TABLE OF CONTENTS

Preparing for your first Plume appointment

It is really helpful to think through your goals and preferences before your visit with a Plume provider. This will help you get the most out of your visit. Before your visit, be sure to read carefully through the materials we send. These include the consent form (which reviews the side effects and risks of hormones) and the hormone information (FAQs) we send through the Spruce app. As you're preparing, you might want to write down any questions you want to ask your provider during your visit - it's easy to forget them all when the visit starts! Here are some important questions to consider, but don't worry if you don't know the answers yet: 

What physical changes, if any, are affirming for you?

 

 Which uptake method would you like to try? Injections, or topical gel?

 

Would you prefer a low dose or a higher one?

 

Do you have any questions that we haven’t addressed?

  

What is testosterone (aka T)?

Testosterone is a naturally occurring hormone that is typically produced in all bodies. Different bodies produce different amounts of this hormone. Plume prescribes synthetic bioidentical testosterone to encourage physical changes in your body. These changes—both dramatic and subtle—can help you to live as your authentic self by changing your gender expression to reflect your gender identity.


What Physical and Psychological Changes Are Possible?

Most folks start to notice changes like lower voice, facial hair growth, and stopping of monthly bleeding after 2-3 months on T. While there are many things that contribute to our mental health, many folks notice feeling better emotionally shortly after starting T. In particular, they notice decreased anxiety and increased confidence. Physical changes will occur more gradually and become noticeable after six months. Most folks will max out on physical changes somewhere between 2-5 years after starting T. 


Not all of these changes are irreversible, but this can vary for each individual. Typically, the changes that are most likely to be irreversible are lowered voice tones and coarse hair growth, such as beard growth. The degree of these “masculinizing” changes is different for each person’s body. Your results will vary, based on your genetics. The effects of T that people most commonly experience include:


Body fat redistribution (decreased in the buttocks/hips/thighs increased in the belly)


Increased muscle mass 


Increased and darker facial and body hair growth 


Redistribution of facial fat / changes in facial structure 


Increased libido (sex drive)

 

Enlargement of some genital parts (ie: clitoral growth)

 

Deepening of the voice 

 

Increased oily skin and acne

 

Increased dryness or discomfort in the genital area

 

Hair loss at the front and top of the head  (this change is more dependent on family history of baldness and typically is more of a concern after a year on T)

 

Change in menstrual periods (typically stopping within 1-6 months of testosterone, depending on dose)

 

Mood changes


There are also some changes that can be less desirable. Fortunately, we have treatments to help make these issues more comfortable:


Increased oily skin and acne 


Increased dryness or discomfort in the genital area 

Recession of the hairline, although hair loss is more dependent on family history of pattern baldness and typically is more of a concern after one year on T



How can I take testosterone?

Testosterone comes in several forms - including a weekly injectable, or daily topicals (cream or gel). Each of these methods are effective in raising your T levels, which will lead to the physical changes discussed above. Choosing a method usually comes down to deciding what feels most comfortable to you, and what fits into your budget.


Injection

Injection is the most common way of taking testosterone. It is a popular choice because it is relatively affordable and doesn’t require daily application (compared to the topicals). Injecting can also make it very easy to adjust your T dose by small increments. Because of this, injection is a good option for “microdosing.” (You can read more about microdosing below). There are two methods of injection. They both use the same dose of T. Both are administered once a week. Both work the same.


intramuscular (IM) injection
an injection into the butt, glute, or thigh area. Alternate your injections between each of those areas and change sides of your body for each injection.



subcutaneous (SC/subq) injection 
uses a shorter, thinner needle. This type of injection is given just under the skin into the belly fat.


If you want, you can always change injection styles. Just let your provider know if you want to switch. Your prescription includes syringes and needles, so you have everything you need. With your prescription, you will get a larger, wider needle to draw up the T because it is in a thick oil. The larger needle enables you to draw the liquid out of the vial quicker. You will also get a thinner needle that you will inject with. You draw up with the thick needle, switch over to the thinner one, and do your shot. We recommend and prescribe the 1-ml syringe because it is easier to see all the markings, especially if you are injecting less than 0.5 ml.


We know some folks can be anxious about injections.. If you feel nervous, that is completely normal! We will provide you with teaching videos and walk you through how to inject if you choose to do injections. Our goal is for you to feel as prepared and relaxed as possible for your first injection, but most people will tell you that it can take weeks to feel comfortable. So slow down, take a deep breath, and do your best! In the end, we have other forms of T that are just as effective.  So if it’s simply too overwhelming and you want to switch methods, let us know and your provider will gladly send a new prescription to the pharmacy of your choice.


With a GoodRx coupon, a 2.5 month supply of T costs about $25, depending on your dose.We typically prescribe testosterone cypionate 200 mg/ml concentration, to be injected once per week. If you have an intolerance to testosterone cypionate, we can prescribe testosterone enanthate instead. 


Topical Gel

Topical gel is a great, effective alternative to injections. Many people choose a topical if they prefer to avoid injections. You apply it every morning after your shower on clean, dry skin (usually to the shoulders or upper arms, but you can talk to your provider about other areas that might work for you). After applying, you should wash your hands, and wait a few minutes before putting a shirt on. Depending on the gel you use, it’s best to wait anywhere from 2-6 hours before showering or swimming. This is when the gel is completely dry. Before this point, anygel that isn’t covered can rub off onto other people, increase their T levels, and cause physical changes in them—unwanted ones! Topical testosterone costs about $50-60/month depending on the formulation and is eligible for a discount with a GoodRx coupon.

Patches

Testosterone patches used to be a way that patients could dose testosterone.  However, in early 2023, T patches stopped being manufactured entirely.  We will update you if these become available in the future.


What is “Microdosing”? 

Microdosing is a newer term that describes using a small amount of a medication to achieve subtler or different effects from more common dosing recommendations. For example, some nonbinary people do not want to look like “men,” but want more masculine features such as more defined facial features or a lower voice. A microdose of T will achieve these changes over a longer period of time, and the changes will be less dramatic than the ones someone might notice on the full dose of T. Microdosing is a very individualized process and we cannot pinpoint specific physical traits or rate of change. However, we can support you while you find the dose that is right for you.

If you want a more subtle physical change, you can choose to go with a lower dose option. If you want to take the quickest route to maximizing physical change, then your Plume provider can help you start at a higher dose. Just let your care team know what feels right for you and we will help you reach your transition goals!


  Are there any possible risks?

When used appropriately under supervision of a medical provider, testosterone has been shown to be safe. Of course, every medication has its risks and it is important to understand these so that you can make an informed decision about your care. We will discuss some of the risks here, but be sure to review the informed consent form (sent through our app prior to your medical visit) and discuss any questions about your medications with your medical provider.


T increases the hemoglobin/hematocrit 

“H/H” for short. Think of H/H as markers for red blood cells in your body. For example, anemia is low H/H because people with anemia have a low number of red blood cells. But, if someone’s H/H were to go too high, there is a theoretical risk of blood clots and stroke because of the blood being too “thick.” There have been no documented cases of this happening with gender-affirming care. It is only a theoretical risk, based on people that have genetic conditions which cause their H/H to go very high—much higher than the levels that T causes. However, to ensure that your H/H stays in the healthy range, we will check your red blood cell count every three months, along with your T levels.


T is a teratogen

 A teratogen is a substance which is known to cause severe birth defects. So, if anybody who is taking T were to become pregnant, there would be a high risk of birth defects in the fetus. If pregnancy is a possibility at all (based on your body parts, those of your partner(s), and your sexual preferences), we strongly encourage contraception to prevent pregnancy while taking T. All forms of birth control are safe to use if you are on T and do not interfere with the effects of T on your body.


T could cause infertility

Over time, T causes levels of estrogen to drop. This, in turn,  causes changes to other body parts, such as your ovaries and uterus. These organs are essential for carrying a pregnancy to term. It is impossible to predict who will be affected by infertility; besides, there are many factors that can contribute to infertility that are not related to T. We recognize that there are many ways to build your family, and that using your genetic material is only one of them. However, if preserving your fertility is important to you, or if you would like to have children who share your genes, then we strongly encourage you to see a reproductive specialist regarding freezing of your eggs. 

 

If somebody on testosterone wants to become pregnant or use their genetic material, they have to stop taking T for 6-9 months beforehand. When T levels have lowered, it’s then possible to become pregnant and carry to term or to store genetic material for future use.   Whatever your hopes are for starting a family, know that you have options. The most important thing is to be aware of the impact T can have on your fertility before starting the medication. We understand you might not yet have a clear answer for yourself and your future family, but as a side effect of your medication, there might be a possibility of becoming infertile later.


What Is Bottom Growth?

Bottom growth is a term used to describe the growth of the clitoris in trans men, nonbinary people, and other FTM (female-to-male) folks who use testosterone. Bottom growth is one of the key physical changes that occur during the process of transition for many trans and nonbinary individuals. 

During the process of transition, FTM folks, nonbinary and transmasculine people, and trans men may use gender-affirming hormone therapy (GAHT, sometimes called HRT or hormone replacement therapy) to increase their testosterone, which can cause clitoral growth. This growth can be significant, with the clitoris becoming larger, longer, and thicker in some individuals. 

Bottom growth is not necessarily the same for all trans men, nonbinary people, and folks who identify as FTM. The amount of growth and the rate of growth will depend on the individual’s body and the amount of testosterone they are taking. Additionally, the size and shape of the clitoris before transitioning will also influence the amount of growth. In some cases, the clitoris may become almost as large as a penis, while in other cases, the clitoris may remain relatively small. 

The growth of the clitoris is a key part of the transition process for many people who take testosterone. Bottom growth can be an exciting and affirming experience for those who are transitioning. The effects of bottom growth can be seen in both physical and psychological ways. For example, some trans men may find that the growth of their clitoris gives them a greater sense of physical comfort and satisfaction, while others may feel increased confidence and satisfaction in their gender identity. 

Bottom growth is an important part of the transition process for many trans and nonbinary individuals, and it is an important part of their journey towards gender affirmation. It is important to remember that the effects of bottom growth can vary greatly from person to person and that everyone’s experience with transition is unique. 

Ultimately, it is important to remember that bottom growth is a natural and normal part of the transition process and that it is an important part of affirming one’s gender identity.

Testosterone and Emotions

The physical effects of taking testosterone as gender-affirming hormone therapy (GAHT) can be dramatic, depending on the dose. Within one year of beginning T, many people experience noticeable changes to their voice, facial shape, hair texture, skin, and body shape. There is a lot of emphasis on these physical changes. Even the not-so-awesome changes (such as hot flashes, balding, voice instability, and acne) are transition milestones for people on T. Some people document these changes on vlogs or blogs or keep a journal during the early part of their gender journey. The first year of transition is very exciting and there are lots of changes to celebrate.

It’s easy to notice physical changes—they’re right there, in the mirror! However, the emotional side of testosterone is not visible the way a new mustache might be. The mood changes that come with using this masculinizing hormone are noticeable, too. They happen in your brain over time. They can be subtle or dramatic. On the outside, your body is changing to match your desired gender expression. On the inside, your brain is changing as well.


One of the most common questions people ask before starting testosterone is about mood change. People ask, “will testosterone make me a rage monster?” They may have concerns about “roid rage” or about experiencing uncontrollable mood swings that could feel violent, scary, or overwhelming. If you had a negative male role model in your life, you may have some valid fears about becoming like that person. Being afraid of cisgender men or toxic masculinity might make you nervous about starting testosterone. After all, those guys have high testosterone levels—so you might wonder if testosterone is to blame for their behavior.


Fortunately, there is no basis for those fears. They are based on stereotypes that link masculinity with unchecked aggression. Your experiences with cisgender men are valid, and we do live in a culture that co-signs a lot of negative or harmful behavior, especially when it is perpetrated by cisgender men. However, that is a cultural problem—not a hormonal issue.


While many of us have complex feelings and opinions about masculinity (and by extension, testosterone), T is not linked with rage or dangerous behavior. Some people report a new sense of emotional detachment after starting testosterone, but medical studies on this phenomenon focus on cisgender women, not transgender men, transmasculine people, or nonbinary people who are using GAHT. Research shows that testosterone actually has a positive effect on moods for people who use T as gender-affirming hormone therapy. Instead of anger, you may be surprised at how joyful you feel on T.


How can testosterone change my emotions?

All hormone therapy—including gender-affirming hormone therapy—influences different body systems. Some studies suggest that testosterone changes emotions by influencing a part of the brain called the mesolimbic pathway. This is the part of the brain linked with the feel-good neurotransmitter dopamine. Higher levels of dopamine and a stimulated mesolimbic pathway are linked with feelings of being rewarded. As your dopamine levels increase, the sky might seem a little bluer and the faces of other people just a little more beautiful.

Using testosterone as a gender-affirming medication can create emotional side effects such as:

  • Gender euphoria

  • Decreased depression and anxiety

  • Increased sex drive

  • Better self esteem

  • Irritability

  • Changes in mental health


Within a year of beginning T, you will likely feel a new sense of confidence. As your body comes into alignment with your identity, you might feel more comfortable saying “take me as I am” instead of “am I good enough for you.” However, there are some challenges that can crop up as well. While most people taking testosterone report an improvement in their moods, others notice that it can have a less-than-rosy effect.


For trans people on testosterone, it is not uncommon to feel an increased sense of irritability or quickness to react. This may manifest as snapping at a friend or feeling like you have less impulse control in the moment. This type of feeling can improve over time, so be patient with yourself. If you have an existing mental health diagnosis, keep in mind that T does have the ability to destabilize you. Instead of blaming yourself or discontinuing your gender-affirming medication, work with your provider to discuss your options.


If you are coping with depression, anxiety, or other mental health issues, reach out to your medical provider to get support. Some people notice that their depression worsens on T. (This can feel confusing, especially if you’re excited to take testosterone or have wanted to transition for a long time.) Since everyone’s body is different, it is not possible to predict how T will affect your mental health. Most commonly, T improves mood because people are living as their authentic selves. Remember that you are a whole person and your care plan should take your other needs into account—not just your gender journey.


Will I be able to cry when I take testosterone?

Adjusting to any new medication means getting used to the feeling of being on hormones. Everyone has a different response to testosterone. It is unlikely that you will have dramatic or overwhelming feelings. Anecdotally, people who take T report that they experience a flattening or dampening of some of their emotional responses, such as an inability to cry.


The science of crying is complex. We don’t have a clear relationship between T and tear production, although some research suggests there is a link. One hypothesis suggests that our bodies release certain types of hormones through crying to reduce cortisol levels, helping your body to literally shed stress. Another hormone called prolactin may stimulate crying, according to studies on the chemical composition of cisgender people’s tears.


While you may notice changes to how often you cry, you may feel your feelings more strongly. They simply aren’t expressed with tears. You may feel more comfortable expressing them because you are living authentically. Instead of hiding from emotions, you allow yourself to experience them. This is part of getting to know yourself and it is a powerful aspect of gender transition.


Testosterone will not change who you are. You may discover new aspects of your personality or learn how you want to live in the world as you transition. Bear in mind that some of these feelings might feel new. As you navigate your emotions and learn to make decisions with those feelings, you may encounter some surprises. For example, you might realize that you can feel very frustrated without acting on it. On the other hand, you may discover that the same emotion inspires you to stand up for yourself for the first time and be more assertive than before. You might find it harder to cry. These are normal changes for many people. They are a hormonal side effect—not a sign that you are an uncaring or cold person.


To help ease your transition onto testosterone, Plume’s trans-led care team will ensure your dosage is correct for your body size and transition goals. You deserve to feel strong and supported as you take on this phase of your gender journey. Shifting emotions are part of every transition. It’s nothing to be ashamed of—it’s simply part of your path as you grow toward the person you want to be.


All about T (webinar)

Tune in for expert, trans-affirming information all about Testosterone with Dr. Alann Weissman-Ward (he/him), Plume doctor and trans man and Alex Guerra (he/him), Plume Community Collaborator and trans man, in conversation about testosterone-based gender-affirming hormone therapy (GAHT). 


The information in this document is derived from national and international guidelines on gender-affirming care, expert opinion, and the personal practice experience by the medical providers of Plume. Guidelines include the UCSF Transgender Center of Excellence, the World Professional Association of Transgender Health and the Endocrine Society