- Transgender patients are less likely to be up to date with vaccinations and screening tests.
- There is no difference in the vaccination schedule between cisgender and transgender patients.
- Transgender patients with no current or past use of hormones should be screened as per the screening guidelines of their natal gender.
- Transgender patients are at a higher risk of HIV and hepatitis. Patients with risk factors should be screened every 6 months.
Vaccination recommendations are the same in both transgender and cisgender populations. Since patients that are transgender do not always have regular primary care follow-up it is important to inquire about whether or not vaccinations are up to date. Remember to encourage patients to receive the human papilloma virus (HPV) vaccine.
Transgender patients are more likely to experience mental health problems compared to the general population. There are also higher rates of attempted and completed suicide. Routinely screen all transgender patients for depression. Refer as needed to a trans-competent mental health provider.
Smoking: Screen all patients for past/current tobacco use via history. Include smoking cessation management as needed. Trans-specific associated risks include increased risk of venous thromboembolism with estrogen therapy or post-op and increased risk of cardiovascular disease with any hormone therapy (especially >50 years old).
Alcohol and Drugs: Screen all patients for alcohol and drug use via history. Refer as needed to an addictions treatment program. In referral to residential addiction programs that have gender-specific programming or facilities, particular attention is needed to ensure the transgender person will be welcomed and that appropriate accommodations will be made in sleeping arrangements, shower use, bathroom use, and group activities. Follow the safe drinking guidelines for cis women in MtF patients taking estrogen as it effects the metabolism of alcohol.
Screening and treatment of known, modifiable cardiovascular risk factors is recommended. Risk factors should be reasonably well-controlled prior to the initiation of hormone therapy. Consider daily aspirin in patients at high risk of coronary artery disease.
- Currently on hormones: Patients with pre-existing coronary artery disease are at an increased risk of future events when using estrogen and/or progestin. These patients should be closely monitored for cardiac events/symptoms, especially during the first 1-2 years of hormone therapy. Risk reduction may be accomplished with the use of transdermal estrogen, lower estrogen doses, or omission of progestin.
Exogenous estrogen increases blood pressure.
- Not on hormones: Screen as per cis gender guidelines; if planning to start hormone therapy within 3 years, goal ≤ 140/90
- Currently on hormones: Monitor blood pressure every 3 months, goal ≤ 140/90. Consider spironolactone (anti-androgen and diuretic) as part of an antihypertensive regimen if needed.
- Not on hormones: Screen and treat hyperlipidemia as per non-transgender guidelines; consider LDL ≤ 3.5 mmol/L if planning to start hormones within 1-3 years.
- Currently on hormones: Annual lipid profile. Transdermal estrogen is recommended for patients with hyperlipidemia, especially hypertriglyceridemia (oral estrogen increases triglycerides); goal LDL ≤ 3.5 mmol/L for low-moderate risk patients and ≤ 2.5 mmol/L for high risk patients.
- Not on hormones: Follow screening guidelines for cisgender patients.
- Currently on hormones: Annual glucose testing if family history of diabetes and/or >5 kg weight gain. Manage diabetes as per cisgender guidelines but insulin-sensitizing agents are recommended if medication is indicated. Decreased estrogen dosing may be indicated if glucose is difficult to control or patient is unable to lose weight.
- Currently on hormones: ~ 4 kg of lean body mass is lost following the initiation of androgen-deprivation treatment. Exercise may help maintain muscle tone.
- Not on hormones, no surgery: No increased risk, follow cisgender screening guidelines.
- Past/present hormone use, no surgery: No evidence of increased risk, follow cisgender screening guidelines. Calcium and vitamin D supplementation recommended. Consider bone density screening for patients >60 years of age who have been off estrogen therapy for > 5 years.
- Screen: Patients on anti-androgen therapy for a significant length of time without co-administration of exogenous estrogen.
- Post-orchiectomy: Estrogen therapy is recommended to reduce the risk of osteoporosis (a very low dose might be sufficient i.e. 0.025 mg transdermal estradiol, or 0.3 mg conjugated equine estrogens). If there are contraindications to estrogen, calcium and vitamin D supplementation is recommended. Consider bisphosphonates if additional risk factors for bone loss.
- (1) Patients with elevated luteinizing hormone levels;
- (2) Patients who have stopped their cross-sex hormones post-orchiectomy for any significant length of time.
- No hormone use: No increased risk of breast cancer compared to cis men; routine screening is not indicated.
- Past or current hormone use: Patients taking feminizing hormones may be at an increased risk for breast cancer, although this risk is still felt to be significantly lower than the risk in cis women. Although screening mammography is currently not supported by the evidence, it is advisable in patients > 50 years of age who have additional risk factors (estrogen and progestin use > 5 yrs, family history of breast cancer, BMI >35). Screening clinical or self-breast exams are not recommended.
- Breast augmentation: Breast augmentation has not been shown to increase the risk of breast cancer. Therefore no screening mammography is recommended. Of note, it may negatively impact the accuracy of mammography done for other indications.
- Post-vaginoplasty: Patients whose penis was used to create a neocervix should receive pap smears according to the guidelines for cis women. Vaginal pap smears should be considered for patients with a history of genital warts, especially if immunocompromised.
- Not on hormones, no surgery: Screening is controversial as in cis men and should be discussed with the patient.
- Past or current hormones, +/- surgery: Screening is controversial as in cis men and should be discussed with the patient. The prostate is not removed in MtF genital surgery. Feminizing hormone therapy appears to decrease the risk of prostate cancer (degree of reduction unknown). Caution should be used when interpreting PSA results in androgen-deficient patients as they may be falsely low, even in the presence of prostate cancer.
HIV, Hepatitis B/C
The transgender population has a higher risk of HIV/AIDS compared to the general population. The trans-specific risk is needle-sharing for injectable hormones or silicone. Screen at risk patients every 6 months. In all other patients consider one time testing. Offer the hepatitis B vaccine to all non-immune patients. Monitor liver enzymes in patients with hepatitis who are also on hormones. Some HIV medications increase/decrease serum estrogen levels but there is no evidence that hormones interfere with the effectiveness of HIV treatment.
Transgender patients (any gender) who have sex with men (TSM) are at an increased risk of sexually transmitted infections (STIs). Ideally, STI prevention and screening is based on a thorough understanding of the specific sexual activities in which a patient engages. However, it is often uncomfortable for the patient to discuss explicit sexual details in the primary care setting. Therefore, if the clinician-patient rapport is not such that a detailed sexual history can be elicited, screen all sexually active patients at least yearly for chlamydia, gonorrhea, and syphilis. If ongoing risk factors are present, consider screening every 6 months.
A urine-based test of a non-clean catch specimen can be used regardless of anatomy, making this the ideal testing method for most transgender patients. Alternatively, a urethral sample can be taken in patients with a natal penis (MtF pre-surgery), or a vagina (MtF post-vaginoplasty). Rectal and pharyngeal samples can be used in patients with symptoms in these areas.
Treat all STIs as per recommended guidelines for the general population.