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Care of The Transgender Patient The Role of The Gynecologist
Care of The Transgender Patient The Role of The Gynecologist
org
GENERAL GYNECOLOGY
Care of the transgender patient: the role of the gynecologist
Cécile A. Unger, MD, MPH
4. A strong desire to be of the other gender (or some alternative gender different from Hormone therapy
one’s assigned gender)
Many transgender patients choose to
5. A strong desire to be treated as the other gender (or some alternative gender initiate hormone therapy to help make
different from one’s assigned gender) their physical appearance concordant
6. A strong conviction that one has the typical feelings and reactions of the other with their gender identity. The diag-
gender (or some alternative gender different from one’s assigned gender) nostic phase must be complete prior to
initiating hormones and many patients
B. The condition is associated with clinically significant distress or impairment in social,
occupational, or other important areas of functioning, or with a significantly increased risk of also remain in therapy during this time
suffering, such as distress or disability period. Some patients choose to overlap
the real-life experience with hormone
Subtypes
therapy, which is encouraged. The main
With a disorder of sex development objectives of hormonal therapy are to
Without a disorder of sex development suppress the sex characteristics associ-
ated with the patient’s natal sex, and to
induce the characteristics of the desired
DSM, Diagnostic and Statistical Manual of Mental Disorders, fifth edition.
sex. Figure 3 describes the options for
Unger. Care of the transgender patient. Am J Obstet Gynecol 2014.
hormonal therapy for both male-to-
female and female-to-male patients and
Figure 4 outlines the standards for
severity of the gender dysphoria and to (at least 12 months) where the patient monitoring hormonal therapy once it is
determine if the patient will benefit lives full time as a person of the desired initiated. Guidelines for initiation and
from a variety of transition processes, sex.14 This experience is imperative for maintenance of hormonal therapy for
including sex reassignment surgery. individuals as they learn to interact in the transgender patients are outlined by the
Additionally, in this stage, patients are community as their desired sex, and Endocrine Society.15 The most impor-
assessed for psychiatric comorbidities helps them to affirm their decision to tant step in the initiation of hormonal
and treated accordingly. Because of move forward with hormonal therapy therapy is to ensure that patients do not
the stigma that is attached to gender and surgical reassignment if desired. have comorbid conditions that could be
nonconformity, prejudice and discrimi- As outlined by the 2011 WPATH exacerbated by hormonal treatments.
nation often ensues toward this popula- standards of care,14 the above-mentioned Per the society’s guidelines, estrogen
tion, which can result in a phenomenon initial management strategies are im- therapy should be used with caution,
termed “minority stress.”1 This type of portant for patients before they proceed if used at all, in male-to-female pa-
social impact and stress can lead in- with further treatment. The most basic tients with history of thromboembolic
dividuals to experience debilitating stress requirement is that patients undergo disease, prolactinoma, significant liver
and anxiety, and therefore, psychiatric assessment by a mental health pro- disease, breast cancer, coronary artery
therapy is sometimes necessary to treat fessional, and have well-documented disease, and migraine headaches with
any comorbid psychiatric conditions gender dysphoria. To proceed with hor- aura. Similarly, female-to-male patients
such as depression, anxiety, and post- monal therapy, a referral from a mental are at risk for exacerbation of breast or
traumatic stress disorder. During this health provider is important and at endometrial cancer and significant liver
diagnostic phase, patients are encouraged least 3 months of the real-life experi- disease while on testosterone therapy.
to participate in the real-life test, which ence is recommended.15 Most surgical In male-to-female patients, androgen
involves an extended period of time procedures require this referral as well, effects are suppressed with progestational
profession.”30 Providers who are knowl- Additional measures can also be taken consider when screening these patients.
edgeable about particular transgender in the office space to make patients more First, while the preoperative male-to-
health issues and sensitive to the needs comfortable with their surroundings. female transsexual can be evaluated by a
of these patients will establish trusting The importance of these measures standard annual rectal examination after
relationships with their patients, which should be instilled in the entire office age 50 years, a postoperative patient
is imperative for providing good medi- staff and cultural competency should be who has had a neovagina created between
cal care. The dynamics of a health care emphasized and taught on a regular ba- the rectum and the prostate may require
relationship can be very challenging, sis. Such measures include making a transvaginal palpation for adequate as-
especially when the patient group is a unisex bathroom available for trans- sessment. Second, prostate-specific anti-
complex one such as the transgender gender patients,31 using a transgender gen (PSA) is sometimes used for prostate
population. There are, however, prac- individual’s preferred name and appro- cancer screening; however, in the setting
tice habits that can be put into effect priate pronouns as often as possible, and of prolonged estrogen exposure, PSA
that might improve patient access to ensuring that all medical forms and levels can be falsely low.33 PSA is there-
health care. The most important thing materials are transgender-inclusive.30 fore not an appropriate test for prostate
that a provider can do is recognize that cancer screening in these patients.
their personal belief system is mutually Health care maintenance The risk of breast cancer is an
exclusive from the medical relationship Because of the challenges associated with important consideration in both male-
that is established with any patient.31 this highly stigmatized community, there to-female and female-to-male trans-
If providers are not comfortable caring is a lack of data on the actual population sexuals. Transwomen sustain long-term
for patients who are transgender, a size of transgender individuals as well as exposure to estrogen. Although there
referral list of physicians who provide outcomes after hormonal and surgical has been no conclusive evidence that the
routine medical care for this commu- therapy. There have been some cases of risk of breast carcinoma is greater in
nity should be easily available to all breast and prostate cancer reported,16 these patients compared to the general
patients. however in a large series of 2200 pa- population, risk factors such as longer
Identifying risk factors and screening tients from 1975 through 2005, no cases duration of feminizing hormonal ther-
for them is also an important part of the of breast cancer were observed.32 No apy, family history of breast cancer, and
medical care for these patients. While follow-up studies have followed up obesity should raise concern for pro-
transgender individuals carry the same patients beyond the age of 65 years; viders. There are good data, however,
risk factors as the general population for therefore, we cannot determine the demonstrating the increased risk of
most diseases, it is important to recog- actual risk of hormonal therapy on breast cancer in postmenopausal women
nize that these patients may be very patients beyond this age. Because there exposed to both estrogens and pro-
sensitive to screening questions that ask is such a paucity of data, there are no gestins.34 Therefore, patients who un-
about sexual behaviors and activities. To published transgender-specific guide- dergo orchiectomy should be taken off
strengthen the physician-patient rela- lines based on level-1 evidence for the of progesterone soon after surgery, and
tionship and establish trust, providers routine health maintenance of these if therapy is continued, they should
should explain to patients that their patients. However, preventative health be screened earlier for breast cancer.
screening questions are routine and that strategies can be extrapolated based on Otherwise, it is reasonable to screen
they are posed to all patients regardless evidence that has been determined to patients according to standard guide-
of sexual preferences or identity. Addi- be accurate for the general population. lines, which include annual or biennial
tionally, using gender-neutral terminol- Figures 6 and 7 list the recommended mammograms starting at age 40 years
ogy such as “partner” or “significant screening guidelines for male-to-female and then annually after age 50 years.
other” and asking broad questions such and female-to-male transsexual pa- Many of these patients have had breast
as “Do you have sex with men, women, tients. Before applying these guidelines augmentation, and while routine mam-
or both?” allows patients to assume to patients, one must first keep in mind mograms are appropriate for screening,
that the provider is both comfortable the patient’s natal sex and then take into providers should acknowledge that in
caring for patients who are lesbian, gay, account the patient’s hormonal and the setting of inadequate screening,
bisexual, or transgender and knowl- surgical status. magnetic resonance imaging studies are
edgeable about this patient group and For instance, prostate cancer screening recommended. Most female-to-male
their health care needs.31 It is important is important in male-to-female patients. patients undergo mastectomy with or
to avoid making assumptions about The prostate becomes atrophic in the without chest-contouring surgery. After
sexual orientation based on an in- setting of androgen suppression, how- this type of surgery, breast tissue
dividual’s gender identity as there is ever the risk of cancer remains. For this still remains and routine screening
significant diversity in sexual preference reason, the Endocrine Society recom- should be applied to these patients as
and behaviors among the transgender mends the same screening guidelines for well, especially if mastectomy only was
community. Gender identity does not prostate disease recommended for natal done.15 This is because a portion
define one’s sexual orientation. men. There are 2 important factors to of administered testosterone can be
ently than in natal women. Prolonged Beginning at age 20, screen routinely for lipid disorders.
testosterone exposure can lead to an Diabetes mellitus
increase in endogenous estrogen levels, General population: Beginning at age 45, screen every 3 years for diabetes; if symptoms present or
which can increase the risk of endome- blood pressure persistently ≥135/80, screen earlier (B).
trial hyperplasia and carcinoma24; there- Transgender population: Screen annually regardless of age
fore, bleeding in these patients should Osteoporosis
not be overlooked. As is the case for General population:
natal women, there is no recommended Begin screening women every 10 years after age 65 or in younger women whose fracture risk
screening for endometrial cancer in is elevated (B)
Initiate vitamin D and calcium supplementation after menopause
asymptomatic transmen. Patients who
still have their ovaries are at risk for Transgender population:
ovarian cancer. While there was concern Begin screening transgender women every 10 years after age 65 or in younger women whose
that exposure to testosterone would fracture risk is elevated or if patients have stopped hormone therapy
Screen transgender men 10 years after initiation of testosterone therapy and then every 10
increase the risk of ovarian carcinoma years thereafter
in female-to-male patients, there is no All patients who have undergone gonadectomy should be started on vitamin D and calcium
evidence to support this.16 Therefore, supplementation regardless of age, this is especially important for transgender men on
testosterone therapy
these patients are considered to be at
Additional screening, transgender population:
similar risk as the general population,
Hepatic function: Screen patients annually for liver function abnormalities
and no screening guidelines currently
exist. Patients who have undergone Prolactinoma: Measure serum prolactin levels at baseline, at 12 months following initiation of
treatment, and biennially thereafter
total hysterectomy with a history of
cervical dysplasia should also have
vaginal cuff screening according to the
Adapted from the U.S. Preventive Task Force (USPTF), American Diabetes Association, Endocrine Society.
ASCCP guidelines. *Grade levels for USPTF recommendations are in parentheses.
Metabolic diseases also need to be
considered in transpatients. Androgen
suppression and estrogen substitution
in male-to-female patients can lead to because of its ability to maintain physi- estrogen therapy has a protective or
increases in visceral fat, which is associ- ologic serum levels of estradiol. Patients detrimental effect in male-to-female pa-
ated with increases in triglyceride levels, should be screened annually for ele- tients.36 Based on this information, the
insulin resistance, hepatic dysfunction, vated blood pressure, with the following recommendation is to monitor lipids
and elevated blood pressure.15 While target goals: systolic blood pressure routinely. Recommendations for the
these metabolic changes can increase 135 mm Hg and diastolic blood general population include screening
morbidity in these patients, a study with pressure 80 mm Hg. Per the US Pre- men aged 35 years and women aged
a median follow-up period of 18 years ventative Services Task Force guidelines, 45 years for lipid disorders (grade A).
reported no increase in risk of death if blood pressure remains persistently For patients who have been exposed to
from cardiovascular causes in this pa- elevated beyond these parameters, anti- prolonged use of testosterone or estro-
tient population.35 Recommendations hypertensive therapy should be initiated. gen, grade-B recommendations should
include using the lowest doses of estro- Testosterone therapy in female-to- be employed, which include screening
gen available as outlined in Figure 2, male patients can lower high-density for all patients aged 20 years. Target
with the transdermal route as one of lipoprotein cholesterol and elevate tri- goals for low-density lipoprotein levels
the preferred modes of administration glyceride levels, but it is unclear if should be 135 mg/dL. Transsexual
REFERENCES 15. Hembree WC, Cohen-Kettenis P, Delemarre- 31. Coren JS, Coren CM, Pagliaro SN, et al.
van de Waal HA, et al. Endocrine treatment Assessing your office for care of lesbian, gay,
1. Myer W, Bockting W, Cohen-Kettenis P, et al.
of transsexual persons: an Endocrine Society bisexual, and transgender patients. Health Care
Harry Benjamin International Gender Dysphoria
clinical practice guideline. J Clin Endocrinol Manag 2011;30:66-70.
Association’s standards of care for gender
Metab 2009;94:3132-54. 32. Gooren LJ, Giltay EJ, Bunck MC. Long-term
identity disorders, 2001, version 6. Available at:
http://www.wpath.org/Documents2/socv6.pdf. 16. van Kesteren PJ, Asscheman H, treatment of transsexuals with cross-sex hor-
Megens JA, et al. Mortality and morbidity in mones: extensive personal experience. J Clin
Accessed Jan. 21, 2013.
transsexual subjects treated with cross-sex Endocrinol Metab 2008;93:19-24.
2. Sanchez NF, Sanchez JP, Danoff A. Health
care utilization, barriers to care, and hormone hormones. Clin Endocrinol 1997;47:337-42. 33. Epstein JI. PSA and PAP as immunohisto-
usage among male-to-female transgender per- 17. Toorians AWFT, Thomassen MC, chemical markers in prostate cancer. Urol Clin
sons in New York City. Am J Public Health Zweegman S, et al. Venous thrombosis and North Am 1993;20:757-70.
2009;99:713-9. changes of hemostatic variables during cross- 34. Anderson GL, Limacher M, Assaf AR, et al.
3. Cohen-Kettenis PT, Pfafflin F. The DSM sex hormone treatment in transsexual people. Effects of conjugated equine estrogen in post-
diagnostic criteria for gender identity disorder in J Clin Endocrinol Metab 2003;88:5723-72. menopausal women with hysterectomy: the
adolescents and adults. Arch Sex Behav 18. Bolona ER, Uraga MV, Haddad RM, et al. women’s health initiative randomized controlled
2010;39:499-513. Testosterone use in men with sexual dysfunc- trial. JAMA 2004;291:1701-12.
4. Selvaggi G, Ceulemans P, De Cuypere G, tion: a systematic review and meta-analysis of 35. Asscheman H, Giltay EJ, Megens JA, et al.
et al. Gender identity disorder: general overview randomized placebo-controlled trials. Mayo Clin A long-term follow-up study of mortality in
and surgical treatment for vaginoplasty in male- Proc 2007;82:20-8. transsexuals receiving treatment with cross-sex
to-female transsexuals. Plast Reconstr Surg 19. Moore E, Wisniewski A, Dobs A. Endocrine hormones. Eur J Endocrinol 2011;164:635-42.
2005;116:135-45e. treatment of transsexual people: a review of 36. Elamin MB, Garcia MZ, Murad MH, et al.
5. American Psychiatric Association. Diagnostic treatment regimens, outcomes and adverse Effect of sex steroid use on cardiovascular risk
and statistical manual of mental disorders, effects. J Clin Endocrinol Metab 2003;88: in transsexual individuals: a systematic review
3rd ed. Washington, DC: 1980. 3467-73. and meta-analysis. Clin Endocrinol 2009;72:
6. Fisk NM. Gender dysphoria syndrome 20. Xavier JM, Simmons R. The Washington 1-10.
(the how, what and why of a disease). In: transgender needs assessment survey, 2000. 37. Centers for Disease Control and Prevention:
Laub DR, Gandy PP, eds. Proceedings of the Available at: http://www.glaa.org/archive/2000/ National Center for HIV/AIDS, Viral Hepatitis,
second interdisciplinary symposium on gender tgneedsassessment1112.shtml. Accessed Feb. STD, and TB Prevention, Division of HIV/AIDS
dysphoria syndrome. Stanford, CA: Division of 3, 2013. Prevention. HIV among transgendered people,
Reconstructive and Rehabilitation Surgery, 21. Gooren L. Hormone treatment of the adult 2011. Available at: http://www.cdc.gov/HIV.
Stanford University Medical Center; 1973. transsexual patient. Horm Res 2005;64:31-6. Accessed Feb. 7, 2013.
7. American Psychiatric Association. Diagnostic 22. Perovic S, Djinovic R. Genitoplasty in male- 38. Operario D, Soma T, Underhill K. Sex work
and statistical manual of mental disorders, to-female transsexuals. Curr Opin Urol 2009; and HIV status among transgender women:
5th ed. Washington, DC: 2013. 19:571-6. systematic review and meta-analysis. J Acquir
8. Murad MH, Elamin MB, Garcia MZ, et al. 23. Hage JJ, Karim RB. Abdominoplastic sec- Immune Defic Syndr 2008;48:97-103.
Hormonal therapy and sex reassignment: a ondary full-thickness skin graft vaginoplasty for 39. Reisner SL, Mimiaga MJ, Bland S, et al. HIV
systematic review and meta-analysis of quality of male-to-female transsexuals. Plast Reconstr risk and social networks among male-to-female
life and psychosocial outcomes. Clin Endocrinol Surg 1998;101:1512-7. transgender sex workers in Boston, Massa-
(Oxf) 2010;72:214-31. 24. Futterweit W. Endocrine therapy for trans- chusetts. J Assoc Nurses AIDS Care 2009;20:
9. van Kesteren PJ, Gooren LJ, Megens JA. sexualism and potential complications of long- 373-86.
An epidemiological and demographic study term treatment. Arch Sex Behav 1998;27:209-26. 40. Healthy People 2020. 2020 Topics and
of transsexuals in The Netherlands. Arch Sex 25. Goddard JC, Vickery RM, Qureshi A, et al. objectives: lesbian, gay, bisexual, transgender
Behav 1996;25:589-600. Feminizing genitoplasty in adult transsexuals: health. Available at: http://healthypeople.
10. Vujovic S, Popovic S, Sbutega-Milosevic G, early and long-term surgical results. BJU Int gov/2020/topicsobjectives2020/overview.aspx?
et al. Transsexualism in Serbia: a twenty-year 2007;100:607-13. topicId¼25. Accessed Feb. 3, 2013.
follow-up study. J Sex Med 2009;6:1018-23. 26. Dangle PP, Harrison SCW. Stress urinary 41. Schaffer J, Fabricant C, Carr B. Vaginal vault
11. Michel A, Mormont C, Legros JJ. incontinence after male to female gender reas- prolapse after surgical and nonsurgical treat-
A psychoendocrinological overview of trans- signment surgery: successful use of pubo- ment of mullerian agenesis. Obstet Gynecol
sexualism. Eur J Endocrinol 2001;145:365-71. vaginal sling. Indian J Urol 2007;23:311-3. 2002;99:947-9.
12. Savic I, Garcia-Falgueras A, Swaab DF. 27. Lawrence AA. Factors associated with 42. De Sutter P. Reproductive options for
Sexual differentiation of the human brain in satisfaction or regret following male-to-female transpeople: recommendations for revision of
relation to gender identity and sexual orientation. sex reassignment surgery. Arch Sex Behav the WPATH’s standards of care. Int J Trans
Prog Brain Res 2010;186:41-62. 2003;32:299-315. 2009;11:183-5.
13. Zhou JN, Hofman MA, Gooren LJ. A sex 28. Feldman J, Bockting W. Transgender 43. Payer AF, Meyer WJ III, Walker PA. The ultra-
difference in the human brain and its relation to health. Minn Med 2003;86:25-32. structural response of human Leydig cells to
transsexuality. Nature 1995;378:68-70. 29. US Census Bureau. Income, poverty, and exogenous estrogens. Andrologia 1979;11:423-6.
14. Coleman E, Adler R, Bockting W, et al. Harry health insurance coverage in the United States 44. More SD. The pregnant manean oxymoron?
Benjamin International Gender Dysphoria As- (2010). Available at: http://www.census.gov/ J Clin Endocrinol Metab 1998;7:319-28.
sociation’s standards of care for gender identity prod/2011pubs/p60-239.pdf. Accessed Feb. 45. Hunter MH, Sterrett JJ. Polycystic ovary
disorders, 2011, version 7. Available at: http:// 3, 2013. syndrome: it’s not just infertility. Am Fam Phys
www.wpath.org/documents/Standards%20of 30. Robinson A. The transgender patient and 2000;62:1079-95.
%20Care%20V7%20-%202011%20WPATH. your practice: what physicians and staff need to 46. Spack SP. Management of transgenderism.
pdf. Accessed Jan. 21, 2013. know. J Med Pract Manage 2010;25:364-7. JAMA 2013;309:478-84.