Residency · Residency · Obstetrics Gynecology

Gender-Affirming Hormone Therapy and Gynecologic Care

Introduction

OB/GYN physicians are increasingly called upon to provide gynecologic care and gender-affirming hormone therapy (GAHT) for transgender and gender-diverse (TGD) patients. Approximately 1.4 million adults in the United States identify as transgender. Competency in GAHT, cancer screening for retained organs, fertility preservation, and creating inclusive clinical environments is essential for equitable care.

Terminology and Inclusive Care

A transgender man (transmasculine) is a person assigned female at birth whose gender identity is male or masculine-spectrum. A transgender woman (transfeminine) is a person assigned male at birth whose gender identity is female or feminine-spectrum. Nonbinary individuals exist outside the male/female binary and may pursue partial, full, or no medical transition. Best practices for inclusive care include using chosen names and correct pronouns, training staff on inclusive language, offering gender-neutral intake forms, minimizing unnecessary genital examinations, and explaining procedures with sensitivity to potential dysphoria.

Gender-Affirming Hormone Therapy for Transmasculine Patients

Testosterone Therapy

Testosterone formulations include cypionate or enanthate IM or subcutaneous (50-100 mg weekly), topical gel (50-100 mg daily), and patches. Expected effects include cessation of menses within 1-6 months, voice deepening at 3-12 months (irreversible), facial/body hair at 6-36 months, clitoromegaly at 3-6 months, fat redistribution at 3-6 months, and increased muscle mass at 6-12 months.

Monitoring

Target total testosterone is 400-700 ng/dL (cisgender male range) at trough levels. CBC monitors for polycythemia (hematocrit greater than 50%). Lipid panel tracks potential HDL decrease and LDL increase. Liver function tests and metabolic parameters are checked periodically.

Gynecologic Considerations

Testosterone achieves amenorrhea in most patients within 6 months; persistent bleeding warrants endometrial evaluation and consideration of adjunctive progestins or GnRH agonists. Vaginal atrophy (dryness, irritation) is common and safely treated with topical vaginal estradiol without causing systemic feminization. Cervical cancer screening follows standard guidelines for patients with a cervix; testosterone-induced atrophy may cause unsatisfactory cytology. Pelvic examinations may trigger significant dysphoria and should be minimized, with self-swab options offered when possible.

<image>Timeline illustration showing the expected physical effects of testosterone therapy in transmasculine patients, with onset and maximum effect timepoints for voice changes, body hair growth, fat redistribution, cessation of menses, clitoromegaly, and acne</image>

Gender-Affirming Hormone Therapy for Transfeminine Patients

Estrogen and Anti-Androgen Therapy

Estrogen options include oral estradiol (2-8 mg daily), transdermal estradiol (0.1-0.4 mg patch twice weekly), or IM estradiol valerate/cypionate. Transdermal is preferred in patients over 40 or with VTE risk factors to avoid first-pass hepatic effects. Spironolactone (100-300 mg daily) is the most common anti-androgen in the US. Micronized progesterone is sometimes added for theoretical breast development benefits. Expected effects include breast development onset at 3-6 months (maximum 2-3 years, irreversible), decreased libido at 1-3 months, testicular atrophy at 3-6 months, and fat redistribution at 3-6 months.

Monitoring

Target estradiol is 100-200 pg/mL and testosterone less than 50 ng/dL. Potassium is monitored with spironolactone. Prolactin is checked annually (estrogen causes lactotroph hyperplasia). VTE risk increases 2-5 fold with estrogen, with transdermal carrying lower risk than oral.

Cancer Screening in Transgender Patients

Cancer screening is based on retained organs, not gender identity. Transmasculine patients with a cervix follow standard cervical screening. Transmasculine patients without mastectomy follow cisgender female breast screening. Transfeminine patients on estrogen begin mammography after 5-10 years of hormone use. Transfeminine patients retain their prostate and follow standard age-based screening. There is no evidence of increased endometrial or ovarian cancer risk with testosterone.

Fertility Preservation

Counseling on fertility preservation should occur before GAHT initiation. Transmasculine patients may undergo oocyte or embryo cryopreservation (testosterone discontinued for stimulation). Transfeminine patients should bank sperm before estrogen therapy. Pregnancy in transmasculine patients requires testosterone discontinuation (teratogenic) and gender-affirming prenatal care.

<image>Flowchart illustrating the cancer screening recommendations for transgender patients based on retained organs and hormonal therapy status, covering cervical, breast, prostate, ovarian, and endometrial cancer screening with corresponding guidelines</image>

Surgical Considerations

Transmasculine surgeries include chest masculinization, hysterectomy with or without oophorectomy, metoidioplasty, and phalloplasty. Gynecologists may perform hysterectomy and oophorectomy as gender-affirming care, with route individualized (testosterone-induced vaginal atrophy may limit vaginal approach). Transfeminine patients post-vaginoplasty require dilation education, granulation tissue screening, and STI screening; Pap smears of the neovagina are not indicated.

Clinical Pearls

Testosterone achieves amenorrhea in most transmasculine patients within 6 months; persistent bleeding warrants workup. Transdermal estradiol is preferred over oral in transfeminine patients over 40 or with VTE risk factors. Cancer screening is based on retained organs, not gender identity -- a transmasculine patient with a cervix needs cervical cancer screening. Fertility preservation counseling should precede GAHT initiation. Creating an inclusive clinical environment is as important as pharmacologic management for delivering quality care.

References

1. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017;102(11):3869-3903.
2. ACOG Committee Opinion No. 823. Health care for transgender and gender diverse individuals. Obstet Gynecol. 2021;137(3):e75-e88.
3. Deutsch MB, ed. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. 2nd ed. University of California, San Francisco Center of Excellence for Transgender Health; 2016.
4. Krempasky C, Harris M, Abern L, Grimstad F. Contraception across the transmasculine spectrum. Am J Obstet Gynecol. 2020;222(2):134-143.

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