Endocrine Care of Transpeople Part II

A Review of Cross-sex Hormonal Treatments, Outcomes and Adverse Effects in Transwomen

Maria Cristina Meriggiola; Giulia Gava


Clin Endocrinol. 2015;83(5):607-615. 

In This Article


Before SRS. Endocrine Society Guidelines suggest a monitoring schedule to minimize potential adverse effects in transwomen receiving CHT (Table 3).[9] In our clinic, accurate family history and personal medical history, together with hepatic, renal blood tests, fasting lipid and glucose and hormonal testing, are performed at baseline to confirm or reveal any health risks and also to rule out sexual differentiation disorders. A fasting lipid panel prior to hormone therapy is suggested as patients with familial hypertriglyceridaemia could be at risk of severe hypertriglyceridaemia with oestrogen therapy. The incidence of thrombophilia in transwomen is similar to that of the general population and routine screening for thrombophilic defects in transwomen is not recommended. However, it is advisable in those individuals with a personal or family history of VTE or in the presence of any other risk factor such as obesity or heavy smoking.[53] Transwomen undergoing CHT should be evaluated every 3 months in the first year and then every 6–12 months thereafter. Serum testosterone levels should be <9·1 nmol/l, and plasma oestradiol levels should be in the upper follicular range (400–600 pmol/l).[20] If intramuscular forms of oestrogens are used, oestradiol levels should be measured midway between injections to avoid measuring peaks and troughs after and before injections.[9] In transwomen undergoing therapy with spironolactone, serum electrolytes (especially potassium) should be monitored every 2–3 months during the first year of therapy.[9] Serum PRL levels in transwomen should be evaluated at baseline, at least annually during the transition period and biannually thereafter.[9] Pituitary magnetic resonance imaging is recommended in patients whose PRL levels do not normalize with the reduction of the oestrogen dose.[9] It should be kept in mind that CPA can also increase PRL levels. Transwomen receiving psychotropic medications can have persistently increased PRL levels.

After SRS

Periodic long-term check-ups should be ensured in transwomen. Screening for prostate cancer should be performed as is recommended for men. A proper evaluation of prostate can be performed also through transvaginal ultrasound.[69] PSA tests and PSA >1·0 ng/ml should be carefully evaluated; however, it should be considered that low levels of PSA may be due to its suppression resulting from androgens deprivation.[9,23] Transwomen with no known risk factors of breast cancer should follow screening guidelines as for women.[9,70] Because of the lack of experience with transwomen of an advanced age, the Endocrine Society guidelines suggest that dual-energy X-ray absorptiometry (DEXA) should be carried out at baseline in all patients at risk of osteoporosis and after the age of 60 or in patients not continuously compliant to hormonal therapy after gonadectomy.[9]