What are the recommended treatments for individuals seeking transgender care?

Recommended Treatments for Transgender Care

Transgender individuals seeking gender-affirming care should receive comprehensive services including hormone therapy (estrogen or testosterone), mental health support, and surgical interventions when indicated, as these treatments demonstrably improve mental health, reduce suicide rates, and enhance overall quality of life. 1

Core Treatment Components

Gender-Affirming Hormone Therapy (GAHT)

For Transgender Women (Male-to-Female):

• Estradiol is the cornerstone medication, available in oral, transdermal, or injectable formulations 2, 3
• Anti-androgens should be added to suppress testosterone while enabling lower estrogen doses 2, 3
  • Spironolactone is most commonly used 3
  • Alternatives include cyproterone acetate, GnRH agonists, bicalutamide, and finasteride 2, 3
• Target hormone levels: testosterone <50 ng/dL, estradiol in cisgender female reference range 3
• Expected physical changes: breast development, decreased muscle mass (3.0-5.5% reduction in lean body mass), skin softening, decreased body/facial hair, reduced libido and erectile function 2, 3, 4

For Transgender Men (Female-to-Male):

• Testosterone therapy via intramuscular injection is the primary treatment 5
• Target testosterone levels: 300-1,000 ng/dL (typical physiological range for cisgender men) 2
• Expected physical changes: deepening voice, facial and body hair growth, increased muscle mass, menstrual suppression, increased libido 2, 4
• Testosterone cypionate can be administered every 2-4 weeks due to slow absorption from lipid phase 5

Baseline Assessment Requirements

Before initiating hormone therapy, obtain:

• Complete blood count, liver function tests, lipid profile, glucose levels 2
• Baseline hormone levels (estradiol and testosterone) 2
• Mental health evaluation, as transgender individuals have higher rates of anxiety, depression, bipolar disorder, OCD, ADHD, autism, and schizophrenia compared to cisgender populations 1, 2
• Fertility preservation counseling is mandatory, as hormone therapy may permanently affect fertility 2

Monitoring Protocol

Initial Phase:

• Check hormone levels at 3 months after initiation 2
• Monitor every 3-6 months during the first year 2, 3

Maintenance Phase:

• Annual hormone level monitoring once stable 2, 3
• Annual cardiovascular risk assessment 2
• Monitor hematocrit in transgender men, as testosterone causes erythrocytosis 2

Surgical Interventions

The decision to pursue surgery should be made collaboratively between the patient and their multidisciplinary healthcare team (primary care physicians, endocrinologists, mental health professionals, surgeons) 1

Common surgical options include:

• Chest masculinization (top surgery) for transgender men - removes breast tissue, though some tissue including nipple-areolar complex typically remains 1
• Breast augmentation for transgender women 1
• Gonadectomy (oophorectomy for transgender men, orchiectomy for transgender women) - eliminates need for certain hormone suppression medications 1
• Genital reconstruction surgery 1

Critical consideration: An accurate anatomic/organ inventory must be documented in the medical record, as retained anatomy affects cancer screening, surgical planning, and systemic therapy decisions 1

Evidence Supporting Treatment Efficacy

The evidence strongly supports gender-affirming care based on mortality and quality of life outcomes:

• When transgender persons receive medically appropriate care, they demonstrate improved mental health, reduction in suicide rates, and lower overall healthcare costs due to fewer mental health and substance abuse-related expenses 1
• Multiple major medical organizations (American Medical Association, American Psychological Association, American Psychiatric Association, ACOG, AAFP) consider gender transition-related medical services medically necessary 1

Critical Safety Considerations

Cardiovascular Risks

Feminizing hormone therapy carries increased thrombotic risk:

• Transgender women have elevated risk of venous thromboembolism, ischemic stroke, and myocardial infarction compared to both cisgender men and women 3
• Risk factors include genetic mutations, smoking, prolonged inactivity, and oral estrogen formulation (oral may carry higher risk than transdermal) 3, 4
• Patients must be informed of these risks before initiating treatment 1

Masculinizing hormone therapy risks:

• Erythrocytosis, increased blood pressure, elevated triglycerides and LDL, decreased HDL, acne, androgenic alopecia 2
• Increased cardiovascular and atherosclerotic risk similar to natal male population 1

Laboratory Interpretation

• After 1 year of hormone therapy, interpret lab values based on affirmed gender rather than sex assigned at birth 2
• Consider cystatin C over creatinine for kidney function assessment in transgender individuals on hormone therapy 2
• Hemoglobin levels decrease significantly in transgender women on estrogen 3

Common Pitfalls to Avoid

1. Failing to obtain comprehensive surgical history - Always document what anatomy is present or absent, as this affects cancer screening and treatment decisions 1, 6

2. Inadequate fertility counseling - This must occur before starting hormones, as effects may be permanent 2

3. Using incorrect pronouns or names - Use patient-identified name and pronouns; this directly impacts patient comfort and willingness to engage in care 6

4. Assuming all transgender patients want the same interventions - Some may pursue only social transition, only hormones, only surgery, or various combinations 1

5. Discontinuing hormone therapy without discussion - For patients on established GAHT, abrupt cessation can worsen gender dysphoria and mental health 1

6. Inadequate monitoring for complications - Particularly thrombotic events in transgender women and erythrocytosis in transgender men 2, 3

Insurance Coverage Considerations

The American College of Physicians recommends that public and private health benefit plans include comprehensive transgender health care services and provide all covered services to transgender persons as they would all other beneficiaries 1. Without coverage, costs can be prohibitively expensive (tens of thousands of dollars for surgery alone), leading to increased stress and more serious health conditions when patients cannot access needed care 1.