Testosterone Dosing for Females
For masculinizing gender-affirming hormone therapy in transgender men and non-binary individuals assigned female at birth, standard testosterone dosing targets serum testosterone concentrations in the typical cisgender male reference range (approximately 300-1000 ng/dL), with effects on hemoglobin, voice, body composition, and sexual characteristics occurring within 3-12 months. 1
Context-Dependent Dosing Strategies
The appropriate testosterone dosing for females depends critically on the clinical indication:
For Gender-Affirming Masculinizing Therapy
Standard-dose testosterone therapy is administered to achieve male-range testosterone levels 1:
Injectable formulations:
Transdermal formulations:
Expected physiological changes include hemoglobin increase to male reference range within 3 months, voice deepening, facial/body hair growth, menstrual suppression, clitoral growth, and increased muscle mass with decreased fat mass 1. These masculinizing effects are largely irreversible, particularly voice changes and hair growth 1.
Low-dose testosterone may be used for non-binary individuals desiring gradual, partial masculinization 1. This approach uses reduced doses of the same formulations to achieve more androgynous effects.
For Postmenopausal Sexual Dysfunction (Off-Label Use)
This indication requires fundamentally different dosing - targeting physiologic premenopausal female testosterone ranges (approximately 15-70 ng/dL), which is roughly 10-fold lower than male levels 1, 2, 3, 4, 5:
- Transdermal preparations are strongly preferred over oral formulations due to first-pass hepatic effects 4, 5
- No FDA-approved testosterone preparation exists specifically for women 2, 3, 4, 5
- Off-label use involves either custom-compounded products (not recommended due to inconsistent dosing) or reduced doses of male-approved transdermal products 3, 4, 5
- High testosterone doses inevitably cause virilization in this population 1
Critical safety distinction: Injections and pellets cause supraphysiological testosterone levels in women seeking treatment for sexual dysfunction and are explicitly not recommended 3. However, these same formulations are standard therapy for masculinizing gender-affirming treatment.
Monitoring Requirements
For masculinizing therapy:
- Target testosterone levels in the cisgender male reference range (500-600 ng/dL mid-cycle for injections) 1
- Monitor hemoglobin/hematocrit (expect increase to male range within 3 months) 1
- Assess for adverse effects: polycythemia, reduced HDL cholesterol, acne, androgenic alopecia, pelvic pain, and potentially increased myocardial infarction risk 1
For sexual dysfunction therapy:
- Baseline total testosterone level (not for diagnosis, but for monitoring to prevent supraphysiologic levels) 4, 5
- Monitor for signs of androgen excess (hirsutism, acne, voice changes) 3, 4, 5
- Maintain testosterone concentrations in the physiologic premenopausal female range 3, 5
Common Pitfalls to Avoid
Do not confuse these two distinct clinical scenarios: The doses appropriate for masculinizing gender-affirming therapy would cause severe virilization and adverse effects in cisgender women seeking treatment for sexual dysfunction 1, 3. Conversely, the low doses used for postmenopausal sexual dysfunction would be inadequate for achieving masculinization in transgender individuals 1.
Avoid oral testosterone formulations when possible due to hepatic effects and unpredictable absorption 1, 4.
For gender-affirming therapy, testosterone is generally continued perioperatively without interruption, unlike estrogen therapy which carries thrombotic concerns 1.
Cardiovascular risk considerations: Conflicting evidence exists regarding cardiovascular safety, with some studies suggesting increased myocardial infarction risk in transgender men, though data remain inconclusive 1. The FDA required labeling changes in 2015 regarding potential cardiovascular risks, though this primarily addressed age-related hypogonadism treatment 1.