My Transition Diary

I've finally got a little time to write this up. After months of deliberation, I switched to Testopel on June 5, and I'm finding it a really positive experience. I had my second Testopel insertion on October 19. A lot of people aren't aware that T pellets are a thing, and some know they exist but haven't heard first-hand accounts about them, so hopefully this will help some folks.

I'm pretty sure most people in the Boston area get their Testopel through Fenway Health; I'm not a Fenway patient, so I went through a local urologist. I've found him to be fantastic, both in general and in terms of Trans-savviness. Contact me for more info if you're in the area and looking for a doctor.

Some basic info about T pellets:

• Testopel is a subdermal implant. It's implanted in subcutaneous fat in your butt, over to the side a bit, near but not actually on the hip. It's basically exactly where I did my shots, both IM and subq.
• The pellets slowly release T, giving you a steady dose that will last anywhere from 3-6 months depending on how efficiently your body absorbs it. The first insertion is done with the expectation that it'll last 4 months. Labs are done after 1 month and after 3 months to check your hormone levels, and when you go back for your second insertion after 4 months, you make a plan from there if anything needs adjusting.
• The pellets themselves ultimately dissolve completely, so there's no need to have them removed. They tend to take about six months to completely dissolve even if the T is used up faster than that.
• Doctors typically want you to be on some other form of T for at least a year prior to going on pellets, because they want to have a sense of what dose works well for you.
• Insertion is done by the doctor making a small incision (maybe an inch long? maybe less? not sure), then inserting a hollow needle, through which they send about ten pellets. The pellets are each about the size of a grain of rice. This takes two or three minutes total, and then they put a couple of steri-strips on the incision - no stitches - and send you on your way.
• The most painful part of the whole procedure is the local anesthetic. They shoot your butt full of quite a lot of lidocaine, so the actual insertion is painless, but the lidocaine is delivered via four injections to the muscle. This takes maybe two minutes, and it's that deep-muscle-soreness kind of hurt, not the sharp stabby kind of hurt that some shots give you.
• Because the entire thing takes 15 minutes or less - a few minutes to prep and inject your butt with lidocaine, five minutes or so to let the lidocaine set in, then a few minutes for the procedure itself - it is billed as a regular doctor's visit, not as surgery, even though technically it is outpatient surgery. That makes it way cheaper.
• Both the procedure itself and the Testopel are 100% covered by my insurance, so the entire thing costs me an $18 copay each time.
• The lidocaine takes about 24 hours to wear off. Once it does, you're sore for a few days or so. I've had two insertions so far and both have left me sore for about a week. It doesn't stop you from walking, sitting, or driving, but I found running uncomfortable, and walked with a slight limp for most of that week. (The limp was partly because I have a really low pain threshold and was being a baby, and partly due to fear that I would burst a pellet or something if I didn't treat the area delicately at first. My urologist assures me that that fear is unfounded. The only restriction I was given around activity was to skip my weekly karate class once after the insertion, and then go back to all activity as normal.)
• You may get some bruising around the insertion area. I had no bruising the first time and some bruising the second time, which I think was partly due to how religiously I iced the area after my first insertion. I didn't have time to ice it very much after the second insertion. The bruising I had last month was completely gone after maybe ten days.
• The incision is held shut with steri-strips, and then you get a big gauze pad taped on top of that. You remove the gauze pad the next morning before you shower, but leave the steri-strips until they fall off by themselves, which might take a week or so. You may not want to have the water directly hitting the insertion area while you're sore, and you don't want to scrub the area because it's sore and because you don't want to prematurely remove the steri-strips, but otherwise there's no issues with showering. I just washed carefully and gently until the steri-strips were gone.
• The pellets do create a small lump under the skin - more flat and spread out, less of a big topographic anomaly. You can't feel a lump under you when you sit, even with your wallet in the way, but you can feel it with your fingers if you press lightly on the area. On a moment-to-moment, day-to-day basis, I'm not aware of it at all.

A few bits and pieces specifically about my experience:

• I kept an eye on my energy level, mood, and libido after both pellet insertions. I had no noticeable change in any of them, nor did I sprout any new body hair or find that my facial hair was growing faster or have a voice change for the first time in years, or anything like that.
• My 1-month labs showed my T levels higher than I think they'd ever been, although they were still within the healthy range for a male of my age.
• My 3-month labs showed my T levels had dropped a whole lot. It was still within the healthy range, but it was a really noticeable drop from two months prior.
• In the month between my 3-month labs and my appointment for reinsertion, I started having what felt very much like hot flashes, except they were a lot milder than I remember them being when I was early on T. I wasn't as hot, and it didn't last as long, as I remember from before, so I wasn't entirely sure whether it was me or just September in New England. When I spoke to my doctor about it at my reinsertion appointment, he said he wouldn't be surprised at all if I were having hot flashes given what happened with my hormone levels.
• Given what my labs did, plus the mild hot flashes, my doctor suggested two options: increasing the number of pellets slightly so my levels wouldn't drop so low by the 4-month mark, or doing a new insertion every 3 months instead of every 4. Because my T levels spiked as much as they did in the first month, I didn't want to increase my dose; I worry that that would raise my T levels high enough that it would start to aromatize to estrogen. Having this procedure done four times a year instead of three isn't ideal, but it's a very small price to pay, so that's what we're trying now. Still ten pellets at a time. Depending on my upcoming labs, I may do eight or nine pellets on the next insertion.

I'm having blood drawn next week for my 1-month labs for this insertion. Here are my relevant labs from my first insertion. Please remember that YMMV! My labs do not reflect what your labs will be, because your body is not my body. When you've met one Trans person, you've met one Trans person. Etc.

• Estradiol:
  • Standard range for males is <20-47 pg/mL
  • My one-month level: 24 pg/mL
  • My three-month level: 14 pg/mL

• Free testosterone:
  • Standard range for males over age 20: 47-244 pg/mL
  • My one-month level: 136 pg/mL
  • My three-month level: 67 pg/mL

• Bioavailable testosterone:
  • Standard range for males over age 20: 130.0 - 680.0 ng/dL
  • My one-month level: 297.0 ng/dL
  • My three-month level: 168.0 ng/dL

• Total testosterone:
  • Standard range for males over age 20: 241.0 - 827.0 ng/dL
  • My one-month level: 758.4 ng/dL
  • My three-month level: 532.4 ng/dL

My SHBG (sex hormone binding globulin) was significantly high, well out of the healthy range, at the three-month mark. I spoke to my PCP about that and she said it's not a concern for me, and my urologist didn't seem concerned about it either. A quick google tells me that SHBG is related to sperm count, so yeah, not super relevant for us.

My LH (luteinizing hormone) was also too high at the three-month mark, but neither doctor was concerned about that either. LH is produced by the pituitary gland, and my urologist said it possibly spiked in reaction to my T levels dropping so much. It was quite a spike - 39.98 mIU/mL when the standard range is 1.24 - 8.62 mIU/mL.

LH works in conjunction with FSH (follicle-stimulating hormone), also produced by the pituitary gland. My FSH was also way high (117.50 mIU/mL when it should be 1.27 - 19.26 mIU/mL) at the three-month mark. My FSH was also high at the one-month mark, although not by much; LH at the one-month mark was totally fine.

I saw my doctor last week for our annual chat and labs, so here are my lab results. It's been one month since my second Testopel insertion, so I was due to have my hormone levels tested, plus my doctor ordered my usual lipid profile.

Vitals:
Blood Pressure: 113/77 mmHg
Pulse/Resting Heart Rate: 90 bpm (standard range: 60-100 bpm, lower is healthier)
SpO2: 98% (healthy is between 96% and 99%)

Lipid profile:
LDL Direct Measure: 74 mg/dL. Standard range: 0-130 mg/dL

Hormone levels:
Albumin: 4.7 g/dL. Standard range: 3.5-4.8 g/dL.
Total Testosterone: 847.3 ng/dL. Standard range: 241-827 ng/dL
Sex Hormone Binding Globulin: 55.1 nmol/L. Standard range: 17.3-65.8 nmol/L
Follicle-Stimulating Hormone (FSH): 89.04 mIU/mL. Standard range: 1.27-19.26 mIU/mL
Luteinizing Hormone (LH): 29.05 mIU/mL. Standard range: 1.24-8.62 mIU/mL
Testosterone, Free: 134 pg/mL. Standard range: 47-244 pg/mL
Testosterone, Bioavailable: 343.0 ng/dL. Standard range: 130-680 ng/dL
Estradiol 17 Beta Serum: 41 pg/mL. Standard range: 14-55 pg/mL

My total testosterone is high, and while my estradiol is within the healthy range, it's a lot higher than it's been in the past, so my guess is that some of the T is aromatizing to estrogen. Hopefully in January we can do eight or nine pellets instead of ten and that'll fix the problem without making my levels too low after three months. I'm a little nervous about these highs and lows, even though I feel fine. I really don't want to have to go back to injections.

I asked my doctor about the ridiculously high levels I'm getting for FSH and LH, and she explained a bit more about that. Those are hormones released by the pituitary gland to tell the ovaries to release an egg or the testicles to produce more sperm. Because I don't have ovaries or testicles, my pituitary is kind of confused about the lack of reaction, and is pumping out more hormones trying to get a reproductive organ to respond. She said it's not anything to worry about, and my urologist wasn't concerned about it when I saw him last month, so I'm not bothered. I'm mostly just amused at the idea of my poor confused pituitary trying so hard to make contact with something, and failing. Bless it.