Highlights
- 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.
- Patients who have not had their cervix surgically removed should receive regular pap smears as per the guidelines.
- Patients who have not had a mastectomy should undergo screening as per the guidelines, regardless of their use of testosterone.
- Transgender patients are at a higher risk of HIV and hepatitis. Patients with risk factors should be screened every 6 months.
Overview
Vaccinations
Vaccination recommendations are identical 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.
Mental Health
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.
Substance Use
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 cardiovascular disease with any hormone therapy (especially if >50 years of age).
Alcohol and Drugs: Screen all patients for alcohol and drug use via history. Refer as needed to a drug addictions program. In referral to residential addiction programs that have gender-specific programming or facilities, particular attention is needed to ensure the patient will be welcomed and that appropriate accommodations will be made in sleeping arrangements, shower use, bathroom use, and group activities. FtM patients should follow the safe drinking guidelines as for cis women.
Cardiovascular Disease
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 may be at an increased risk of future cardiac events when taking testosterone. Patients with a moderate-high risk of coronary artery disease should be closely monitored for cardiac events/symptoms.
Hypertension
- Not on hormones: Screen as per cisgender guidelines, goal blood pressure <140/90.
- Currently on hormones: Monitor BP every 3 months, goal <140/90 especially if the patient has polycystic ovarian syndrome (PCOS).
Lipids
- Not on hormones: Screen and treat hyperlipidemia as per cisgender guidelines; consider LDL <3.5 mmol/L if planning to start hormones in 1-3 years.
- Currently on hormones: Annual lipid profile. Avoid supraphysiologic testosterone levels in patients with hyperlipidemia. Daily topical or weekly intramuscular (IM) testosterone regimens are preferable to bi-weekly IM injection. Goal LDL <3.5 mmol/L for low-moderate risk patients and <2.5 mmol/L for high risk patients.
Diabetes
Consider screening via history for PCOS and screen for diabetes if PCOS is present. Screen and manage diabetes as per cisgender guidelines.
Musculoskeletal Health
- Currently on hormones: ~ 4 kg of lean body mass is gained following initiation of testosterone. To avoid tendon rupture during strength training, encourage gradual increase in weight load and emphasize more repetitions rather than increased weight.
Osteoporosis
- Not on hormones: No increased risk, follow cisgender guidelines. Consider screening in all patients >60 years of age.
- Past/present hormones: Impact of testosterone on bone mineral density (BMD) is unclear but some studies suggest it maintains bone density. Calcium and vitamin D supplementation is recommended.
- Screen:
- (1) Patients >50 years of age who have been on testosterone for a significant amount of time and have additional risk factors for osteoporosis;
- (2) Patients > 50 years of age who have been on testosterone for 5-10+ years, regardless of risk factors for osteoporosis;
- (3) Patients who have stopped testosterone.
- Screen:
- Past/present hormones + post-oophorectomy: Limited evidence to suggest bone loss post-oophorectomy. Testosterone therapy is recommended (dose needed unclear). If there are contraindications to testosterone, consider bisphosphonate treatment. Calcium and vitamin D supplementation is recommended.
- Screen:
- (1) Patients >50 years of age who have been on testosterone for 5+ years;
- (2) Patients who stop their testosterone post-oophorectomy;
- (3) Patients > 60 years of age and on testosterone < 5 years.
- Screen:
Breast Cancer
- No chest surgery, +/- testosterone: Follow breast cancer screening guidelines as per cis women.
- Post-chest surgery, +/- testosterone: Breast cancer risk is reduced with chest surgery but still appears higher in this population compared to cis males (some breast tissue remains post-chest surgery for cosmetic purposes). Yearly chest wall and axillary physical exams are recommended.
Cervical Cancer
- Cervix intact: Patients should receive screening according to the guidelines for cis women. Labs should be informed of patient’s hormonal status as testosterone can cause atrophic changes that mimic cervical dysplasia. Atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesions (LSIL) are unlikely to represent pre-cancerous lesions in otherwise low-risk patients. Consider total hysterectomy if high grade dysplasia and the patient is unable to tolerate pap smears.
- Post-total hysterectomy (cervix completely excised): As per the guidelines for cis women, if there is no history of high-grade cervical dysplasia/cervical cancer, no future pap smears are recommended. If there is a history of dysplasia/cancer, patients requiring ongoing screening as per the cis women guidelines.
Ovarian/Uterine Cancer
No screening guidelines exist for any population although some studies suggest an increased risk of ovarian cancer among FtM patients on testosterone and in cis women with PCOS. There is a higher incidence of PCOS in FtM patients regardless of their hormone use and screening for PCOS symptoms with history and physical should be considered. Changes in a patient’s hormones are usually the cause of irregular vaginal bleeding. However unexplained vaginal bleeding should be appropriately investigated as it would be in cis women. Consider preventive total hysterectomy and oophorectomy if fertility is not an issue, the patient is < 40 years of age, and the patient’s health will not be adversely affected by surgery.
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.
STIs
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 vaginal swab can be done in patients pre-vaginectomy. 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.