Gender-Affirming Care Practice Questions

Q: A 35-year-old transgender woman desires fertility preservation before starting feminizing hormone therapy. She has limited financial resources. Which option provides the best balance of efficacy, cost, and time efficiency?

Sperm banking before hormone initiation. ***Sperm banking before hormone initiation*** - **Sperm banking** is the gold standard for fertility preservation as it is the most **cost-effective**, non-invasive, and proven method for transgender women. - It should be performed **before** starting feminizing therapy because hormones like **estrogen** and **anti-androgens** suppress the HPG axis and severely impair **spermatogenesis**. *Testicular tissue cryopreservation* - This is currently considered an **experimental technique** and is not standard clinical practice for adult fertility preservation. - It is significantly more **expensive** and requires an invasive surgical procedure (testicular biopsy) compared to simple masturbation for sperm banking. *Delaying hormone therapy until natural conception* - This is often not a viable or desirable option for many patients due to the high risk of worsening **gender dysphoria** during the delay period. - It assumes the patient currently has a partner with whom they can conceive naturally and does not address **long-term fertility** needs. *Sperm extraction after 6 months of hormone therapy* - After 6 months of hormone therapy, **testicular atrophy** and **azoospermia** are common, making extraction via **TESE** much less likely to be successful. - To attempt this, the patient would likely need to **discontinue hormone therapy** for months, leading to a return of secondary masculine characteristics and significant psychological distress.

Q: A 28-year-old transgender man presents 6 months after initiating testosterone therapy with persistent vaginal bleeding despite amenorrhea for 4 months. Labs show testosterone 650 ng/dL and hemoglobin 9.2 g/dL. What is the most appropriate next step?

Perform transvaginal ultrasound and endometrial sampling. ***Perform transvaginal ultrasound and endometrial sampling*** - Unexpected **vaginal bleeding** after achieving amenorrhea in a transgender man requires investigation to rule out **endometrial hyperplasia** or malignancy. - Although testosterone causes vaginal atrophy, it can also be **aromatized into estrogen**, potentially leading to endometrial proliferation; investigation is warranted given the significant **anemia**. *Add progestin therapy* - While progestins are used to stop heavy bleeding, they should not be started before a **diagnostic evaluation** of the endometrium has been performed in this context. - Adding progestin without a diagnosis could mask **underlying pathology** like malignancy or structural abnormalities. *Increase testosterone dose* - The patient's testosterone level (650 ng/dL) is already within the **physiologic male range** (300-1000 ng/dL). - Increasing the dose may lead to higher rates of **aromatization to estrogen**, potentially worsening the endometrial issues rather than stopping the bleeding. *Discontinue testosterone and observe* - Discontinuing gender-affirming therapy can cause significant **psychological distress** and is not the standard first step for investigating bleeding. - Observation is inappropriate here because the patient is **anemic** and requires an active diagnostic workup to identify the source of blood loss.

Q: A 24-year-old transgender man on testosterone therapy for 18 months presents with amenorrhea, deepening voice, and facial hair growth. Screening for which complication should be prioritized during follow-up?

Cervical cancer screening with Pap smear. ***Cervical cancer screening with Pap smear*** - **Transgender men** who have not undergone a total hysterectomy retain their **cervix** and remain at risk for **cervical cancer**, requiring screening as per standard guidelines. - **Testosterone therapy** can cause **vaginal atrophy**, which may lead to higher rates of unsatisfactory Pap results; however, it does not eliminate the need for monitoring. *Osteoporosis assessment with DEXA scan* - **Testosterone** is generally **bone-protective** as it is aromatized to estrogen, and bone mineral density often remains stable or increases during therapy. - **DEXA scans** are not routinely prioritized in young patients unless they are at high risk or have undergone **gonadectomy** without adequate hormone replacement. *Breast cancer screening with mammography* - While important if **chest reconstruction surgery** hasn't occurred, this patient is only 24; routine **mammography** usually begins at age 40 or 50. - Screening priority is based on **natal anatomy** present, and for a 24-year-old, cervical screening is the immediate age-appropriate intervention. *Endometrial hyperplasia evaluation* - Long-term **testosterone therapy** typically leads to **endometrial atrophy** rather than hyperplasia due to the suppression of the hypothalamic-pituitary-ovarian axis. - Routine ultrasound or biopsy for **endometrial hyperplasia** is not recommended in asymptomatic transgender men on testosterone.

Question 1

A 35-year-old transgender woman desires fertility preservation before starting feminizing hormone therapy. She has limited financial resources. Which option provides the best balance of efficacy, cost, and time efficiency?

Accepted Answer

Sperm banking before hormone initiation

Answer

Testicular tissue cryopreservation

Answer

Delaying hormone therapy until natural conception

Answer

Sperm extraction after 6 months of hormone therapy

Question 2

A 28-year-old transgender man presents 6 months after initiating testosterone therapy with persistent vaginal bleeding despite amenorrhea for 4 months. Labs show testosterone 650 ng/dL and hemoglobin 9.2 g/dL. What is the most appropriate next step?

Accepted Answer

Perform transvaginal ultrasound and endometrial sampling

Answer

Add progestin therapy

Answer

Increase testosterone dose

Answer

Discontinue testosterone and observe

Question 3

A 32-year-old transgender woman on estradiol and spironolactone for 2 years wishes to undergo gender-affirming vaginoplasty. Pre-operative hormonal management should include:

Accepted Answer

Discontinuing estradiol 4 weeks before surgery due to VTE risk

Answer

Continuing current hormone regimen until surgery

Answer

Adding progesterone to improve tissue quality

Answer

Increasing estradiol dose for better surgical outcomes

Question 4

A 24-year-old transgender man on testosterone therapy for 18 months presents with amenorrhea, deepening voice, and facial hair growth. Screening for which complication should be prioritized during follow-up?

Accepted Answer

Cervical cancer screening with Pap smear

Answer

Osteoporosis assessment with DEXA scan

Answer

Breast cancer screening with mammography

Answer

Endometrial hyperplasia evaluation

Gender-Affirming Care — MCQs

Gender-Affirming Care — MCQs

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