Canada’s Testosterone Shortages

There’s been lots of hub-bub about the recent testosterone shortage in Canada, with many people expressing surprise that this could happen. When I was considering testosterone therapy and weighing my options, one thing I felt sure of was that because testosterone is a common medication for men — not a “transsexual drug” — I wouldn’t be subjected to shortages. This was naive. In the 3 years and 9 months of being on testosterone, I’ve experienced not one testosterone shortage, but four. Testosterone shortages seem to be quite common here in Canada.

I started on Testosterone Cypionate, which in Canada is branded as Depo-Testosterone (aka Depo) and made by Pfizer. In December 2008, there was a Depo shortage and my pharmacist substituted Testosterone Enanthate, aka Delatestryl, then made by Theramed. (Aside from custom compounds, Depo and Delatestryl are the only injectable testosterone preparations available in Canada.* We don’t have Sustanon, Reandron, Omnadren, Nebido et al.)

I wrote about the differences between Testosterone Cypionate and Enanthate here. Chemically speaking, they’re practically the same, with the main difference being the concentration of testosterone offered by each brand:

• Depo-Testosterone (cypionate): 100 mg / ml
• Delatestryl (enanthate): 200 mg / ml

The only payload of this is that when I’m using Depo, I have to inject twice the volume. Initially, a 2cc shot looked a little intimidating, but it’s really of no issue.

In August 2010, I picked up my Delatestryl at the pharmacy and… Surprise! The price had doubled. Nevertheless, I stayed on Delatestryl (for the smaller injections) and then in the summer of 2011, there was a shortage. My pharmacist had no information about this, so out of curiosity I called Theramed myself. They were less than helpful. I spoke with my dollars and switched back to Pfizer’s Depo-T rather than wait for Delatestryl to return to market, and was pleased to find out that Depo had actually had come down in price by a whopping $3. Win!

Fast forward just a few months and I started hearing about another Delatestryl shortage rearing its head at pharmacies across Canada in late November and December, 2011. That story got a bit bigger when Benjamin posted this video. I commented on it, offering up the straightforward solution: get your doctor to switch your prescription to Depo. Hassle over, plus pay half as much. However, by the time reporter Katie Toth picked up on Benjamin’s story and was quoting officials from Toronto’s  Sherbourne Health Centre advising trans men that “they can be switched to a different compound,” I’d found out while trying to get my prescription filled that there was now also a shortage of Depo. We weren’t just talking about a shortage of T, this was now a full outage.

Aside from the misinformation about access to Depo in Toth’s articles that appeared on Xtra.ca and Rabble.ca, I think Toth missed some other important points:

The articles failed to mention the without-warning price increase of Delatestryl.  (The Xtra article also has incorrect information about Delatestryl pricing… I don’t know anyone who goes through a vial of Delatestryl in a month.)

I spoke to my doctor about the testosterone shortage outage, and he said that he believes many drug shortages are “orchestrated” to drive up demand and prices. This leads me to wonder… Will Pfizer increase the price of Depo soon? My sister, who’s a doctor, mentioned that fertility drugs have recently gone up in cost as well. I don’t know much about the hormone protocols for trans women, and wonder if this has impacted Canadian trans women at all? Big Pharma knows hormones are Big Business. Is there some kind of legislation in place in Canada that prevents Valeant, Pfizer and friends from setting pricing to their whims?

Also, I think it’s important to note that testosterone shortages affect all men using therapeutic T, not just trans men. Here in my small community of about 1000, I’m the only trans man but I know there are several other men on T. I imagine being off it would affect us differently, but I don’t want to compare who has it worse. Suffice it to say that without our prescribed medication, we probably all feel off.

Testosterone Shortages Are More Common Than You Think

You’re less likely to feel the effects of a shortage if you live in an urban center. My pharmacist told me that as a controlled substance, a drug that not a huge number of people are on, and one that’s dispensed in amounts that last for several months, testosterone isn’t heavily stocked in pharmacies. This is especially true in small towns. Pharmacies rely on their distributor to have stock. When your pharmacy, their distributor and the manufacturer are all out of stock, that’s when YOU will experience a shortage.

This time around, my timing was off. I ran out of T on December 4. I got a smaller dose than normal and I haven’t been able to buy more since. I’ve now missed two shots, it will be three as of this Wednesday. (I inject every 2 weeks.) Word on the street is that Delatestryl may be back on the shelves this week, and I’ve heard mumblings that Depo is back in stock already, so I’ll check with my pharmacist.

What To Do When There’s a Testosterone Shortage

The best way to ward off the effects of a shortage is to not let yourself run out of T to begin with. It seems like an obvious and wise plan indeed to always keep a backup vial around. Given that I only go through four vials of T a year, keeping one spare around won’t raise any red flags with my doctor. The obstacle for me is that I don’t have convenient and regular access to a pharmacy. I live an hour from any pharmacy, and I combine chores into a single “town day” every couple of weeks. I can’t just pop in and pick up my T like I could if I lived in the city. It’s really just a matter of advance planning though.

Here are some of the suggestions that I’ve seen bandied around for averting this most recent Delatestryl shortage:

1. Switch to Depo. Normally this would be the ticket but the concurrent Depo shortage made this a moot point.
2. Get injectable T compounded. Only certain compounding pharmacies can do this, they need the right facilities (namely, a sterile hood.) This is probably a pretty good option if you have access to such a pharmacy and if you’re willing to spend a bit more.
3. Check with your local trans health clinic. If you have access to such a clinic, you may find that they keep their own stock of T on hand and can give you a shot. For example, Linc from TranArchy informed me that the Three Bridges Community Health Centre in Vancouver will do this (provided you have an existing Rx.)
4. Switch to Androgel. My understanding is that many trans men are not satisfied with the effects of T gel, but this could be a good stop gap solution provided getting a new Rx from your doctor isn’t a big hassle and you’re OK with the higher expense of gel.
5. Cross the border. Legally speaking, you can import testosterone into Canada as long as you have a valid prescription and physically carry it across the border. However, I don’t see this as a valid option given the expense of time and money.
6. Get T from a friend. I wouldn’t do this for legal reasons and because I think it could damage the trust that my doctor has in me.
7. Underground labs.This is a dumb idea, don’t do it. Not only is it illegal, and something your doctor would seriously frown upon, you’re likely to get something that’s cut or something that’s not T at all.  See:  Don’t Be Silly: A Public Service Announcement on HRT.
8. Patience.

I opted for the latter, patience. I’ve looked at this outage as a cleanse of sorts. Granted, I feel I have the luxury of this choice because I have a few years of T in me and I’ve had a hysterectomy. Were I earlier in transition, or pre-hysto, these shortages would cause me significant anxiety.

What It’s Like Being Off Testosterone

It’s been almost 6 weeks since my last (short) shot of T. I’m thoroughly surprised that my energy levels and mood seem unchanged. I haven’t been without symptoms of hormonal flux though:

Within a week of being late for a shot, my dick shriveled to about half its size. It doesn’t get hard and I have zero sex drive. I’m confident that this will all return to normal once I’m back on the juice but it’s another nail in the coffin for metoidioplasty for me. (More on this in another post.)

Hot flashes, oh my! They’ve consistently increased to the point where I’m having several an hour. I’m constantly taking off my shirt, or putting it back on.  In retrospect, I think I was having (much less frequent) hot flashes prior to running out of T and this makes me wonder if my dosage is correct.

I’m having more headaches, and I think it’s hormonal, but I can’t really be certain.

It’s been over a year since I’ve had blood work done so I plan on arranging that once I’ve been back on T for 8 weeks or so. As I mentioned earlier, I’m going through exactly four vials of T a year (a total expense of $625.79 since April 2008.) For most of 2011, I was on a reduced dose between 160-180 mg by choice, but given the incidence of hot flashes that I was having even before this recent shortage, I’m considering going back to 190 or 200mg. I like the idea of injecting as little as I can get away with, but without sacrificing health or well-being.

In the end, testosterone shortages are a problem for Canadian trans men, but luckily full outages aren’t that common. While I certainly prefer having an uninterrupted supply of my medication, it’s good to know how my body responds without testosterone and that I don’t fall into low energy and bad moods without it.

UPDATE, 01/16/12 – Related Links:

• Current Drug Shortages + Bulletin – Shows T. Cypionate returning to the US in early Feb 2012
• Worldwide testosterone shortage??? – Forum thread about recent Sustanon and Primoteston shortages

UPDATE, 01/18/12:

My local pharmacies still can’t get any injectable testosterone in for me. My headaches and hot flashes are increasing in frequency and intensity, and I’m feeling pretty weak (my workout this morning was lame.) I guess my limit for being off T is about 4 weeks. I considered calling the doctor and requesting a prescription for Androgel, but I just got a hold of a pharmacy in the next town over who happen to have a single 10ml vial of Sandoz-made Cypionate. YES!

* I’m a bit surprised by this because I didn’t know we could get Sandoz brand T in Canada. The pharmacist noted that Sandoz is also out of stock so she can’t order more if it. She put my name on the bottle, my doc’s calling my prescription in tonight, and I can pick it up on Friday. Just a couple more uncomfortable days…