INJECTING
GUIDE
By
Patric Magee
Testosterone, like all
prescription medications, should not be used without appropriate medical
supervision. Dosage and advice
regarding injection should be obtained from your physician and his/her
instructions should be followed. This
document is only provided as a resource for those who are
interested in information on IM (intramuscular) injections of
testosterone. It is not, and
should not, in any way or form be considered as medical
advice or recommendation. If
you rely on others to administer your shots, make sure they know what they’re
doing.
PRELIMINARIES
Track your injections on a
monthly calendar and note any unusual symptoms or
changes from your usual injection routine. Try to keep to your schedule
as much as possible. A day or two usually won’t matter that much in a
pinch, as long as you do not make it a regular occurrence.
Note which side you inject on each time.
Ideally you should alternate sides if
possible.
Hint:
You can use a shoebox or other similar container to organize your injection
supplies. A clean washcloth
or paper towel can be used as a surface area from which to work. (I usually sit
at my home desk for injections to allow comfortable seating and a clear,
open surface area.)
You will need:
Syringes come in many
different sizes. Many transguys use 3ml syringes because they are injecting
volumes of up to 1 ml, sometimes more.
This means 3ml is the maximum amount the syringe holds. (A milliliter or
ml is the same as a cubic centimeter or cc.)
Needles are identified by
length and thickness (or gauge). Gauge
of needles ranges from 12 (really huge) to 30 (too tiny to inject T).
Most will use needles in the 21-23 gauge range.
Since T is viscous (thick like oil rather than water), using smaller than
a 23 gauge needle is not usually possible, as the T can’t easily squeeze
through that small of hole. Compounded
T may be less viscous than name
brand. A 20 gauge is probably too big for many (it hurts more).
Larger gauge needles also will leave a larger hole and therefore will
cause more bleeding and possible leak of T from the site.
Needles also have a ‘bevel’, which is the angled part of the needle
tip where the hole is.
Hint: Confused?
Gauge size is opposite of how most things are measured. The bigger the number,
the smaller the thickness, and vice-versa.
Needle length is determined by
the location of injection and the person being injected. Usually 1 inch to 1 ½
inch is usual for intramuscular injections. Thinner guys will probably be able
to use 1 inch, but bigger guys may need 1 ½ inch. Ask your doctor for which is
best for your build, and based on your choice of injecting sites.
Often needles and syringes are
supplied together (attached, in the same wrapper) but sometimes they are
separate. Either is acceptable, and your pharmacist will supply you with what
you need based on your doctor’s prescription.
Syringes have a shelf life of
1 year. They may be used after this date,
but the rubber seal around the needle can begin to deteriorate and leak
over time.
Open the wrapper and inspect
the syringe and needle for damage or defect. Tighten the needle cap onto the syringe body snuggly. There
may be a small amount of
moisture visible in the body of the syringe. This is to lubricate the
plunger and
is sterile and safe. Return the syringe to the plastic wrapper tray to
strive for cleanliness.
Hint:
defect is fairly rare, but always a good idea to check each syringe
regardless. You might want to not use syringes with a badly angled
needle.
The
Vial
Try to keep the medication
vial in sealed container or bag while not in
use. Testosterone
should be stored at room temperature and protected from
light. DO NOT refrigerate. Crystals will form if chilled. DO NOT inject
if you see crystals,
warm up the vial in your hand until solution is clear. If you find any
solid particulate in the vial that does not go away with warming, do not use the
T in that vial as it may be contaminated. Consult your pharmacist.
Lightly shake the vial to
reduce any
potential separation of ingredients.
Air bubbles are normal from shaking, and allow these to mostly clear
before using. Cloudiness or darkening of the solution is not normal-DO NOT USE
if not sure. Inspect
for foreign objects. On very rare occasion, a small rubber piece
can break off from the top rubber seal and free-float in the vial (more
on this later). DO NOT USE
the vial and contact your pharmacist. Some pharmacists may replace your
vial if it is contaminated, but make sure you bring the vial with you.
Most compounded vials will
have a 6-month expiration date and brand vials are good for 1 year. Do not use
beyond that without the recommendation of your physician or pharmacist.
If you ever notice anything
questionable about an injectable medication, or anything that is different or
unusual, DO NOT USE and ask your physician or pharmacist.
New vials have a metal or
plastic seal that needs to be broken off before
using. Put
a small amount of alcohol on your cotton ball (future reference to cotton balls
implies for them to be lightly embedded with alcohol unless described otherwise,
not too much that it
drips off), and carefully wipe the top of the vial/rubber seal (before
inserting the syringe). This
is important every time, as a small amount of solution can be
left behind on the top of vial after your last injection. This residual
solution on the seal can harbor bacteria and can be injected into the
vial if it is not cleaned first.
This can contaminate your vial and cause you to have serious infections if you
inject the contaminated T.
Remove the wrapper from the
Band-Aid and stick a corner of the Band-Aid
onto the cleaned edge of a nearby counter/desk/table edge.
Hint:
you’ll only have one hand available later if you are injecting yourself, so
getting everything ready before hand makes
it much easier.
Pick up the syringe by the
barrel, carefully remove the needle cap, and pull back the plunger to a little
more than the amount that will be injected (example- 1.2 ml if you are
filling 1ml). Insert syringe into vial. The beveled edge of the needle should be
upward and insert the needle at an angle into the rubber stopper. Inserting the
needle straight into the stopper can cause small fragments of the stopper to
break lose into the solution and contaminate the vial. Always use a slight
angle. “Coring the stopper”, or breaking off a small piece into the vial is
a “user error”, not a defect, and the vial may or may not be replaced by the
pharmacist. Never use any medication that has visible contamination.
Inject the air into the vial.
There is an air pressure vacuum
inside the vial and there will be a need to balance the pressure inside
when you remove the solution. You should inject the same amount of air to
replace the T that you will be removing. Having a
slightly higher pressure inside the vial will make the solution come out
more easily.
Too much isn’t good either though, so don’t over do it or it may
squirt out.
NEVER wipe or touch the needle
(even with alcohol). If the
uncapped
syringe tip or the needle touches any surface, discard and get a new one.
A bad infection
isn’t worth the cost of a needle or syringe.
Turn
the vial upside down and use backlighting to see what’s going on
inside the vial as the syringe is filled. Make sure the needle bevel is
below the surface of the T in the vial or you will be sucking air into your
syringe.
Fill the syringe slightly over
what will be used (and has been
prescribed). There will be a few air bubbles inside.
Carefully hold the vial with the inserted
syringe upside down with one hand and “flick” the syringe with your
finger to dislodge air
bubbles to rise towards the needle. Gently push the plunger and force all
air back
into vial. There may be a need to withdraw more solution back into the
syringe
to get the desired amount, if so, there will be more little bubbles and
it may be necessary to wait a second to let them converge. The place
where the
plunger’s black rubber contacts the syringe body is where to read the
mark for measurement.
There may be small, residual bubbles of air in the loaded syringe. This
small amount of air will be absorbed into the blood and not a major concern.
Also a small amount of air (about a tenth of an ml) can be useful when you
inject (more on this later). When finished, withdraw the needle out quickly at
the same angle it entered.
ALWAYS inspect the syringe for
foreign objects and never use if there is anything suspicious floating in the
solution after filling.
Hint:
watching doctors and nurses on TV can give you an idea of how to fill a syringe
and/or inject in a basic sense, but realize that they are actors, not medically
trained, and not necessarily doing it the proper way. Emergency reality
shows may be more helpful. Always ask your doctor about any injection
questions or concerns. An even better resource is nurses – since they
are the ones who are usually giving shots and do most patient teaching about
injection technique.
Recap the syringe, without
touching the needle to the cap edge, and return to wrapper tray. DO NOT attempt
to wipe off
any excess solution on the needle.
Carefully wipe the top of the vial (rubber stopper) off again with alcohol
and return the vial to its box, bottle or bag.
NEVER wipe or touch the needle
(even with alcohol). If the
uncapped syringe tip or needle touches any surface, discard and get a new
one. If the
syringe has already been filled and the needle gets contaminated, you can
unscrew the needle and replace
with a clean one. Work over
a clean, clear surface so that if you do drop anything, it doesn’t fall on the
floor. Again, a bad infection isn’t worth the cost of a syringe or needle.
In general when giving T
shots, the bigger the muscle, the better. There
are several sites on the body that are used for injection. Where you inject
depends on the amount and type of medicine. Two common places can accommodate up
to a full ml are the buttock and thigh, so they are the ones most often used by
transmen. The upper-outside quadrant of the buttock is standard and preferred
based on the depth of the muscle. Many transmen also use the
large quad muscle in the upper leg (thigh). The buttocks hurt a little
less, but they are harder to reach if you are giving yourself a shot. Some
transmen alternate all four sites. The arms (bicep or deltoid muscle) are also
used for some injections, but because they are smaller muscles, they cannot
accommodate as much volume. However, some transmen who use less than a half ml
sometimes could use their arms.
Make sure the needle is the
proper
size for the site: 1.5 inches is usual for buttocks because the fat is
thicker there; 1 inch for the leg. These injections are going
deep into muscle tissue, and you may have problems if the needle can’t
reach through the layer of fat.
For the buttocks, imagine each
individual buttock is divided into quarters, or imagine 4 circles touching each
other in a square pattern. The upper, outer quarter, or outer, upper circle
(towards your side, not your spine) is the “safe spot” to avoid other
important structures like nerves or large blood vessels.
Remember the idea is to inject into the thickest part of the muscle, so
feel around within the selected area for a thick place and avoid areas that feel
“shallow” or close to bone.
If injecting into the butt,
find a spot that is in the correct quadrant
and that is identifiable (notice moles, skin variations, bumps, etc that
will make it easy to relocate later) but avoid over-using any one site.
Feel for the thickest, “meatiest” part of the muscle.
Hint:
injecting into the same exact spot all the time can build up scar
tissue and make the site harder to inject into. Try for minor variations;
rotate to nearby spots on a regular basis but try to keep to thick,
muscular areas.
If standing and injecting into
buttock,
try to avoid putting weight on the on the injection leg. Put full body
weight on the alternate side and only use enough pressure on the injection leg
to steady your balance. This relaxes the muscle your injecting into, which makes
it hurt less.
If another is injecting you,
laying on your side, with the spot to be injected upward and outward on the edge
of the bed, is a comfortable alternative.
For the thigh, you want to
inject into the front of your thigh and into the outside half of
the leg. The part of your “inner thigh” that is more toward your groin has
several important nerves and blood vessels in it, so to avoid hitting these,
stay on the outer half of your thigh. You want to aim for about the midway part
between your hip and knee. Anywhere in the ‘middle third’ of your thigh is
ok (the lower third being toward your knee and the upper third being toward your
hip.)
Hint:
lightly rub the backside of your knee if you find that your muscles
are tense and hard, this tends to relax the large muscles in the leg. The
more relaxed the muscle, the less pain and resistance you will have injecting.
“Bunching” the muscle ensures it is relaxed and gives a thicker muscle to
inject into.
Hint:
the thigh works well for those with short arms and for those with bad backs (for
those who can’t reach
around to the butt). It’s also a lot easier to
see what you’re doing and you can use your dominant hand for either
side.
Grab
a cotton ball and wipe the area vigorously and thoroughly. Clean an
area at least 3 inches in diameter. When you clean, start from the center
and wipe in circles of increasing size. This makes sure you do not drag
‘dirt’ from the outside into the clean area in the middle.
Hint:
injecting after your shower makes the whole area even cleaner before you use the
alcohol swab.
If injecting into the leg,
deeply grab a large “bunch” of
muscle with the non-injecting hand. With the other hand, grab a cotton
ball and wipe the injection area vigorously and thoroughly.
(Again, outwardly increasing circles.) The bunching of the muscle ensures
that the muscle is relaxed fully and that you will be injecting into a deep
tissue mass, this is helpful and may reduce knots, but is not necessary. Clean
an area at least
3 inches in diameter. Even steady hands miss the target on occasion so
wipe the general area that you are aiming for. If you ‘forget’ where you
wiped, wipe it again. As far as cleaning the skin goes, too
clean is never a problem, not clean enough can be. Pick up the syringe by
the barrel. While still
holding your muscle, uncap the syringe while carefully holding onto the
barrel. (You can put the cap of the syringe into your mouth to pull it off as
long as you only touch the cap)
Hint:
It is better to let go of the muscle than drop the syringe-use good judgment and
caution in handling any syringe. If
this is too awkward, just uncap the needle first and take careful notice of
where you had chosen your spot.
Hint:
I currently use my upper leg and sit at my desk for injections. I rest my leg on
top of a file drawer to take tension off the leg muscles so it can be
completely relaxed. Propping up the leg is very helpful for full
relaxation, but make sure it is resting on a sturdy object.
Locate the area that you’ve
cleaned, and aim for the center. Avoid hairs,
moles, scars, etc as much as possible. You will want to put the needle in
perpendicular (straight in, not angled) to the skin. With
a steady and light punching movement, insert the full depth of the
needle into the relaxed muscle in one stroke. You generally can’t go in
too deep – especially if you have a lot of fat, but don’t stab too hard
either. Inserting
very slowly, “screwing it in” or with multiple, separate movements
makes it
hurt more and does more tissue damage (bruising, knots). Avoid
any side-to-side movement of the syringe once inserted.
Hint:
I seldom feel
any pain at all during most shots with a sharp, quick insertion.
Injecting into
a flexed muscle is painful, more difficult, and will cause a knot.
If
you do feel bad pain, take a deep breath and wait a second or
two. Often this will subside quickly. If it hurts really, really bad,
especially an ‘electric’ pain that you feel in more than just the spot where
you put the needle in, you
may have hit a nerve. If you feel this is the case, remove the needle;
apply a (dry, not alcohol soaked) cotton ball to
the site. Then you can start again in a very nearby area. This may be
tricky and you might need to use your Band-Aid for
the first attempt’s site and ready another.
Hint:
face it guys, sometimes injecting is going to hurt, but try to keep
the pain in perspective to how much you’ve suffered in the past
(compare
it to a broken bone, bad abrasion, sprain, surgery, etc) and realize it
will usually pass very quickly.
If you’re really nervous about injecting, practice on an apple or an
orange with a
syringe and play around with getting comfortable with it; poking it in,
proper angle, etc.
Hint:
I usually do my shot in the morning after a warm shower. The warm
water relaxes the muscles and the area is nice and clean. There also
might be less sensation from the shot as well if the nerves are not yet
fully “awake”, as what usually occurs earlier in the morning. There
may be less anxiety as well. Try
to relax. (But be awake enough to know what you’re doing and never
inject while intoxicated or otherwise impaired)
Once the needle is fully
inserted into the muscle, slightly pull back on
the plunger-about only .1 ml or less. This is called aspiration and
ensures that
you are not in a blood vessel. Normally,
if you are in a deep muscle,
you’ll see some tiny air bubbles and maybe a very small spot of blood.
If you are in
a blood vessel, there will be a lot of blood and no bubbles. If you do
hit a vessel
(don’t panic guys, it’s not that common) pull the needle out just a
tiny bit
and try to aspirate again. You will usually not need to re-insert the needle
to a new location.
Hint:
this sounds really serious and is scary for many guys. Relax a
little, but do it right. Some nurses that I’ve watched don’t even
bother to
aspirate at all because it’s so rare a problem, especially if you use the
right location.
Hint:
If you want to keep holding the bunch of muscle, you’ll have to do this with
one hand
if injecting into the leg. Pull outward on the plunger with the index finger of
the hand that is holding the syringe. It’s a bit awkward but gets easier with
time and practice.
Once you’re in and
aspirated, begin to slowly push down (or gently squeeze) the
plunger.
For a 1ml shot, count to at least 10 while you’re injecting (for .5ml
count to
5, etc). The solution is viscous (thick) and it often will be a little hard to
push through the needle. Carefully, give the plunger a final firm
squeeze to ensure all possible solution has been injected.
Hint:
If you left a tenth of an ml of air in the syringe when you drew the T into the
syringe you can use that air to push the remainder of the T into your muscle,
and to decrease bleeding and seepage of T out of the hole. In nursing, this is
called an ‘air lock’ and is a common technique to make shots bleed less.
When ready to remove the
needle, release the bunch of muscle you’ve been
holding the whole time (if using the leg).
Pull the needle out only half
way and wait a second or two. This allows the tissue inside to “close
up” on
itself and decreases bleeding and solution backflow.
Grab a (dry) cotton ball and you are ready to remove the needle.
Quickly pull the needle straight out and apply the cotton ball to the
site. Usually for me there is only a tiny spot of blood. Sometimes a
small vein will be broken or “passed through” while inserting the
needle.
This may cause some minor bleeding, but mixed with some solution
backflow, looks like a lot. Apply pressure with the cotton ball for a
minute and see if it has stopped. Don’t panic if a little blood runs
down your leg
and be prepared for this occasional instance to occur (have a towel under
your leg/site, or at least handy).
Hint:
bloodstains can be removed from the carpet or clothing with a cloth or cotton
ball soaked with hydrogen peroxide. It might also remove all other color as
well, be careful.
After
shots, while still applying pressure on the site with a
cotton ball or prep pad, rub the muscle in a deep and circular motion.
This breaks up
the “clump” of solution in the muscle and reduces knots and swelling.
Apply a Band-Aid or tape a
gauze pad over the site (optional) and dispose of the needle and syringe
properly.
Needles are a medical waste.
Syringes can be disposed of in the trash, but needles cannot be treated this
way. Breaking needles is a BAD
idea, and putting them in a Sharps container is sufficient. Different
municipalities have different laws governing needle disposal. Your pharmacist is
the best guide to the local laws. Your pharmacist can also usually provide you
with ‘Sharps Containers.’ These are rigid (usually plastic) disposal
receptacles that discourage removal of the needles once they have been
deposited. A Sharps container should be kept in a safe place in your home. Each
time you use a needle deposit it in the Sharps container. When it is full, you
can usually return it to your pharmacist and get a new one (often for a small
fee.)
If your pharmacist cannot help
you with this, contact your town’s municipal waste authority and they can
inform you of the local laws. There are also some mail order companies that will
provide you Sharps containers that you can ship back when full. Syringe bodies
can be recycled by some facilities, ask if not sure before
placing in your recycle bin.
If you are traveling, you can
either bring the Sharps home container with you, or inquire at your hotel as
they may have a hotel Sharps container you can use. (If you have friends who are
insulin dependent diabetics they can be an awesome resource for advice about
Sharps while traveling) If you transport your used needles home from vacation to
dispose of, make sure you do it in a puncture-proof container so the guy
handling your luggage doesn’t get stuck. When traveling with injection
supplies, make sure to have your vial with
name clearly marked as prescribed and doctor’s contact info.
If away from home, needles
should never be placed in the trash - small Sharps containers are cheap and
available for travel. Syringe
bodies can be thrown away. Be considerate in realizing that finding
syringes and injection supplies can be disturbing or frightening to
others, and fascinating for kids to want to play with. Be discrete, and
it’s always better to err on the side of caution.
If someone else is injecting
for you, it is generally advised that they
should not recap the needle after injection to avoid any contamination by
a needle
prick.
REMEMBER:
Always consult your doctor or nurse with any questions or concerns
surrounding injection. Excessive or uncontrolled bleeding, severe nerve pain or
loss of function after an injection should be handled by a medical
professional immediately.
Swelling, redness, and burning
at the injection site may indicate
infection or allergy. See your physician as soon as possible.
HIV and many other dangerous
diseases and infections can be spread by
blood contact. Always be
careful and considerate of other’s safety.
NEVER SHARE NEEDLES.
DISPOSABLE NEEDLES SHOULD NOT
BE REUSED.
Refer to local HIV/AIDS
organizations for more information on HIV and
STDs.
Never
attempt to self-prescribe hormone therapy. Prescription medications should only
be used under medical supervision. Testosterone is also a DEA controlled
substance, so in additional to the medical risks of undertaking unsupervised
hormone therapy, there are substantial legal risks associated with using it
without a prescription.
Initial
evaluation by a health provider should include a history and physical exam as
well as possibly blood tests or other tests to make sure that your hormone
therapy is done as safely as possible. Follow-up usually happens more frequently
in the first year of treatment, but after that, is generally every 6-12 months.
Blood tests often include a complete blood count (CBC), testing for high
cholesterol and diabetes or pre-diabetes, and sometimes tests of liver function.
Most importantly though, an ongoing relationship with a health practitioner can
provide you with individual health maintenance and screening that is dependent
whether you are cisgender (one-sided) or transgender.
Injecting medication is safe,
inexpensive, and convenient for many. Take
the time to do it right and beware of any medical concerns surrounding
your testosterone use. Know about the health risks associated with using
T and learn about possible side effects and drug interactions.
BE
RESPONSIBLE!
BE
SAFE!
Copyright © 2006
By Pat Magee
All Rights Reserved
Grateful acknowledgment for
contributions, advisement and help in editing this document goes to:
Elisabeth
S. Blair, ANP
Elizabeth Fuhrmann, RN, PhD
Nick Gorton, MD
Michael Hernandez
Grace Moore, RN, CS, FNP
…and all the guys who shared
their experiences and horror stories, as well as some really great tips.
OCTC has a limited license to disseminate and distribute the above until otherwise notified in writing, so long as it is provided free of charge.