Trans Summer School: Testosterone
If your body is longing to pump out some estrogen and you’d rather it didn’t, your doctor will start you on testosterone therapy. Estrogen blockers are also available, but they aren’t widely used — usually your testosterone will be enough to do the trick. You may also hear testosterone discussed as a “masculinizing” or “male” hormone, but it doesn’t have to be either of those things for you unless you want it to be. Not everyone who produces or takes testosterone is a guy, and not everyone who takes testosterone is doing so to cultivate a “masculine” appearance.
Before your doctor will prescribe testosterone, they will request some tests to get a baseline idea of your hormone and cholesterol levels, among other things. They’ll also discuss the risks and benefits, go over an informed consent form, and possibly conduct a physical. You may be able to get hormones immediately, or you can wait: no one will ever push you into taking hormones, and if you feel pressured, find a new doctor!
Taking testosterone will have a number of effects on your body including causing you to grow more body hair, making your skin a little thicker and coarser, increasing your sex drive, increasing the chance of balding later in life, and lowering your voice. Be advised that if you have androgen insensitivity syndrome (AIS), you will not respond to testosterone therapy.
How is it administered?
This medication comes in the form of injections, pills, patches, creams, and gels. Depending on the format, you may take testosterone every day, every week, or every two weeks. Your doctor will use periodic blood tests to assess your hormone levels and determine if the dosage needs to be adjusted, especially if you have a mental health condition like bipolar disorder or schizophrenia, which can be negatively affected by peaks and troughs in hormone levels. (You may have heard that people with certain mental health conditions can’t take testosterone, or can only take low doses. That’s incorrect, but you do need to be more careful as you find a dose that works.)
What are the risks?
Testosterone can cause elevated cholesterol, especially in people with a family history of it. You may be able to make some dietary adjustments to address that problem, or you may need to go on medication to address your cholesterol levels. If you have an oophorectomy (removal of those pesky ovaries), you will need to stay on testosterone to preserve bone strength, although you can take a lower dose. (Fun fact corner: testosterone actually increases bone density, reducing your risk for osteoporosis later in life!)
People on testosterone are more likely to develop high blood pressure and insulin resistance. The redistribution of fat on the body is also associated with a buildup of abdominal fat — and we’re not talking about a beer belly, but so-called “visceral fat” around your internal organs. This has been linked with some health problems. Some patients also experience an increase in red blood cells and hemoglobin as their bodies adjust to this drug, and if levels get too high, they can create a risk of stroke. Headaches and migraines are also documented issues for some patients, and it may be necessary to explore another delivery method if they become persistent.
Getting your levels right is important. Some people like staying on a low dose for mild physical changes, while others like to go higher. “Stacking” (adding other drugs or increasing your dose) won’t make your body change faster — in fact, your body will start converting the excess testosterone in your body into estrogen!
There are potential fertility concerns with testosterone as well — we don’t know enough about the drug to be definitively certain about its effects on future fertility, but we do think there’s reason to be concerned. If you’re interested in lending your genes to a future human, you should discuss the possibility of egg banking with your doctor, just to be certain that you’ll have some material to work with when you’re ready.
However, while testosterone may make you infertile, some people continue to ovulate, and there is a risk of pregnancy, especially in the early months of HRT. You should always use a birth control method to prevent pregnancy, and of course testosterone doesn’t protect you from STIs, so you’ll want to use condoms every time you have sex, regardless as to any other birth control method you might use. Testosterone is a teratogen (it interferes with fetal development to cause sometimes fatal anomalies), and your doctor may refuse to prescribe testosterone without proof that you are using birth control — a long-acting reversible contraceptive (LARC) can be a great option for you.
What are the side effects?
Separate from risks, side effects are the things that tend to happen to your body on testosterone — many of which are desirable, and some of which are irreversible. Starting testosterone is a big decision, because some of these changes will emerge within months, and even if you go off the drug, these side effects will linger! One of the most immediate side effects for people on injectable testosterone is amenorrhea, which is usually highly desired. People using a transdermal (patch, cream, gel) formulation find that their periods stop a little later, but usually within six months.
Over time, people taking testosterone will experience some irreversible side effects including body hair growth, facial hair growth, rougher skin, a deeper voice, and clitoral enlargement. As you get older, staying on testosterone will also cause some balding (take a look at the heads on your maternal side to see what you can expect). Side effects that will go away after stopping testosterone include increased sex drive, vaginal dryness (lube is your friend!), redistributed body fat, higher muscle mass, and oilier skin, which tends to cause more acne.
You may have heard about ‘roid rage and absorbed stereotypes about testosterone and mood all your life, but you might be surprised by the reality. Many people on testosterone actually start to feel calmer, more focused, and happier, because they finally have the right hormones in their bodies, and the physical changes they experience may help mitigate their dysphoria and discomfort. That said, as discussed above, some people with mental health conditions need to be careful, especially at the start, to make sure that their dosage doesn’t conflict with their mental health needs. People who notice dramatic mood swings and personality changes should talk to their doctors about switching to a different delivery method or adjusting their dose.