Version 7, October 28, 2018
A few years ago I was at my yearly appointment with my endocrinologist, when she asked me, “Beverly, I wish I could convince more of my new patients to start out on injections. Too many of them just want pills. Do you have any suggestions?” I think I said something about needle and syringe selection, so that patients were not being forced to use 22 gauge needles — or some other unhelpful comment. But I knew that really wasn’t enough — something easier, and less scary, was badly needed. Shortly after, I learned of a patient in Canada using estradiol valerate (EV) subcutaneous injections, and decided to try it on myself. After a few months of experiments and tests I was ready to mention it to others, and after finding a medical study verifying its effectiveness, I was ready to recommend it to doctors too — many of whom, it turns out, were already quietly using it on their patients.
I’ll begin with practical information. Following that will be the medical and clinical information, experimental results, and group knowledge.
To start, you need to get the right syringe and needle combination. Pharmacists, nurses, and most doctors have not been trained on best practice for oily hormones by subcutaneous methods, and usually recommend the wrong equipment — equipment suitable for vaccinations, antibiotics, insulin, etc. Oil based hormones have different requirements. If you doubt that, ask a doctor specializing in fertility treatments.
Getting the right equipment requires first determining the volume of hormones per injection. For best results it must be less than 1cc (which equals 1 milliliter, or 1 ml.) so that a small diameter syringe can be used, which enables use of a 30 gauge needle with high viscosity liquids. (Due to the laws of hydraulics.) If you inject 2ml of hormones per 10 days, for instance, you will need to split it and change your schedule to 1ml every 5 days. (Larger syringes such as the 3ml syringe are not suitable because they make using small needles impossible with oily hormones — don’t let your pharmacist give you the wrong syringes!) This determines the type of equipment you must use. There are two cases. Check to see which applies to you.
Case 1: This applies to you if each time, you inject more than 0.3cc but less than 1cc. You will need 3 things: (1) a 1cc Luer Lock syringe, (2) a draw needle, and (3) an injection needle.
For Case 1, item #1, the syringe, I suggest three alternatives. These BD syringes are excellent, at about 50 cents each: http://www.allegromedical.com/syringes-c570/syringe-luer-lok-1cc-sp-p550722.html. The Kendall syringes are quite adequate, for about 40 cents each: https://www.mdsupplies.com/medical-supplies-Kendall-SYRINGE-1cc-TB-LL-WZPRDXDUQ9.html. The Easytouch brand is not personally familiar to me, but is very low cost at under 30 cents each: https://www.missourimedicalsupplies.com/easytouch-1cc-luer-lock-syringe-bx-100/ . You will find other sources for each of the above syringes, with varying prices and availability. Note: take care that you do NOT accidentally buy the “Luer Slip” style of syringe — such syringes do not lock to the needle, but instead they slip on more loosely, inviting a “pop off” accident when injecting oily hormones. Slip-type syringes are only suitable for less viscous injections such as vaccines. Luer-Lock syringes twist on the needle, making it impossible for it to leak or pop off when injecting oily hormones, which may require more pressure. If you are in a location where ordering syringes is restricted, you can try ordering thru EBAY, which generally evades such restrictions. Here is a typical listing.
For Case 1, item #2, the draw needle, I prefer a 1.5 inch 20 gauge needle such as: https://www.mdsupplies.com/medical-supplies-Dynarex-Hypodermic-Needle-20G-1-12-needle-25CXRSY64J.html See this listing for a typical EBAY source, if you have trouble ordering from other sources.
For Case 1, item #3, use a 0.5 inch 30 gauge needle, such as this inexpensive one:
https://www.mdsupplies.com/medical-supplies-Exel-Hypodermic-Needle-30g-x-12-4GPJ5A6DRL.html See this listing for a typical EBAY source, if you have trouble ordering from other sources.
Case 2: this applies to you if each time, you inject 0.3cc or less. For this low volume, instead of following Case 1 above, you MAY choose (it’s optional) to use the all-in-one insulin syringe. In choosing case 2, keep in mind that this has a disadvantage that filling the syringe is VERY time consuming because it has to be drawn thru a 30g needle. Also, its needle is not as sharp, and may be slightly less painless to use. If either of these factors will bother you, go back to Case 1. Otherwise, in this case, you only need to buy one piece of equipment — the 0.3cc insulin syringe. Here is one in a box of 100: http://www.allegromedical.com/syringes-c570/ultra-fine-syringe-lo-dose-p191846.html. Here is a typical EBAY source listing. And this inexpensive source. Now you’re set.
Fill the syringe with the proper dose of your oil-based hormones (Estradiol Valerate, Estradiol Cypionate, Progesterone in Oil, Testosterone Cypionate/ Propionate/ Enanthate/ etc.) How you do this depends on how your hormones are packaged, and I have covered that subject elsewhere. I’ll assume you know how to fill your syringe, and have done so, and are ready to inject.
The location should be in a part of your body which has a fatty layer. Choose either your abdomen or your hip. If it is the abdomen, it must be at least 4 inches away from your navel, where the fatty layer thins. Here is the procedure, spelled out.
(1) With the needle attached to the syringe and all air expelled, loosen the cap of the needle, then lay the syringe down within reach.
(2) Apply alcohol to the area to be injected. LET DRY COMPLETELY. Don’t blow on it, but you can fan it with something if you are impatient. It may sting if your skin isn’t dry.
(3) Using one hand, pinch your skin between thumb and forefinger. Not too hard.
(4) With the other hand, pick up the syringe, and tilt it so that the cap falls off the needle.
(5) Then gently place the 30 gauge needle on the skin at a 45 degree angle to your skin. While gently touching the skin, you may move the tip a tiny bit to a place with the least sensation. Then while applying the lightest pressure you can, use a gentle twisting motion back and forth of the syringe, like you are spinning it slightly in your fingers. The needle will sort of swim into your skin with minimum sensation. When I do this, the sensation is often so little that I would not know it had happened if I wasn’t watching. The spinning motion seems to cause the nerves, which are sort of tough, to simply move out-of-the-way a bit as the needle moves past. Do NOT jab. Spin the needle in very lightly. Once you get familiar with this technique, you can make a game of it — see how completely painless you can make it.
(6) Now that the needle is fully inserted, you may release the pinch on your skin. Relax and use both hands to withdraw the plunger slightly to verify that you are not in a vein. (This is optional.) Then press the plunger to inject. Remove the needle. You’re done. The change in the tension on your skin, when you released the pinch, will help to prevent any leaking or a drop of blood from showing. But don’t be anxious if you see a drop of either. You’re all right. Wipe again with alcohol.
I have two videos. This one is for Case 1, using the conventional Luer Lock syringe: https://youtu.be/KooPrAWrlFA
This one is for Case 2, with the insulin syringe: https://youtu.be/kcIFYL-mDlQ
Now let’s talk about the medical aspects.
The location recommended by manufacturers for hormone injection is the buttocks (NOT the thigh!). But a recent study shows that the blood levels for fat layer subcutaneous injection (“SubCut”) of these oil-based hormones will be similar to gluteal IM.(ref 1) So, why would we consider a SubCut injection, if we are already giving ourselves a buttocks IM injection? First, one reason doctors have for refusing to allow their transsexual patients to inject themselves is fear that they might hit the Sciatic nerve. This mistake is almost unheard of when injections are done by trans women – the scare stories are nearly all of novice nurses doing this – but it’s been a pretext used by doctors to deny injection as an option to their patients. You can sidestep this objection by requesting your doctor set you up to do your hormones by SubCut instead. If your doctor objects that hormones are not specified to be administered that way by the manufacturer (which is true) you can give them this article (1) to read, which proves that the method can have similar effectiveness. Furthermore, you should present this proof that subcutaneous injection is widely used, effective, and safe for FTM trans men. (3) In both cases, the injection is an oil-based steroid ester – if one works well, the other should also. In this way, SubCut can be a bargaining tool you can use to get your doctor to start you on injections. Second, a proper IM injection into the gluteus generally requires that you be standing. Not all trans women can stand while injecting — some may be wheelchair bound, feel unconfident, or be otherwise disabled. These patients can benefit from SubCut abdomen or hip injections of hormones, which can be easily done while sitting. And finally, many patients are anxious that injections might hurt and they avoid injections, but these subcutaneous injections are so painless that few patients will object. Those who are needle phobic should find it easier to deal with the tiny needles.
Informal testing on myself, comparing the bioavailability of hormones each way, showed that the SubCut method is at least 85% the efficiency of conventional Gluteus Medius/Maximus IM injections. The half life is slightly shorter, but similar. My informal results were confirmed by blood tests as well. In group settings, we generally observe that best feminization is observed with the shortest cycles, with a twice-a-week cycle giving a significant benefit. This fits the overall observation that best feminization is achieved more by avoiding estradiol dropouts than by creating estradiol surges. A once-a-week cycle for Estradiol Cypionate seems to be good, but Estradiol Valerate does not do as well when stretched that far. I do not have good data on testosterone esters in this respect, but any injection schedule which prevents peak/trough ratios from exceeding about 1.5 appears to give good results and I personally believe this applies to all the esters.
Since 2016 at the latest, all or nearly all MTF and FTM patients at The Mayo Clinic are going on Subcutaneous injection from Day 1, according to one of the patients in the program. (2) MTF patients use the 20mg/cc or 40mg/cc strength of Estradiol Valerate. Dr. Todd Nippoldt is in charge of the program. The doctor has published nothing I can find so far on MTF using subcutaneous, but given his program, I would imagine that a paper will be published soon. That would be the first, and would surely be very influential. The patient I contacted reports that everyone is doing well and that the clinic staff are talking about it in their presentations.
At present, many new transsexual men are being started on subcutaneous Testosterone Cypionate injections instead of IM in the Northern California area. Is it possible I played a role in this? I’ve used my contacts with local hormone expert Jennifer Hastings MD and indirectly through many patients in the area — but who knows. But as of today, in California, transsexual women still need to boldly request subcutaneous administration from their doctors, who may never have had clinical experience with it. This situation has been improving rapidly throughout 2017 and we can expect that to accelerate as news of the Mayo Clinic program spreads. In the meantime, subcutaneous hormone administration has also became accepted in one Canadian province with good results, according to another report.
Recently, Fenway Health in Boston has begun advising subcutaneous injection of hormones for trans people, and including a detailed procedure in their handout. (4) However, they advise using an 18g needle for drawing from vials, which may cause damage to the seal to accumulate faster than necessary. I use a 22g needle for drawing. They also mention a 5/8ths inch needle, 25g or 26g, instead of the 1/2 inch 30g needle I suggested above. The 30g will generally cause significantly less injection pain.
Informal group knowledge, consisting of around 50 subcutaneous Estradiol-using trans women, seems to favor using subcutaneous over IM. The users cite the advantages of comfort and ease, and often express relief that they don’t have to wrestle with awkward positions to give themselves proper buttocks IM injections. Patients who had been using thigh injections (which give poor bioavailabililty and halflife compared to buttocks IM) may report some improved feminization effectiveness and improved mood and emotional stability. SubCut injections may also make it easier to go from a long cycle (7 day) injection schedule to a shorter one (twice a week). A few users have complained of stinging — but this may be due to not allowing alcohol to dry adequately, or not using proper needles.
With modern knowledge that parenteral estradiol has major health benefits over oral estradiol, there was still a missing piece of the puzzle: a convenient and safe personal injection method. It’s clear that subcutaneous injection of oil-based hormones is in many ways, an important step forward in establishing injection as the most favored administration method for oil-based sex hormones.
(1) “Comparative pharmacokinetics and pharmacodynamics after subcutaneous and intramuscular administration of medroxyprogesterone acetate (25 mg) and estradiol cypionate (5 mg).” Contraception. 2011 Dec;84(6):565-70. doi: 10.1016/j.contraception.2011.03.014. Epub 2011 May 11.
(2) Callie Amber Foxx, private communication, Nov. 2, 2017.
(3) “Subcutaneous Injection of Testosterone Is an Effective and Preferred Alternative to Intramuscular Injection: Demonstration in Female-to-Male Transgender Patients”, Spratt, The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 7, 1 July 2017, Pages 2349–2355, https://doi.org/10.1210/jc.2017-00359
(4) “Transgender Health Injection Guide” no visible date, Fenway Health, Boston MA. [link]