9 min read

The Menopause Experience for Transgender and Gender Diverse Individuals 

There is almost no information about the experience of menopause for people other than cisgender women (women who have been assigned female sex at birth and who’s gender matches their assigned sex at birth) who have or previously had typically functioning ovaries. Many people are not aware that menopause or menopause-like symptoms can affect a variety of people, including those who are transgender, gender diverse, and those who never had ovaries. 

Menopause is a significant life transition marked by hormonal changes that impact physical, emotional, and mental well-being. Menopause is traditionally defined as 12 consecutive months passing since the last menstrual period due to loss of ovarian follicular function, and typically signifies the end of reproductive years. This cisgender technical definition excludes the experiences of those who are transgender, gender diverse, and people who may not have periods but still go through menopause. A more expansive definition of menopause is needed to encompass the experiences of all those who experience menopause or menopause-like symptoms from a hormonal process that differs from cisgender women. More information regarding the experience of cisgender women during menopause can be found in this previous blog post.

This blog post explores the intersection of experience of menopause in transgender and gender-diverse individuals while considering the importance of gender-affirming care, the potential impact of hormone therapy, and current healthcare disparities. We will also touch upon common symptoms of menopause and the necessity of understanding and addressing them for transgender individuals.

The Use of Gender Affirming Hormone Therapy 

Transgender and gender-diverse individuals may seek a range of social, psychological, behavioural, and medical interventions including gender-affirming hormone therapy (GAHT), gender-affirming surgery, and gender-affirming mental health care, depending on the individual goals of each person. GAHT can be desired to promote physical characteristics that bring an individual’s body in alignment with their gender (e.g., facial and pubic body hair, breast development, muscular build) and can significantly improve mental health, gender dysphoria, and quality of life. GAHT can be used in conjunction with gender-affirming surgeries or alone as a medical treatment to bring hormone levels to ranges typically found in cisgender individuals. One life stage that can be impacted by GAHT is menopause. The experience of menopause or menopause-like symptoms in a person will depend on anatomy at birth, current anatomy, and the types of gender-affirming care they have received, if any.  

Menopause for Transmasculine and AFAB Non-Binary People 

The transmasculine and gender diverse (TMGD) spectrum includes transgender men and non-binary individuals whose sex was assigned female at birth (AFAB). TMGD folx can experience menopause or menopause-like symptoms in a variety of ways and may be complex. 

TMGD individuals who have not used GAHT or undergone gender-affirming surgeries and retain their ovaries will likely experience menopause similar to cisgender females around midlife when estrogen levels decrease. The symptoms of menopause can be unpleasant and include hot flashes, genital dryness, trouble sleeping, mood swings, and loss of libido. The experience of menopause may trigger gender dysphoria (a sense of unease or distress that may occur when one’s biological sex does not match their gender identity) and erode psychological well-being in TMGD individuals, an important consideration for healthcare professionals when providing gender-affirming care.

Many TMGD individuals choose to use masculinizing GAHT with testosterone, and may or may not opt for gender-affirming surgery, both of which can affect the experience of menopause. It is not uncommon for TMGD individuals to experience symptoms of menopause while using testosterone such as hot flashes, drying of the internal genitals (vagina), and emotional changes. The decision to undergo gender-affirming surgery, such as a hysterectomy (removal of the uterus) with or without bilateral salpingo-oophorectomy (removal of the ovaries), is an  important consideration for TMGD individuals. Removal of both ovaries immediately decreases estrogen levels and results in surgically-induced menopause at that time. TMGD individuals may opt to retain one or both of their ovaries for many reasons after a hysterectomy, including to preserve fertility and the option of reproducing, or to maintain endogenous hormone production if GAHT is unavailable. Currently, there is inadequate data on the long-term risks or benefits for TMGD people who undergo gynecological gender-affirming surgery and retain their ovaries, and more research is needed.

Additionally, pelvic pain (described as cramping) is frequently reported by transgender people using testosterone, although the cause is poorly understood and must be further researched. There appears to be a link between pelvic pain and a post-traumatic stress disorder diagnosis, but without a clear understanding of the cause, a multidisciplinary biopsychosocial and trauma-informed approach is required to address possible factors. There is absence of data on menopause in trans people using GAHT with testosterone, necessitating the need for an individualized approach by healthcare practitioners and future research in this area. 

Menopause for Transfeminine and AMAB Non-Binary People

The experience of menopause looks different for transfeminine and gender-diverse (TFGD) people, including transgender women and non-binary individuals assigned male at birth (AMAB). TFGD individuals may experience menopause-like symptoms but not menopause itself, as they do not have ovaries. These menopause-like symptoms may occur if TFGD individuals use feminizing GAHT, including estrogen, and there are fluctuations in these hormone levels. The type and amount of feminizing GAHT administered to TFGD individuals should be individualized to the patient’s goals during gender-affirming care, but may change throughout the lifetime and therefore cause menopause-like symptoms. For example, the amount of GAHT may change before a feminizing gender-affirming surgery, a common approach by physicians.

There has been only one study published looking at the experiences and beliefs of menopause among trans women, in which trans women did not feel menopause was relevant. However, the lack of research on the long-term effects of GAHT in trans women raised concerns about potential long-term effects as they age. There has been conflicting research suggesting that TFGD individuals using GAHT, particularly estrogen, have increased risk for venous thromboembolism (VTE) and cardiovascular disease (CVD) relative to cisgender women and men. However, these studies have not considered the effect of menopause and may not apply to older populations of TFGD individuals. More research is required. 

The State of Current Research

The lack of rigorous medical intervention outcome studies among transgender and gender-diverse people highlights one of many inequities trans folx experience in healthcare, and highlights the need for further research in this area. Existing studies are compromised by barriers in access to care among different regions, a lack of older adults included in studies, inconsistent methodology, and small sample sizes. Current available guidelines on GAHT are limited in their scope of application for older transgender and gender diverse populations, and standards may different between nations. 

Regarding menopause, most of the information is collected from cisgender women. As such, published work refers to people experiencing menopause collectively as “women” and does not clarify how findings may apply to the specific needs of transgender and gender-diverse people. This gendered language contributes to the exclusion and discrimination of transgender and gender-diverse people, who experience greater healthcare disparities compared to their cisgender counterparts. Understanding the experiences of transgender and gender-diverse individuals during hormone transitions and potential menopause-like symptoms is essential for healthcare providers to provide optimal patient-centred care that is gender-affirming and inclusive. Failure to do so may contribute to the mistreatment and continued discrimination of these individuals. 

The Bottom Line

Menopause or menopause-like symptoms can occur in transgender and gender-diverse individuals, challenging existing definitions of menopause and current research that is centred around cisgender women. The occurrence of menopause or menopause-like symptoms in an individual depends on a variety of factors, including past and current anatomy and the use of gender-affirming hormone therapies. It is important that healthcare providers acknowledge and recognize menopause or menopause-like symptoms in transgender and gender-diverse patients, as this experience may contribute to gender dysphoria, decreased psychological well-being and altered quality of life. The word and concept of menopause can feel gender-affirming or invalidating for an individual, and it is best practice to model the individual language of individuals. There is conflicting and inconsistent data on the health effects of gender-affirming hormone therapy for aging transgender and gender-diverse individuals, and much more research is needed. 

Written by Shelby Cender, UBC MND Student 

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