masculinising hormones

testosterone

what is it & how is it used?

Testosterone (sometimes called “T”) is the main hormone that promotes masculine physical traits. It works directly on tissues in your body (e.g. stimulating clitoral growth) and indirectly by suppressing oestrogen production. We typically aim for testosterone levels in the lower end of the cis male range of 10-15 nmol/L. However, these goals vary from person to person and some people may prefer lower dosing.

testosterone options

  • Brand: Primoteston

    Timing: every 2-4 weeks

    Pros: rapid changes, cheap, no specialist review required

    Cons: more side effects at beginning & end of cycle, more regular injections

    Cost: $30-40 for 3 shots (not on PBS)

  • Brand: Reandron

    Timing: every 12 weeks

    Pros: rapid changes, more stable T levels

    Cons: not able to self-injection, requires specialist review

    Cost: $40 per shots (after specialist review)

  • Brand: Testogel

    Timing: daily

    Pros: more stable levels, fewer ups & downs, no needles, easier to do low-dose therapy

    Cons: initial changes more delayed, daily treatment, risk of exposure onto others, requires specialist review to get on PBS

    Cost: $70 per box or $30 per box after specialist review

When using testosterone for gender affirmation it must be prescribed in consultation with an endocrinologist, sexual health physician, paediatrician, or urologist in order to qualify for a PBS prescription.

changes on testosterone

The purpose of masculinising hormone therapy is to bring together the mind and body to lessen gender dysphoria. Every person will experience change to a different extent and at a different rate depending on various factors. This can include your age, the number of hormone receptors in your body, and how responsive your body is to testosterone. There is no way of knowing how your body will respond to testosterone before starting.

Testosterone affects the entire body. It’s not possible to pick some changes and not others.

    • growth of your clitoris (typically 1-3cm)

    • increased sex drive

    • oilier skin & increased acne

    • feeling hungry

    • vaginal dryness

    • increased growth, coarseness, and thickness of hairs on the arms, legs, chest, back & abdomen

    • increased muscle mass & upper body strength

    • redistribution of body fat to the waist, less around the hips

    • voice starts to crack & drop (this can take a year to finish changing)

    • menstrual periods stop

    • gradual growth of facial hair (usually 1-4 years to reach full growth)

    • possible “male”-pattern blading

    • reduced fertility

    • vaginal & breast tissue atrophy (reduction in size)

Most of the effects of testosterone happen in the first two years. You will usually have a review one month after starting hormones or changing your dose, then every three months in the first year. After dosing is stable, review appointments usually occur every six months.

At appointments in the first two years, your doctor will likely:

  • look at your facial/body hair and, if you shave, ask how quickly your hair grows back

  • ask about changes to your sex drive, clitoris, or other sexual changes; menstrual period; skin; and voice

  • order a blood test to see what your hormone levels are

  • ask how you feel about the changes that have happened thus far

permanent changes

Most noticeable changes caused by taking testosterone are not fully reversible, even if you stop taking the hormone.

Irreversible:  deeper voice, male-pattern baldness, facial hair, clitoral growth

Reversible:  menstrual periods, muscle/fat/skin changes

changes to fertility

It’s unclear whether testosterone affects fertility in the longer term. Your menstrual period will usually stop within 3-6 months of starting testosterone. After some time, there can be atrophy of your vagina and ovaries.

Some people opt to freeze eggs before starting Testosterone. This involves a procedure similar to IVF where you receive hormones, and eggs are then collected through the vagina wall and frozen for later use. If you ever decide to carry a pregnancy, you must stop your testosterone for several months. Many transmen have had successful pregnancies when they have stopped testosterone, and some have donated eggs to a female partner.

risks & side effects

The long-term safety of testosterone is not fully understood.  Most of the studies on hormone therapy involve non-trans men taking testosterone.  There may be long-term risks that are not yet known.

testosterone can increase the risk of heart disease, stroke and diabetes

Testosterone tends to:

  • Decrease good cholesterol (HDL) and increase bad cholesterol (LDL)

  • Increase fat deposits around internal organs and in the upper abdomen

  • Increase blood pressure

  • Decrease the body’s sensitivity to insulin,

  • Cause weight gain

These changes may increase the risk of heart attack, stroke and diabetes.  The risks are more significant for those who smoke, are overweight, or have a family history of heart disease.  Many contributing factors to these conditions can be reduced by creating a care plan tailored to your specific situation.  Stopping smoking, exercising, eating well and having periodic blood tests are all critical steps in reducing your risks.

testosterone can increase red blood cells and haemoglobin

The increase is usually only to the average male range; however, a higher increase can cause potentially life-threatening problems such as stroke and heart attack.  Blood tests will check on this.

testosterone can cause or worsen headaches and migraines

Tell your doctor if you are getting frequent headaches/migraines or if the pain is unusually severe.

cancer risk is not significantly affected

Breast cancer, ovarian cancer and uterine cancer are all sensitive to oestrogen, and there is evidence that some testosterone is converted to oestrogen.  However, studies have not found a definite increase in the rate of cancers in trans men on testosterone. Risk is likely to be increased if you have a family history of these cancers, are aged >50, or are overweight.  It is important to discuss screening tests that may be appropriate.

testosterone can negatively affect mental health.

In some people, testosterone can cause increased irritability, frustration and anger.  People with bipolar disorder or schizophrenia may destabilise.  Using daily Transdermal testosterone can help with mood swings.

pelvic pain in trans folk

Some people develop pelvic pain after being on testosterone for some time.  This can be like period pain and can occur monthly or in a random fashion.  Tell your doctor if this happens to you so it may be properly investigated.

testosterone can increase skin oiliness and acne

Testosterone stimulates the skin’s oil glands, which can result in the skin being more oily as a result, and feeling a bit rougher than before. This can also increase acne or pimples on the face and the body. If this becomes a problem or frustration, you can talk with your doctor about how to help. Anti-bacterial body and face wash, used daily, can be helpful, as can a cleanse, tone and moisturising routine.

what hormones won’t change

hormone therapy won’t solve all body image problems

The point of hormone therapy is to feel more comfortable with your body by bringing your physical characteristics closer to your internal sense of self. This can increase self-esteem and make you feel more confident and attractive. However, the changes may not necessarily meet your expectations. It can be hard to separate gender dysphoria from body image problems, and counselling can help achieve greater self-acceptance.

hormone therapy won’t make you into somebody else

Many people experience positive emotional changes with hormone therapy.  But after the excitement wears off and you’ve incorporated the changes into your daily life, you’ll likely find that your personality remains unchanged.  Whatever you see as your strengths and weaknesses will still be there.  Hopefully, you will be happier and more accepting of yourself, but if you expect all of your problems to disappear, you may be disappointed.

This extends to mental health concerns as well.  People who were depressed because of gender dysphoria may find that taking hormones improves their depression.  However, if you have depression caused by biological factors, the stresses of transphobia, or unresolved personal issues, you may still be depressed after you start hormone therapy.  

hormone therapy won’t provide you with a perfect community

For some trans people, hormone therapy is a ritual affirming that they are who they say they are.  Making physical changes is a way to bring who you are to the rest of the world so that other people can see it.  This process of self-emergence can be very liberating, but it does not guarantee that you will find acceptance or understanding.

When starting hormones, there can be a drive to find other people who have gone through similar experiences.  There are a lot of very cool trans people to talk with about hormones, but having taken hormones doesn’t automatically make trans people welcoming, approachable or sensitive.  Being realistic about the likelihood that you will sometimes feel lonely and alone after you start taking hormones is part of emotionally preparing for hormone therapy.

hormone therapy won’t remove all “female”/”feminine” aspects of your body.

Some physical characteristics are not affected by hormone therapy or are only slightly changed.  This includes things developed before birth (vagina, chromosomes) and physical changes during puberty.

Testosterone makes your voice pitch drop, but it does not change intonation and other speech patterns associated with gender socialisation rather than hormones.

Testosterone does not make breast tissue disappear; you will need surgery for this change.

Once your bones have stopped growing after puberty, testosterone won’t change the size or shape of your bones.  You will not grow taller or get bigger hands or feet.

Since effects on fertility are unpredictable, there is a chance you could still become pregnant.  Depending on how you have sex, you may need to use birth control.  Testosterone is toxic to the developing foetus, and you cannot take it whilst pregnant.

Testosterone tends to make the vagina drier and the cervix more fragile, so if you have vaginal sex, you should add extra lubricant to avoid breaking latex or tearing your vaginal lining.