British Journal of Anaesthesia, xxx (xxx): xxx (xxxx)

doi: 10.1016/j.bja.2020.01.024
Advance Access Publication Date: xxx
Review Article

REVIEW ARTICLE

Perioperative considerations for transgender women undergoing

routine surgery: a narrative review
Yasmin Lennie1,*, Keitebe Leareng2 and Lis Evered1
1
St Vincent’s Hospital, Melbourne, Australia and 2Launceston General Hospital, Launceston, Australia

*Corresponding author. E-mail: dryasminlennie@gmail.com

Summary
A transgender woman is a person assigned male sex at birth who identifies as a woman. With the numbers of trans-
gender identity on the rise, encountering a transgender woman requiring routine surgery is becoming more common in
anaesthetic practice. The perioperative period can be challenging for transgender women, but these challenges can be
mitigated by a skilled and sensitive perioperative team. Engagement with patients and their primary physicians is
important. Whilst there are anaesthetic issues relevant to both transgender women and men, there are many issues
unique to transgender women. This article focuses only on considerations for the perioperative care of the transgender
woman. This narrative review provides an overview of the factors influencing the safe care of the transgender woman
presenting for routine surgery, including the potential social and pharmacological factors to consider, and anatomical
changes to be aware of from previous gender confirming or feminisation surgeries that can influence clinical decision-
making.

Keywords: gender identity; perioperative period; sex reassignment surgery; transgender persons; transsexualism

A transgender person identifies as a gender that differs from
the sex they were assigned at birth.1 A transgender woman is a
person assigned male sex at birth who identifies as a woman.
Being transgender may be associated with gender dysphoria, a
psychological illness defined by the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition as ‘a difference between
one’s experienced or expressed gender and their assigned
gender, causing significant distress or problems functioning’.2
There are various measures one may take to align themselves
physically and mentally with that of their gender identity, all of
which may impact on care before, during, and after anaes-
thesia. This includes specific concerns, such as the potential
difficult airway, pharmacological interactions, challenges in
predicting perioperative risk, and the need for sensitive pre-
operative assessment and perioperative care. (Table 1)
Relevance
Whilst the authors’ interests in this topic have arisen from
experiences in Australia, similar trends in transgender
population growth and management are seen worldwide;
therefore, many of the aspects pertaining to the perioperative
care of the transgender woman mentioned in this article will
be applicable worldwide.
In the USA, it is estimated nearly 1 million people identify as
transgender.1 Census data3 suggest that the true number of
transgender persons in Australia is largely unknown, and likely
under-reported, but recent estimates show approximately 35%
of transgender persons in Australia identify as a transgender
woman.4 Similarly, the Office for National Statistics in the UK is
unable to ascertain accurate population data, but is considering
options for producing gender identity population estimates in
the 2021 census. The 2017 National LGBT Survey in the UK
found that, of the 108 100 valid responses, 13% were trans-
gender of which 3.5% were transgender women.5
Worldwide, an increasing number of medical institutions
now offer gender health services to manage the medical needs
of the transgender patient. Recent studies show rapid increases
in referrals to these services, both in Australia and abroad, with
an increasing rate of medical gender transition.4,6e8

Received: 01 November 2019; Accepted: 27 January 2020

© 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
For Permissions, please email: permissions@elsevier.com

1
 2 - Lennie et al.

Table 1 Key considerations for perioperative care of transgender women. PONV, postoperative nausea and vomiting; VTE, venous
thromboembolism.

Hormone therapy
 In the perioperative period, the physiological and psychological effects of both continuing and discontinuing these medications
need to be carefully considered, and a discussion with the patient and their managing endocrinologist is advised, particularly
when major surgery is planned.
 There are no clearly established guidelines on the management of female hormone therapy in the perioperative period.
 VTE and PONV prophylaxis, and biochemical and neuromuscular monitoring should be considered where appropriate.
Gender confirmation surgery
 Urology input may be required in certain circumstances.
 Care must be taken to maintain patient privacy in the perioperative environment.
Airway
 Careful history taking, examination, and consideration of nasendoscopy pre-induction in those that have had vocal feminisation
surgery may be warranted, as intubation may prove difficult because of surgical narrowing of the glottis.
 Any recent airway surgery may still be healing, and airway instrumentation may lead to trauma.
 Front-of-neck access for cricothyroid puncture or emergency cricothyroidotomy may prove more difficult or impossible secondary
to scarring or loss of the cricothyroid membranous space.
 Equipment useful in the management of a difficult airway should be readily available.
Other
 Because of the significant stigma faced by the transgender patient, care should be taken to minimise anxiety and unwanted
attention or discomfort during the perioperative visit.
 Patient wishes for preferred name and pronouns should be respected.
 The transgender population has higher rates of communicable disease and substance abuse. Care must be taken to minimise risk
to both patient and staff.
 There are limited data available in the transgender female population that allow accurate interpretation of common laboratory
values, perioperative risk assessment tools, and drug dosing calculations or algorithms commonly utilised in anaesthesia. Extra
precautions should be taken and additional monitoring implemented where possible.

Given the rapid increase in those seeking gender realign-
ment, encountering a transgender woman requiring routine
surgery is likely to become more common in anaesthetic
practice. The safe perioperative management of these patients
may pose a potential knowledge gap for many anaesthetists,
with no curriculum objectives specifically focused on the
transgender woman in the current Australian and New Zea-
land College of Anaesthetists or Royal College of Anaesthetists
curriculum, and with few local guidelines and resources
existing related to the perioperative care of this emerging
population.9,10 A 2016 report published by the UK House of
Commons Women and Equalities Committee highlighted the
lack of awareness and knowledge in treating transgender pa-
tients amongst doctors in the UK.11 The General Medical
Council produced guidelines in response to this. Similar
guidelines have also been produced in Australia. However,
specific issues relating to perioperative care were not specif-
ically addressed.12,13
Whilst there are anaesthetic issues relevant to both trans-
gender women and men, there are many issues unique to
transgender women that we believe should be highlighted and
discussed in further detail than what is covered in the current
anaesthetic literature; therefore, this article focuses in greater
detail only on considerations for the perioperative care of the
transgender woman and does not cover the issues unique to
transgender men. Broader aspects pertaining to the perioper-
ative care of all transgender patients, including important
discussion on terminology and further discussion of psycho-
social considerations, have been covered in recent review ar-
ticles by Shah and colleagues14 and Tollinche and colleagues15
therefore have not been covered in detail in this article.
The perioperative period can be challenging for trans-
gender women, but these challenges can be mitigated by a
skilled and sensitive perioperative team. Engagement with
patients and their primary physicians is important. This
article aims to outline some of the common therapies utilised
by transgender women, and the potential perioperative con-
siderations for routine surgery, with emphasis on those who
have undergone prior gender confirmation and feminisation
procedures.
Gender realignment
It is important to note that transgender women may utilise
none, some, or all of the following therapies; therefore, careful
and respectful history taking before operation is required.16
Hormone therapy
Commonly utilised hormone therapies by transgender women
are either oral or transdermal Oestradiol with or without an
anti-androgen, such as cyproterone acetate, spironolactone,
or bicalutamide. Oestrogens are potent stimulants of the
hypothalamicepituitaryeadrenal axis, so their physiological
effects must be taken into consideration.17 Feminising treat-
ment with oestrogens and anti-androgens can produce
desired physical changes, such as breast growth, decreased
facial and body hair, and fat redistribution to a more female
shape.18 Anti-androgen therapy is not required if orchidopexy
has occurred.13 The potential effects of each of these to
consider in a preoperative clinical assessment are summar-
ised as follows.
Oestrogen therapy
Oestradiol can be administered topically, transdermally, or
orally. A consideration for the anaesthetist, as with any
transdermal patch remaining in situ during the operative
period, is awareness of the placement in relation to any
warming device that may be utilised, as heating may lead to
increased drug uptake.19

A transgender woman is typically on a considerably higher
dose of oestrogen when compared with postmenopausal
women on ‘low-dose’ hormone replacement therapy.4,13,20e22
Data from postmenopausal women on hormone replace-
ment therapy have demonstrated the metabolic effects of oral
preparations on the liver. Oral administration can cause
increased hepatic production of several products. These
include corticosteroid-binding globulin, sex-hormone-binding
globulin, triglycerides, and high-density lipoprotein (HDL
cholesterol).23,24 Few studies specific to transgender women
are available, often with conflicting results. There may, how-
ever, be a beneficial effect on lipid profile in the transgender
female when compared with men, although this is attenuated
by increased weight, blood pressure, and markers of insulin
resistance. The quality of data available looking at the overall
safety profile in transgender women is low and further
research is needed.24e30 Potential effects relevant to the
anaesthetist are summarised as follows:
(i) Cardiovascular: clotting may be affected, as oestrogen can
cause a decrease in Factor VII, serum fibrinogen, and Anti-
thrombin III. Changes to protein C and S concentrations
may also occur. These effects are reduced with trans-
dermal administration.23,31e34 Several studies of post-
menopausal women have also shown a correlation
between oestrogen therapy and increased venous
thromboembolism (VTE) and stroke risk. This risk is lower
with transdermal preparations.35e39 High-dose ethinyl
oestradiol (100 mg daily) was previously used for hormone
therapy in transgender women until the association with
increased risk of thromboembolic disease (6e8%) and
possibly elevated risk of cardiovascular death in this
population was discovered. This formulation and dosing
regimen are no longer recommended, and although the
VTE risk is believed to be lower with oestrogen regimens
used in current practice, the rate of VTE in transgender
women on oestrogen therapy is still elevated compared
with the general population, and also compared with
women using oral contraceptive and hormone replace-
ment therapy.40 Myocardial infarction and stroke risk
appear to be higher in women of transgender history on
hormonal therapy when compared with non-transgender
women, especially if ethinyl oestradiol is used, but large
prospective trials are lacking.13,25,26,41e43 Prophylactic VTE
measures should be considered perioperatively where
indicated, particularly for the transgender woman in the
first year of oestrogen therapy or if she is a smoker.
(ii) Decreased protein binding: hormone-mediated decreases
in a1-acid glycoprotein and albumin are seen with high
oestrogen concentrations used in non-transgender
women undergoing in vitro fertilisation. This reduction is
potentially significant for highly protein-bound drugs, but
data are lacking in the transgender population. Local an-
aesthetics, such as bupivacaine, have been shown to
result in increased amounts of free drug when high-dose
oestrogen therapy is utilised.44 This should be consid-
ered when local anaesthetics are used perioperatively.
Dose reduction or close monitoring for toxic effects may
be warranted.
(iii) Increased postoperative nausea and vomiting (PONV) risk:
female sex is a known risk factor for PONV by a mecha-
nism largely unknown, but possibly related to oestrogen.45
It is unclear how this risk is extrapolated to transgender
women on oestrogen therapy, but should be considered in
Transgender women and routine surgery - 3
perioperative planning, especially as a common side-
effect of oestrogen therapy itself is nausea. Appropriate
anti-emetic prophylaxis should be considered.
(iv) Withdrawal symptoms: there is a risk for psychological
and physiological withdrawal symptoms if oestrogen is
ceased perioperatively. These risks include depression,
irritability, autonomic hyperactivity, and decreased
seizure threshold. Proposed mechanisms include a
decrease in g-aminobutyric acid, and central serotonin-
ergic, dopaminergic, and noradrenergic system activities.
There is also potential for psychological distress as a result
of the reinstitution of male hormonal effects.17,46 The use
of sugammadex may also lead to lower oestrogen levels,
but the extent is unclear.47 It is critically important to
consider these effects when deciding on a medication
management plan in the perioperative period. Early dis-
cussion with the woman and her managing endocrinolo-
gist is highly recommended. Typically, hormone therapy is
ceased 2e4 weeks before operation if deemed necessary.48
(v) Neuromuscular block: oestrogens may affect neuromus-
cular block because of a possible decrease in pseudocho-
linesterase activity, as seen in studies involving non-
transgender women, which may lead to prolonged mus-
cle paralysis from succinylcholine.49 Neuromuscular
monitoring is recommended.
Cyproterone acetate
Cyproterone acetate is an anti-androgen with progestogenic
actions. Increased prolactin concentrations occur commonly,
but are of little consequence to anaesthetic care.50 Elevation of
liver enzymes and even fulminant hepatic failure can occur,
but are more likely with the larger doses used in prostate
cancer compared with those used in the transgender
woman.51 Adrenal suppression, a mild reduction in haema-
tocrit, and increased thromboembolic events have been re-
ported, although usually when used in combination with
oestrogen therapy. High doses have been associated with a
feeling of dyspnoea with a corresponding respiratory alka-
losis.50,52e54 Haematological and biochemical testing to iden-
tify underlying electrolyte or acidebase abnormalities,
anaemia, or liver dysfunction may be helpful before operation,
especially if undergoing major surgery or with a recent in-
crease in dose. Medication withholding should be discussed
with the treating endocrinologist.
Spironolactone
Spironolactone has moderate anti-androgenic activity beyond
its primary action as an antagonist of aldosterone, affecting
sodiumepotassium exchange in the distal convoluted renal
tubules. Effects are both diuretic and antihypertensive, and
potassium is also retained. Potential physiological effects of
concern to the anaesthetist include hypotension and fluid
depletion, hyperkalaemia and electrolyte disturbance,
gastrointestinal (GI) upset, nausea and vomiting, gastritis,
hepatic dysfunction, and thrombocytopaenia. To avoid vol-
ume depletion intraoperatively, dose withholding on the day
of surgery is suggested.55
Bicalutamide
Bicalutamide is a non-steroidal anti-androgen, without any
other endocrine activity. Bicalutamide is extensively
 4 - Lennie et al.

Fig 1. (a) Schematic illustration of before and after cricothyroid approximation (CTA) surgery showing the original vocal cord length
becoming elongated after rotation of the thyroid lamina towards the cricoid cartilage to achieve an increased vocal fold tension. (b) Before
CTA. (c) After CTA.

metabolised by the liver and is an inhibitor of CYP3A4. It has Airway considerations

been shown to increase plasma concentrations of midazolam
Accurate airway assessment may be difficult using conven-
by up to 80% and has also been shown to displace warfarin
tional techniques in the transgender woman as a result of
from its protein binding sites, which can lead to an increased
facial and laryngeal procedures used for both cosmetic and
warfarin effect. Common side-effects also relevant to the
vocal feminisation, which may not be immediately apparent
anaesthetist include GI upset and vomiting, anaemia, and
to the anaesthetist. This may subsequently pose a challenge
hepatic dysfunction. Uncommonly, interstitial lung disease
during airway instrumentation and intubation. These pro-
has been reported.56
cedures are discussed as follows.

Cosmetic feminisation
Gender confirmation surgery
Cosmetic surgery is a rapidly growing field. There are many
There are various surgical procedures that can be used for
procedures now available to the transgender woman to femi-
gender realignment. Surgery specific to reassigning the male
nise her appearance. Mandible reduction, brow reduction,
genitalia to the female can be achieved using various vaginal
chin narrowing, and rhinoplasty are examples that are
reconstructive methods with the goals of creating a functional
growing in popularity.59 These changes may make airway
and aesthetically satisfactory vagina and vulva, with accept-
assessment and management for the anaesthetist misleading
able sexual and normal micturating functions.57 Techniques
or more challenging because of changes in face shape. For
may include the following: penectomy (removal of the penis),
example, chin augmentation using artificial implants may
orchidectomy (removal of the testicles), and vulvoplasty (with
misleadingly lead to a longer perceived thyromental distance.
or without vaginoplasty, in which penile and scrotal tissues
Mandible reduction may lead to a more crowded oropharynx
are used to construct a vulva). Newer techniques can include
and more difficult airway management.
recreating the clitoris using the glans of the penis. The urethra
Thyroid chondroplasty or tracheal shave surgery aims to
is repositioned, and a vaginoplasty may be performed to create
minimise the tracheal cartilage using a front-of-neck inci-
a vaginal canal between the rectum and the bladder using a
sion.59 For the anaesthetist, this procedure may make esti-
graft.58
mation of thyromental distance or identification of front-of-
Existing techniques may utilise fixation to structures in the
neck structures more challenging, particularly in the obese
pelvis, an awareness that may be of importance to the
patient. Scar tissue may make identification and puncture of
anaesthetist during intra-abdominal or pelvic surgery, with
the cricothyroid membrane in an emergency more difficult.
the potential for structural injury or bleeding. In addition,
The transgender woman may have airway anatomy in
indwelling urinary catheter placement may prove challenging.
keeping with their previously male development; this should be
A urologist may be required on both occasions.
remembered when selecting airway equipment, such as laryn-
Body feminisation, commonly involving breast surgery,
goscope blades, laryngeal mask airways, and tracheal tubes.
may include artificial implants that need to be considered,
particularly when positioning the patient for surgery.
Vocal feminisation
It is important to emphasise that professional behaviour
and patient privacy should be maintained, particularly in the To achieve a more feminine voice, the transgender woman
operating theatre. may, in addition to speech therapy, have undergone surgery to

Fig 2. (a) Before anterior commissure advancement. (b) After anterior commissure advancement showing incision of the thyroid cartilage
at the level of anterior commissure and insertion of a silicone implant to achieve vocal fold lengthening and increased tension.
improve vocal quality and elevate pitch, which may add
further complexity to airway management. Vocal feminisation
can be achieved by increasing the vocal cord tension, short-
ening the vocal cord length, or decreasing the vocal cord
mass.60 These changes can be achieved endoscopically, open,
or a combination of both. There are multiple variations and
described techniques in the literature, but the following are
examples of some of the commonly offered procedures.
Open surgery
Cricothyroid approximation (CTA), anterior commissure
advancement, and open feminisation laryngoplasty involve
the larynx being opened anteriorly and may involve changes
to the laryngeal skeleton.
Cricothyroid approximation (Fig. 1) involves rotation of the
thyroid lamina towards the cricoid cartilage resulting in
elongation and increased tension of the vocal folds. This
usually involves dissection of a part of the thyroid cartilage
and subluxation to move the cricoid cartilage posteriorly and
superiorly, and the thyroid cartilage anteriorly and inferiorly,
bringing the two cartilages closer together to increase vocal
cord tension. This technique may effectively remove the entire
cricothyroid membrane and space.61,62
Anterior commissure advancement (Fig. 2) involves incision of
the thyroid cartilage at the level of the anterior commissure
and insertion of an implant. The result is stretching of the
vocal cords to an increased length and resulting increased
tension. Externally, it can leave the impression of a second
prominence or ‘second Adam’s apple’.
Open feminisation laryngoplasty (Fig. 3) involves removal of the
anterior thyroid cartilage and front third of the vocal folds, and
Transgender women and routine surgery - 5
suturing the anterior section of the cords together, achieving
tightening of the cartilages and the cords. A smaller aperture
and a functionally shorter and tenser vocal cord are created.63
Endoscopic surgery
There are several similar endoscopic techniques that exist for
vocal feminisation that aim to create a smaller glottic aperture
and to achieve a more feminine voice. Anterior commissure
web formation (Fig. 4) is one example. This technique involves
de-epithelisation or removal of the mucosa of the anterior
commissure along the anterior third of the vocal folds, plus the
suturing of the anterior cords or surrounding muscle. Once
healed, a scar or webbing is formed, creating a shorter
vibrating vocal fold segment with a resultant narrower aper-
ture and increased vocal cord tension.61,64e66
The resultant scarred and smaller glottic aperture is of
relevance to the anaesthetist as tracheal intubation may prove
more difficult and a smaller-diameter tracheal tube may be
required.
Further considerations in the perioperative
period
Patient interactions and environmental considerations
The patient’s preferred name and pronouns should always be
used when interacting with the patient or during clinical
handover with treating staff.67
Being transgender is still associated with a significant
stigma. This stigma should be considered in the perioperative
setting when considering the perioperative environment. Pri-
vacy should always be respected, and patients should be
 6 - Lennie et al.

Fig 3. (Left to right) Before, during, and after open feminisation laryngoplasty demonstrating removal of the anterior thyroid cartilage and
front third of the vocal folds and suturing of the anterior section of the cords to achieve tightening of the cartilages and the cords.

Fig 4. Before, during, and after anterior commissure web formation demonstrating the endoscopic view of the de-epithelisation of the
medial aspect of the anterior third of both vocal folds, followed by approximation of the vocal folds to create an anterior synechia or web,
thereby simulating the dimensions of a female glottis and subsequently shortening the vibrating portion of vocal folds.

roomed according to their gender identity where available.
Single rooms may be preferable if there is significant anxiety
related to their in-hospital treatment or risk of being ‘outed’.
Contact should be limited to those only directly related to the
patient’s care, and chaperones should also be considered
during examinations.6,15
Associated medical and psychological conditions
There are several other important conditions to consider when
caring for a transgender women in the perioperative period.
These include:
(i) Psychiatric illness: there is a high prevalence of associated
psychiatric conditions in the transgender population,
especially depression and anxiety.4 Suicide remains one of
the leading causes of mortality in the transgender popu-
lation.25 In addition to the effect these illnesses may have
in the perioperative period, pharmacological therapies
and potential drug interactions may exist. Selective sero-
tonin reuptake inhibitors, serotonin and noradrenaline
reuptake inhibitors, and monoamine oxidase inhibitors all
have well-documented interactions relevant to the
anaesthetist.68
(ii) Smoking: transgender persons have a three-fold higher
rate than the age-matched Australian population mean
for smoking rates.4 History and examination to identify a
coexisting disease are recommended. The physiological
effects of smoking, including airway irritability, increased
carbon monoxide concentrations, and increased rates of
postoperative chest and wound infections are also rele-
vant to the anaesthetist.69

(iii) Substance abuse risk: there is a high rate of alcohol or drug
misuse in the transgender population. Substance use was
identified as a coping mechanism for discrimination faced
for being transgender.6
(iv) Human immunodeficiency virus (HIV): transgender
women are nearly 49 times more likely to be infected with
HIV than all adults within reproductive age.6 Universal
precautions to minimise occupational exposure and care
with aseptic technique and sterility to prevent hospital-
acquired infection should be adhered to. HIV-associated
disease and opportunistic pathogens, in addition to po-
tential anaesthesia medication interactions with anti-
retrovirals, should be considered.70
Perioperative risk assessment
Several perioperative risk calculators and scoring systems use
sex in risk stratification, but ignore the use of oestrogen
therapy. These calculators have not been validated in trans-
gender women. It is unclear how the risk profile for the
transgender woman who has undertaken hormonal or surgi-
cal transition is affected and how these calculators should be
used in this population. Examples of commonly used periop-
erative assessment tools that utilise sex include the Cardiac
Risk Index, the American College of Surgeons’ National Sur-
gical Quality Improvement Program risk prediction, the STOP-
Bang tool for obstructive sleep apnoea risk, and the CHADS2-
Vasc scoring systems. Male sex often scores higher in risk
stratification, and some of these tools may underestimate risk
in the transgender woman if female sex is selected.67,71
A prospective study by Wierckx and colleagues42 showed
that transgender women experienced more myocardial in-
farctions than the control women, but a similar proportion
compared with control men. The prevalence of cerebrovas-
cular disease was higher in transgender women than in con-
trol men. Given the lack of prospective data available, in
practice, it may be advisable to select the sex that confers the
highest risk for the particular risk one is trying to predict, with
any results used in caution.
Drug dosing in anaesthesia
Limited data are available about the effects of hormonal
therapy on anaesthetic drug pharmacology and drug delivery
algorithms. There will be some fat redistribution to a more
female shape with hormone therapy that may influence the
volume of distribution of fat-soluble drugs, but drug modelling
data available in this population are lacking.
Anaesthesia delivery models used for total i.v. anaesthesia
that require selection of sex will influence drug calculation
and delivery; for example, the Schneider model for propofol
infusion and the Minto model for remifentanil administration
both utilise sex to calculate lean body weight as a part of their
algorithms. The use of depth of anaesthesia monitoring, such
as processed EEG, may be helpful in this scenario.
The calculation for ideal body weight also differs by sex.
This should be kept in mind when calculating drug doses.72
Laboratory values
There is limited evidence to guide how best to interpret labo-
ratory values in the transgender woman, particularly those
who have been on hormonal therapies.22 These hormonal
therapies have varying effects on haematological and
Transgender women and routine surgery - 7
biochemical parameters, and this should be considered when
interpreting these results. There are many reference ranges
and calculated laboratory parameters that use sex routinely,
and examples include:
(i) Renal function: creatinine concentrations are influenced
by many factors, including diet and muscle mass. Creati-
nine concentrations decrease in transgender women tak-
ing hormone therapy as a result of a decrease in lean body
mass.73,74 The CockcrofteGault formula for creatinine
clearance and the Modification of Diet in Renal Disease
glomerular filtration rate equation for calculating glomer-
ular filtration are examples that utilise sex. A lower
creatinine will correspond with a higher estimated
glomerular filtration rate, giving the perception that
filtration is occurring at a higher rate. There are no studies
looking specifically on how to interpret renal function in
the transgender woman, but it is important to consider
whether the sex assigned at birth or the gender identity
has been used in the electronic medical record, and which
sex has been used for the calculation when commenting
on any changes in renal function, particularly when hor-
mone therapy has been recently commenced. Confusion
over eligibility for transplant in a transgender patient has
been reported because of this issue.67,73e75
(ii) Haematocrit and defining anaemia: reference ranges for
the evaluation of haematocrit levels in transgender per-
sons have not been established; however, a decrease in
haematocrit is often observed in transgender women on
hormonal therapy.53 The European Network for the
Investigation of Gender Incongruence study53 found that,
in transgender women, serum haematocrit had decreased
to a level that can be found in the reference range of the
identified gender from 3 months after the initiation of
gender-affirming hormonal treatment. In transgender
women continuing established hormone therapy peri-
operatively, haematocrit can be interpreted within the
reference ranges for the female sex. It is unclear what
reference range to use if there has been cessation of ther-
apy; however, with parts of the world moving towards a
unified haemoglobin reference range, this may not be of
consequence in the future.
Conclusions
The transgender woman who has undergone gender realign-
ment will become more commonly encountered in anaesthetic
practice and can provide unique challenges to the anaesthetist.
The importance of taking a respectful and detailed history
cannot be stressed highly enough. Careful consideration of the
anatomical, physiological, pharmacological, and psychological
aspects of anaesthetic care in this unique population is
important in providing safe and optimised care.
Authors’ contributions
Conception and manuscript preparation: YL
Illustrations and contribution to ‘Airway considerations’ sec-
tion: KL
Review and editing of manuscript: LE
Declarations of interest
The authors declare that they have no conflicts of interest.
 8 - Lennie et al.
References
1. Meerwijk EL, Sevelius JM. Transgender population size in
the United States: a meta-regression of population-based
probability samples. Am J Public Health 2017; 107: e1e8
2. Zucker KJ. The DSM-5 diagnostic criteria for gender
dysphoria. In: Trombetta C, Liguori G, Bertolotto M, edi-
tors. Management of gender dysphoria: a multidisciplinary
approach. Milan: Springer-Verlag Mailand; 2015. p. 33e7
3. Australian Bureau of Statistics. Census of population and
housing: reflecting Australiadstories from the census. Available
from: https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/
bySubject/2071.0∼2016∼
MainFeatures∼
SexandGenderDiversityinthe2016Census∼100.
[Accessed 7 June 2019]
4. Cheung AS, Ooi O, Leemaqz S, et al. Sociodemographic
and clinical characteristics of transgender adults in
Australia. Transgend Health 2018; 3: 229e38
5. Government UK. National LGBT survey: summary report
2019. Available from: https://www.gov.uk/government/
publications/national-lgbt-survey-summary-report/
national-lgbt-survey-summary-report. [Accessed 23
December 2019]
6. Australian Government Department of Health. Trans-
gender and gender diverse health and wellbeing background
paper 2014. Available from: https://www2.health.vic.gov.
au/Api/downloadmedia/%7B3165C620-0649-4EA1-
BBA1-4CA4CEF4F58A%7D. [Accessed 6 June 2019]
7. Wiepjes CM, Nota NM, de Blok CJM, et al. The Amsterdam
cohort of gender dysphoria study (1972e2015): trends in
prevalence, treatment, and regrets. J Sex Med 2018; 15:
582e90
8. Delahunt JW, Denison HJ, Sim DA, Bullock JJ, Krebs JD.
Increasing rates of people identifying as transgender
presenting to Endocrine Services in the Wellington region.
N Z Med J 2018; 131: 33e42
9. Australian and New Zealand College of Anaesthetists.
Anaesthesia training program curriculum. Available from:
http://www.anzca.edu.au/documents/anaesthesia-
training-program-curriculum.pdf. [Accessed 6 June 2019]
10. Royal College of Anaesthetists. Curriculum for a CCT in
anaesthetics 2010. Available from: https://www.rcoa.ac.uk/
sites/default/files/documents/2019-08/TRG-CU-CCT-
ANAES2010.pdf. [Accessed 23 December 2019]
11. House of Commons Women and Equalities Committee.
Transgender equality. First report of session 2015e16 2015.
Available from: http://www.publications.parliament.uk/
pa/cm201516/cmselect/cmwomeq/390/390.pdf. [Accessed
23 December 2019]
12. General Medical Council. Trans healthcare. Available from:
https://www.gmc-uk.org/ethical-guidance/ethical-hub/
trans-healthcare. [Accessed 23 December 2019]
13. Cheung AS, Wynne K, Erasmus J, Murray S, Zajac JD. Po-
sition statement on the hormonal management of adult
transgender and gender diverse individuals. Med J Aust
2019; 211: 127e33
14. Shah SB, Khanna P, Bhatt R, Goyal P, Garg R, Chawla R.
Perioperative anaesthetic concerns in transgender pa-
tients: Indian perspective. Indian J Anaesth 2019; 63: 84e91
15. Tollinche LE, Walters CB, Radix A, et al. The perioperative
care of the transgender patient. Anesth Analg 2018; 127:
359e66
16. GLAAD. GLAAD media reference guidedtransgender. Avail-
able from: https://www.glaad.org/reference/transgender.
[Accessed 7 June 2019]
17. Hochberg Z, Pacak K, Chrousos GP. Endocrine withdrawal
syndromes. Endocr Rev 2003; 24: 523e38
18. T’Sjoen G, Arcelus J, Gooren L, Klink DT, Tangpricha V.
Endrocrinology of transgender medicine. Endocr Rev 2019;
40: 97e117
19. Hao J, Ghosh P, Li SK, Newman B, Kasting GB, Raney SG.
Heat effects on drug delivery across human skin. Expert
Opin Drug Deliv 2016; 13: 755e68
20. Ettinger B. Vasomotor symptom relief versus unwanted
effects: role of estrogen dosage. Am J Med 2005; 118:
74Se8S
21. Safer JD, Tangpricha V. Care of transgender persons.
N Engl J Med 2019; 381: 2451e60
22. Unger CA. Hormone therapy for transgender patients.
Transl Androl Urol 2016; 5: 877e84
23. Walsh BW, Schiff I, Rosner B, Greenberg L, Ravnikar V,
Sacks FM. Effects of postmenopausal estrogen replace-
ment on the concentrations and metabolism of plasma
lipoproteins. N Engl J Med 1991; 325: 1196e204
24. van Velzen DM, Paldino A, Klaver M, et al. Car-
diometabolic effects of testosterone in transmen and es-
trogen plus cyproterone acetate in transwomen. J Clin
Endocrinol Metab 2019; 104: 1937e47
25. Asscheman H, Giltay EJ, Megens JAJ, de Ronde W, van
Trotsenburg MAA, Gooren LJG. A long-term follow-up
study of mortality in transsexuals receiving treatment
with cross-sex hormones. Eur J Endocrinol 2011; 164:
635e42
26. Asscheman H, Gooren LJ, Eklund PL. Mortality and
morbidity in transsexual patients with cross-gender hor-
mone treatment. Metabolism 1989; 38: 869e73
27. Canonico M, Plu-Bureau G, Lowe GD, Scarabin PY. Hor-
mone replacement therapy and risk of venous thrombo-
embolism in postmenopausal women: systematic review
and meta-analysis. BMJ 2008; 336: 1227e31
28. Hembree W, Cohen-Kettenis P, Delemarre-van de
Waal HA, et al. Endocrine treatment of transsexual per-
sons: an Endocrine Society clinical practice guideline.
J Clin Endocrinol Metab 2009; 94: 3132e54
29. Hembree WC, Cohen-Kettenis PT, Gooren L, colleagues.
Endocrine treatment of gender-dysphoric/gender-
incongruent persons: an Endocrine Society clinical prac-
tice guideline. J Clin Endocrinol Metab 2017; 102: 3869e903
30. Maraka S, Ospina NS, Rodriguez-Guitierrez R, et al. Sex
steroids and cardiovascular outcomes in transgender in-
dividuals: a systematic review and meta-analysis. J Clin
Endocrinol Metab 2017; 102: 3914e23
31. Chetkowski RJ, Meldrum DR, Steingold KA, et al. Biologic
effects of transdermal estradiol. N Engl J Med 1986; 314:
1615e20
32. Brosnan JF, Sheppard BL, Norris LA. Haemostatic activa-
tion in post-menopausal women taking low-dose hor-
mone therapy: less effect with transdermal
administration? Thromb Haemost 2007; 97: 558e65
33. Wessler S. Estrogen-associated thromboembolism. Ann
Epidemiol 1992; 2: 439e43
34. van Kesteren PJ, Asscheman H, Megens JA, Gooren LJ.
Mortality and morbidity in transsexual subjects treated
with cross-sex hormones. Clin Endocrinol (Oxf) 1997; 47:
337e42

35. Viscoli CM, Brass LM, Kernan WN, Sarrel PM, Suissa S,
Horwitz RI. A clinical trial of estrogen-replacement ther-
apy after ischaemic stroke. N Engl J Med 2001; 345: 1243e9
36. Anderson GL, Limacher M, Assaf AR, et al. Effects of
conjugated equine estrogen in postmenopausal women
with hysterectomy: the Women’s Health Initiative ran-
domized controlled trial. JAMA 2004; 291: 1701e12
37. Hendrix SL, Wassertheil-Smoller S, Johnson KC, et al. Ef-
fects of conjugated equine estrogen on stroke in the
women’s health initiative. Circulation 2006; 113: 2425e34
38. Pang SC, Greendale GA, Cedars MI, et al. Long-term effects
of transdermal estradiol with and without medrox-
yprogesterone acetate. Fertil Steril 1993; 59: 76e82
39. Olie V, Canonico M, Scarabin PY. Risk of venous thrombosis
with oral versus transdermal estrogen therapy among
postmenopausal women. Curr Opin Hematol 2010; 17: 457e63
40. Asscheman H, T’Sjoen G, Lemaire A, et al. Venous
thrombo-embolism as a complication of cross-sex hor-
mone treatment of male-to-female transsexual subjects: a
review. Andrologia 2014; 46: 791e5
41. Gooren LJ, Giltay EJ, Bunck MC. Long-term treatment of
transsexuals with cross-sex hormones: extensive per-
sonal experience. J Clin Endocrinol Metab 2008; 93: 19e25
42. Wierckx K, Elaut E, Declercq E, et al. Prevalence of car-
diovascular disease and cancer during cross-sex hormone
therapy in a large cohort of trans persons: a case-control
study. Eur J Endocrinol 2013; 169: 471e8
43. Shatzel JJ, Connelly KJ, DeLoughery TG. Thrombotic issues
in transgender medicine: a review. Am J Hematol 2017; 92:
204e8
44. Tsen LC, Arthur GR, Datta S, Hornstein MD, Bader AM.
Estrogen-induced changes in protein binding of bupiva-
caine during in vitro fertilization. Anesthesiology 1997; 87:
879e83
45. Apfel CC, Heidrich FM, Jukar-Rao S, et al. Evidence-based
analysis of risk factors for postoperative nausea and
vomiting. Br J Anaesth 2012; 109: 742e53
46. Schmidt PJ, Ben Dor R, Martinez PE, et al. Effects of
estradiol withdrawal on mood in women with past peri-
menopausal depression: a randomized clinical trial. JAMA
Psychiatry 2015; 72: 714e26
47. Merck Sharp & Dohme Limited. Bridion 100 mg/ml solution
for injection summary of product characteristics 2019. Avail-
able from: https://www.medicines.org.uk/emc/product/
6409. [Accessed 23 December 2019]
48. Tangpricha V, den Heijer M. Oestrogen and anti-androgen
therapy for transgender women. Lancet Diabetes Endocrinol
2017; 5: 291e300
49. Robertson GS. Serum protein and cholinesterase changes
in association with contraceptive pills. Lancet 1967; 1:
232e5
50. Nota NM, Dekker MJHJ, Klaver M, et al. Prolactin levels
during short- and long-term cross-sex hormone treat-
ment: an observational study in transgender persons.
Andrologia 2017; 49, e12666
51. Kim JH, Yoo BW, Yang WJ. Hepatic failure induced by
cyproterone acetate: a case report and literature review.
Can Urol Assoc J 2014; 8: e458e61
52. Therapeutic Goods Administration. Australian product infor-
mation: androcur 50 mg (cyproterone acetate). Available from:
https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.
nsf/pdf?OpenAgent&id=CP-2009-PI-
Transgender women and routine surgery - 9
01092-3&d=201906261016933TGA.
[Accessed 10 June 2019]
53. Defreyne J, Vantomme B, Van Caenegem E, et al. Pro-
spective evaluation of hematocrit in gender-affirming
hormone treatment: results from European network for
the investigation of gender incongruence. Andrology 2018;
6: 446e54
54. Fuss J, Claro L, Ising M, et al. Does sex hormone treatment
reverse the sex-dependent stress regulation? A longitu-
dinal study on hypothalamus-pituitary-adrenal (HPA) axis
activity in transgender individuals. Psychoneuroendocrinol-
ogy 2019; 104: 228e37
55. Therapeutic Goods Administration. Product information:
aldactone (spironolactone) 2014. Available from: https://
www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?
OpenAgent&id=CP-2010-PI-04112-
3. [Accessed 10 June 2019]
56. Therapeutic Goods Administration. Australian product in-
formation: APO-bicalutamide 50mg (bicalutamide) tablets 2019.
Available from: https://www.ebs.tga.gov.au/ebs/picmi/
picmirepository.nsf/pdf?OpenAgent&id&
equals;CP-2010-PI-06230-3. [Accessed 10 June 2019]
57. Seim LA, Irizarry-Alvarado JM. Perioperative management
of female hormone medications. Curr Clin Pharmacol 2017;
12: 188e93
58. Bizic M, Kojovic V, Duisin D, et al. An overview of neo-
vaginal reconstruction options in male to female trans-
sexuals. ScientificWorldJournal 2014; 2014: 638919
59. Altman K. Facial feminization surgery: current state of the
art. Int J Oral Maxillofac Surg 2012; 41: 885e94
60. Song TE, Jiang N. Transgender phonosurgery: a systematic
review and meta-analysis. Otolaryngol Head Neck Surg 2017;
156: 803e8
61. Casado JC, O’Connor C, Angulo MS, Adria  n JA. Wendler
glottoplasty and voice-therapy in male-to-female trans-
sexuals: results in pre and post-surgery assessment. Acta
Otorrinolaringol Esp 2016; 67: 83e92
62. Kanagalingam J, Georgalas C, Wood G, Ahluwalia S,
Sandhu G, Cheesman AD. Cricothyroid approximation
and subluxation in 21 male-to-female transsexuals.
Laryngoscope 2005; 115: 611e8
63. Thomas JP, Macmillan C. Feminization laryngoplasty:
assessment of surgical pitch elevation. Eur Arch Oto-
rhinolaryngol 2013; 270: 2695e700
64. Schwarz K, Fontanari AMV, Schneider MA, et al. Laryngeal
surgical treatment in transgender women: a systematic
review and meta-analysis. Laryngoscope 2017; 127:
2596e603
65. Mastronikolis NS, Remacle M, Biagini M, Kiagiadaki D,
Lawson G. Wendler glottoplasty: an effective pitch raising
surgery in male-to-female transsexuals. J Voice 2013; 27:
516e22
66. Misołek M, Niebudek-Bogusz E, Morawska J, Orecka B,

Scierski W, Lisowska G. Gender-related voice problems in
transsexualsdtherapeutical demands. Endokrynol Pol
2016; 67: 452e5
67. Rosendale N, Goldman S, Ortiz GM, Haber LA. Acute
clinical care for transgender patients: a review. JAMA
Intern Med 2018; 178: 1535e43
68. Peck T, Wong A, Norman E. Anaesthetic implications of
psychoactive drugs. Contin Educ Anaesth Crit Care Pain 2010;
10: 177e81
 10 - Lennie et al.
69. Rodrigo C. The effects of cigarette smoking on anesthesia.
Anesth Prog 2000; 47: 143e50
70. Prout J, Agarwal B. Anaesthesia and critical care for pa-
tients with HIV infection. Contin Educ Anaesth Crit Care Pain
2005; 5: 153e6
71. Chung F, Subramanyam R, Liao P, Sasaki E, Shapiro C,
Sun Y. High STOP-Bang score indicates a high probability
of obstructive sleep apnoea. Br J Anaesth 2012; 108:
768e75
72. Ingrande J, Lemmens HJ. Dose adjustment of anaesthetics
in the morbidly obese. Br J Anaesth 2010; 105: i16e23
73. Wiik A, Andersson DP, Brismar TB, et al. Metabolic and
functional changes in transgender individuals following
cross-sex hormone treatment: design and methods of the
GEnder Dysphoria Treatment in Sweden (GETS) study.
Contemp Clin Trial. Commun 2018; 10: 148e53
74. Klaver M, Dekker M, de Mutsert R, Twisk JWR, den
Heijer M. Cross-sex hormone therapy in transgender
persons affects total body weight, body fat and lean body
mass: a meta-analysis. Andrologia 2017; 49, e12660
75. Whitley CT, Greene DN. Transgender man being evalu-
ated for a kidney transplant. Clin Chem 2017; 63: 1680e4
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