pasta time

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That pink line on the left graph is estradiol, also called E2. That tiny little bump from 30 pg/ml to ~45 pg/ml is the main reason I'm killing doctors.

The purple line is estrone, or E1. During first-pass metabolism, which happens when you take something orally, the liver turns E2 into E1. Roughly NINETY-FIVE PERCENT of oral estrogen gets turned into E1 during first-pass metabolism. Increased E1 levels are most of why estrogen carries an increased risk of blood clots. Injectable estrogen still carries this warning but, according to everything I've read and my endocrinologist, that's just because they err on the side of caution. That giant fucking purple mountain is the second reason I'm killing doctors.

(Estrone/E1 is not inherently evil. The research is, as always, fucking abysmal, but it's thought to be important for breast development. It's not important enough that you need 95% of your E2 converted to E1.)

Taking it sublingually (under the tongue) or buccally (tucked into your cheek) avoids first-pass metabolism by introducing it into your bloodstream directly. Patches, gel, and injections do the same, just much more effectively, both because you're not inevitably swallowing some of the dose and because they're designed for direct absorption.

Reader, I beg of you: Do not accept the 1mg dose. Your doctor is slow-walking you in the hopes that you're Not Actually Trans.

(I am not a doctor or medical professional, skate at your own risk)

So, let's talk about sublingual estrogen and how it's different than just swallowing it (and different from injections). Before that, though, always remember: More estrogen does not mean better transition. It's more complicated than that.

This is a graph of hormone levels for someone taking 2mg of estradiol valerate 3-4x/day.

That's pretty high! Given that, on average, 200 pg/ml is enough to achieve 90% suppression of testosterone and 500 pg/ml suppresses 95%, many people would not need a T blocker with these levels. I personally had E at 207 pg/ml and T at "<15" ng/dl (the test only goes down to 15), which could be too low, with no blocker.

That being said, it's important to note that I use injectable estrogen, which (unlike sublingual) has a built-in extended release mechanism. Transfem science has this to say about sublingual estradiol:

Oral estradiol tablets can be taken sublingually instead of orally. Sublingual use of estradiol tablets has several-fold higher bioavailability relative to oral administration and hence achieves much higher overall estradiol levels in comparison. Sublingual use of oral estradiol tablets can be employed instead of oral administration to reduce doses and hence medication costs or to produce higher estradiol levels for the purpose of achieving better testosterone suppression when needed. However, sublingual estradiol is very spiky in terms of estradiol levels when compared to oral estradiol and has a short duration of highly elevated estradiol levels. As such, it may be advisable for sublingual estradiol to be used in divided doses multiple times throughout the day in order to maintain at least somewhat steadier estradiol levels. The therapeutic implications for transfeminine people of the spikiness of sublingual estradiol, for instance in terms of testosterone suppression and health risks, have been little-studied and are mostly unknown. In any case, when used as a form of high-dose estradiol monotherapy and taken multiple times per day, strong though still incomplete testosterone suppression has been observed

Here's a graph of hormone levels after a single sublingual dose of estradiol (ignore everything but the pink E2 line):

That's what "very spiky" means. The half-life of a medication works the same as radiation, it's the amount of time it takes for your body to eliminate half the dose. Sublingual estradiol has a half-life of a few hours, so it can be very tough to maintain levels sufficient for monotherapy. For comparison, here's a graph of simulated hormone levels on injected estradiol valerate:

The blue line is a single dose, the orange line is 4mg every 7 days, and the pink line is 2mg twice a week (what I take). There are longer-lasting esters than valerate (enanthate is very popular in the DIY community), but all available injectable esters have a half-life measured in days. This is a big part of why injectable monotherapy is so popular: you don't have to take pills multiple times a day and, for most people, you don't need to worry about an anti-androgen. I'm less knowledgeable about gel/patches, but to my understanding they're between sublingual/oral and injected estrogen in terms of half-life with patches essentially being a more controlled version of gel. Regardless, don't fall into the anxiety trap that is trying to "optimize" your medical transition. Tragically, the science just isn't there, that's why the best most helpful doctors are the ones willing to let us experiment and see what works for us. There are in fact plenty of girls who have gotten a lot of results out of doses that would horrify us if we heard about it on the internet with no context. You should still learn about this stuff to be a better advocate for yourself.

and like, I should be able to push through it, but I just don't care. and that's the problem, professors are usually willing to work with you If You Care. but caring was the thing that was fucking killing me.

so it's like. i don't care about college, I don't care about the work I'm doing, I don't care about this class or this paper or this grade or whatever, I Do Not Care. but I feel like I have to act like I care in order to be helped.

the feeling that I am constantly disappointing EVERYONE, whether my bosses or supervisors or professors or advisors, has been weighing on me so much for so long. I don't want to be someone who Doesn't Care.

my partner was a TA for an intro-to-subject course in grad school. finals week rolls around and the students are required to submit this big module assignment they've had like a month to do for a decent chunk of their grade. if you've submitted everything, you'll see a summary screen with a star beside each module name showing it's been completed.

an hour before the assignment deadline, he receives an email from a student claiming they completed the assignment, but the system is not allowing them to submit. there's an image attached to the email. partner goes to open what he assumes is a screenshot of that summary page.

instead, he sees that the student has taken a photo of their laptop from about 2 feet away, with that page open. strange, but it wouldn't be the first time a college freshman has lacked the tech literacy to take a screenshot. he almost doesn't look twice at it, but he realizes something about it just feels a little bit...off. so he zooms in.

the student had CUT STARS OUT OF CONSTRUCTION PAPER and TAPED THEM TO THEIR LAPTOP SCREEN BESIDE EACH MODULE NAME. you could see where they actually had completed the first couple of modules, but the stars for all the subsequent ones were like, double the size of the first two and exactly as uneven/irregular as you'd expect if you were freehanding them with scissors.