What is the recommended testosterone therapy regimen for individuals transitioning to male?

Recommended Testosterone Therapy Regimen for Transgender Men

The standard recommended testosterone therapy for transgender men is to achieve serum testosterone levels in the cisgender male reference range (300-1,000 ng/dL), with a target of mid-normal range (500-600 ng/dL) to minimize side effects while maximizing desired masculinizing effects. 1

Testosterone Administration Options

Injectable Testosterone (First-line option)

• Testosterone cypionate or enanthate: 50-400 mg intramuscularly every 2-4 weeks 2
  • Most commonly administered subcutaneously for patient comfort 3
  • Initial follow-up 1-2 months after starting therapy, then every 3 months for the first year 1
  • Injections should be given deep in the gluteal muscle 2
  • Measure testosterone levels midway between injections 1

Transdermal Options

• Testosterone gels or patches: Alternative to injections 3
• Particularly beneficial for patients with:
  • Cardiovascular risk factors 1
  • Risk of erythrocytosis 3
  • Need for more stable hormone levels 1
• Measure testosterone levels in the morning for consistent results 1

Long-Acting Option

• Testosterone undecanoate: Provides extended release 3
• Caution: Risk of pulmonary oil microembolism and anaphylaxis (subject to risk evaluation and mitigation strategy) 3, 1

Monitoring and Dose Adjustments

Laboratory Monitoring Schedule

• Every 3 months during first year, then every 6-12 months if stable 1
• Complete blood tests should include:
  • Testosterone levels (target: 500-600 ng/dL)
  • Hematocrit/hemoglobin (watch for polycythemia)
  • Lipid profiles
  • PSA (if age-appropriate)

Dose Adjustment Protocol

• If testosterone levels are too high: Reduce dose, increase monitoring to every 1-2 months until stable 1
• If experiencing significant fluctuations: Consider switching from injections to transdermal preparations 1
• For persistent menstruation: Verify adequate testosterone levels before adding progestin 1

Expected Effects and Timeline

Physical Changes

• Early changes (within first few months):

  • Increased libido
  • Voice deepening (irreversible)
  • Cessation of menstruation
  • Body fat redistribution
  • Increased muscle mass and strength 3, 4

• Later changes (continuing after 1 year):

  • Facial and body hair growth
  • Clitoral enlargement
  • Potential male-pattern baldness 4

Psychological Benefits

• Reduced gender dysphoria
• Decreased perceived stress, anxiety, and depression 4

Managing Side Effects and Risks

Common Side Effects

• Acne
• Androgenic alopecia
• Genital dryness
• Pelvic pain 1

Serious Risks to Monitor

• Erythrocytosis/Polycythemia:

  • If hematocrit rises above reference range: temporarily withhold therapy, reduce dosage, or consider phlebotomy 3, 1
  • Advise smoking cessation and weight loss if BMI is high 3

• Cardiovascular considerations:

  • May increase blood pressure, triglycerides, and LDL cholesterol while decreasing HDL 3
  • Consider transdermal preparations for patients with cardiovascular risk factors 1

• Fertility implications:

  • Counsel about potential impact on fertility 3
  • Consider fertility preservation options before starting therapy 3

Special Considerations

Low-Dose Option

• Low-dose testosterone (≤62.5 mg/week) can be effective for:
  • Achieving menstrual cessation
  • Increasing lean body mass
  • Producing masculinizing effects with potentially fewer side effects 5
  • May be preferred by some non-binary individuals or those seeking more gradual changes

Menstrual Suppression

• If breakthrough bleeding occurs despite adequate testosterone levels:
  • Add a progestin to eliminate menstruation 1
  • Consider GnRH analogs if progestins are contraindicated 1

Pitfalls to Avoid

• Never discontinue testosterone abruptly without medical supervision 1
• Avoid testosterone levels above physiologic range as this increases risk of side effects 1
• Don't prescribe exogenous testosterone to patients interested in preserving fertility without appropriate counseling 3
• Don't neglect regular monitoring of hematocrit, which commonly increases with testosterone therapy 6

Recent evidence suggests that even low-dose testosterone therapy can achieve adequate muscular development and masculinizing effects while potentially minimizing side effects 5, offering a viable option for those concerned about adverse effects of standard dosing.