Yesterday’s post was getting a bit long, so for those who weren’t doing web design in the late 90s/early 2000s here’s some background.

The constraints of 1999

The late 90s were a time of rapid change in the world wide web, the first big browser war was brewing. Netscape Navigator browser got bloated with the Communicator product they were pushing and Microsoft’s bundling of Internet Explorer with Windows rapidly pushed Netscape out of the market. Both implemented parts of HTML4 and CSS 1 and 2 in differently buggy ways, and they both had different ways of using JavaScript to animate elements on the page. Back then we called it Dynamic HTML!

The main constraints I’m following are:

CSS

CSS! Yes that’s right, we had CSS in 1999! CSS 1 support was reasonable, text and element alignment, text and background colour, and font face were reliable. Padding and margin worked on some elements. CSS2 support which included floats and positioning were not really ready.

Most existing sites still used <font> tags, but CSS was starting to be accepted. CSS let you alter text formatting on links (removing the underline was controversial to say the least) and IE4 introduced the :hover selector on a tags, allowing for mouse-over colour changes. Yes, bold-on-hover was a real thing we did!

Page layout

Layout choices are very limited. There’s no way to break an element out of the document flow (no floats, no CSS positioning), and there are only two ways to have multiple regions on a page.

First we have frames. Frames let you divide the window in to multiple separate named documents, so you could have a left frame 200px wide called ‘menu’ containing the site menu, and the rest of the document as a frame called ‘main’. <a target="main"> in the menu would cause the link to open in the main frame. This still exists as the <iframe> element, but frames are long deprecated. I won’t use frames in the main series, perhaps as an aside.

The other was the (mis)use of the <table> element. You’ll see this soon.

Fonts

Only fonts pre-installed on the user’s system could be used, no web fonts! In the early days this meant taking a guess and hoping. In the mid 90s Microsoft released their Core Fonts for the Web project, which was a bundle of fonts licensed for non-commercial use available for download. There was some traction getting them bundled on non-Windows systems, but it took a long time. Generally multiple fallbacks were provided.

Colour choices

Even though most people in 1999 had video cards that supported at least 24-bit “true colour” at 800x600 people using 16-bit “high colour” were still around. Due to how different systems mapped the colourspace it was common for colours that were distinct on one system to be the same on another.

Images

Even with a storage limit of 10MB this wasn’t the major restriction. Most of the world used dialup modems, with speeds of 56kb/s reasonably common. Even this extremely lightweight website would take around 10 seconds to download (though without custom fonts it’d probably be sub second), and the front page of English language Wikipedia would take close to two minutes.

This means decorative images had to be kept small to avoid stuttering loads - under 10kb each. SVGs were still a few years away, so we have GIF, JPEG and PNG.

Additionally browsers often only allowed a few requests in parallel (2-6 depending on your browser) so using multiple images would result in a site that slowly drew as each image downloaded in turn. Each request needed a whole new TCP connection, in New Zealand fetching from the US that would result in a minimum time of 250ms per image.

Animations

A memory surfaced during this project. In 1999 animations stopped when you scrolled the page. There often wasn’t enough video memory for off-screen rendering, so the whole content area was re-painted on every scroll action. If you dragged the scroll bar the document didn’t drag in real time, but if you pushed the down-arrow repeatedly animations would effectively stop as the timer was disabled during the re-render.

Character set

Unicode definitely exists, but it’s not in use. The ISO 8859-1 character set is generally available, though the Windows codepage 1252 is often actually used. Non-ASCII characters are rare outside of personal sites due to cross-platform and cross-language rendering problems. I’ll be sticking to ASCII characters.

I’m not going to keep up the narrative style from the last post, so from now on it’s back to first person.

In this post I’ll go through the design updates, and I’ll post a follow-up detailing the constraints that went in to this.

Lets get designing!

First, since basic CSS worked in 1999 I’ll add some CSS inside the <head> tag to make the background trendy black and text awesome white, and set the font to something sans-serif for the body and something more impactful for the headings.

<style type=text/css>
body { 
    background-color: black; 
    color: white;
    font-family: "Verdana", "Helvetica", sans-serif;
}
h1, h2, h3, h4, h5, h6 {
    font-family: "Impact", "Helvetica", sans-serif
}
</style>

I’ve also obtained some page dividing gifs from the internet archive! There aren’t many ways to divide a page up, so images like this are used to visual separate parts of a page.

<center><img src=zdivider.gif width=600 height=1></center>

Using center tags because I don’t recall using <div> tags that early. I think it might have been one of those Netscape vs IE things? I know Netscape had the <layer> tag.

Now to add some links to the future pages of the site. The pages aren’t there yet, but that’s OK because it’s under construction right? They’ll just 404 for now

<center>
  <a href=about.html>About Me</a> - 
  <a href=guestbook.html>Guestbook</a> - 
  <a href=pets.html>Pets</a></center>

Though I think it’s important to add another indication that the site is under construction

<center>
  <img src=underconstruction.gif width=567 height=36 alt="under construction">
</center>

Now let’s add a fancy animated star background by adding <body background=background.gif>. Yes, CSS for this worked, but what’s more 1999 than mixing styling systems?

Now we can’t really read the links using the default blue and purple. A lot of people wouldn’t be bothered but we can fix it with some more CSS! And add a hover effect for people using IE4!

a:link { color: #44F }
a:visited { color: #F4F }
a:active, a:hover { color: #F66; font-weight: bold }

And as a bonus I’ll add a picture of my cat. The photo isn’t from 1999, but the cat was alive then!

Check out the updates!

Next time

Next up it’s time for some interactivity with a guestbook!

Author’s notes

Corrections to part 1

In my first post I neglected an important detail - the background colour! In the 90s - at least when using Netscape Navigator and earlier versions of Internet Explorer - the default background colour wasn’t white, it was a mid grey colour. #C0C0C0 to be precise. Why? I’m not entirely sure. I’ve fixed this.

The site from part one has been archived at https://thea.net.nz/~thea/part1/

Styling and layout

Web browsers are amazingly backwards compatible, almost everything from 1999 still works (except <blink>). There is a problem though - window size. It’s hard to find statistics from the era, but a substantial number of visitors would have been using 800x600 monitors, with 1024x768 also being common. By comparison my 15“ laptop has an effective screen resolution of 1680x1050, and my desktop monitors are even larger.

So I’ve decided I’m going to add some CSS to cap the document width at 1000 pixels and centre it in the browser. Though to be honest this was a common thing to do in 2008 when larger screen sizes appeared and broke the layouts.

To change from my regular ramblings about healthcare and reading one to many rose-tinted reckons about how things used to be, let’s make a website like it’s 1999!

What this is and isn’t

My aim is to show how you got your site online in 1999, but not to be historically accurate, so

• I will be using modern HTML and CSS. Quirks mode belongs in the past
• The server software will be modern, because if it wasn’t the server would already be compromised.
• I will be using secure methods rather than accurate ones, but I’ll note where this is different.

But I will show how we made websites dynamic and the compromises made when you had limited space!

I’ll make another post on the server setup if you want to follow along. Ask nicely and I might just give you access to TheaNET.

Setting the stage

It’s 1999! You’ve just signed up for your first internet connection with your local ISP, TheaNET! Hey that’s your name as well! They’re a very modern ISP, supporting your new V92 56k modem, and you get 30 hours of connection per month for a very reasonable $29.95.

Looking through the signup pack they sent you, there’s a CD with Netscape Communicator and a bunch of trial apps, some pamphlets, and a letter with connection details on it. One part catches your eye:

All accounts come with complementary website hosting with 10MB of disk space and 100MB of traffic per month.

Not only can you browse all the sites on the internet, you can make your own. This is truely the future.

A few weeks later

How hard can it be? You’ve gone to the local bookstore and purchased a copy of “HTML Made Easy”. The first chapter tells you to open notepad, enter this text, and save it to index.html on your desktop

<html>
<head><title>Thea's Website</title></head>
<body>
<h1>Thea's Website</h1>
<p>Welcome to Thea's website!</p>
<p>This site is still under construction, please check back soon!</p>
</body>
</html>

Now to upload it. The instructions from TheaNET say

To upload to your website, use a program like WinSCP (included on the CD-ROM) or a similar sftp tool. Copy the files in to the public_html directory (if you can’t see it, you can create it). Use your dialup login and password to access your web hosting.

After some fiddling around with the copy program you get the public_html directory created and index.html copied over. Entering https://www.thea.net.nz/~thea/ in to your web browser you see your website come to life! On the internet!

It doesn’t look great, but it’s a start, it says it’s under construction so everyone knows you aren’t finished, and you’re about to read the chapters on images and text formatting.

… to be continued!

Editors Notes

scp instead of ftp

Because I want to make this something safe for others to follow I use scp for file copying. While I could set up an FTP server not only are maintained and secure FTP servers pretty rare, the protocol really doesn’t work well with modern networking. The server I’m using does not have a public IP address.

Generally ISPs did not include shell access with hosting and only allowed ftp access, which is possible with scp as well.

What’s with ~thea?

This is a user directory! In 1999 using a per-user subdomain was not very common, and on UNIX-like systems ~ is used to represent the home directories where users store their files. ~ is your home, ~thea is Thea’s home. The Apache web server continued this convention to represent each user, but served out of public_html in that user’s home directory.

This disappeared as websites got more dynamic due to cookies. Cookies are stored per-domain, so if you had http://www.thea.net.nz/admin/ which set an admin cookie, http://www.thea.net.nz/~nefarious_user/cookie_stealer.html would be able to steal it and gain admin access.

This will come up again later.

You forgot the doctype!

Nobody used a doctype in 1999!

So to follow along at home with my website like it’s 1999 series you’ll need a webserver like it’s not 1999. A genuine 1999 webserver would last about 15 minutes on the modern internet.

To set up your own server you’re going to need some degree of experience with UNIX-like systems, DNS, and domain management. I’m not sure if there are many tutorials on this out there, I learnt them a long time ago.

I’m using a virtual machine on my home server, because I’m the sort of person who has a home server. But here’s what I did:

Create a virtual machine to run the server

You could use whole physical machine if you have one handy. I created a VM with 12GB of disk space, 512MB of RAM and 1 vCPU.

An ISP would be able to afford a system with more disk space than this in 1999, but a single core of my 3.5Ghz Intel core i5 4690 would far outclass anything an ISP ran in 1999, even if it is 10 years old at this point.

Install FreeBSD 14.1

Why FreeBSD? I remember it being quite common at the time, and the first UNIX-like server I had a shell account on was FreeBSD. Linux was already well established in 1999, but a lot of the people still regarded it as an upstart that still needed to prove itself. FreeBSD is actually younger than Linux by a couple of years, but its BSD heritage gave it more weight in some opinions.

Also for this series I feel being slightly foreign to most people is an advantage.

I’m not going to include a guide for the installer, the FreeBSD website has documentation.

You can also run Linux, Alpine has everything we need available.

Create a non-root user

useradd my_user. Just remember to add it to the wheel group so you can use su when you SSH in.

Install critical administration utils with pkg

Yes I could use ports, but pkg is good enough.

pkg install vim

Install Apache httpd

pkg install apache24

I’m using Apache despite there being more modern options that are probably better for almost any other use, like nginx and lighttpd. However Apache still supports cutting-edge 90s features that most other servers have removed or never supported, like server-side include processing, CGI script support, and .htaccess support for per-directory configuration overrides. These will come in handy.

Configure Apache

In /usr/local/etc/apache24 edit httpd.conf and uncomment the LoadModule lines for include_module and userdir_module. Also uncomment the line Include etc/apache24/extra/httpd-userdir.conf.

Done!

Yep, that’s pretty much it. The root site is in /usr/local/www/apache24/data.

What’s missing?

SSL

For that true 1999 experience SSL is terminated outside the web server. An ISP in 1999 wouldn’t offer SSL as standard, it used a lot of CPU and required a dedicated IP address per domain name (mostly).

If you’re following along you should use Let’s Encrypt and certbot to configure SSL for you.

Firewall setup

You should think about this, especially if you’re intending to allow other users access to your server. You probably don’t want random servers running.

Things I may add for the future:

• Email hosting, SMTP and local delivery at least, probably not IMAP or POP3 unless I move it off my home server.
• A database, probably PostgreSQL. I know MySQL was more favoured at the time, but I prefer Postgres.
• Perl and python modules as required to run the demos I have planned.

Everyone lucky enough to be prescribe progesterone in the form of oral micronised progesterone capsules has probably been told to ensure they take them on an empty stomach. This isn’t that uncommon with medications, eating can affect the way they are absorbed. Out of curiosity I wondered what the problems are, in case I forget and have a snack just before taking it.

First, a caution. Always take medication in the manner prescribed by your doctor. This information is just for curiosity.

It turns out there was a study done in 1993. Micronised progesterone for oral administration came to the market in 1980, so it’s been around a while and a lot of the studies are fairly old. It’s a well understood product.

The study¹ handily titled “The absorption of oral micronized progesterone: the effect of food, dose proportionality, and comparison with intramuscular progesterone” was performed on 15 post-menopausal women, so it’s a very small sample size. To quote their results:

Concomitant food ingestion increased the area under the serum P concentration versus time curve (AUC_{0 to 24}) and the maximum serum P concentration (C_max) without affecting time to maximum serum concentration (T_max) (P < 0.05). Micronized P absorption and elimination were first-order processes and exhibited dose-independent pharmacokinetics between 100 and 300 mg.

So to translate that - taking your progesterone with food increases your absorption of progesterone, over the 24 hour period more total progesterone was absorbed, higher blood progesterone levels were measured, but the time taken to get to the maximum progesterone level was the same as for fasting. Secondly, the absorption of progesterone scales directly with dose, it doesn’t seem to drop down or rapidly increase.

But how much more progesterone is absorbed? From the paper’s conclusion:

Absorption of micronized P was enhanced twofold in the presence of food.

So taking progesterone with food results in twice the absorption rate compared to fasting. The peak is higher but the rate of metabolism is unaffected, so the end result is a consistently higher serum progesterone level (you can look at the paper to see the graphs and numbers)

Why are we told to take progesterone on an empty stomach? I can’t find an answer. It could be to avoid the peak - nearly six times higher when taken with food - or there could be other interactions not documented in this paper. If I find out more I’ll post an update!

One thing everyone who takes oral oestrogens, whether for contraception, menopausal HRT or gender-affirming HRT, gets told by their doctor is that oral oestrogen raises the risk of blood clots - called a thromboembolism in the medical world. However we’re never really told what the risk actually is. If the rate without the medication is 1 in 100,000 per year and the increase in risk is 10% - to 1.1 in 100,000 of people on the medication - then perhaps it’s not a problem? But if increase is to 50 in 100,000 - a 500% increase if I can do maths today - then that might be more concerning.

So let’s dig in to the literature again!

Summary (for the TL;DR)

Yes oestrogen HRT increases the rate of blood clots, but dose doesn’t make much difference when using bio-identical 17β-estradiol. The difference in risk of using pills, patches gels or injections is still not clearly understood. The rates reported are not adequately controlled for dose form, oestrogen type, and additional risk factors.

Synthetic oestrogen such as ethinyl estradiol have a much higher risk than bio-identical 17β-estradiol.

Overall the risk of HRT containing bio-identical 17β-estradiol is higher that the general population, but still a very low risk.

Does oestrogen itself increase blood clots?

While a study showing a correlation between oestrogen levels during pregnancy and blood clots has previously been widely circulated, a more modern study¹ shows that in the absence of oestrogen-containing medications sex hormone levels have no significant impact on rates of blood clots. Oestrogen levels during pregnancy are an order of magnitude higher than would be achieved by any form of medication.

So no, oestrogen levels are not the cause of blood clots, at least when in the normal physiological range.

The story is different with oestrogen-containing medications

Does HRT increase the rate of blood clots?

In short, yes.

The main clots that have been studied are venous thromboembolisms - VTE - which are clots that form in veins, generally in your arms and legs. We’re often told it depends on the dose level and route of administration - pills, transdermal patch/gel, injection or implant - with pills being the worst.

Fortunately there have been two studies performed on this recently! They are both meta-analyses, which means their authors haven’t done a direct study, but have identified previous good studies and combined their results. In particular they’ve found studies that not only recorded the rate of VTE, but also the type of oestrogens used, the dose, route of administration, and any other hormone medication used alongside. So many papers just say “transgender HRT has this rate of VTE” with no detail of what form, dose, or administration route is being used! This makes my job easier.

I’m only going to refer to one of the papers here, because it cites the other. I’ll link to both.

Publication: Managing the risk of venous thromboembolism in transgender adults undergoing hormone therapy ²

The paper I’m going to cite identified 13 studies that had observed the rate of VTE and also noted the form of oestrogen and dose used. I’m going to be a bit naughty and do a pull-quote from the results before discussing it more, to set the stage a bit

Finally, even if the risk from exogenous estrogen use remains significant statistically, the absolute clinical risk remains low.

In plain English - even if HRT causes an increase in blood clots which can be measured, it’s still a very low rate.

In depth

This analysis found that the synthetic oestrogen ethinyl estradiol causes a much larger increase in the rate of VTE than bio-identical estradiol. Synthetic progestins - such as cyproterone acetate - were also found to have a larger effect on VTE rate than estradiol valerate in any form.

The paper also says that:

Data suggest a positive correlation between estrogen use and VTE. A recent review³ found the overall incidence rate to be 2.3 events per 1,000 patient-years.

which cites the other paper - but there’s another point made. VTEs are associated with other health conditions and behaviours. Smoking tobacco is well known to increase the rate of blood clots, as are having high blood pressure, hypertension, undergoing surgery, and being HIV positive. Additionally acute stress and other mental health conditions are correlated with blood clot rates. From the paper:

Only one study to date demonstrates an occurrence of VTE in the absence of risk factors beyond hormone therapy.

That study⁴ followed 676 trans women over 8 years on predominantly oral oestrogen, and only had one incidence of VTE.

Their conclusion?

Firstly, avoid ethinyl estradiol containing medications. They have a significantly higher risk of blood clots

Secondly,

Although there seems to be clear evidence that transdermal estrogens dosed up to 0.1 mg/day or below are a lower risk for VTE than other forms of estrogen, it is unclear whether this is related to the delivery method or a dose effect.

0.1mg/day is a low transdermal dose. The current PATHA guidelines go up to 0.2mg/day, which has similar risks to oral estradiol valerate.

Risk mitigation is an important part of the care of transgender patients due to the many risks associated with not providing hormone therapy (ie, poor mental health) and the potential risks associated with hormone therapy. Further study of the relationship between estrogen and the risk of VTE will serve to inform the safest possible care for transgender patients

So as always, the conclusion is there’s not enough data to draw a solid conclusion, but treatment should be based on risk mitigation and acknowledge that focussing on risk minimisation may have worse outcomes for the patient.

So where are we?

Women not on any form of oestrogen medication have a VTE rate of around 4.2 per 10,000 person-years. With a rate of 23 per 10,000 patient-years according to that study that’s a large difference, but the analysis included use of synthetic hormones that are known to have far higher risk. They also noted that only one study identified a blood clot occurring without other know risk factors present - that paper gave a rate of 7.8 per 10,000 person-years.

Unlike menopausal HRT, the risks associated with different delivery mechanisms is not as clear-cut.

So yes, you will have a higher risk of blood clots on any form of estrogen and you should try to manage it through other factors you can control, such as not smoking and monitoring your health.

Short post time!

Basic biology says that having an XX or XY karyotype determines reproductive organs.

Intermediate biology says it’s the SRY gene, which is normally on the Y but can be on the X.

Advanced biology says we have no idea and it could be anything!

SRY-negative 46,XX male with normal genitals, complete masculinization and infertility

This is a post I’ve been trying to write for months, but it’s difficult to actually finish, or at least figure out the point I’m trying to make…

So I have ADHD. I was diagnosed 18 months ago, which at 38 makes it a rather late in life diagnosis. However now I actually know why my brain doesn’t work the way most people expect it to I have a whole new way of managing my life which has really changed things.

Most of my school years were in the 90s, and the prevailing perception of ADHD at the time was children, almost exclusively boys, being hyperactive and disruptive. This of course lead to the counter view by some groups of it being caused by “bad parents who just want to drug their children”. Neither of these views are correct, and both are very unhelpful. Needless to say despite it being suggested from a young age I never had any formal assessment or support.

I don’t have many symptoms of hyperactivity - though my psychiatrist did raise an eyebrow about that when I showed my health tracker reading over 4,000 steps on a work from home day when I didn’t go outside - but mostly inattention. The inattention side of ADHD is quite insidious as hyperactivity at least has external signs, but inattention is invisible to others, and yourself, until too late. For me this made school and university some of the worst times of my life, no matter what I tried from the ‘conventional wisdom’ I just got told over and over again to pay attention and work on time management skills, but nobody ever thought to teach me how. It turns out that that’s because most people just have those skills at some level, who knew?

And that’s the crux of ADHD for me - I’m not running around disrupting things, and I’m not just distracted. ADHD is an executive dysfunction. The executive - much like in a business - manages priorities. It doesn’t actively do them, but it determines what should be done when, for how long, and what the expected outcome is. If a business has a dysfunctional executive then supplies don’t arrive on time, they don’t make the right products at the right time, and important documents aren’t filed properly, or if these things are done they are done at the very last minute.

On the more social side, lack of prioritisation leads to lack of time perception. I don’t catch up with my friends not because I don’t want to, but because I fail to prioritise organising things until it becomes too socially awkward to do it!

Sound familiar? It certainly did to my life. No planning “life hack” worked, no organiser or list helped, because critically you have to prioritise using those, and when your whole problem is an inability for your brain to prioritise they are never going to work.

So what did help?

Certainly medication has helped, but ADHD medication is a double-edged sword. Which is an odd saying because a double-edged sword is definitely superior to a single edged one and both will cut you if you swing it at yourself, but I guess hilt-less makes even less sense? Anyway I digress. ADHD medication helps with inattention, but that’s all it really does. With medication you can focus on things and it’s harder to get distracted but it doesn’t really help with the prioritisation, so it’s even easier to focus on the wrong thing than before. Like writing this post when it’s time to cook dinner!

The real help for me was CBT, cognitive behavioural therapy. Like all forms of psychotherapy it’s not going to work for everyone but for me the focus on understanding why my brain works in the way it does was key. Now that I know it’s the prioritisation area that’s causing me issues I can work around that using a combination of calendar alerts, scheduled reminders, and routines. I’ve disabled almost every notification outside and made a habit of checking apps either at the end of a task or a certain time each day - no YouTubers, I won’t use the notification bell, I’ll just check the subscriptions page when I’m ready! I don’t get any notifications from Slack, or Facebook, or Discord, or any of the other sources that ping people constantly. This means I know if something notifies me it’s something I’ve already prioritised.

It still doesn’t help with things outside that, I have a huge todo list for my hobbies and keep finding new ones, but those aren’t causing (much) of a problem with my daily life.

And I guess that comes to my last point (have I made any points?). It’s not worth getting diagnosed if you don’t have any problems in your day to day life. However if your career is stuck in a rut, you’re having to pay late fees on bills because you just forgot to pay them, or your social life is suffering because you just forget to organise things, perhaps it’s worth talking to a specialist.

I’m still quite irritated that this wasn’t dealt with when I was young, with the knowledge of how to manage ADHD I might have done things other than software development, and certainly wouldn’t have had as many issues with anxiety. I’ll never know though, can’t change that so the only thing to do is improve things from now!

An article just appeared on the news that GPs consider self-requested medical testing “concerning and unnecessary”. Of course, I think they’re wrong, but I’m going to outline some reasons.

Firstly, a question to those against this. Why do people feel the need to self-request medical tests?

Tests requested by a medical practitioner are free, when you self-request they are not, often costing more than a GP appointment. Clearly people feel they are not getting the care they need - I have had my health concerns completely dismissed by GPs with no follow-up so understand why someone would get tests done by themselves.

I’m sure there’s a lot of misinformation out there are people getting unnecessary tests, but we should not remove a service just because some people use it - at their own cost - when they don’t need to.

So, back to why people self-request tests, and I’m going to start with a transgender perspective.

Transgender healthcare is frequently poor. I know people who’ve been ignored, gaslighted and outright lied to by the people supposed to provide the medical guidance for their transition, so to keep GPs honest they get their own tests. This should not be necessary, but it’s a reality for a lot of us. Most often this seems to be providing menopausal levels of oestrogen and refusing to do any tests, so by getting these tests people can find out what’s actually happening and change GPs. Without the ability to do self-requested tests there’s no way to double-check a GP’s opinion.

Secondly, “DIY” therapy - that is obtaining hormones illegally without a prescription - is not uncommon. This is often because doctors have refused to provide care, or won’t provide care the patient wants. Self-requested testing is used by DIYers to monitor their own levels, ensuring that they’re not exceeding appropriate levels and actually have medication containing the hormones they want. Why do they DIY? Simply because specialists refuse to prescribe injected oestrogen or any sort of testosterone therapy so people take it on themselves to get the medication, and sometimes because they’re refused an increase in dosage. I explored some of this in a post on considering DIY therapy.

Lastly, because people modify their treatment regimes without consulting a doctor. Perhaps increasing or decreasing an anti-androgen, or altering the time of day medications are taken. Getting this done with GP approval can be very hard, especially if your GP sticks rigidly to the guidelines and does not take your wishes in to account. Self-requested testing can help show if you’re on the right track or not, and to ensure your levels are at the GP-expected ones before a test they’ll see.

None of these tests would be self-requested if people got the care they want, but that can be very hard and costly to do - even when the cost of tests is taken in to account.

And for non-hormone tests?

Also sometimes it’s easier than booking an appointment with your GP and taking time out of your day to see them for a five minute request. When GPs are booked out for multiple weeks in advance getting a test when you know what you need can take too long. Sometimes your request would be declined, then you just wasted the cost of the appointment.

Personally I’ve done self-requested tests for hormone panels (and once for a blood type test, because while interesting it’s not medically important to know in advance), mostly to get data on medication timing and drop-off for my own curiosity, but also to check levels while using DIY progesterone before I found a GP who’d prescribe it properly.

Is there a conclusion?

Not really. Just my opinion that restricting people from obtaining their own medical tests isn’t going to help trust in the medical profession.

Have anything else to add? You can reply on the Fediverse - @blog@thea.hutchings.gen.nz - or via the comment form below.

Progesterone is by far the most controversial hormone in transgender HRT. Almost bizarrely so, the amount of clinical misinformation, dis-information, gaslighting, and just straight ignorance is astounding. So let’s look in to it!

Misinformation?

I’ve been told that progesterone has “no benefits”, which from personal experience is not true (“no proven benefits” is technically correct, but we’ll get in to that later), and others I know have been told that it’s “risky” - though without specifying the risks - and even that it’s a carcinogen, which would be pretty astonishing if true given that progesterone is part of every healthy human’s system!

What is progesterone?

Progesterone is a human sex hormone, like testosterone and oestrogen (yes there’s an oestrone, but oestrogen always seems to be used instead, perhaps because oestrone isn’t the most clinically important oestrogen). Biologically progesterone is the main precursor to testosterone, which itself is the main precursor to oestradiol.

The broader class of similar hormones is called progestogens, all progestogens have similar behaviour with varying degrees of potency, as do oestrogens (oestrone, oestradiol etc) and androgens (testosterone, dihydrotestosterone etc). There are also many synthetic progestogens, collectively known as progestins. These are often used in contraceptive pills, among other uses.

Progestogens play an important role in the reproductive system, it’s well known as the hormone that regulates the menstrual cycle but progesterone is also important for spermatogenesis and has effects on sleep, appetite, and the immune system¹.

For people with an active menstrual cycle progesterone has monthly spikes up to 1200% of the baseline ², but everyone else over 16 will have a serum level between 0.3-3nmol/L ³.

So what does it do?

As with everything we’re still discovering everything, but these are some of the functions that have been shown in research several times.

Progesterone is involved in breast tissue maturation⁴. While progesterone does not have any effect on initial breast growth, once Tanner stage IV is reached progesterone causes lobuloalveolar development, filling out the breast, increasing the size of the areola, and preparing the tissue for milk production. So progesterone does have a function in breast growth.

Heart health is also impacted, particularly the QT interval. Oestrogens increase the QT interval whereas androgens and progesterone shorten it⁵. This isn’t a significant thing for most people, but it’s definitely an effect. Additionally 100mg-300mg has been shown to lower blood pressure⁶.

Sleep is another area that’s affected, with progesterone being shown to reduce stress hormone levels, increase deep sleep, and prevent sleep disruptions ². Again not a huge thing clinically, but it’s not “nothing”.

Risks?

The form of progesterone generally considered the best among the transgender community is micronised bio-identical progesterone. This is identical to natural human progesterone that has been processed to make the powder as fine as possible and then suspended in a food oil (generally sunflower from what I’ve read). As this is identical to natural progesterone it has no known negative side effects in regular oral doses⁷, and only site-related side effects in other forms (eg injection site pain).

A lot of literature mentions an increase in drowsiness or memory function, but the paper that seems to be the source mentions this is with 300-1200mg per day, with symptoms increasing with dose⁶. The paper seems to suggest that this is due to the metabolism of progesterone to 5𝛼- and 5𝛽- pregnanolone in the liver, which is due to the administration route. Oral administration always results in a high level of liver metabolism.

So for bioidentical micronised progesterone the risks seem minimal, even if there are no effects.

Progestins then?

Progestins are synthetic drugs that mimic progesterone. They are used because progestins can be designed to avoid liver metabolism, which supposedly reduces the risk of side-effects and greatly reduces the dose required. The most referenced one in HRT is medroxyprogesterone acetate (most common brand is depro-provera), but there’s another one that’s much more common in New Zealand.

Cyproterone Acetate

Cyproterone Acetate, or CPA, is the most common anti-androgen prescribed for feminising hormone therapy in New Zealand. CPA is a progestogen and is said to be 1000 times more potent than progesterone itself. So if you’re on 12.5mg/day of cyproterone acetate it will be stronger than 100mg of progesterone daily in terms of progesterone receptor activation.

No evidence of effect?

This is technically correct. There have been very few studies on the effects of progestogens in transfeminine hormone therapy. Medroxyprogesterone Acetate in Gender-Affirming Therapy for Transwomen: Results From a Retrospective Study uses a synthetic progestogen and was inconclusive, and the only clinical article I have found that takes a deeper look recommends using progesterone as it’s important to cis women (Progesterone Is Important for Transgender Women’s Therapy—Applying Evidence for the Benefits of Progesterone in Ciswomen ⁸).

So?

Unfortunately all this evidence hasn’t been enough to sway clinicians from their desire to deny treatment which, while it may have limited effects, is demonstrably safe. Personally I have found it helpful for my mental health and sleep quality at the very least.

I also really wish it wasn’t necessary to become an amateur endocrinologist to know whether doctors are telling us the truth about the medication we’re prescribed, but here we are.

Also Jerilynn C Prior has done some some amazing work on the way progesterone has been (and continues to be) ignored as an essential part of woman’s health. I wish I could talk to her and get more background, but alas I’m not a real endocrinologist.