Gel vs injections for trans men: what @eddyquekett got right

What did @eddyquekett actually say?

They're four months into testosterone therapy and chose gel over injections for two reasons: control over dosing pace, and a pre-existing clotting disorder. On the clotting point, they said testosterone raises their risk "only really to the levels that I would have had had I been a cis man." They also argued that gel produces steadier testosterone levels, avoiding the post-injection spike they believe increases clot risk. At their next appointment, they plan to ask whether weekly injections might be safer than monthly ones because of the smaller per-dose spike.

This is a remarkably well-reasoned personal explanation. Most people on TikTok don't engage with the pharmacokinetics of their own medication. Credit where it's due.

Does the science back this up?

Mostly, yes, but with some important nuance that the video glosses over. The claim about gel producing steadier serum testosterone levels is well-supported. The clotting argument is plausible but more complicated than presented.

Testosterone gel does produce more stable serum concentrations compared to intramuscular injections, which create a supraphysiological peak in the first 24-72 hours post-injection (Bhasin et al., 2010, Journal of Clinical Endocrinology and Metabolism). That peak is real and measurable.

On venous thromboembolism (VTE) risk: testosterone therapy is associated with increased VTE risk, particularly in the first six months of use, regardless of formulation. A large cohort study by Martinez et al. (2016, JAMA Internal Medicine) found elevated VTE risk in the early months of testosterone use, though absolute risk remained relatively low in healthy individuals. Whether the delivery method meaningfully modifies that risk in people with inherited thrombophilias is not well-established in the literature. The "smaller spike, smaller risk" logic is biologically reasonable, but it hasn't been definitively proven in clinical trials for people with clotting disorders specifically.

What did they get wrong (or right)?

The claim that testosterone raises their clotting risk "only really to the levels" of a cisgender man is a simplification that could give people false reassurance. It's not entirely wrong, but it's incomplete.

Someone with a pre-existing thrombophilia doesn't have a baseline risk equivalent to a typical cisgender man. They have an elevated baseline risk to begin with. Adding exogenous testosterone on top of a clotting disorder is not simply "catching up" to male-typical risk. The interaction between thrombophilia and testosterone-induced polycythemia (increased red blood cell production) is a real clinical concern. Polycythemia raises blood viscosity and compounds clotting risk independently of the delivery method (Glueck et al., 2014, Clinical and Applied Thrombosis/Hemostasis).

What they got right: the core logic about gel providing better pharmacokinetic stability is accurate. The reasoning about wanting reversibility and dose control early in transition is clinically sensible and widely echoed in gender-affirming care guidelines (WPATH Standards of Care, version 8, 2022). The plan to discuss weekly versus monthly injections with their prescriber is exactly the right approach, not a self-prescription.

What should you actually know?

If you have a clotting disorder and are considering testosterone therapy, the delivery method conversation is worth having with your doctor, but don't assume gel is automatically safe or that injections are automatically dangerous.

A few things the video doesn't mention: hematocrit monitoring is standard practice during testosterone therapy because rising red blood cell counts are one of the main modifiable VTE risk factors. This applies to gel users too, not just injection users. Anyone with a thrombophilia starting testosterone should ideally be co-managed with a hematologist or have their clotting disorder formally assessed before and during treatment.

The "weekly injections mean smaller spikes" argument has intuitive appeal and some pharmacological basis, but it's not established as a VTE risk-reduction strategy in published clinical guidelines for people with thrombophilias. It's a reasonable hypothesis worth discussing with a prescriber, which is exactly what @eddyquekett says they plan to do.

• Testosterone cypionate and enanthate peak roughly 24-72 hours post-injection and return to baseline over 7-14 days depending on the ester and individual metabolism.
• Gel produces steadier levels but absorption varies significantly between individuals and application sites.
• Polycythemia, not just the testosterone level itself, is a key driver of VTE risk during testosterone therapy.

The broader point: this video is a good example of a patient who has done their homework. The clotting science is more complex than presented, but the conclusions they've drawn are reasonable given what's publicly available. Talking to your prescriber before changing your formulation is the right call, not copying someone's TikTok regimen.