Menopause is a natural process that occurs when the ovaries stop producing estrogen and progesterone, leading to the cessation of menstrual periods. Menopause can cause various physical and psychological symptoms, such as hot flashes, night sweats, genital dryness, mood swings, insomnia, and decreased libido.
Menopause is usually associated with cisgender women, but it can also affect transgender and gender diverse people who have or had ovaries, or who use or used estrogen-based hormone therapy. However, there is a lack of research and awareness on the specific needs and experiences of this population.
In this blog post, we will discuss some of the challenges and options for menopause treatment in gender diverse patients, based on the latest scientific evidence and expert recommendations.
Menopause and Aging in Gender Diverse Patients
Transgender men on lifelong gender-affirming hormone therapy (GAHT) will often not experience menopause in the traditional sense (1). However, transmasculine people using testosterone therapy may notice pelvic pain and genital dryness. Genital dryness can often be successfully treated with genital application of topical estrogen or DHEA, which are not systemically absorbed. Pelvic physical therapy and trigger point release may be beneficial for pelvic pain (2). Trans men who have the ovaries surgically removed may temporarily experience hot flashes and night sweats, even with adequate testosterone therapy (1). Most guidelines do recommend mammography starting at age 40 for average risk trans men who have had top surgery or reduction due to the remaining tissue that is used to shape the chest (3).
Transgender women and transfeminine people using estrogen need to be monitored for blood clots, breast cancer, and bone loss. To reduce the risk of blood clot, patients and providers may consider switching to a transdermal formulation of estrogen around the age of 45. If feminizing hormone therapy is withdrawn, trans women may experience menopausal symptoms such as hot flashes and night sweats, although this is less likely if the gonads remain intact (1). The typical recommendation is to begin mammography after 5 years of estrogen therapy if over the age 40 and of average risk (3).
Gender diverse people assigned female at birth (AFAB) will experience menopause at the average age of 51. Menopausal hormone therapy (MHT) with estrogen and progesterone is a first-line treatment for hot flashes, night sweats, genital discomfort, and prevention of bone loss. However, feminizing hormones may not be aligned with the goals of treatment for gender diverse individuals. Therefore, non-hormonal medications, supplements, cognitive and behavioral interventions may be preferred in this population. Most guidelines do recommend mammography starting at age 40 for average risk, gender diverse AFAB who have had top surgery or reduction due to the remaining tissue that is used to shape the chest (3).
Challenges for Gender Diverse Patients
Gender diverse patients may face several barriers and difficulties when it comes to menopause treatment, such as:
Lack of access to competent and affirming health care providers who are knowledgeable about the effects of GAHT and menopause on their health and well-being.
Lack of data and guidelines on the optimal management of menopause symptoms and long-term health risks in gender diverse patients, especially those who use or used testosterone-based GAHT.
Lack of recognition and validation of their gender identity and expression, which may be affected by menopause symptoms or treatments.
Increased risk of dysphoria, depression, anxiety, and stigma due to menopause symptoms or treatments that may conflict with their gender identity or expression.
Difficulty finding peer support and resources that are relevant and inclusive of their diverse experiences and needs.
Options for Menopause Treatment
The main goals of menopause treatment are to relieve symptoms, improve quality of life, and prevent or reduce the risk of chronic conditions such as osteoporosis, cardiovascular disease, and dementia. The most common and effective treatment for menopause symptoms is MHT, which involves taking estrogen, progesterone, testosterone and/or DHEA to replace the hormones that are no longer produced by the ovaries.
However, MHT is not suitable or desirable for everyone, and it may have some side effects and risks, such as increased risk of blood clots, stroke, breast cancer, and endometrial cancer. Therefore, MHT should be individualized and tailored to each patient’s preferences, needs, and medical history, in consultation with their health care provider.
For gender diverse patients, MHT may have additional benefits or drawbacks, depending on their gender identity, expression, and goals. For example, MHT may help to maintain or enhance feminizing effects in trans women and transfeminine people, or to reduce or reverse masculinizing effects in trans men and transmasculine people who have stopped or reduced testosterone therapy. On the other hand, MHT may also cause unwanted changes in appearance, voice, body hair, or genitalia that may trigger dysphoria or distress.
Therefore, gender diverse patients should discuss the pros and cons of MHT with their health care provider, and consider the following factors:
The type, dose, route, and duration of MHT, which may vary depending on the patient’s anatomy, medical history, and gender-affirming goals. For example, trans women and transfeminine people may prefer oral or transdermal (systemic) estrogen, while trans men and transmasculine people may prefer topical or genital estrogen, which is not systemically absorbed. Progesterone may be added to MHT to protect the endometrium (the lining of the uterus) from cancer, or to induce breast development, but it may also cause mood swings, weight gain, or acne and may further increase the risk of blood clot in trans women (4,5). Progesterone does not yet have a proven benefit in transfeminine gender affirming care but may be considered on a case by case basis (5).
MHT may have an impact on bone composition and fracture risk. Trans women should optimize their bone health through regular weight-bearing exercise, smoking cessation, vitamin D supplementation, and adequate dosing of GAHT to achieve estradiol concentrations >50 pg/mL. For transmasculine people over age 50, testosterone therapy has a protective effect on the bone mineral density (2).
The alternative or complementary treatments for menopause symptoms, such as non-hormonal medications, herbal remedies, dietary supplements, lifestyle changes, and behavioral therapies. These treatments may have less or no impact on gender-affirming effects, but they may also have less evidence of efficacy or safety, or may interact with MHT or GAHT. Therefore, patients should consult their health care provider before using any of these treatments.
Conclusion
Menopause treatment in gender diverse patients is a complex and individualized process that requires careful consideration of the benefits and risks of different options, as well as the patient’s gender identity, expression, and goals. Gender diverse patients should seek out competent and affirming health care providers who can provide them with accurate information, respectful care, and shared decision making. Gender diverse patients should also seek out peer support and resources that can help them cope with the physical and emotional changes of menopause, and celebrate their diversity and resilience.
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Sources:
Medical News Today. Do transgender people experience menopause? Retrieved from Medical News Today website
Cheung, A. S., Nolan, B. J., & Zwickl, S. (2023). Transgender health and the impact of aging and menopause. In Proceedings of the 18th World Congress on Menopause: Invited Papers, 256-262.
The Confusing World of Breast Cancer Screening for Transgender People. Retrieved from https://www.breastcancer.org/news/screening-transgender-non-binary
Defreyne, J., Vander Stichele, C., Iwamoto, S. J., & T’Sjoen, G. (2022). Gender-affirming hormonal therapy for transgender and gender-diverse people—A narrative review. Best Practice & Research Clinical Obstetrics & Gynaecology, 86, 102296. https://doi.org/10.1016/j.bpobgyn.2022.102296
Fenway Health. (n.d.). Progesterone options. Retrieved from https://fenwayhealth.org/wp-content/uploads/Progesterone-Options-English.pdf
Glyde, T. (2022). LGBTQIA+ menopause: Room for improvement. The Lancet, 400(10363), 1578-1579. https://doi.org/10.1016/S0140-6736(22)01935-3
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