Testosterone Cypionate Starting Dose for Women (IM)
Start intramuscular testosterone cypionate at 50 mg weekly for adult women, which is the lower end of the evidence-based range and minimizes the risk of supraphysiologic levels while allowing for effective masculinization. 1
Recommended Starting Dose
The guideline-recommended starting dose for injectable testosterone enanthate or cypionate is 50-100 mg weekly via intramuscular injection. 1
Weekly dosing of 50-100 mg provides more stable testosterone levels compared to biweekly administration (100-200 mg every 2 weeks), reducing fluctuations that contribute to adverse effects. 1
In transgender patients specifically, starting at the lower end (50 mg weekly) and titrating upward is supported by recent evidence showing that higher starting doses often lead to supraphysiologic levels. 2, 3
Target Testosterone Levels
Aim for serum total testosterone in the physiologic male range of 300-1,000 ng/dL, with mid-normal values of 450-600 ng/dL preferred to optimize clinical response while minimizing adverse effects. 1
Measure testosterone levels 2-3 months after treatment initiation or any dose change, checking midway between injections to capture representative values. 1
Administration Considerations
Testosterone cypionate can be self-administered in the anterolateral thigh or given by another person in the gluteal region using a 21-23 gauge, 1-1.5 inch needle. 1
Subcutaneous injection is an effective and well-tolerated alternative to intramuscular administration, achieving therapeutic testosterone levels equivalent to IM with doses of 50-150 mg weekly across a wide BMI range. 3, 4, 5
Among patients who switched from IM to subcutaneous administration, all 22 patients in one study had a mild or marked preference for subcutaneous injections, with none preferring IM. 3
Dose Titration Strategy
If serum testosterone remains below target range (300-1,000 ng/dL) at 2-3 months, increase the dose incrementally by 25 mg weekly. 1, 3
The typical effective dose range is 50-150 mg weekly, with most patients achieving therapeutic levels at 75-80 mg weekly. 3
Once stable levels are achieved, monitor testosterone every 6-12 months along with hematocrit/hemoglobin, as erythrocytosis occurs in up to 43.8% of patients on injectable testosterone. 1
Common Pitfalls to Avoid
Do not start at doses higher than 100 mg weekly, as recent evidence suggests guideline-recommended starting doses of 5-30 mg every 2 weeks (equivalent to 2.5-15 mg weekly) may already be too high and lead to supraphysiologic levels. 2
Avoid biweekly dosing (100-200 mg every 2 weeks) in favor of weekly administration, as the former creates greater fluctuation in testosterone levels and increases the risk of erythrocytosis and other adverse effects. 1
Do not forget to prescribe necessary supplies: 18-gauge needles for drawing, 21-23 gauge 1-1.5 inch needles for injection, 1-3 mL syringes, alcohol prep pads, and a sharps container. 1
Monitor for erythrocytosis at every visit, as injectable formulations carry significantly higher risk (43.8%) compared to transdermal preparations (15.4%), and this risk is dose-dependent. 1