Interpreting Your Results

Step-by-Step Guide

Step 1: Check Your E2 Level

Result	Meaning
< 50 pg/mL	Too low — increase E2 dose
50–100 pg/mL	Low — consider increasing
100–200 pg/mL	✅ Target range
200–300 pg/mL	Acceptable (especially for monotherapy)
> 300 pg/mL (trough)	High — consider reducing if SHBG is elevated

Step 2: Check Your T Level

Result	Meaning
> 200 ng/dL	Not suppressed — increase AA or E2
100–200 ng/dL	Partially suppressed — increase AA
50–100 ng/dL	Borderline — consider increase
< 50 ng/dL	✅ Target range
< 20 ng/dL	Fully suppressed — consider reducing AA if side effects

Step 3: Check SHBG

Result	Meaning
40–120 nmol/L	Normal range for trans women on HRT
120–150 nmol/L	Moderate elevation — monitor
> 150 nmol/L	High — consider switching from oral to transdermal/injectable E2

Case Examples

Case 1: New Starter, Good Results

E2: 120 pg/mL    ✅
T:  40 ng/dL     ✅
SHBG: 55 nmol/L  ✅

Assessment: Great levels! Continue current regimen. Re-test in 3 months.

Case 2: E2 Too Low, T Not Suppressed

E2: 45 pg/mL     ❌ Low
T:  180 ng/dL    ❌ Not suppressed
SHBG: 30 nmol/L  ✅

Assessment: Estrogen dose is too low. Increase E2 first (e.g., from 2 mg to 4 mg oral). Re-test in 6–8 weeks.

Case 3: Good E2, T Not Suppressed

E2: 150 pg/mL    ✅
T:  85 ng/dL     ❌ Borderline
SHBG: 60 nmol/L  ✅

Assessment: E2 is fine but T needs more suppression. Increase anti-androgen (e.g., spiro 100 → 150 mg/day, or switch to CPA/bica).

Case 4: High SHBG Problem

E2: 200 pg/mL    ✅
T:  30 ng/dL     ✅
SHBG: 180 nmol/L ❌ High

Assessment: E2 and T look good, but SHBG is high — likely from oral estrogen. Consider switching to transdermal or injectable E2 to lower SHBG and free up more active hormones.

Case 5: Monotherapy Working

E2: 250 pg/mL    ✅ (acceptable for monotherapy)
T:  25 ng/dL     ✅
SHBG: 80 nmol/L  ✅
Regimen: EV 6 mg every 5 days, no AA

Assessment: Monotherapy is working well. Maintain current dose. No anti-androgen needed.

Case 6: High E2 but T Not Suppressed

E2: 320 pg/mL    ❌ High trough
T:  70 ng/dL     ❌ Not suppressed
SHBG: 140 nmol/L ⚠️ Elevated
Regimen: EV 10 mg every 5 days, no AA

Assessment: Very high E2 dose with inadequate T suppression. Adding an AA (e.g., bicalutamide 25–50 mg) would be better than increasing E2 further. Also consider reducing E2 slightly.

Troubleshooting Guide

"My E2 is in range but I see no changes"

Possible Cause	Next Step
High SHBG	Check SHBG; switch from oral to transdermal/injectable
Too early	HRT takes years — are you < 6 months in?
Genetics	Some people are slow responders
Low free E2	Check free E2 (requires special test)
DHT still high	Add DHT test; consider finasteride if elevated

"My T is not going down"

Possible Cause	Next Step
AA dose too low	Increase spiro to 200 mg or switch to CPA/bica
E2 dose too low (for monotherapy)	Increase injectable E2
Non-adherence	Are you taking meds consistently?
Testosterone production issue	Check LH; if suppressed, consider DHT or adrenal source

"My prolactin is elevated"

Level	Action
< 25 ng/mL	Normal — no action needed
25–50 ng/mL	Mild elevation — monitor; recheck in 3 months
50–100 ng/mL	Moderate elevation — consider switching off CPA if on it; rule out other causes
> 100 ng/mL	Significant elevation — stop CPA; consider pituitary MRI
> 200 ng/mL	High concern — likely prolactinoma; seek endocrinology consult

Common Patterns and Solutions

Pattern	Likely Cause	Solution
High E2, high SHBG, normal T	Oral estrogen	Switch to transdermal/injectable
Normal E2, high T	AA insufficient	Increase or switch AA
Normal E2, normal T, no changes	SHBG high or genetics	Check SHBG; be patient
High E2, normal T, no AA	Monotherapy working	Nothing — this is the goal!

References

1. UCSF Transgender Care. Feminising hormone therapy. https://transcare.ucsf.edu/guidelines

2. Hembree WC, et al. (2017). Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons. JCEM. https://academic.oup.com/jcem/article/102/11/3869/4157558