Question:  “I’m post-orchiectomy, and on estrogen injections, and am having problems with swollen ankles and feet.  And I seem to be more sensitive to cold too.  What is my problem?” My answer:

This is a common complaint for trans women on hormones, especially after most of the last testosterone is eliminated.  It can be accompanied by a mild “cold hands and feet syndrome”.  I’ve had this symptom since about 1990. And yes, it can be related to your testosterone level dropping to very low levels. This is sometimes called estrogen dominance (an inappropriate term) and it is sometimes mistaken by doctors for hypothyroidism.

So what’s happening here? In some women, higher estrogen levels lead to this side effect. Pregnancy is notorious for causing water retention, but it is also especially noticeable when taking exogenous hormones (HRT). But the causes are not as simple as just the estrogen level — it also affects the thyroid system, and the adrenal system, and the renin-aldosterone system, and probably more, even. One might think that these puffy feet symptoms could be useful to gauge where one’s estrogen levels are — except that symptoms can suddenly and paradoxically return when levels fall too.

This is a clue that it is NOT SIMPLE. The complexity is compounded by your choices. Specifically, what you eat. I did a series of tests on myself this year (2024), mostly to evaluate the effects of hormones on my blood pressure, and at first thought I had discovered a clear relation, only to see later that a significant part of the hormone effects on water retention in my case were caused by the food cravings associated with hormonal surges and dropouts — especially, a tendency to consume salty foods when estrogens levels are falling — PMS, in other words.

But you want to know what to do, right? First let me say I’m not a doctor, and the symptoms have features in common with edema and circulatory issues which can be caused by other unrelated things, so if your symptoms are severe seek a medical diagnosis. That said, this is so familiar to me personally, in addition to experiences of dozens of others I’ve encountered in our Facebook Group, that I can suggest some things that I imagine your doctor would approve. Here are 9 strategies you can try if you are bothered by estrogen-related water retention symptoms. You can do one or all of them. 

 (option 1) Add progesterone!! Immediately! your symptoms may quickly begin subsiding because progesterone suppresses some of these unwanted estrogen side effects. In my case, I have injected a small dose of progesterone every 2 days. If you want to get this symptom under control overnight, injecting P has a good chance of doing that. See my article on injection. You can try progesterone pills, but my experience is they are probably unlikely to help, and will be quite slow too. You can also try progesterone cream — but I’ve never had any success with it for this problem, and I don’t think it will help.

 (option 2) Your estrogen levels might be high — cut your estrogen dose. This may gradually cause the swelling to subside, but it could take 2 weeks or before you really see results. Cutting it in half would probably be right. Then later you might try raising it again, especially if you are using progesterone to help with the estrogen dominance. Balance this strategy against your needs for estrogen-based HRT for other reasons.

(option 3) Walk long distances. Keep your feet up when sleeping. Jog daily. The more you exercise your lower body, the less likely it is to pool up with the water retention. This can give fast results, but the amount it helps is limited.

(option 4) Wear compression socks. These are easily available and they will reduce the swelling fairly quickly. Try wearing them overnight.

(option 5) Add a tiny bit of testosterone to your bloodstream. There are a variety of ways to do this, and I cannot give you specifics, except that the amount you would need is extremely tiny – don’t overdo it. Of course, this can cause some negative effects to your feminized traits, so I include it due to desire for completeness. Otherwise, it is not recommended for most.

(option 6) Take plant-derived Flavonoid vein efficiency boosters. These really work, though to a minor extent. Two main ones are Diosmin and Rutin. These are all available from your vitamin source. They are safe, not too expensive, and help your vascular system. After all, that’s the issue — when your lower body veins become more efficient, the water retention reduces because the fluid is recirculated back. This is easy, safe, and convenient to do. If you are bothered by hemorrhoids, it may help with that too. If it benefits you a lot, stay on it. (If you are taking any kind of blood thinners or anticoagulants, check with your doctor.)

(option 7) The fluid retention is aggravated by heat, so try to stay cool!  You might try covering your legs for a while with a wet towel in the evenings to cool them off.  Sleeping cool is also helpful.  Sleeping with your feet somewhat elevated will help too.  Your sleep conditions will make a difference. During the night, your body works to balance your electrolytes. As I said earlier, this is a good time to wear compression socks too.

(option 8) Stand up! If you spend much of the day seated in a chair, you are applying pressure to the large veins in your thighs and that can encourage accumulation of fluid in the lower extremities. Stand up at least 15 times an hour.

(option 9) Watch your diet! Hormonal shifts may be causing you to consume too much salt, which causes you to consume or retain more water. If you know you are doing this, you can either try to control your cravings with will power, or you can modify your potassium/sodium electrolyte balance by eating food high in potassium. For instance, eat a meal of cooked spinach with mashed potatoes. Also consider beans, lentils, raisins, yogurt, orange juice, and fish. Adding extra potassium to your diet in this way may have effects on your water retention in 1-2 days, and it may reduce your blood pressure too.

So there are the 9 options. As I said, I do all of them except #5. They work. The foot and ankle puffiness is somewhat shocking and worrisome, but it’s not much of a danger in general. It could lead to spider veins, which is unattractive. It also makes it hard to fit into your shoes. I’m sure you’ve noticed that. Oh! I want to say one more thing. This is important. So now we know that you’re a woman who does best in a narrow estrogen range. Not all transwomen are like this but you and I are in this same boat. The best way to manage it is to have your estrogen intake very accurately measured. Methods like sublingual pills, gels, and patches cause wild variations up and down and very poor control. The most accurate way to dial in your dose is by injection, and in particular, long-needle gluteus IM injection. It took me a year to adjust in my dose, very slowly changing up and down to get the perfect spot — no swelling, no mood swings, clear head, warm and fuzzy feminine feeling, everything perfect. Keep your estrogen balanced with progesterone, your sodium balanced with potassium, and your cravings under control, and you’ll do just fine. Good luck!