Table V. Role of the gynaecologist in the treatment and follow-up of transsexual individuals.

FTM-transsexual individuals
Treatment
Discuss different options for fertility preservation. Exclude gynaecological malignancy pre-operatively. Perform hysterectomy and bilateral salpingo-oophorectomy, preferably through a laparoscopic approach. Perform vaginectomy, preferably through a vaginal approach. This can also be done by a urologist or plastic surgeon, depending on whoever has most experience with this procedure within the multidisciplinary team.
Follow-up
Perform a yearly gynaecological check-up as long as the FTM-individual is under hormone treatment and surgical castration and hysterectomy has not yet been performed. A yearly pelvic ultrasound, performed through the abdominal wall if technically feasible, is advised to rule out significant endometrial hyperplasia and ovarian tumours. When the individual has been sexually active cervical screening should not differ from national screening guidelines. Breast cancer screening should follow national guidelines. Post-operative follow-up of these patients should be done by the endocrinologist, with expertise regarding androgen replacement therapy, and by the urologist and/or the plastic surgeon.
MTF-transsexual individuals
Treatment
Although some gynecologists are involved in the creation of the neo-vagina, in most multidisciplinary teams this is the responsability of the plastic surgeon.
Follow-up
Vaginal examinations in MTF-transsexuals are perfectly feasible and well tolerated. According to the transsexual women the gynaecologist has an important place in their follow-up. The gynaecologist is best placed to diagnose and treat vaginal infections. Sexual functioning is suboptimal in many transsexual women. The gynaecologist often has experience in sexual and relational problems and is well placed to treat these patients and/or refer them to specialised therapists. Some of these women have been or are being treated for condylomata. A Pap-smear of the vaginal vault should be performed according to the national guidelines on cervical cancer screening. Breast cancer screening should not differ from the national screening guidelines and clinical breast examination should be part of the follow-up of these women. Transvaginal palpation of the prostate has little value. However, transvaginal ultrasound of the prostate is technically feasible and well tolerated. It should be the first designated imaging exam whenever prostatic disease is suspected. Bone health is an important issue in the follow-up of transsexual women and the gynaecologist has ample experience in the matter of low bone density and estrogen therapy. However both low bone density and estrogen therapy remain the responsibility of the endocrinologist within the multidisciplinary team.