Medical Management of Adult Transsexual Persons

Emily L. Knezevich, Pharm.D; Laura K. Viereck, Pharm.D; Andjela T. Drincic, M.D.


Pharmacotherapy. 2012;32(1):54-66. 

In This Article

Surgical Intervention and Postoperative Hormone Therapy

Sex Reassignment Surgery

Sex reassignment surgery is the ultimate goal for most transsexual patients. Criteria must be met to undergo surgery and have been outlined by the Endocrine Society.[1] They include being of legal age and using cross-sex hormone therapy for at least 1 year while participating in real-life experience as the desired gender. The patients must have participated in psychotherapy and have knowledge of costs, complications, and long-term expectations of the surgery. It is preferred that patients being treated with hormone therapy for GID have demonstrated the ability to maintain stable mental health and relationships with others as well as achieved a feeling of comfort in their gender identity. Available surgeries for transsexual patients can be extensive and quite costly. Because the procedures are not typically recognized as medically essential by insurance companies, many patients are required to pay for procedures entirely by their own means.

Male-to-Female Surgery Sex reassignment surgeries for MtF patients include breast augmentation, gonadectomy, penectomy, and vaginoplasty.[1] In neovagina creation, the skin of the penis in inverted to create the vaginal wall with the scrotum serving as the labia majora. Tampon dilators must be worn to maintain depth and width of the vagina until it is being used frequently for intercourse. Cosmetic surgery can create labia minora and a clitoris with neurovascular supply from the previous tip of the penis.

Breast augmentation procedures should be delayed until at least 2 years of cross-sex hormone therapy has been completed since breasts will continue to grow during this time.[1] Breast augmentation is often sought, as 50–60% of MtF individuals deem breast development to be insufficient with cross-sex hormone therapy alone.[1,14] Patients may also consider electrolysis or laser treatments to remove facial and body hair, or surgery to lessen the width of the jaw to a more feminine appearance.

Since estrogen therapy may cause an increased risk of venous thrombosis, therapy is often interrupted for surgery. It has been recommended to discontinue cross-sex hormone administration for 3–4 weeks before elective surgical intervention and for 1 week after or until complete mobilization is regained, whichever is longer.[1,14] After sex reassignment surgery, antiandrogen therapy may be discontinued, but some patients continue to use it to reduce sexual hair growth.

Female-to-Male Surgery Many FtM patients undergo mastectomy as hormone therapy only marginally decreases breast size.[1] In genital reconstruction, the scrotum is created from the labia majora. Surgically, penile and testicular prostheses are implanted; however, to achieve an erection, a mechanical device must be inserted. To ablate functioning female sex organs, oophorectomy, vaginectomy, or a complete hysterectomy may be performed.

Hormone Therapy

Many patients choose to continue cross-sex hormone therapy for fear that they will lose the physical characteristics of the identified sex without the continuation. In MtF patients, the dose of cross-sex hormones should be significantly reduced after surgery; some sources recommend a decrease to half the preoperative dose and further dose titration based on serum hormone levels, whereas FtM patients often continue testosterone therapy at doses they used preoperatively.[1,3,10,11] Continuation of cross-sex hormones may also be beneficial after surgery in maintaining BMD.[10]


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