There isn’t currently much data about the menopause and trans people. However, anyone with a female reproductive system who identifies as a man, but hasn’t undergone any medical interventions, is likely to go through menopause at some point.
Most trans people who start their transition at pre-menopausal age will never go through menopause in terms of the hormone depletion effects. This is because gender affirming hormones are typically given for life, so if a trans person starts hormone treatment before going through menopause they will never experience it.
For trans women taking oestrogen, there is no need to withdraw oestrogen treatment at any particular age to induce menopause. It was previously thought that there was a risk associated with lifelong oestrogen treatment, but although the dosage might be reduced in some circumstances, this no longer seems to be the case.
For trans people, their experiences of menopause and perimenopause can be as complex and difficult as cis people with added elements of dysphoria and erasure (the tendency to intentionally or unintentionally remove LGBTQ+ groups or people from record) to manage as well.
Gender-affirming hormone therapy
The experience and timing of menopause for transgender and gender diverse (TGD) individuals vary, depending on sex assigned at birth and the types of gender-affirming care received. TGD people, who make up approximately 0.5–3% of the world population, are those who have a gender different from that assigned to them at birth. Unfortunately, research concerning the impact of gender-affirming care on menopause and the midlife transition in this population is lacking, and guidelines regarding clinical management are minimal.
The transgender population, including those assigned female at birth (AFAB) and those assigned male at birth (AMAB), has been understudied in terms of experiences through the menopause transition and midlife.
Additionally, there is no formal recommendation or guidance on continuation of gender-affirming hormone therapy (GAHT) through midlife. While gender-affirming therapies for transgender patients are well defined and supported by organisational guidelines, including the World Professional Association for Transgender Health, and the Endocrine Society, evidence on continuation of therapy and dose adjustments into mid-life are lacking.
Data from a few large cohort studies and small cross-sectional studies suggest increased risk of venous thromboembolism (VTE), stroke and myocardial infarction in those AMAB on GAHT. For those AFAB on testosterone therapy, risks of cardiovascular disease and stroke and to bone health are not well defined, given inconsistent findings from large cohort studies. Currently, the decision to continue GAHT for transgender patients is guided by patient preference along with clinician guidance. Further research is warranted regarding risks of continuing GAHT into mid-life for both AMAB and AFAB patients. Given the significant benefit of GAHT in this population, however, this data would be most helpful for counselling on risks along with appropriate monitoring and prevention for related morbidities during mid-life in the setting of GAHT use.
Lived experience
In 2021, Tania Glyde (they/them), a psychotherapist, counsellor and author working with Gender, Sex and Relationship Diverse (GSRD) identified clients, responded to the House of Commons Select Committee on Women and Equalities Enquiry on Menopause. Tania had been researching the experiences of LGBTQIA+ menopausal people in therapy and the wider healthcare system, and their research How can therapists and other healthcare practitioners best support and validate their queer menopausal clients? went on to be published in the peer-reviewed journal Sexual and Relationships Therapy.
In response to the following question from the Committee: What are the challenges you think that LGBT+ people experiencing menopause face in terms of diagnosis and treatment?, Tania identified:
1. Lack of information, especially about perimenopause
Some of this is also what the mainstream population faces – systemic ageism, minimisation of health impacts, and a lack of information from a young enough age to understand when perimenopause may be happening. Some may be holding inaccurate information, particularly something they may have been told in their family when young, and not realise it is inaccurate.
2. Existing trauma and health issues
The LGBTQ+ population tends to have a higher level of addiction and of mental illness than average. Also, a higher level of trauma. This may be exacerbated by perimenopause without the person realising.
3. Practitioner assumptions
Practitioners may make assumptions about the habits, lifestyles and even the genitals of their clients and patients. A common assumption is that all patients are heterosexual and cisgender. Asexual people may be told that they will ‘find someone’ and thereby find their presumed sexual self. This is stressful and an experience like this may cause someone to stay away from getting help.
4. Poor trans and non-binary awareness
Trans and non-binary patients may face ridicule or stonewalling by clinic staff, ie mocking pronouns and ignoring name changes. Practitioners may dismiss anything they do not immediately understand, including dysphoria. (This is even more serious when someone transitions and the gender marker on their records is changed, but then they are left out of cervix, prostate or breast screenings.) The lack of joined up thinking here causes escalating stress and is damaging to mental health. Having to deal with this level of prejudice in our healthcare system, that is supposed to be for all, is enough to turn a person away, and someone may not access the healthcare they need.
5. Anticipatory stress
Poor experiences in healthcare mean that many LGBTQ+ people may experience a lot of stress before seeking help. None of this is beneficial to health. This also applies in terms of a sense of needing to perform for gatekeepers, such as if someone is starting transition when also coming into menopause. From my research: ‘Participants who were both considering transition and entering menopause had to perform for two sets of gatekeepers: GPs (by taking care not to mention gender in case they were denied testosterone), and gender clinics (by taking care not to mention menopause in case they were told they weren’t trans enough).’
6. Practitioners needing greater understanding of GSRD identities
LGBTQIA+ people are not a homogeneous group. As well as LGBTQIA+ identities, the GSRD umbrella includes consensual non-monogamy, BDSM/kink lifestyle and practices, and being a current or ex-sex worker. If healthcare practitioners do not understand this, the person may feel stigmatised and not mention these further aspects of their life.
7. Inadequate explanation of hormones
Sex hormones are treated in a very binary way. Few people realise that the ovaries produce testosterone, and the testes produce oestrogen.
Of course, ‘It’s your hormones dear’ has been used to stigmatise and gaslight cisgender heterosexual women, so there may be an assumption that all patients feel the same. In fact, supplemental hormones, for those who wish to, (or are able to), take them, are also seen as part of life and a way to feel, and appear, more congruent. Non-binary people, for example, may microdose testosterone rather than take a full dose. There needs to be far more joined up thinking about how oestrogen, progesterone and testosterone, exogenous and endogenous, interact with the body and with each other, and the best use of them for each individual patient across the board.
Education is poor to the point that a transmasculine or non-binary person may be experiencing, for example, Genitourinary Symptoms of Menopause, but fear using topical oestrogen in case it feminises them. People are suffering in silence and education is needed.
Someone AFAB transitioning by taking oestrogen blockers and testosterone will be in the position of going into puberty and menopause at the same time. Again, this needs to be named and understood.
Seeking help
If you feel uncomfortable talking to your GP about your menopause symptoms for any reason, Stonewall has a list of NHS organisations that are Diversity Champions and an information service that can offer advice on who to contact. You can call them on 08000 50 20 20.
Do you have something to add to this conversation? Get in touch.
