Hrt Mishaps - Blog Posts

I went the injectable route at the advice of a friend; and I always wanted to share my knowledge on this subject with others. Talk about perfect timing, too - it’s injection day!

Disclaimer: there’s a lot of room for variation in terms of what’s injected, how it’s injected, etc.; be sure to ask for and follow the instructions of your provider.

Medications

I inject 1ml of 5mg/ml Estradiol Cypionate (brand name: “Depo-Estradiol”), every two weeks; and 1ml of 150mg/ml Medroxy-Progesterone Acetate (brand name: “Depo-Provera”) every ninety days.

Keep a diary of your injections; and in particular the manufacturer, lot, expiration, and serial number of every medication (all of which will be clearly printed on the packaging). This information can be helpful when identifying issues.

Vials

Both medications come in little glass vials. There’s a sterile plastic cap on top (which you break off); and underneath, a rubber seal designed to prevent air from entering the vial.

The Progesterone comes in a single-use vial, containing just one dose; you dispose of the vial afterwards. The Estradiol comes in a multi-use vial, containing five doses; you keep the vial for next time.

Note: there is a risk that multi-use vials can become contaminated with bacteria. Be sure to follow the injection process carefully; maintain sterility; and store your medication in an appropriate location and at the correct temperature, per the instructions.

In medical settings, multi-use vials are good for 30 days after opening; at which point they are disposed of. In my case, I’m keeping the vial for 52 days. I wouldn’t recommend pushing too far past that, as the longer the vial is in use, the higher the risk of contamination.

Injectable supplies

Each injection requires the following:

A syringe,

A large needle (mine are 18g, 1.5′ long, and pink),

A small needle (likewise, 25g, 1′ long, and light blue),

Two alcohol pads,

A Band-Aid (mine has llamas on it)!

Normally you’ll be proscribed a syringe with one of the needles already attached; and the other needle by itself. Alcohol pads and Band-Aids can be purchased from your local pharmacy.

Needles

During the injection process, you will need to switch the needle attached to the syringe. The syringes I use feature a “Luer-Lock” connection, which means they screw on and off.

Each needle comes with a protective plastic cap; you always want the cap on the needle when attaching or removing it from the syringe. (Safety aside, the needles are intentionally designed to make them difficult to add or remove without the cap attached.)

There’s a reason there are two needles: when you need to suck fluid into the syringe, it’s very difficult if the needle is too small. (This is why blood draw needles tend to be on the bigger side.) When you need to squirt fluid out of the needle, however, the size doesn’t matter as much. (Plus: smaller needles cause less discomfort when poking people!)

So the big needle is going to be what you use to draw your medication; and the small needle is what you use to inject it. (When I started my regimen, I asked my provider if a nurse could show me what to do. I wasn’t aware at the time that there were different needles involved; so when I saw the big needle, I was terrified!)

Drawing the medication

First things first: wash your hands! (At every step, you want to prevent the possibility of germs getting into your supplies or worse, into you!)

Take your vial, remove and discard the plastic cap, and clean the surface of the rubber seal with an alcohol pad. (This prevents contaminants from being carried into the vial.)

Next, you attach the large needle to the syringe, and withdraw the plunger so that it contains the same amount of air as the medication you wish to withdraw. (In my case, 1ml.) The plunger will have a rubber seal that meets the inside of the syringe surface; the top of the seal is what you will be measuring against.

Hold the vial level, and with the syringe pointing down, insert the needle through the rubber seal of the vial. Now, carefully turn everything upside down: you should have the syringe pointing up, and the vial pointing down (with the medication pooling around the seal).

Inject the air in the syringe into the empty space in the top of the vial; this will help keep the pressure in the vial constant. Submerge the needle tip in the medication, and gently draw it into the syringe.

It’s normal to have some air left in the syringe; or to accidentally draw some in from the vial. You can squirt some medication back into the syringe to remove the air bubbles; or tap the syringe to shake them free. Tiny air bubbles are normal and harmless; but you don’t want a large bubble in there!

When finished, withdraw the needle from the vial smoothly and quickly. (This is a non-issue with thicker medications, such as Estradiol; but with a thinner medication - such as Progesterone - withdrawing the needle slowly can cause a small amount of medication to squirt out of the vial.)

Preparing the injection

Remove the large needle from the syringe and replace it with the small one. Push the plunger ever so slightly; if you see a tiny drop of medication at the end of the small syringe; this confirms that there’s no air remaining.

You should now have a filled syringe, ready to go!

These injections are intramuscular; that is to say, the goal is to create a 'depot’ (i.e. little bubble) of the medication in a muscle. This is exactly the same as most vaccinations; except they are normally delivered in the deltoid muscle of the arm, whereas these injections will be delivered to the vastus lateralis muscle in the upper thigh.

(Location is determined by a number of factors; primarily, the size of the depot being created. Vaccinations tend to involve very small amounts of fluid; and so it is more convenient to inject them into the likewise smaller deltoid.)

Imagine the top of your thigh is divided horizontally into three sections, and you can see the dividing lines. The line nearest your body is the target. It is recommended that you rotate your injection site with every shot. My rotation schedule looks like this:

Outside of the left thigh,

Outside of the right thigh,

Middle of the left thigh,

Middle of the right thigh,

Inside of the left thigh,

Inside of the right thigh.

Keep in mind that some spots are more awkward to access than others. (Today’s injection was in the outside right thigh; as I’m left-handed, having to reach across my body is a nuisance.)

Once you know where the injection will be going, clean the area with your other alcohol pad. Give it some time for the alcohol on your skin to evaporate. (You can fan air over the skin to speed up this process.)

If there is still alcohol on your skin when you perform the injection, it will be carried into your tissue and create a burning sensation. This is not dangerous; but it is unpleasant and something you will want to avoid.

Inserting the needle

Everything is ready! (Also, there are no images for this part; I needed both hands here for what I was doing.)

Sit on a chair or similar object, so you can your thighs are horizontal and your lower legs vertical. Find a position where your muscles are relaxed. (Tense muscle tissue is harder to penetrate; it won’t stop you from completing the injection, but it can cause more discomfort.)

Take the syringe in your dominant hand, and hold it like a throwing dart. With your other hand, pull the skin of your thigh taut, towards your knee. (This is the “Z-Track” method - it helps to prevent your medication from leaking back out of the injection site.) Take care not to place your fingers on the area you just cleaned.

Now, the part that gets people: you have to stick the needle in your thigh. Understandably, there is fear that this will hurt. It’s okay if you need a minute to work up the courage! Try to keep in mind that if you do everything right, discomfort should be minimal.

When you are ready: stick the needle in, quickly and smoothly, at a 90º angle.

Do not hesitate. (I totally get it - but if the needle doesn’t fully insert, you’re either going to have to push it the rest of the way, or remove it and try again. The faster and more confidently you insert the needle, the less you will feel it!)

Don’t worry about it going too far in. There’s a plastic nub at the end of the needle, designed specifically to prevent this from happening.

If everything has gone to plan, then the needle should be fully inserted in the thigh, and no longer visible. You can now remove the hand holding your skin taut. (This can feel a little weird at first, as the underlying tissue is trying to move back into position against the needle.)

Delivering the medication

With one hand, hold the tip of the syringe steady against your skin (so that you don’t accidentally withdraw the needle). With the other, slowly depress the plunger, injecting the medication into your muscle.

How slow? Slow. Nursing guidelines recommend ten seconds per 1ml of fluid injected. I normally double that. (Also: as aforementioned, Estradiol is frequently delivered in an oil-based medium, which makes it thicker. Thicker fluids take longer - and more effort - to push through a small needle. When in doubt, go slower.)

Cleanup

Once the medication is fully delivered, carefully remove the needle, and place the cap back on. You might see a drop of either medication or blood at the injection site; this is normal. Cover with a Band-Aid. You’re done!

Place both of your capped needles in a solid container. (I use an old prescription bottle.) This way, when you dispose of them, there’s no danger of someone getting poked by a used needle.

All other supplies should be disposed of (barring the aforementioned multi-use vials). Tempting though it might be to save time and money, do not reuse syringes or needles. (This is just asking for an infection!)

Aftercare

It’s normal for the injection site to be sore the next day (as if you had an invisible bruise). This is because the act of creating the bubble of medication in the muscle does a small amount of damage.

It’s not normal for the site to swell; turn red; itch; or become hot to the touch. These are signs of an infection. Such infections are easy to treat (usually with a course of antibiotics); but it’s important to seek medical attention quickly, as they can cause serious complications if left unattended. (This is especially true of the red patch grows rapidly!)

What can go wrong?

I’m not going to lie: lots of things.

A couple of times, inserting the needle has triggered a leg spasm. This doesn’t hurt; it just feels really, really weird.

Occasionally I will accidentally hit a blood vessel with the needle. (This is unavoidable; you can’t see them from the surface.) This doesn’t pose an issue other than being mildly painful.

I once hit a nerve the same way. The pain from doing so left me in tears. (I want to stress however, that this happened once in fifty-seven shots.)

There was a syringe with a defective plunger that wouldn’t depress the whole way. That was frustrating; but simply meant I had to start over and go again.

Likewise, I had a friend whose needle detached from the syringe while it was still in her thigh. Obviously, an upsetting scenario; but one that can be avoided by ensuring that the needles are firmly locked into place prior to use.

If you have questions or issues, and need help - be sure to ask to talk to a nurse at your provider’s office! They spend a lot of time poking people in various ways, and have a wealth of expertise to offer.

Another really resource is trans men! The amount of information they’ve gathered on the analogous act of injecting Testosterone is staggering! When I run into a problem I’ve never seen before, they are my first port of call.

What can go right?

If you perfect your technique and can overcome the mental hurdle of sticking a needle in yourself, the process can be quick and discomfort-free!

On the science side: different methods of administering Estradiol have corresponding levels of bioavailability (i.e. how much of the Estradiol actually ends up in your system and doing what it’s supposed to instead of, say, accidentally being digested). Of these, intramuscular injection has the highest degree of bioavailability .

Additionally, the hormone levels of cis women are not static; there’s a complex interplay at work where they rise and fall. Injecting Estradiol every two weeks more closely resembles this cycle than taking the same amount of medication every day.

A final plus: you only have to remember to take your medication fortnightly!

In conclusion

I hope this is helpful to every trans woman thinking about going down the injectable rabbit hole. It can be rather daunting; but if you’re willing to invest the time and effort, it can be incredible rewarding!

why the fuck did I willingly switch to injectable estrogen im fucking terrified of needles

Struck a nerve

Every two weeks I inject estradiol into my upper thigh muscle. There are six sites to choose from - the inner, middle, and outer surfaces of each leg - which I rotate through.

I'm a fan of middle thigh area. It's very easy to get a nice, perpendicular needle insertion. (The inner and outer thighs are trickier, often necessitating holding the needle at an angle or in a way where my own hand obscures the target.)

My last shot was into the right middle thigh. Perfect! I readied the syringe, swabbed the skin with an alcohol wipe, let it dry, pulled the skin taught, darted the needle in and screamed.

See, you can't really see what's under the skin; so sometimes you hit something on the way in that you shouldn't - like a blood vessel. I have an unerring ability to find blood vessels. It sucks, and it's unpleasant, but bearable.

This wasn't a blood vessel. It was a nerve.

There was probably a good minute or so of straight crying - needle sticking straight up out of my thigh, a tiny monument to my act of self-sabotage. Eventually I calmed down enough to inject the syringe contents and clean up.

I get that these sorts of things will happen when you routinely stab yourself on a fortnightly schedule but all the same, that was an experience I hope never, ever to repeat!

Tests

Every six months I have my hormone levels tested. I take a lab order from my endocrinology office, pop into a local clinic, have blood drawn, and see my endocrinologist a week later to review the results.

It was during today’s review that we discovered the lab had missed a test. It was okay - my provider was still able to make sense of the results.

However, I did give the clinic a call to find out what happened. I really, really like them - they are very pleasant to deal with, there’s no waiting, and their pricing is very reasonable.

However, this is the third time something like this has happened; so I gave them a call to figure out what the problem was and what I could do to avoid it in future.

Her: “Hi, this is [the laboratory]. How can I help you today?” Me: “Hi, this is Lauren. I think I might be missing a test result?” Her: “Well let’s see if we can find it for you, Ms. Lauren.”

I already like this person - calling me ‘miss’ instantly melts my heart!

Her: “Can I have your date of birth?” Me: “Sure, it’s- oh god, I just remembered I’m forty again.” Her: *Laughter* Her: “That’s okay! Welcome to the club.”

Seriously, this is one of the best personal interactions I’ve had all day!

Her: “So what test do you think you’re missing, Ms. Lauren?” Me: “Uh... testosterone.” Her: “Oh. Oh!” Me: “Yeah... Probably the last one you would have guessed!” Her: *More laughter*

It took some digging through their records, but this wonderful person helped me figure out that my lab order did indeed have a testosterone reading on it, and that this was overlooked. (Most likely because the lab order is a piece of paper that the blood draw technician is required to read and then re-enter into a terminal; there’s much lost between finger and screen!)

Going forward, I’ll be keeping a much closer eye on which tests were ordered and what was actually entered into the system - hopefully that way nothing else gets missed!

Double oh-no

I swear, self-administering an intramuscular injection is like flying a space shuttle. It seems so simple - all you are trying to do is move an object in space from Point A to Point B - and yet there are so many little variables you have to keep track of; any which of one could result in a catastrophic failure if not accounted for.

Tonight I did my Estradiol shot; and I swear in short order I:

Couldn't relax my thigh muscle (despite my best efforts);

Inserted the needle at an angle;

Hit a vein on the way in (unavoidable, but annoying).

I'm not sure what the problem was with (1) - maybe the way I was sitting? I suspect (2) is because you are supposed to make the skin taut, and I've been doing that by pulling it in a single direction... Maybe I need to stretch it taut instead?

The things I put myself through for the sake of aligning my mind and body...

Cellulitis

For the uninitiated, cellulitis is a bacterial infection under the surface of the skin. It isn’t so bad by itself - some redness, some swelling - but by virtue of being trapped below the surface, it often takes medical intervention to clear. Additionally, if untreated, it can lead to some nasty and potentially fatal complications (like necrotizing fasciitis and blood poisoning).

I’m familiar with the premise as a couple of years ago I had a bout on my kneecap thanks to - of all things - the tiniest of ingrown hairs; one course of antibiotics and all was well in the world.

Until. Until.

As I have reported previously, my first few months of Estradiol shots went well (barring a period of psyching myself out). Thereafter, everything was good... Until the day I got a big, red, ugly patch at the injection site.

“Oh,” I say to myself, “I’ve really screwed up”. I fastidiously ensure that my medicine vial, needles, and leg are sterile; but evidently somewhere along the way I missed a step.

I went to see my family doctor; he agrees that it’s cellulitis (even deeper than normal as the bacteria was fundamentally injected an inch into my thigh muscle), proscribes doxycycline; and I’m on my way. (There was a slight detour where I suffered the most agonizing heartburn of my life in response to that particular antibiotic, but that’s neither here nor there.)

Fast forward: next shot, and the same thing happens. Like an idiot, I suddenly realize: “I’m using the same vial of Estradiol as last time; and it’s contaminated”.

(I should have thrown it out as a precaution; but the cost of American healthcare tends to breed a conservationist approach to medications. Plus, it honestly didn’t occur to me at the time.)

My doc probably thought I was an idiot but thankfully did not offer his opinion.

I bought more Estradiol, and was perhaps three shots into the new vial WHEN THE SAME THING HAPPENS AGAIN.

And I’m in tears. I don’t understand what it is I’m doing wrong; there’s so much surplus alcohol on my skin that the needle burns going in. There’s simply no way I can carry on with an injection regimen that results in an infection each and every time.

Thankfully, in this particular instance, it was a very small instance of cellulitis and cleared by itself. I was pretty shook up all the same.

My next best guess was that the Estradiol was being stored at the wrong temperature. It’s supposed to be at room temperature (which is classified as something like 68 - 75º F). I kept my medicine in our bathroom closet; and while I checked the temperature in there and it never seemed over range, the closet does back directly only the location of our furnace.

I also asked my endocrinology clinic if I should be storing my Estradiol in the refrigerator, and their answer could be summarized as: “IDK, maybe? It’s worth a try”.

(This isn’t an attack on them - they are great! As much as I wish it were otherwise however, trans individuals represent a small slice of the population. Medical provider experience is directly proportional to the sort of ailments they treat; and Estradiol storage issues are not something that commonly end up on their radar. This is one of the reasons why it’s so important for trans folk to become experts in and advocates of their own medical needs.)

Anyhow, I moved the medicine to the bedroom and so far, that seems to have done the trick!

My reason for mentioning this however is as follows: yesterday, post-injection, I had some major soreness in my thigh (as if someone had punched me right in the muscle). Most likely it was just regular, garden-variety soreness; but the sensation was close enough to the early onset of cellulitis that I seriously started freaking out.

Thankfully it’s calmed down today, and there isn’t a patch of redness in sight. Still: the trials and tribulations to go through!

Self-fulfilling prophecy

I’ve discussed before that I administer my Estradiol via intramuscular injection; and that sometimes this does not go to plan. This is not the only HRT-related mishap that I have experienced.

The first few months of injections were without issue.

Thereafter, I started to experience increasing amounts of pain with each shot; and in turn, I became more and more reluctant to - you know - actually stick the needle in my leg.

On the fifth go-around, I realized that I was breaking one of the (many) cardinal rules my endocrinology clinic had educated me on: don’t tense up! A tense muscle is a dense muscle; and it takes a lot more effort (and subsequently, discomfort) to push a needle through the tissue. My desire to avoid pain was, ironically, the cause of a great deal of pain!

I learned to relax, and not to hesitate when sticking myself (seriously, it’s like ripping off a Band-Aid - quick and forceful is so much more tolerable than slow and steady)!

I’m not going to pretend that popping the needle in is fun by any stretch; but it’s tolerable. If I have to do this twenty-eight times a year, between now and eternity, to attain True Girl Form... That’s a price I can live with!

Oh no

I was doing my progesterone shot last night and the plunger in the syringe got stuck 20% of the way in. I really put some force behind but, but it wasn’t moving and I was terrified that if it did suddenly give way I’d dump the entire contents of the syringe into my thigh in a split-second.

(I’m not sure of the exact ramifications for doing so, but my nurse practitioner was quite clear during instruction that this was an undesirable outcome.)

I really didn’t want to toss the rest of the progesterone (it’s not like I had more on hand), so I withdrew the syringe and switched to a fresh needle. Poked myself again, depressed the plunger, and...

...The syringe got stuck again.

As classic “Well, what the hell do I do now?” scenarios go, sitting there with an immovable syringe sticking out of your thigh has to count pretty highly, I reckon.

I wiggled the plunger a bit and applied more force than sensible, and finally the damn thing overcame whatever the resistance was and immediately dumped half the load (so I guess I will find out why that’s a no-no in short order). Everything proceeded smoothly from there.

I’m still nonplussed as to what the issue was. A manufacturing defect in the syringe itself perhaps? Some kind of sediment in the progesterone blocking the barrel of the needle? I have no idea.

I just really hope that this doesn’t happen again...

Update 1: I talked to my friend about this and her first go-around, the needle disengaged from the syringe while it was in her leg. OMG!

Update 2: I had more soreness than usual but was otherwise okay; so I’m guessing that firehosing half the dose didn’t do too much damage, thankfully.