Xander (they/them), a 22-year-old non-binary person assigned female at birth (AFAB), arrives at their local pharmacy with a new prescription: injectable testosterone cypionate, 50 mg IM (intramuscular) weekly. It’s an exciting milestone – Xander is finally starting gender-affirming hormone therapy (GAHT). But they’re also anxious about this new medication. “How should I inject this? Is there anything else I should know?”
This article is meant to help answer medication related questions just like Xander’s. Whether you’re starting GAHT, supporting a loved one, or a healthcare provider unfamiliar with gender-affirming care, it is important to understand medication safety aspects of hormone therapy.
Gender-Affirming Hormone Therapy (GAHT)
GAHT supports individuals in aligning their physical traits with their gender identity. GAHT can significantly reduce gender dysphoria, improve mental and physical well-being and may be used alone or alongside surgery and social transition. For some individuals, it also supports long-term health, such as preserving bone density after certain organ removals.
Before starting GAHT, discuss fertility preservation with your healthcare provider if future family planning is important to you. Many clinics use an informed consent model, where providers explain the benefits, risks, and what to expect from treatment while supporting the level of change that feels right for you – whether that is full or partial masculinization or feminization.
Types of GAHT
Feminizing Hormone Therapy is used by trans women and transfeminine or non-binary individuals. Estrogen, often combined with anti-androgens like spironolactone, encourages breast development, skin softening, and fat re-distribution. It comes in different dosage forms – oral (to be taken by mouth), patch (to be applied on skin), and injectable. Oral estrogens may carry a slightly higher risk of blood clots compared to patches or injections, but they are more affordable and commonly used. If you are concerned about the risks of blood clots associated with estrogen, discuss with your healthcare provider.
Masculinizing Hormone Therapy, or testosterone, is used by trans men and transmasculine or non-binary individuals. Testosterone deepens the voice, increases muscle mass, stops menstrual periods, increases libido, shifts fat distribution and body hair patterns. Testosterone is most often given as weekly intramuscular (IM) or subcutaneous (SC) injections, which are cost-effective and widely used. Gels and patches are alternative topical dosage forms for individuals who do not prefer needles or injections; however, topical dosage forms may transfer the medication to others through skin contact and cause unwanted masculinizing effects.
How should Xander inject the medication? After learning about the potential risks of topical transfer with gels or patches, Xander decides to stick with testosterone injections.
Safe Injection Practices
If you have not been formally trained with the use of injectable medications, ask your pharmacist or healthcare provider to walk you through the steps. Community clinics, public health units, and resources like Rainbow Health Ontario (https://www.rainbowhealthontario.ca/): A Guide to Self-administering Intramuscular or Subcutaneous Injections (https://www.rainbowhealthontario.ca/resource-library/a-guide-to-self-administering-intramuscular-or-subcutaneous-injections/) may also offer help and support.
When using injectable testosterone (or other injectable medications), safe medication use considerations are essential. For example:
• Always use a sterile needle and never re-use it. Dull needles will increase pain and infection risk.
• Draw up the medication with a wider needle (e.g., 18-gauge), then switch to a smaller one (e.g., 25-gauge) for injection to minimize pain and
scarring.
• Never share needles. This will increase the risk of infections (e.g., HIV and hepatitis).
• Dispose used needles in a sharps container. Many pharmacies and harm reduction programs offer free sharps disposal service.
Is there anything else Xander should know?
Medication Therapy Management/Monitoring
Hormones are powerful medications that require monitoring. Regular blood work helps track hormone levels and monitor liver function, cholesterol, red blood cell counts, etc. Based on your anatomy, you may also need cancer screenings like pap smears or mammograms. Let your healthcare provider know if you smoke or vape. Individualized care is key, especially during your transition.
Medication Shortages
Testosterone shortages are quite common. If a medication shortage occurs, avoid turning to unregulated or street-sourced hormones, which may be unsafe, contaminated, or improperly dosed. Instead, talk to your pharmacist about alternatives, such as compounded hormone therapies (see below). Supportive clinics may sometimes be able to offer temporary solutions.
Compounded Hormone Therapies
Some individuals use compounded estrogen or testosterone in dosage forms like customized gels or creams. These are prepared by specialty compounding pharmacies that are accredited and regulated by provincial pharmacy regulatory authorities (or Colleges). DIY or unverified hormonal products could be harmful and should be avoided.
By Mona Mollaeizadeh, Heather Amann, and Certina Ho
Mona Mollaeizadeh and Heather Amann are PharmD Students at the Leslie Dan Faculty of Pharmacy, University of Toronto; and Certina Ho is an Assistant Professor, Teaching Stream, at the Leslie Dan Faculty of Pharmacy and Department of Psychiatry, University of Toronto.
