Introduction to masculinising hormone therapy
If you wish to pursue HRT, you should consult a qualified healthcare professional. HRT is safe when done under proper medical supervision, with regular blood testing to ensure that everything is fine. If cost is a concern, consider going to the public healthcare system rather than seeing a private doctor.
We strongly caution against obtaining hormones through the black market, due to the high potential for dangerous side effects.
As an example, a batch of testosterone purchased online by a member of the Asia-Pacific Transgender Network was tested and discovered to contain petrol. Other sources may be severely watered down and consist primarily of oil, or may be mixed or laced with toxic substances like mercury that could cause serious damage to your body.
In other cases, consistency may be an issue, where what seems like the same dosage may end up introducing wildly different levels of hormones into your body.
A person’s hormonal profile is dependent on the gonads they were born with. Most people undergoing transmasculine hormone therapy would have ovaries, and thus the chief clinical goal of the treatment would be to decrease and eliminate the effects of estrogen and increase the level of testosterone in the body so that its masculinising effects can take place.
Testosterone (T) is the main sex hormone used in medical transitions to masculinise the body. It is responsible for and determines the body’s secondary sex characteristics, much like estrogen and progesterone in women.
While it is most commonly delivered via injections, transdermal applications (patches, gels, creams), or implants may also be used, though these are rarely available or not available in Singapore.
Anti-estrogens are not needed for transmasculine HRT as T is usually sufficient to masculinise the body.
Sex hormones affect the brain, influencing cognition, emotions and behaviour. Androgens and estrogens both play roles in regulating sexual desire and arousal.
Obtaining masculinising hormone therapy in Singapore
Your doctor will assess your suitability for hormone therapy and discuss the risks and benefits of treatment.
Ideally, you’ll first be given baseline laboratory blood tests to determine if you have any concurrent medical issues that may affect your suitability for HRT or your dosage level.
This also allows your doctor to know if any future medical concerns are due to HRT or pre-existing conditions.
These tests should be repeated regularly after treatment is initiated to ensure that everything is going fine, after which the frequency can be decreased to about once a year.
Some doctors will recommend starting on a low dose and gradually ramping up to normal dosage levels so as to give your body time to adapt. If you are a singer, this process may also help to protect your voice by slowly breaking it in.
Other doctors may not do so, however, because of logistical difficulties (managing and charging for the flux in hormone levels and HRT administered).
For more information on how to obtain gender-affirming hormone treatment in Singapore, take a look here.
Forms & delivery of testosterone
Many forms of T can be used for HRT. However, options in Singapore are limited to Depo-T (testosterone cypionate), Sustanon 250 (combination of 4 esters), Nebido (testosterone undecanoate), and Androgel.
Depo-T (T cypionate)
Delivery: Intramuscular (IM) injections or subcutaneous injections
Concentration: 100mg/ml
Frequency: Once every 1-3 weeks
Solvent: Cottonseed oil
Sustanon 250
A mix of four esters — T propionate, T phenylpropionate, T isocaproate, T decanoate.
Delivery: IM injections or subcutaneous injections (not recommended)
Concentration: 250mg/ml
Frequency: Once every 1-4 weeks
Solvent: Arachis (peanut) oil and benzyl alcohol.
T undecanoate (Nebido)
Delivery: IM injections only
Concentration: 1000mg/4ml
Frequency: Once every 10-14 weeks
Solvent: castor oil
Androgel
Delivery: Transdermal gel
Concentration: 50mg/packet
Frequency: Once per day
Solvent: Alcohol. Androgel contains 1% non-esterified T.
While healthcare professionals in Singapore prefer intra-muscular injections, subcutaneous injections are an alternate delivery mode for Depo-T and Sustanon 250.
Depo-T and Sustanon 250 can be self-injected, but Nebido must be administered by a healthcare professional.
Possible allergies
The cheapest and most common form of testosterone, testosterone cypionate (of which Depo T is a branded version of) is suspended in cottonseed oil, which some people are allergic to. Testosterone enanthate is a similarly-priced alternative suspended in sesame seed oil, but is not presently available in Singapore.
Sustanon 250 is suspended in arachis (peanut) oil. While it is tentatively deemed safe for those with peanut allergies, caution is still advised, and if you have a severe allergy to peanuts (or soy), it is best you stay away.
Signs of an allergic reaction include spreading redness and swelling at the injection site as well as itching. Some soreness is normal after an injection and should go away after a couple days.
Speak to your health provider should you have any concern about allergic reactions to HRT.
Expected changes on transmasculine hormone therapy
Effects of masculinising HRT will often include: deepening voice; increased muscle growth and strength, increased energy and appetite; clitoral growth; decrease in fatty breast tissue; cessation of menstruation; growth/thickening of facial and body hair; increase in libido (especially with respect to visual stimuli); increased sweating; rougher and more oily skin; changes to body odour; reduction in fat-to-muscle ratio; fat redistribution away from hips, thighs and buttocks to the abdomen; increase in gross motor skills with decline in fine motor skills; and an increase in bone density.
Every person’s body is ultimately different, and expected changes will likely vary significantly between individuals due to factors like genetics, diet and hormone levels as well as HRT regimen and at what age HRT began.
Anecdotal reports include slight increases in height, feet and hand size. For those who go on HRT as adults, this is due to cartilage and muscle growth rather than bone growth.
Some potential side effects include acne, mood swings, anxiety, hot flashes and other menopausal symptoms, loss of fertility, increased risk of heart disease, polycythemia (overly high red blood cell count), vaginal dryness and atrophy, and male pattern hair loss.
Should you choose to stop HRT for any reason — from finances, health, a desire to have children, an inability to socially transition, or a desire to detransition — it is important to note that some effects of T will remain permanent.
While there is a general timeline where you can expect the effects of T to show in your body, the speed and extent of your bodily changes differs from person to person. This can be affected by your dosage, dose frequency, delivery method, and your body’s sensitivity to T. Most major changes set in within 2-5 years, though your body continues masculinising beyond that and it may take up to a decade (or longer) to see the full extent of T’s effects on your body.
Effect | Onset | Permanency | Notes |
Increased energy and appetite | Immediate | Reversible | On T, your metabolism is likely to increase along with your caloric needs. You may feel hungry much more often, especially in the first few years of T when your body is growing and changing like that of a teenage boy’s. |
Increase in libido | <1 week | Reversible | This is very common but not universal. |
Clitoral growth | <1 week | Permanent | This is one of the first noticeable physical changes and may feel uncomfortable for a few days. Wear comfortable, loose clothing to prevent chafing. |
Changes to skin texture, and acne | 1-6 months | Partially Reversible | T makes your skin more oily, so if you currently suffer from ezcema or dry skin, T may resolve those problems. Acne is triggered by a sudden increase in androgens and tends to resolve after a while, but this can take years for some individuals, while others never have acne at all. |
Increased muscle mass and strength | 1-6 months | Reversible | |
Cessation of menstruation | 2-6 months | Reversible | Occasional spotting may be observed for a while after cessation. |
Changes to jaw and face shape | Months | Reversible | Changes are most significant over the first year but continue over your life. Many trans people find it helpful to log their transition process with daily or monthly selfies. Looking back can help you see how far you’ve come. |
Hair texture and thickness | Varies | Varies | Eyebrows get thicker. Some people also experience their hair changing from curly/wavy to straight and vice versa. |
Facial hair | 3-6 months | Permanent | This is highly dependent on ethnicity and genetics; many East Asian men will never have a full beard, and facial hair may take years to show up in any significant amount. |
Body hair | 3-6 months | Permanent | As above. |
Deepened voice | 3-12 months | Permanent | Your voice will start breaking within the first few months and stabilises after a few years, but your voice continues maturing as you age: note how adult men sound different from teenage boys. While voice changes are permanent, your pitch can be heightened through voice training should you choose to detransition or need to pass as female. |
Body fat redistribution | 2-10 years | Reversible | While body fat redistribution starts earlier, it does not really become noticeable until a few years. This includes changes to your breast density, hips, thighs and butt. |
Male-pattern hair loss | Varies | Usually permanent | This is dependent both on genetics (on both sides of your family) as well as stress levels. Hair may thin more slowly and and potentially regrow slightly if you stop T. |
Infertility | Unknown | Varies | This may be reversible for some, but it may not occur at all. Note that T does not stop you from potentially becoming pregnant and is not itself a form of birth control. |
Vaginal dryness and atrophy | Varies | Reversible | Dryness can also be resolved with topical estrogen cream |
This list is non-exhaustive, and represents only the effects most commonly experienced by those on T. You cannot pick and choose which effects will occur to you, when they will occur, and to what degree. However, going on low dose T may help in achieving slower or fewer effects. Looking at AMAB relatives may also act as a guide for what you can expect, but that does not necessarily account for all the changes you may experience on T.
Some effects of a previous feminine puberty cannot be reversed with transmasculine hormone therapy; skeletal changes, like widening and rounding of the pelvis, cannot be reversed after your growth plates close during puberty.
Notes on fertility
HRT may result in infertility — but it does not act as a form of contraception and you should take all necessary precautions.
HRT usually, but not always, results in infertility, but there is still a very small chance of getting pregnant even while on testosterone.
Take all necessary precautions, especially since cessation of menstruation would not be available as a sign of pregnancy.
Loss of fertility may or may not be reversible upon cessation of HRT, depending partly on how long it has been. Some trans people thus choose to bank their sperm or eggs prior to undergoing HRT.
Others temporarily pause HRT while they attempt to have a child, with success varying on a case-by-case basis. Trans men on HRT who wish to get pregnant have to stop T for several months to a year (testosterone could harm a fetus) and undergo a regimen of female hormones.
Risks and tests
To monitor your health, doctors will perform some lab tests on your body. These mostly test for your testosterone levels, red blood cell (RBC) count, liver function, clotting factor, and lipid profile.
You can take a look at this guide for more information.
Test name | Description |
Serum total T test | A serum total testosterone test measures the total of bound and free T in your system — bound meaning T binded to a protein (sex hormone binding globulin or albumin) and free meaning the active form of testosterone that binds to androgen receptor sites on cells.
Normal test levels for the serum total T test range anywhere between 300-1100 ng/dl (nanograms per deciliter) or 11.01-40.38 nmol/L (nanomoles per liter). Note that reference values listed for tests will vary from lab to lab. Every body will have a different sensitivity to androgens, and so this number will not necessarily indicate results in terms of masculinisation. These levels are merely a guideline for you and your doctor to measure progress. |
Complete blood cell count | The complete blood cell count measures your blood cells to see if some potential side effects of T have been occurring, including increased red blood cell count, increased haemoglobin, and increased hematocrit levels, all of which may indicate potential polycythemia.
Polycythemia is an abnormally high level of red blood cells. An excess of red blood cells thickens the blood, impeding its passage through small blood vessels and causing a number of potential health problems, like thrombosis, haemorrhage and heart failure.
A complete blood count (CBC) test usually measures the following:
– Number of red blood cells (RBCs)
– Number of white blood cells (WBCs)
– Total amount of hemoglobin (HGB) in the blood
– The fraction of the blood composed of red blood cells (hematocrit or HCT)
– The mean corpuscular volume (MCV– the size of the red blood cells, derived from MCV = HCT/HGB)
Normal CBC levels for males are as below – do note that reference values listed for tests will vary from lab to lab.
RBC (males): 4.7 to 6.1 million cells/ul (cells per microliter)
WBC: 4,500 to 10,000 cells/ul
Hemoglobin (males): 13.8 to 17.2 gm/dl (grams per deciliter)
Hematocrit (males): 40.7 to 50.3%
MCV: 80 to 95 femtoliter |
Liver function test | A liver function test looks into alterations in liver function from testosterone therapy (though changes may not be entirely be from T alone).
Common tests that measure for specific enzymes include:
AST (aspartate aminotransferase, sometimes also called SGOT)
ALT (alanine aminotransferase, sometimes also called SGPT)
ALP (alkaline phosphatase)
GGT (gamma glutamyl transferase).
Other tests that are used to evaluate liver function include: Albumin, Bilirubin, and PT (prothrombin time, an evaluation of clotting in the blood). |
Clotting factor test | If you have an abnormal PT (prothrombin time) test, a clotting factor test is done to determine which coagulation factors have been affected. T has been reported to suppress some clotting factors, and increase the anticoagulant effects of medication like Warfarin. |
Lipid profile test | A lipid profile test helps determine risk of heart disease. It includes total cholesterol, HDL (good) cholesterol, LDL (bad) cholesterol and triglyceride testing. Increased levels of T may contribute to the elevation of LDL (bad) cholesterol, which is why this should be monitored. |