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Patient Resources

Transgender Health Treatments

March 10, 2022

Decisions about medical care for transgender and gender non-binary people seeking gender-affirming medications and surgeries should be a collaborative decision among you, your mental health professional and a trained endocrinologist or experienced medical provider. Talk honestly with your healthcare providers about what is best for you.  

Feminizing Hormone Therapy 

Feminizing hormone therapy includes medications that will reduce the level of testosterone while providing enough estrogen (or estradiol) to allow feminizing changes to occur. It is important to let your provider know if you take any other prescribed medications or over-the-counter supplements as these may interfere with feminizing medications. Estradiol serves two roles in feminizing treatment:  

  • Estradiol is powerful at reducing your testosterone levels. 
  • Estradiol is a hormone that promotes feminine physical changes. 

Estradiol can be given in many ways, most commonly, oral, transdermal, or injectable. Your provider should review the pros and cons of each of these. It is important to review your medical history with your provider particularly if you have a history of cancer (including breast or prostate), heart disease, stroke, blood clots, liver disease or smoking, because your risks associated with hormone therapy may be increased if you have any of these.  

The most concerning risk related to estradiol therapy is increased risk of blood clots. The risk is minimized by using transdermal patches and bioidentical estradiol and by avoiding all smoking. 

Other possible concerns sometimes related to estradiol therapy include:  

  • Change in cholesterol profile (higher triglycerides) 
  • High blood pressure 
  • Possibly heart disease/stroke, particularly if you are older than age 50 years 
  • Breast cancer (same as cisgender population) 
  • Gall bladder stones 

Because the risk of blood clots with estrogens seems related to total dose, most feminizing treatment includes other testosterone lowering or blocking medicines in addition to estradiol. In the United States, the most common medication against testosterone is spironolactone. Spironolactone pills may block the effects of testosterone and also reduce the levels in the blood. With the fall in testosterone level, you may notice breast tenderness. The most other common side effects include increased urination, dizziness, risk of high potassium and possibly lower blood pressure. Your provider will monitor your potassium levels. If these side effects are too significant, speak to your health care provider about alternatives.  

Infographic on understanding estrogen.

Physical changes may take some time to occur. Below we have provided a general expected timeline. It is important to know that everyone is different. Your height, voice and Adam’s apple will not change with hormone therapy. 

In 1 to 3 months: 

  • Decrease in sexual desire and function (including erections
  • Baldness slows and may reverse slightly 

In 3 to 6 months: 

  • Softer skin 
  • Decrease in testicular size 
  • Breast development and tenderness (permanent effect)
  • Change in body fat distribution- moving more to the hips and buttocks area 

In 6 to 12 months: 

  • Hair may become softer and finer 

Feminizing hormones will decrease sperm production; however it is still possible to get your partner pregnant if you engage in vaginal sex. You may need to use additional birth control measures. If you wish to have children in the future, consider banking sperm before starting hormone therapy. 

Your provider will recommend that you regularly come for follow up care after these hormones have started. Follow up visits may include physical examinations, measurement of hormone levels and sometime other testing depending on your age and medical problems. Other tests may include a bone density, mammogram, prostate assessment, sexually transmitted infection (STI) screen and follow up of blood sugar and cholesterol. If you are older than 50 years of age, your doctor may want to evaluate your risk of heart disease a little more carefully. 

Masculinizing Hormone Therapy 

Masculinizing hormone therapy includes medications that will increase testosterone levels in your body to cause masculinizing changes to occur. It is important to let your provider know if you take any other prescribed medications or over-the-counter supplements as these may interfere with masculinizing medications. 

Testosterone can be given in many ways. The most common include injections (shots), gel and patches. It is important to let you provider know your entire medical history such as heart disease and cancers if any. 

The primary risk related to testosterone therapy is elevation of red blood cell count. Other possible concerns sometimes related to testosterone therapy include:  

  • Change to cholesterol profile (for example, lower HDL cholesterol)  
  • Sleep apnea 
  • Acne
  • Vaginal tissue thinning or irritation
  • Soreness at the injection site 

Image of patient guide on the truth about testosterone treatments.

Below we have provided a list of common physical changes. Changes may be noticeable in 1 to 6 months and will continue throughout life. It is important to know that everyone is different. Things that will not change include height or breast size.

In 1 to 6 months: 

  • Balding (depending on your age and family pattern)  
  • Deeper voice (permanent effect)
  • Acne 
  • Increased and coarser facial and body hair (semi-permanent effect)
  • Change in the distribution of your body fat- to the belly area 
  • Enlargement of the clitoris (permanent effect)  
  • Menstrual cycle stops 
  • Increased muscle mass and strength 

If you might want children in your future, talk to your provider about fertility options before starting hormone therapy. Even though your periods may stop when you take masculinizing hormone therapy, you should still use birth control if you engage in vaginal sex. 

Your provider will recommend that you regularly come for follow up care after these hormones have started. Follow up visits may include physical examinations, measurement of hormone levels and sometime other testing depending on your age and medical problems. Other tests may include a bone density, mammogram, pelvic exam and/or pap smear, sexually transmitted infection (STI) screen and follow up of blood sugar and cholesterol. 

Gender-Affirming Surgery 

Gender-affirming surgeries can be performed to better align the bodies of transgender and gender non-binary people with their gender identities. Not all gender diverse people need or want gender-affirming surgeries. 

Facial feminization surgery, chest surgery, and breast augmentation require 1 letter of support from a mental health provider competent in transgender health who determines that the patient meets the World Professional Association of Transgender Health (WPATH) Standards of Care criteria for surgeries. Genital surgery requires referrals and letters of support from two mental health providers competent in transgender health who determine that the patient meets the WPATH criteria.   

Some insurance companies do not cover all recommended services, even though they are medically necessary. You should determine what coverage is provided by by health insurance with your surgical provider.

Chest-wall contouring/Male Mastectomy (“top surgery”): This procedure removes most of the breast tissue; however, breast cancer surveillance still needs to continue when indicated. 

Hysterectomy: This involves the removal of the uterus 

Bilateral Salpingo-oophorectomy: This involves the removal of both fallopian tubes and ovaries. 

Metoidioplasty: This procedure lengthens the hormonally enlarged clitoris. Can also include formation of a scrotum and closure of the vaginal canal. Urethral diversion may enable standing with urination. Penetrative sex may not be possible. 

Phalloplasty: This is a surgical procedure to construct a penis. A penile prosthesis is needed for sexual intercourse. 

Breast Augmentation (“top surgery”): This procedure increases breast size with fat grafting or implants. 
 
Orchiectomy: This procedural involves the removal of one or both testicles, and can be done in conjunction with other surgeries, such as vaginoplasty. 
 
Vaginoplasty: This provedure creates a vaginal vault, and the vaginal lining may be created from penile skin or part of bowel. An orchiectomy is performed, the labia majora (vaginal lips) are created using scrotal skin, and the clitoris is created from a portion of the penis. The prostate is left in place. 

Facial Feminization Surgery: This is when masculine facial structures are changed into a more feminine appearance. Examples include hairline advancement, brow lift, forehead contouring, rhinoplasty (nose surgery), and chin and jaw modification. 

Tracheal Shave: This procedure reduces the size of the “Adam’s apple.”

Potential complications include:

  • Bleeding 
  • Infection 
  • Wound healing concerns 
  • Fistulas 
  • Persistent pain or loss of sensation 
  • Loss of sexual pleasure and functioning 
  • Blood clots 
  • Urinary concerns (e.g., incontinence) 
  • Pelvic floor dysfunction 
  • What treatment options will help to align my body with my gender identity?  
  • How will I know when it's time for gender-affirming medication or surgery?  
  • What are the side-effects of gender-affirming hormone therapies?  
  • What are the potential complications of gender-affirming surgeries? 

Infographic of transitions of care transgender health.

 

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