CN: Discussion of testosterone based hormone replacement therapy, injections

Medication adherence is a big issue for any medication that needs to be taken long term. The WHO estimates there are problems with medication adherence in 50% of patients with chronic diseases in developed nations. People in poverty are impacted disproportionately, and generally poor adherence can lead to poor outcomes for patients. Although being transgender is not a disease, medication adherence is often a struggle for transgender men taking testosterone for hormone replacement therapy. Exact statistics are hard to get on this specific situation, but the WHO data suggests the hypothesis that this is a common problem for hormone replacement therapy as well. Anecdotally, I know far more guys who have struggled with compliance than those who have not, after the first year or so on T.

Better medications won’t solve the cost and doctor access issues. For most people a new prescription is required every six months or a year. Most insurance still doesn’t pay for hormone replacement therapy, and many transgender people in the United States and some other countries don’t have medical insurance with good drug coverage anyway. Keeping a consistent medical care provider for long periods of time can be difficult (especially for a population with low employment stability), and having to convince new doctors to continue your old medications, especially doctors not already familiar with caring for trans patients, is often a hassle.

However, at least some of the adherence problems people encounter are related to the medications themselves. The current most common dosing schedule for testosterone is injections of testosterone cypionate or testosterone enanthate on a bi-weekly basis, though some people do weekly injections. There are daily options available, such as a topical gel or patches, though these are less common both due to difficulty getting high enough hormone levels, and increased cost.

Although bi-weekly injections are the most common dosing schedule for trans men, they also seem to be the most difficult to adhere to long term. The shots are infrequent enough to be easy to forget, but frequent enough that being late on a dose can lead to decreasing hormone levels fairly rapidly. Injections are particularly difficult to adhere to because they are uncomfortable and scary for many people, and the best place to inject (the upper lateral quadrant of the gluteus maximus) is difficult to reach on your own. Over the long term, years and decades, it can be really difficult to stay on schedule for many people. Injections get delayed, then skipped, much more often than many trans men would like to admit.

There has been a longer term option available for some time, in the form of an implant. The Testopel implants last for between 3 and 6 months (usually 3-4 months) and require an in-office procedure to administer. The in-office procedure and cost of the implants themselves unfortunately mean the cost to the patient is very high: at least $500 every 3 months for the implants, plus office visit costs, compared to around $60 for 3 months of testosterone cypionate injections.

A longer term injectable option is available in the United States, since 2014 (it has been available longer in some other countries). Testosterone undecanoate (Brand name Aveed) became FDA approved in 2014, and has since been studied in transgender men. Injections are given in a medical office once every 10 weeks. Unfortunately the price point is currently even higher than the implants at $882 per injection, plus an office visit. I hope that this cost will decrease, but that may not happen for 20 years, when the patent expires, so getting insurance coverage for this and the implants is likely to happen sooner.

My insurance currently covers my testosterone, though I’m unclear on if that’s an oversight because officially they don’t cover transition related care. Nonetheless, I’m going to make an endocrinology appointment, and see if I can get one of these longer term options covered. If covered, these could make a significant difference in my quality of life and decrease stress.