FTM Long-Term Health

Testosterone is (often a lifelong therapy, so the long term views matter: what happens to your bones, what cancer screening you still need, what to do around surgery, and what aging on T looks like.

Some amount of HRT is for life

If your ovaries are removed, your body loses its ability to make sex hormones (both testosterone and estrogen), and going without any replacement causes bone loss and hypogonadism (the health effects of having too little sex hormone). WPATH SOC8 is blunt: “Sex steroid treatment is especially important after gonadectomy to avoid the sequelae of hypogonadism, the risk of developing osteoporosis, and for the maintenance of mental health and quality of life.”¹

Recommendations:¹²

• No dose reduction is needed after removal of the ovaries dosing targets typical male-range replacement regardless (UCSF). A lower dose is a choice you can make, but it must stay adequate to protect bone.
• Stopping T entirely after the removal of the ovaries is a dangerous scenario people left with no sex hormone at all develop hypogonadism and accelerated bone loss.³ If you ever stop T after ovary removal, you need some form of hormone replacement.
• Dose needn’t drop with age either, “no upper age limit exists for testosterone replacement” (UCSF), though SOC8 concedes “it is not known if doses of GAHT should be reduced in older TGD people”.¹²

Bones:

• Most studies show no change or an increase in bone mineral density in trans men on T; long-term users show larger cortical bone size, and 10-year prospective (following people forward in time) Amsterdam data found no clinically relevant BMD decline.²⁴⁵
• Fracture risk is not increased: in the nationwide Dutch cohort, fractures occurred in 1.7% of trans men, lower than age-matched reference men (3.0%; OR 0.57, an odds ratio below 1 means lower odds).⁶
• Screening (UCSF/Fenway): DEXA (a low-radiation bone-density scan) of hip and spine at 65 for everyone; 50-64 with risk factors (smoking, low BMI, corticosteroids); any age if gonadectomy plus ≥5 years without hormone therapy.²⁷ UCSF’s bone health page expands on this.

Hormone prerequisites by surgery:¹⁸

• Top surgery (chest masculinization): no hormone requirement. no set time on T, or any T at all (some surgeons suggest waiting 6-12 months so chest contours settle whic is a timing preference and not a cessation).
• Hysterectomy (surgery to remove the uterus) and oophorectomy: SOC8 suggests ≥6 months on T first (unless not indicated/desired), plus fertility counseling beforehand and a hormone-replacement plan if you’re not on T. Some insurers/surgeons still apply older 12-month criteria.
• Metoidioplasty and phalloplasty (surgeries to create a penis): stable regimen with ≥6 months minimum and because results depend on clitoral growth (maximal at 1-2 years), the common surgical convention is ~1 year on T before metoidioplasty.¹⁹
• Lifelong urological (urinary-tract) follow-up is encouraged after genital surgery.¹

Cancer screening

ACOG’s principle: “any anatomical structure present that warrants screening should be screened, regardless of gender identity.”¹⁰

Chest/breast:

• No top surgery (or reduction only): screen per guidelines for cisgender women (mammography by local age schedule).¹¹
• After top surgery: no evidence-based screening protocol exists. Residual tissue means risk isn’t zero, but it’s unquantified; mammography may not be technically feasible; annual chest-wall exams are “not based on evidence.”¹¹¹ Breast cancer in trans men on T is rare (Dutch nationwide cohort: 4 cases in 1,229 trans men; ~1/5 the cis-women rate).¹² Take a family history, report new lumps promptly, and make an individual plan. An MRI or ultrasound may make sense for higher-risk people (e.g., BRCA, a gene that raises breast-cancer risk).¹ UCSF’s breast-screening page for trans men is the best plain-language walkthrough. See FTM Evidence Gaps.

Cervical:

• While you have a cervix, screen per cis-women guidelines.¹³
• Pap tests (cervical screening swabs) on T have a ~10× higher unsatisfactory-result rate (correlates with time on T, due to atrophic changes the tissue gets thinner and drier) so a “failed” Pap is common and should not be a concern. self-collected HPV swabs (HPV = human papillomavirus, the virus behind most cervical cancers) can be a more comfortable alternative.¹³¹
• HPV vaccination (ages 9-26) meaningfully reduces risk.¹³ UCSF’s cervical-screening page has tips for making screening more comfortable.

Uterus/ovaries:

• No routine endometrial (womb-lining) or ovarian screening, and no prophylactic (preventive) organ removal. SOC8 Statement 15.9: “We recommend against routine oophorectomy or hysterectomy solely for the purpose of preventing ovarian or uterine cancer for transgender and gender diverse people undergoing testosterone treatment and who have an otherwise average risk of malignancy.”¹
• The endometrium conflict: the traditional narrative is that T atrophies (thins) the endometrium (the womb lining) but the largest histology series (studies of the actual tissue) (Grimstad 2019, n=94) found 69% had active/proliferative (still-growing) endometrium, 1 hyperplasia (overgrowth) without atypia (abnormal cells), and zero cancers.¹⁴ Only ~5 endometrial-cancer case reports in trans men exist.¹⁵ Risk appears no higher than baseline, but unexplained bleeding after amenorrhea (no periods) always warrants evaluation (especially over 35) see FTM Periods and Fertility.⁷

The long-term vitals checklist

• Total T + hematocrit/hemoglobin (red-blood-cell measures): ~every 3-6 months in year 1, then 1-2×/year once stable (see FTM Blood Testing).¹⁶
• BP (blood pressure), weight, lipids (blood fats like cholesterol), glucose (blood sugar): per standard population screening. no extra T-specific schedule is evidence-based.¹⁷
• Standard age-appropriate screening (colorectal etc.) per anatomy; HIV/STI screening and HPV/Hep A/B vaccination as indicated.⁷
• Mortality data: in the Amsterdam 5-decade cohort, trans-men mortality wasn’t elevated vs cis men (SMR 1.2, “not statistically significant,” meaning the small difference could be chance); the small excess vs cis women was driven by non-natural causes and not by hormone effects.¹⁸

Smoking

Trans adults smoke markedly more than cis adults (35.5% vs 20.7% current cigarettes in US national data), and on T smoking is a force multiplier: it roughly doubles erythrocytosis (too many red blood cells) risk, worsens cardiovascular risk (and muddies most studies claiming T itself is cardiotoxic, i.e. harmful to the heart), and is a significant predictor of top-surgery complications.¹⁹²⁰²¹ SOC8 advises tobacco abstinence before gender-affirming surgery.¹ If you smoke, quitting does more for your long-term safety on T than any dose tweak. See FTM Risks and Side Effects.

Further reading

No single website, this one included, should be your only source of info; these are reputable places to keep reading.

• UCSF Transgender Care - Bone health and osteoporosis - plain-language bone guidance, including DEXA screening schedules.
• Fenway Health - The Medical Care of Trans and Gender Diverse Adults (2021, free PDF) - a full clinical guide that’s still readable for patients.
• ACOG Committee Opinion 823 - the “screen the anatomy you have” principle, from US OB-GYNs.
• WPATH Standards of Care v8 - the global guideline’s chapters on surgery, reproductive health, and lifelong care.

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Related pages: FTM HRT | FTM Blood Testing | FTM Risks and Side Effects | FTM Periods and Fertility | Surgeries | FTM Evidence Gaps | Research Papers

Footnotes

1. WPATH Standards of Care v8 (Coleman et al., 2022), Chapters 12, 13, 15 - https://pmc.ncbi.nlm.nih.gov/articles/PMC9553112/ ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸ ↩⁹ ↩¹⁰ ↩¹¹

2. UCSF Transgender Care - Overview of masculinizing hormone therapy; Bone health and osteoporosis - https://transcare.ucsf.edu/guidelines/masculinizing-therapy ; https://transcare.ucsf.edu/guidelines/bone-health-and-osteoporosis ↩ ↩² ↩³ ↩⁴

3. hysto.net - osteoporosis risk after hysterectomy/oophorectomy (community resource, consistent with SOC8 bone guidance) - https://www.hysto.net/osteoporosis-hysterectomy-transmen.htm ↩

4. Van Caenegem E et al., bone mass/geometry after long-term cross-sex hormonal therapy, JCEM 2012 - https://pubmed.ncbi.nlm.nih.gov/22564669/ ↩

5. Wiepjes CM et al., Bone Safety During the First Ten Years of GAHT, J Bone Miner Res 2019 - https://pubmed.ncbi.nlm.nih.gov/30537188/ ↩

6. Wiepjes CM et al., Fracture Risk in Trans Women and Trans Men, J Bone Miner Res 2020 - https://pubmed.ncbi.nlm.nih.gov/31487065/ ↩

7. Fenway - The Medical Care of Trans and Gender Diverse Adults (2021) - https://fenwayhealth.org/wp-content/uploads/Medical-Care-of-Trans-and-Gender-Diverse-Adults-Spring-2021-1.pdf ↩ ↩² ↩³

8. UCSF Transgender Care - Information on Testosterone Hormone Therapy (patient document) - https://transcare.ucsf.edu/article/information-testosterone-hormone-therapy ↩

9. UCSF Transgender Care - Phalloplasty and metoidioplasty - https://transcare.ucsf.edu/guidelines/phalloplasty ↩

10. ACOG Committee Opinion 823 (2021) - https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2021/03/health-care-for-transgender-and-gender-diverse-individuals ↩

11. UCSF Transgender Care - Breast cancer screening in transgender men - https://transcare.ucsf.edu/guidelines/breast-cancer-men ↩ ↩²

12. de Blok CJM et al., Breast cancer risk in transgender people (nationwide cohort), BMJ 2019 - https://pubmed.ncbi.nlm.nih.gov/31088823/ ↩

13. UCSF Transgender Care - Screening for cervical cancer in transgender men - https://transcare.ucsf.edu/guidelines/cervical-cancer ↩ ↩² ↩³

14. Grimstad FW et al., Uterine pathology in transmasculine persons on testosterone, AJOG 2019 - https://pubmed.ncbi.nlm.nih.gov/30579875/ ↩

15. Seay et al., endometrial cancer case report + literature review (2023) - https://pmc.ncbi.nlm.nih.gov/articles/PMC10209109/ ↩

16. Endocrine Society Clinical Practice Guideline (Hembree et al., 2017), rec 4.1 - https://pubmed.ncbi.nlm.nih.gov/28945902/ ↩

17. UCSF Transgender Care - Cardiovascular disease - https://transcare.ucsf.edu/guidelines/cardiovascular ↩

18. de Blok CJM et al., Mortality trends over five decades, Lancet Diabetes Endocrinol 2021 - https://pubmed.ncbi.nlm.nih.gov/34481559/ ↩

19. Buchting FO et al., Transgender Use of Cigarettes, Cigars, and E-Cigarettes, Am J Prev Med 2017 - https://pubmed.ncbi.nlm.nih.gov/28094133/ ↩

20. Madsen MC et al., Erythrocytosis in a Large Cohort of Trans Men, JCEM 2021 - https://pmc.ncbi.nlm.nih.gov/articles/PMC8118580/ ↩

21. Ederer IA et al., 180 transmasculine top surgeries while continuing T, Aesthetic Plast Surg 2023 - https://pubmed.ncbi.nlm.nih.gov/36510021/ ↩