By Dr. Jerrica Kirkley | June 16, 2020
Thank you for scheduling with one of our trans-specialist providers. Please take the time to read this complete document before your first appointment. This information will help you decide what medications may support your unique needs and desires. Knowing what medications you have in mind or questions you have at the time of your appointment will free up both you and the provider to more effectively address your needs.
Some things to think about as you read the information in this document:
- What physical changes, if any, are affirming for you? If you don’t know what changes might occur, this document should help.
- Which uptake method? Injections, topical gel, or patch?
- Do you want a low dose or not?
- What questions do you have that this document hasn’t addressed?
We look forward to meeting you!
~ Your Plume Care Team
Testosterone (T for short)
Testosterone is a naturally occurring hormone that is typically produced in all bodies, but in different amounts for different bodies. Synthetic bioidentical testosterone is what we use when we prescribe it to encourage physical changes in the body to live our authentic selves in respect to our gender identity or lack thereof.
- T increases the hemoglobin/hematocrit (called H/H for short) – You can think of these as markers for red blood cells in the body. For example, anemia is low H/H. But, if the H/H were to go too high, there is a theoretical risk of blood clots and stroke because of the blood being too “thick”. There have been no reports of this happening with gender-affirming care. It is only a theoretical risk based on people that have genetic conditions which cause their H/H to go VERY high – much higher than the levels that T causes. We will check your H/H every 3 months, along with your T levels to make sure you are staying in healthy ranges.
- T is a teratogen – This is a fancy medical word meaning a substance which is known to cause severe birth defects. So, if anybody who is taking T were to become pregnant, there would be a high risk of birth defects. If this is a possibility at all based on one’s body parts and those of their partner(s), we strongly encourage contraception to prevent pregnancy while taking T. All forms of birth control are safe to use if you are on T and do not interfere with the effects of T on the body.
- T could cause infertility – Over time T causes the levels of estrogen in the body to drop, which then causes changes to other body parts that are important in allowing pregnancy to occur. We can’t predict who this will occur in and there are many factors that can contribute to infertility outside of T. We recognize that there are many ways to build family, and that using your genetic material is only one of them but if preserving fertility (having children with your own genetic material) is important to you then we strongly encourage you to see a reproductive specialist regarding freezing of certain body parts that can be used to make a pregnancy later. If somebody on testosterone wants to become pregnant or use their genetic material, then they have to stop T for 6-9 months to complete the necessary processes. There are some providers who are having success taking samples of certain body parts to freeze and use for later while folks are actively on T. The most important thing is to be aware of all this before starting T. We understand you might not yet have a clear answer for yourself, but you need to be OK starting T knowing there might be a possibility of becoming infertile later.
Most folks start to notice changes like lower voice, facial hair growth, and stopping of monthly bleeding at around 2-3 months. While there are many things that contribute to our mental health, many folks notice feeling better emotionally shortly after starting T – in particular, decreased anxiety and increased confidence. Physical changes will occur more gradually. Most folks will max out on physical changes somewhere between 2-5 years after starting T. We have to consider that every change is irreversible, but this can vary for each individual. Typically, the changes that are most likely to be irreversible are voice drop and coarse hair growth, such as beard growth. The degree to which a change expresses is different for each body based on your genetics, however, commonly include:
- Body fat redistribution to more central and less on the outside of the body
- Increase in muscle mass
- Increased and darker facial and body hair growth
- Broadening of the shoulders
- More angular eyes and face
- Increase in libido
- Enlargement of some genital parts
- Deepening of the voice
There are some changes that can be less desirable for some people, but affirming for others. Fortunately, we have treatments to help with these things:
- Increased oily skin and acne
- Increased dryness or discomfort in the genital area
- Recession of the hairline – this one is more dependent on family history of pattern baldness and typically is more of a concern after being on T for at least a year
Uptake Method, Dose, and Frequency
- Injection – The most common uptake method. Injections cause changes the quickest and tend to cause more prominent change compared to other methods at the same dose. It is very easy to adjust the dose by small increments. Because of this, it is a good option for “microdosing” (read more about microdosing below).There are two methods of injection. Intramuscular (IM) injection is an injection into the butt, glute, or thigh area. You can rotate injections between each of those areas and you should rotate sides of the body for each injection. Subcutaneous (SC) injection uses a shorter, thinner needle and is given just under the skin in the belly. They both use the same dose, both are once a week, and both work the same. It just comes down to whether you want to poke yourself in the butt, thigh, glute, or belly. You can always change needles and injection styles. Because needles are part of your prescription, let your provider know if you want to switch. With a goodrx coupon, a 2.5 month supply costs about $25 depending on your dose.We typically prescribe testosterone cypionate 200 mg/ml concentration to be injected once per week. If you have an intolerance to testosterone cypionate, we can also prescribe testosterone enanthate. Weekly injections help keep levels more stable than twice weekly. Your prescription includes syringes and needles sent to the pharmacy so you have everything you need. You will get a larger, wider needle to draw up the T because it is in a thick oil. The larger needle enables you to draw the liquid out of the vial quicker. You will also get a thinner needle to switch over to that you will inject with. We recommend and prescribe the 1-ml syringe because it is easier to see all the markings, especially if you are injecting less than 0.5-ml. We know some folks can be anxious about injections. Don’t worry, we will provide you with teaching videos and walk you through how to inject if you choose to do injections.
- Topical gel – Will result in more gradual change. You apply it every morning. It takes about 3 hours to dry. If not completely dry it can rub off onto other people, increase their T levels, and cause physical changes. Costs about $50-60/month depending on the formulation with a goodrx coupon.
- Patch – Rarely used. Also causes more gradual change. It can be hard to keep the patch on and isn’t very easy to adjust the dose. Is very expensive without insurance coverage. Over $600/month even with a goodrx coupon.
Determining The Right Dose
If you want more gradual change, we can go with a lower dose option. If you want to take the most accelerated route to maximal physical change, then we can start at a higher dose. Just let your provider know what feels right for you and we will find something that fits!
Microdosing is a newer term that describes using a small amount of a medication to achieve lesser or different effects from more common dosing recommendations. This is a very individualized process and we cannot pinpoint specific physical traits or rate of change.
We know that was a lot of information. Hopefully, it was helpful and educational.
We truly look forward to meeting you and assisting you in a personal and meaningful way.
Your Plume Care Team
The information in this document is derived from national and international guidelines on gender-affirming care, expert opinion and the personal practice experience by the medical providers of Plume. Guidelines include the UCSF Transgender Center of Excellence, the World Professional Association of Transgender Health and the Endocrine Society.