FTM Dosages

This page describes the dosing plans published in clinical guidelines (A transfem wrote this and has no major opinions on them just yet) plus how titration (gradually adjusting your dose) works, why blood-test timing matters, and a documented problem worth knowing about: a substantial minority of people are underdosed for months without anyone noticing.

Standard regimens in the standards of care

The two main guidelines, the Endocrine Society (2017) and WPATH SOC8 (2022), specify the same adult regimens:¹²

Formulation	Guideline regimen (Endocrine Society / SOC8)
Testosterone enanthate or cypionate	50-100 mg IM/SubQ weekly, or 100-200 mg IM every 2 weeks
Testosterone undecanoate	1000 mg IM every 12 weeks, or 750 mg IM every 10 weeks
Testosterone gel	50-100 mg/day
Testosterone patch	2.5-7.5 mg/day

SOC8’s footnotes: doses are “titrated up or down until sex steroid hormone levels are in the therapeutic range,” and regimens “may have to be adapted to what [medication] is available.”²

Other major protocols fill in the starting picture:

• UCSF publishes three tiers per formulation: low (explicitly flagged for genderqueer/nonbinary goals), typical, and maximum: e.g., cypionate/enanthate 20 → 50 → 100 mg/week; gel 1% 12.5-25 → 50 → 100 mg/day. UCSF also notes that label dosing assumes cis men with low but not no testosterone, so trans men may need higher doses than on the label.³
• NHS (UK) typically starts gels at ~40 mg/day (e.g., Testogel 16.2 mg/g, 2 pumps), Sustanon 250 mg every 4 weeks, or Nebido 1000 mg every 12 weeks after a loading phase.⁴
• Fenway (US community health): 50 mg/week start, increase after ~1 month; standard 50-100 mg/week.⁵
• Rainbow Health Ontario: start 20-50 mg weekly (or 40-100 mg every 2 weeks), titrating by 10-20 mg steps every 4-6 weeks.⁶

So “start low and titrate up” and “start near full replacement” both appear in reputable guidance. For intentionally low regimens, see FTM Low-Dose and Nonbinary.

Note on long acting formulations

As you approach the lowest part of your cycle you may experience energy and emotional side effects! I would personally recommend taking a blood test before EVERY injection to adjust when you should take your next dose.

Why do I recommend so many tests? The goal is to have a trough level within the “cis male reference range”, human bodies can vary a lot during the 10-14 weeks of undecanoate so making sure you’re within the right ranges and not too high or low is important!

• AusPATH recommends trough levels be within 10-20 nmol/L(288.4-576.8 ng/dl).⁷
• WPATH SOC8 recommends trough levels staying at or above 400 ng/dl (13.87 nmol/L).²
  • They mention a general target range of 400-700 ng/dl (13.87-24.27 nmol/L), treat this as a safe trough range from them
• Endocrine Society recommends the same as WPATH.¹

Now that you know the ranges and have a test you can make decisions on when to do your injection! If you’re still above the 20-24 nmol/L level then you can hold off a few days if you aren’t experiencing any major side effects from the low point. If you’re at around 15 nmol/L then it’s a safe bet to get your injection done right away.

Check out FTM Target Ranges for more indepth info on this!

Titration

Titration means adjusting the dose in steps based on blood results and how you feel. UCSF’s framing is the clearest: dose changes should be driven by patient goals, in the context of clinical response, hormone level monitoring, and safety monitoring (hemoglobin and hematocrit). with periods stopping by 6 months as the objective clinical-response benchmark.³ Typical triggers clinicians act on:

• Levels below target + slow progress or symptoms (low energy, libido, mood; ongoing bleeding) → reasonable to increase slowly.³
• Persistent menstruation past ~6 months → progestins (progesterone-like hormones) or GnRH analogues (drugs that switch off the ovaries’ hormone production) can be added if testosterone alone doesn’t suppress it (see FTM Periods and Fertility).³⁴
• Above male-range levels → reduce the dose; your body converts some of the excess testosterone into estradiol, which adds risk, not extra masculinization.⁶
• High hematocrit (the share of your blood made up of red blood cells) → check levels including a peak, adjust dose, change frequency or route; see FTM Blood Testing.³

Note from Aria:

You can do titration yourself on DIY! Get blood tests as often as you reasonably can and adjust to make sure you’re reaching your own target levels safely after each test.

Trough vs peak blood testing

The same person can look “high,” “normal,” or “low” depending on when in the dosing cycle the blood is drawn. The conventions (see FTM Target Ranges for the numbers):

• Weekly injections: draw midway between injections for a representative level (Endocrine Society convention).¹²
• Troubleshooting: if you get period-like symptoms (migraines, pelvic cramping, mood swings, bleeding returning before shot day), checking a peak (1-2 days post-injection) and a trough (just before the next dose) can reveal wide swings.³
• Undecanoate (Nebido/Reandron): only the trough, just before the next injection, is clinically meaningful.²
• Gel: after at least a week of daily use, >=2 hours after application (UK practice: 4-6 hours, and no gel on the blood-draw arm that day).²⁴

Note from Aria:

I would recommend always getting a trough level when testing so you know what your levels drop to, having levels that are too low near the end of your cycle can cause a few issues ranging from emotional to physical so keeping the trough in check is important no matter the medication or cycle!!

Weekly vs fortnightly

Injectable esters (cypionate and enanthate) given every 2-4 weeks produce supraphysiologic peaks and sub-physiologic troughs. The end-of-cycle crash (fatigue, low mood, irritability, bleeding returning in the final days before a shot) is some of the oldest community knowledge in transmasc spaces, and it’s now validated at guideline level: the World Anti-Doping Agency’s physician guidelines for transgender athletes note that injections every 1-4 weeks “may result in fluctuating blood testosterone levels with peaks and troughs,” and that “more stable and physiological levels are achieved with shorter intervals between doses (e.g., weekly versus every two weeks).”⁸ The Endocrine Society’s own regimen table builds in the same logic (weekly at half the fortnightly dose).¹

If you’re on a 2-4-week interval and feel the crash, the documented clinical options are: shorten the interval (same total dose split weekly), switch from IM to SubQ, or switch to a transdermal form.³ This is a conversation to bring to your prescriber to adjust in a medical setting if at all possible, for individuals on DIY make these changes with care and extra reliance on blood tests, try to get a GP/Doctor looped in to monitoring your health during these periods.

Underdosing

The transfem side of HRT has long had issues with underdosing with estradiol prescriptions. The transmasc version looks different, but the outcome, people left for months without a healthy sex-hormone balance, is the same. A few case examples of this:

• Deutsch et al. 2015 (the study UCSF cites to justify level monitoring): 31 trans men started on typical regimens (SubQ cypionate 50-60 mg/week, 5 g/day gel, or 4 mg/day patch). At 6 months, only 68% had male-range testosterone levels, 16% were still menstruating, and only 29% had male-range estradiol. In other words, roughly 1 in 3 people on standard starting doses were still sub-therapeutic at 6 months. without blood tests, nobody would know.³
• UCSF explicitly warns that some providers skip level monitoring and follow clinical progress only, but that “omitting such monitoring runs the risk of a suboptimal degree of virilization if testosterone levels have not reached the target range.”³
• PATHA’s primary-care protocol illustrates the gap: its starting doses are reasonable, but the first testosterone level is deliberately not checked until 3-6 months (“it takes time for levels to stabilise”) - meaning a slow responder stays sub-therapeutic, undetected, for up to half a year.⁹
• Underdosing may be symptomatic beyond slow changes: breakthrough bleeding and pelvic pain on T are associated with lower testosterone levels, plausibly reflecting incomplete hormonal suppression.¹⁰
• Community reports: very low starts with increases only every 3-6 months; legacy “100 mg every 3-4 weeks” scripts with week-3 crashes and returning periods; gel regimens never titrated past 1-2 pumps despite female-range levels; providers refusing increases because “clinical response” matters more than numbers.

What you can do

• Get your levels checked at ~3 months after starting or any dose change(If possible get them once a month while titrating! having this information can be useful for your care provider or even yourself!!), not just twice a year. The Endocrine Society/SOC8 schedule (every ~3 months in year 1) exists precisely because titration without levels is guesswork.¹²
• Know your numbers and your lab’s male reference range. Ask for a copy of results, or look them up in your patient portal. See FTM Target Ranges and How to read your own results.
• Ask for trough testing if you’re on injections and suspect end-of-cycle symptoms, a mid-interval or peak reading can hide a trough crash.
• Bring data to the appointment: symptoms with dates, when in the shot cycle they occur, and your level history. “My trough is 9 nmol/L and my period returned in week 2” moves a conversation further than “I don’t feel right.”
• If a provider won’t titrate despite documented low levels and symptoms, seeking a second opinion from a prescriber experienced in trans care is reasonable. Changing health care providers is always okay, it’s your health and you decide who assists you with it.

One honest counterpoint so this section isn’t misread: guidelines deliberately treat clinical response, not lab numbers, as the goal of therapy, and UCSF cautions that once you’re stably in range, frequent re-testing adds little.³⁶ The critique above is about never checking during titration, not about relaxing monitoring once you’re stable. Where guidelines disagree on monitoring tempo, see FTM Blood Testing.

Further reading

One page shouldn’t be your only source, these are worth a look too.

• UCSF’s overview of masculinizing hormone therapy where the low/typical/maximum dosing tiers and titration advice come from
• Endocrine Society 2017 clinical practice guideline the source of the standard regimen table (dense, but authoritative)
• WPATH Standards of Care v8 the international standards; Chapter 12 has the official regimens
• diyhrt.wiki - Transmasculine HRT guide community-maintained wiki on HRT
• diyhrt.info - Transmasculine Guide community-maintained HRT information website

Footnotes

1. Endocrine Society Clinical Practice Guideline (Hembree WC, et al.), J Clin Endocrinol Metab 2017;102(11):3869-3903 - https://academic.oup.com/jcem/article/102/11/3869/4157558 ↩ ↩² ↩³ ↩⁴ ↩⁵

2. WPATH Standards of Care v8 (Coleman E, et al., 2022), Chapter 12, Tables 4-5 - https://pmc.ncbi.nlm.nih.gov/articles/PMC9553112/ ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷

3. UCSF Gender Affirming Health Program, “Overview of masculinizing hormone therapy” (incl. Deutsch MB, Bhakri V, Kubicek K. Obstet Gynecol 2015;125(3):605-10, quoted verbatim) - https://transcare.ucsf.edu/guidelines/masculinizing-therapy ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸ ↩⁹ ↩¹⁰

4. Tavistock & Portman NHS FT Shared Care Prescribing Guideline (transmasculine), Jan 2022; Nottingham Centre for Transgender Health info sheet (2022) - https://medicines.bedfordshirelutonandmiltonkeynes.icb.nhs.uk/wp-content/uploads/2021/12/Transgender-transmasculine-scg-tavistock-Jan-22.pdf ; https://www.nottsapc.nhs.uk/media/gxfnn13a/masculinising-hormones-information-sheet.pdf ↩ ↩² ↩³

5. Fenway Health / National LGBTQIA+ Health Education Center, “Gender-Affirming Hormone Therapy” - https://lgbtqiahealtheducation.org/wp-content/uploads/2020/03/14d.-Gender-Affirming-Hormone-Therapy.min_.pdf ↩

6. Rainbow Health Ontario (Sherbourne Health), “Masculinizing Hormone Therapy” + Guidelines for Gender-Affirming Primary Care, 4th ed. - https://www.rainbowhealthontario.ca/TransHealthGuide/gp-mascht.html ↩ ↩² ↩³

7. AusPATH / Cheung AS, et al. “Position statement on the hormonal management of adult transgender and gender diverse individuals,” Med J Aust 2019;211:127-133 - https://auspath.org.au/ ↩

8. WADA, TUE Physician Guidelines - Transgender Athletes, v2.1 (October 2023) - https://www.wada-ama.org/sites/default/files/2023-12/tue_physician_guidelines_transgender_athletes_-_version_2.1_-_october_2023.pdf ↩

9. PATHA-endorsed Primary Care Gender-Affirming Hormone Therapy Initiation Guidelines (NZ, March 2023) - https://patha.nz/assets/Primary-Care-Gender-Affirming-Hormone-Therapy-Initiation-Guidelines-v2.pdf ↩

10. Grimstad FW, et al., J Sex Med 2023 (pelvic pain, breakthrough bleeding and lower testosterone levels), via ISSM summary - https://www.issm.info/sexual-health-headlines/what-is-the-prevalence-of-pelvic-pain-in-transgender-men/ ↩