FTM forms of HRT

Testosterone comes in several forms, and no one is technically “stronger” than the others although there are community reports of injections being more effective. all of them can reach the same target levels when the dose is adjusted (see FTM Target Ranges). The real differences are how steady your levels stay, how often you dose, what it costs, and practical downsides like needles or gel transfer. Guidelines stress matching the form to your goals, budget, and life: the best one is the one you can actually stick with.¹

Injections

Injections are the most common form of transmasculine HRT, in a large US cohort, about 77% of transmasc people used injectable testosterone (51% intramuscular, 27% subcutaneous).²

Cypionate and enanthate (short-acting esters)

An ester is testosterone attached to a carrier molecule that controls how slowly your body absorbs it. These two oil-based esters are essentially interchangeable: both are injected weekly (or every two weeks), with half-lives (the time half the dose takes to wear off) around 7-8 days. Cypionate dominates in the US; enanthate dominates in Europe and is common in Australia. Both are cheap generics and the backbone of most regimens.³

IM vs SubQ

Vials are usually officially labelled for intramuscular (IM) injection but many clinics now teach subcutaneous (SubQ) injection. This is one of the clearest cases of community knowledge preceding the trials: gender diverse people were using SubQ for years before the studies confirmed it. The pivotal 2017 study (Spratt et al., 63 trans men on weekly SubQ cypionate/enanthate) found every participant reached male-range levels, nearly all stopped menstruating, and all 22 patients asked preferred SubQ over IM.⁴

A 2022 review (Figueiredo et al.) concluded SubQ gives comparable levels to IM with less peak-trough fluctuation (smaller swings between the high right after a shot and the low before the next one), easier self-administration, and less discomfort, while noting the evidence is still “limited” (no large long-term randomized trial).⁵ An 8-year cohort in transmasculine youth found it safe and effective.⁶ SubQ is technically off-label (the esters are still usually labelled IM), but it’s a mainstream, guideline-supported choice.

Sustanon (mixed esters)

Sustanon 250 is a blend of four testosterone esters (short + long acting) given by deep IM injection, usually 1 mL every 2-6 weeks, every 4 weeks is the typical UK starting default, and it’s licensed in the UK specifically as supportive therapy for female-to-male trans people. Self-administration is the goal in NHS practice.⁷ The mix of esters smooths levels somewhat but still produces peaks and troughs. it also uses arachis (peanut) oil, a iisue for those with a peanut allergy.

Testosterone undecanoate (Nebido / Reandron; Aveed in the US)

The long-acting injection: 1000 mg every 12 weeks (as Nebido, marketed as Reandron 1000 in Australia) or 750 mg every 10 weeks (Aveed, US), after an early loading dose. It gives the most stable, near-physiological levels of any injectable, with only ~4-5 clinic visits a year.¹⁵

Undecanoate is not self-administered.

The large 3-4 mL injection volume carries a rare risk of pulmonary oil microembolism (tiny oil droplets reaching the lungs) and anaphylaxis (a severe allergic reaction), so it’s given by a clinician, not at home. In the US it’s restricted to a registered-provider program (Aveed REMS) with a 30-minute post-injection observation.¹⁷

Transdermal gel

Transdermal just means “through the skin.” Gel is applied once daily (usually mornings) to clean, dry skin of the shoulders/upper arms, delivering 50-100 mg/day. It produces the most stable, physiological day-to-day levels of any form, involves no needles, and is easy to adjust or stop. Downsides: it’s a daily routine, absorption varies between applications and people, it costs more than injections, and it raises DHT (a stronger hormone your body makes from testosterone) somewhat more.¹⁵

Gel can transfer to other people.

Secondary transfer through skin contact (or contaminated towels/clothing) has caused masculine changes in children, serious enough that US gel labels carry an FDA boxed warning (the strongest safety warning a drug label can have). Mitigation: apply to shoulders/upper arms only, wash hands with soap and water after applying, let it dry and cover with clothing, and wash the site before anticipated skin-to-skin contact.⁸

The gel can be toxic to pets!

As with people it can transfer to pets if you fail to very carefully and thoroughly wash your hands after application. Be mindful around your animals <3

Patches

Testosterone patches (2.5-7.5 mg/day) are easy and give predictable levels, but a high rate of application-site skin irritation and poor adhesion with sweating limit their use, only ~1-3% of patients use them in cohorts, and they’re unavailable in some countries.¹⁵

Pellets (implants)

Testopel pellets (75 mg each) are implanted under the skin of the hip/buttock in a minor in-clinic procedure every 3-6 months, the official label says 150-450 mg (2-6 pellets), though real-world series commonly use 6-14 pellets to sustain male-range levels.⁹ “Fit and forget” convenience, but the dose can’t be adjusted once implanted, and there’s a risk of infection, hematoma (a pocket of blood under the skin), and pellet extrusion (a pellet working its way back out).

Oral testosterone undecanoate

Modern oral undecanoate (Jatenzo, Tlando, Kyzatrex in the US; the older Andriol elsewhere) is absorbed via the intestinal lymphatic system (part of the body’s fluid-filtering network), bypassing first-pass liver metabolism, so it does not carry the liver toxicity of the old 17-alpha-alkylated orals (methyltestosterone), which are now discouraged. Taken twice daily with food; ~80-88% of users reach male-range levels in the (cis-male) trials. Main cautions: blood-pressure elevation (boxed warnings on two brands), polycythemia (too many red blood cells), and lipid (blood fat) changes.¹⁰ Important caveat: these products were studied almost entirely in cisgender men with hypogonadism (bodies that don’t make enough testosterone). use for transmasculine HRT is off-label and not specifically studied.

Comparison table

Form	Route & how	Typical frequency	Level stability	Pros	Cons
Cypionate / enanthate	Self-injection, IM or SubQ	Weekly (or every 2 weeks)	Moderate - peaks & troughs, worse at 2-week intervals	Cheapest; long track record; flexible dosing	Needles; cyclic mood/energy at longer intervals; raises hematocrit more than gel
SubQ route (cypionate/enanthate)	Small needle (25G) into belly/thigh fat	Weekly	More stable than IM	Less pain, easier self-injection, preferred by patients	Off-label (technically); erythrocytosis question unresolved
Sustanon 250	Deep IM, self or clinician	Every 2-6 weeks (often 4)	Moderate; mixed-ester peaks	Standard in UK; licensed for FTM; cheap	Peaks/troughs; peanut-oil vehicle
Undecanoate (Nebido/Reandron/Aveed)	Deep IM by a clinician	Every 10-12 weeks	Very stable	~4 injections/yr; no weekly needles; steady levels	Clinic visits; rare oil-microembolism risk; costly
Gel (Testogel, AndroGel, Tostran, etc.)	Applied to shoulders/arms daily	Daily	Stable, physiological	No needles; easy to adjust/stop; less polycythemia	Transfer risk to partners/children; daily burden; cost; variable absorption
Patch	Adhesive patch, changed daily	Daily	Stable, predictable	No needles	High skin-irritation rate; peels with sweat; scarce in some countries
Pellets (Testopel)	Implanted in-clinic (minor procedure)	Every 3-6 months	Stable long plateau	Nothing to remember between procedures	Can’t adjust dose once placed; procedure each time; extrusion/infection risk
Oral undecanoate	Capsule, twice daily with food	Twice daily	Moderate (2 daily peaks)	No needles, no transfer risk; no liver toxicity	Blood-pressure warning; costly; off-label/unstudied for trans use

Stability ranking, most → least stable: pellets ~ undecanoate ~ daily gel/patch > weekly injection (SubQ > IM) > every-2-week injection > twice-daily oral.⁵

Formulation and red blood cells

Polycythemia, too many red blood cells, measured as a high hematocrit (the share of your blood made up of red blood cells), differs by form: in a Melbourne study of 180 transmasc indaviduals, it occurred in 23% on IM enanthate, 15% on IM undecanoate, and 0% on transdermal testosterone at comparable blood levels.¹¹ If your hematocrit runs high, route is one of the levers your clinician can pull. see FTM Blood Testing and FTM Risks and Side Effects.

Australia notes

Australian practice (reflected in Melbourne/Sydney studies) leans on testosterone enanthate (Primoteston) and testosterone undecanoate (Reandron 1000), with gels (e.g., Testogel) also common, especially for low-dose regimens. Most testosterone products are PBS-subsidised, so roughly A$7 with a concession card to ~A$40/month, after a one-time specialist involvement; note Primoteston itself is not PBS-listed and is prescribed privately.¹²¹³ See FTM Access for the full pathway.

Deciding on route

There is no “best” route, you’re most likely to thrive on whichever one you can actually stick with. If you hate needles, gel works just as well. If daily routines fail you, a weekly shot or a quarterly undecanoate visit may fit better. If trough crashes hit you on 2-weekly injections, that’s fixable (weekly dosing, SubQ, or transdermal), see FTM Dosages. Bring your preferences to your clinician to decide together.¹⁵

Further reading

Don’t take one website’s word for it, these cover the same ground from different angles.

• UCSF’s overview of masculinizing hormone therapy the friendly clinical guide this page leans on, with a form-by-form rundown
• diyhrt.wiki - Transmasculine HRT guide community wiki with practical detail on injection routes, gear, and technique
• Figueiredo et al., 2022 review of SubQ injections the open-access evidence review behind the SubQ section
• Mayo Clinic - Masculinizing hormone therapy a mainstream hospital’s plain overview of the options
• TransHub - testosterone prescribing in Australia the Australian picture, including PBS subsidy rules

Footnotes

1. UCSF Gender Affirming Health Program, “Overview of masculinizing hormone therapy” (Deutsch MB, ed., 2nd ed.) - https://transcare.ucsf.edu/guidelines/masculinizing-therapy ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

2. Frontiers in Reproductive Health (2024), route distribution in a large transmasculine cohort - https://www.frontiersin.org/journals/reproductive-health/articles/10.3389/frph.2024.1344111/full ↩

3. Sizar O, et al. “Androgen Replacement,” StatPearls (NCBI Bookshelf) - https://www.ncbi.nlm.nih.gov/books/NBK534853/ ↩

4. Spratt DI, et al. “Subcutaneous injection of testosterone is an effective and preferred alternative to intramuscular injection in transgender men,” JCEM 2017 - https://pubmed.ncbi.nlm.nih.gov/28379417/ ↩

5. Figueiredo MG, Gagliano-Jucá T, Basaria S. “Testosterone Therapy With Subcutaneous Injections: A Safe, Practical, and Reasonable Option,” JCEM 2022 - https://pmc.ncbi.nlm.nih.gov/articles/PMC9006970/ ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

6. Laurenzano SE, et al. “Subcutaneous Testosterone Is Effective and Safe as GAHT in Transmasculine and Gender-Diverse Adolescents and Young Adults,” Transgender Health 2021 - https://pmc.ncbi.nlm.nih.gov/articles/PMC8664110/ ↩

7. Sheffield Partnership NHS FT, “Transman Prescribing Guidelines” (2022); Sustanon 250 UK SmPC - https://www.sheffieldpartnership.nhs.uk/sites/default/files/2022-12/Transman%20Prescribing%20Guidelines%20%282022%29.pdf ; https://www.medicines.org.uk/emc/product/5373/smpc ↩ ↩²

8. FDA, AndroGel (testosterone gel) 1% label. boxed warning: secondary exposure (2009) - https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/021015s022lbl.pdf ↩

9. DailyMed, TESTOPEL (testosterone pellets) prescribing information; review of testosterone pellets - https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=03b9c0b1-5884-11e4-8ed6-0800200c9a66 ; https://pmc.ncbi.nlm.nih.gov/articles/PMC4431706/ ↩

10. “Treatment of Symptomatic Male Hypogonadism with New Oral Testosterone Therapies: A Comparative Review of Jatenzo, Tlando, and Kyzatrex,” Medicines (MDPI) 2025 - https://www.mdpi.com/2305-6320/13/1/1 ↩

11. Nolan BJ, et al. “Prevalence of polycythaemia with different formulations of testosterone therapy in transmasculine individuals,” Intern Med J 2021 - https://pubmed.ncbi.nlm.nih.gov/32237098/ ↩

12. TransHub (ACON, Australia), clinical guidance on PBS-listed testosterone - https://www.transhub.org.au/clinicians/endocrinology/ ↩

13. Nolan BJ, et al. “Testosterone concentrations and prescription patterns of 1% testosterone gel in transgender and gender diverse individuals,” Ther Adv Endocrinol Metab 2022 - https://pmc.ncbi.nlm.nih.gov/articles/PMC8918760/ ↩