Acne can get worse before it gets better.

Testosterone increases activity in the skin’s oil-producing glands, which can lead to oilier skin and acne on the face, chest, shoulders, or back. UCSF notes that acne commonly becomes most noticeable during the first year of testosterone therapy and often decreases afterward.

Treatment is generally similar to hormonal acne treatment and can range from basic skin care and over-the-counter products to prescription washes, lotions, and medications when acne is persistent, painful, or causing scarring.

Keeping testosterone within an appropriate physiologic range may also matter. UCSF notes that avoiding excessive hormone peaks with some injection schedules may help reduce acne for some people.

Testosterone can change genital tissue as well as external appearance.

Testosterone commonly causes bottom growth, increased genital sensitivity, and changes to vaginal tissue. Lower estrogen activity in these tissues can lead to dryness, thinning, irritation, discomfort with penetration, or pain during sex.

ACOG notes that testosterone-related vaginal atrophy may also make tissue more prone to small tears and changes in the local microbial environment, potentially contributing to conditions such as bacterial vaginosis, cystitis, cervicitis, or painful intercourse.

Options can include lubricants, vaginal moisturizers, and in appropriate cases low-dose topical vaginal estrogen. ACOG notes that topical estrogen has minimal systemic absorption and generally does not interfere with masculinizing testosterone therapy.

Genital symptoms deserve treatment even if discussing this part of the body is uncomfortable or dysphoria-inducing.

A more masculine hairline and male-pattern baldness are not the same thing, but both can occur.

Testosterone commonly causes some recession around the temples, producing a more typically masculine hairline. People who are genetically susceptible may also develop androgenetic alopecia, or male-pattern hair loss, with progressive thinning at the temples or crown.

How much hair loss occurs is heavily influenced by genetics, and it can begin relatively early or years after starting testosterone. UCSF specifically identifies both frontal/temporal recession and male-pattern baldness as possible effects of masculinizing hormone therapy.

If preserving scalp hair is important to you, bring up changes early. Treatments for androgenetic hair loss like oral finasteride or topical minoxidil may be used, although medication choices should be discussed in the context of your transition goals.

Testosterone increases red blood cell production.

A rise in hemoglobin and hematocrit is expected for many people taking testosterone. Once someone is amenorrheic and has testosterone levels in the typical male physiologic range, their results may appropriately resemble male reference ranges rather than female ones.

The concern is when red blood cell levels become excessively elevated, sometimes referred to as erythrocytosis or polycythemia. Persistent elevation deserves evaluation rather than simply being dismissed as a normal consequence of testosterone.

Clinicians may look at testosterone level and dose timing as well as other contributors such as smoking, sleep apnea, cardiopulmonary disease, or other medical conditions.

Testosterone may produce changes in cholesterol, including reductions in HDL (“good” cholesterol) and, in some studies, increases in triglycerides or LDL. ACOG notes these lipid changes in transmasculine people receiving testosterone, while also noting that available evidence has not established that these changes translate directly into increased cardiovascular events.

The Endocrine Society recommends assessing cardiovascular risk factors during hormone therapy using tools such as lipid testing, diabetes screening, blood pressure, and other evaluation appropriate to the individual.

That means cholesterol should be interpreted alongside the bigger picture (age, blood pressure, smoking, diabetes, family history, medications, and other cardiovascular risks) not treated as an isolated testosterone problem.

Changes can happen, but testosterone does not produce one predictable emotional response.

Some people notice changes in energy, libido, emotional intensity, or mood after starting testosterone. Others notice very little. UCSF specifically cautions against assuming that emotional or mental-health symptoms are automatically caused by testosterone, because mood changes have many possible causes.

For people using injections, hormone levels may rise and fall between doses. UCSF notes that these cyclic fluctuations can sometimes contribute to mood symptoms in susceptible individuals, which is one reason a provider may consider the timing and frequency of injections when symptoms consistently track the dosing cycle.

Persistent depression, severe irritability, anxiety, major sleep changes, or dramatic shifts in functioning should be evaluated rather than accepted as something someone simply has to tolerate because they are taking testosterone.