What is Gender-Affirming Hormone Therapy?

Gender-affirming hormone therapy (GAHT) for transgender men (assigned female at birth, identifies as male) uses testosterone to induce male secondary sexual characteristics and align physical features with gender identity.

Expected Physical Changes:

Changes that WILL occur with testosterone:

• Voice Deepening: Permanent; begins 3-6 months, stabilizes 1-2 years
• Facial and Body Hair Growth: Begins 6-12 months; continues for years (pattern/density varies by genetics)
• Increased Muscle Mass and Strength
• Body Fat Redistribution: From hips/thighs to abdomen (more masculine pattern)
• Cessation of Menstruation: Usually within 2-6 months (not immediate contraception!)
• Clitoral Enlargement: Begins 3-6 months; maximal at 1-2 years (typically 1-3 cm)
• Increased Libido
• Skin Changes: Oilier skin, acne (especially early on)
• Vaginal Dryness/Atrophy
• Male Pattern Baldness: Risk increases (depends on genetics)

Changes that WILL NOT occur with testosterone alone:

• Height: No change in bone structure after puberty
• Breast Tissue: Will NOT disappear (chest reconstruction/"top surgery" needed for flat chest)
• Reproductive Organs: Uterus, ovaries, vagina remain (hysterectomy/oophorectomy are separate procedures)
• Hand/Foot Size, Bone Structure: No change

Testosterone Regimens:

• Injectable (Most Common):
  • Testosterone Cypionate or Enanthate: 50-100 mg IM weekly OR 100-200 mg IM every 2 weeks
  • Subcutaneous injection also effective
• Transdermal Gel: 50-100 mg/day (applied to skin; allow to dry before contact with others)
• Transdermal Patch: 2.5-7.5 mg/day
• Subcutaneous Pellets: Implanted every 3-6 months
• Avoid: Oral testosterone (hepatotoxic, unreliable absorption)

Goal Testosterone Levels:

• Target mid-normal cisgender male range: 400-700 ng/dL
• Measured mid-cycle (if injectable) or any time (if gel/patch)

Timeline of Effects:

• 1-3 months: Oilier skin, acne, increased libido, clitoral growth begins, menstruation stops (usually)
• 3-6 months: Voice deepening begins, facial hair starts (light)
• 6-12 months: Increased muscle mass, body hair growth, further voice changes
• 1-2 years: Continued facial hair, voice stabilizes, clitoral growth maximal
• 2-5 years: Beard/body hair continues to develop (pattern varies)

Risks and Side Effects:

• Polycythemia (Elevated Red Blood Cells): Monitor hematocrit; may need dose adjustment or phlebotomy
• Acne: Sometimes severe; may need dermatologic treatment
• Male Pattern Baldness: Genetic predisposition
• Cardiovascular Risk: Possible increased risk (monitor cholesterol, BP, weight)
• Metabolic Changes: Weight gain, insulin resistance, dyslipidemia (increased triglycerides, decreased HDL)
• Mood Changes: Increased aggression or irritability (rare)
• Vaginal Atrophy: Dryness, discomfort; topical estrogen can help (doesn't feminize)
• Infertility: Often permanent; ovulation may stop but NOT reliable contraception
• Uterine/Ovarian Changes: Possible increased risk of PCOS-like changes

Pre-Treatment Evaluation:

• Mental health evaluation (gender dysphoria diagnosis, informed consent)
• Medical history and physical exam (including pelvic exam)
• Baseline labs: Testosterone, estradiol, lipids, glucose/HbA1c, liver function, CBC
• Fertility counseling and preservation options

Monitoring:

• First Year: Labs every 3 months (testosterone, hematocrit, lipids, liver function)
• After Stable: Labs every 6-12 months
• Monitor blood pressure, weight, acne, mood
• Hematocrit Target: <50-52%; if>50%, consider dose reduction or phlebotomy

Long-Term Health:

• Bone Health: Maintain adequate testosterone; if hysterectomy/oophorectomy performed, ensure hormone replacement
• Cardiovascular Screening: Monitor lipids, BP, diabetes risk
• Cervical Cancer Screening: Continue Pap smears if cervix present (regardless of testosterone use)
• Breast/Chest Tissue: If chest reconstruction not done, continue breast cancer screening
• Ovarian/Uterine Health: If organs retained, monitor as needed; some recommend hysterectomy/oophorectomy after prolonged testosterone use to reduce cancer risk (controversial)

Menstruation Cessation:

• Testosterone usually stops menstruation within 2-6 months
• If bleeding continues, consider adding progestin (medroxyprogesterone, norethindrone) or GnRH agonist
• Continued bleeding warrants evaluation (endometrial hyperplasia, fibroids, etc.)

Fertility Preservation:

CRITICAL: Testosterone often causes infertility (though not guaranteed). Discuss options BEFORE starting:

• Egg Freezing (Oocyte Cryopreservation): Requires ovarian stimulation with fertility medications
• Embryo Cryopreservation: Egg retrieval + fertilization with sperm (requires partner or donor)
• Ovarian Tissue Cryopreservation: Experimental

Pregnancy:

• Testosterone is NOT contraception—pregnancy is still possible
• Stop testosterone if planning pregnancy (teratogenic)
• Ovulation may resume after stopping testosterone
• Some transgender men carry pregnancies; specialized prenatal care needed