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Masculinisation Questions

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What are the main effects that testosterone will have on me?

Facial hair and beard will grow, Your voice will break, crack and deepen with the development of an Adam’s Apple. Your body fat redistributes to a more male pattern and your muscle bulk will increase. You will find that your body odour and sweat change, and your hairline may recede – even to include male pattern baldness. Your sex drive may increase, along with growth of your clitoris, people notice vaginal dryness, and periods stop.

Will I become infertile?

Although we should consider that this treatment may permanently affect fertility, this may not always be the case. Usually, you stop ovulating, but it is still possible to get pregnant, and some transgender men are able to stop testosterone and achieve a successful pregnancy.

Egg storage is the best way of increasing your chances of fertility preservation, but this can be long-winded and expensive. Successful pregnancy rates from frozen eggs are low and we need more work in this area to improve storage and subsequent fertilisation and implantation. Private fees can be reduced by ‘egg-sharing’ where a proportion of the eggs harvested are donated to another couple.

Why do you recommend starting with testosterone gel?

The gel soaks into the lower layer of skin and is then absorbed throughout the day. This gives a nice steady blood level, and also gives the opportunity to mimic a natural puberty by starting with a low dose and working up. The injections can have problems with peak blood levels just after an injection, and then troughs when the next injection becomes due.

How do I apply the testosterone gel?

Apply the gel first thing in the morning to your arms or shoulders. Let it soak in and your skin dry and then cover with your clothes. Don’t wash or shower the area for two hours. If you are going to have close contact with someone else then wash the area before doing so.

Why do I have to start at a low dose and when can I increase?

There is no evidence that higher doses cause greater masculinisation. We should try and mimic the natural changes of a male puberty as much as possible. Increase in doses should be tailored to your physical changes and in line with your blood levels and also keeping safety in mind.

When can I swap to injections?

The injection technique needs to be taught by a doctor or a nurse, or we need to know that a doctor or nurse will give them to you. This often means we need the full co-operation of your GP surgery. Once your levels and changes are stable we can swap to injections.

How do I get rid of my female hormones?

The best way is to use the puberty blocking injections, these completely suppress oestrogen production from the ovaries, although some oestrogen is also produced by fat cells. These injections are expensive and need someone to inject them for you, so they are not always achievable. Testosterone alone can reduce oestrogen production and stop periods, and this is usually achieved by six months on T.

Can we use Aromatase Inhibitors?

Aromatase inhibitors (AIs) are drugs used to suppress oestrogen levels in people who have oestrogen-dependent cancers such as breast cancer. It is not known what effect these drugs may have on helping to reduce oestrogen levels in the context of transgender care. They may be considered as a short term adjunct to get periods to stop.

What testosterone level am I looking for?

For full masculinisation in adults, we aim for a testosterone level between 15 and 35 mol/l, taking into account the physical changes that have occurred. Adolescents, younger people and non-binary people may have lower levels.

At what age should I stop testosterone?

There are no guidelines on the upper age of treatment of transgender men or non transgender men. This should be a two-way discussion between the person and their doctor.

What if I have had cancer before?

If you have had a sex-hormone dependent cancer such as breast cancer in the past, then you should discuss your masculinisation plans with your cancer doctor.

Will I lose my hair?

This all depends on your genetics. If there is a history of hair loss amongst the males in your family then it is likely that you too will lose your hair. This can either be at your fringe and temples, or in the typical ‘bald spot’ on your crown. Treatments for this include the over-the-counter minoxidil (Regaine), or you can use medication such as finasteride or dutasteride.

Do I need to have womb scans if I don’t have a hysterectomy?

If you are not having periods then there is no evidence that you will be at risk of endometrial hyperplasia or womb cancer. However, as always, any unexpected vaginal bleeding should be investigated.

How can I minimise the chances of getting acne?

Spots, oily skin and acne are all well-known side effects of testosterone therapy. There are many topical lotions, and skin treatments and medications that can help. It usually subsides with time and can be avoided by keeping levels from going too high.

Do I need to have a hysterectomy?

There is no absolute need for this and it should be performed on a case by case basis.

If I stop treatment, what will happen?

There are some changes that will be permanent and will not change back if you stop treatment. Any bony structure changes will stay, and facial hair and voice changes will not completely regress. After stopping T your periods will return and your fertility may also return to normal although this is not guaranteed.

Should I continue to use contraception?

If you are having vaginal sex then you should think very carefully about contraception if you do not want to get pregnant. Just because you are not having periods does not guarantee that your are not ovulating. The copper coil is a good non-hormonal choice, or if you are still having unwelcome periods then a hormone coils is a good option.

What are the treatment options for nonbinary people?

This should be an individualised approach depending on what the person would most like to achieve in their gender-affirming treatment. It may be that binding or tucking is sufficient, or maybe surgical procedures. Hormone treatment may just involve taking lower doses of the hormone that suits them best.