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Choosing your therapy

Choosing the route of hormone therapy that is right for you

Feminizing hormone therapy typically involves blocking or suppressing testosterone production and giving estradiol (estrogen). Masculinizing therapy typically involves giving testosterone. There is no one best route, dose, or way to take gender-affirming hormones. Individuals may factor in medical conditions, personal preference, cost and insurance coverage, convenience, and many other factors when determining the right hormone plan for them. Often one’s hormone plan changes over time as one’s goals, preferences, insurance, or other factors change. 

The information provided here is not comprehensive, but is intended to give people some general information to consider regarding hormone options available at PPMI.

Injectable testosterone or estradiol

There are two methods of injection:

  • Intramuscular (IM) injections are injections into muscular tissue, typically the thigh or buttock; a common example of an IM injection is a flu vaccine.
  • Subcutaneous (SQ or SC) injections are injections into the fatty tissue under the skin and are often done on the abdomen or thigh; a common example of another SC injection medication is insulin for diabetes.

Both IM and SC injections for hormone therapy are given at the same dose once a week (occasionally every 14 days), and they work the same way. Both IM and SC injections can be done by patients or a support person. 

Unfortunately, due to restrictions regarding the administration of controlled substances, PPMI cannot administer your hormone medications for you. 

We encourage patients to watch these videos created by Planned Parenthood of Greater Texas for instructions on IM and SC injections and to ask the health center team if you have any questions. 

At PPMI we can prescribe estradiol for IM injection and can prescribe testosterone for either IM or SC injection. 

Testosterone cypionate is the most common form of injectable testosterone and is the most common method by which people use testosterone for gender-affirming care. While the extent and speed of changes is ultimately determined by your testosterone dose and levels, as well as individual characteristics, anecdotally some folks find injections bring about changes more quickly than testosterone gels. Injections can be dosed in low/intermediate dosing or more standard dosing aimed at achieving male physiologic hormone levels. For people who are allergic to testosterone cypionate, the alternative testosterone enanthate is used instead.

  • Out of pocket cost (without insurance): The GoodRx coupon price for a month of testosterone cypionate is currently about $15–30; whereas testosterone enanthate is about $35–50 a month (assuming multi-use vials, with a new vial used each month). Syringes and needles are also needed.

Estradiol valerate (delestrogen) is the most common form of injectable estradiol. Injectable estradiol is often sufficient to suppress testosterone levels without the additional use of spironolactone; however, many people use spironolactone for testosterone suppression along with injectable estradiol.

  • Out of pocket cost (without insurance): The GoodRx coupon price for a month estradiol valerate is currently about $35–70 (assuming multi-use vials with a new vial used each month). Syringes and needles are also needed.

If you are having trouble finding your needles or syringes in stock at a pharmacy, or need to purchase them over the counter, please be aware that syringes and needles can also be purchased over the counter at suppliers like: Amazon (syringes and needles), Bulk Syringes, or the non-profit Trans Needle Exchange. Sharps disposal bins can also be purchased at the pharmacy, or sharps can be disposed of in hard plastic containers (like a laundry detergent container) labeled “Sharps” with a sealed and taped lid. More information regarding disposing of sharps (needles) in Michigan can be found here.

Testosterone gels

Testosterone gels are applied daily. Gels commonly come as pumps or individual packets. Most people apply them in the morning (ideally following showering) to the shoulders, abdomen, or upper arms; the gels should not be applied to the genitals. Folks should wash their hands after applying and wait a few minutes for the gel to dry before dressing. Gels take several hours to dry completely; this is important to know because if not completely dry, the gel can rub off on others, who could absorb the gel and experience changes related to testosterone exposure. Depending on the brand, it is recommended folks wait 2–5 hours after application before swimming or showering. If you expect direct skin contact with someone else, it is recommended that you wash the application site before contact. While the extent and speed of changes is ultimately determined by your testosterone dose and levels as well as your individual characteristics, anecdotally some folks find testosterone injections bring about changes more quickly than gels.

  • Out of pocket cost (without insurance): The GoodRx coupon price for a month of Androgel (2 pumps daily) is at least $95.

Estradiol pills

Estradiol pills can be swallowed (also called oral or PO) or dissolved under the tongue (also called sublingual or SL). Typically pills by either route are taken twice daily. The type of estrogen (micronized estradiol) used in feminizing hormone therapy has different properties and risk profiles than the estrogen used in most birth control (ethinyl estradiol). While the same estradiol pill type is used for oral and sublingual routes, the dosing is different and it is important to talk to your provider before switching routes so that dosing can be adjusted accordingly. In general, higher doses are needed for oral dosing than sublingual dosing in order to achieve the same blood hormone levels. Additionally, oral estradiol is absorbed in the stomach and sent straight to the liver for processing (medically this is called “first pass metabolism”), whereas sublingual estradiol is absorbed directly into the bloodstream. This leads to different effects on the liver and blood hormone levels throughout the day depending on the route the pill is used. Based on our understanding of these medications and limited studies, we think oral estradiol may have a higher risk of blood clots than other routes and generally do not recommend oral pills for people with an increased clot or heart disease risk.

  • Out of pocket cost (without insurance): The GoodRx coupon price for a month of estradiol tablets is currently about $10–35. 

Estradiol patches

Estradiol is also available as a patch that you place on your skin. There are two types of these patches: one that needs to be changed once a week, and another that needs to be changed twice a week. Based on the data currently available, the patch appears to be the safest estradiol in terms of blood clotting risk; for people with higher risk of heart problems or blood clots, this is often the recommended estradiol route. Many people need to wear two (or sometimes three) patches at the same time to get the dose of hormones they need. Patches only come in a beige color at this time. Some people struggle with patches peeling or not sticking well, and some others experience skin irritation.

Spironolactone

Spironolactone is a direct androgen blocker. Spironolactone is a pill that is swallowed, typically twice a day. Most people tolerate spironolactone well. Spironolactone has a diuretic function, meaning that it can make you urinate/pee more often. Normal kidney function is required to use spironolactone, as is monitoring of potassium levels. Spironolactone can also lower blood pressure a small amount; people with low blood pressure may then experience dizziness when they go rapidly from sitting to standing positions when taking spironolactone. Anecdotally, some people report experiencing brain fog while taking this medication.

  • Out of pocket cost (without insurance): The GoodRx coupon price for a month of spironolactone is $10–30.

Finasteride

Finasteride blocks the conversion of testosterone to dihydrotestosterone (or DHT), which is a strong form of testosterone. DHT plays a big role in scalp hair loss; finasteride may be prescribed to people who make testosterone or take testosterone and are worried about scalp hair loss. Finasteride is also used as an alternative to spironolactone for people who cannot take or tolerate spironolactone as a testosterone blocker. Of note, finasteride does not block testosterone production, so testosterone blood levels will not be suppressed in the same way they are by spironolactone (meaning, testosterone levels will not be a reflection of the action of finasteride on DHT). In cisgender men taking finasteride medication for hair loss, a very small subset of people experience sexual dysfunction with finasteride which can be long-lasting; this has not been studied in trans or nonbinary people.

  • Out of pocket cost (without insurance): The GoodRx coupon price for a month of finasteride 5mg tablets (which can then be cut in quarters) is <$10.

Prometrium

Progesterone is another hormone that can be used as part of feminizing hormone therapy. We unfortunately don’t have studies that have explored the impact progesterone has on feminization. Anecdotally, some people experience increased breast development, mood improvement, and increased libido with progesterone. When folks choose to add progesterone to their regimen, we generally recommend bioidentical progesterone, called micronized progesterone or Prometrium (brand name). Micronized progesterone is administered as a pill that is swallowed nightly. Side effects may include drowsiness, mood changes, nausea, or weight gain; the subtle increased risk of cardiovascular disease and breast cancer seen with another type of progesterone (medroxyprogesterone) is thought to be less likely to occur with prometrium but is not studied. For folks who would like to try adding prometrium to their regimen, some suggest using estrogen for 1–2 years before adding progesterone based on theoretical concerns for tubal breast shape if added early (again, no research). When folks desire to try progesterone, we suggest individuals consider trying prometrium for 6 months and continuing on it if they notice positive effects vs. discontinuing if they have not noticed a positive change.

  • Out of pocket cost (without insurance): The GoodRx coupon price for a month of prometrium is $10–30.