Transgender Health in Obstetrics and Gynaecology

Being transgender is not a psychiatric condition, even though gender identity services are led by psychiatrists.

Service Context

• Referrals to gender identity services increased by more than 50% each year from 2012; 2,016 referrals in 2016–2017, with rising demand for gender reassignment surgery
• Waiting times of 18–24 months are typical
• There is a high incidence of suicide and self-harm among people who remain untreated. This is why a harm-reduction approach using GP "bridging prescriptions" is endorsed by the UK practice guidelines for assessment and treatment of adults with gender dysphoria

Eligibility for Gender-Affirming Treatment

• Persistent and well-documented gender dysphoria
• Capacity to make informed decisions and give consent
• Any significant medical or mental health concerns reasonably controlled
• A realistic, achievable plan already implemented or about to be

Adolescents may be offered reversible GnRH analogues as hormone blockers to delay puberty, giving time to explore gender identity. These are prescribed only with endocrinology input alongside active engagement with gender development services.

Monitoring

Before starting hormone treatment: physical examination and baseline bloods.

Monitor blood pressure, FBC, renal profile, liver function, fasting glucose, lipid profile, thyroid function, and oestrogen, testosterone and prolactin every 6 months for 3 years, then annually once clinically stable.

Approximately 80% of patients report significant improvement in gender dysphoria on hormonal therapy.

Oestrogen Therapy (trans women)

• Estradiol oral tablets 1–6 mg daily
• Estradiol transdermal gel, 2–4 measures (500 micrograms each) daily
• Estradiol patches 50–150 micrograms twice weekly

Testosterone and dihydrotestosterone should be suppressed well below the normal male range. Adrenal androgens (androstenedione, DHEA) are not suppressed; although weak, they convert to testosterone and dihydrotestosterone. Finasteride blocks conversion to dihydrotestosterone. For persisting androgenisation, low-dose cyproterone acetate or spironolactone may be added.

Risks:

• VTE risk is much reduced now that ethinylestradiol is no longer used; modern oestrogen therapy does not confer a significantly increased VTE risk. Where additional VTE risk factors exist, use transdermal oestrogen — avoiding first-pass hepatic metabolism lowers thromboembolic risk
• Oestrogen can cause an obstructive pattern of liver dysfunction, particularly when oral; switch to topical if this is detected
• Increased incidence of gallstones
• Breast cancer incidence in trans women on oestrogen is reported as the same as the background male rate, but screening still applies as appropriate

Testosterone Therapy (trans men)

• Testosterone esters (Sustanon) 250–500 mg IM every 2–6 weeks by serum levels
• Testosterone enanthate 250–500 mg IM every 2–6 weeks (for those with peanut allergy)
• Testosterone gel 5 mg daily
• Testosterone undecanoate (Nebido) 1 g IM every 10–14 weeks

Gender Reassignment Surgery

Approval requires a verifiable period — usually at least 12 months — living in a gender role congruent with gender identity, plus 12 months of continuous appropriate endocrine treatment.

Trans women: penectomy, orchidectomy, vaginoplasty, clitoroplasty, labiaplasty, cricothyroid approximation (phonosurgery), thyroid cartilage reduction, breast augmentation, feminising facial surgery. The last four are not currently NHS-funded but are available privately.

Trans men: bilateral mastectomy and chest reconstruction, hysterectomy, vaginectomy, salpingo-oophorectomy, metoidoplasty, phalloplasty, urethroplasty, scrotoplasty, penile or testicular prosthesis.

Fertility

• Gender reassignment surgery causes irreversible sterility, and patients must understand this
• Prolonged oestrogen in trans women reduces testicular volume and sperm quality — reversible on stopping
• Testosterone in trans men causes reversible amenorrhoea; ovarian follicles are not depleted but follicular growth may be affected. Contraception is still required
• Gamete storage before starting hormones is important. For those already on cross-sex hormones, interrupt therapy for 3 months to allow reversal of treatment effects
• Thawed oocytes are fertilised by ICSI. The HFEA reported a 2018 birth rate per embryo transfer using frozen eggs of 19%, only 2% below the overall 2016 IVF rate of 21%
• NHS funding is available for fertility preservation and storage, though patients may self-fund later treatment. Standard maximum storage is 10 years, extended to a maximum of 55 years for transgender individuals

Gynaecological Care of Trans Men

• Abdominal ultrasound is preferable to transvaginal scanning, which may be painful
• Onset of bleeding in someone previously amenorrhoeic on testosterone, or any abnormal bleeding, should prompt consideration of endometrial hyperplasia
• Testosterone causes cortical and thecal ovarian thickening resembling PCOS; long-term significance is unknown, and PCOS is not associated with increased ovarian cancer risk
• Ovarian cancer risk may be relatively higher because most trans men have never been pregnant nor used the combined pill, both protective
• Hysterectomy is often considered after 4–5 years of testosterone therapy, for theoretical endometrial cancer risk from unopposed oestrogen produced by aromatisation of testosterone. Reported endometrial cancer incidence is nonetheless low, and recent histopathology suggests testosterone actually causes endometrial atrophy resembling the postmenopausal state. Patients usually also prefer bilateral salpingo-oophorectomy to abolish endogenous oestrogen, allowing GnRHa discontinuation and improving testosterone efficacy. Revisit fertility preservation before surgery
• Any trans man who has retained a cervix should still undergo cervical screening
• Trans men remain eligible for breast screening if breast tissue remains after bilateral mastectomy

Pregnancy in Trans Men

• Overall outcomes and complications do not appear to differ substantially from the general population
• Care must be affirmative and inclusive. Loneliness and isolation are common, driven by gender dysphoria, absence of role models, and repeatedly challenging the assumption that a gestational parent is a mother
• There are no clear recommendations on mode of delivery in this population or its effect on gender dysphoria
• Many trans men choose to chest-feed, including after chest masculinisation surgery. Support their infant feeding choices while being alert to effects on dysphoria

Gynaecological Problems in Trans Women

• After gender reassignment surgery: vaginal discharge, dyspareunia, a "short" vagina, vaginal hair, voiding difficulties, or lack of lubrication
• HIV prevalence among transgender women has been reported at 19%, with an odds ratio of 48.8 compared with the general population — involve sexual health services

References

• The Obstetrician & Gynaecologist (TOG), RCOG journal — transgender health reviews
• UK practice guidelines for the assessment and treatment of adults with gender dysphoria
• HFEA data on frozen oocyte outcomes

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — see references below

Clinically reviewed by NHS obstetricians and gynaecologists

MRCOG AI is an independent educational tool. It is not affiliated with, endorsed by, or connected to the Royal College of Obstetricians and Gynaecologists (RCOG).