Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

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transgender women (male-to-female transgender persons whose sex assigned at birth was male)

1st line – individualized multidisciplinary management

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transgender women (male-to-female transgender persons whose sex assigned at birth was male)
1st line – 

individualized multidisciplinary management

A multidisciplinary approach to management is strongly recommended; relevant disciplines include (but are not limited to) endocrinology, surgery, voice and communication, primary care, reproductive health, sexual health, and mental health.[4]​ However it is important to note that in some parts of the world, speciality services for transgender people are limited or wholly unavailable; in this setting, nonspecialist clinicians, for example, primary care providers may need to take on a greater role in the provision gender-affirming care, highlighting the need for continuing training and professional development in line with current best practices.[4]

Options for gender-affirming care include hormone therapies and surgeries. Adjunctive options include hair removal, speech and language therapy and supportive counseling. Management is highly individualized, and that there is no "one size fits all" approach. Transgender people may choose to undergo all, some, or none of the above interventions to support their gender affirmation.

Transgender people as a group experience relatively poorer access to health services compared to other patient groups. Noted barriers include bias and stigma by healthcare professionals and a lack of knowledge around best practices, including safety and efficacy of treatments.[46][47]​​ An open, nonjudgemental and inclusive approach is important and may help to encourage people to be forthcoming with their concerns, and less likely to obtain hormones from unlicensed sources.[41]

Transgender people also experience an increased risk of general mental health issues, including depression, anxiety, post-traumatic stress disorder, suicidality, and substance use disorders.[1][2]​​​[14]​ Ongoing screening, assessment, and management of any mental health conditions is therefore important.

Usually, clinicians maintain that hormone treatment should generally not be started unless the patient has already changed gender role.[31]​ This may include legally changing registration to that of the preferred sex and changing the person’s name on all documents, as well as making friends, family, and other contacts aware of this change and asking them to treat the person as their experienced sex. 

Based on clinical experience, advantages of this approach are that it can allow both patient and clinician to appreciate the degree to which the change in gender expression and role can be practically applied. Regrets following gender-affirming treatment are rare, but do occur; regret is more likely to occur in those who experience difficulties with social transition.[43][50]

Less commonly, hormone treatment is used for patients who do not wish to make a social gender role transition, or who are unable to do so.[4]

There is universal agreement within international standards of care that social transition of at least 1 year (plus 1 year of continuous hormone treatment) should precede any genital surgery.[4]​​[31] Longer periods may be needed if there are any problems living in the new gender role. Patients should not undergo surgical treatment until they are thriving (not merely surviving) in their new gender role.

Note that legal transition should not be dependent on use of medication or surgery, and varies according to local (i.e., national or state) laws; clinicians and patients should consult their relevant local legal guidance.[41]

Consider – estrogens

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transgender women (male-to-female transgender persons whose sex assigned at birth was male)
Consider – 

estrogens

Treatment recommended for SOME patients in selected patient group

Hormonal treatment is preferably done working as part of a multidisciplinary team containing (or having easy access to) an endocrinologist.

Criteria for hormone therapy include the following:[4]

  • Gender incongruence is marked and sustained.

  • The individual meets diagnostic criteria for gender incongruence prior to gender-affirming hormone treatment in regions where a diagnosis is necessary to access health care.

  • The individual demonstrates capacity to consent for the specific gender-affirming hormone treatment.

  • Other possible causes of apparent gender incongruence have been identified and excluded.

  • Mental health and physical conditions that could negatively impact the outcome of treatment have been assessed, with risks and benefits discussed.

  • The individual understands the effect of gender-affirming hormone treatment on reproduction and they have explored reproductive options.

A thorough discussion of the risks versus benefits of treatment is essential prior to treatment initiation, and guides shared decision-making.

Gender-affirming hormone treatment aims to elicit in a birth-assigned male patient the secondary sexual changes seen in birth-assigned females at puberty. These changes will be superimposed on whatever male pubertal changes have already occurred and will not reverse them. Effects of treatment may include breast growth, increased body fat percentage, decreased libido, decreased testicular size, and decreased erectile function.[41]​ There is no effect on vocal quality.[41] Facial and bodily hair growth is slowed only slightly and never stopped. For information on expected timing of feminizing effects of estrogen see Patient discussions.

Estrogen is either used alone, or with adjunctive androgen suppression therapy. A wide variety of different formulations and preparations are available, and local formularies vary considerably. In practice, both oral and transdermal estrogens are commonly used. In theory, transdermal estrogen may be associated with a lower risk of venous thromboembolism (VTE) and stroke (based on knowledge of the "first pass effect" and from extrapolation of data derived from postmenopausal women receiving hormone replacement therapy).[52]​ Any absolute risk will be dependent on the individual’s baseline risk for VTE. In clinical practice, oral estrogen is commonly used in transgender women who have a low baseline risk for VTE. For those ages over 45 years or with other risk factors for VTE, transdermal preparations are usually preferred.[41]

Currently available data do not provide clear guidance on dose titration; instead this should generally be based on patient goals.[41] As with any medication, use of the lowest dose possible to achieve the desired results is recommended.[41] Based on clinical experience, one approach is to start treatment with a low/moderate dose and build over time. Ultimately the goal is to reach a dose that produces a serum estradiol in the normal female premenopausal range.[41] Clinical experience suggests that high-dose treatment from the outset is associated with early duct fusion and the eventual formation of small, hard, conical breasts that cannot be made larger or more naturally textured with any subsequent hormonal manipulation.

It typically takes 2 or more years for patients to achieve maximal feminizing results from hormones. If there was gonadal suppression with a gonadotropin-releasing hormone agonist, the same dose will be needed after any genital surgery, although in later life doses might need to be lowered to achieve the same hormone levels as hepatic sex steroid metabolism can decrease with age.

For patients who go on to have orchidectomy, hormone therapy with estrogen is usually continued lifelong, unless contraindications develop.[4]

For recommended blood test monitoring regimens for patients newly started and established on hormone therapy see Monitoring.

Consult your guidelines and drug formularies for estrogen options and formulations.

Consider – androgen suppression therapy

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transgender women (male-to-female transgender persons whose sex assigned at birth was male)
Consider – 

androgen suppression therapy

Treatment recommended for SOME patients in selected patient group

Used in transgender women in whom native androgen production is not suppressed by full-dose estrogen therapy.[58]​ These tend to be younger patients (<40 years). Androgen suppression using a gonadotropin-releasing hormone (GnRH) agonist is preferred where available, given favorable safety and efficacy data.[31][53]​​​​ This treatment carries fewer side effects than when used for prostate cancer and is usually well tolerated, with bone density being protected by the parallel sex steroid therapy.

Disadvantages of GnRH agonists are the requirement for parenteral administration and a relatively greater cost, which sometimes prevents placement on available formularies. GnRH agonists are now used routinely in some countries, including the UK, but in other parts of the world, including the US, their use is limited due to cost and insurance coverage difficulties.

Alternative options for androgen suppression where GnRH agonists are not available include spironolactone, cyproterone, and 5-alpha reductase inhibitors.[4][31]​ Spironolactone is commonly used in the US.[41] Cyproterone is available in most countries, but not the US; overall, its use is decreasing due to its association with a number of adverse effects, including hyperlipidemia and raised prolactin levels.[54]

It typically takes 2 or more years for patients to achieve maximal feminizing results from hormones. If there was gonadal suppression with a GnRH agonist, the same dose will be needed after any genital surgery, although in later life doses might need to be lowered to achieve the same hormone levels as hepatic sex steroid metabolism can decrease with age.

For patients who go on to have orchidectomy, hormone therapy with estrogen is usually continued lifelong, unless contraindications develop.[4]

For recommended blood test monitoring regimens for patients newly started and established on hormone therapy see Monitoring.

Consult your guidelines and drug formularies for GnRH agonist options and formulations.

Consider – speech and language therapy

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transgender women (male-to-female transgender persons whose sex assigned at birth was male)
Consider – 

speech and language therapy

Treatment recommended for SOME patients in selected patient group

Transgender women wishing to achieve increased congruence between their voice and experienced gender may benefit from referral to a speech and language therapist/pathologist with specific training and experience in this field.[41]

Consider – hair removal

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transgender women (male-to-female transgender persons whose sex assigned at birth was male)
Consider – 

hair removal

Treatment recommended for SOME patients in selected patient group

This can be done with electrolysis or laser treatment. All other methods are nonpermanent.

Consider – head and neck surgery

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transgender women (male-to-female transgender persons whose sex assigned at birth was male)
Consider – 

head and neck surgery

Treatment recommended for SOME patients in selected patient group

Thyroid cartilage reduction is a usually unproblematic procedure that is sometimes needed in tall, thin, patients whose thyroid cartilage is unacceptably prominent. It can be combined with a cricothyroid approximation.

A cricothyroid approximation procedure can be done alone or combined with a thyroid cartilage reduction. It alters vocal quality to a more feminine pitch. It should only be attempted when speech therapy has failed, and usually requires follow-up speech therapy.[41]

Craniofacial surgery is a complex and sometimes very radical surgery that is sometimes helpful but should only be contemplated when treatment with hormones has been fully utilized and when simpler cosmesis has failed.

Consider – augmentation mammoplasty

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transgender women (male-to-female transgender persons whose sex assigned at birth was male)
Consider – 

augmentation mammoplasty

Treatment recommended for SOME patients in selected patient group

Although not a formal prerequisite, it is desirable that patients receive feminizing hormone treatment for a minimum of 12 months prior to augmentation mammoplasty.[32]​ Based on clinical experience, a minimum of 2 years is preferable. This is because it can be aesthetically problematic if natural breast development under estrogen stimulation follows an augmentation mammoplasty.

Consider – genital surgery

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transgender women (male-to-female transgender persons whose sex assigned at birth was male)
Consider – 

genital surgery

Treatment recommended for SOME patients in selected patient group

Some transgender people live successfully in their preferred gender role without surgery, but for others, genital surgery is the final (and most considered) step in the treatment process.

Criteria for genital surgery include the following:[4]

  • Gender incongruence is marked and sustained.

  • Meets diagnostic criteria for gender incongruence prior to gender-affirming surgical intervention in regions where a diagnosis is necessary to access health care.

  • Demonstrates capacity to consent for the specific gender-affirming surgical intervention.

  • Understands the effect of gender-affirming surgical intervention on reproduction and they have explored reproductive options.

  • Other possible causes of apparent gender incongruence have been identified and excluded.

  • Mental health and physical conditions that could negatively impact the outcome of gender-affirming surgical intervention have been assessed, with risks and benefits have been discussed.

  • Stable on their gender affirming hormonal treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated).*

*This was graded as a suggested criterion.

Furthermore, many clinics prefer that the patient has experienced 1-2 years in the desired gender role. The patient must over that period of time have shown improved psychological, social, and, probably, occupational function.[32]

Genital surgery typically involves penectomy and orchdiectomy. The surgery uses the existing genitals to fashion a vulva, neoclitoris and hood, labia, and (often) a neovagina. Preoperative genital hair removal is sometimes needed, particularly in patients who have been circumcised. Clinical experience suggests that the cosmetic results can be very good.

Ongoing mental health and psychosocial support may be required before and after surgery, as appropriate. Long-term follow-up by the primary surgeon/gynecologist/primary care physician is encouraged for transgender women who have undergone vaginoplasty.[4]

Consider – other aesthetic procedures

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ONGOING
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transgender women (male-to-female transgender persons whose sex assigned at birth was male)
Consider – 

other aesthetic procedures

Treatment recommended for SOME patients in selected patient group

Options are varied, and include liposuction, lipofilling, gluteal augmentation, and hair reconstruction.[41]

transgender men (female-to-male transgender persons whose sex assigned at birth was female)

1st line – individualized multidisciplinary management

Back
ONGOING
|
transgender men (female-to-male transgender persons whose sex assigned at birth was female)
1st line – 

individualized multidisciplinary management

A multidisciplinary approach to management is strongly recommended; relevant disciplines include (but are not limited to) endocrinology, surgery, voice and communication, primary care, reproductive health, sexual health, and mental health.[4]​ However it is important to note that in some parts of the world, speciality services for transgender people are limited or wholly unavailable; in this setting, nonspecialist clinicians, for example, primary care providers may need to take on a greater role in the provision of gender-affirming care, highlighting the need for continuing training and professional development in line with current best practices.[4]

Options for gender-affirming care include hormone therapies and surgeries. Adjunctive options include hair removal, speech and language therapy and supportive counseling. Management is highly individualized, and that there is no "one size fits all" approach to treatment. Transgender people may choose to undergo all, some, or none of the above interventions to support their gender affirmation.

Transgender people as a group experience relatively poorer access to health services compared to other patient groups. Noted barriers include bias and stigma by health care professionals and a lack of knowledge around best practices, including safety and efficacy of treatments.[46][47]​​​ An open, nonjudgemental and inclusive approach is important and may help to encourage people to be forthcoming with their concerns, and less likely to obtain hormones from unlicensed sources.[41]​ 

Transgender people also experience an increased risk of general mental health issues, including depression, anxiety, post-traumatic stress disorder, suicidality and substance use disorders.[1][2]​​​[14]​ Ongoing screening, assessment, and management of any mental health conditions is therefore important.

Usually, clinicians maintain that hormone treatment should generally not be started unless the patient has already changed gender role.[31]​ This may include legally changing registration to that of the preferred sex and changing the person’s name on all documents, as well as making friends, family, and other contacts aware of this change and asking to treat the person as their experienced sex.

Based on clinical experience, advantages of this approach are that it can allow both patient and clinician to appreciate the degree to which the change in gender expression and role can be practically applied. Regrets following gender-affirming treatment are rare, but do occur; regret is more likely to occur in those who experience difficulties with social transition.[43][50]​​​

Less commonly, hormone treatment is used for patients who do not wish to make a social gender role transition, or who are unable to do so.[4]

There is universal agreement within international standards of care that social transition of at least 6 months to 1 year (plus a year of continuous hormone treatment) should precede any genital surgery.[4][31]​ Longer periods may be needed if there are any problems living in the new gender role. Patients should not undergo surgical treatment until they are thriving (not merely surviving) in their new gender role.

Note that legal transition should not be dependent on use of medication or surgery, and varies according to local (i.e., national or state) laws; clinicians and patients should consult their relevant local legal guidance.[41]

Consider – androgens

Back
ONGOING
|
transgender men (female-to-male transgender persons whose sex assigned at birth was female)
Consider – 

androgens

Treatment recommended for SOME patients in selected patient group

Treatment is preferably done working as part of a multidisciplinary team containing (or having easy access to) an endocrinologist.

Criteria for hormone therapy include the following:[4]

  • Gender incongruence is marked and sustained.

  • The individual meets diagnostic criteria for gender incongruence prior to gender-affirming hormone treatment in regions where a diagnosis is necessary to access health care.

  • The individual demonstrates capacity to consent for the specific gender-affirming hormone treatment.

  • Other possible causes of apparent gender incongruence have been identified and excluded.

  • Mental health and physical conditions that could negatively impact the outcome of treatment have been assessed, with risks and benefits discussed.

  • The individual understands the effect of gender-affirming hormone treatment on reproduction and they have explored reproductive options.

A thorough discussion of the risks versus benefits of treatment is essential prior to treatment initiation, and guides shared decision-making.

Gender-affirming hormone treatment aims to elicit in a birth-assigned female patient the secondary sexual changes seen in birth-assigned males at puberty. These changes will be superimposed on whatever female pubertal changes have already occurred and will not reverse them. Goals of treatment may include development of facial hair, deepening of the voice, and increasing body hair and muscle mass. Other effects of treatment may include fat redistribution, hairline recession, changes in body odour, reduced libido, cessation of menses, vaginal atrophy and increased clitoral size.[41] Vaginal atrophy may increase susceptibility to small amounts of vaginal tearing (similar to in postmenopausal women), and so prescription of a topical lubricant/estrogen may be required.[41] For information on expected timing of masculinizing effects of testosterone see Patient discussions.

Androgens are administered in dosages sufficient to induce menopause, usually once monthly but, more rarely, as often as once every 2 weeks. Once menopause is achieved, it is often possible to decrease the frequency without menstrual periods returning.

Gonadotropin suppression is generally not needed, as androgens alone usually suppress ovarian function very well.

The aim of therapy is to achieve serum testosterone levels in the normal physiologic range for young males at all times.

It typically takes 2 or more years for patients to achieve maximal masculinizing results from hormones.[4]

For patients who go on to have oophorectomy, hormone therapy with testosterone is usually continued lifelong, unless contraindications develop.[4]

For recommended blood test monitoring regimens for patients newly started and established on hormone therapy see Monitoring.

Consult your guidelines and drug formularies for testosterone options and formulations. Preparations, doses, and licensing restrictions for testosterone vary according to country of practice. A variety of preparations and routes of administration are available, including injectables, gels, patches, and buccal tablets.

Consider – bilateral mastectomy

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transgender men (female-to-male transgender persons whose sex assigned at birth was female)
Consider – 

bilateral mastectomy

Treatment recommended for SOME patients in selected patient group

There is no consensus about when patients should undergo bilateral mastectomy. Although hormone therapy is not a formal prerequisite to bilateral mastectomy, most practitioners take the view that it should come after a change of gender role and treatment with androgens. Some patient groups would argue that it should precede both.

Consider – hysterectomy and bilateral oophorectomy

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transgender men (female-to-male transgender persons whose sex assigned at birth was female)
Consider – 

hysterectomy and bilateral oophorectomy

Treatment recommended for SOME patients in selected patient group

Some transgender people live successfully in their preferred gender role without surgery, but for others, genital surgery is the final (and most considered) step in the treatment process.

Criteria for genital surgery include the following:[4]

  • Gender incongruence is marked and sustained.

  • Meets diagnostic criteria for gender incongruence prior to gender-affirming surgical intervention in regions where a diagnosis is necessary to access health care.

  • Demonstrates capacity to consent for the specific gender-affirming surgical intervention.

  • Understands the effect of gender-affirming surgical intervention on reproduction and they have explored reproductive options.

  • Other possible causes of apparent gender incongruence have been identified and excluded.

  • Mental health and physical conditions that could negatively impact the outcome of gender-affirming surgical intervention have been assessed, with risks and benefits have been discussed.

  • Stable on their gender affirming hormonal treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated).*

*This was graded as a suggested criterion.

The aim of hormone therapy prior to oophorectomy and hysterectomy is principally to introduce reversible estrogen suppression, before the patient undergoes irreversible surgical intervention.

Furthermore, many clinics prefer that the patient has experienced 1-2 years in the desired gender role. The patient must, over that period of time, have shown improved psychologic, social, and, probably, occupational function.[32]

Some transgender men desire hysterectomy and/or oophorectomy as part of masculinizing surgery. Previously, consideration of hysterectomy and bilateral oophorectomy was recommended within 2 years to obviate the risk of gynecologic malignancy.[31] However, the World Professional Association for Transgender Health now recommends against routine oophorectomy or hysterectomy solely for the purpose of preventing ovarian or uterine cancer for transgender people undergoing testosterone treatment and who have an otherwise average risk of malignancy.[4]

The route of hysterectomy is dependent on clinical findings, surgical, and patient preference.[41] Approaches include laparoscopic, transvaginal, and transabdominal. An advantage of the laparoscopic approach is that it avoids leaving a large abdominal scar.

Vaginal access may be difficult if patients are nulliparous and have often not experienced penetrative intercourse. A transabdominal approach should utilize any incision other than a Pfannenstiel incision because this incision is pathognomonic of gynecologic surgery and the resulting scar may look unusual in a male.

Consider – phalloplasty

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transgender men (female-to-male transgender persons whose sex assigned at birth was female)
Consider – 

phalloplasty

Treatment recommended for SOME patients in selected patient group

Some transgender people live successfully in their preferred gender role without surgery, but for others, genital surgery is the final (and most considered) step in the treatment process.

Criteria for genital surgery include the following:[4]

  • Gender incongruence is marked and sustained.

  • Meets diagnostic criteria for gender incongruence prior to gender-affirming surgical intervention in regions where a diagnosis is necessary to access health care.

  • Demonstrates capacity to consent for the specific gender-affirming surgical intervention.

  • Understands the effect of gender-affirming surgical intervention on reproduction and they have explored reproductive options.

  • Other possible causes of apparent gender incongruence have been identified and excluded.

  • Mental health and physical conditions that could negatively impact the outcome of gender-affirming surgical intervention have been assessed, with risks and benefits have been discussed.

  • Stable on their gender affirming hormonal treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated).*

*This was graded as a suggested criterion.

Furthermore, many clinics prefer that the patient has experienced 1-2 years in the desired gender role. The patient must, over that period of time, have shown improved psychologic, social, and, probably, occupational function.[32]

This is a complex, often multi-stage procedure.

Donor sites for phalloplasty can include the forearm, abdominal skin, or tissue from elsewhere on the patient's body. The complexity, duration, and expense of the procedure are such that only a large minority of patients chose to undergo this surgery.

Clinical experience suggests that the cosmetic and functional results are fairly good, but the result in, even the best centers, is clearly distinguishable from a native penis.

Consider – other aesthetic procedures

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transgender men (female-to-male transgender persons whose sex assigned at birth was female)
Consider – 

other aesthetic procedures

Treatment recommended for SOME patients in selected patient group

Options are varied, and include liposuction, lipofilling, and pectoral implants.[41]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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