By Dr. Jerrica Kirkley, MD
Co-contributors: Rachel Percelay and Alyssa Billingsley, PharmD
You’ve likely heard of the hormone testosterone. Testosterone is a hormone that is typically produced in all bodies, but in different amounts for different bodies. It is one of the sex steroid hormones involved in the development of the various physical changes classically associated with puberty like hair growth, and changes in voice and body parts.
If you’re transgender, a broad term generally describing someone whose gender identity is different from their sex assigned at birth, testosterone (often shortened to “T”) might be a part of your gender-affirming hormone therapy. This is inclusive of gender non-conforming and non-binary folks. Testosterone can also be an important therapy for intersex folks. Here we’ll review gender-affirming care, and what it might look like for someone using testosterone-based therapies.
What is gender-affirming care?
Gender-affirming care is, at its core, exactly what it sounds like — healthcare that affirms you to live authentically in your gender. Previously, care for transgender people often followed an outdated one-size-fits-all framework of a provider dictating the same set of hormones and surgery for every trans person seeking medical care. Instead, gender-affirming care allows each person to seek only those interventions they desire to affirm their own gender identity.
As part of gender-affirming care, gender-affirming hormone therapy (GAHT) is prescribed to encourage physical changes in the body to help people live their authentic selves with respect to their gender identity or lack thereof. Research has shown that the gender-affirming care model improves health outcomes for trans people. In fact, it is considered standard of care and is supported as a medical necessity by nearly every major medical association in the United States, including the American Medical Association, the American Academy of Family Physicians, and the American Psychiatric Association.
GAHT vs. hormone replacement therapy
Since GAHT and hormone replacement therapy (HRT) are often confused or used interchangeably, let’s take a moment to differentiate them.
Hormone replacement therapy classically describes the process of prescribing hormones to cisgender people, meaning those individuals whose gender identity matches their sex assigned at birth, often to relieve symptoms of hormone imbalance. For example, estrogen may be prescribed to postmenopausal cisgender women to help with hot flashes.
The term HRT has often been used by the trans community to describe the process of gender-affirming hormone therapy. However, GAHT is a more accurate description of the use of hormones by trans folks because nothing is technically being “replaced.” The medical community who takes care of trans folks is moving away from saying “HRT,” and instead, is using “GAHT” so as not to conflate the different therapeutic practices.
Who typically uses testosterone-based GAHT?
The answer: No singular gender identity is required for testosterone-based GAHT. But generally speaking, it is commonly prescribed to to trans men, and transmasculine, nonbinary, and intersex folks.
Testosterone for testosterone-based GAHT
Testosterone is the cornerstone of testosterone-based GAHT, which uses synthetic testosterone.
The Endocrine Society, the University of California, San Francisco, and the World Professional Association for Transgender Health have published clinical guidelines around how to use medications for GAHT. We’ll briefly compare the three main uptake methods and doses of testosterone you might be prescribed for testosterone-based GAHT: injection, gel, and patch. Please note that all doses listed below are sample starting ranges and are adjusted based on a personalized conversation with your provider.
1) Injection
Injection is the most common uptake method for testosterone in GAHT. While the extent and speed of change is ultimately determined by your testosterone dose and levels in your body as well as your individual genetic makeup, anecdotally it seems that injections bring about change quicker than other forms.
There are two methods of injection: intramuscular (IM) and subcutaneous (SC). IM injections are injections into the thigh area. SC injections use a shorter, thinner needle and are given just under the skin in the belly. Both IM and SC injections are given at the same dose once a week, and they work exactly the same way.
Testosterone cypionate is the most common form of injectable testosterone. For people who are allergic to testosterone cypionate, the alternative testosterone enanthate is used instead. The lowest GoodRx price for a month of testosterone cypionate is currently about $10 and about $33 for a month of testosterone enanthate.
2) Topical gel
Topical gel causes more gradual changes than injections. It is applied every morning to the skin and takes about 3 to 4 hours to completely dry. This is important because if it’s not completely dry, the gel can rub off on other people, they can absorb it, and they can experience physical changes related to higher T levels themselves. There are a variety of formulations of testosterone gel. Based on the lowest GoodRx price currently available, testosterone gel therapy can cost as little as $50 to $60 a month.
3) Patch
To be more comprehensive about the ways that testosterone can be administered for GAHT, we included the patch on this list. However, in practice, the patch, which goes by the brand name Androderm, is rarely used. Physical changes are also more gradual changes with the patch than with the injection, and it’s difficult to adjust the dose with the patch. Even with a GoodRx discount, the testosterone patch can cost over $600 a month.
What can I expect from testosterone-based therapy?
Most folks first start noticing changes like lower voice, facial hair growth, and stopping of monthly bleeding at about 2 to 3 months after starting testosterone by the injection method. Some folks notice feeling better emotionally shortly after starting T — in particular, they report less anxiety and more confidence. Some other physical changes that occur more gradually include:
- Body fat redistribution
- Increased muscle mass
- Increased and darker facial and body hair growth
- Broadened shoulders
- More angular eyes and face
- Increase in libido (sex drive)
- Enlargement of some genital parts
- Deeper voice
Most people will max out on physical changes somewhere between 2 to 5 years after starting testosterone.
What are some risks of testosterone-based therapy?
The first point we’ll discuss is related to testosterone increased hemoglobin/hematocrit (called H/H, for short). H/H is a number you’d find on a blood test and tells healthcare providers about the amount of red blood cells you have in your body. For example, in anemia, H/H is low. But, if H/H were to get too high, there may be a theoretical risk of blood clots and stroke because of the blood being too “thick.”
There have been no reports of this happening with GAHT. It is only a theoretical risk based on people that have genetic conditions leading to very high H/H levels – much higher than the levels that testosterone causes. Your provider will check your H/H every 3 months, along with your T levels to make sure you are staying in healthy ranges.
Additionally, testosterone is a teratogen, a substance which is known to cause severe birth defects. So, if someone taking T were to become pregnant, there would be a high risk of birth defects. Therefore, contraception is strongly encouraged for people on T who could possibly become pregnant based on one’s body parts and those of their partner(s). All forms of birth control (e.g. the pill, implant, IUDs) are fine to use with testosterone and will not interfere with T’s effectiveness.
T could also cause infertility. Over time, T causes estrogen levels in the body to drop, which then causes changes to other body parts that are important for pregnancy to occur. If preserving fertility (having children with your own genetic material in some way) is important to you, you may want to consult a reproductive specialist to see if you can freeze your genetic material so you can try to make a pregnancy happen later.
If you are on testosterone therapy and want to become pregnant or collect genetic material, you’d generally have to stop T for 6 to 9 months to complete the necessary processes.
How to learn more
If you want to learn more about estrogen-based GAHT, the best place to start is by talking to your healthcare provider. However, if you don’t have one, you can find a local gender-affirming provider near you by visiting the WPATH provider directory or checking to see if you live in a state covered by Plume.
If you’d like to get started with Plume and make an appointment to see a healthcare provider, please sign up here.
For information about coupons for any medications discussed here, please visit GoodRx.
