Monitoring
Clinical review
For patients receiving hormone treatment, medical evaluation by the hormone-prescribing physician every 2-3 months in the first year, and every 6-12 months thereafter, is recommended.[4][31][44] This is to monitor for appropriate signs of masculinisation/feminisation, and for the development of any adverse reactions (e.g., venous thromboembolism, cardiovascular impairment). It typically takes at least 2 years for patients to achieve maximal masculinising/feminising results from hormones.[31]
Patients who undergo gonadectomy require hormone replacement treatment, surveillance, or both, to prevent adverse effects associated with chronic hormone deficiency.[31]
Blood tests
For patients receiving hormone treatment, laboratory (blood test) monitoring is recommended every 2-3 months in the first year, and every 6-12 months thereafter.[4][31][44] A clinical priority is maintaining testosterone/oestrogen levels within the physiological range for birth-assigned female/birth-assigned male patients respectively, given that supraphysiological doses may lead to an increased risk of adverse effects.[31] Long-term monitoring of lipids, prolactin, liver functional tests (plus haematocrit in transgender men only) from baseline is advisable, although derangements are rare. The Endocrine Society guidelines contain detailed standard monitoring plans for patients on both testosterone and oestrogen cross-hormone therapy, including recommended serum hormone levels.[31]
Note that there are particular considerations with regard to testosterone monitoring according to whether a topical or injected preparation is used. With topical testosterone preparations levels should be measured at least 6 hours after the preparation was applied, making sure the blood is drawn from a different site to the one the preparation was earlier applied. Injected preparations need a peak and trough level. The trough is the level that pertains to the day the injection is due and should be at the bottom end of the normal male range. The peak level is that which applies a week after the injection is given, and should be at the top end of the normal male range. This ensures that at no point in the dosing cycle is the level supraphysiologically high or low. Longer acting preparations need a single, trough, measurement that should be at the bottom end of the normal range.
Mammography in transgender women
It is not clear whether there is any need for mammographic breast cancer screening in transgender women. Data are sparse, but only five breast cancers have ever been reported in this patient group, and these were in patients on unsupervised treatment regimes that included progesterone (which raises the risk of cancer in birth-assigned females on hormone replacement therapy). Avoiding the use of progesterone in treatment seems greatly to decrease the risk of breast cancer.[57] Based on a potential increased risk of breast cancer with feminising hormones, the Endocrine Society guidelines suggest that transgender taking feminising hormones follow breast screening guidelines recommended for birth-assigned women.[31] It may be necessary to take into consideration the length of time of hormone use, dosing, current age, and the age at which hormones were initiated.[4]
Mammography in transgender men
If mastectomy has not been performed, standard breast screening guidance applies.[4]
Prostate screening in transgender women
Transgender women treated with oestrogens should follow screening guidelines for prostatic disease and prostate cancer recommended for birth-assigned men.[31] Manual prostate checks may be performed via the vaginal canal in transgender women who have received genital surgery, as the prostate is located on the anterior wall of the vagina.[4] Although there are case reports of prostate cancer in transgender women, most were in people who started hormone therapy after the age of 50 years, and it is considered likely that these people had pre-existing lesions before initiating hormone treatment.[59] It is important to note that following the initiation of gender-affirming hormone treatment, prostate-specific antigen (PSA) may be a less-useful measuring tool for prostate cancer, given that PSA levels ordinarily plummet in transgender women taking gender-affirming hormone therapy, meaning that extra care is needed in interpreting results.[38] Guidance on screening and recommended PSA ranges in transgender women is currently lacking; establishment of a baseline PSA level prior to hormone therapy is often recommended.
Gynaecological monitoring
Anyone with an intact uterus, cervix, or ovaries should be offered the usual screens for malignancies of these organs.[4] Gender-affirming hormones have not been shown to affect cancer risk, but the quality of evidence is low and longer-term studies are needed.[55]
Previously, total hysterectomy and oophorectomy were recommended for transgender men taking testosterone therapy, but the World Professional Association for Transgender Health now recommends against against routine oophorectomy or hysterectomy solely for the purpose of preventing ovarian or uterine cancer for transgender men undergoing testosterone treatment and who have an otherwise average risk of malignancy.[4][31]
Patients re-registered as male may be automatically dropped out of cervical cancer screening programmes and should be advised to proactively seek such screening.
Bone mineral density measurement
This is recommended for patients with risk factors for osteoporosis, and in particular for those who stop hormone treatment following gonadectomy.[31]
Aortic aneurysm screening
Transgender women should be offered abdominal aortic aneurysm screening in keeping with routine screening programmes for birth-assigned men.
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