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Care for Transmasculine Individuals

The terms transmasculine or non-binary (TMNB)  describe individuals who were sex-assigned female at birth who identify on the more masculine spectrum of gender identity. The transgender and gender-diverse experience is as varied as is people’s expression of their identity. TMNB persons may choose a number of medical or surgical therapies to help align their bodies with their gender identity. Individuals may choose to use masculinizing hormone therapy (testosterone) or undergo surgical procedures such as bilateral mastectomy (“top surgery”), hysterectomy with or without gonadectomy, or phalloplasty/metoidioplasty (“bottom surgery”). Although hormone therapy is a medically necessary treatment for many TMNB individuals with gender dysphoria, not all TMNB patients experience gender dysphoria and not everyone desires hormone treatment.

The obstetrician/gynecologist is uniquely trained to help TMNB patients with several medical needs, including fertility, family planning, cervical and breast cancer screening, menstrual dysphoria, pelvic pain, and gynecologic surgeries.

The most important job of the physician is to provide safe, affirming care. The social and economic marginalization of transgender and non-binary individuals is widespread, which leads to health care inequities and poorer health outcomes for this population. Obstetrician/gynecologists should avoid judgments and assumptions, recognizing we may have unconscious bias toward western binary models of gender. One way to mitigate our biases and welcome gender-diverse patients is to collect and use gender data, including chosen name, pronouns, gender identity, and sex. Incorporation of trauma informed care technique is important to provide appropriate care. Providers should mirror the language that patients use for their bodies and parts.

Providers should limit historical questions to those that are relevant to the current visit. For example, spending significant time asking about gender issues could distract from the chief concern of a particular visit. Taking an anatomic inventory allows the physician to tailor the physical examination and screening tests. If patients have breasts, they should be screened according to guidelines for non-transgender (cisgender) women. No reliable evidence exists to guide the screening of TMNB patients who have undergone mastectomy for benign indications. Routine masculinizing chest surgery leaves some breast tissue, as it is not a radical mastectomy. There are unknown risks associated with this residual breast tissue and mammography may not be technically feasible. As in cisgender female patients, chest self-awareness and presence any new masses or skin changes in chest tissue should prompt clinical evaluation. Family history screening for familial cancer syndromes should be routinely performed, and patients should be offered genetic consultation and subsequent risk reducing medical and surgical management.

A sexual history is essential for providing contraceptive, reproductive, and HIV/sexually transmitted infection counseling and care. It is important to directly ask if patients are sexually active with people with penises or vaginas, single or multiple partners, if they are at risk of pregnancy (partner/s produce sperm), and how they are asexually active (which parts are they using for sex).. This information can be used for STI screening and STI prevention with barrier methods as well as pre- and post-exposure prophylaxis for HIV and bacterial STIs. Patients at risk for pregnancy should be offered contraception regardless of testosterone use. Gender-affirming hormone therapy is not effective contraception. Any type of contraception can be used in TMNB persons, and there is no interference with gender affirming hormone therapy. All patients should be offered fertility preservation before medical or surgical transition. Patients with clinically evident genitourinary atrophy should be offered topical estrogen therapy like that offered in the management of menopause.

To guide preventive medical care, any anatomical structure present that warrant screening should be screened, regardless of gender identity. The health care provider should adjust the pelvic examination to be sensitive and supportive. Options include HPV self-swab or provider placed vaginal swab, using a pediatric speculum, encouraging the patient to distract themselves with music/videos, having a support person present, exam under anesthesia, and administering pre-examination benzodiazepines. Of note, testosterone use significantly increases the incidence of an unsatisfactory cytology result due to genitourinary atrophy-consider concurrent HPV testing for all patients to better assess risk.

Health care providers should be aware that most patients experience secondary amenorrhea after 6 months of weekly injectable testosterone use that achieves levels of male testosterone (>350mg/dl). Use of gels, testosterone dosing inconsistency or changes, biweekly injectable testosterone, obesity, and low dose testosterone are associated with increased break through bleeding. Any persistent abnormal uterine bleeding (bleeding beyond the first year while on testosterone or new-onset bleeding) should be evaluated using standard gynecologic protocols including menstrual history, bleeding pattern, use of gender affirming hormone therapy or hormonal contraceptives, pelvic ultrasound (can be transabdominal if feasible), STI screening, atrophy/post-coital bleeding, and endometrial biopsy if concern for hyperplasia. Hysterectomy with or without unilateral/bilateral salpingo-oophorectomy is medically necessary for patients with gender dysphoria who desire this procedure. Route of hysterectomy recommendations are the same in TMNB patients as in cis-gender women. Unilateral or bilateral ovarian conservation decisions should be guided by dysphoria, family planning/fertility preservation desires, comfort with use of exogenous sex hormones (lifelong if bilateral gonadectomy is performed), presence of additional pathology such as ovarian masses or endometriosis, family history/genetic risk, and risk of surgical menopause or hypogonadism, Ovarian preservation has no influence on future bottom surgery or testosterone dosing.

Further Reading:

Deutch M, Amato P, Courey M, et al. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. Center of Excellence for Transgender Health Department of Family & Community Medicine University of California, San Francisco. 2nd edition. Published June 17, 2016. Available at: https://transcare.ucsf.edu/guidelines. Verified September 2020

Health Care for Transgender and Gender Diverse Individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021 Mar 1;137(3):e75-e88. doi: 10.1097/AOG.0000000000004294. PMID: 33595253.

Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. [published corrections appear in J Clin Endocrinol Metab. 2018;103(2):699 and J Clin Endocrinol Metab. 2018;103(7):2758-2759]. J Clin Endocrinol Metab. 2017;102(11):3869-3903. PMID: 28945902

Bacot-Davis VR, Moran AH. Transgender preventative health-chest/breast cancer screening. Front Health Serv. 2024 Aug 14;4:1434536. doi: 10.3389/frhs.2024.1434536. PMID: 39206444; PMCID: PMC11349637.

Initially titled “Transgender Care”.  Title Changed May 2024.

Initial Approval: September 2020; Published January 2021, Revised and Renamed May 2024. Revised July 2026.

 

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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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