What is the recommended dosing for testosterone (T) therapy in female-to-male hormone treatment?

Testosterone Dosing for Female-to-Male Hormone Therapy

For female-to-male transgender patients, start with testosterone cypionate or enanthate 50 mg weekly via subcutaneous or intramuscular injection, targeting serum testosterone levels in the mid-normal male range (500-600 ng/dL), with dose adjustments up to 100-200 mg every 2 weeks or 50-150 mg weekly based on measured levels. 1, 2

Initial Dosing Strategy

• Begin with 50 mg weekly of testosterone cypionate or enanthate as the standard starting dose 2, 3
• This dose achieves therapeutic testosterone levels across a wide range of body mass indices (19.0 to 49.9 kg/m²) 2
• The median effective dose in clinical studies is 75-80 mg weekly, with a range of 50-150 mg needed to achieve target levels 2

Route of Administration: Subcutaneous vs Intramuscular

Subcutaneous injection is equally effective to intramuscular and strongly preferred by patients:

• All patients (22/22) who switched from intramuscular to subcutaneous delivery preferred the subcutaneous route, with 20/22 showing marked preference 2
• Subcutaneous delivery causes significantly less discomfort and allows for self-administration 2, 3
• Both routes achieve normal male testosterone ranges with equivalent efficacy 2, 3
• Minor and transient local reactions occur in only 14% (9/63) of patients using subcutaneous injections 2

Alternative Dosing Schedules

If using a biweekly schedule instead of weekly:

• 100-200 mg every 2 weeks of testosterone enanthate or cypionate 1, 4
• Weekly dosing (50 mg weekly) provides more stable serum levels and avoids the supraphysiologic peaks and subtherapeutic valleys seen with biweekly dosing 1

Target Testosterone Levels and Monitoring

• Target mid-normal male range: 500-600 ng/dL 1
• For patients on injections, measure testosterone levels midway between injections to assess the trough/mid-cycle value 1
• Initial monitoring should occur after treatment initiation and after any dose change 1
• Once stable levels are confirmed, monitoring every 6-12 months is sufficient 1

Expected Timeline of Physical Changes

Dose-dependent early effects (first month):

• Higher doses (250 mg every 2 weeks) produce faster onset of voice deepening, facial hair growth, and menstrual cessation compared to lower doses (125 mg every 2 weeks) 4
• However, by 6 months, all dosing regimens achieve equivalent therapeutic effects 4

Standard timeline with 50 mg weekly:

• Menstrual cessation occurs in 85% of patients within 6 months, with average time of 2.9 months 3
• Hemoglobin increases to male reference range within 3 months 1
• Voice deepening, facial/body hair growth, clitoral enlargement, and body composition changes develop progressively 1

Dose Titration

• Adjust dose based on measured testosterone levels to maintain target range of 500-600 ng/dL 1
• If levels are subtherapeutic, increase by 25-50 mg increments 2
• Maximum doses typically do not exceed 150 mg weekly or 200 mg every 2 weeks 1, 2

Critical Safety Monitoring

Monitor for adverse effects:

• Polycythemia (elevated hemoglobin/hematocrit) 1
• Reduced HDL cholesterol 1
• Androgenic alopecia and acne 1
• Pelvic pain or genital dryness 1
• Potentially increased myocardial infarction risk, though data are conflicting 1

Perioperative Management

Continue testosterone therapy perioperatively 1

• Unlike estradiol therapy, testosterone does not carry significant thrombotic risk 1
• There is no evidence supporting routine discontinuation before surgery 1
• Cessation may carry negative psychological consequences 1

Common Pitfalls to Avoid

• Avoid starting with excessively high doses (>100 mg weekly), as this leads to supraphysiologic peaks and increases cardiovascular risk 1
• Do not use biweekly dosing schedules without recognizing the fluctuations in testosterone levels, which cause mood and sexual function variability in some patients 1
• Do not measure testosterone levels at random times—always measure midway between injections for accurate assessment 1
• Do not use transdermal preparations as first-line in transgender men, as gels show unpredictable absorption and patches cause significant skin irritation 1