In this blog post, we explore the multifaceted nature of menopause in transgender individuals. To describe the terms "transgender" and "cisgender", it is important to define the differences between gender identity and biological sex:
Gender identity refers to an individual's deeply felt internal sense of their own gender, which may be male, female, a combination of both, or neither. Biological sex is the sex assigned to a person at birth based on physical attributes such as external genitalia. It is typically binary: either male or female.
A transgender person is someone whose gender identity differs from their biological sex. Someone whose gender identity matches their birth-sex is called cisgender.
A transgender person’s internal sense of their own gender does not align with the sex they were assigned at birth. If a person was assigned female at birth but identifies as male, they would be considered transgender or in this case a trans man. If this person identifies as female, the term cisgender or cis woman is used.
Transgender individuals may undergo a process of transitioning, which can include social, medical, or legal steps to align their gender presentation with their gender identity. Not all transgender individuals undergo the same steps, and the experience is highly individual.
Understanding menopause in transgender individuals
Irrespective of gender identity, menopause can bring about a range of physical and emotional challenges. The decline in estrogen levels during menopause can manifest in physical and emotional changes, such as hot flashes and mood swings.
Aging trans adults face unique challenges, including concerns about mistreatment in care settings, isolation, and increased vulnerability to financial stressors. Menopause care, often seen through a predominantly cisgender, heterosexual, and white lens, challenges in providing inclusive care for everyone. Despite countries like the UK having inclusive menopause treatment guidelines, some individuals are still denied appropriate care or offered antidepressants instead of hormone replacement therapy (HRT), often leading to healthcare avoidance.
Regardless of menopause, typical menopause symptoms such as weight gain, elevated risks of cardiovascular disease and depression are already observed in many members of the trans community. Studies report that more than 60% of trans individuals have a history of diagnosed depression and anxiety and over 40% have attempted suicide. Moreover, according to a US-study, trans women and trans men are more likely to be overweight than cis women. Compared to cis women, trans women reported higher rates of diabetes, angina/coronary heart disease, stroke, and myocardial infarction. Trans women also reported higher rates of cardiovascular disease than cis men.
A person who was assigned female at birth but identifies as male is considered a trans man.
What do we know about menopause in trans men?
Masculinizing hormone therapy induces genital and reproductive system changes, accompanied by often poorly understood pelvic pain and sometimes persistent menstruation.
Trans men who have undergone hormone replacement therapy with testosterone, may have already experienced a cessation of menstrual cycles and thus not go through traditional menopause later in life. However, the natural aging process introduces its own hormonal changes, mimicking certain aspects of menopause. Trans men who did not undergo gender-affirming hormone therapy may experience the same menopausal symptoms as cis women.
Trans men who do not receive hormone therapy can experience the same menopause symptoms as cis women. If hormone therapy is chosen, menstruation often stops as a result of the therapy. In this case, there is no classic menopause.
A person who was assigned male at birth but identifies as female is considered a trans woman.
What do we know about menopause in trans women?
Trans women who do not undergo feminizing hormone therapy remain with a male hormone profile and, like cis men, will not experience menopause. However, feminizing hormone therapy is a critical aspect of gender-affirming care for many trans women (assigned male at birth). If this hormone therapy is discontinued, menopause-like symptoms may occur. However, there is no general recommendation to simulate a menopause in middle age by discontinuing hormone therapy.
Trans women who embark on feminizing hormone therapy undergo significant physiological changes. The therapy involves achieving serum estradiol and testosterone concentrations within the cisgender female range. Notable effects include breast growth, fat redistribution, reduced muscle mass, and altered hair growth. However, some physical characteristics induced by male puberty, such as voice pitch and bone structure, remain unchanged. Similar to menopause in cis-women, adverse effects may include weight gain and cardiovascular issues.
Feminizing hormone therapy in trans women, particularly with oral estradiol, is also associated with an elevated risk of venous thromboembolism. Studies indicate a two-fold to five-fold increased risk relative to cisgender populations. Earlier studies reported a higher risk of cardiovascular morbidity and mortality in trans individuals using ethinyl estradiol and transdermal estradiol has been recommended for those with risk factors. Recent larger cohort studies, however, show inconsistent findings, emphasizing the need for further research. However, screening for cardiovascular health and risk reduction are crucial for aging trans individuals.
Sex steroid concentrations play a vital role in bone health, raising concerns for aging trans individuals. Studies suggest compromised bone microarchitecture in trans individuals on feminizing hormone therapy, emphasizing the importance of optimizing bone health through exercise, smoking cessation, and adequate vitamin D levels.
Trans women are born without ovaries and do not experience a classic menopause. However, hormone therapy and its discontinuation can lead to menopause-like symptoms.
What can we do better?
Menopause in transgender adults is a multifaceted journey influenced by hormone therapies, aging, and associated health risks. Affirming healthcare environments, inclusive language, and a comprehensive understanding of individual experiences can help optimize health outcomes for everyone. As research continues, considering the unique needs of transgender individuals during menopause will contribute to better-informed and empathetic care practices.
Emphasizing the importance of personalized, collaborative decision-making in any middle-aged patient ensures that healthcare providers, cis and trans individuals navigate this transformative period together.
