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

Knowledge of a patient's gender-affirming surgeries and hormone therapy fundamentally alters both the physical examination approach and differential diagnosis by changing anatomical structures, physiological parameters, and disease risk profiles that no longer align with sex assigned at birth. 1

Essential Information to Obtain Before Any Clinical Encounter

Two-Step Approach to Gender Identity

• Confirm both sex assigned at birth and current gender identity using a private, two-step questioning approach to understand the patient's baseline anatomy and current hormonal milieu 1
• Document all gender-affirming surgeries performed, including chest procedures (mastectomy, breast augmentation), genital surgeries (vaginoplasty, phalloplasty, orchiectomy, hysterectomy), and facial/neck procedures (cricothyroid approximation, tracheal shave) 1
• Record the complete hormone therapy regimen: specific medications, dosages, duration of therapy, and route of administration (oral, transdermal, injectable) 1

Reproductive Organ Inventory

• Directly ask about presence or absence of specific organs rather than making assumptions based on gender presentation—this is a critical pitfall that leads to missed diagnoses 1
• Document fertility preservation status and which reproductive organs remain intact 1

Physical Examination Modifications Based on Surgical History

Airway and Neck Examination

• Patients with cricothyroid approximation surgery (voice feminization) no longer have an accessible cricothyroid membrane, making standard emergency front-of-neck airway access impossible 1
• Avoid airway instrumentation for 8-12 weeks following vocal pitch-raising procedures unless absolutely necessary 1

Chest Examination

• Transgender men may wear chest binders that must be removed before thoracic examination 1
• Post-mastectomy patients still require chest wall examination for underlying cardiac and pulmonary pathology—the absence of breast tissue does not eliminate the need for cardiovascular and respiratory assessment 1
• Transgender women on prolonged estrogen therapy develop breast tissue and acquire breast cancer risk, requiring standard breast examination and screening 1

Genitourinary Examination

• Transgender women who have not undergone orchiectomy retain prostate tissue and maintain prostate cancer risk despite feminizing hormone therapy 1
• Examination approach must be tailored to the specific surgical procedures performed—vaginoplasty creates neovaginal tissue that requires different assessment than natal anatomy 1

Differential Diagnosis Modifications

Laboratory Value Interpretation Algorithm

• For patients on gender-affirming hormone therapy ≥12 months: interpret laboratory values using reference ranges for affirmed gender 1, 2
• For patients on hormone therapy <12 months: interpret values in context of the specific type, dose, and duration of therapy 2
• Hemoglobin increases to male reference range within 3 months of testosterone therapy—failure to adjust reference ranges leads to missed anemia diagnoses in transgender men 1, 2
• Hemoglobin decreases to female reference range in transgender women on feminizing therapy 2

Exceptions to Affirmed Gender Reference Ranges

• Troponin and PSA should continue using reference ranges from sex assigned at birth regardless of hormone therapy duration 2
• Red blood cell indices, liver enzymes, electrolytes, and creatinine are significantly influenced by hormone therapy and should use affirmed gender ranges after 12 months 2

Cardiovascular Risk Stratification

• Screen for venous thromboembolism, ischemic stroke, and myocardial infarction in patients on feminizing therapy—estrogen significantly increases thrombotic risk 1, 2
• Monitor for polycythemia in transgender men on testosterone, which significantly increases cardiovascular risk 1, 2
• Testosterone therapy increases blood pressure, elevates triglycerides and LDL cholesterol, and decreases HDL cholesterol 2

Cancer Screening Modifications

• Transgender women retain prostate cancer risk and develop breast cancer risk with prolonged estrogen exposure 1
• Transgender men who retain a uterus and cervix require continued cervical cancer screening regardless of testosterone therapy 1
• Post-mastectomy transgender men no longer require breast cancer screening but need chest wall examination 1

Common Clinical Pitfalls and How to Avoid Them

Assumption-Based Errors

• Never assume absence of organs based on gender presentation—directly ask about surgical history 1
• Do not attribute all mental health symptoms to gender identity rather than evaluating for independent psychiatric conditions 1
• Avoid using legal names that differ from preferred names during clinical interactions 3

Medication Management

• Continue gender-affirming hormone therapy throughout the perioperative period unless specific contraindications exist 1
• Total intravenous anesthesia pharmacokinetic models are not validated for transgender patients on established hormone therapy—use processed EEG monitoring for depth of anesthesia 1

Communication Approach

• Use the patient's chosen name and pronouns throughout all interactions 3, 4
• Confirm preferred language and terms before discussing anatomy or procedures, as individuals have varying degrees of dysphoria around gendered terminology 3
• Record preferred name, pronouns, and communication preferences in the medical record to prevent repeated uncomfortable conversations 3

Hormone Therapy-Specific Physical Changes Affecting Examination

Feminizing Therapy Effects (Target testosterone <50 ng/dL, estradiol in cisgender female range)

• Breast development, decreased muscle mass, softening of skin, decreased body/facial hair, decreased libido, and reduced erectile function 2
• Weight gain and potential compromised bone structure 2

Masculinizing Therapy Effects (Target testosterone 300-1,000 ng/dL)

• Thicker vocal cords producing deeper voice, body and facial hair growth, menstrual suppression, increased libido, and clitoral growth 2
• Acne, androgenic alopecia, and potential pelvic pain 2