Ahhhhh yes, now where was I? I’ve corrected my spiralling debt thanks to an early release of superannuation due to financial hardship. Taking away from future me isn’t too bad - especially as future me shouldn’t really exist. The fact that present day me exists is surprising to… me. For now I’m past that.

I’ve hit a bit of a problem with the ever-fast-approaching start of university. I can’t handle groups of people. Groups of people I don’t know anyway.

I have trialled visiting a gender therapy group repeatedly and either break down and fail to leave or get to the group, enter the building and… panic. I then escape the situation. Fear extinction will be difficult to achieve - especially in such a short time before university starts.

Doing nothing now will likely result in me deferring until 2025. In an effort to mitigate this I tried to restart antidepressants. I picked out the least side effect riddled one. In my case, that would be duloxetine (Cymbalta), an SNRI.

And no. I can’t even. Unrelenting bruxism 24/7. At the lowest dose. Every damn time. Bruxism is a documented adverse effect of serotonergic antidepressants, so that part was not imaginary. What I cannot conclude from it is that “something is wrong with my serotonin system” or that one mechanism explains every antidepressant I’ve failed to tolerate over the past decade. So where to from here?

My anxiety seems to fuel my depression and seems to be specific to interacting with groups of people. Of course there are the drugs that no one wants to prescribe because they are bad for you. Mainly drugs in the barbiturate and benzodiazepine-classes. I would argue that killing myself is also bad for me. I would rather feel better some of the time than none of the time. They are not available to me, so…

I’m trialling bupropion (Zyban, Wellbutrin), usually described as a norepinephrine-dopamine reuptake inhibitor. It has little direct serotonergic activity and, importantly for me, I wasn’t getting the same bruxism. There is evidence that bupropion can improve anxiety symptoms when they occur alongside depression, although pooled trials found a modest advantage for SSRIs in highly anxious depression. So “might help my anxious depression” was reasonable; “this is an anxiety medicine” would not be.

I had what I called a two-week honeymoon where everything felt magical and stimulating. Calling bupropion “pretty much a stimulant” and waiting for receptor down-regulation was me inventing a neat mechanism for my subjective early response. There is no universal two-week honeymoon rule. Now I wait and see whether the benefit lasts.

In other news I’ve scraped the top end of the so-called healthy BMI range. BMI is a rough population screening measure rather than a complete verdict on an individual body, but dropping from 34.8 to 24.8 reflected a substantial change in my weight and risk profile.

I was also thinking about deliberately cycling my weight to see whether GAHT changed where I regained fat. That was an experiment I was considering, not an evidence-based method for forcing fat redistribution, so don’t read it as a transition protocol.

What an excellent segue into the medication side of things for being a transgender woman. I’ve been monitoring a few things over the past month or so.

Progesterone is expensive and I am poor. So I had been comparing compounded progesterone with commercial Prometrium. At 400mg/day split twice daily, the compounded product gave me a slightly higher serum progesterone result on one set of tests. That does not establish bioequivalence between the formulations. Formulation, particle size, vehicle, food and release characteristics can all change progesterone pharmacokinetics.

However, there was one unexpected effect I appreciated. When I took oil-based Prometrium 200mg with food I experienced a short-lived sedated, mildly euphoric feeling that reminded me subjectively of diazepam. This is not a recommendation to take Prometrium with food: the Australian product information specifically says not to, because food increases its bioavailability. I also noticed this effect after stopping finasteride, which made progesterone-derived neurosteroids such as allopregnanolone an interesting possible explanation, but I had not measured those metabolites.

For a few hours each day, at a big hit to my wallet, I can leave my anxiety behind and actually get things done. It’s a very desirable side effect for me. For now I am not taking any progesterone to retest my baseline - it should be very low but not quite zero.

One of the reasons for retesting my baseline was a pretty big confounding factor: I was now taking modified-release compounded progesterone, so comparing the serum result directly with immediate-release Prometrium was messy. For one week I self-increased the modified-release product to 800mg/day trying to see whether anything changed. Nothing obvious did. That was a very high self-directed dosing experiment and a terrible way to establish formulation equivalence. It stays here because it happened, not because it is something to repeat.

I’m also checking serum DHT. A serum DHT result is real data, but it does not directly tell me the androgen exposure inside a particular hair follicle, where local 5-alpha reductase activity matters. I was mainly looking for broad shifts in steroid precursors on progesterone versus off progesterone. I’ll do another post when I have additional data.

It was also neat to see what my estradiol levels were soon after another set of pellets was implanted. I measured just over 1500pmol/L at about one week, compared with roughly 700pmol/L before the newest implants, and around 1200pmol/L another three weeks later. I originally called anything above 400pmol/L “gravy”. That’s not how this works. The Australian guidance I was using targeted roughly 250 to 600pmol/L, with treatment adjusted to clinical response. A higher concentration is not automatically a better transition result, and these early post-implant levels were above that target rather than a bonus.

See what the bupropion made me do? This post is massive. Oh well, until next time! 🥰

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