Hormones - Testosterone

FORGE documents are written for both SOFFAs (significant others, friends, family and allies) and FTMs+; the terms "you" and "your" may refer to transmen, genderqueers, and/or SOFFAs, as appropriate to the context.

Many people wonder about how to begin their journey with testosterone. This follow-up will not address the process of HOW to get hooked up with a physician who will prescribe testosterone, but will address the more practical, health, and emotional issues associated with testosterone use.

The best way to determine which method of testosterone delivery will work best for you is to work closely with an informed (or willing to be informed) health care provider. However, sometimes physicians don't have much information about the use of testosterone in FTMs+ (or any other person, for that matter). It's often difficult for physicians to find reliable and accurate information on dosage and testosterone delivery methods. As many physicians have found, "oral" history and current "patient-to-patient" information can often prove most useful. In other words, those using testosterone often find they know more about the types of testosterone that are available, typical dosages, common side effectives, effective treatment methods for health issues that arise from using testosterone, etc. than their physician does. This is not to imply that physicians should not try to be as informed as possible and do their own research, but some physicians who have not treated FTMs (or non-trans testosterone-deficient men) may rely on you to help provide them with information about testosterone.

Sheila Kirk's book " Masculinizing Hormonal Therapy for the Transgendered" (now out of print, but many copies still available through used bookstores) [ASIN: 1887796029] is a useful resource -- written by a physician -- and specifically deals with hormone and healthcare needs of transgender individuals. Buying a copy for your physician may be helpful in educating him/her and/or validating the information you share with your provider.

So what's typical? Every body is unique and there are no set formulas or formats for starting or using testosterone. The insert in injectable testosterone recommends using between 50 to 400 mg of testosterone every 1 to 4 weeks. This doesn't give a physician much to go on for prescribing to an FTM! [The difference between 50mg every 4 weeks and 400mg every week is tremendous!]

The most TYPICAL dose of injectable testosterone (either cypionate or enanthate, either 100mg/ml or 200mg/ml strength) is 200mg every 2 weeks. Some physicians prefer to start low and build up (providing a gentle hormonal transition), while others prefer to "turbo charge" the system by starting high and reducing the dose over time (simulating the peaks young boys often experience in puberty).

One common gauge of how much testosterone is "enough" is checking the level of testosterone in the blood. In non-trans men, average testosterone levels can range from 200 to 1200. Many physicians like to see FTMs using supplemental testosterone to be in the 400-800 range.

Many people can simply "feel" in their body what the right dosage is over time. Many may feel a sense of "jones-ing" or can feel when they need more testosterone, or "instinctively know" when they have too much in their body. Checking blood levels can help to confirm this and give reliable feedback that can determine dosage amounts.

Clearly, not everyone wants to have blood levels in the "normal" range for bio-men. Not everyone wants to masculinize quickly or to end up appearing 100% "male" (whatever that might mean by society's standards).

Discussing with your healthcare provider ahead of time what effects you would LIKE to see, as well as how fast you may like to see changes, will help determine the initial dosage. While it may seem odd to individuals who are rarin' to go, some people want a very slow and gradual transition (perhaps due to transitioning on the job, family, partner, or just personal preference).

What kinds of testosterone are available?

a. Injection (Intramuscular)
- Depo Testosterone - Testosterone Cypionate (in a cottonseed carrier oil)
- DELATESTRYL - Testosterone Enanthate (in a sesame seed carrier oil)

b. AndroDerm (or Testoderm TTS Patch) (transdermal patch)
http://www.androderm.com/

c. Testoderm (scrotal patch)
(not appropriate/effective for FTM surgically constructed scrotums)

d. Androgel (testosterone-rich gel)
http://androgel.com/main.html

e. Compounded testosterone cream
(No name brand is available. Compounding pharmacies can mix testosterone in a carrier cream based on your physician's prescription.)

f. Testopel® (Bartor Pharmacal) (Pellets)
http://rain.prohosting.com/~martydr/untitled.html
http://www.pdrhealth.com/drug_info/rxdrugprofiles/drugs/tes1595.shtml

For more general information about testosterone, check out FORGE's Testosterone 101 at http://www.forge-forward.org/handouts/Hormones.pdf

Injecting.

Unfortunately, many physicians offices do NOT teach their clients (or support people that come with their client) how to self-inject. Some physicians may "require" you to come into their office every 2 weeks (or other time frame) for someone in their office to do the injection. This can be costly, inconvenient, and medicalize a process that could be routine and natural to you. If you are going to be self-injecting, please ask your physician to have someone in their office teach you how to inject safely and effectively. (Not injecting into the muscle may result in your body's inability to process the testosterone. Injecting into a blood vessel could have serious/life-threatening consequences.) If they are unwilling to teach you, there are many ways to learn, including a FORGE handout on self-injection, located at http://www.forge-forward.org/handouts/injection.pdf

Often times, if you know other FTMs or SOFFAs in your area, they may be willing to help teach you, or do the injection for you if you are unable to do so yourself.

It is often helpful to see - on another person, or to have them show you on your body - where safe places to inject are located. Sometimes just looking at medical textbook pictures or other 2D graphics don't help as much as seeing a 3D person and "pin-pointing" exactly where to stick!

Some people are needle shy. Injecting may not be the best method for getting testosterone into your system. For more information on needle-phobia and techniques to work with fears about needles, read FORGE's handout "Just a Prick: Dealing with Needle Anxiety" at http://www.forge-forward.org/handouts/Needle-anxiety.pdf

While injecting used to be the norm, many physicians and FTMs are finding that the use of gels, creams and patches containing testosterone is easier and more convenient than injecting. These methods of delivery have the benefit of maintaining more even levels of testosterone. Some health insurance companies, though, may only cover injectable testosterone and will not pay for other methods. Also, care must be taken when using gels and creams to not have skin to skin contact with others (particularly women), since the testosterone can transfer from your skin to theirs, resulting in reducing your dose, and providing the other person with likely unwanted testosterone!

Discussion with your provider will help you determine what method is best for you.

Compounding. Compounding pharmacies are places where medications can be prepared, mixed or "assembled" from components that are not always available through commercial pharmaceutical houses. This means that if you were allergic/sensitive to carrier oils for injectable testosterone (cotton seed or sesame seed) that are sold through companies like Upjohn Pharmaceuticals, a compounding pharmacist would be able to use a different oil carrier and mix in the correct amount of testosterone. Likewise, pharmacists can create creams or other mixtures that include testosterone. The benefits of this are enormous; namely, specifically designing the exact dose in just the right format for your needs.

Often local neighborhood pharmacies will compound medication. If you wish to go this route, you can ask around at local pharmacies or use one of the several online or mail-order pharmacies.

One local pharmacy in Wisconsin that works with many transgender clients is Community Pharmacy in Madison . They are a compounding pharmacy and can work with individuals and providers on supplying you with exactly what you need.

Community Pharmacy
341 State Street
Madison , WI 53703
608-251-3242
608-251-4454 (prescriptions)
http://www.communitypharmacy.coop/

Online pharmacies. The pharmacies listed below frequently deal with clients requesting testosterone:

Kronos Compounding Pharmacy
3675 S. Rainbow Blvd. #103
Las Vegas , NV 89103-1059
Phone: 1-800-723-7455
http://www.kronospharmacy.com

ApotheCure
13720 Midway Rd. #109
Dallas , TX , 75244
Phone: 972-960-6601
Fax: 1-800-687-5252

Strohecker's Pharmacy
2855-A S.W. Patton Road
Portland , OR 97201
Phone: 503-222-4822
Fax: 503-222-4868
http://www.stroheckersrx.com

There are many places online that discuss typical changes associated with testosterone use. Changes that are desirable to some people may not be positive to others. For a general list of typical expected desirable changes, go to: http://www.forge-forward.org/handouts/Hormones.pdf

At our March 2004 meeting, we discussed that what tends to happen first are vocal changes. This can include deepening pitch, vocal tiredness and possibly even a sore throat, difficulty singing, and radical shifts in tone (cracking to smooth, high to low). Other early changes can include a change in how urine and other body fluids smell. Due to the Ph change, urine and other body fluids may also change in appearance as well - such as underarm staining of white t-shirts.

Several members at the meeting discussed how they felt the need to stretch more, that areas of their body felt tight, tense or contracted. One member noted that muscles and ligaments grow and change at different paces, so it's important to go slow when lifting weights or exercising, and it's essential to stretch often.

Other early changes include cessation of menstruation, acne, hot flashes, and change in body size (either overall weight gain or loss, as well as changes in the size of specific body parts such as feet, shoulders, neck, fingers, hips). Breast tissue may change in its density and shape, but typically does not reduce in overall size.

Changes can continue to occur and solidify upwards of 5 or more years. Many long-term testosterone users notice that change never stops - there are always changes in hair growth pattern, etc.

Consult http://www.forge-forward.org/handouts/Hormones.pdf for general information about typical "negative" side effects.

Cardiovascular

Cardiovascular side effects are of concern to many who consider testosterone use. Taking testosterone can place a person at a risk level typically associated with non-trans men, who are reported to have higher incidences of cardiovascular health issues. Increased blood pressure, elevated lipid levels, and potential increased risk for heart disease are among the most common cardiovascular risks.

FTMs who use testosterone are no different than anyone else who has high blood pressure or cholesterol or other cardio risks. Eating healthy, exercising, using medications (when appropriate) and other methods are often successful in minimizing or reducing risks. Talk with your healthcare provider about creating a plan to maintain or reduce your cardiovascular risks.

Liver

Another potentially serious side effect commonly associated with testosterone use is the change in liver function. When liver levels are elevated, some physicians believe that cessation of testosterone is one of few viable options to help the liver return to its normal functioning. While testosterone is not always the culprit for high liver levels [e.g. alcohol use, other medications, family history, etc. may be the reason(s)], there are a few effective ways of reducing liver risks and increasing liver health:

~ reduce or eliminate alcohol

~ be cautious about potential infection with hepatitis

~ use milk thistle as a supplement to your diet

~ consider reducing testosterone dose and/or changing to another delivery method

Polycythemia

Polycythemia is more prevalent in people taking testosterone than people who don't. It is a condition of the blood that is basically opposite of anemia. Many physicians are unfamiliar with non-cancerous polycythemia - which is the type FTMs can experience when using testosterone. Polycythemia is a blood disorder in which there is an excess of red blood cells flowing through the body. Symptoms can include fatigue, headache, difficulties breathing, dizziness, itching, and high blood pressure. The most common treatment is phlebotomy (i.e. giving/removing blood). It is ESTIMATED that as many as 25% of people using exogenous testosterone may be polycythemic.

FORGE reported on polycythemia and ways of dealing with this condition in the April 2003 social support meeting follow-up resource located on the web at http://www.forge-forward.org/socialsupport/limitlessgender.html#polycythemia

Not much is known about long term (or even short term) serious side effects directly linked to testosterone use.  As noted above, testosterone use CAN increase the risk of cardiovascular disease.  In addition to these risks, there may be others that are not yet as well known or identified.  Little research has been conducted on the use of testosterone in "female" bodies - especially longitudinal studies involving a large number of subjects - so we are unsure of what long term serious effects may be correlated with hormone use.

Many people fear cancer and question if there are increased risks of cancer when taking testosterone. The bottom line answer is that we don't really know.  The next few paragraphs will try to provide a bit more detail:

Breast cancer.

Any person can get breast cancer.  It is believed that 1 in 9 women may get breast cancer.  While the majority of people (who were assigned female at birth) using testosterone don't typically consider themselves women, if they have not had "top" surgery, they are at the same level of risk as women.  If there has been chest reconstruction, there is also still a risk, but usually a lesser one, since many chest reconstruction techniques remove much (if not all) of the breast tissue.  At the 2001 Harry Benjamin International gender Dysphoria Association Symposium in Galveston, Texas, A. Evan Eyler, MD and Stephen Whittle noted that "A reduction in the relative risk of breast cancer following female reduction mammoplasty has been reported (Brown et al 1999; Baasch et al 1996) but individuals who have experienced female pubertal breast development remain at risk for breast cancer unless all breast tissue is removed."

Of course, it's important to remember that ALL people, including non-trans men, can have cancerous breast/chest tissue. Regular manual exams - by yourself and also by a heathcare provider - can greatly increase the likelihood of early detection. 

[There does not seem to be any greater risk of breast cancer associated with testosterone use.]

Gynecologic cancers (uterine, cervical, etc.)

One reason for deaths or serious illness/complications from gynecologic cancers stems from the late detection of these cancers. Delayed detection may be a more serious problem for FTMs than women due to either or both 1) physician discomfort and/or unwillingness to examine the FTM's full body, performing regular pelvic exams with PAP smears; 2) the emotional discomfort and/or embarrassment many FTMs feel when faced with seeing a physician for a pelvic exam. Both issues are tremendously serious, and extremely prevalent. More and more physicians are having experiences with transgendered patients and are appropriately taking care of the health of their patient's entire body, so this issue MAY be diminishing as a central barrier to care. However, the discomfort FTMs may feel is possibly more difficult than educating healthcare providers. Hopefully peer-to-peer conversations and problem-solving about this issue will help reduce fear, embarrassment, and/or emotional discomfort. FTMs should also work with their provider to find examination techniques that are the least emotionally stressful, or physically painful.

For many of us who boldly transition to become the people we are - often dealing with difficult situations of coming out, possibly painful surgery to make our bodies congruent with our internal sense of how our body should be, breaking cultural norms by crossing gender "boundaries" -- it seems senseless to be willing to risk our lives by not caring for our masculine body that also happens to have one or more organs such as a uterus, cervix, vagina, or ovaries. If we've come this far - taken so many risks and courageous steps - why not try to prolong our lives (the lives as masculine people we so longed to be), by taking good medical care of our complete bodies?

PCOS

Polycystic Ovary Syndrome (PCOS) is a medical condition that affects approximately 5% of female-born women. Symptoms of PCOS may include hirsutism (development of body hair without supplemental testosterone), changes in menses (including irregular or absent periods, or dysmenorreah), and obesity. Some individuals with PCOS do not show any of these symptoms. People with PCOS are at increased risk for an overgrowth of the uterine lining (endometrial hyperplasia), cancer of the endometrium, and breast cancer.

Women with PCOS tend to have elevated levels of dehydroepiandrosterone (70%) and/or adrenal androgen, 11beta hydroxyl androstenedione (50%) -- i.e. simply put, they have a high level of androgens (testosterone-like substances) in their body.

It is ESTIMATED that as many as 25% of all FTMs taking testosterone may have PCOS and/or polycystic ovaries or uterine fibroids. Often, the use of testosterone aggravates fibroids and polycystic ovaries.

One common treatment for women with PCOS is to treat with estrogens. The majority of FTMs find this treatment unacceptable and opt for the removal of the uterus and ovaries, which resolves this condition.

Because the rate of PCOS is believed to be up to 5 times higher in testosterone-taking FTMs, the presumption is that the testosterone is responsible for the condition. However, Dr. Walter Futterweit -- who has treated over 1200 people who have PCOS -- conducted a study of more than 80 pre-transition FTMs. He found that 27% had features of polycystic ovaries prior to starting on testosterone. He also found that 75-80% pre-transition FTMs had enlarged polycystic ovaries which were exactly identical to those found in women with polycystic ovaries. He notes, " So this is quite a significant percentage and makes us think again of other potential pathological or physiological derangements that may occur not just in terms of altering the mindset of genetic females but what it is that also may be a factor in the causation of PCOS."

While no one has proven that testosterone creates a greater likelihood of developing PCOS, some physicians and researchers believe there is a correlation. Two ways to maintain good health and address issues as they arise is to have a good working relationship with your healthcare provider and have regular pelvic exams.

Remembering Robert Eads.

Many know of Robert Eads - an incredibly sweet FTM, portrayed in the award-winning Kate Davis documentary _Southern Comfort_ - who lost his life due to ovarian cancer that was not caught in time or treated aggressively, in large part because of his transgender status. Robert is by no means the only FTM who has been refused gynecologic healthcare or who was emotionally uncomfortable with obtaining crucial medical care of his "female" organs.

It is a tragedy when anyone loses their life because of provider incompetence or the person's fear or apprehension around procedures that could save their lives. Please take care of the body you have, even if it might be emotionally difficult to do so. If your physician won't treat your whole body, consider finding another one who will.

Testosterone may or may not create changes in emotional states. As a person masculinizes with testosterone use, there may be societal variables that may influence emotional health (for the better or worse), as well as additional stressors (job, family, etc.). However, many people who start on testosterone do report feeling an overall DECREASE in depressive-type symptoms, resulting in feeling more alive and excited about life. There can be subtle differences in mood; some people "develop a backbone" by which you may stand up for yourself more and do not allow others to criticize or diminish your sense of worth. Increased confidence can shift self and other's perceptions, which may lessen depressive symptoms.

Moods may also change in how they manifest. For example, someone who used to be withdrawn or weepy when they were depressed may shift (after starting on testosterone) to being angry.

Quite a few people talking testosterone note that they have difficulties crying. For some, this means that they don't seem to get upset or saddened by situations. For others, they may experience the same degree of feelings and WISH to cry (feel like crying), but no tears come.

No two people are alike and thus there cannot be broad generalizations about how testosterone impacts mood. Some people, especially partners and family members, worry about aggressive behavior and moods. While this can occur in some individuals, it's not clear whether testosterone is the cause, and it most certainly is not true in all FTMs.

For an in-depth look how trans+ and mental health intersect (not only about testosterone use, but other factors), check out the 54 page FORGE Connectivity focused on mental health issues located on the web at http://www.forge-forward.org/newsletters/v07i02/connectivity-v7i2.pdf

Often 101 guides to hormonal transition don't address sexual or more "personal" types of changes. FORGE believes it is important to not shy away from any aspect of transition or the trans/SOFFA experience.

Smell.
FTMs who take testosterone can have a dramatic change in how they smell. This can include everything from armpit/sweat smells, to urine odor, to sexual secretion smell and taste. Partners or others who are intimate with an FTM may notice these changes more than the transitioning person. Since smell is often considered the most powerful of the senses, changes in how someone smells can cause some tension in relationships and affect desire.

Getting clean.
You wouldn't think that testosterone would change how you need to shower, would you? With genital growth, it can create lots of nooks and crannies (namely under the "hood" or "foreskin" of the "clitoris") to collect lots of smelly stuff. It's particularly important to pull back that "foreskin" and scrub it clean - presuming you want to stay smelling clean and fresh.

Acne.
While acne typically doesn't fall under the TMI category, it can when discussing extreme cases of acne or noting that acne can happen anywhere on the body. When hormones are initially shifting from an estrogen base to a testosterone base, acne can pop up all over. Commonly, acne appears on the face, shoulders and back, sometimes on the chest or belly. Sometimes, though, acne can develop on or around nipples, on thighs, butts, arms, necks, and even on and around genitals.

Libido.
Many people using testosterone notice a dramatic increase in libido. While this is often a welcomed change, it can be distracting as well as time-consuming! Some FTMs report feeling the need to masturbate or find sexual release several times a day (initially) or many times a week. Frequently, increased libido decreases over time and can return back to pre-testosterone levels, or slightly above. This change can impact not just the FTM but his partner(s), too (when applicable)! Some relationships need to be creative so that everyone gets their needs met and no one ends up having to compromise their principles or desires!

There is an incorrect assumption within the "mainstream" trans+ community (as well as in general society) that if you are transgendered, you will automatically want to be on hormones and have surgery. This, of course, is not true for everyone. FORGE follow-ups have not given enough bandwidth to issues and concerns of folks who are non-transitioning, choose not to use hormones and/or have surgery, and/or who choose to live outside of the binary gender paradigm. [Often what is reported here are issues that arise from our group discussion. Currently our membership/participants have been people who are pursuing medical transition.]

We will cover this issue in greater depth in another FORGE follow-up resource (as well as at our in-person meetings).

Mark Behar, PA and Paul Maes, DO are no longer at the Aurora Clinic on Wisconsin Avenue . No further information on where they are practicing is known at this time.

Community Pharmacy
341 State Street
Madison , WI 53703
608-251-3242
608-251-4454 (prescriptions)
http://www.communitypharmacy.coop/