Last week, we discussed some of the things to know before starting testosterone. This week, we’re going into more depth about two topics that we discuss a lot with clients taking T: CONTRACEPTION and HAIR LOSS (and some HAIR GROWTH.) Many of the hair loss options are also applicable for people taking estradiol or not taking any gender affirming hormones. The contraceptive options are mostly focused on people with ovaries.
Content advisory: anatomical terms, reproductive talk.
So you’re on T, and those early changes are happening: your skin is oilier, maybe you’re seeing a little more definition in your arms, maybe you’re strength training and noticing that it’s easier to build muscle, perhaps you’ve got some T acne along with the oilier skin (check out our tips on treating acne!)
You may notice that monthly bleeding is lighter and doesn’t last as long, or has stopped. Perhaps you’re getting some bottom growth, and your body odor has changed and you just plain feel different. Hopefully these are all building gender euphoria!
SEX TALK TIME:
You may find that your experience of arousal and orgasm are changing as well. Read more about libido and other changes while on gender affirming care and sexual health resources in our earlier articles!
We’re big fans of human sexuality here at QueerDoc, and we support and encourage your exploration of your changing body, should that be something you’re keen on. There are a few things we need to discuss:
LUBE.
Lube lube lube lube. Do you have a lube song? Sing your lube song as you reach for more lube.
Your body’s production of lubrication may be lessening at the same time that less estrogen in your body is causing vaginal tissues to thin. You might feel a dry or uncomfortable: lube helps with that during sexy times, and can protect your tissues from damage. If you’re uncomfortably dry during non-sexy times, talk to your provider! They can help!
Also: CONTRACEPTION!
Testosterone lightens monthly bleeding, and bleeding may stop altogether. Testosterone may also stop ovulation. But there’s no way to be sure.
Testosterone is not birth control.
If you are sexually active with someone whose body can make sperm, there’s any chance that semen could get near your uterus, you need to use contraception.
If you’re on T and want to get pregnant, talk to your provider about when to stop T before trying to conceive.
If you are sexually active with anyone, you may be at risk for sexually transmitted infections. Regular testing, open and honest conversations, and using barrier methods can help reduce your risk. We love Whitman Walker Health’s sexual health guide for trans bodies.
And, we gotta admit, it’s not a great time in many parts of the USA for reproductive rights. Contraception you can count on can also support your mental and emotional health.
Your Options
There are multiple methods of contraception to choose from. Taking testosterone does not rule out any forms of birth control, so your choice depends on preference and other risk factors.
Hormonal options:
Will taking hormonal contraceptives make my testosterone less effective?
Studies indicate that testosterone blood levels don’t change in individuals taking both testosterone and the pill. So, it is unlikely that taking anything with estrogen will hinder your testosterone therapy. However, if you use hormonal contraceptives, you may experience estrogen or progesterone-related side effects like chest tenderness. If you have persistent bleeding, adding a hormonal contraceptive or non-hormonal option like anastrozole can stop menses. Hormonal contraceptives can also lessen cramping and backaches associated with bleeding.
Some things to think about:
If you experience bottom dysphoria, contraception might be a difficult topic.
Common dysphoria triggers include:
- A pelvic exam (not required for many forms of birth control)
- Frequency of use (pills need to be taken daily)
- Packaging and cultural associations
- Some forms are inserted before use, either by a clinician (an IUD) or by you (a diaphragm, ring.)
- Some forms are visible or can be felt (a patch, an implant, IUD strings may be felt by a partner.)
Oral combined contraceptives (OCPs – “The Pill”) contain both estrogen and progesterone. They are very effective at stopping bleeding and are highly effective as birth control. However, they need to be taken every day.
SubQ Depo Provera (progesterone only) can be injected at home and is also very effective at stopping bleeding. Injections are every three months (some individuals may start with three monthly injections before switching to every 12 weeks.)
IUDs are also highly effective and once inserted, may be used for years. However, they do require a pelvic exam and an invasive procedure. Insertion can be painful and cause dysphoria for some, and may cause spotting. Both copper and progesterone-only IUDs are available.
Other forms of hormonal contraception include combined contraceptives like patches and vaginal rings, and progesterone-only pills (the mini-pill) or implants (Norplant.)
Non-hormonal forms include diaphragms and condoms (both internal and external.) Non-hormonal methods are less effective at preventing pregnancy. They also must be placed on or in the genitals, which can be dysphoric for some people.
IMPORTANT: hormonal forms of contraception do not protect against sexually transmitted infections.
This chart describes contraceptive options and common pros and cons for people squaring it up:
We do prescribe hormonal contraception at QueerDoc, both for gender affirming reasons (to suppress bleeding) and for pregnancy prevention reasons. If you’re in one of the states we serve, and are interested, book a 15-minute introductory appointment to get more info. You don’t have to be a gender care patient of ours to book a sexual health visit.
HAIR LOSS and HAIR GROWTH
Hair can be a source of gender dysphoria and gender euphoria. Thankfully, we have tools in gender affirming care to both alleviate dysphoria and promote euphoria. This next section applies to people on testosterone and people on estradiol: preventing hair loss and encouraging hair growth.
What your hair will do is highly dependent on your existing genetics. If you know how hair has acted in your biological family, your hair will likely follow suit.
The Top Of Your Head: Balding and Hair Loss
As we discussed in previous weeks, the enzyme 5-alpha reductase converts testosterone to DHT in the body, and DHT drives hair loss by aging hair follicles. Finasteride and dutasteride are two medications which limit this conversion and lower the amount of DHT in the body. They are commonly available in oral formulations, and can be compounded as creams or liquid solutions. Finasteride and dutasteride support the longevity of hair follicles, and thus help prevent hair loss from follicles no longer being able to support healthy hair growth.
Topical vs. Transdermal: It Matters For Treating Hair Loss
We describe finasteride and dutasteride solutions/creams as transdermal because we’ve seen lowered levels of DHT on blood tests in patients using these medications topically: they may have some systemic effects.
Transdermal: solution penetrates the top layer of the skin and may enter the bloodstream.
There is evidence that transdermal dutasteride is more effective than oral finasteride in preventing hair loss. We can also prescribe transdermal finasteride.
But wait, there’s more! In addition to preventing hair loss, we can encourage hair growth.
Minoxidil is available over the counter in either foam or liquid forms and is applied directly to the scalp. Minoxidil is a vasodilator: it opens up blood vessels and helps provide more nutrients to hair follicles so that they can support hair growth. We recommend using the 2.5% or 5% varieties. Minoxidil is also available in a 10% strength version, but it doesn’t work any better and may cause more irritation than the lower-strength versions.
Have you seen the commercials for super long lush lashes by Latisse?
Latisse is a prostaglandin analog that was initially used to treat glaucoma (high pressure inside the eyes.) One of the side effects discovered among users was thicker, longer, and darker eyelashes. And thus, a new drug use was found. Latanoprost and bimatoprost are two examples of prostaglandin analogs and may be prescribed in gender affirming care.
But you wanna know what is super cool?
You can combine these products and use them all together!
A combined formulation of finasteride, dutasteride, and latanoprost is available from compounding pharmacies and can be used topically.
Rolling it All Together: Microneedling
There is evidence that microneedling/derma rolling is another effective tool in promoting hair growth. Derma rollers have short needles that, when rolled across the skin, create small, shallow punctures. The theory is that these tiny wounds trigger inflammation and the body’s healing response and thus promote healthier hair follicles.
You Can Microneedle AND Apply Hair Growth/DHT-Limiting Solutions
Yep! Better penetration of the medications we talk about above may be achieved by applying solutions after microneedling.
What About PRP for Hair Loss?
PRP (Platelet Rich Plasma)
There is limited but promising data that PRP can encourage hair growth. In the PRP process, you’ll have blood drawn. The blood is then centrifuged to separate out the plasma and platelets. The plasma and platelets are then injected into the scalp. Pro warning: the injections sting!
Plasma is the yellowish liquid that makes up most of the blood in the body. It’s mostly water but contains nutrients, hormones, proteins, and antibodies (and other good and important things like enzymes.)
Platelets are the parts of the blood that help stop bleeding in wounds and kick-start the healing process.
Injecting PRP into the scalp brings lots of nutrition and healing factors to an area that might not otherwise get a lot of these bonuses.
Did We Mention? YOU CAN DO ALL OF IT TOGETHER!
Yep!
We commonly recommend that patients who are concerned about hair loss on their scalp:
- Apply their choice of minoxidil, finasteride, dutasteride, or latanoprost (or a combination of) to the scalp daily or as frequently as their skin tolerates
- Microneedle with a small needle roller weekly
- Microneedle with a larger needle roller monthly
- PRP every 4 – 8 weeks.
CAVEATS:
- We recommend using the same roller as was studied. It has 192 pins. Rollers with more pins may not penetrate deeply enough, and rollers with fewer pins may penetrate the scalp too deeply.
- Anything hair-related takes a long time to work. It may take months or years to see the full effect.
- Insurance doesn’t often cover these prescriptions and products. You can ask your provider to write a letter of medical necessity to try to get some coverage for treatment costs.
- Since these are topical methods, you may expose other people to the medications.
What About My Face? BEARDS
Often, beard growth is very gender affirming for individuals on T. Beards can also take a really long time to achieve maximum growth, and biological family history is a good indicator of what kind of beard you may be able to grow. Genetics play a huge role in your potential beard. We’ll repeat here: beards take a long time to grow in. That long time may be years.
There is limited evidence that topical minoxidil can help peach fuzz turn into coarser, darker beard hair. We recommend applying minoxidil to your beard area daily (or as often as your skin will tolerate) to encourage the little light hairs (vellus hairs) to get bigger and darker (terminal hairs.) Start after you have fuzz, and give it a good six months of consistent use before you scrutinize the effects.
We’ve seen ads, but we haven’t seen the evidence that you can microneedle your beard area and promote hair growth. Theoretically, microneedling your beard area could work the same way as micro needling your scalp.
Other Treatments Include:
Hair Transplants
In a hair transplant, a surgeon moves hair follicles from one place on the scalp to another.
Laser Hat
Recent studies have found that regular treatment with low-level infrared light can stimulate hair growth. Laser hat treatment can be done at home, but we recommend using a laser hat that replicates the conditions in the study: light at a wavelength of 655 nm.
References:
Krempasky C, Harris M, Abern L, Grimstad F. Contraception across the transmasculine spectrum. Am J Obstet Gynecol. 2020 Feb;222(2):134-143. doi: 10.1016/j.ajog.2019.07.043. Epub 2019 Aug 5. PMID: 31394072.
Dhurat R, Sukesh M, Avhad G, Dandale A, Pal A, Pund P. A randomized evaluator blinded study of effect of microneedling in androgenetic alopecia: a pilot study. Int J Trichology. 2013 Jan;5(1):6-11. doi: 10.4103/0974-7753.114700. PMID: 23960389; PMCID: PMC3746236.
Dhurat R, Mathapati S. Response to Microneedling Treatment in Men with Androgenetic Alopecia Who Failed to Respond to Conventional Therapy. Indian J Dermatol. 2015 May-Jun;60(3):260-3. doi: 10.4103/0019-5154.156361. PMID: 26120151; PMCID: PMC4458936.
Yoon JS, Ku WY, Lee JH, Ahn HC. Low-level light therapy using a helmet-type device for the treatment of androgenetic alopecia: A 16-week, multicenter, randomized, double-blind, sham device-controlled trial. Medicine (Baltimore). 2020 Jul 17;99(29):e21181. doi: 10.1097/MD.0000000000021181. PMID: 32702878; PMCID: PMC7373546.
