How does knowledge of a patient's gender confirming treatment, such as surgeries and hormonal (hormone replacement therapy) therapies, impact the physical exam and differential diagnosis?

Impact of Gender-Affirming Treatment on Physical Examination and Differential Diagnosis

You must directly ask about and document all gender-affirming surgeries and hormone therapy at every clinical encounter, as anatomical structures may not correspond to gender presentation, fundamentally altering both your physical examination approach and differential diagnosis. 1

Critical Information to Obtain

Essential History Components

• Confirm sex assigned at birth and current gender identity using a two-step question approach in a private setting 1
• Document all gender-affirming surgeries performed, including chest procedures (mastectomy, breast augmentation), genital surgeries (vaginoplasty, phalloplasty, metoidioplasty, orchiectomy, hysterectomy), and facial/neck procedures 1
• Record current hormone therapy regimen (testosterone, estradiol, anti-androgens), dosage, duration, and route of administration 1, 2
• Ask about fertility preservation and presence/absence of reproductive organs 1, 2

Critical pitfall: Many gender-affirming procedures are obtained through private healthcare or internationally and may not appear in medical records—voluntary disclosure in a safe, affirming environment is essential 1

Physical Examination Modifications

Airway Assessment Considerations

• Patients with cricothyroid approximation surgery may no longer have an accessible cricothyroid membrane, making standard emergency front-of-neck airway impossible 1
• Facial feminization procedures alter standard airway assessment accuracy—do not rely on typical predictors 1
• Avoid airway instrumentation for 8-12 weeks following vocal pitch-raising procedures unless absolutely necessary 1

Chest Examination

• Transgender men may have chest binders that should be removed (with consent) before examination 1
• Post-mastectomy patients still require chest wall examination for underlying cardiac/pulmonary pathology 1
• Transgender women with breast augmentation require breast cancer screening according to duration of hormone exposure 1

Genitourinary and Reproductive Organ Assessment

• Offer pregnancy testing to all patients with uterus and ovarian tissue ages 12-55 years, regardless of testosterone use or stated contraception 1
• Transgender men on testosterone may still have functional uterus, ovaries, and cervix requiring cancer screening 1
• Transgender women post-orchiectomy have no testicular tissue but may retain prostate requiring screening 1
• Neo-vaginas require different examination techniques and are not susceptible to cervical cancer but may develop other malignancies 1

Differential Diagnosis Modifications

Laboratory Value Interpretation

For patients on gender-affirming hormone therapy ≥12 months, interpret laboratory values using reference ranges for affirmed gender 2, 3:

• Hemoglobin increases to male reference range within 3 months of testosterone therapy 2, 3
• Hemoglobin decreases to female reference range with feminizing therapy 2
• Use sex-assigned-at-birth reference ranges for troponin and PSA 2

Hormone Therapy-Specific Risks

Feminizing therapy (estrogen + anti-androgens) increases risk of 1, 2, 3:

• Venous thromboembolism
• Ischemic stroke
• Myocardial infarction
• Weight gain

Masculinizing therapy (testosterone) increases risk of 2, 3:

• Erythrocytosis/polycythemia
• Hypertension
• Dyslipidemia (elevated triglycerides/LDL, decreased HDL)
• Acne and androgenic alopecia
• Pelvic pain

Cancer Risk Stratification

• Screen based on current anatomy, not gender identity 1
• Transgender men retain risk for cervical, ovarian, and uterine cancer unless organs surgically removed 1
• Transgender women retain prostate cancer risk and develop breast cancer risk with prolonged estrogen exposure 1
• Gender-diverse individuals appear under-screened and present with later-stage cancers 1

Pharmacological Considerations

Drug Dosing Adjustments

• Body composition changes after 3 months of established hormone therapy, approaching affirmed gender by 6 months 1
• Total intravenous anesthesia pharmacokinetic models are not validated for transgender patients on established hormone therapy—use processed EEG monitoring 1
• Volume of distribution and renal clearance may differ from both birth sex and affirmed gender during transition 1

Perioperative Hormone Management

Continue gender-affirming hormone therapy throughout the perioperative period unless specific contraindications exist 1. Discontinuation significantly worsens gender dysphoria and mental health outcomes 3.

Common Clinical Pitfalls

• Assuming absence of organs based on gender presentation rather than directly asking about surgical history 1
• Using legal name instead of preferred name, causing gender dysphoria and eroding trust 1
• Failing to monitor for polycythemia in transgender men on testosterone, significantly increasing cardiovascular risk 2, 3
• Attributing all mental health symptoms to gender identity rather than evaluating for independent psychiatric conditions 4, 5
• Discontinuing hormone therapy due to side effect concerns without recognizing the severe mental health consequences 3