Gender Identity Service

Feminising Treatment

Blood tests

Estradiol, SHBG, testosterone, Urea and Electrolytes (U and E’s), LFT’s, Lipid profile including Triglycerides, and Prolactin should be done six monthly for a year and then annually.  Estradiol levels are ideally between 350-750 pmol/l if aged < 40; 300-600 pmol/l if aged 40-50; 200-400 pmol/l if aged > 50 or younger with significant CV risk factors particularly smoking or high BMI (> 40 kg/m2).

Hormones

If starting Estradiol over the age of 40 we would recommend conventional treatment for 10 years then reducing dosing down. If started under the age of 40 we would recommend a dose reduction between 40-50 with an aim to tailing off and potentially stopping treatment between 60 and 70. However, we would recommend an individualised approach should be employed after discussion with the individual regarding the risks and benefits. If lower gender affirming surgery is not performed, we would recommend continuing a hormone blocker.

Mammograms

Transwomen become eligible when they turn 50 for mammography on the breast screening programme. If she continues to take estradiol after the age of 70, she should continue to attend the breast screening programme. In addition, she should remain ‘breast aware’.

Prostate

If the patient develops any urological symptoms, consideration should also be given to the fact that she still has a prostate gland in situ.

Osteoporosis

There is no evidence for routine DEXA scanning in trans-feminine individuals. Trans-feminine individuals may have lower bone density than matched cis-males, but they are at no greater risk of osteoporosis than matched cis-females, provided that they have not had androgen blockade or gonadectomy without estradiol treatment. We would encourage an individualised approach to DEXA scanning based on the presence of other risk factors such as low BMI, corticosteroid use, alcohol excess or medical conditions associated with reduced BMD in line with national guidelines.

Masculinising Treatment

Blood tests

Testosterone, Estradiol, LFTs, FBC, Lipid profile including Triglycerides, to be done six monthly for a year and then annually.  Testosterone levels should be in the lower third of the reference range immediately before Sustanon or Nebido injections (trough levels), middle third of the reference range on Nebido (for samples taken mid-way between injections) and testosterone gel (taken 4 to 10 hours after application).  The lower third of the male reference range is usually around 8-12 nmol/L and the middle third of the male reference range is usually around 15-22 nmol/L but does depend on the normal range for the local assay as these vary.

Hormones

There is no recommendation of an upper age limit to stop masculinising treatment and we would recommend a pragmatic and individualised approach after an analysis of the risks and benefits.

Uterus and Ovaries

There is currently no evidence for an increased risk of endometrial or ovarian cancer with testosterone treatment, but any symptoms which could suggest a problem with these organs, particularly vaginal bleeding, pelvic pain or abdominal bloating should be investigated further.

Cervical Screening

Attendance for routine cervical screening tests should remain the same as per the NHS Cervical Screening Programme recommendations, however the invitation process and informing of results are outside the NHS Cervical Screening Programme process and should now be organised within your GP practice. If you have not already done so and your patient is registered as male, with a new NHS number, you should liaise directly with the screening lead for cervical screening who will advise on further action.

There are challenges regarding recalls for cervical screening and we know that there is poor uptake of cervical screening in this group. Consideration should be made of what may make the individual more comfortable and less concerned about this procedure including the use of vaginal Estradiol. There is further information on our website for health care professionals regarding cervical screening.

Testosterone

Testosterone treatment is not contraceptive and is a teratogen. Contraceptive needs should be considered if required.

Osteoporosis

There is no evidence for routine DEXA scanning in trans-masculine and non-binary individuals and typically they show no change or an increase in BMD as a result of testosterone hormone treatment. We would encourage an individualised approach to DEXA scanning based on the presence of other risk factors such as low BMI, corticosteroid use, alcohol excess or medical conditions associated with reduced BMD in line with national guidelines.

Screening

Useful links:

Endometrial Screening

There are no clear guidelines for management of abnormal uterine bleeding or endometrial surveillance in this population. There is a theoretical concern of endometrial pathology based on data of increased risk with increased serum androgens in cis post-menopausal women. Current data from a trans male population suggests trans men are at no increased risk of endometrial cancer. Longer term studies are lacking. The World Professional Association for Transgender Health (WPATH) recommend health care professionals apply the same respective local screening guidelines (including the recommendation not to screen) developed for cisgender women at average and elevated risk for developing ovarian or endometrial cancer in their care of transgender and gender diverse people who have the same risks. Some UK services undertake a 2 yearly transvaginal ultrasound to assess endometrial thickness, but the Leeds service does not recommend routine screening only prompt investigation if concern.

Sexual health and contraception

The College of Sexual & Reproductive Healthcare have guidance on contraception for specific populations, including transgender and non-binary people.

General health

Advice and Guidance Service

We understand that GPs may feel that they have limited experience with cross sex hormones and feel uncertain about prescribing them. There are long waits for our hormone appointments, and we aim to offer support, advice and guidance for GPs who are looking after patients who have been discharged from the hormone clinic.

If you have a clinical query that is not answered, we are happy to respond to these on receipt of a written email or letter from yourselves to the Leeds Gender Identity Service inbox. In order for us to respond to this in a safe and timely fashion, please include an update on the problem the person is experiencing with their hormones, your query, an up-to-date medical summary including patient details, what hormones they are receiving, medications, allergies, their most recent blood tests (and how this was times in relation to their hormones) as well as a BMI and blood pressure reading.  We cannot arrange to review these patients in clinic, but we can offer further advice and support.

If you would like to organise further training for your practice to improve your knowledge and confidence with hormone prescribing, please contact the Leeds Gender Identity Service inbox and we will do our best to facilitate this.

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Page last updated: 22nd May 2026 5:00pm

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