Comprehensive Gynecologic Care of the Transfeminine Patient.

Estrogen is the primary feminizing hormone therapy for transfeminine patients and is available in multiple formulations.

• Available routes of administration include oral, transdermal (patch or gel), and injectable forms.
• Transdermal estrogen is associated with lower risk of venous thromboembolism compared to oral estrogen.
• Estradiol valerate and estradiol cypionate are common injectable formulations used in feminizing hormone therapy.
• Hormone therapy effects include breast development, redistribution of body fat, softening of skin, and reduction in body hair.

Anti-androgens are commonly used alongside estrogen to suppress testosterone in transfeminine hormone therapy.

• Spironolactone is the most commonly used anti-androgen in the United States for transfeminine patients.
• Other anti-androgens include bicalutamide and cyproterone acetate (the latter not available in the US).
• Gonadotropin-releasing hormone (GnRH) analogues can also be used for testosterone suppression.
• The goal of anti-androgen therapy is to achieve testosterone levels in the typical female reference range.

Feminizing surgeries include a range of procedures, with vaginoplasty being the most commonly sought genital gender-affirming surgery.

• Penile inversion vaginoplasty is the most commonly performed technique for creation of a neovagina.
• Other vaginoplasty techniques include peritoneal pull-through and intestinal vaginoplasty.
• Additional feminizing surgeries include orchiectomy, breast augmentation, and facial feminization surgery.
• Gynecologists may encounter patients at various stages of surgical transition and should be familiar with altered anatomy.

Postoperative complications of vaginoplasty include neovaginal stenosis, granulation tissue, and fistula formation.

• Neovaginal stenosis is one of the most common complications and may require dilation, topical estrogen, or surgical revision.
• Rectovaginal and urethrovaginal fistulas are serious complications requiring surgical management.
• Granulation tissue in the neovagina can be treated with silver nitrate application or surgical excision.
• Regular neovaginal dilation is recommended postoperatively to maintain vaginal depth and caliber.

Evidence-based cancer screening recommendations for transfeminine patients differ from those for cisgender women and depend on anatomy and hormone use.

• Transfeminine individuals who have not undergone orchiectomy retain risk for testicular cancer and should be counseled accordingly.
• Breast cancer screening should be considered for transfeminine individuals who have used estrogen for 5 or more years, beginning at age 50, per some guidelines.
• Those with a neovagina created from penile or scrotal tissue may be at risk for HPV-related pathology and should undergo appropriate screening.
• Prostate cancer screening recommendations for transfeminine patients with a prostate gland should follow general population guidelines, noting that PSA levels may be lowered by estrogen therapy.

Gynecologists play a critical role in providing gender-affirming care despite existing barriers related to education and training.

• Many gynecologists report inadequate training in transgender health care.
• The article emphasizes that with proper education, gynecologists can fill a significant gap in care for transfeminine patients.
• Inclusive language and affirming clinical environments are highlighted as essential components of competent care.
• The authors note increasing visibility of transfeminine individuals as a driver for the need for expanded gynecologic competency in this area.