Testosterone Discontinuation and Dose Reduction in Female-to-Male Transition
Yes, testosterone can be stopped or titrated down in transgender men, but doing so will result in physiological changes reverting toward baseline within 3 months, and inadequate dosing negatively impacts bone density and may compromise quality of life. 1, 2
Physiological Effects of Stopping or Reducing Testosterone
When testosterone therapy is discontinued, laboratory values and physical characteristics return to baseline within 3 months, including red blood cell indices, liver enzymes, creatinine, and QTc intervals reverting to female reference ranges 1
Inadequate testosterone dosing can negatively impact bone density, making appropriate dosing and monitoring essential for skeletal health 2
After stopping testosterone, clinical interpretation of lab values should use the reference range for sex assigned at birth once therapy has been stopped for ≥3 months 1
Clinical Considerations for Dose Reduction
The standard target testosterone level is 300-1,000 ng/dL (mid-normal male range), and levels below this range may not provide adequate masculinization or bone protection 2, 3
Testosterone can be titrated down in increments, but maintaining trough levels below 300 ng/dL risks inadequate hormonal support for bone health and may result in return of menses and loss of masculinizing effects 2
Gender-affirming hormone therapy with testosterone is medically necessary for many transgender individuals, with strong evidence showing improvements in quality of life and relief of psychological distress associated with gender dysphoria 2, 4
Monitoring After Dose Reduction or Discontinuation
Monitor testosterone levels at 3 months after any dose adjustment or discontinuation to assess hormonal status 2, 5
Check bone density if testosterone is discontinued long-term or maintained at subtherapeutic levels, as inadequate androgen exposure increases osteoporosis risk 2
Hemoglobin will decrease to female reference range within 3 months of stopping testosterone, eliminating the need for polycythemia monitoring 1, 2
After 3 months off testosterone, interpret all lab values (creatinine, red blood cell indices, QTc) using female reference ranges 1
Common Clinical Scenarios
Patients considering pregnancy must stop testosterone, as it is contraindicated during pregnancy and fertility may return after discontinuation 6, 7
Some individuals may prefer low-dose testosterone to achieve partial masculinization, though long-term safety data for this approach is limited 6
Older transgender men may require dose adjustment due to age-related changes in metabolism and cardiovascular risk, though specific guidelines for geriatric dose reduction are lacking 8
Critical Pitfalls to Avoid
Do not abruptly stop testosterone without counseling the patient about expected physical changes, including return of menses, voice changes stabilizing but not reversing, and potential psychological distress 2, 4
Avoid maintaining subtherapeutic testosterone levels long-term without monitoring bone density, as this creates a hypogonadal state that increases fracture risk 2
Do not assume all masculinizing effects will reverse - voice deepening and facial hair growth are largely permanent even after testosterone discontinuation 2