All The T
Gender Affirming Medical Care with Testosterone
All The T
Gender Affirming Medical Care with Testosterone
Everyone's body is different and may react differently to medications. It is important to remember that because everyone is different, your medicines or dosages may vary widely from those of your friends or what you may have read about hormone therapy online. If you are starting testosterone as an adult, you are, in effect, entering puberty again. First puberty usually takes several years from start to finish, and second puberty is no different. Many people want changes to happen as quickly as possible, but taking higher doses of hormones will not necessarily make things happen faster. Higher doses can, however, endanger your health.
Effects of gender affirming medical care with testosterone
1) Physical Changes
The first changes you will probably notice are that your skin will become a bit thicker and oilier. Your pores will become larger, and there will be more oil production. You may develop acne, which in some cases can be bothersome or severe. Acne can be managed with good skincare techniques as well as typical acne treatments. You may notice that you perceive pain or temperature differently, or that things just “feel different” when you touch them. You will probably notice skin changes within a few weeks. In these first few weeks, you will notice that the odors of your sweat and urine will change and that you may sweat more overall.
Your chest will not change much during transition, though you may notice some breast pain or a slight decrease in size. For this reason, many top surgeons recommend waiting for at least six months after beginning testosterone therapy before having chest reconstruction surgery.
Weight will begin to redistribute around your body. Fat will diminish somewhat around your hips and thighs and the fat under your skin throughout your body will become a bit thinner, giving your arms and legs more muscle definition and a slightly rougher appearance. Testosterone may cause you to gain fat around your abdomen. Your muscle mass will increase significantly, as will your strength. However, in order to maximize your development and maintain your health, you should exercise most days (4-6 times a week) with a goal of at least 60 minutes a day mixing resistance training with aerobic training. Tip: testosterone helps your muscles get stronger faster than your tendons do. To reduce your risk of tendon injury, do not increase exercise intensity (weight, duration, frequency) across a specific muscle and tendon group by more than 10% per week. It is helpful to focus some weight training on the upper body as this will enhance muscle development of the arms, chest, and back. If you plan to have top surgery, then it is important to develop these muscles so that you get the best results. Check out our article on building angularity for workout ideas.
The fat under the skin in your face will decrease and shift around to give your eyes and face in general a more angular, sharper appearance. Please note that your bone structure will not change, though some people in their late teens or early twenties may see some subtle bone changes. Facial changes can take up to two years or more before completing.
The hair on your body (chest, back, and arms) will increase in thickness, become darker, and will grow at a faster rate. You may expect to develop a pattern of body hair similar to other men in your family. However, again, please remember that everyone is different and that it can take up to five years or longer to see the final results. Most transmasculine people notice some degree of frontal scalp balding, mostly in the area of the temples. Depending on your age and family history, you may develop thinning or even complete hair loss at the front and top of the scalp.
Facial hair varies from person to person. Some people develop a thick beard quite rapidly, others may take several years to do so, while others may never develop a full thick beard. This is a result of genetics and the age at which you start testosterone therapy. You might notice that cisgender men also have a varying degree of facial hair thickness, and a varying age at which their facial hair is fully developed.
2) Emotional Changes
Your overall emotional state may or may not change, as this varies from person to person. Puberty is a roller coaster of emotions, and the second puberty you will experience during your transition is no exception. You may find that you have access to a narrower range of emotions or feelings, have different interests, tastes, or pastimes, or behave differently in relationships with other people. While psychotherapy is not for everyone, most people would benefit from a course of supportive psychotherapy while in transition to help them explore these new thoughts and feelings and get to know their new selves. Most studies show a significant improvement in overall well-being after gender affirming hormone therapy begins. This is most likely due to better physical body alignment with psychological gender identity.
Soon after beginning hormone treatment, you will likely notice a change in your libido. Quite rapidly, your clitoris will begin to grow and will become more prominent during arousal. You may find that different sex acts or different parts of your body bring you erotic pleasure. Your orgasms will feel different, with perhaps more peak intensity and more focused on your genitals, as opposed to a whole-body experience. We recommend that you explore and experiment with your new sexuality through masturbation, using sex toys, and involving your sexual partner(s).
4) Reproduction/ Fertility
At first, you may notice that your periods become lighter, arrive later, or are shorter in duration than previously. Some people will have heavier or longer-lasting periods for a few cycles before stopping altogether. Usually, it takes 6-12 months for menstrual periods to stop completely.
Testosterone greatly reduces your ability to become pregnant. However, it is not a reliable form of birth control! If you are on testosterone and have genital sex with a person who has sperm, you must continue to use an alternative birth control method to prevent pregnancy. Testosterone is not safe to use during pregnancy, as it can cause congenital disabilities.
Transgender men can become pregnant while on testosterone. If you suspect you may be pregnant, take a pregnancy test as soon as possible so that you and your doctor can immediately discuss your plans.
If you want to become pregnant, you should stop your testosterone treatment and wait until your doctor tells you that it is okay to begin trying to conceive. Your doctor may check your testosterone levels before clearing you to start.
Testosterone therapy may alter and decrease ovulation and permanently decrease your ability to become pregnant. If this happens, you may need to use fertility drugs or use techniques such as in-vitro fertilization to become pregnant in the future. It is possible that after taking testosterone, you may completely lose the ability to become pregnant. “Freezing” embryos or eggs is an alternative for potentially preserving your fertility. Fertility preservation is rarely covered by insurance. It is possible that you may lose your ability to have a biological child completely.
After being on testosterone for some time, you may experience a small amount of spotting or bleeding. This may occur if you miss a dose or change your dosage. You should report any bleeding or spotting to your doctor. In some cases, your doctor will recommend an ultrasound to rule out serious problems with the uterus. Sometimes, a biopsy is also needed. These may be physically and emotionally difficult but are very important for diagnosis. If this might cause you distress, talk to your doctor about your pain and anxiety management options and ask for recommendations for trauma-informed providers.
5) Health Monitoring
Cancer risks and screening:
Your risk of cervical cancer relates to your past and current sexual practices. The HPV vaccine can significantly reduce your risk of cervical cancer, depending on your age when you get the vaccine and how many sexual partners you have had before receiving the vaccine. Pap smears are generally recommended every 3-5 years; more or less frequent pap smears may be recommended by your doctor depending on your sexual history and the results of your prior pap smears.
Testosterone treatment is not thought to increase your risk of ovarian cancer, but there are not enough studies to know for sure. Most ovarian cancers are discovered late, when the cancer is at an advanced stage, and in individuals aged 45 to 65. Because we do not have any highly effective lab tests that screen for ovarian cancer, pelvic examinations are recommended every one to two years for people with ovaries. The doctor uses a gloved hand to examine the vagina, uterus, and ovaries during a pelvic examination.
As above, we recognize that any procedures involving genitals may be distressing. Please let your providers know, and ask about your options. It is okay to ask for a different provider if you do not feel safe.
The risk of breast cancer while on testosterone treatment is not significantly increased. However, there has not been enough research on this topic to be certain of the actual risk. It is still important to receive periodic mammograms or other screening procedures as recommended by your doctor. After breast removal surgery, there is still a small amount of breast tissue left behind. It may be difficult to screen this small amount of tissue for breast cancer, though there are almost no cases of breast cancer in transmasculine people after chest reconstruction surgery.
Testosterone may change your overall health risk profile. Your risk of heart disease, diabetes, high blood pressure, and high cholesterol may go up, though these risks may be less than a cisgender man’s risks. Since men, on average, live about five years less than women, theoretically you may be shortening your lifespan by several years by taking testosterone.
Lab work to expect:
Your doctor will order periodic labs to monitor your health, including blood count tests, cholesterol levels, kidney and liver function tests, and blood sugar levels. Your testosterone levels will need to be routinely checked during the first year or two of transition and less frequently afterward.
Your body will make more red blood cells while you are on testosterone. If your body produces too many red blood cells, your blood can get too thick, which raises your risk of stroke, heart attack, and other conditions. The changes in your blood chemistry may also strain your liver, leading to liver damage.
Some of the effects of hormone therapy are reversible if you stop taking testosterone. How much can be reversed depends on how long you took testosterone. Clitoral growth, hair growth, voice changes, and hair loss are not reversible.
If you have had your ovaries removed, it is important to remain on hormones until at least age 50 (and perhaps beyond), to prevent a weakening of the bones, known as osteoporosis. Your dosage after ovary removal may be much lower than before. It is also highly recommended that you take calcium and vitamin D supplements to help maintain healthy bones.
6) How to take testosterone
Testosterone comes in several forms. Most transmasculine people begin using an injectable form of testosterone. Generally, you are started at a lower dose and slowly increase over several months in order to avoid negative side effects.
There are also transdermal forms (gels, creams, and patches) available. Sometimes insurance will not cover these. There are some long-acting injectable and implantable forms sometimes available through in person clinics, as well.
The usual blood test schedule is approximately every 3 months for one year, then every 6 months for one year, then yearly.
Taking more testosterone will not make your changes progress more quickly and can be unsafe. Excess testosterone can be converted to estrogen, which can then increase your risks of endometrial hyperplasia or cancer, make you feel anxious or agitated, harm your liver, and can cause your cholesterol or blood count to get too high. It is important to be patient and remember that this puberty can take years to develop all of its changes.