnRH agonists are prohibitively expensive. I mean give me a break, it's like 500 dollars after insurance for a shot of lupron.

Even now, I still take 1mg of estrogen a day. This is a standard dosage for hormone replacement therapy in post-menopausal women.

What do you speak of when you refer to 'dual anti-androgen medications?' The only drug approved for that use in the United States is spironolactone.

As for the whole 'informed consent' thing, people are going to tell the shrink what they think they shrink wants to hear. I don't believe that it's possible to stop somebody from doing it if they really want to, therapy or not. I've also commented a number of times that I do not feel that any reason is more legitimate than any other reason. I know a number of people that many would refer to as autogynephiliacs who have been successfully transitioned for years.

While that is fine and helps those who are wanting to transition, you run the risk of coming across people who have too much money and no clue.

Why would we be more likely to run across these people if we self administer?

Doses I quoted are the average listed in the linked professional endocrinology journal article - and if they don't understand how hormones affect the body, well then they are in the wrong line of work.

I like how catty that response was. Or should I say Katty? nyuk nyuk nyuk

I think I figured your numbers so low because I take 17β sublingually, not ethinyl orally. The journal you reference also makes no mention of finasteride, so I am unsure as to why you would recommend it wholesale.

[Saschadzg]

Hi,

I get i.m. injection of estrogene (estradiol valerate) In the US Delestrogen is available. It has the most feminizing effect. I got Neofollin from Slovakia while on vacation in the Czech Republic. Before, I got Estradiol Depot Jenapharm, combined with Progesteron Depot Jenapharm (hydroxyprogesterone caproate). Jenapharm is a German company of the Bayer concern located in Jena, Thüringen, Germany, th former largest doping producer of the Eastern Block.

Oral estrogen endangers your liver when taken for a prolonged time. On ther long run, transdermal and injections are healthier. Ethinyl estradiol beyond the age of 30 increases risk of stroke and heart attack. After SRS doses may be reduced significantly.

Kvetinka

[Bettypooh]

....I will argue the fact that a doctor will be able to understand the interactions of the medication better than any lay person will....

On this point I must disagree I have found that most Doctors who do not 'specialize'

in TG work usually know less about TG hormones than the person they're treating Not their fault, really, since no Med schools cover it well and save for the 'specialist' they may treat less than a half dozen TG people in their entire career with only a few needing HRT which necessarily limits their experience, and unfortunately their knowledge Even in general terms too many think that Doctors know this kind of thing when many don't I have two friends who suffered permanent disabling results from well-known prescribed drug interaction problems so my advice is to always do your own research and to reach out past your 'circle of friends' and those user-compiled TG websites that think they know best when they may actually be no better Look for Medical info that is verifiable and when possible peer-reviewed and accepted. And if need be, educate your Doctor. Give them a list of those real Medical websites and other Doctors that have accurate info so they can treat you and everyone else better If their real motivation is to help people they will be glad you helped them- if not you need another Doctor!

Bettypooh

[Bettypooh]

,,,,people are going to tell the shrink what they think they shrink wants to hear. I don't believe that it's possible to stop somebody from doing it if they really want to, therapy or not....

This is soooooo true There are even people who will coach you through the answers you need to give to jump through the required hoops so that you can get your diagnosis letter You think they are your friends, but are they really? Which is better for you, getting what you want or getting what you need? Shortcutting the process can be shortcutting yourself. This is serious life-or-death business so approach it accordingly If you are self-medding don't get anywhere near the maximum dosages because every body is different and one wrong choice on your part can become fatal, no matter how well intended the info you went by was Play it safe so we can see you here again

Bettypooh

[Khoraz]

I understand your logic completely. I saw a therapist for years and always just told him what he wanted to hear for a while. While it wasn't for the reason this topic is based off of, correct results are much more valuable than the results a person wants. Better off just being yourself to a therapist rather than staging the whole session to get what you want. It will just bite your ass in the end!

[Saschadzg]

This is soooooo true There are even people who will coach you through the answers you need to give to jump through the required hoops so that you can get your diagnosis letter You think they are your friends, but are they really? Which is better for you, getting what you want or getting what you need?

The final decision is with the individual patient. You cannot transfer it to any doctor.

[Guest Katharsys]

So I thought I would finally come back and revisit this thread before letting it die fully.

I finally have my script, and just walked out of wally-world with medication in hand:

• Estridol - 1 mg QD, 30 Days: $4
• Medroxyprogesterone - 5 mg QD, 30 days: $4
• Sipronolactone - 100 mg B.I.D., 30 days: $26.86
• Finasteride - 5 mg QD, 30 days $9

Total cost for the full run is $43.68 for the month.

One other point I think I should clear up here, and that is the issue of finasteride.

Finasteride only blocks the conversion of testosterone to dihydrotestosterone.It's worthless for anything other than preventing hair loss or coarse hair growth, and even then it might hurt more than it helps. It doesn't reduce overall serum testosterone levels As a matter of fact, finasteride can INCREASE serum testosterone levels in those who have low testosterone counts: http://cat.inist.fr/...psidt=15249285. ....

What do you speak of when you refer to 'dual anti-androgen medications?' The only drug approved for that use in the United States is spironolactone.

Finasteride is a synthetic anti-androgen. Unlike spironolactone, where the anti-androngenic effects are a side-effect, finasteride is specifically an anti-androgen that was created to help with benign prostatic hyperplasia. It works by blocking the 5-alpha reductase enzyme, that yes, converts testosterone into DHT which is the more potent form of testosterone. DHT has three times greater affinity for androgen receptors than testosterone and has 15-30 times greater affinity than adrenal androgens - it fits the androgen receptors more easily and more fully than plain old T. DHT is also the primary driving force in the development of the primary sexual characteristics while still a fetus. The other bad part of DHT is that unlike plain testosterone, it cannot be converted over by the body into estrogen.

Sprionolactone on the other hand is a diuretic that was discovered to have anti-androgen properties in that it directly inhibits testosterone secretion and by its inhibiting androgen binding to the androgen receptor. However, even as it works to block the androgen receptors, is doesn't prevent the formation of DHT. That is why the two combined will produce a better result.

While you are right that taking finasteride can cause a boost in the initial free serum T levels, this is excess testosterone that can be converted by the body to estrogen. Add to this spironolactone is working to prevent the T from binding to the receptors and suddenly all the testosterone in the system is bio-available for conversion to estrogen - at least until the pituitary gland figures out there is too much and shuts down production in the testes.

While the document I cited does not specifically mention finasteride, I can provide other studies that do. As there is a chance that finasteride can cause some issues with people who have latent liver abnormalities, it should be used only after a liver enzyme panel has been done. However, since many of the online resources out there, such as TransGenderCare (which used to have feeder links into IHP), specifically mentions finasteride as part of their suggested program, I figured I would include it.

Alrighty then, I am done. Cya all!

[Saschadzg]

Hi,

in Europe and Germany we have cyproterone acetate as anti-androgene, brand name Androcur by BAYER.

Kvetinka

[Guest Katharsys]

Hi,

in Europe and Germany we have cyproterone acetate as anti-androgene, brand name Androcur by BAYER.

Kvetinka

Heh, in many ways I am envious of that. Cypertone Acetate is an excellent anti-androgen and even has a minor progesterone effect. By itself, it kicks the butt of both spironolactone and finasteride combined in terms of how well it works.

Sadly we can't get that here (legally) since the FDA refuses to clear it due to safety issues. **sigh** But one can hope.

[Guest munchkitten]

Kat, if you get Sprio in the 25mg pills, it's 13.34 here with tax for my 100mg. plus 10 for the estradol ( 6mg)

and howard brown FTMFW.

[Guest Katharsys]

Kat, if you get Sprio in the 25mg pills, it's 13.34 here with tax for my 100mg. plus 10 for the estradol ( 6mg)

and howard brown FTMFW.

Heh munchy, yeah it is the same here. My $26 is is for a 200 mg dosing (100 mg x twice daily) so it is double the 100 mg price

I am only on 1 mg of E currently, so that is running me $4.

[Guest munchkitten]

Why is your sprio dose so high? and damn your Estrogen dose is puny LOL.

[Guest Katharsys]

Why is your sprio dose so high? and damn your Estrogen dose is puny LOL.

Doc just decided to up it to 200 mg just because it won't hurt - besides, he is also using it to help control my high BP. My free and total T levels were low to begin with - free was something like 300 ng/dl, can't remember the total number - which is low/normal for genetic XY. I am not sure where the level is currently, but I know he is going to do a level check at this next appointment.

As for the E dosage, I was already having conversion reactions for the month I was on just the spiro (that evil ache that means something is happening). I am now just shy of a month on full HRT and already getting the development of the tissue in the breast area. So while I am thinking of asking the doc to up it on the next appointment, the 1mg dose is working just fine for me. It is more that I am having a case of the HRT impatience - yeah, I know it won't make it go any faster if I were to get it upped