Testosterone therapy is increasingly prescribed for gender-affirming care and certain medical conditions, with clitoral growth (clitoromegaly) being one of the most consistent physical changes observed. This effect results from androgenic receptor activation in genital tissues, leading to structural modifications that typically persist even after treatment discontinuation. Understanding the mechanisms, timeline, and individual variation in clitoral enlargement is essential for informed decision-making. This article examines how testosterone treatment affects clitoral size, the expected timeline of changes, factors influencing individual responses, and when to seek medical advice during therapy.

How Testosterone Affects Genital Tissue

Testosterone therapy, commonly prescribed for gender-affirming care or certain medical conditions, exerts significant effects on genital tissues through androgenic receptor activation. The clitoris contains androgenic receptors, making it responsive to testosterone. When testosterone binds to these receptors, it triggers cellular changes that promote tissue growth, increased vascularity, and structural modifications.

The mechanism involves testosterone converting to dihydrotestosterone (DHT) via the enzyme 5-alpha reductase, which is present in genital tissues. DHT is a more potent androgen than testosterone itself and plays a crucial role in the development and growth of erectile tissue. This process mirrors the androgenic effects seen during typical male puberty, where similar tissues develop under hormonal influence.

Key physiological changes include:

• Enhanced blood flow to the clitoral tissue

• Changes in sensory perception, which can vary between individuals

• Growth of the erectile tissue (corpora cavernosa)

• Thickening of the clitoral shaft

These changes typically persist once they occur, as the structural modifications to tissue generally remain even if testosterone is discontinued. The extent of these changes varies considerably between individuals due to genetic factors, receptor sensitivity, dosage, and duration of treatment. Treatment should aim to maintain testosterone within the male physiological range, as higher doses do not necessarily produce greater effects and may increase health risks. Understanding these mechanisms helps patients and healthcare professionals set realistic expectations about the physical changes associated with testosterone therapy and enables informed decision-making regarding treatment options.

Clitoral Changes During Testosterone Treatment

Clitoral growth, medically termed clitoromegaly, is one of the most consistent and noticeable effects of testosterone therapy. Research indicates that the majority of individuals undergoing testosterone treatment experience some degree of clitoral enlargement, with this being reported as one of the earliest physical changes to occur. The growth primarily affects the clitoral glans (the visible external portion) and the clitoral shaft, which becomes more prominent and palpable.

Typical changes include an increase in both length and girth of the clitoris. Studies of transgender men receiving standard testosterone doses report average growth, though individual variation is substantial. Some individuals may experience minimal growth, whilst others may see more pronounced changes. The clitoris may also become more erectile, meaning it becomes firmer and more prominent during arousal, similar to penile erection.

Beyond size changes, many individuals report altered sensation and function:

• Sensory changes, which may be pleasurable, decreased, or occasionally uncomfortable

• Changes in arousal patterns and sexual response

• Changes in the appearance of the clitoral hood, which may appear more retracted as the glans enlarges

• Potential for the clitoris to protrude more noticeably

These changes usually persist even if testosterone therapy is discontinued, though further growth typically ceases when treatment stops. For many individuals receiving gender-affirming care, clitoral growth is a desired outcome that aligns with their treatment goals. However, it is essential that all patients considering testosterone therapy receive comprehensive counselling about these irreversible changes before commencing treatment. Importantly, testosterone doses above the male physiological range are not recommended to enhance growth, as this increases health risks without proven additional benefit.

Timeline and Extent of Physical Changes

The timeline for clitoral growth during testosterone therapy follows a relatively predictable pattern, though individual experiences vary. Initial changes typically begin within the first 3 to 6 months of treatment, with many individuals noticing increased sensitivity or subtle size changes during this early period. The most rapid growth generally occurs during the first year of therapy, after which the rate of change gradually slows.

Most significant growth is observed within the first 1 to 2 years of testosterone treatment, with changes generally stabilising thereafter. The final extent of growth depends on multiple factors including testosterone dosage, individual receptor sensitivity, genetic predisposition, and treatment duration.

Factors influencing the extent of clitoral growth include:

• Dosage and formulation: Testosterone should be maintained within the male physiological range; higher levels do not necessarily produce greater changes and increase health risks

• Age at initiation: Younger individuals may experience different growth patterns

• Genetic factors: Family history and ethnic background influence tissue response

• Baseline anatomy: Initial clitoral size affects the proportional change observed

It is important to note that growth is not uniform or predictable for any individual. Two people receiving identical testosterone regimens may experience markedly different outcomes. Regular monitoring during treatment allows healthcare providers to assess changes and address any concerns. Monitoring typically includes testosterone levels (timed according to the formulation used), full blood count (particularly haematocrit/haemoglobin), liver function tests, lipid profile, and blood pressure. Patients should be aware that whilst growth typically plateaus, the changes achieved usually persist, and the clitoris will not return to its pre-treatment size if testosterone is discontinued.

Managing Expectations and Individual Variation

Setting realistic expectations is crucial for individuals considering or beginning testosterone therapy. Whilst clitoral growth is a common and expected outcome, the degree of change cannot be predicted with certainty for any individual. Healthcare professionals should provide comprehensive counselling that acknowledges both the typical range of changes and the significant individual variation that exists.

Some individuals may feel disappointed if growth is less than anticipated, whilst others may feel concerned if changes are more pronounced than expected. Psychological preparation and ongoing support are essential components of care. Gender identity clinics and endocrinology services typically provide access to counselling and peer support, which can help individuals process their experiences and adjust expectations as treatment progresses.

Important considerations during testosterone therapy include:

• Contraception: Testosterone is not a contraceptive and is teratogenic (harmful to a developing foetus). Effective contraception is essential if pregnancy is possible

• Fertility: Testosterone may affect fertility; discussion about fertility preservation options should occur before starting treatment

• Clothing and comfort: Some individuals may need to adjust underwear choices or clothing for comfort as changes occur

• Genital dryness: Testosterone can cause vaginal/genital atrophy and dryness; lubricants or, in some cases, topical oestrogen preparations may be recommended

• Sexual function: Changes in sensation and erectile function may affect sexual experiences, requiring communication with partners

• Body image: Regular self-examination helps individuals track changes and identify any concerns

For those receiving gender-affirming care, clitoral growth is often a welcomed masculinising effect. However, individuals receiving testosterone for other medical reasons (such as certain hormonal conditions) should be fully informed about this irreversible change before treatment begins. Open communication with healthcare providers throughout treatment enables concerns to be addressed promptly and ensures that the therapeutic approach remains aligned with the individual's goals and wellbeing.

When to Seek Medical Advice

Whilst clitoral growth is an expected effect of testosterone therapy, certain symptoms warrant medical evaluation to ensure safety and appropriate management. Patients should be educated about normal versus concerning changes and encouraged to maintain regular follow-up appointments with their prescribing clinician, typically an endocrinologist or gender identity specialist.

Seek medical advice if you experience:

• Severe pain or persistent discomfort in the clitoral area that interferes with daily activities

• Signs of infection such as redness, swelling, warmth, discharge, or fever

• Bleeding or ulceration of the clitoral tissue

• Sudden or rapid changes that seem disproportionate to treatment duration

• Urinary symptoms such as difficulty urinating, pain, or changes in urinary stream

• Psychological distress related to physical changes that affects mental health or quality of life

Routine monitoring during testosterone therapy should include regular physical examinations and blood tests to assess hormone levels and overall health. NHS England service specifications for adult gender dysphoria services emphasise the importance of multidisciplinary support and regular review. Monitoring typically includes testosterone levels, full blood count, liver function tests, lipid profile, and blood pressure checks at intervals determined by your healthcare team.

In the UK, care is often provided through a shared care arrangement between your GP and a specialist service. For concerns about testosterone treatment, contact your GP or specialist team. For urgent issues, contact NHS 111 or urgent care services. If you experience side effects from testosterone treatment, report them through the MHRA Yellow Card scheme.

For individuals experiencing discomfort or concerns about clitoral changes, healthcare providers can offer practical advice on management strategies including appropriate hygiene, clothing adjustments, and topical treatments if irritation occurs. In rare cases where clitoral growth causes significant functional problems or distress, referral to a specialist in genital surgery may be appropriate to discuss options. However, most individuals adapt well to changes with time and appropriate support. Maintaining open communication with your healthcare team ensures that testosterone therapy remains safe, effective, and aligned with your personal health goals.

Frequently Asked Questions