Primary Care for Transgender Women

Foundations & Initial Assessment - Trans Welcome Wagon

• Key Terms:
  • Gender Identity: Internal sense of self.
  • Gender Dysphoria: Distress from gender incongruence.
  • Affirming Language: Crucial; use chosen name/pronouns.
• Initial Steps:
  • Create a safe, respectful, confidential space.
  • Comprehensive history: medical, mental health (screen for anxiety/depression), social support, substance use.
  • Clarify transition goals & expectations.
  • Initiate informed consent process.
  • Assess for risks (e.g., STIs, HIV).

⭐ Documenting gender identity, chosen name, and pronouns accurately in medical records is a critical first step for affirming care and patient safety.

Feminizing Hormone Therapy - Estrogen Engine Start

• Goal: Induce female secondary traits, suppress male ones.
• Estrogen Options:
  • Oral: Estradiol 2-6 mg/day.
  • Transdermal (patch/gel): Estradiol 0.05-0.2 mg/day. Preferred if ↑VTE risk.
  • Parenteral (IM): Estradiol valerate/cypionate 5-20 mg q2wks or 2-5 mg qwk.
• Anti-Androgens:
  • Spironolactone: 100-300 mg/day (monitor K+).
  • Cyproterone Acetate (CPA): 12.5-25 mg/day (monitor LFTs, prolactin).
  • GnRH Agonists: Most potent.
• Monitoring (q3mo for 1yr, then annually):
  • Estradiol: Target 100-200 pg/mL.
  • Testosterone: Target <50 ng/dL.
• Timeline: Breast growth (3-6mo), fat redistribution (3-6mo), ↓libido (1-3mo).

⭐ Transdermal estrogen carries a lower VTE risk than oral forms, crucial for patients with higher baseline VTE risk.

Health Maintenance & Screening - Femme Health Checkpoint

• Cardiovascular: Monitor BP, lipids, glucose. Estrogen ↑ VTE risk.
• Bone Health: DEXA if risk factors (e.g., GnRH agonist, low BMI, fracture history).
• Cancer Screening:
  • Breast: Mammography age 50-74 (or earlier if >5-10 yrs estrogen/risk factors).

  ⭐ Transgender women on long-term estrogen therapy (typically >5 years) should follow breast cancer screening guidelines similar to cisgender women.

  • Prostate: Discuss PSA if prostate present, age >50 & risk factors.
  • Anal: Consider for anal receptive intercourse.
• Hormone Levels: Estradiol, testosterone, prolactin. Monitor LFTs.
• Mental Health: Screen for depression, anxiety.

Managing Complications & Special Issues - Side Effect Surfing

• VTE (Estrogen): Counsel (DVT/PE symptoms). Prefer transdermal (↓risk). Assess individual risk factors.
• Hyperkalemia (Spironolactone): Monitor K+ (esp. renal disease, ACEi/ARBs). Dietary advice.
• Mood Changes (Estrogen/Anti-androgens): Validate. Differentiate. Consider dose/agent adjustment.
• Hepatotoxicity (CPA): Monitor LFTs. Discontinue if significant ↑.
• Other common: Weight gain (lifestyle), ↓libido (discuss expectations), breast tenderness (reassurance).

⭐ Transdermal estrogen is associated with a lower risk of VTE compared to oral estrogen in transgender women.

High‑Yield Points - ⚡ Biggest Takeaways

• Feminizing hormone therapy: Estrogen (oral/transdermal) plus anti-androgens (e.g., spironolactone).
• Monitor: VTE risk (↑ with oral estrogen), lipids, prolactin, potassium (spironolactone), liver function.
• Cancer screening: Breast (mammography), prostate (if present), cervical (if cervix present).
• Regular cardiovascular risk assessment and bone density screening (DEXA) are vital.
• Address mental health (depression, anxiety), sexual health (STIs), and fertility preservation pre-therapy.
• Ensure routine health maintenance, including vaccinations, tailored to anatomy and risk factors.