Troubleshooting and FAQs for Transmasculine/Non-Binary Individuals on Testosterone Treatment

Routine Monitoring

Blood tests: Testosterone, Estradiol, LFTs, FBC, Lipid profile including Triglycerides, to be done six monthly for a year and then annually.  Testosterone levels should be in the lower third of the reference range immediately before Sustanon or Nebido injections (trough levels), middle third of the reference range on Nebido (for samples taken mid-way between injections) and testosterone gel (taken 4 to 10 hours after application).  The lower third of the male reference range is usually around 8-12 nmol/L and the middle third of the male reference range is usually around 15-22 nmol/L but does depend on the normal range for the local assay as these vary.

Hormones: There is no recommendation of an upper age limit to stop masculinising treatment and we would recommend a pragmatic and individualised approach after an analysis of the risks and benefits.

Uterus and Ovaries: There is currently no evidence for an increased risk of endometrial or ovarian cancer with testosterone treatment, but any symptoms which could suggest a problem with these organs, particularly vaginal bleeding, pelvic pain or abdominal bloating should be investigated further.

Cervical Screening: Attendance for routine cervical screening tests should remain the same as per the NHS Cervical Screening Programme recommendations, however the invitation process and informing of results are outside the NHS Cervical Screening Programme process and should now be organised within your GP practice.  If you have not already done so and your patient is registered as male, with a new NHS number, you should liaise directly with the screening lead for cervical screening who will advise on further action.

There are challenges regarding recalls for cervical screening and we know that there is poor uptake of cervical screening in this group.  Consideration should be made of what may make the individual more comfortable and less concerned about this procedure including the use of vaginal Estradiol.  There is further information on our website for health care professionals regarding cervical screening.

Testosterone treatment is not contraceptive and is a teratogen.  Contraceptive needs should be considered if required.

Osteoporosis: There is no evidence for routine DEXA scanning in trans-masculine & non binary individuals and typically they show no change or an increase in BMD as a result of testosterone hormone treatment. We would encourage an individualised approach to DEXA scanning based on the presence of other risk factors such as low BMI, corticosteroid use, alcohol excess or medical conditions associated with reduced BMD in line with national guidelines.

Vaginal Atrophy: Testosterone changes the vaginal epithelium in a similar way to post-menopausal changes in cis gender women.  The proliferation of the epithelial cells slows and becomes thinner and more fragile causing bleeding, discomfort, pain with intercourse, vaginal discharge or recurrent UTIs.  As a result, vaginal examinations can be distressing not just due to dysphoria but also due to discomfort and pain.  Consideration can be given to using vaginal estrogens to treat the atrophy.

The recommendations are not limited to the below.  If atrophy is suspected and the individual is unable to tolerate a full examination, we would suggest treatment for 4-6 weeks before another attempt at vaginal examination is made.  In some severe cases it may necessitate more frequent and prolonged application of topical Estradiol than in post-menopausal females.

Vagifem/Vagirux: 10mcg tablet daily for 2 weeks then 1 tablet twice per week (if still symptomatic at 2 weeks it would be appropriate to continue with application for 4-6 weeks before titrating down to 1 tablet twice per week).

Ovestin cream 0.1%: 1 application per day for 2-4 weeks then reduction based on symptoms down to a maintenance dose of one application twice per week.

Occasionally a combination of a vaginal preparation and a vulval preparation are also required along with vaginal moisturizers such as coconut oil.  We would also recommend lubricants for penetrative intercourse.

If vaginal bleeding is a problem, please see our separate advice above on: ‘How to Approach Vaginal Bleeding for Transmen and Non-Binary Individuals on Testosterone Treatment’

·      How to Approach Vaginal Bleeding in Transmen on Testosterone Treatment Topical Testosterone (Testogel): Risk of hard to children following accidental exposure.

Requests for HSBO (Hysterectomy and salpingo oophorectomy – historically transmen receiving testosterone were advised to have this surgery.   There is currently no evidence for an increased risk of endometrial or ovarian cancer with testosterone treatment, but any symptoms which could suggest a problem with these organs, particularly vaginal bleeding, pelvic pain or abdominal bloating should be investigated further. The WPATH (World Professional Association for Transgender Health) recommend against routine oophorectomy or hysterectomy solely for the purpose of preventing ovarian or uterine cancer for transgender and gender diverse people undergoing testosterone treatment and who have an otherwise average risk of malignancy.

Screening:

·      How to Approach Cervical Screening for TGNB Individuals – Info for Health Professionals

–  Screening information for transgender people: https://www.gov.uk/government/publications/nhs-population-screening-information-for-transgender-people/nhs-population-screening-information-for-trans-people

–             Cancer research UK screening information: https://www.cancerresearchuk.org/about-cancer/cancer-symptoms/spot-cancer-early/screening/trans-and-non-binary-cancer-screening

–             Live through this Cancer Charity supporting and advocating for LGBTIQ+ people affected by cancer: cervical screening campaign: https://livethroughthis.co.uk/removethedoubt/

–             Endometrial Screening: There are no clear guidelines for management of abnormal uterine bleeding or endometrial surveillance in this population.  There is a theoretical concern of endometrial pathology based on data of increased risk with increased serum androgens in cis post-menopausal women.  Current data from a trans male population suggests trans men are at no increased risk of endometrial cancer.  Longer term studies are lacking.  The WPATH (World Professional Association for Transgender Health) recommend health care professionals apply the same respective local screening guidelines (including the recommendation not to screen) developed for cisgender women at average and elevated risk for developing ovarian or endometrial cancer in their care of transgender and gender diverse people who have the same risks.  Some UK services undertake a 2 yearly transvaginal ultrasound to assess endometrial thickness, but the other NHS services do not recommend routine screening only prompt investigation if concern.

Sexual health and Contraception:

–             FSRH: Contraceptive Choices and Sexual Health for Transgender and Non-Binary People: https://www.fsrh.org/documents/fsrh-ceu-statement-contraceptive-choices-and-sexual-health-for/

General health:

–             Cancer in Trans and Non-Binary Individuals – UK Cancer and Transition Service: https://www.wearetransplus.co.uk/uk-cancer-and-transition-service-for-professionals/

–             Macmillan – https://www.macmillan.org.uk/cancer-information-and-support/impacts-of-cancer/transgender

–             Bone Health – Consider BMD/DXA if additional osteoporosis risk factors

Surgical and hair removal information

When you and your clinical team agree that you are ready for surgery, the Gender Dysphoria National Referral Support Service (GDNRSS) will process your referral to the surgical provider. The GDNRSS team have Clinical Nurse Advisors who can provide information on the following:

Surgical techniques used by various providers and surgeon teams

Typical recovery times following surgery

Potential post-surgical complications

Surgical eligibility criteria, where providers have these in place

Waiting times for surgical providers

Supporting patients to change provider

They can provide virtual consultations and also have a Single Point of Access support line that you can call for information about your referral, the status of your chosen provider and practical information such as travel and parking, who can accompany you, what to take with you and where to report to when you get there. For more information about this service, download this leaflet. 

You can contact the Gender Dysphoria National Referral Support Service by calling 0300 131 6775 or by emailing agem.gdnrss@nhs.net.