🩸 HRT Lab Timing & Optimal Levels

💡 Pro tips:
• Draw both steady-state (4-6wk) AND trough (10-14wk) on first cycle to establish patient's metabolism pattern
• Fast metabolizers may need 10-20% higher doses or shorter cycles
• If patient crashes at week 8 but trough labs look okay — consider splitting into two smaller insertions
• E2 peaks are expected; only concerning if sustained or symptomatic beyond week 4

💡 Pro tips:
• If patient has big mood/energy swings between injections → trough is too low → increase dose or switch to more frequent (e.g., weekly → 2x/week)
• For T cypionate: half-life ~8 days; for enanthate ~4.5 days
• Always draw AM (before 10am) for T — diurnal variation can shift results 20-30%
• Monitor hematocrit every 6-12 months on T injections

💡 Pro tips:
• NEVER draw from the arm the cream was applied to — contamination gives falsely elevated results (sometimes 10x+)
• Wash hands thoroughly after application
• Absorption varies hugely by site, skin thickness, and individual
• If levels seem disproportionately high vs symptoms → suspect contamination, redraw from opposite arm
• Scrotal/labial application absorbs 5-8x more than other sites

💡 Pro tips:
• Patches give the most stable levels of any delivery method — less peak/trough variation
• If trough is low, try: step up patch strength, add a second patch, or switch to twice-weekly if on weekly
• Patch adhesion matters — if it's peeling, levels will drop. Tegaderm overlay helps
• Lower VTE risk than oral estrogen (avoids first-pass liver metabolism)

💡 Pro tips:
• Oral estrogen ↑ SHBG, ↑ clotting factors, ↑ triglycerides — check lipids + SHBG periodically
• Higher VTE risk than transdermal routes
• Sublingual use (dissolve under tongue) bypasses first-pass → better E2:E1 ratio but shorter duration
• If switching from oral to transdermal: levels may look "lower" because less E1 inflation — go by symptoms

💡 Pro tips:
• Better E2:E1 ratio than oral — bypasses first-pass liver metabolism, so less estrone (E1) production
• Shorter duration than oral → often requires BID or TID dosing
• Peaks are HIGH but brief — don't panic at a peak-level draw; trough is what matters for dosing
• Lower impact on clotting factors, SHBG, and triglycerides vs oral (partial first-pass avoidance)
• Patients must let tablet fully dissolve (5-10 min) — no eating, drinking, or swallowing saliva during
• If patient swallows too quickly → essentially becomes oral with worse absorption

💡 Pro tips:
• Troches have dual absorption: ~50% buccal (like sublingual, bypasses liver) + ~50% swallowed (first-pass, more E1)
• E2:E1 ratio is between oral and sublingual — better than oral but not as clean as pure sublingual
• Flavored base can affect absorption — fat-soluble bases (cocoa butter, PEG) absorb differently than polyglycol
• Hold in cheek for full dissolve time (15-30 min) — don't chew or swallow early
• Compounding pharmacy quality matters — absorption can vary significantly between pharmacies
• If levels seem inconsistent → check patient technique first before adjusting dose
• Common in compounding because pharmacies can combine E2 + T + sometimes progesterone in one troche
• If switching from troche to sublingual tablet: may need lower dose (sublingual absorbs more efficiently)