So, I get asked this question a lot. What do I order when I can order whatever I want for MTF HRT?

Well, basically, its this list. Each of the things on this list has a very specific reason why i'd check it, and I wouldn't check all of them on everyone, I often remove various things based on that patient's individual situation, but here is the "full" list. There are a few other random labs I might order in very specific situations, but this is my most common list pretty much.

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• Check CBC (includes diff/plt) (This is fairly obvious why)
• Check estradiol (This is fairly obvious why)
• Check estrone (only in a patient taking oral E2, otherwise I don't order this. I don't care what the estrone is really i care its ratio to E2. Physiologically in cis females it is almost never more than 5:1 E1:E2, and so I am more concerned about people who have stupidly high ratios like 10:1 to 100:1 as the competition of estrone for the E2 receptor really only becomes biochemically significant at those much much higher ratios.
• Check comprehensive metabolic panel (This is fairly obvious why)
• Check testosterone, total, MS (This is fairly obvious why)
• Check FSH and LH (Sometimes, depends on the situation, if I'm concerned someone could be underdosed, I use the FSH and LH as an indicator of that. I prefer them to be almost zero but not totally zero. This is the "happy zone" where SHBG, total E2 and free e2 seem to do best. Aka "just enough" hormones.
• Check hemoglobin A1C (Check this once a year, or twice in an obese patient)
• Check estradiol, free (This number is very important, as you can have all of the E2 in the world, but if none is free, you will get no effect from it)
• Check sex hormone binding globulin, QN, serum or plasma (This is used as an indicator of basically the past two weeks of hormone dosing, if it shoots too high, the person is overdosed, if its quite low, they are underdosed. Your liver produces this in response to E2 levels, and the "spike" from injections tends to drive it up more than other ways of dosing. Pellets seem to result in the lowest SHBG relative to E2 level and therefore the highest fraction free e2)
• Check estrone sulfate (In a patient on non-oral methods for a prolonged period of time, sometimes in some people E1S drops. If it drops below 6000pg/ml, sometimes that person will get a surge of development / breast tenderness / etc if I pulse them with a week of oral E2 with 3 weeks off, then repeat. The lower the E1S the more likely this seems to succeed. I think this works via transactivation of the ErA like it does in breast cancer, but I'm not certain. All I know is it occasionally works and it seems more likely to work when E1S is low. To be clear, estrone sulfate is not estrone, it is estrone that has gone over steroid sulfatases to be made into something else which is more of a "storage" estrogen.
• Check lipid panel, standard (I do this annually)
• Check dihydrotestosterone (In a patient on progesterone or who uses any androgen or if I just am concerned about androgens)
• Check 3A androstanediol glucuronide, elisa (If I am concerned about any androgen)
• Check igf 1, lc/MS (I have found that when I took all the best developed people in my practice in terms of chest, and all the worst, and ran this lab, there seems to be an association with poor IGF-1 levels and poor breast development and good breast development with higher levels. The two MTF's who got breast reductions both had z-scores over 2 I will send someone to endocrine for treatment (as insurance would never let a FP do it) if they are more than 2 standard deviations below the mean. If they are below 0 but not below -2 for a z score, I recommend natural ways of boosting IGF-1. I DO NOT RECOMMEND THE USAGE OF PEPTIDES. This is way too easy to screw up and give yourself diabetes or acromegaly. I am still not certain about the importance of IGF-1 specifically for breast development, but there is at least some research out there supporting this idea.
• Check DHEA sulfate (Another androgen that can be elevated and come from adrenal sources even in someone post op)