What is the recommended plan of care for a female to male (FTM) transgender patient?

Plan of Care for Female-to-Male Transgender Patients

Female-to-male transgender patients should receive testosterone therapy as the cornerstone of medical transition, with comprehensive monitoring and multidisciplinary support to optimize mental health outcomes, quality of life, and minimize health risks. 1

Initial Assessment and Documentation

Establish accurate organ inventory and preferred identity documentation in the electronic medical record before initiating care. 1

• Document preferred name, pronouns, and gender identity separately from legal name and sex assigned at birth 1
• Record complete anatomical inventory (presence of uterus, ovaries, cervix, breasts) as this directly impacts screening needs and treatment decisions 1
• Screen for liver abnormalities and obtain baseline complete blood count to assess for polycythemia before initiating testosterone 1, 2
• Assess cardiovascular risk factors, obtain lipid profile, glucose, and baseline hormone levels 2

This documentation prevents dysphoria-inducing interactions in clinical settings, where 28% of transgender patients report harassment and 2% experience physical abuse 1. Using incorrect names or pronouns negatively impacts patient satisfaction and retention in care 1.

Testosterone Therapy Initiation

Initiate testosterone cypionate or enanthate at 50 mg subcutaneously weekly, adjusting to achieve serum testosterone levels within the normal male range (300-1,000 ng/dL). 3, 4, 5

• Subcutaneous administration is equally effective as intramuscular injection, with 91% of patients showing marked preference for subcutaneous route due to less discomfort and ease of self-administration 3, 6
• Dose range typically 50-150 mg weekly (median 75-80 mg) to achieve therapeutic levels 3
• Subcutaneous testosterone maintains stable serum levels between weekly injections (mean 627 ± 206 ng/dL total testosterone) 6
• Maximum virilization effects occur after 3-5 years of regular use, with visible male characteristics appearing within 6 months 4

The subcutaneous route is effective across wide body mass index ranges (19.0-49.9 kg/m²) with only minor, transient local reactions in 14% of patients 3.

Monitoring Protocol

Monitor testosterone and estradiol levels at 3 months initially, then every 3-6 months during the first year, then annually if stable. 2, 4

• Maintain total testosterone within male physiological range (300-1,000 ng/dL) 4
• Among premenopausal patients, 96% achieve amenorrhea and 66% achieve estradiol <50 pg/mL 3
• Monitor for polycythemia with regular complete blood counts 1, 2
• Assess liver function periodically, though testosterone-related transient elevations are usually self-limited 1

After 6 months of testosterone therapy, use male reference ranges for laboratory interpretation including creatinine clearance and lean body mass calculations. 1

Mental Health and Quality of Life Outcomes

Testosterone therapy produces a 20% decrease in depression after 1 year and a 5.5-point increase on a 10-point quality of life scale. 7, 2

• No evidence exists that testosterone therapy produces adverse mental health outcomes 7, 2
• Regret rate for gender-affirming hormone therapy is approximately 1% for trans men 7
• When regret occurs, 37% is due to loss of family/social/occupational support rather than dissatisfaction with medical transition itself 7

Never discontinue testosterone due to concerns about potential regret, as this significantly worsens gender dysphoria and mental health outcomes. 7, 2

Surgical Considerations and Timing

Coordinate with surgery teams for chest masculinization (top surgery) and consideration of hysterectomy with bilateral oophorectomy. 1

• Chest masculinization typically retains some breast tissue including nipple-areolar complex, requiring continued breast cancer screening 1
• After bilateral oophorectomy, patients no longer require goserelin or leuprolide for estrogen-dependent conditions 1
• Surgical decisions should account for both medical necessity and gender dysphoria relief 1

Ongoing Screening Requirements

Continue cervical cancer screening if cervix remains, and breast cancer screening for residual breast tissue after chest surgery. 1, 8

• Breast cancers have been reported in residual mammary tissue after chest masculinization 8
• Vaginal, cervical, and endometrial carcinomas remain possible if these organs are retained 8
• Imaging (particularly breast MRI) helps determine volume of residual breast tissue for screening decisions 1

Common Pitfalls to Avoid

• Do not use sex-assigned-at-birth reference ranges after 6 months of testosterone therapy for creatinine, body composition calculations, or chemotherapy dosing 1
• Do not require removal of chest binders for all procedures—coordinate with surgical teams to remove only when medically necessary, ideally after induction 1
• Do not mandate urine pregnancy testing without offering serum beta-hCG alternative, as this triggers significant gender dysphoria 1
• Do not assume insurance coverage—19% of transgender persons lack health insurance, and many plans exclude transition-related care despite medical necessity 1

Multidisciplinary Team Composition

Assemble a care team including primary care physician, endocrinologist, mental health professional, and surgical specialists as needed. 1

• This team determines the most appropriate individualized care plan 1
• Mental health support during recovery is valued, with 61% of patients grateful for chaplain visits and 58% requesting follow-up support calls 7
• Comprehensive transgender health care services improve mental health, reduce suicide rates, and lower overall healthcare costs due to fewer mental health and substance abuse-related expenses 1