Caring for trans and gender-diverse patients

A quick guide for clinicians who aren’t specialists in trans care: GPs, practice nurses, pharmacists, gynaecologists, emergency doctors, ward nurses and anaesthetists. Most of a trans person’s healthcare happens outside a gender clinic. This guide is for those encounters.

Downloads

• Print draft · A4 · 4 pages
  Caring for trans and gender-diverse patients: print sheets (PDF) — two companion sheets, printed front and back: Sheet 1 · In clinic and Sheet 2 · In the ED / on the ward. Draft 0.7.
• Decision cards · A4 · 11 cards
  Caring for trans and gender-diverse patients: decision cards (PDF) — flowcharts and quick tables: which drug to hold; clot, heart attack or stroke; surgery and anaesthesia; reading a blood result; high haematocrit; ran out of hormones; testing the organs present; pelvic pain or bleeding; after genital surgery; headache or seizure; contraception. Draft 0.7.
• Full guide · A4 · 36 pages
  Caring for trans and gender-diverse patients: full referenced text (PDF) — the complete guide with all references, in Eden Openly’s publication format. Draft 0.17, not yet deposited.

Decision cards (flowcharts)

Tap a card to see it full size. Each card is also in the decision cards PDF above.

1. Hold the problem drug2. Clot, heart attack or stroke3. Surgery and anaesthesia4. Reading a blood result5. Haematocrit above 54%6. Ran out of hormones7. Organs present8. Pelvic pain or bleeding9. After genital or chest surgery10. Headache, visual change or seizure11. Contraception and emergency contraception

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How to read this guide

• This page is the full referenced text behind the print sheets. Every clinical claim is cited to the numbered references.
• Where no source states something and the wording is our own, it is marked (EO advice). On the print sheets the same lines carry ◆.
• ⧗ marks a clause awaiting specialist review.
• UK and US documents are worked examples. Each country edition replaces them with local guidance. Planned editions: English, Korean, Japanese, Traditional Chinese, Thai and Malay.
• This guide is general education for clinicians. It is not individual medical advice and doesn’t replace local protocols or specialist advice.

→ Sheet 1 · In clinic · Sheet 2 · In the ED / on the ward · Tools that assume one of two sexes · References

Sheet 1 · In clinic

1. The first two minutes

Negative experiences in healthcare are common, and they keep people away. In the 2015 US Transgender Survey (about 28,000 respondents):

• a third of those who had seen a provider in the past year reported at least one negative experience related to being trans;
• 23% had not sought care they needed for fear of mistreatment [35].

In a 2017 Korean national survey of trans adults, 42.7% had delayed or avoided hospital visits in the past 12 months [36]. SOC8 notes that past negative experiences are associated with avoiding care in the future [7]. The first few minutes of a consultation decide whether the patient comes back.

• Name and pronouns. Ask what name and pronouns the patient uses, use them throughout, and record them where your system allows [7,34]. Ask which words they prefer for their body, too [7].
• Only the history you need. Limit questions about gender history to what’s relevant to today’s problem. Patients shouldn’t have to teach you [34]. In the US survey, 15% had been asked unnecessary or invasive questions about being trans that were unrelated to their visit [35]. If a question is relevant, saying why you’re asking helps. (This last point is EO advice; it isn’t stated in the sources.)
• Records. Where your system allows, keep the name and sex on legal documents (needed for identity checks) separate from the name and pronouns the patient uses [34]. Keep an up-to-date list of the organs present, so that screening and examination follow anatomy rather than the sex marker [7]. Treat gender history as confidential and share it only on a need-to-know basis [7].
• Sharing. Ask what may be shared, and with whom, and record it. Don’t tell relatives or next of kin about gender history or hormones without consent, unless disclosure is justified in the public interest; being next of kin doesn’t authorise disclosure [98]. In the UK, disclosing someone’s gender history after legal recognition can be an offence [98].
• Title and pronouns. Record name, pronouns and title (or no title), and use them in letters, even where the sex field is binary [7,52].
• What you write travels. Records, request forms, referral letters, prescriptions and anything shared with insurers or employers may be seen by many people. In some jurisdictions, disclosing that someone is trans carries legal or safety risk. Agree with the patient how information is recorded and shared, and record the minimum necessary, accurately: the clinical fact (the hormone and dose, or the organs present) rather than the identity when that is enough. Clinically essential information, safeguarding duties and legally required reports can’t be left out: explain any disclosure that can’t be avoided, and use restricted-access fields where your system has them. (EO advice.)
  • Fear of a record drives people away from care. In the Korean survey:
    • 10 of the 61 people who had bought hormones without a prescription said they didn’t want a record of treatment in their medical history;
    • 9 of the 25 who had not sought a diagnosis feared discrimination from a psychiatric diagnosis on their record [36].
  • A patient who can’t trust what you write will stop telling you, or stop coming [7,35].
• Examination. Examine only what’s relevant to the presenting problem. A respiratory infection, for example, isn’t a reason to examine the genitals [34]. Explain what you plan to do and why before you start, and remind the patient they can stop the examination at any time [34]. For intimate examinations, explain why the examination is needed and what it involves. Offer a chaperone wherever possible, and don’t assume the patient doesn’t want one. This is professional guidance for any patient; the UK’s GMC is one example [45]. If no suitable chaperone is available, or the patient isn’t comfortable with the one offered, offer to delay the examination if the delay won’t harm their health [45]. Let the patient choose the chaperone’s gender where possible [76]. Use the smallest speculum and lubricant, and offer self-insertion or self-collected swabs where suitable [34,82].
• If you misgender someone, apologise briefly, correct yourself and carry on. (EO advice.)

2. What they may be taking

Self-sourced hormones. Some patients take hormones bought online or obtained from friends, often because prescribed care is hard to reach. How common this is varies widely by setting:

SOC8 notes that self-sourced hormones are, for many people, “the only means of acquiring medically necessary” treatment, and asks clinicians to take a harm-reduction approach [7]. Ask without judgement, check bloods and blood pressure, and help the patient move to prescribed, monitored treatment [7]. See also section 8.

Don’t stop hormones on your own. Stopping is itself an intervention:

• Stopping oestrogen can bring back distressing symptoms, including low mood and anxiety, within a few days [39].
• It may cause bone loss, and will after the ovaries or testes have been removed [7].
• SOC8 asks that any interruption be “as brief as possible” [7].

When to hold the problem drug, not the hormones. Holding a drug for a clinical reason isn’t stopping hormones. Don’t stop the oestradiol or testosterone by reflex: hold the drug that is the problem, and reassess as the situation changes, because acute illness, surgery, thrombosis or a new interaction can shift the balance. (EO advice.)

Usual doses (an overview for checking a regimen, not a substitution calculator: products differ by country and strength) [3,7]:

Doses are adjusted to hormone levels [7]. HIV drugs can change them (Sheet 2) [60].

• Running out, or a prescriber’s service closing: bridge, don’t stop. Continue the established regimen, on the same route where possible (Sheet 2, “Ran out of hormones”) [7].
• Starting or restarting in older age: reassess cardiovascular and VTE risk, prefer transdermal oestradiol, start low and titrate [7,34].
• Nonbinary patients may want partial or lower-dose regimens. Some combinations of effects aren’t achievable, so discuss what to expect [7,34].
• Some testosterone effects are permanent, even if it’s stopped: a deeper voice, facial hair, male-pattern hair loss and genital growth [7].

3. Red flags (act or refer)

4. Screening: screen the organs present

The UK programme is used below as a worked example; each country edition replaces it with the local programme.

• Cervix present (trans men and nonbinary people): offer cervical screening as for cisgender women [7]. People registered as male may not be invited automatically and may need to opt in (NHS England) [20].
  • On testosterone, unsatisfactory samples are about ten times more common, and more so the longer it has been taken [16]. Screening can be uncomfortable or painful [20].
  • A smaller (paediatric) speculum helps, as long as it isn’t so short that it needs excessive pressure. A small amount of water-based lubricant on the outer speculum also helps [16,20].
  • Vaginal oestrogen for about a week beforehand is listed as one anecdotal option [16].
  • Testosterone use helps the lab interpret the sample [16]. Agree with the patient whether to note it on the form: for someone registered as male, it discloses that they are trans (see the section 5 tips). Screening should never be a condition of testosterone treatment [16].
  • HPV self-sampling may suit some patients [7].
  • After vaginoplasty there is no cervix, so no cervical screening [89].
• Breast tissue:
  • Trans women on long-term oestrogen: screen as for cisgender women, taking hormone duration and age into account [7]. UCSF advises not starting screening before at least 5 years of feminising hormones, nor before age 50 [34]. In the UK this is ages 50–71, every 3 years. Patients registered as male are referred by their GP [20].
  • Trans men without chest surgery: screen as for cisgender women [7].
  • A new lump goes on the usual urgent pathway. Breast cancer risk on oestrogen is higher than in men, lower than in women [91]. If the sex marker blocks a referral or test, override it or escalate [71].
  • After chest masculinisation: after reduction only, screen as for cisgender women. After mastectomy, no screening approach is validated [34]. A new lump still needs investigating: mammography may not be feasible, so ultrasound or MRI may be needed [34]. This is for investigating a lump, not for screening.
• Prostate: always retained after vaginoplasty. It can be examined via the neovagina, where it lies on the anterior wall [7]. Screen according to individual risk [3]. PSA is markedly suppressed on oestrogen, so a “normal” PSA doesn’t reassure (see section 5) [21,22].
• Bone density: hormone therapy itself isn’t an indication for DXA [7]. Consider DXA:
  • after gonadectomy, especially with gaps in hormones or after stopping them [3,7];
  • in long-term low sex-hormone states [7];
  • with the usual risk factors.

  For low-risk trans women on hormones, the Endocrine Society suggests screening from age 60 [3].

  • For DXA Z-scores, use the reference database for the person’s gender identity (for nonbinary people, sex recorded at birth). For FRAX, there’s no evidence on which sex to enter, so state which one you used [90].
• Sexual health: test for STIs at every site used for sex. After vaginoplasty there’s a prostate but no cervix [89]. The neovagina and neovulva can still be infected, for example with gonorrhoea, chlamydia or herpes, and a urine test may be more useful than a neovaginal swab for gonorrhoea and chlamydia [127]. For PrEP, see section 8.
• Cardiovascular: check blood pressure, lipids, glucose and HbA1c, weight and smoking, as for anyone [3,7].
  • No risk calculator is validated for people on hormones. Use the sex assigned at birth, the affirmed gender or an average of the two, depending on age at starting and duration, and consider running both [7,34].
  • SOC8 suggests the affirmed gender is likely most appropriate if hormones started around puberty [7].

5. Reading the bloods

The rule of thumb: after about 12 months on stable hormones, many results behave like those of the patient’s affirmed gender. Some don’t. The lab report usually flags against the legal sex on file, so the flag can be wrong in either direction. (“Stable” in the reference-interval studies means at least 12 months on hormones [23,24].)

Practical tips

• Take blood away from gel sites (use the other arm, or another site if gel goes on both). Gel on the skin can falsely raise testosterone or oestradiol. If a result looks implausibly high, check LH and FSH [59].
• After gonadectomy, raised LH and FSH with low sex steroids suggest under-replacement [34].
• If a system blocks a test because of the sex marker, ask the laboratory to override it, and don’t drop the test [59,71].
• Interpret the result yourself. The lab flags against the sex on file. Read the result against the ranges in this table rather than relying on the flag.
• Agree with the patient what goes on the request form. Forms and results are seen by many people. In some jurisdictions, disclosing that a patient is trans carries legal or safety risk. If lab input would help, give the clinical fact, not the identity: for example, “on oestradiol 4 mg/day since 2023”. Never withhold what the laboratory needs for a safe result. Where disclosure risk is real, agree the minimum with the patient, and record your own interpretation of the result in the notes. (EO advice.)
• Before acting on an “abnormal” flag, ask whether it’s actually expected on hormones.
• Before 12 months, or during interruptions, values sit somewhere in between, so interpret with care.

6. Emergencies and inpatients

See Sheet 2 · In the ED / on the ward.

7. Mental health

• Higher rates, and why. Depression and anxiety are more common in trans people than in the general population [7,46]. Being trans is not a mental illness. SOC8 links the higher rates to stigma, discrimination, violence and trauma, often called “minority stress” [7,46,47]. Most of this evidence comes from cross-sectional surveys, so it shows association, not proven cause [46,47]. Social support is linked to better mental health [7].
• Not a condition to treat away. Attempts to change someone’s gender identity (“conversion practices”) don’t work. They are linked to depression, suicidal thoughts and suicide attempts [7].
  • SOC8 says they should not be offered [7].
  • The UN Independent Expert on SOGI calls them “by their very nature degrading, inhuman and cruel”. He found that they cause “profound psychological and physical damage” and has recommended that States ban them (¶83, ¶86, ¶87(a)) [48].
  • As of May 2025, 15 countries banned them nationwide by law, and 14 more did so indirectly through executive circulars and directives [49].
  • Each edition’s local reviewer should check the position in their country.
• Support, not gatekeeping. Offer or refer to mental health support that respects the person’s gender. Don’t make therapy a condition of routine or gender-affirming care [7]. Depression or anxiety isn’t a reason to delay treatment, unless it affects the person’s capacity to consent [7]. If they’re admitted for mental health reasons, continue their hormones unless there’s a medical reason not to, and use their name and pronouns on the ward [7].
• Ask directly about thoughts of suicide, plans and means. Don’t use risk scales to predict suicide [96].
• Abuse can target identity: threats to out someone, misgendering, and denying their identity [93,101]. Ask when the patient is alone [96]. Controlling how someone presents is a recognised tactic [105]; controlling or hiding their hormones is one form of it. (EO advice.) Refer to specialist LGBT+ domestic abuse services where available (in the UK, for example, Galop). Standard safety plans may not fit, and sharing information can out the person [105]. Confidentiality is subject to local safeguarding and mandatory reporting law; assess immediate danger. (EO advice.)
• If capacity is lost (for example dementia), keep using the person’s established name and pronouns [7]. Decisions about hormones follow local capacity and best-interests law, any advance decision and the person’s known wishes; a relative’s preference isn’t authority on its own. Involve the original prescriber where possible. (EO advice.)

8. Pharmacists

Interactions to check

Injections

• Testosterone enanthate and cypionate can be given subcutaneously or intramuscularly [3,7]. Injectable undecanoate is intramuscular only, never subcutaneous (an oral undecanoate also exists); follow the exact product’s protocol. Nebido (EU/UK): inject very slowly, over two minutes, and observe the patient during and immediately after each injection for pulmonary oil microembolism [51]. Aveed (US): inject over 60–90 seconds, then observe in the healthcare setting for 30 minutes after every injection; it is supplied only through a restricted programme (REMS) [114].
• Teach technique and give sharps disposal advice.
• Never share needles. Sterile equipment protects against blood-borne infection [7].

Self-sourced products. The dose and content may be unknown, and injectables may not be sterile [7]. For injected oestradiol, ask which ester, the dose, how often, and the date of the last injection. (EO advice.) Contraceptive pills used as hormones contain ethinylestradiol, which carries the highest clot risk [7]. Don’t refuse care. Take a non-judgemental history and help the patient towards prescribed, monitored treatment [7].

9. Fertility and contraception

• Testosterone is not contraception. Pregnancy can happen on testosterone, even when periods have stopped, and after long-term use [7,52,53]. Testosterone may harm a developing fetus, so it should be stopped before trying to conceive and throughout pregnancy [7,52].
• Contraception for people on testosterone. All current methods can be considered, subject to the usual medical contraindications [53]. Progestogen-only methods and IUDs (copper or hormonal) are often preferred, and progestogens can also stop bleeding. Oestrogen-containing methods aren’t ruled out, but are usually avoided unless there’s a clear reason [53]. Progestogen-only methods aren’t thought to interfere with masculinisation [52], though data are limited [53]; the copper IUD contains no hormones [53].
• Emergency contraception on testosterone: levonorgestrel, ulipristal or a copper IUD (the most effective). It’s unlikely to interfere with testosterone [53].
• Enzyme inducers (see section 8; they include efavirenz and nevirapine) reduce the effect of combined methods, all progestogen-only pills and the implant, during use and for 28 days after stopping. Use a copper IUD, LNG-IUS or injectable instead [104]. Emergency contraception with an enzyme inducer: copper IUD first (it can be fitted up to 5 days after unprotected sex [113]), and anyone referred on for a copper IUD should be given oral emergency contraception at the time of referral in case it can’t be fitted [113]; if an IUD isn’t possible, levonorgestrel 3 mg (a double dose, off-licence, as is any levonorgestrel use after 72 hours [113]) within 96 hours, explaining that its effectiveness in this situation is unknown [104,113]. FSRH’s interaction guidance allows a single standard dose of ulipristal, with advice that effectiveness is unknown [104], but its emergency contraception guideline says ulipristal isn’t recommended in this situation [113]: prefer the copper IUD or levonorgestrel. Never double the ulipristal [104]. For other HIV drugs, including boosted regimens, use the Liverpool checker before choosing contraception [60,104]. An inducer affects only the person taking it, not their partner’s contraception. (EO advice.)
• Feminising hormones are not contraception either. They reduce sperm production but don’t reliably stop it. If pregnancy is possible, use condoms or another method [7].
• Fertility preservation. Discuss fertility before starting hormones, and refer for egg or sperm storage if wanted [3,7]. Fertility often returns after stopping hormones, but this can’t be guaranteed: long-term data are limited [3,7]. Sperm production can return after stopping hormones, sometimes only after many months, and quality is often reduced (9 cases) [92]. Storage before starting remains advised [7,92].

10. Words that help, words that hurt

Ask which terms the person prefers, including for their body [7]. The pairs below come from a US media style guide [55,56]. Each edition’s local reviewer will check the equivalents in their own language.

11. Where to get help

• Local gender services and referral routes (a country-specific panel for each edition).
• Community organisations (country-specific).
• The Eden Openly evidence reviews: ER-005 (feminising hormone therapy), ER-008 (hormone monitoring and target ranges), ER-023 (erythrocytosis), and the companion Evidence Notes.
• Ask a Colleague: the clinician-to-clinician consult network (link once live).

Sheet 2 · In the ED / on the ward

For emergency doctors, ward nurses, anaesthetists and hospital pharmacists. Find the presentation, act on the first lines, and use the clinic sheet for background. Numbers in [ ] refer to the shared source register.

Before anything else

1. Name and pronouns. Ask what the patient uses and use them throughout [7,58]. The wristband and labels may carry the legal name, so link it to the name used [59,71], and confirm identity by your local positive-identification policy (for example date of birth and hospital number), including at handover. (EO advice.)
2. Ask which organs and surgeries are present. Pregnancy testing, catheterisation, screening, transfusion and reference ranges all depend on it [7].
3. What you write travels. Agree with the patient how forms, referrals and reports are worded, and record the minimum necessary: the clinical fact (the hormone and dose, the organs present) rather than the identity, when that is enough. This can’t override essential clinical documentation, safeguarding or legally required reports. (EO advice; see Sheet 1, section 1.)
4. Pregnancy test whenever pregnancy is possible (a uterus and ovaries, and a possible exposure), whatever the sex on file and even on testosterone or without periods. Offer it before surgery (see Surgery), before imaging or drugs that could harm a pregnancy, and in abdominal or pelvic pain [7,16,58]. Never delay resuscitation or life-saving treatment for it. A bedside urine test avoids system blocks. Systems that use legal sex can block these orders [59,71]: ask the laboratory to override, and don’t drop the test. (EO advice.)
5. Don’t stop hormones by reflex. Hold the drug that is the problem, and reassess if the situation changes (EO advice). See “When to hold the problem drug” in Sheet 1, section 2. Ask about self-sourced hormones too.
6. Tools that assume one of two sexes. Many scores and cut-offs do. See the table at the end of this sheet.
7. Blood transfusion. Compatibility is set by ABO, RhD and antibody testing, as for anyone. The blood bank also needs the sex assigned at birth, or whether the patient could become pregnant, to choose RhD status [59]. As for anyone who could become pregnant, an RhD-negative patient with a uterus should get RhD-negative red cells, including in emergencies [59]. Trans women can receive RhD-positive blood if needed [59]. Tell the transfusion service on a need-to-know basis, explaining why: this is sharing for direct care [58,98]. Never delay an emergency transfusion for this: follow the local emergency protocol. K-negative red cells and anti-D follow local policy for anyone who could become pregnant. (EO advice.)
8. VTE: assess every admission as soon as possible [97]. Count oestrogen as a risk factor [50]; it isn’t a reason to withhold prophylaxis [97].

By presentation

Chest pain or suspected MI

• Treat as for any patient.
• Troponin: use serial measurements. If your lab reports sex-specific cut-offs, ADLM provisionally recommends the one for the affirmed gender [59]. In one cohort, affirmed-gender thresholds didn’t significantly reclassify patients [70]. Data are limited [26]; interpret a borderline result against the trend, the ECG and the clinical picture [26].
• ECG: new ST elevation at the J-point in at least two contiguous leads, without LV hypertrophy or LBBB, suggests acute coronary occlusion. The V2–V3 thresholds differ by sex and age, and the lowest is ≥1.5 mm [116,121]. Using ≥1.5 mm in V2–V3 for everyone is a conservative choice for escalation, not a validated trans-specific rule. Where fibrinolysis rather than PCI is the reperfusion route, confirm with cardiology before treating on this threshold alone. (EO advice.) An ECG below threshold doesn’t rule out an occlusion MI: use serial ECGs, troponin and the clinical picture.
• PE on the differential: oral hormone use is a PERC criterion, so PERC can’t rule out PE in someone taking oestrogen [68]. Don’t use PERC for anyone on oestrogen, by any route. (EO advice.) Go to Wells and D-dimer or imaging.
• If MI is confirmed: hold cyproterone [106]. Don’t stop oestradiol or testosterone by reflex: decide early with the cardiology team and the prescriber, considering the hormone, its route and dose. (EO advice.)

Stroke or TIA

• Treat on the usual stroke pathway. Hormone therapy isn’t listed among the conditions that weigh against IV thrombolysis in current US guidance [124], nor in its 2019 predecessor [103].
• Hold cyproterone [106]. Decide about oestradiol early with the stroke team and the prescriber (route, dose, cause of the stroke, bleeding risk); don’t stop it by reflex or continue it unreviewed. (EO advice.)
• Consider cerebral venous sinus thrombosis (see Headache) [67].

Suspected or confirmed DVT or PE

• Suspected DVT or PE: assess on the usual clinical-probability pathway (Wells score, then imaging or D-dimer), giving interim therapeutic anticoagulation if results will be delayed, as your local protocol directs [125]. Confirmed: anticoagulate as standard [125]. Hormones aren’t a reason to delay any of these steps. (EO advice for the last point.)
• Confirmed VTE and hormones: oestradiol is a joint decision with the patient and prescriber. Continuing it on full-dose anticoagulation is a recognised option, and if oestrogen continues, anticoagulation shouldn’t be stopped [41,110]. SOC8 notes acute VTE as a rare reason to suspend hormones [7]. Review route, dose and adherence before deciding; SOC8 suggests transdermal oestradiol after a VTE [7]. (EO advice for the order of steps.)
• Cyproterone: hold it. It is contraindicated with existing thrombosis or embolism [12,106].
• Check for self-sourced ethinylestradiol or contraceptive pills [7].
• On testosterone: check haematocrit.

Headache, visual change or seizure on hormones

• First: assess airway, breathing, circulation and consciousness, and look for red flags. Don’t let fundoscopy or visual-field testing delay imaging or referral for stroke, seizure, thunderclap headache or raised pressure; check fundi and fields when feasible. (EO advice.) Sudden focal signs: see Stroke or TIA.
• Cerebral venous sinus thrombosis: gender-affirming hormones, oestrogen or testosterone, are listed risk factors [67]. With red flags, image the brain urgently by the usual pathway: a sudden severe (thunderclap) headache needs immediate non-contrast CT for haemorrhage; add CT or MR venography if sinus thrombosis is possible; MRI is preferred for suspected meningioma. (EO advice for the imaging order.)
• Meningioma (cyproterone, especially long-term use or 25 mg/day or more) [9,10]: new focal neurology, seizures or visual disturbance need urgent standard assessment and imaging, usually MRI. There’s no routine screening MRI for people without symptoms. (EO advice.) If a meningioma is found, stop cyproterone permanently [9,12]; discuss oestradiol with the neurosurgical team and the prescriber, and tell them about the cyproterone. (EO advice.) 25 mg/day or more marks higher observed risk, not a level below which risk is absent: flag it to the prescriber [9,11,109]. Some meningiomas regress after stopping [11].
• Pituitary: check prolactin. A prolactinoma is rare [15]. With visual symptoms or a markedly raised prolactin, arrange MRI and formal visual fields (Sheet 1, section 5) [14,99].
• Testosterone: check haematocrit (see below).
• Lamotrigine: oestradiol is expected to lower its levels, and limited data support this [50,117]. Check a level and discuss the dose with neurology [72].

Abdominal or pelvic pain, if the person has a uterus or ovaries

• Unstable (shock, peritonism): resuscitate and call emergency gynaecology or surgery at once. If pregnancy is possible, treat as a ruptured ectopic until proven otherwise, but consider other bleeding and torsion. Don’t wait for a pregnancy test. (EO advice.) With high suspicion, a negative urine test doesn’t exclude pregnancy: send serum hCG. (EO advice.) In acute bleeding, follow the haemoglobin trend and the physiology; on testosterone the normal range is the male one [23].
• Pregnancy test first. Testosterone doesn’t reliably prevent pregnancy, and ovulation can occur without periods [7,16].
• Consider ectopic pregnancy [16] and the usual surgical causes, including ovarian torsion. Ovaries kept after hysterectomy can still develop disease [7].
• Then consider: atrophic or infectious vaginitis, cervicitis, cystitis, STIs, adhesions or post-surgical causes, and musculoskeletal or pelvic-floor causes [16].
• If the test is positive with pain or bleeding, it is an ectopic pregnancy until proven otherwise: same-day gynaecology assessment. (EO advice.) Stop testosterone and refer [7,51].
• Offer a choice of ward or a side room. (EO advice.)

Vaginal bleeding on testosterone

• With heavy bleeding or instability: resuscitate, hold anticoagulants and reverse them per the local major-haemorrhage protocol, and see “Before anything else” for transfusion. (EO advice.)
• Check observations and haemoglobin (male range on testosterone) [23]. Exclude pregnancy, check hormone levels, image the pelvis (transabdominal if transvaginal is declined), and involve gynaecology [16]. Ask about missed doses, changes in interval or formulation, and new medicines. (EO advice.)
• Differential: missed or late doses, pregnancy, coagulopathy or anticoagulants, and structural causes; involve gynaecology [34,73].

Acute scrotal pain (testes present)

• Suspect torsion. Admit as an emergency to urology for exploration; don’t wait for imaging. Repair is ideally within 6 hours [34,100].
• Torsion can still happen on feminising hormones. (EO advice.)

After vaginoplasty

Refer back to the operating surgeon, or to a local reconstructive urologist if surgery was abroad [57]. Keep the dilation schedule during any admission, unless the surgical team says otherwise [57].

After phalloplasty or metoidioplasty

• Retention: bladder scan, then urology [43,57]. Non-urologists shouldn’t attempt blind urethral catheterisation [43,44]. If the bladder needs decompressing, a suprapubic catheter is placed by an experienced clinician [44,57].
• The vaginoplasty catheter advice (coudé tip) doesn’t apply. (EO advice.) If a suprapubic catheter is in place or was recently removed, check, flush or re-site it through that tract first; otherwise a suprapubic catheter by an experienced clinician, ideally ultrasound-guided. Decompression shouldn’t wait for a transfer: if transfer would delay it, the most experienced clinician available places a suprapubic catheter under ultrasound, with phone advice from urology; if urology isn’t on site, escalate or transfer. (EO advice.)
• Weak stream, dribbling, straining, recurrent UTI, or leaking from a new opening suggest a stricture or fistula: refer before retention develops [57].
• Strictures usually form at a join in the new urethra, most often between its fixed part and the part within the phallus, typically 6–36 months after surgery [44,57].
• Ask which stage of surgery they’re at and where they pass urine from. (EO advice.)
• Erectile implant that is red, hot or exposed: urology the same day (EO advice). Infection can occur at any time, and treatment is usually removal [57].

After chest masculinisation surgery

• Early, one-sided, tense swelling and pain, sometimes with bruising, is a haematoma until proven otherwise. Most need evacuation, so get urgent surgical review [34].

Airway and anaesthesia after facial or voice surgery

• Airway assessment is unreliable after facial or neck procedures. Jaw reduction can crowd the oropharynx, chin implants make thyromental distance unreliable, and a tracheal shave makes front-of-neck landmarks harder to find [58].
• After cricothyroid approximation (a voice-raising operation), there may be no cricothyroid membrane, so standard emergency front-of-neck access may not be possible. Plan an alternative in advance [58].
• Within 8–12 weeks of voice surgery, avoid instrumenting the airway unless absolutely necessary. If anaesthesia is needed, prefer regional or sedation, then a supraglottic airway. If intubation is unavoidable, use a microlaryngeal tube (internal diameter 5–6 mm) [58]. Afterwards the glottis may stay smaller (glottoplasty can narrow it by up to a third): use the smallest suitable tube [58].
• Discuss with the gender-affirming surgeon where possible [58]. For surgery near the larynx (for example thyroid surgery), tell the operating surgeon about any previous voice or laryngeal surgery and get the operation note. (EO advice.)

Surgery, elective or emergency

• Hormones: don’t delay emergency surgery over hormones. (EO advice.) For elective surgery, testosterone is generally continued [58]. Oestradiol is an individual decision, considering route, previous VTE, the procedure and thromboprophylaxis [58]; in older patients, some withhold or reduce it temporarily [41]. Agree the plan between anaesthesia, surgery and the prescriber. (EO advice.)
• Offer a pregnancy test to anyone with a uterus and ovaries aged 12–55, whatever their contraception (UK anaesthesia guidance; follow your local policy) [58]. This is the perioperative rule; outside surgery, test whenever pregnancy is possible.
• VTE: assess VTE and bleeding risk with the usual tool; oestrogen isn’t a reason to withhold prophylaxis [97]. NICE’s general advice is to consider stopping oestrogen-containing contraceptives or HRT 4 weeks before elective surgery [97]. Trans-specific guidance favours an individual decision about oestradiol [41,58]. No study we identified shows that routinely stopping it before surgery reduces VTE [110] (EO review: an absence of evidence).
• Other drugs follow the usual perioperative rules, which differ by country. For SGLT-2 inhibitors, UK guidance omits them on the day before and the day of surgery and checks blood ketones daily [94]; US labels say to withhold them for at least 3 days before surgery (ertugliflozin at least 4), and to restart once the person is clinically stable and eating [120,122]. After emergency surgery, watch for ketoacidosis, including euglycaemic ketoacidosis [122]. Follow your local protocol.
• Sugammadex counts as one missed pill for oral contraceptives, including progestogen-only ones: follow the missed-pill advice. Non-oral hormonal methods need extra non-hormonal contraception for 7 days [95,104]. Testosterone isn’t contraception. Its effect on oestradiol therapy is unclear [58].
• Chest binder: remove it before anaesthesia, with the patient’s consent, and agree when it goes back on [58].
• Spironolactone: watch for hyperkalaemia and AKI [19,58].
• Haematocrit on testosterone: use a recent full blood count where your preoperative-testing policy calls for one. (EO advice.)
• Ward: ask the patient where they would feel safe, follow local policy, and offer a side room where possible [58].
• Transfusion: see “Before anything else”, point 7.

Sepsis, AKI and drug dosing

• In AKI, eGFR is unreliable [61]. Use the change from baseline, and adapt doses while function is unstable [61,62].
• Loading doses: don’t automatically reduce an indicated antibiotic loading dose just because renal function is uncertain; follow drug-specific protocols. (EO advice.) For vancomycin in critically ill adults with suspected serious MRSA infection, consensus suggests 20–35 mg/kg by actual body weight, maximum 3 g, then AUC-guided monitoring; follow your local protocol [115].
• Maintenance doses: once kidney function is stable, calculate eGFR with both the male and the female setting to show the uncertainty [59]; there’s no agreed method [59,62]. eGFR and Cockcroft–Gault creatinine clearance aren’t interchangeable: use whichever the drug’s label specifies. Female-based equations may underestimate kidney function in trans adults on either hormone [63]. Dosing weights (ideal or adjusted body weight) are sex-based too. Involve a clinical pharmacist and use drug levels. (EO advice, following [62].) ⧗
• Then adjust by drug levels wherever you can (for example aminoglycosides) [61,62].
• Contrast: don’t withhold contrast needed for diagnosis because of a sex-dependent eGFR. Use the range and the clinical trend. (EO advice.)
• Cystatin C also moves with hormones, inflammation, steroids and thyroid disease, so it isn’t a fix in acute illness [62].
• Spironolactone: hold it during the illness (sick-day rule) [19,74].
• VTE: assess as for any medical admission; offer prophylaxis if VTE risk outweighs bleeding risk [97].

High potassium, dehydration or low blood pressure on spironolactone

• Treat hyperkalaemia as standard.
• Hold spironolactone [19]. Decide about an ACE inhibitor or ARB by the potassium level, renal function and why it was prescribed. (EO advice.) ⧗ Treat severe hyperkalaemia, with ECG monitoring, per your emergency protocol. Also review NSAIDs, heparins, co-trimoxazole (trimethoprim) and potassium supplements [19]. Its active metabolites last 14–17 hours, so recheck potassium after stopping [19].
• Keep the oestradiol going. Oestradiol alone may not fully suppress testosterone, so tell the prescriber, who will choose what to restart [3,75].

Haematocrit above about 54% on testosterone

• Unwell (headache, visual change, chest pain, neurological signs or signs of a clot): assess urgently. Check BP, hydration and oxygen saturation, and look for thrombosis, including venous sinus thrombosis [67], and other causes. Discuss with haematology: venesection is an option for selected patients, not an automatic emergency treatment [86]. (EO advice.)
• Guidelines advise holding testosterone until the haematocrit falls, looking for hypoxia and sleep apnoea, and restarting at a lower dose. Venesection is an option [86]. With undecanoate, “hold” means deferring the next injection. Levels fall slowly, so check the trough before the next dose [51,86]. Switching formulation is a prescriber decision. (EO advice.)
• Other causes: smoking, lung disease and high BMI [25]; sleep apnoea [86]; SGLT-2 inhibitors [51]. If the rise is unexplained, consider a primary cause and discuss with haematology. (EO advice.)
• The thresholds come from other populations and haven’t been validated by outcome data in trans men [129]; an unvalidated threshold isn’t a wrong one. (EO advice for the last point.)

HIV: antiretrovirals, PrEP and PEP

• HIV treatment is not a reason to stop hormones [7].
• Check every regimen on the Liverpool HIV interaction checker (hiv-druginteractions.org) [60].

  • Unboosted integrase inhibitors (dolutegravir, bictegravir, raltegravir) don’t interact. Cobicistat-boosted elvitegravir does. Cabotegravir doesn’t affect hormones, but high-dose testosterone with exercise training may lower long-acting cabotegravir and rilpivirine levels [60].

  • Oestradiol: ritonavir-boosted PIs, efavirenz, etravirine and nevirapine are predicted to lower it; cobicistat-boosted regimens, unboosted atazanavir and fostemsavir to raise it [60].

  • Cyproterone and testosterone: all boosted regimens and unboosted atazanavir raise them, so review the dose with the prescriber or pharmacist, and don’t raise an established low cyproterone dose to match the chart (EO advice); lenacapavir raises cyproterone only; efavirenz, etravirine and nevirapine lower them [60].

  • Check hormone levels if in doubt [7].

• PrEP: daily PrEP works for trans women who take it [88]. Hormones modestly lower PrEP drug levels (about 12–32% in small studies); PrEP didn’t lower oestradiol in those studies [66,87]. Use daily, not event-driven (“2-1-1”), PrEP for anyone on oestradiol [81,87]. For receptive vaginal or front-hole sex, baseline HIV testing and injectable options, see Sheet 1, section 8 [7,81].
• PEP: start as soon as possible, ideally within 24 hours and no later than 72 hours. Continue for 28 days. Preferred regimens: bictegravir/emtricitabine/tenofovir alafenamide, or dolutegravir plus tenofovir (TAF or TDF) plus emtricitabine or lamivudine [111]; neither interacts with hormones [60]. Take a baseline HIV test (rapid if available), but don’t delay the first dose for laboratory results. PEP isn’t recommended when the source has HIV with sustained viral suppression; if it isn’t known whether the source has HIV, decide case by case [111]. Retest with antigen/antibody plus HIV RNA at 4–6 weeks (this can be skipped if PEP started within 24 hours, no doses were missed and PrEP isn’t starting) and finally at 12 weeks after exposure, and offer PrEP if exposure risk continues [111]. Check interactions [60].
• Contraception with enzyme-inducing HIV drugs (efavirenz, nevirapine): see Sheet 1, section 9 [104].
• STIs: test every site used for sex. After vaginoplasty there’s a prostate but no cervix [89]; the neovagina can still be infected, and a urine test may be more useful than a neovaginal swab for gonorrhoea and chlamydia [127]. Some laboratories reject specimens labelled “neovaginal”: agree the labelling with your laboratory in advance. (EO advice for the last point.)

Self-sourced hormones, injections and silicone

• Ask, without judgement: what was taken, how, and from where [7]. Check hormone levels when the result will change a decision. (EO advice.)
• Injection abscess: culture the pus and check tetanus status. (EO advice.) A septic abscess, or one at a hormone injection site, follows usual management: imaging mustn’t delay drainage. (EO advice.) Where silicone or filler was injected, ask what was injected: nodules can evolve into sterile abscesses or fistulas, and granulomas can form [34]. Ultrasound, CT or MRI can help [34]; image first and involve the surgical team before incising, since surgical excision may be needed [34]. (EO advice for the order of steps.) After silicone or filler injections, abscesses can involve M. abscessus, so send AFB culture [34,102].
• Shared needles or non-prescribed injections: offer HIV, hepatitis B and hepatitis C testing, and hepatitis B vaccination [80].
• Silicone or “filler” injections (“pumping”): ask specifically.
  • Sudden breathlessness, low oxygen, fever or confusion soon after injection suggests silicone embolism. It can be fatal, and neurological involvement carries the worst outlook [34,77]. Give oxygen and escalate early to critical care. (EO advice.)
  • Later problems: hard lumps and granulomas, infection, migration and high calcium [34,102]. Check calcium if there are symptoms or extensive granulomas. (EO advice.)
  • It’s common in some settings: in one San Francisco sample, one in six trans women had had filler injections [78].
• Help the patient move to prescribed, monitored treatment [7].

Assault or violence

• Trans people experience high rates of violence [35], including 1.7–2.5 times the rate of intimate partner violence [93]. Ask in private, as you would any patient. Abuse can target identity: threats to out someone, misgendering, denying their identity and controlling how they present [93,101,105]. Refer to specialist LGBT+ domestic abuse services where available [105].
• Sexual assault: emergency contraception and HIV PEP are time-sensitive: start PEP within 72 hours, without waiting for test results, and continue for 28 days with follow-up testing (see HIV) [111]. Offer post-rape care: emergency contraception and a pregnancy test if pregnancy is possible, PEP, STI prophylaxis and hepatitis B vaccination as your local protocol indicates, and psychosocial support [80]. Offer forensic examination with consent, by a trained team per local protocol. (EO advice.) Use a trauma-informed approach [127]: say what you are going to do before each step, ask consent for each part of the examination, and offer self-collected swabs for STI testing where suitable. (EO advice for the steps.) Sample the sites the person is concerned about [59]; after vaginoplasty, use the smallest speculum or an anoscope with lubricant [82]. There is no cervix [89]. Neovaginal and atrophic tissue tear more easily [82]. Trans survivors may find exposing their body very difficult [105]; offer a choice of examiner gender where possible. (EO advice.)
• Police: the patient decides. Don’t share with the police without consent unless required by law or justified in the public interest [98].
• In police and safeguarding reports, share only the minimum legally or clinically necessary; trans status is often not needed. (EO advice.)
• Document every injury fully, including what was said. “Minimum necessary” applies to gender history, not to injuries. (EO advice.)
• After facial surgery, tell the radiologist about any implants or previous facial or laryngeal procedures. (EO advice.) Facial injuries after facial or voice surgery: see Airway [58].
• Ward: ask the patient where they would feel safe, and offer a side room where possible [58].

Mental health crisis

• Do the standard risk assessment, as for anyone. Ask directly about thoughts of suicide, plans and means; don’t use risk scales to predict suicide [96].
• Don’t attribute the crisis to being trans, and don’t use it to question the person’s identity. Being trans isn’t a mental illness [7].
• Continue hormones on admission unless contraindicated, and use the person’s name and pronouns [7].
• Searches and intimate care: offer staff of the gender the patient prefers, where safe and possible. Make an individual plan for dilators and binders with the patient and the psychiatric team (and the surgical team after recent surgery), weighing stenosis risk against ligature and safety policy, rather than removing them by default; dilation is time-critical after recent vaginoplasty [57]. (EO advice, except the dilation point.)
• Binders restrict breathing [58], so plan ahead of restraint, sedation or rapid tranquillisation: remove them with consent where possible, by the least restrictive approach, and follow your rapid-tranquillisation protocol. (Extrapolated from anaesthesia; there are no psychiatric data.)
• Antipsychotics commonly raise prolactin [99].
• Overdose of spironolactone or oestradiol: manage as in each SmPC (section 4.9) and with your poisons service [19,50].
• Psychotropics: spironolactone reduces lithium clearance [19]; enzyme-inducing anticonvulsants lower oestradiol [50]; lamotrigine levels shift with oestrogen [72].
• Ward: ask the patient where they would feel safe; offer a side room where possible [58].

Fracture after gonadectomy or a long gap in hormones

• After a low-trauma fracture, assess as a fragility fracture: bone profile, falls assessment and osteoporosis treatment. (EO advice.) DXA is indicated after gonadectomy or prolonged hypogonadism [90].
• Re-establish hormone therapy: first ask why hormones stopped (a clot, a hormone-sensitive cancer, a meningioma, access or choice), then refer back to the prescriber. (EO advice.) After gonadectomy, hormone replacement is needed [3], and anti-androgens are for those who haven’t had an orchidectomy [58]. Over 45, transdermal oestradiol is suggested [7].
• FRAX: there is no evidence on which sex to enter. State which one you used [90]. T-scores use the female reference database for everyone [90]. Screen for secondary causes as usual [90]. DXA Z-scores use the database for the person’s gender identity (for nonbinary people, sex recorded at birth) [90].

Breast lump

• A clinically suspicious lump goes on the local suspected-cancer pathway, whatever the sex marker; don’t route it as gynaecomastia. (EO advice.) Breast cancer is more common in trans women on oestrogen than in men, though less common than in women [91]. The breast radiologist chooses the imaging: after chest surgery or with implants, mammography may not be feasible, and ultrasound or MRI may be needed [34].
• If the sex marker blocks a test or referral, override it or escalate. Don’t delay [71].
• Note any implants or silicone injections: injected silicone can make mammography ineffective [34]. Ask about family history. Don’t stop oestradiol while awaiting a diagnosis; if cancer is confirmed, hormones are a decision for the breast team, patient and prescriber. (EO advice.)

Ran out of hormones, or self-sourced supply on the ward

• First, is there a reason to hold a drug now (Sheet 1, “When to hold the problem drug”)? If so, don’t bridge that drug; call the prescriber. (EO advice.)
• Bridge, don’t stop. Verify the regimen (product, route, dose, schedule, last dose) from prescriptions, packaging or pharmacy records, and continue it if it’s clinically appropriate; SOC8 supports maintaining existing hormones on admission [7]. Substitute only with pharmacy or the prescriber: formulations aren’t dose-equivalent, and the Sheet 1 dose table is an overview, not a conversion chart. Don’t reproduce an unverified self-sourced dose; if it can’t be verified, bridge with a formulary product in the usual range (section 2) rather than give nothing. (EO advice.) ⧗ Never substitute ethinylestradiol or a combined pill [7].
• If the patient is nil by mouth, oestradiol can be given as a patch, gel or injection [3,7].
• Injectable oestradiol: a verified injection schedule continues on the ward: give the due dose rather than skip it. Valerate and cypionate can be given IM or SC [126]. (EO advice for the first point.)
• Testosterone is a controlled drug in many countries, including the UK (Schedule 4 Part II) and the US (Schedule III) [83,84]. Check local rules before prescribing or supplying it.
• Self-sourced products usually can’t be given on the ward; follow local patients’-own-drugs policy, and replace them with a prescribed equivalent. Contact the home prescriber, and take baseline bloods as the clinical situation needs. If a blocker is unavailable, oestradiol alone short-term is reasonable, though testosterone suppression may be lost; tell the prescriber [3,75]. (EO advice, except where cited.)
• Lamotrigine: if oestrogen stops, lamotrigine levels may rise. Watch for toxicity and consider a level [72].
• Warfarin: monitor INR closely when testosterone starts or stops [51,73]. Anticoagulated: consider subcutaneous rather than intramuscular injection, for testosterone esters and for injectable oestradiol [126]. (EO advice.)

Tools that assume one of two sexes

References

Numbering follows the working register and will be compacted at version 1.0. “Read in full” means the full text was read; “Abstract only” means only the abstract was available to us.

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