[automated] update transfemscience

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+<?xml version="1.0" encoding="utf-8"?><feed xmlns="http://www.w3.org/2005/Atom" ><generator uri="https://jekyllrb.com/" version="3.10.0">Jekyll</generator><link href="https://transfemscience.org/feed-posts.xml" rel="self" type="application/atom+xml" /><link href="https://transfemscience.org/" rel="alternate" type="text/html" /><updated>2025-05-08T19:10:31-07:00</updated><id>https://transfemscience.org/feed-posts.xml</id><title type="html">Transfeminine Science</title><subtitle>Transfeminine Science is a site for information on hormone therapy for transfeminine people.</subtitle><author><name>Transfeminine Science</name></author></feed>

transfemscience.org/feed.xml

@@ -1,4 +1,4 @@
-<?xml version="1.0" encoding="utf-8"?><feed xmlns="http://www.w3.org/2005/Atom" ><generator uri="https://jekyllrb.com/" version="3.10.0">Jekyll</generator><link href="https://transfemscience.org/feed.xml" rel="self" type="application/atom+xml" /><link href="https://transfemscience.org/" rel="alternate" type="text/html" /><updated>2025-02-12T20:49:20-08:00</updated><id>https://transfemscience.org/feed.xml</id><title type="html">Transfeminine Science | Articles</title><subtitle>Transfeminine Science is a site for information on hormone therapy for transfeminine people.</subtitle><author><name>Transfeminine Science</name></author><entry><title type="html">Puberty Blockers: A Review of GnRH Analogues in Transgender Youth</title><link href="https://transfemscience.org/articles/puberty-blockers/" rel="alternate" type="text/html" title="Puberty Blockers: A Review of GnRH Analogues in Transgender Youth" /><published>2022-01-30T15:04:00-08:00</published><updated>2022-01-31T00:00:00-08:00</updated><id>https://transfemscience.org/articles/puberty-blockers</id><content type="html" xml:base="https://transfemscience.org/articles/puberty-blockers/"><![CDATA[<h1 id="puberty-blockers-a-review-of-gnrh-analogues-in-transgender-youth">Puberty Blockers: A Review of GnRH Analogues in Transgender Youth</h1>
+<?xml version="1.0" encoding="utf-8"?><feed xmlns="http://www.w3.org/2005/Atom" ><generator uri="https://jekyllrb.com/" version="3.10.0">Jekyll</generator><link href="https://transfemscience.org/feed.xml" rel="self" type="application/atom+xml" /><link href="https://transfemscience.org/" rel="alternate" type="text/html" /><updated>2025-05-08T19:10:31-07:00</updated><id>https://transfemscience.org/feed.xml</id><title type="html">Transfeminine Science | Articles</title><subtitle>Transfeminine Science is a site for information on hormone therapy for transfeminine people.</subtitle><author><name>Transfeminine Science</name></author><entry><title type="html">Puberty Blockers: A Review of GnRH Analogues in Transgender Youth</title><link href="https://transfemscience.org/articles/puberty-blockers/" rel="alternate" type="text/html" title="Puberty Blockers: A Review of GnRH Analogues in Transgender Youth" /><published>2022-01-30T15:04:00-08:00</published><updated>2022-01-31T00:00:00-08:00</updated><id>https://transfemscience.org/articles/puberty-blockers</id><content type="html" xml:base="https://transfemscience.org/articles/puberty-blockers/"><![CDATA[<h1 id="puberty-blockers-a-review-of-gnrh-analogues-in-transgender-youth">Puberty Blockers: A Review of GnRH Analogues in Transgender Youth</h1>
 
 <!-- Supports up to four authors per article currently (author, author2, author3, author4) -->
 
@@ -467,13 +467,13 @@ Using the term desistence in this way does not imply anything about the identity
 <ul>
   <li>Abbott Laboratories. (2009). <em>Estradiol. Architect System.</em> Abbott Park, Illinois/Wiesbaden, Germany: Abbott Laboratories. [<a href="https://web.archive.org/web/20200127014925/http://www.ilexmedical.com/files/PDF/Estradiol_ARC.pdf">PDF</a>]</li>
   <li>Behre, H. M., Abshagen, K., Oettel, M., Hubler, D., &amp; Nieschlag, E. (1999). Intramuscular injection of testosterone undecanoate for the treatment of male hypogonadism: phase I studies. <em>European Journal of Endocrinology</em>, <em>140</em>(5), 414–419. [DOI:<a href="https://doi.org/10.1530/eje.0.1400414">10.1530/eje.0.1400414</a>]</li>
-</ul>]]></content><author><name>{&quot;first_name&quot;=&gt;&quot;Aly&quot;, &quot;last_name&quot;=&gt;&quot;W.&quot;, &quot;author-link&quot;=&gt;&quot;/about/#aly&quot;, &quot;articles-link&quot;=&gt;&quot;/articles-by-author/aly/&quot;}</name></author><category term="github" /><category term="workspace" /><summary type="html"><![CDATA[An Interactive Web Simulator for Estradiol Levels with Injectable Estradiol Esters By Aly | First published July 16, 2021 | Last modified April 12, 2023]]></summary><media:thumbnail xmlns:media="http://search.yahoo.com/mrss/" url="https://transfemscience.org/assets/images/injectable-e2/simulator-screenie.png" /><media:content medium="image" url="https://transfemscience.org/assets/images/injectable-e2/simulator-screenie.png" xmlns:media="http://search.yahoo.com/mrss/" /></entry><entry><title type="html">An Informal Meta-Analysis of Estradiol Curves with Injectable Estradiol Preparations</title><link href="https://transfemscience.org/articles/injectable-e2-meta-analysis/" rel="alternate" type="text/html" title="An Informal Meta-Analysis of Estradiol Curves with Injectable Estradiol Preparations" /><published>2021-07-16T12:00:00-07:00</published><updated>2024-06-27T00:00:00-07:00</updated><id>https://transfemscience.org/articles/injectable-e2-meta-analysis</id><content type="html" xml:base="https://transfemscience.org/articles/injectable-e2-meta-analysis/"><![CDATA[<h1 id="an-informal-meta-analysis-of-estradiol-curves-with-injectable-estradiol-preparations">An Informal Meta-Analysis of Estradiol Curves with Injectable Estradiol Preparations</h1>
+</ul>]]></content><author><name>{&quot;first_name&quot;=&gt;&quot;Aly&quot;, &quot;last_name&quot;=&gt;&quot;W.&quot;, &quot;author-link&quot;=&gt;&quot;/about/#aly&quot;, &quot;articles-link&quot;=&gt;&quot;/articles-by-author/aly/&quot;}</name></author><category term="github" /><category term="workspace" /><summary type="html"><![CDATA[An Interactive Web Simulator for Estradiol Levels with Injectable Estradiol Esters By Aly | First published July 16, 2021 | Last modified April 12, 2023]]></summary><media:thumbnail xmlns:media="http://search.yahoo.com/mrss/" url="https://transfemscience.org/assets/images/injectable-e2/simulator-screenie.png" /><media:content medium="image" url="https://transfemscience.org/assets/images/injectable-e2/simulator-screenie.png" xmlns:media="http://search.yahoo.com/mrss/" /></entry><entry><title type="html">An Informal Meta-Analysis of Estradiol Curves with Injectable Estradiol Preparations</title><link href="https://transfemscience.org/articles/injectable-e2-meta-analysis/" rel="alternate" type="text/html" title="An Informal Meta-Analysis of Estradiol Curves with Injectable Estradiol Preparations" /><published>2021-07-16T12:00:00-07:00</published><updated>2025-05-08T00:00:00-07:00</updated><id>https://transfemscience.org/articles/injectable-e2-meta-analysis</id><content type="html" xml:base="https://transfemscience.org/articles/injectable-e2-meta-analysis/"><![CDATA[<h1 id="an-informal-meta-analysis-of-estradiol-curves-with-injectable-estradiol-preparations">An Informal Meta-Analysis of Estradiol Curves with Injectable Estradiol Preparations</h1>
 
 <!-- Supports up to four authors per article currently (author, author2, author3, author4) -->
 
 <p>By 
 <!-- First author --><a href="/about/#aly">Aly</a><!-- Second author --><!-- Third author --><!-- Fourth author --> | First published July 16, 2021
-   | Last modified June 27, 2024</p>
+   | Last modified May 8, 2025</p>
 
 <h2 id="abstract--tldr">Abstract / TL;DR</h2>
 
@@ -1944,10 +1944,10 @@ Using the term desistence in this way does not imply anything about the identity
 
 <h4 id="rothman-et-al-2024">Rothman et al. (2024)</h4>
 
-<p>Rothman, M. S., Ariel, D., Kelley, C., Hamnvik, O. R., Abramowitz, J., Irwig, M. S., Soe, K., Davidge-Pitts, C., Misakian, A. L., Safer, J. D., &amp; Iwamoto, S. J. (2024). The Use of Injectable Estradiol in Transgender and Gender Diverse Adults: A Scoping Review of Dose and Serum Estradiol Levels. <em>Endocrine Practice</em>, ahead of print. [DOI:<a href="https://doi.org/10.1016/j.eprac.2024.05.008">10.1016/j.eprac.2024.05.008</a>]:</p>
+<p>Rothman, M. S., Ariel, D., Kelley, C., Hamnvik, O. R., Abramowitz, J., Irwig, M. S., Soe, K., Davidge-Pitts, C., Misakian, A. L., Safer, J. D., &amp; Iwamoto, S. J. (2024). The Use of Injectable Estradiol in Transgender and Gender Diverse Adults: A Scoping Review of Dose and Serum Estradiol Levels. <em>Endocrine Practice</em>, <em>30</em>(9), 870–878. [DOI:<a href="https://doi.org/10.1016/j.eprac.2024.05.008">10.1016/j.eprac.2024.05.008</a>]:</p>
 
 <blockquote>
-  <p>In recent years, we have noted trends in our clinical practices with TGD adults requesting injectable estradiol, particularly in the United States. The reasons given can vary; it may be due to ease of weekly or every two weeks administration, fatigue of taking daily oral medications and skin reactions to or cost of transdermal preparations. There have been discussions as to the roles of estrone/estradiol ratios in feminization and whether injectable estradiol might lead to more favorable results, however research has not supported a role for estrone in optimizing feminizing outcomes [13]. There is also a belief that higher levels can be attained with 82 injections and may lead to faster and more complete feminization; however, there is a lack of data in the literature to support these conclusions. Such conversations occurring on reddit.com and even some hormone provider websites, are perhaps related to the historical use of high dose injectable estradiol noted above [14]. However, there is a paucity of data to guide clinicians on what dose, type and at what interval estradiol esters should be injected and when levels should be measured to ensure physiologic range estradiol levels. In fact, recent reports and clinical observations have raised concerns that the dosing suggested in guidelines may result in supraphysiological estradiol levels and that higher doses and levels may put patients at elevated risk of thromboembolic events [15-18]. This scoping review examines the available data on levels achieved with various dosages of estradiol injections in TGD adults. We also report on testosterone suppression, route (i.e., SC vs. IM), and type of estradiol ester as well as timing of blood draw relative to dose, where available.</p>
+  <p>In recent years, we have noted trends in our clinical practices with TGD adults requesting injectable estradiol, particularly in the United States. The reasons given can vary; it may be due to ease of weekly or every two weeks administration, fatigue of taking daily oral medications and skin reactions to or cost of transdermal preparations. There have been discussions as to the roles of estrone/estradiol ratios in feminization and whether injectable estradiol might lead to more favorable results, however research has not supported a role for estrone in optimizing feminizing outcomes [13]. There is also a belief that higher levels can be attained with injections and may lead to faster and more complete feminization; however, there is a lack of data in the literature to support these conclusions. Such conversations occurring on reddit.com and even some hormone provider websites, are perhaps related to the historical use of high dose injectable estradiol noted above [14]. However, there is a paucity of data to guide clinicians on what dose, type and at what interval estradiol esters should be injected and when levels should be measured to ensure physiologic range estradiol levels. In fact, recent reports and clinical observations have raised concerns that the dosing suggested in guidelines may result in supraphysiological estradiol levels and that higher doses and levels may put patients at elevated risk of thromboembolic events [15-18]. This scoping review examines the available data on levels achieved with various dosages of estradiol injections in TGD adults. We also report on testosterone suppression, route (i.e., SC vs. IM), and type of estradiol ester as well as timing of blood draw relative to dose, where available.</p>
 </blockquote>
 
 <blockquote>
@@ -1960,12 +1960,41 @@ Using the term desistence in this way does not imply anything about the identity
   <p>16. https://transfemscience.org/articles/injectable-e2-meta-analysis/. [March 16, 2024].</p>
 </blockquote>
 
+<h4 id="toffoli-ribeiro-et-al-2024">Toffoli Ribeiro et al. (2024)</h4>
+
+<p>Toffoli Ribeiro, C., Gois, Í., da Rosa Borges, M., Ferreira, L. G. A., Brandão Vasco, M., Ferreira, J. G., Maia, T. C., &amp; Dias-da-Silva, M. R. (2024). Assessment of parenteral estradiol and dihydroxyprogesterone use among other feminizing regimens for transgender women: insights on satisfaction with breast development from community-based healthcare services. <em>Annals of Medicine</em>, <em>56</em>(1), 2406458. [DOI:<a href="https://doi.org/10.1080/07853890.2024.2406458">10.1080/07853890.2024.2406458</a>]:</p>
+
+<blockquote>
+  <p>Utilizing a previously published meta-analysis method of estradiol concentration-time data from publicly available information on cisgender women who had used EEn or EEn/DHPA [17], we reanalyzed and integrated data from various studies. […]</p>
+
+  <p>[…] The V3C Fitter and Desmos tools, accessible online at https://alyw234237.github.io/injectable-e2-simulator/v3c-fitter/ and https://www.desmos.com/calculator/ndgvp2avhj?lang=pt-BR respectively, were utilized for fitting the three-compartment pharmacokinetic model. […]</p>
+</blockquote>
+
+<blockquote>
+  <p>Pharmacokinetics of injectable estradiol enanthate</p>
+
+  <p>[…] The boxplot graph (Figure 5) illustrates that the median estradiol levels in trans women using EEn/DHPA fell within this population’s expected average range values (100–200pg/mL).</p>
+</blockquote>
+
+<blockquote>
+  <p><img src="/assets/images/injectable-e2/toffoli-ribeiroa-et-al.-2024-een-meta-analysis.png" alt="" />
+Figure 5. Meta-analysis of estradiol concentration-time data from cisgender women under EEn alone or EEn/DHPA. Fitted data curves from various studies individually and combined into a single-dose curve over 30 days were generated based on an informal meta-analysis of published estradiol concentration-time data from cisgender women under EEn or EEn/DHPA [17]. […]</p>
+</blockquote>
+
+<blockquote>
+  <p>References</p>
+</blockquote>
+
+<blockquote>
+  <p>[17] Aly. 2021. An informal meta-analysis of estradiol curves with injectable estradiol preparations. Transfeminine Sci. https:// transfemscience.org/articles/injectable-e2-meta-analysis/</p>
+</blockquote>
+
 <h3 id="update-3-herndon-et-al-2023">Update 3: Herndon et al. (2023)</h3>
 
 <p>In March 2023, the following study on injectable estradiol in transfeminine people was published online:</p>
 
 <ul>
-  <li>Herndon, J. S., Maheshwari, A. K., Nippoldt, T. B., Carlson, S. J., Davidge-Pitts, C. J., &amp; Chang, A. Y. (2023). Comparison of Subcutaneous and Intramuscular Estradiol Regimens as part of Gender-Affirming Hormone Therapy. <em>Endocrine Practice</em>, <em>29</em>(5), 356–361. [DOI:<a href="https://doi.org/10.1016/j.eprac.2023.02.006">10.1016/j.eprac.2023.02.006</a>] [<a href="https://www.sciencedirect.com/science/article/abs/pii/S1530891X23000502">URL</a>]</li>
+  <li>Herndon, J. S., Maheshwari, A. K., Nippoldt, T. B., Carlson, S. J., Davidge-Pitts, C. J., &amp; Chang, A. Y. (2023). Comparison of Subcutaneous and Intramuscular Estradiol Regimens as part of Gender-Affirming Hormone Therapy. <em>Endocrine Practice</em>, <em>29</em>(5), 356–361. [DOI:<a href="https://doi.org/10.1016/j.eprac.2023.02.006">10.1016/j.eprac.2023.02.006</a>]</li>
 </ul>
 
 <p>The study was a retrospective analysis of individualized injectable estradiol in adult transfeminine people who received hormone therapy at the <a href="https://en.wikipedia.org/wiki/Mayo_Clinic">Mayo Clinic</a>. Doses of injectable estradiol were adjusted by clinical providers based on estradiol levels, testosterone suppression, and feminization goals, and subsequently these clinical data were retrospectively studied by Mayo Clinic researchers. The primary aim of the study was to compare injectable estradiol by intramuscular versus subcutaneous routes. However, other general considerations for injectable estradiol, such as dosing, estradiol levels, testosterone suppression, type of injectable estradiol ester (estradiol valerate vs. estradiol cypionate), and estradiol monotherapy versus concomitant use of antiandrogens, were also assessed. The paper noted that the study was the largest to assess injectable estradiol in transfeminine people to date and was the first to directly compare intramuscular and subcutaneous injectable estradiol routes in transfeminine people.</p>
@@ -2003,7 +2032,7 @@ Using the term desistence in this way does not imply anything about the identity
 <p>In February 2024, the following short review on injectable estradiol dosing in transfeminine people by Micol Rothman and colleagues was published online:</p>
 
 <ul>
-  <li>Rothman, M. S., Hamnvik, O. P. R., Davidge-Pitts, C., Safer, J. D., Ariel, D., Tangpricha, V., Abramowitz, J., Soe, K., Sarvaideo, J., Kelley, C., Irwig, M. S., &amp; Iwamoto, S. J. (2024). Revisiting Injectable Estrogen Dosing Recommendations for Gender-Affirming Hormone Therapy. <em>Transgender Health</em>, ahead of print. [DOI:<a href="https://doi.org/10.1089/trgh.2023.0209">10.1089/trgh.2023.0209</a>]</li>
+  <li>Rothman, M. S., Hamnvik, O. P. R., Davidge-Pitts, C., Safer, J. D., Ariel, D., Tangpricha, V., Abramowitz, J., Soe, K., Sarvaideo, J., Kelley, C., Irwig, M. S., &amp; Iwamoto, S. J. (2024). Revisiting Injectable Estrogen Dosing Recommendations for Gender-Affirming Hormone Therapy. <em>Transgender Health</em>, <em>9</em>(6), 463–465. [DOI:<a href="https://doi.org/10.1089/trgh.2023.0209">10.1089/trgh.2023.0209</a>]</li>
 </ul>
 
 <p>Here is the abstract of the paper:</p>
@@ -2015,7 +2044,7 @@ Using the term desistence in this way does not imply anything about the identity
 <p>Then, in May 2024, the following longer and more comprehensive review on injectable estradiol dosing in transfeminine people by Rothman and most of the same other academics was published online:</p>
 
 <ul>
-  <li>Rothman, M. S., Ariel, D., Kelley, C., Hamnvik, O. R., Abramowitz, J., Irwig, M. S., Soe, K., Davidge-Pitts, C., Misakian, A. L., Safer, J. D., &amp; Iwamoto, S. J. (2024). The Use of Injectable Estradiol in Transgender and Gender Diverse Adults: A Scoping Review of Dose and Serum Estradiol Levels. <em>Endocrine Practice</em>, ahead of print. [DOI:<a href="https://doi.org/10.1016/j.eprac.2024.05.008">10.1016/j.eprac.2024.05.008</a>]</li>
+  <li>Rothman, M. S., Ariel, D., Kelley, C., Hamnvik, O. R., Abramowitz, J., Irwig, M. S., Soe, K., Davidge-Pitts, C., Misakian, A. L., Safer, J. D., &amp; Iwamoto, S. J. (2024). The Use of Injectable Estradiol in Transgender and Gender Diverse Adults: A Scoping Review of Dose and Serum Estradiol Levels. <em>Endocrine Practice</em>, <em>30</em>(9), 870–878. [DOI:<a href="https://doi.org/10.1016/j.eprac.2024.05.008">10.1016/j.eprac.2024.05.008</a>]</li>
 </ul>
 
 <p>Here is the abstract of this paper:</p>
@@ -2034,6 +2063,10 @@ Using the term desistence in this way does not imply anything about the identity
 
 <p>Aside from Micol Rothman herself, these reviews were also authored by other well-known experts in transgender health. For instance, two of the coauthors, Joshua Safer and Michael Irwig, were authors for the WPATH SOC8 hormone therapy chapter (<a href="https://www.wpath.org/media/cms/Documents/SOC%20v8/SOC8%20Full%20Contributor%20List%20-%20FINAL%20UPDATED%2009232021.pdf">WPATH SOC8 Full Contributor List</a>). Additionally, Safer was one of the authors for the Endocrine Society’s transgender hormone therapy guidelines (<a href="https://doi.org/10.1210/jc.2017-01658">Hembree et al., 2017</a>). As such, it would appear that transgender medicine has finally started to seriously correct injectable estradiol dosing. This is a very important development. Now, the appropriate dosing and intervals of injectable estradiol will need to be more precisely established and the corrections will need to make their way into updated transgender hormone therapy guidelines and general clinical practice.</p>
 
+<p>A letter to the editor commented on and concorded with Rothman and colleagues’ second literature review:</p>
+
+<p>Patel, K. T., &amp; Tangpricha, V. (2024). Parenteral Estradiol for Transgender Women: Time to adjust the dose. <em>Endocrine Practice</em>, <em>30</em>(9), 893–894. [DOI:<a href="https://doi.org/10.1016/j.eprac.2024.07.005">10.1016/j.eprac.2024.07.005</a>]</p>
+
 <h3 id="update-5-kariyawasam-et-al-2024">Update 5: Kariyawasam et al. (2024)</h3>
 
 <p>In March 2024, the following study of estradiol levels with different routes of estradiol in transfeminine people, including injectable estradiol, was published:</p>
@@ -2062,6 +2095,173 @@ Using the term desistence in this way does not imply anything about the identity
   <p>Lastly, while estradiol valerate and cypionate are only FDA-approved for intramuscular administration, many patients prefer subcutaneous administration. There are small studies that suggest the pharmacokinetics of intramuscular and subcutaneous estradiol are similar [4]. While the UCSF Guidelines comment on the use of subcutaneous estradiol, other guidelines should be updated to include this option for patients [2].</p>
 </blockquote>
 
+<h3 id="update-7-toffoli-ribeiro-et-al-2024">Update 7: Toffoli Ribeiro et al. (2024)</h3>
+
+<p>Toffoli Ribeiro, C., Gois, Í., da Rosa Borges, M., Ferreira, L. G. A., Brandão Vasco, M., Ferreira, J. G., Maia, T. C., &amp; Dias-da-Silva, M. R. (2024). Assessment of parenteral estradiol and dihydroxyprogesterone use among other feminizing regimens for transgender women: insights on satisfaction with breast development from community-based healthcare services. <em>Annals of Medicine</em>, <em>56</em>(1), 2406458. [DOI:<a href="https://doi.org/10.1080/07853890.2024.2406458">10.1080/07853890.2024.2406458</a>]:</p>
+
+<blockquote>
+  <p>This study examines the effects of a commonly used injectable hormone combination, specifically estradiol enanthate with dihydroxyprogesterone acetophenide (EEn/DHPA), […] Our research focused on a retrospective longitudinal study involving a large cohort of transwomen evaluated between 2020 and 2022, comprising 101 participants. We assessed serum levels of estradiol (E2), testosterone (T), luteinizing hormone (LH), and follicle-stimulating hormone (FSH), comparing the EEn/DHPA hormonal regimen with other combined estrogen-progestogen (CEP) therapies. […] Our findings indicated that participants using the EEn/DHPA regimen exhibited significantly higher serum E2 levels (mean: 186 pg/mL ± 32 pg/mL) than those using other therapies (62 ± 7 pg/mL), along with lower FSH levels, but no significant differences in T and LH levels. […] These results suggest that an injectable, low-cost EEn/DHPA administered every three weeks could serve as an alternative feminizing regimen, particularly considering the extensive long-term experience of the local transgender community. Further longitudinal studies on the efficacy of feminizing-body effects and endovascular risks of various parenteral CEP types are warranted to improve primary healthcare provision for transgender persons.</p>
+</blockquote>
+
+<blockquote>
+  <p>Introduction</p>
+</blockquote>
+
+<blockquote>
+  <p>Injectable combined estrogens with progestogens (CEP) have long been widely used in Brazil and other Latin American countries, predominantly among ciswomen as an injectable contraceptive and by Brazilian transgender women and travestis as GAHT [8]. Despite the absence of recognition by the Endocrine Society as an alternative hormonal regimen due to concerns regarding thrombogenicity and challenges in routine monitoring through blood testing, the prevalent use of CEP necessitates evaluating its regimen recommendations. This has led our research to delve deeper into understanding CEP regimens, considering the experiences of travestis amidst distinct sociocultural lifestyles and limited access to public endocrinological care services [15,16]. Hence, our objective is to elucidate our observations in monitoring trans individuals utilizing CEP regimens by evaluating hormone levels […] within a cohort of transwomen employing the most common injectable CEP, namely estradiol enanthate with dihydroxyprogesterone acetophenide (EEn/DHPA) and comparing these observations with other GAHT regimens.</p>
+</blockquote>
+
+<blockquote>
+  <p>Subjects and methods</p>
+</blockquote>
+
+<blockquote>
+  <p>Estradiol enanthate pharmacokinetics curve</p>
+
+  <p>Utilizing a previously published meta-analysis method of estradiol concentration-time data from publicly available information on cisgender women who had used EEn or EEn/DHPA [17], we reanalyzed and integrated data from various studies. A unified single-dose curve for 30 days was created. We employed least squares regression for studies with four or more concentration-time data points (solid lines). We manually adjusted other studies with three data points to fit into a single-dose curve.</p>
+
+  <p>Each study’s data were adjusted for baseline estradiol levels or endogenous estradiol production and then normalized by 10 mg. The V3C Fitter and Desmos tools, accessible online at https://alyw234237.github.io/injectable-e2-simulator/v3c-fitter/ and https://www.desmos.com/calculator/ndgvp2avhj?lang=pt-BR respectively, were utilized for fitting the three-compartment pharmacokinetic model. Estradiol levels from transgender women on EEn/DHPA in this study were presented using a box plot graph featuring percentiles at 10, 25, 50, 75, and 90.</p>
+</blockquote>
+
+<blockquote>
+  <p>Results</p>
+</blockquote>
+
+<blockquote>
+  <p>Hormonal levels during the follow-up of feminizing regimens</p>
+
+  <p>Scatter plot graphs depicted the measurement of sex hormones (Figure 2). Serum estradiol levels in the EEn/ DHPA group (mean: 186.4pg/mL ± 32.8pg/mL) were significantly higher than those in the group using other therapies (62.2±6.9pg/mL) (Figure 2(A)). Within the EEn/DHPA group, serum FSH levels were significantly lower compared to the other group (Others) (Figure 2(B)). However, no significant difference was found between the groups concerning testosterone (Figure 2(C)) and LH (Figure 2(D)) levels.</p>
+</blockquote>
+
+<blockquote>
+  <p>Pharmacokinetics of injectable estradiol enanthate</p>
+
+  <p>Serum estradiol levels in trans women using EEn/DHPA reached the target levels for this population during hormone therapy, a trend not observed in participants using other feminizing hormone therapies (Table 1). The boxplot graph (Figure 5) illustrates that the median estradiol levels in trans women using EEn/DHPA fell within this population’s expected average range values (100–200pg/mL).</p>
+</blockquote>
+
+<blockquote>
+  <p><img src="/assets/images/injectable-e2/toffoli-ribeiroa-et-al.-2024-een-meta-analysis.png" alt="" />
+Figure 5. Meta-analysis of estradiol concentration-time data from cisgender women under EEn alone or EEn/DHPA. Fitted data curves from various studies individually and combined into a single-dose curve over 30 days were generated based on an informal meta-analysis of published estradiol concentration-time data from cisgender women under EEn or EEn/DHPA [17]. For studies with four or more concentration-time data points (solid lines) and the fit of combined data (thick black line), least squares regression to a three-compartment pharmacokinetic model was employed. A single-dose curve was manually adjusted for studies with three data points (dashed lines). Data from each study were adjusted for endogenous estradiol production via baseline or trough estradiol levels subtraction and normalized by 10mg. The graph illustrates estradiol levels from the transwoman cohort in a boxplot. The shaded area represents the optimal target range for estradiol levels in transwomen under hormone therapy. The boxplot graph displays the percentiles 10, 25, 50, 75, and 90 for estradiol levels of transwomen under EEn/DHPA in this study (N=53).</p>
+</blockquote>
+
+<blockquote>
+  <p>Discussion</p>
+</blockquote>
+
+<blockquote>
+  <p>Our study represents a pioneering contribution to the literature by demonstrating that Brazilian trans women undergoing EEn/DHPA therapy achieved estradiol levels comparable to those observed during the follicular phase in cisgender women. […]</p>
+</blockquote>
+
+<blockquote>
+  <p>Our study further noted that DHPA demonstrates comparable efficacy to cyproterone or other anti-androgens in achieving optimal LH pituitary suppression and reducing testosterone levels. EEn/ DHPA, an affordable injectable contraceptive widely accessible in South American countries, presents a promising avenue for attaining target hormone levels among transfeminine individuals.</p>
+
+  <p>Additionally, our investigation, which reviewed pharmacokinetic data, supports the potential implementation of EEn/DHPA in a 21-day regimen to sustain optimal estradiol levels. While alternative medications exist to inhibit testosterone production and action, their availability varies based on regional healthcare provider systems. […]</p>
+
+  <p>EEn/DHPA, commonly used as a long-lasting injectable contraceptive [21–23], has found application in feminizing hormone therapy for transfeminine people, notably in travestis in Brazil [7,8,24,25]. […]</p>
+</blockquote>
+
+<blockquote>
+  <p>In conclusion, our long-term cohort study suggests that administering parenteral estradiol enanthate with dihydroxyprogesterone acetophenide every three weeks could serve as a practical option for feminizing hormone regimens in transgender women. Nonetheless, adopting an individualized approach that takes into account each individual’s goals, response to prior hormone therapies, and medical history is crucial. This personalized approach is central to improving healthcare provision and ensuring optimal outcomes in bodily changes. By continuing to explore and refine hormone therapy regimens, we can better support the health and well-being of transgender individuals on their gender-affirming journey.</p>
+</blockquote>
+
+<blockquote>
+  <p>References</p>
+</blockquote>
+
+<blockquote>
+  <p>[17] Aly. 2021. An informal meta-analysis of estradiol curves with injectable estradiol preparations. Transfeminine Sci. https:// transfemscience.org/articles/injectable-e2-meta-analysis/</p>
+</blockquote>
+
+<h3 id="update-8-misakian-et-al-2025">Update 8: Misakian et al. (2025)</h3>
+
+<p>Misakian, A. L., Kelley, C. E., Sullivan, E. A., Chang, J. J., Singh, G., Kokosa, S., Avila, J., Cooper, H., Liang, J. W., Botzheim, B., Quint, M., Jeevananthan, A., Chi, E., Harmer, M., Hiatt, L., Kowalewski, M., Steinberg, B., Tausinga, T., Tanner, H., Ho, T. F., … Ariel, D. (2025). Injectable Estradiol Use in Transgender and Gender-Diverse Individuals throughout the United States. <em>The Journal of Clinical Endocrinology &amp; Metabolism</em>, dgaf015. [DOI:<a href="https://doi.org/10.1210/clinem/dgaf015">10.1210/clinem/dgaf015</a>]:</p>
+
+<blockquote>
+  <p>Context: Guidelines for use of injectable estradiol esters (valerate [EV] and cypionate [EC]) among transgender and gender-diverse (TGD) individuals designated male at birth vary considerably, with many providers noting supraphysiologic serum estradiol concentrations based on current dosing recommendations.</p>
+
+  <p>Objectives: This work aimed to 1. determine the dose of injectable estradiol (subcutaneous [SC] and intramuscular [IM]) needed to reach guideline-recommended estradiol concentrations for TGD adults using EC/EV; 2. describe the relationship between estradiol concentration relative to timing/dose of last estradiol injection and other covariates; and 3. determine dosing differences between IM/SC EV/EC.</p>
+
+  <p>Methods: A cross-sectional retrospective study was conducted across 6 US medical centers including TGD adults on same-dose injectable estradiol for more than 75 days, with confirmed timing of estradiol concentration relative to last injection, from January 1, 2019 to December 31, 2023. Descriptive statistics were used to describe patient characteristics and weighted linear mixed models to evaluate relationship between various covariates and estradiol concentration.</p>
+
+  <p>Results: Data from 562 patients were included. Among those injecting every 7 days who reached the guideline-recommended estradiol concentration (n = 131, 27.5%), the median estradiol dose was 4.0 mg (interquartile range, 3.0-5.0 mg). Among all patients, the majority reached supraphysiologic estradiol concentrations (&gt;200 pg/mL [&gt;734 pmol/L]) while dose and timing in the injection cycle were significant covariates for the estradiol concentration. There were no significant dosing differences between IM/SC EV/EC.</p>
+
+  <p>Conclusion: Injectable estradiol esters effectively reach guideline-recommended estradiol concentrations but at lower doses than previously recommended. Estradiol concentrations are best interpreted relative to timing of last injection. Route of administration and type of ester do not significantly affect estradiol concentrations.</p>
+</blockquote>
+
+<blockquote>
+  <p>[…]</p>
+</blockquote>
+
+<p>And a letter to the editor commenting on the paper:</p>
+
+<ul>
+  <li>Milano, C., &amp; Harper, J. (2025). Comments on Injectable Estradiol Use in Transgender and Gender-Diverse Individuals in the US. <em>The Journal of Clinical Endocrinology &amp; Metabolism</em>, dgaf134. [DOI:<a href="https://doi.org/10.1210/clinem/dgaf134">10.1210/clinem/dgaf134</a>]</li>
+</ul>
+
+<h3 id="update-9-slack-et-al-2025">Update 9: Slack et al. (2025)</h3>
+
+<p>Slack, D. J., Di Via Ioschpe, A., Saturno, M., Kihuwa-Mani, S., Amakiri, U. O., Guerra, D., Karim, S., &amp; Safer, J. D. (2025). Examining the Influence of the Route of Administration and Dose of Estradiol on Serum Estradiol and Testosterone Levels in Feminizing Gender-Affirming Hormone Therapy. <em>Endocrine Practice</em>, <em>31</em>(1), 19–27. [DOI:<a href="https://doi.org/10.1016/j.eprac.2024.10.002">10.1016/j.eprac.2024.10.002</a>]:</p>
+
+<blockquote>
+  <p>Introduction: […] This study investigates the effect of route of administration (ROA) and dose of estradiol on estradiol (E2) and testosterone (T) levels in transfeminine individuals.</p>
+
+  <p>Methods: We conducted a chart review of 573 patients with an active prescription for estradiol for feminizing GAHT and serum hormone levels available.</p>
+
+  <p>Results: […] Intramuscular estradiol was associated with lower T and higher E2 compared to oral and transdermal ROAs (P &lt; .001), with many achieving target hormone levels even at low doses.</p>
+
+  <p>Conclusions: […] The intramuscular ROA appears to be the most potent delivery of estradiol with impact on serum hormone levels with doses on the low end of guideline-suggested ranges.</p>
+</blockquote>
+
+<blockquote>
+  <p>[…]</p>
+</blockquote>
+
+<h3 id="update-10-carlson-et-al-2025">Update 10: Carlson et al. (2025)</h3>
+
+<p>Carlson, S. M., Dominguez, C., Jeevananthan, A., &amp; Crowley, M. J. (2025). Follow-Up Estradiol Levels Based on Regimen Formulation With Guideline-Concordant Gender-Affirming Hormone Therapy. <em>Journal of the Endocrine Society</em>, <em>9</em>(3), bvae205. [DOI:<a href="https://doi.org/10.1210/jendso/bvae205">10.1210/jendso/bvae205</a>]:</p>
+
+<blockquote>
+  <p>Context: Endocrine Society guidelines for dosing of feminizing gender-affirming hormone therapy (GAHT) have remained essentially unchanged since 2009. The Endocrine Society recommends periodic monitoring of serum estradiol levels, with the goal of maintaining levels in the premenopausal cisgender female range (100-200 pg/mL). However, it is not clear whether guideline-concordant dosing consistently produces guideline-recommended levels across common estradiol formulation types (oral pills, parenteral injections, transdermal patches).</p>
+
+  <p>Objective: All transgender and nonbinary patients receiving estradiol-based GAHT between October 2015 and March 2023 were reviewed at a single center, with the goal of determining the frequency with which guideline-concordant dosing with different estradiol formulations led to guideline-recommended estradiol levels.</p>
+
+  <p>Methods: Demographics, GAHT regimen, and estradiol levels were obtained via chart review, and data were analyzed descriptively.</p>
+
+  <p>Results: The analytic population included n = 35 individuals, including n = 9 prescribed oral estradiol pills, n = 11 prescribed parenteral injections, and n = 15 prescribed transdermal patches. With guideline-concordant doses of oral estradiol (mean 2.8 mg daily), the mean follow-up level was 168 pg/mL; 32% of follow-up levels were subtherapeutic and 14% were supratherapeutic. With guideline-concordant doses of parenteral estradiol (mean 5.8 mg weekly), the mean midpoint follow-up level was 342 pg/mL; 91% of midpoint follow-up levels were supratherapeutic. With guideline-concordant doses of transdermal estradiol (mean 0.09 mg/day), the mean follow-up level was 81.5 pg/mL; 70% of follow-up levels were subtherapeutic.</p>
+
+  <p>Conclusion: Supratherapeutic follow-up estradiol levels were common with guideline-concordant parenteral estradiol doses, as were subtherapeutic follow-up levels with guideline-concordant transdermal doses. These findings may suggest the need for revision of guideline-recommended estradiol doses for these formulations</p>
+</blockquote>
+
+<blockquote>
+  <p>[…]</p>
+</blockquote>
+
+<h3 id="update-11-kanin-et-al-2025">Update 11: Kanin et al. (2025)</h3>
+
+<p>Kanin, M., Slack, M., Patel, R., Chen, K. T., Jackson, N., Williams, K. C., &amp; Grock, S. (2025). Injectable Estradiol Dosing Regimens in Transgender and Nonbinary Adults Listed as Male at Birth. <em>Journal of the Endocrine Society</em>, bvaf004. [DOI:<a href="https://doi.org/10.1210/jendso/bvaf004">10.1210/jendso/bvaf004</a>]:</p>
+
+<blockquote>
+  <p>Context: Many transgender and nonbinary (TGNB) individuals assigned male at birth (AMAB) seek hormone therapy to achieve physical and emotional changes. Standard therapy includes estradiol, with or without an antiandrogen. Our clinical observations suggest that currently recommended injectable estradiol dosing may lead to supratherapeutic estradiol levels.</p>
+
+  <p>Objective: We sought to evaluate whether lower-than-recommended doses of injectable estradiol were effective in achieving serum estradiol and testosterone goals.</p>
+
+  <p>Methods: We conducted a retrospective cohort study to evaluate injectable estradiol dosing in treatment-naive AMAB individuals initiating hormone therapy. Data from a single provider at an academic center from January 2017 to March 2023 were analyzed. A total of 29 patients were eligible for inclusion. The primary variables of estradiol dosage, serum estradiol, and testosterone levels were analyzed over 15 months.</p>
+
+  <p>Results: The average estradiol dose decreased from 4.3 to 3.7 mg weekly (P &lt; .001) during the study period with a final on-treatment estradiol level of 248 pg/mL. All individuals achieved a testosterone level of less than 50 ng/dL during the study period. The average initial on-treatment testosterone level was not significantly different from average final on-treatment measurement of 24.0 mg/dL (P = .95). […]</p>
+
+  <p>Conclusion: Lower doses of injectable estradiol can achieve therapeutic estradiol levels with excellent testosterone suppression. […]</p>
+</blockquote>
+
+<blockquote>
+  <p>[…]</p>
+</blockquote>
+
+<p>This study had been previously published as a conference abstract:</p>
+
+<ul>
+  <li>Kanin, M., Slack, M., Patel, R., Chen, K. T., Jackson, N., Williams, K., &amp; Grock, S. (2024). 8309 Injectable Estradiol Dosing Regimens; A Retrospective Review of Hormone Therapy for Gender-Diverse Adults Assigned Male at Birth. <em>Journal of the Endocrine Society</em>, <em>8</em>(Suppl 1), bvae163-1706. [DOI:<a href="https://doi.org/10.1210/jendso/bvae163.1706">10.1210/jendso/bvae163.1706</a>]</li>
+</ul>
+
 <h2 id="supplementary-material">Supplementary Material</h2>
 
 <ul>
@@ -2093,11 +2293,12 @@ Using the term desistence in this way does not imply anything about the identity
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+  <li>Carlson, S. M., Dominguez, C., Jeevananthan, A., &amp; Crowley, M. J. (2025). Follow-Up Estradiol Levels Based on Regimen Formulation With Guideline-Concordant Gender-Affirming Hormone Therapy. <em>Journal of the Endocrine Society</em>, <em>9</em>(3), bvae205. [DOI:<a href="https://doi.org/10.1210/jendso/bvae205">10.1210/jendso/bvae205</a>]</li>
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+  <li>Chantrapanichkul, P., Stevenson, M. O., Suppakitjanusant, P., Goodman, M., &amp; Tangpricha, V. (2021). Serum Hormone Concentrations in Transgender Individuals Receiving Gender-Affirming Hormone Therapy: A Longitudinal Retrospective Cohort Study. <em>Endocrine Practice</em>, <em>27</em>(1), 27–33. [DOI:<a href="https://doi.org/10.4158/EP-2020-0414">10.4158/EP-2020-0414</a>] [<a href="https://archive.is/arQvz">Table</a>]</li>
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-</ul>]]></content><author><name>{&quot;first_name&quot;=&gt;&quot;Aly&quot;, &quot;last_name&quot;=&gt;&quot;W.&quot;, &quot;author-link&quot;=&gt;&quot;/about/#aly&quot;, &quot;articles-link&quot;=&gt;&quot;/articles-by-author/aly/&quot;}</name></author><category term="github" /><category term="workspace" /><summary type="html"><![CDATA[An Informal Meta-Analysis of Estradiol Curves with Injectable Estradiol Preparations By Aly | First published July 16, 2021 | Last modified June 27, 2024]]></summary></entry><entry><title type="html">An Exploration of Sublingual Estradiol as an Alternative to Oral Estradiol in Transfeminine People</title><link href="https://transfemscience.org/articles/sublingual-e2-transfem/" rel="alternate" type="text/html" title="An Exploration of Sublingual Estradiol as an Alternative to Oral Estradiol in Transfeminine People" /><published>2021-06-11T20:26:25-07:00</published><updated>2024-03-30T00:00:00-07:00</updated><id>https://transfemscience.org/articles/sublingual-e2-transfem</id><content type="html" xml:base="https://transfemscience.org/articles/sublingual-e2-transfem/"><![CDATA[<h1 id="an-exploration-of-sublingual-estradiol-as-an-alternative-to-oral-estradiol-in-transfeminine-people">An Exploration of Sublingual Estradiol as an Alternative to Oral Estradiol in Transfeminine People</h1>
+</ul>]]></content><author><name>{&quot;first_name&quot;=&gt;&quot;Aly&quot;, &quot;last_name&quot;=&gt;&quot;W.&quot;, &quot;author-link&quot;=&gt;&quot;/about/#aly&quot;, &quot;articles-link&quot;=&gt;&quot;/articles-by-author/aly/&quot;}</name></author><category term="github" /><category term="workspace" /><summary type="html"><![CDATA[An Informal Meta-Analysis of Estradiol Curves with Injectable Estradiol Preparations By Aly | First published July 16, 2021 | Last modified May 8, 2025]]></summary></entry><entry><title type="html">An Exploration of Sublingual Estradiol as an Alternative to Oral Estradiol in Transfeminine People</title><link href="https://transfemscience.org/articles/sublingual-e2-transfem/" rel="alternate" type="text/html" title="An Exploration of Sublingual Estradiol as an Alternative to Oral Estradiol in Transfeminine People" /><published>2021-06-11T20:26:25-07:00</published><updated>2024-03-30T00:00:00-07:00</updated><id>https://transfemscience.org/articles/sublingual-e2-transfem</id><content type="html" xml:base="https://transfemscience.org/articles/sublingual-e2-transfem/"><![CDATA[<h1 id="an-exploration-of-sublingual-estradiol-as-an-alternative-to-oral-estradiol-in-transfeminine-people">An Exploration of Sublingual Estradiol as an Alternative to Oral Estradiol in Transfeminine People</h1>
 
 <!-- Supports up to four authors per article currently (author, author2, author3, author4) -->
 
@@ -2443,7 +2651,7 @@ Using the term desistence in this way does not imply anything about the identity
 
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@@ -2478,7 +2686,7 @@ Using the term desistence in this way does not imply anything about the identity
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+  <li>Lobo, R. A. (1987). Absorption and metabolic effects of different types of estrogens and progestogens. <em>Obstetrics and Gynecology Clinics of North America</em>, <em>14</em>(1), 143–167. [<a href="https://pubmed.ncbi.nlm.nih.gov/3306517/]">PubMed</a>] [DOI:<a href="https://doi.org/10.1016/S0889-8545(21)00577-5">10.1016/S0889-8545(21)00577-5</a>] [<a href="https://www.obgyn.theclinics.com/article/S0889-8545(21)00577-5/fulltext">URL</a>]</li>
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@@ -3675,7 +3883,7 @@ Using the term desistence in this way does not imply anything about the identity
 
 <h3 id="update-1-langley-et-al-2021-patch-study-results">Update 1: Langley et al. (2021) [PATCH Study Results]</h3>
 
-<p>In February 2021, a report on long-term cardiovascular outcomes for the <a href="https://en.wikipedia.org/wiki/Prostate_Adenocarcinoma:_TransCutaneous_Hormones">Prostate Adenocarcinoma: TransCutaneous Hormones</a> (PATCH) trial was published (<a href="https://doi.org/10.1016/S0140-6736(21)00100-8">Langley et al., 2021</a>) [<a href="https://files.transfemscience.org/pdfs/Langley%20et%20al.%20(2021)%20-%20Transdermal%20Oestradiol%20for%20Androgen%20Suppression%20in%20Prostate%20Cancer.pdf">PDF</a>; <a href="https://files.transfemscience.org/pdfs/Langley%20et%20al.%20(2021)%20[Appendix]%20-%20Transdermal%20Oestradiol%20for%20Androgen%20Suppression%20in%20Prostate%20Cancer.pdf">Supplementary appendix</a>]. The PATCH trial is a large ongoing <a href="https://en.wikipedia.org/wiki/Phases_of_clinical_research#Phase_II">phase 2</a>/<a href="https://en.wikipedia.org/wiki/Phases_of_clinical_research#Phase_III">3</a> randomized controlled trial of high-dose transdermal estradiol patches versus GnRH agonists for the treatment of prostate cancer in men (<a href="https://doi.org/10.1016/S0140-6736(21)00100-8">Langley et al., 2021</a>). The estradiol patch dosage employed is specifically three to four 100 μg/day FemSeven or Progynova TS patches (<a href="https://doi.org/10.1016/S0140-6736(21)00100-8">Langley et al., 2021</a>). In the February 2021 report of the study, 1,694 men were enrolled and randomized, with 790 included in the analysis for the GnRH agonist group and 904 included in the analysis for the estradiol patch group (<a href="https://doi.org/10.1016/S0140-6736(21)00100-8">Langley et al., 2021</a>).</p>
+<p>In February 2021, a report on long-term cardiovascular outcomes for the <a href="https://en.wikipedia.org/wiki/Prostate_Adenocarcinoma:_TransCutaneous_Hormones">Prostate Adenocarcinoma: TransCutaneous Hormones</a> (PATCH) trial was published (<a href="https://doi.org/10.1016/S0140-6736(21)00100-8">Langley et al., 2021</a>). The PATCH trial is a large ongoing <a href="https://en.wikipedia.org/wiki/Phases_of_clinical_research#Phase_II">phase 2</a>/<a href="https://en.wikipedia.org/wiki/Phases_of_clinical_research#Phase_III">3</a> randomized controlled trial of high-dose transdermal estradiol patches versus GnRH agonists for the treatment of prostate cancer in men (<a href="https://doi.org/10.1016/S0140-6736(21)00100-8">Langley et al., 2021</a>). The estradiol patch dosage employed is specifically three to four 100 μg/day FemSeven or Progynova TS patches (<a href="https://doi.org/10.1016/S0140-6736(21)00100-8">Langley et al., 2021</a>). In the February 2021 report of the study, 1,694 men were enrolled and randomized, with 790 included in the analysis for the GnRH agonist group and 904 included in the analysis for the estradiol patch group (<a href="https://doi.org/10.1016/S0140-6736(21)00100-8">Langley et al., 2021</a>).</p>
 
 <p>In those given estradiol, the median estradiol level was around 215 pg/mL (5%–95% range ~100–550 pg/mL) (<a href="https://doi.org/10.1016/S0140-6736(21)00100-8">Langley et al., 2021</a>). About 93% of the men in this group achieved suppression of testosterone levels into the castrate range (&lt;50 ng/dL), which was notably equal to the rate of suppression in the GnRH agonist group (~93%) (<a href="https://doi.org/10.1016/S0140-6736(21)00100-8">Langley et al., 2021</a>). However, actual testosterone levels—as opposed to rates of testosterone suppression—were not provided in this report and hence comparison between groups is unavailable for this metric (<a href="https://doi.org/10.1016/S0140-6736(21)00100-8">Langley et al., 2021</a>). After about 4 years median follow up, there were no significant differences on a variety of cardiovascular outcomes between the estradiol group and the GnRH agonist group (<a href="https://doi.org/10.1016/S0140-6736(21)00100-8">Langley et al., 2021</a>). Among these outcomes included VTE, <a href="https://en.wikipedia.org/wiki/Thromboembolic_stroke">thromboembolic stroke</a>, and other <a href="https://en.wikipedia.org/wiki/Arterial_embolism">arterial embolic events</a> (<a href="https://doi.org/10.1016/S0140-6736(21)00100-8">Langley et al., 2021</a>). These results are in contrast to previous large clinical trials of PEP in prostate cancer, which found increased cardiovascular morbidity and risk of VTE but notably involved higher estradiol levels than employed in the PATCH trial (<a href="https://doi.org/10.5173/ceju.2009.03.art1">Ockrim &amp; Abel, 2009</a>; <a href="/articles/pep-cardiovascular-analysis/">Sam, 2020</a>). Based on their promising safety findings, the PATCH researchers stated that transdermal estrogen should be reconsidered for the treatment of prostate cancer (<a href="https://doi.org/10.1016/S0140-6736(21)00100-8">Langley et al., 2021</a>).</p>
 
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@@ -3889,7 +4097,7 @@ Using the term desistence in this way does not imply anything about the identity
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