Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Transgender women: Evaluation and management

Vin Tangpricha, MD, PhD
Joshua D Safer, MD, FACP
Section Editors
Peter J Snyder, MD
Alvin M Matsumoto, MD
Deputy Editor
Kathryn A Martin, MD


The terms transgender and gender incongruence describe a situation where an individual's gender identity differs from external sexual anatomy at birth. Health care providers should be familiar with commonly used terms (table 1). Gender identity-affirming care, for those who desire, can include hormone therapy and affirming surgeries as well as other procedures such as hair removal or speech therapy [1].

This topic will use the term transgender in the broadest sense to include any person with incongruence between gender identity and external sexual anatomy at birth. The evaluation and management of transgender women are discussed here. The evaluation and management of transgender men, the primary care of the transgender adult, and gender nonconformity in children and adolescents are reviewed separately. (See "Transgender men: Evaluation and management" and "Primary care of transgender individuals" and "Gender development and clinical presentation of gender nonconformity in children and adolescents" and "Management of gender nonconformity in children and adolescents".)


Several large medical professional organizations have issued guidelines to assist providers in the care of transgender individuals (the World Professional Association for Transgender Health [WPATH] [1], the Endocrine Society [2], the American Congress of Obstetricians and Gynecologists [ACOG] [3]).

The Endocrine Society has released updated guidelines for the treatment of gender dysphoria/gender incongruence [4]. The new guidelines replace the term "transsexual" with "gender dysphoria" or "gender incongruence" and specify detailed professional qualifications for clinicians who diagnose, assess, or treat individuals with gender dysphoria/gender incongruence. Specifically, they now suggest that decisions regarding social transition for prepubertal youth be made in conjunction with a mental health or similarly experienced professional. They continue to recommend the management and monitoring of transgender adolescents, and adult men and women by a multidisciplinary team, as well as counseling patients about the time course of hormone-induced physical changes and options for fertility preservation. We agree with the updated guidelines.


Prevalence — Previous research had suggested that 0.3 to 0.5 percent of the adult population was transgender [5,6]. The prevalence of transgender depends upon the definition used to classify a person as transgender. In studies that included only individuals who had undergone hormone therapy, gender-affirming surgery, or had diagnostic codes documenting transgender, the reported prevalence of transgender was 7 to 9 per 100,000 people [7]. However, studies that include transgender status based upon self-report indicate a prevalence of transgender of approximately 871 per 100,000 people [7]. One study estimated that there are approximately 25 million transgender individuals worldwide [8].

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: May 16, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgend 2012; 13:165.
  2. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2009; 94:3132.
  3. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Health-Care-for-Transgender-Individuals (Accessed on August 03, 2016).
  4. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2017; 102:3869.
  5. Conron KJ, Scott G, Stowell GS, Landers SJ. Transgender health in Massachusetts: results from a household probability sample of adults. Am J Public Health 2012; 102:118.
  6. Reisner SL, Conron KJ, Tardiff LA, et al. Monitoring the health of transgender and other gender minority populations: validity of natal sex and gender identity survey items in a U.S. national cohort of young adults. BMC Public Health 2014; 14:1224.
  7. Collin L, Reisner SL, Tangpricha V, Goodman M. Prevalence of Transgender Depends on the "Case" Definition: A Systematic Review. J Sex Med 2016; 13:613.
  8. Winter S, Diamond M, Green J, et al. Transgender people: health at the margins of society. Lancet 2016; 388:390.
  9. Saraswat A, Weinand JD, Safer JD. Evidence supporting the biologic nature of gender identity. Endocr Pract 2015; 21:199.
  10. Luders E, Sánchez FJ, Tosun D, et al. Increased Cortical Thickness in Male-to-Female Transsexualism. J Behav Brain Sci 2012; 2:357.
  11. Wilson JD. The role of androgens in male gender role behavior. Endocr Rev 1999; 20:726.
  12. World Professional Association for Transgender Health. Standards of care for gender identity disorders. http://wpath.org/publications_standards.cfm (Accessed on September 13, 2011).
  13. Leinung MC, Urizar MF, Patel N, Sood SC. Endocrine treatment of transsexual persons: extensive personal experience. Endocr Pract 2013; 19:644.
  14. Terada S, Matsumoto Y, Sato T, et al. Factors predicting psychiatric co-morbidity in gender-dysphoric adults. Psychiatry Res 2012; 200:469.
  15. Murad MH, Elamin MB, Garcia MZ, et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol (Oxf) 2010; 72:214.
  16. Smith YL, van Goozen SH, Cohen-Kettenis PT. Adolescents with gender identity disorder who were accepted or rejected for sex reassignment surgery: a prospective follow-up study. J Am Acad Child Adolesc Psychiatry 2001; 40:472.
  17. Colizzi M, Costa R, Todarello O. Transsexual patients' psychiatric comorbidity and positive effect of cross-sex hormonal treatment on mental health: results from a longitudinal study. Psychoneuroendocrinology 2014; 39:65.
  18. Gooren LJ. Clinical practice. Care of transsexual persons. N Engl J Med 2011; 364:1251.
  19. Weinand JD, Safer JD. Hormone therapy in transgender adults is safe with provider supervision; A review of hormone therapy sequelae for transgender individuals. J Clin Transl Endocrinol 2015; 2:55.
  20. Gooren L. Hormone treatment of the adult transsexual patient. Horm Res 2005; 64 Suppl 2:31.
  21. Becerra Fernández A, de Luis Román DA, Piédrola Maroto G. [Morbidity in transsexual patients with cross-gender hormone self-treatment]. Med Clin (Barc) 1999; 113:484.
  22. American Psychiatric Association. Gender dysphoria. In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association, Arlington, VA 2013. p.451.
  23. Moore E, Wisniewski A, Dobs A. Endocrine treatment of transsexual people: a review of treatment regimens, outcomes, and adverse effects. J Clin Endocrinol Metab 2003; 88:3467.
  24. Tangpricha V, Ducharme SH, Barber TW, Chipkin SR. Endocrinologic treatment of gender identity disorders. Endocr Pract 2003; 9:12.
  25. Meyer WJ 3rd, Webb A, Stuart CA, et al. Physical and hormonal evaluation of transsexual patients: a longitudinal study. Arch Sex Behav 1986; 15:121.
  26. Zitzmann M, Erren M, Kamischke A, et al. Endogenous progesterone and the exogenous progestin norethisterone enanthate are associated with a proinflammatory profile in healthy men. J Clin Endocrinol Metab 2005; 90:6603.
  27. Dittrich R, Binder H, Cupisti S, et al. Endocrine treatment of male-to-female transsexuals using gonadotropin-releasing hormone agonist. Exp Clin Endocrinol Diabetes 2005; 113:586.
  28. Schroeter CA, Groenewegen JS, Reineke T, Neumann HA. Ninety percent permanent hair reduction in transsexual patients. Ann Plast Surg 2003; 51:243.
  29. van Kesteren PJ, Asscheman H, Megens JA, Gooren LJ. Mortality and morbidity in transsexual subjects treated with cross-sex hormones. Clin Endocrinol (Oxf) 1997; 47:337.
  30. Toorians AW, Thomassen MC, Zweegman S, et al. Venous thrombosis and changes of hemostatic variables during cross-sex hormone treatment in transsexual people. J Clin Endocrinol Metab 2003; 88:5723.
  31. Asscheman H, T'Sjoen G, Lemaire A, et al. Venous thrombo-embolism as a complication of cross-sex hormone treatment of male-to-female transsexual subjects: a review. Andrologia 2014; 46:791.
  32. Asscheman H, Giltay EJ, Megens JA, et al. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol 2011; 164:635.
  33. Levy A, Crown A, Reid R. Endocrine intervention for transsexuals. Clin Endocrinol (Oxf) 2003; 59:409.
  34. Gooren LJ, Giltay EJ. Men and women, so different, so similar: observations from cross-sex hormone treatment of transsexual subjects. Andrologia 2014; 46:570.
  35. Gooren LJ, Giltay EJ, Bunck MC. Long-term treatment of transsexuals with cross-sex hormones: extensive personal experience. J Clin Endocrinol Metab 2008; 93:19.
  36. Giltay EJ, Gooren LJ. Effects of sex steroid deprivation/administration on hair growth and skin sebum production in transsexual males and females. J Clin Endocrinol Metab 2000; 85:2913.
  37. Lapauw B, Taes Y, Simoens S, et al. Body composition, volumetric and areal bone parameters in male-to-female transsexual persons. Bone 2008; 43:1016.
  38. Hancock AB, Garabedian LM. Transgender voice and communication treatment: a retrospective chart review of 25 cases. Int J Lang Commun Disord 2013; 48:54.
  39. de Bruin MD, Coerts MJ, Greven AJ. Speech therapy in the management of male-to-female transsexuals. Folia Phoniatr Logop 2000; 52:220.
  40. Feldman J, Safer J. Hormone therapy in adults: suggested revisions to the sixth version of the standards of care. Int J Transgend 2009; 11:146.
  41. Klein C, Gorzalka BB. Sexual functioning in transsexuals following hormone therapy and genital surgery: a review. J Sex Med 2009; 6:2922.
  42. van Kesteren P, Lips P, Gooren LJ, et al. Long-term follow-up of bone mineral density and bone metabolism in transsexuals treated with cross-sex hormones. Clin Endocrinol (Oxf) 1998; 48:347.
  43. Mueller A, Dittrich R, Binder H, et al. High dose estrogen treatment increases bone mineral density in male-to-female transsexuals receiving gonadotropin-releasing hormone agonist in the absence of testosterone. Eur J Endocrinol 2005; 153:107.
  44. Ruetsche AG, Kneubuehl R, Birkhaeuser MH, Lippuner K. Cortical and trabecular bone mineral density in transsexuals after long-term cross-sex hormonal treatment: a cross-sectional study. Osteoporos Int 2005; 16:791.
  45. Wierckx K, Elaut E, Declercq E, et al. Prevalence of cardiovascular disease and cancer during cross-sex hormone therapy in a large cohort of trans persons: a case-control study. Eur J Endocrinol 2013; 169:471.
  46. Wierckx K, Mueller S, Weyers S, et al. Long-term evaluation of cross-sex hormone treatment in transsexual persons. J Sex Med 2012; 9:2641.
  47. Canonico M, Plu-Bureau G, Lowe GD, Scarabin PY. Hormone replacement therapy and risk of venous thromboembolism in postmenopausal women: systematic review and meta-analysis. BMJ 2008; 336:1227.
  48. Blosnich JR, Brown GR, Wojcio S, et al. Mortality Among Veterans with Transgender-Related Diagnoses in the Veterans Health Administration, FY2000-2009. LGBT Health 2014; 1:269.
  49. Nota NM, Dekker MJ, Klaver M, et al. Prolactin levels during short- and long-term cross-sex hormone treatment: an observational study in transgender persons. Andrologia 2016.
  50. van Haarst EP, Newling DW, Gooren LJ, et al. Metastatic prostatic carcinoma in a male-to-female transsexual. Br J Urol 1998; 81:776.
  51. TʼSjoen G, Van Caenegem E, Wierckx K. Transgenderism and reproduction. Curr Opin Endocrinol Diabetes Obes 2013; 20:575.
  52. Wallace SA, Blough KL, Kondapalli LA. Fertility preservation in the transgender patient: expanding oncofertility care beyond cancer. Gynecol Endocrinol 2014; 30:868.
  53. De Sutter P. Gender reassignment and assisted reproduction: present and future reproductive options for transsexual people. Hum Reprod 2001; 16:612.
  54. Karim RB, Hage JJ, Mulder JW. Neovaginoplasty in male transsexuals: review of surgical techniques and recommendations regarding eligibility. Ann Plast Surg 1996; 37:669.
  55. Fisher AD, Castellini G, Ristori J, et al. Cross-Sex Hormone Treatment and Psychobiological Changes in Transsexual Persons: Two-Year Follow-Up Data. J Clin Endocrinol Metab 2016; 101:4260.
  56. Wierckx K, Gooren L, T'Sjoen G. Clinical review: Breast development in trans women receiving cross-sex hormones. J Sex Med 2014; 11:1240.
  57. Green R. Sexual functioning in post-operative transsexuals: male-to-female and female-to-male. Int J Impot Res 1998; 10 Suppl 1:S22.
  58. Lawrence AA, Latty EM, Chivers ML, Bailey JM. Measurement of sexual arousal in postoperative male-to-female transsexuals using vaginal photoplethysmography. Arch Sex Behav 2005; 34:135.
  59. Weyers S, Elaut E, De Sutter P, et al. Long-term assessment of the physical, mental, and sexual health among transsexual women. J Sex Med 2009; 6:752.
  60. Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav 2003; 32:299.