Can primary care providers (PCPs) offer transgender care, including hormone replacement therapy (HRT) with medications such as estradiol or testosterone?

Can Primary Care Provide Transgender Care?

Yes, primary care providers can and should offer comprehensive transgender care, including hormone replacement therapy with estradiol or testosterone. The American College of Physicians explicitly recognizes that primary care physicians are integral members of the transgender health care team and are positioned to prescribe and monitor gender-affirming hormone therapy 1.

Primary Care's Role in Transgender Health

Primary care providers are well-suited to deliver gender-affirming hormone therapy as part of routine practice. The care team for transgender patients includes primary care physicians, endocrinologists, and mental health professionals, with primary care physicians continuing to deliver long-term care 1, 2. Research demonstrates that providing hormone therapy through primary care increases accessibility, reduces wait times, and depathologizes gender diversity 3.

Key Competencies Required

Primary care providers need specific knowledge to provide competent transgender care:

• Understanding hormone therapy protocols: PCPs should know how to prescribe transdermal 17β-estradiol (50-100 μg/24 hours) for transgender women and testosterone cypionate/enanthate (starting at 50 mg subcutaneously weekly) for transgender men 4, 5.

• Monitoring parameters: Target testosterone levels <50 ng/dL for transgender women and 300-1,000 ng/dL for transgender men, with monitoring every 3 months initially, then every 3-6 months during the first year, then annually if stable 4, 6, 5.

• Screening based on anatomy present: Continue cervical cancer screening if cervix remains, breast cancer screening for residual breast tissue after chest surgery, and prostate screening for transgender women 1, 5.

Practical Implementation Algorithm

Step 1: Create a Welcoming Environment

• Document preferred name, pronouns, and gender identity separately from legal name and sex assigned at birth in the electronic health record 5.
• Flag charts to alert staff to use preferred name and pronouns 1.
• Establish complete anatomical inventory (presence of uterus, ovaries, cervix, breasts, prostate) as this directly impacts screening needs 5.

Step 2: Initial Assessment Before Starting Hormones

For transgender women (assigned male at birth):

• Baseline complete blood count, liver function, lipid profile, glucose, and hormone levels 6.
• Screen for contraindications: history of estrogen-sensitive cancers, uncontrolled cardiovascular disease, history of venous thromboembolism 4.

For transgender men (assigned female at birth):

• Screen for liver abnormalities and obtain baseline CBC to assess for polycythemia 5.
• Assess cardiovascular risk factors, obtain lipid profile, glucose, and baseline hormone levels 5.

Step 3: Initiate Hormone Therapy

For transgender women:

• Start transdermal 17β-estradiol patch 50 μg/24 hours (preferred over oral due to lower thrombotic risk) 4, 6.
• Add spironolactone 50-100 mg daily, divided into 1-2 doses 4, 6.
• Avoid ethinyl estradiol due to increased thromboembolism risk 6.

For transgender men:

• Initiate testosterone cypionate or enanthate 50 mg subcutaneously weekly 5.
• Adjust to achieve serum testosterone levels 300-1,000 ng/dL 5.

Step 4: Monitoring Schedule

• Check hormone levels at 1-3 months, then every 3-6 months during first year, then annually 4, 6, 5.
• Monitor CBC for polycythemia in transgender men 5.
• Annual physical examination and laboratory monitoring including lipid profile and liver function 4, 6.

Addressing the Knowledge Gap

The primary barrier to transgender care in primary care is lack of provider knowledge, not inability to provide the care. Half of transgender patients report having to "teach" their physician about transgender health, and 19% have been denied medical care due to their transgender status 1. Medical schools provide a median of only 5 hours on LGBT-related issues over the entire curriculum 1.

However, hormone treatments are generally straightforward once physicians recognize that gender identity is stable 7. The American College of Physicians publishes comprehensive resources including The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health to support primary care providers 1.

Clinical Outcomes Supporting Primary Care Delivery

When transgender persons receive medically appropriate care, they experience improved mental health, reduction in suicide rates, and lower overall healthcare costs 1. Specifically, 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 5.

Primary care-based models demonstrate high patient satisfaction due to accessibility, relationship-centered care, and timeliness 3. The cost of including transgender health care in health plans is minimal, with two-thirds of employers reporting zero costs for transition-related coverage 1.

Common Pitfalls to Avoid

• Do not require mental health clearance before initiating hormone therapy in adults with clear gender dysphoria - this creates unnecessary barriers and delays care 3.

• Do not use sex-assigned-at-birth reference ranges after 6 months of hormone therapy for creatinine, body composition calculations, or medication dosing 5.

• Do not prescribe oral estradiol as first-line therapy - transdermal formulations have lower thrombotic risk due to avoiding first-pass hepatic metabolism 4, 6.

• Do not assume all transgender women need progesterone - current evidence does not support routine use and may increase risks of breast cancer, thromboembolism, and stroke 4.

• Do not mandate urine pregnancy testing without offering serum beta-hCG alternative for transgender men, as this triggers significant gender dysphoria 5.

When to Refer

While primary care can manage most transgender hormone therapy, consider referral to endocrinology for:

• Complex cases with multiple comorbidities affecting hormone metabolism 1.
• Difficulty achieving target hormone levels despite dose adjustments 7.
• Significant adverse effects requiring specialized management 8.

The evidence strongly supports primary care as an appropriate and effective setting for providing gender-affirming hormone therapy, with the main requirement being provider education and willingness to learn 1, 9, 3.