Dr. Leslie Greenberg's Blog

Transgender women medical care

I recently attended a medical lecture on transgender medical care. Here were some take-home points about transgender women.

3 commonly prescribed feminizing medications:

Here is an excellent checklist and consent regarding starting feminizing medications.

1. Estradiol (oral/transdermal/intramuscularly). Oral and transdermal are the most common.  Estradiol is often used for postmenopausal females.  Most physicians are accustomed to giving this. The effects of these medications are both reversible and irreversible.

Reversible (loss of muscle mass, weight gain, skin changes, erectile dysfunction, mood, nausea, increased risk of blood clots, diabetes and hypertension).

Irreversible effects (breast growth, testicle size reduction, infertility).  Because of infertility, discuss fertility plans with the patient.  Estradiol 2 mg by mouth daily may help the patient inch up.  If the patient wants to shut down male attributes, a therapeutic dose may be estradiol 6 mg. Transdermal estrogen decreases clot risk.

2. Antiandrogen.  Spironolactone is often used.  This may cause premature breast bud fusion in adolescents.  Many physicians start with estrogen and then add spironolactone later and the dose of spironolactone can be titrated up.  Bicalutamide is an old drug that (was originally used for prostate cancer) is also used for antiandrogen effects.  It has had case report of liver failure and this should be discussed with patients.  Patients may learn of bicalutamide on Youtube. The physician and patient should used shared decision making when this drug is used.

3. Progestagens.  They promote breast growth.  Synthetic type is Depo Provera (injected subcutaneous or intramuscular every 3 months) or bio identical oral tablets of micronized progesterone.  Usual dose of micronized progesterone is 100 mg po taken nightly. 

Labwork:

Within 3 months blood lab work is done.

The treatment goal is to manipulate testosterone in all patients.  Estradiol goal is around 100.  But if the testosterone is less than 55, the medication is therapeutic.  Sex hormone binding globulin lab does not need to be obtained as it does not give us much information.

Two labs: testosterone and estradiol levels are important and will change care.

Surgery:

1. Medications often cause increased breast formation.  Many plastic surgeons perform breast augmentation for transgender women.
2. Orchiectomy (removal of testicles) is often performed by urologists. 
3. Gender-affirming vaginoplasty.  This is done at tertiary care centers who specialize in this. The surgeries make a neo-vagina with the penis and scrotum. The nerve bundle at the glans penis are placed to make a clitoris. 80% of patients after this surgery have orgasms with genital stimulation. THE PROSTATE IS PRESERVED. The prostate is kept in place to help suspend the bladder to maintain continence. Because the prostate is still present, this needs appropriate screening for prostate cancer.

Be sure your primary care physician knows which organs you have. This will let us know which health screenings you need.

Prostate cancer screening is needed in transwomen that still have a prostate.  Rectal exam does not feel the prostate after a neovaginal surgery was performed.  The prostate is felt through a vaginal exam. Your physician should consider PSA per guidelines and shared guidelines with the patient are done.  Prostate cancer is thought to be low, but we do not know.Let us help you appropriately.

I hope this helps.

I also have a transgender man medical care blog.