The information on this site is not meant to replace individual medical consultation with your doctor. Please speak with your medical provider about any medical interventions you are interested in.
How it Works
Testosterone is a naturally occurring hormone in all people. It promotes development of traditionally “masculine” secondary sex characteristics, including male hair distribution, deepening of the voice, and increased muscle mass. At certain levels, it also suppresses estrogen production. Therefore, it prevents traditional “feminine” development and function, such as formation of body curves and menstruation [“having periods”].
Depending on one’s gender identity and developmental goals, testosterone can improve an individual’s feelings about their body. When indicated and appropriate, gender-affirming hormone therapy has been shown in multiple studies to have a protective effect on mental health and wellness.
Readiness
It is important to note that assessing if gender medical treatments, like hormones, are right for someone and if that person is ready to start is complicated. Every program has it’s own model for making decisions about when it is appropriate to start gender medical treatments based on one’s cognitive, emotional, and physical development using a family-centered approach for shared decision-making.
What to Expect
Effects of testosterone typically become noticeable within months and may take several years for full effect. You will need to continue masculinizing hormone therapy for the rest of your life to keep all the desired effects. Some changes will go away if you stop taking testosterone (reversible effects). Some changes will be permanent even if you stop taking testosterone (irreversible effects). You are NOT locked into a decision to take testosterone, and if it is not working for you, please let us know so we can discuss options.
| Reversible | Irreversible |
|---|---|
| ● Stops periods* (1-12mo) ● Increased acne , coarser skin (1-6mo) ● Increased body odor, sweat (1-3mo) ● Emotional changes, increased energy, and irritability (1-3mo)** ● Change or increase in sex drive ● Increased muscle mass/definition, broadening of shoulders, and redistribution of fat from hips and buttocks to abdominal region (6-12mo) | ● Deepened voice (3-6mo) ● New and increased facial/body hair (6-12mo) ● Clitoral enlargement (1-4cm; 3-6mo) – may cause discomfort from friction necessitating underwear with more support ● Vaginal and uterine dryness and atrophy, possible pelvic pain |
What it Won’t Do: Increase height, reverse breast growth, prevent pregnancy, grow a ‘typical’ penis or testes, create an Adam’s apple, or change the size or shape of bones.
Important Considerations
We are still learning about the use of Testosterone in transgender and gender diverse individuals and the risks are not fully understood. Gender-affirming hormones are not FDA-approved but are commonly used off-label for gender-affirming care, and have been for over 50 years.
- Blood Clots: There is no known risk of spontaneous clots, but testosterone increases red blood cell production that can thicken one’s blood which increases the very rare risk of a clot. We monitor red blood cell concentration with routine lab work so that we can recognize and manage this risk.
- Smoking nicotine or other substances increases your risk of blood clots and heart disease. If you use nicotine and are interested in starting testosterone, we recommend that you stop using nicotine. We can give you options and resources to help you quit using nicotine.
- Weightlifting: Higher dose testosterone has a risk of tendon rupture. This is not documented in people using testosterone at doses for gender care. If you lift weights, then be careful and increase weight slowly or focus on increasing reps instead.
- Cancer: Testosterone’s effect on risks for adult cancers is multifactorial and still being researched. Testosterone typically is a factor in prostate and testicular cancers which are not relevant in patients assigned female at birth. It is not a significant factor in breast cancer, and in other cancers, it is not as influential as family history, tobacco use, obesity, and lifestyle.
- Other Long-term Risks: Testosterone may increase risk for hereditary balding and cardiovascular disease. We may monitor for some of these things, including liver health, insulin resistance, cholesterol changes, and high blood pressure.
- Regret: Due to testosterone having irreversible effects and the degree of any effect being based on genetic, there is a risk that you may not like the outcome. Research shows that later regret is rare, but it does sometimes happen. It is important to us that if you do not like the effect that you are getting, you let your provider know right away. No one is “locked into” any treatment or decision.
Fertility
Testosterone may affect fertility (the ability to have a child that is biologically related to you). We recommend that you talk to a fertility expert and consider preserving your fertility before you start Testosterone. There have been select cases where people have stopped testosterone and had successful natural or assisted reproduction, but also anecdotal cases of infertility that may or may not have been related to testosterone.
Testosterone can stop “periods,” but does not provide birth control. If you are having sex with a partner who has sperm, you should use another form of birth control. Testosterone will not prevent transmission of sexually transmitted infections.
Testosterone is harmful to a developing fetus. It must be stopped during pregnancy and lactation.
Mental Health
Most people using testosterone for gender affirmation report feeling better on hormones. Many people do note feeling more irritable the first month(s) and eventually describe their emotions being slightly less accessible [e.g., you might not cry as easily]. You will still be you and will acclimate to the way testosterone affects your mood and thinking. Let your provider know how you are doing—they are here for you and can connect you to any resources or mental health services.
Dosing
Dosing is guided by desired physical effects, any emotional concerns, and achieving blood testosterone levels of someone your age assigned male at birth (typically, 280 – 1080 ng/dL). There are limitations in how much effect you might have based on your genes and where you are developmentally. Note that everyone breaks down testosterone at a different rate, so if you break it down slowly, you may be on a lower dose than someone who breaks it down quickly. Some people may simply desire a lower level for a more androgynous appearance. Removing the ovaries or using other medications (i.e., puberty blockers) may change the testosterone dose needed.
Too much testosterone can convert to estradiol, resulting in higher estradiol levels and the opposite of desired effects. It can also lead to more side effects and unnecessary risks.
Follow-up and Labs
Follow up and labs, including testosterone level, are initially every 3-4 months, and space out to 1-2 times a year.
How It’s Given
Testosterone is available in the following forms. Insurance coverage may require preauthorization.
- Subcutaneous [under the skin] Injection:
- Administer: 1 injection weekly at home
- Supplies: 25-gauge (5/8th inch) injection needle; 18-gauge (1 inch) draw needle; luer lock 1 cc syringe
- A spring loaded autoinjector is available called Xyosted©. Prior authorization/approval from insurance is required, but it has been shown to be a desirable alternative for patients with needle phobia.
- We recommend starting with the subcutaneous (SQ) injection which has good absorption, low cost, reliable effect, and minimizes emotional highs and lows. They are less painful than intramuscular (IM) injections [below] and use a much smaller needle. Our nurses will teach you how to give yourself the shot and provide you with a written guide.
- Intramuscular [into the muscle] Injection:
- Administer: 1 injection weekly to every other week at home
- Supplies: 22-gauge 1-1 ½ inch needle; 18-gauge (1 inch) draw needle; luer lock 1 cc syringe
- Transdermal Gel
- Administer: Apply to dry, intact skin once daily; allow to dry completely before dressing or skin-to-skin contact with others and wash hands carefully after applying. This is done at home.
- Subcutaneous Implant: Testopel© pellet 75mg
- Administer: 6-12 pellets implanted every 3-4 months In-Clinic ONLY
- Location: implanted between the skin and the buttocks muscle
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