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.
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.
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.
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.
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.
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!
Every so often articles pop up claiming that transgender hormone therapy is “experimental” or “unapproved”. HRT has been used by transgender people since the 1950s, so it definitely isn’t experimental though like all medicine it’s always improving. However it is “unapproved”, or, as it’s more commonly known, off-label.
This isn’t strange though, many medicines are used off-label. One that I’ve had before is bupropion which comes in multiple brands with different approvals. The only approved brand of bupropion in New Zealand is Zyban, and its approval is only for an aid to quit smoking in 150mg doses. Overseas the Wellbutrin XL brand, which has the same active ingredient and same doses as Zyban, is approved as an anti-depressant. Because Wellbutrin isn’t approved in NZ doctors just prescribe Zyban, this is off-label but backed by overseas approvals.
Bupropion is also used for ADHD. While this is backed by emerging research it isn’t approved for ADHD treatment anywhere, so all ADHD treatment with Zyban is off-label.
Using approved medicines for off-label uses is permitted under NZ law at the discretion of doctors, the safe treatment levels and side effects are established so the risk is minimal. Unlike completely unapproved medicines there’s no special requirement to record these prescriptions.
So why don’t manufacturers apply for these uses? Because it costs money. To get approval in NZ you need a sponsor in the country - normally the importer - and have to submit all the documentation to Medsafe, pay them, and wait. While overseas approvals do help the process they aren’t automatically recognised. So if you make Wellbutrin are you going to go through this, knowing that Pharmac won’t fund it because they already fund one sort of bupropion? Nope. If you make Zyban are you going to pay for the update to the approved indications and submit all the documentation given that doctors can already prescribe? Unlikely.
The only time the Medsafe fee is worth paying is for medicines advertised direct to consumer, as only approved indications can be advertised. This also applies for advertisements sent to clinicians, but there are ways to avoid that and clinicians do read published studies so are likely to be aware of changes.
So where does this leave HRT? The market is small, so the expensive studies required are both hard to justify and hard to find participants for, the medicines are already approved and available, and safe levels are established in literature (and given the hormones are bio-identical easy to validate). This means no manufacturer is going to go to the effort of getting their medicine approved for transgender HRT - menopausal HRT is the vast majority of its use.
Disclaimer: I’m not a medical professional, but I’ve got familiar with the terms from them. I hope this will help others understand what medical professionals mean.
I’m going to cover two things in this post, what informed consent means in the broader medical context and what it means to transgender healthcare.
I’ve now heard from multiple people that their doctors or endocrinologists have told them laboratory tests for oestrogen levels are either inaccurate or cannot detect exogenous oestrogen, so there’s either no reason to test or no reason to take action based on test results. This always seems to be used to deny increase in hormone doses, but for decreases the blood levels are always trusted. Interesting that…