The LGBTQ+ community is currently celebrating a landmark Supreme Court win along with Pride Month. Across the country, workplace discrimination on the basis of sexual orientation or gender identity is now illegal.
This ruling represents a major step forward for LGBTQ+ individuals. At the same time, LGBTQ+ people, especially transgender people, are still experiencing health care disparities and barriers to health care access. One of those barriers is a lack of knowledge on the part of some health care professionals.
Here are six things to know about caring for transgender patients. Additional resources on transgender patient care are available here.
Hormone replacement therapy
When a patient is considering a transition, the first medical step is usually hormone replacement therapy. When taking hormones, transgender people should have primary care follow-ups every two to three months for the first 12 months and then one to two times annually thereafter. Blood levels of testosterone and estradiol should be checked at these appointments and then hormones can be dosed accordingly.
Physicians should do basic blood monitoring and also check patients’ weight, blood pressure, lipids and hemoglobin A1C (a marker for diabetes) every few months.
For many patients, the benefits of hormone therapy outweigh the risks. Nonetheless, physicians should be aware of these risks and should counsel patients on them before patients start hormone therapy.
Estrogen use increases the risk of blood clots, particularly in obese people who are over age 40, those who smoke, those who have little physical activity, and those who have underlying blood-clotting disorders. This risk is thought to be less with non-oral routes of administration.
Estrogen use also increases the risk of cardiovascular events in people over age 50 with underlying cardiac risk factors, including diabetes and high blood pressure. Other risks include the development of Type 2 diabetes and gall stones, but it is unknown exactly how likely these are to develop in an individual.
All of the above risks are rare but can happen. If someone already has some of these cardiac risk factors, a cardiologist should be on board. Patients should be counseled on these risks prior to starting. The dosage of the hormone will be adjusted according to the patient’s goals, side effect profile and tolerability.
Patients taking testosterone have an increased risk of blood clotting disorders. Administration via an adhesive skin patch may decrease this risk. Masculinizing hormone therapy can also result in modest weight gain and worse lipid profiles.
In terms of malignancies, testosterone therapy in female to male (FtM) patients does not increase the risk of breast cancer and cervical cancer, though it may increase the risk of abnormal pap smears.
Evidence on the effect of testosterone therapy on the development of ovarian and endometrial cancers is limited.
If a transgender person has risk factors for a specific type of cancer, the general recommendation is to proceed with screening regardless of the hormone replacement therapy.
Breast cancer screening for transgender women is not recommended until after at least five years of feminizing hormone use, regardless of age.
After at least five years, it is then advised to get a mammogram every two years. Prostate cancer screening in MtF individuals follows the same schedule as that for biological men. In addition, there is no evidence for increased risk of testicular cancer with hormone replacement therapy.
In FtM patients, routine monitoring for endometrial cancer is not recommended due to proposed degeneration effects of testosterone on the uterine tissue. The guidelines for cervical cancer screening are the same as for biological women, including getting the first pap smear at age 21 and then every three years thereafter.
In terms of the ovaries, transgender men should receive the same recommended screenings as biological women based on history and presentation.
Monitoring of osteoporosis
Transgender people without testicles, and who are not using hormone replacement, should follow general prevention guidelines for osteoporosis. However, all transgender people regardless of sex assigned at birth or use of hormone replacement should begin testing (DEXA scan) at the age of 65.
People should get tested earlier if they have risk factors, including family history of osteoporosis, substance use or fractures. Research has overall found inconsistent results in terms of the risk of osteoporosis after receiving hormones.
Counsel transgender patients on all their reproductive options before they initiate their transition. In FtM individuals, there have been reports of people getting pregnant while still taking testosterone. In this case, testosterone should be stopped as it can be harmful in pregnancy. It is not known how long in advance of a pregnancy that testosterone should be stopped.
In MtF individuals, prolonged use of estrogen can damage sperm generation. Therefore, patients who may want children in the future should consider freezing sperm samples before beginning hormone therapies.
Options that may aid in reproduction include tissue cryopreservation and in vitro fertilization.
It is essential for transgender patients to have routine follow-ups annually to develop individualized treatment plans based on their individual circumstances, medical problems and goals of treatment. As access to care rises, transgender people can minimize their risks of disease, accomplish their transitional goals and live better lives.