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.  Often it is accompanied by “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. In some women, higher estrogen levels lead to this side effect. 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. 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 which can be caused by other unrelated things. 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 8 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 will begin subsiding because progesterone suppresses some of these unwanted estrogen side effects. In my case, I religiously inject a small dose of progesterone every 2 days. If you want to get this symptom under control overnight, only injecting P will do that. See my article on injection. You can try progesterone pills — they will perhaps help but will be less effective and quite slow too. You can try progesterone cream — but I’ve never had success with it, and I don’t think it will help.

 (option 2) 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.

(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. Your endocrinologist will give you a funny vaginal applicator for it. If you don’t have a vagina yet, just use it somewhere you would like to have a vagina. [Pardon the TS humor.  🙂 ]  I don’t do this myself and cannot tell you how fast it works. I don’t like adding T. I spent too much effort getting rid of it.

(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.

(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.

So there are the 8 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. 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 dial 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. This means balancing the progesterone with the estrogen. Good luck!