Sometimes, I like to just sit back and sort of play through the mental records of all the transgender patients I've had over the past decade and try and make correlations between things I've noted. This helps me spot patterns I hadn't recognized like "Tall thin transgender women tend to have higher e1:e2 ratios than obese ones do on oral estradiol, I wonder why?"

In ten years, I have never had a teen MTF get anything less than stellar breast development.

In ten years, I have rarely ever seen an elderly MTF get stellar breast development.

every patient in my practice I strive to basically achieve the following situation:

Use the lowest E2 dose possible to fully suppress LH and FSH without spiking SHBG over 125nmol/l while achieving the highest percent free E2 possible. If someone wants to call something in MTF HRT "The Powers Method". That's pretty much it at the moment. Every patient has some sort of goldilocks number for E2 at pg/ml where LH and FSH zero, SHBG is normal range, and free E2 % is maximized. This stops gonadal androgen production, and I suspect results in maximal receptor saturation for ErA ErB while exposing the patient to the minimal thrombotic risk possible. Excessive E2 doses are not helpful for further feminization. Period.

Regardless, the teens just do way better despite being on very similar regimens for the same period of time.

To that, there are a multitude of biochemical differences between a teenager and an elderly person, but one of the most primary ones would be the difference in growth hormone levels. While kids are growing, their body releases growth hormones on a level vastly exceeding anything seen after that in adulthood. Both HGH and IGF-1 are considerably elevated in teen years compared to adulthood.

However, the idea of routinely administering HGH or IGF-1 to a transgender woman to assist in breast development is generally a very bad idea. Excess of growth hormone results in acromegaly, which includes enlargement of the hands, feet, nose, jaw, forehead, ears, and other tissues resulting in a hyper-masculine appearance. In short, don't go buy some HGH and start shooting it up because "Dr. Powers Says So". I assuredly do not.

That being said, when I look at my patient population, the patients in the upper range of the bell curve for breast development of any age tend to be rather healthy, physically fit people. Those with poor development are generally sedentary, regardless of whether or not they are obese or underweight.

The human body is a fairly slick machine. It has millions of years of evolution coding for a multitude of different responses to situations it might encounter. That being said, its not going to waste energy and efforts on producing growth hormones that are simply not needed based on the demands put on that body. While it would be sweet to just be as buff as a chimp with no effort, myostatin and other mechanisms prevent this from happening to me unless I put in serious effort to result in that level of muscle development.

Regardless, I have been running growth hormone values now on anyone who wanted one or could get it done for free for over a year, and I can state with "some" degree of confidence that those with the worst breast development tend to have growth hormone scores 1-3 standard deviations below the mean.

I looked into various ways that I could help patients naturally boost this, and after about 18 months of trial and error, I can say that no supplement really did much at all to make a significant impact. Only two things really nudged the lab values on recheck. Considerable increases in protein intake, and high intensity training.

Basically, when you go kill it at the gym, you put microtears into your muscle and other tissues. You suffer a small amount of damage microscopically. Your body responds to this by releasing growth and other hormones to repair this damage, and to make you stronger/healthier so that next time you go to the gym (or jungle) you are stronger and better prepared.

When you are a child, you get these growth hormones for "free". They just are naturally produced in large quantities as you are growing, but as an adult, you just don't. The sort of sedentary "skinny E-girl" lifestyle that many of my poor breast development patients seem to struggle with I believe may be contributory to this result.

About 6 months ago, I asked some patients who were very heavily invested in maxing their natural development to do a trial of eating at least 90g of protein daily coupled with some high intensity exercise multiple times per week. On more than a few occasions, patients noted that 2-3 days after the high exercise day, they would suddenly have breast tenderness or engorgement which had not been present for months. Is this clinically significant? I don't know. Breast tenderness is not a guaranteed sign of breast development, but over that timeframe, some patients who had been on hormones for 5 years noted progress made that they had not seen in a long time.

In short, like most things in medicine, eating well and living an active lifestyle with exercise may be to your benefit. I suspect the effect is mediated through this mechanism, but I am still yet unsure, and its far too early for me to even make a strong conjecture on it, but I think much like my 6p21 situation, "Something" is assuredly here to be found, and I'm intending to invest more effort into exploring this in the coming year or two.

Edit: To clarify the level of exercise necessary, it is the amount where the following day you feel your muscles are sore where you did the activity. You effectively must do some degree of damage in order for your body to want to then do the repair mechanisms to make you stronger. That is literally how weightlifting works for people who are trying to gain muscle mass and strength

I'm sure that some amount of exercise would produce some amount of growth hormone bump, but if your goal is to precipitate that effect, it's through basically suffering.