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# FTM Testosterone Therapy Basics

DISCLAIMER
The information contained herein is to be used for educational purposes only. The author is not a medical professional, and this information should not be considered medical advice. This information should NOT be used to replace consultation with or treatment by a trained medical professional. The listing of a medication herein does not imply endorsement by the author.

Overview
What kind of changes does T therapy bring?
Other changes reported by trans men
Will T make me a different person?
How fast do the changes happen?
If I double up my doses, will my changes happen twice as fast?
Can I decide which changes I will get?
Do I have to stay on T my whole life?
What will happen if I stop taking T? What changes are permanent?
Bone Density: An important factor to consider
What are the different types of testosterone available, and how do I take them?
What are the health concerns associated with FTM testosterone therapy?
Where can I find reliable information about testosterone and health care to show my doctor?

Also check out the page "Myths and Misconceptions about Testosterone, Transition, and Trans Men" for additional information.

Overview
For trans men who have been born into "typically female bodies" (i.e., bodies that have functional ovaries), as well as trans men who were born into intersex bodies, the goal of testosterone therapy is to induce and maintain the presence of masculine secondary sex characteristics.

In FTM testosterone therapy, testosterone (often called "T" for short) can be administered into the body in a number of ways. The most common method is injection (either subcutaneous or intermuscular) with a syringe. Other delivery methods include transdermal application through gel, cream, or patch applied to the skin; orally by swallowing tablets (this method is very uncommon as it has been shown to have negative effects on the liver); sublingually/buccally by dissolving a tablet under the tongue or against the gums; or by a pellet inserted under the skin. The T-delivery method used will depend on the type of medication available in the country of treatment, the health risks/benefits for the patient, personal preference, and cost.

Testosterone is not stored by the body for future use, so in order to maintain healthy levels, it must be administered in timed intervals and in appropriate dosages. Injectable and subcutaneous T pellets remain active in the body the longest. Injectable T is typically administered between once a week to once every three weeks, and subcutaneous T pellets are replaced every 3-4 months. Transdermal T (patch, gel, or cream) is typically applied to the skin in smaller daily doses; oral and sublingual/buccal T are also typically taken daily. (For more information on different types of T and common dosages, click here.)

What kind of changes does T therapy bring?
Over time, the ongoing administration of testosterone will result in the development of masculine secondary sex characteristics, as well as the cessation of menses (monthly periods).

The following masculinizing effects can be expected as a result of testosterone therapy. These effects may take several months to be noticeable, and will continue to develop over a period of years.

- Thickening of the vocal chords and deepening of the voice
- Facial hair growth (mustache and/or beard growth)
- Increased body hair growth (notably on arms, legs, chest, belly, and back)
- Increased body musculature
- Enlargement of the clitoris
- Cessation of menses (monthly periods)
- Potential hair loss at the temples and crown of the head, resulting in a more masculine hairline; possibly male-pattern baldness
- Migration of body fat to a more masculine pattern (i.e., fat deposits shifting from hips, thighs and buttocks to the abdomen area)
- Increased activity of the skin's oil glands (i.e., skin becomes more oily, which may result in acne)
- Increase in red blood cells (RBC)
- Change in cholesterol levels may occur-- the "good" cholesterol (HDL) may go down and the "bad" cholesterol (LDL) may go up.
- Scent of body odors and urine may change
- Skin may become rougher in feeling and/or appearance.
- Increase in sex drive

Other changes reported by trans men
The changes listed below have been noted anecdotally by some trans men, but are not usually listed in the medical literature as masculinizing effects of testosterone therapy.

- The face may become more angular in appearance, with a squarer jaw.
- Increase in size of feet and/or the width/thickness of hands. Some trans men report going up in shoe size, and some report that their hands become a bit wider. This may be attributed to cartilage, muscle, or connective tissue growth.
- Increase in energy level.
- Increase in appetite.
- Slight decrease in density of the fatty breast tissue. (While this may decrease the size of the breasts somewhat in some individuals, it should be noted that T will most likely not significantly decrease breast size-- most trans men require surgery to remove breast tissue.)
- Emotional changes. Some trans men report shortness of temper or feeling lethargic/down at different stages of their T cycle (i.e., just after a shot, or a few days before their shot). Others report that T has made them feel more even-tempered and calm. It is difficult to predict what emotional changes, if any, an individual will experience while taking T. As with any new medication or substance you might introduce into your body, it is wise to observe your feelings, make note of them, and discuss them with your doctor if they concern you. Certain emotional ups and downs might be alleviated by adjusting the amount and timing of the dosage, and sometimes these ups and downs will settle down over time on testosterone.

Will T make me a different person?
Many people worry that taking T will drastically change their personality, or that it will make them become a different person on the inside. While T may effect certain moods and feelings, it is generally not considered to be something that will magically change who a person is at their core. Of course, taking T is usually a life-changing experience, and with any life-changing experience one can expect to feel some changes, both good and bad. However, for the most part, the person taking T will not suddenly become someone else. (See also Myths and Misconceptions about Testosterone, Transition, and Trans Men for a more detailed discussion of this point.)

How fast do the changes happen?
The speed at which changes take place will differ depending on several variables, including the dosage of T, the intervals at which it is taken, the delivery method used, and the individual's own bodily sensitivity to the effects of testosterone. In other words, not all individuals will see the same results from T therapy-- even at the same dosage and over the same period of time!

Results are influenced by genetic make-up/heredity. Some men (both trans and non-trans) simply do not tend to grow thick facial or body hair. Some men tend toward male-pattern baldness, and some tend toward deeper voices. There will always be a range in the characteristics that different individuals will develop.

It has been hypothesized that the earlier hormone therapy is started in life, the more effective it will be in terms of masculinizing effects. However, many trans men have begun hormone therapy late in life and have been very satisfied with their results.

In general, the first changes noticed by most trans men upon starting T therapy are lowering of the voice, increased sex drive, and enlargement of the clitoris. These changes usually begin to happen within the first few months of hormone treatment.

Changes from taking testosterone are cumulative, meaning that they build gradually over time. Between the first 6 to 12 months of treatment, many trans guys note the culmination of enough physical changes so that they begin to be read as men "on the street." The most major changes have usually set in between 2 to 5 years, though trans men continue to report hair growth, hair loss, and other changes for many years to come. It may take several years, for example, for a beard to fully grow in, even though the first signs of facial hair might begin on the upper lip or chin during the first few months of treatment.

If I double up my doses, will my changes happen twice as fast?
Believe it or not, it is possible that doubling your dose might actually slow your changes. This is because excess testosterone in your body can be converted into estrogen by an enzyme called "aromatase." This conversion is part of the body's natural feedback system-- if there is an abundance of testosterone in the body, it is converted ("aromatized") to estrogen in order to maintain a "normal" hormonal balance. Therefore, taking very large doses of testosterone might not be a great idea.

Be patient. Speak openly to your doctor, have your T levels checked periodically (especially during the first year of treatment), take note of your changes and the feelings in your body, and adjust your dosage within reasonable limits if necessary. You might even find that a slightly lower dose could work better for you.

For more on T dosing, click here to go to the section "Testosterone Types and Delivery."

Can I decide which changes I will get?
It is not possible to pick and choose which changes will come with T therapy, just as it is impossible to predict exactly when they will occur and to what degree. You might look at your father, male siblings or other male relatives on either side of your family to try to predict possible results, but even that might not be an accurate indicator of what is to come.

Consider, too, the fact that most non-trans boys cannot pick and choose what happens to their own bodies when they go through puberty. Some non-trans guys end up with acne while others have clear skin, some grow lots of facial hair quickly while others can never grow a beard or mustache, some develop deep voices while others might see little change in their voices over time, some experience male-pattern baldness at and early age while others keep a full head of hair their whole lives, and so on. There is a wide range of characteristics in all men (and in all people, for that matter), and we cannot always predict which changes or characteristics we will develop individually.

Do I have to stay on T my whole life?
Generally, most trans men remain on a maintenance level of T for their whole lives, even after they have gone through significant masculinization. There are a number of reasons for this, both health-related and emotionally-related.

First, if your ovaries are still present and functional, the cessation of testosterone may cause the return of certain feminine body characteristics, including monthly periods (see section below on "What changes are permanent?" for more information on stopping T). Second, if your ovaries have been removed or are no longer functional and you stop taking testosterone, your body will not be able to produce a "normal" amount of either estrogen or testosterone by itself. This would cause a menopause-like state, which could include hot flashes, loss of bone mass (see also the section below on bone density), and other health considerations. Maintaining a level of testosterone within a healthy range over the lifetime of a trans man can protect against those potential problems. There are differing medical opinions as to the benefits and drawbacks to hormone replacement therapies-- be sure to speak to your doctor if you are considering stopping testosterone therapy for any reason.

There are other reasons why trans men remain on T for their whole lives. Many feel more emotionally balanced and at home in their bodies with a maintenance level of testosterone. T can also help maintain the libido. Finally, for some men, testosterone is an integral part of their male identity.

What will happen if I stop taking T? What changes are permanent?
You may choose to stop taking T at any time, either for health or personal reasons. Some of the effects of testosterone are permanent, and some are reversible, as summarized below.

It should be noted that starting and stopping hormone therapies will have a major effect on your body as it is forced to adjust to changes. Therefore, all health considerations should be weighed carefully with a medical professional before beginning or ending any hormonal treatment.

Voice: The voice should stay at the pitch level that it has reached at the point T therapy is stopped.

Facial/body hair: The hair that has come in on the face and body at the point of stopping T will continue to grow in, but large quantities of new hair will most likely not appear. If an individual has developed a patchy beard, it will probably remain in that same patchy state upon quitting T; he will be able to shave it and it should continue to grow back. It might change slightly in texture or growth rate-- depending in part on whether the individual's ovaries are still active and producing estrogen-- but the beard will not disappear. Electrolysis would be required for permanent hair removal.

Clitoris growth: Will generally stay at the length/thickness it has grown to in its flaccid state.

Muscle/fat changes: Will revert back to more female patterns, if the ovaries are still present and active. If the individual does not have a large body fat percentage to begin with and remains trim, a return to female fat patterns won't be as dramatic.

Hair Loss on Head: There have been different anecdotal reports regarding the rate of hair loss upon stopping T. Some individuals who have quit taking T report that their hair loss stopped immediately. Others report that their hair continued to fall out for a while after stopping T. If an individual has lost some head hair, it most likely will not grow back upon stopping T.

Menstrual cycle: If the ovaries are still working, menses will return.

Skin oils and acne may lessen.

Body scent may change.

Sex drive may decrease.

Red blood cell count and cholesterol levels will probably revert to levels that are closer to the prior, pre-T levels. Again, whether or not an individual has functioning ovaries may play a part in the results, as will overall health.

Bone Density: An important factor to consider
In general, the maintenance of healthy bone density in all people is partly dependent on both estrogen and testosterone levels. When an individual's body produces estrogen as its main sex hormone (as in the case of female-bodied people), that estrogen in healthy levels protects against bone loss. If a female-bodied person were to begin testosterone therapy, there would be a time of transition in the body while hormone levels adjust. While testosterone would soon become a more dominant presence in the body of a trans man, he would still retain some estrogen in his system, both through the presence of his ovaries (if he has not had an oophorectomy) and/or via the natural aromatization of testosterone into estrogen (which takes place whether or not the ovaries are still present and functional).

If a trans man discontinues testosterone therapy, there are two possible outcomes for his hormone balance. If he still has his ovaries and they are still functional, the cessation of testosterone would shift the body back to a more estrogen-dominant system.

If he no longer has functional ovaries due to oophorectomy or some other reason, then the cessation of testosterone would leave him without a significant amount of either testosterone or estrogen in his system. This would be problematic for maintaining bone density. Some medical professionals therefore advise against stopping testosterone treatment once the ovaries have been surgically removed or are no longer functional. It is thought that continuing a maintenance dose of testosterone (or estrogen, in the event that an individual no longer wishes to continue testosterone therapy, though this would of course have feminizing effects) will help protect against bone loss and osteoporosis, a condition that literally means "porous bones."

An individual can also help protect against bone loss by taking calcium supplements and performing weight-bearing exercise. All these factors should be considered and discussed with your doctor to help ensure healthy bones.

What are the different types of testosterone available, and how do I take them?
To learn learn more about the different types of testosterone, examples of dosages, and the different delivery methods for testosterone, please go to the section "Testosterone Types and Delivery."

What are the health concerns associated with FTM testosterone therapy?
To learn more about related health concerns, please go to the section "FTM Testosterone Therapy and General Health."

Where can I find reliable information about testosterone and health care to show my doctor?
Check out the following two web sites, which contain free, downloadable information written by care providers for care providers and trans patients. You may wish to forward these web addresses to your care provider(s).

> Dr. Nick Gorton's site
> www.nickgorton.org
> Contains the downloadable book Medical Therapy and Health Maintenance for Transgender Men: A Guide For Health Care Providers by R. Nick Gorton MD, Jamie Buth MD, and Dean Spade Esq. This is the most complete care guide available for FTM patients to date-- an excellent resource to show your doctor.

> Trans Care Project of Vancouver, British Colombia
> www.vch.ca/transhealth/resources/tcp.html
> Completed in January of 2006, the Trans Care Project created a series of training materials and practice guidelines for clinicians treating trans patients, as well as consumer information about trans health for trans people-- FTM and MTF. Their materials are downloadable in PDF, and cover numerous topics of concern to trans people and their care providers. Another great site to show your doctor.

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