Understanding Menopause in Transgender Individuals : Hormones, Therapy, and Care

1. Brief Introduction of Menopause

   Menopause is a brief biological process that marks the end of a female’s reproductive years. It is the permanent cessation of menstrual periods and occurs between the ages of 45 and 55 years and can also occur earlier or later in life.

   In this transition, there is a decline of certain hormones particularly estrogen and progesterone by the ovaries. As a result, females no longer ovulate or release eggs and are also not able to conceive. Menopause is confirmed after 12 consecutive months without a menstrual period. It is a significant milestone in a female’s life and comes with various physical and emotional changes.

2. Symptoms of Menopause

   There are several signs and symptoms that can be associated with menopause. These include :⁽⁵⁾

   • Hot flashes
   • Mood swings
   • Changes in the body composition such as reduced muscle tone and increased fat
   • Changes in bladder health leading to more frequent urination or incontinence
   • Difficulty in sleeping

   Cisgender females may also experience changes in the frequency and occurrence of periods up to menopause. Once menopause sets in there may be vaginal dryness and pain during sex.

3. Transgender People and Their Unique Experience with Hormone Therapy

   Transgender individuals often undergo hormone therapy as a gender-affirming process, which is known as gender-affirming hormone replacement therapy (GAHT). In this process, hormones are administered that align with their gender identity. It includes feminizing hormones for transgender women and masculinizing hormone therapy for transgender men.

   A few unique experiences and considerations associated with hormone therapy for transgender individuals include: 

   • Hormone therapy aligns a person’s physical appearance with their appearance and gender identity. which increases their feelings of authenticity and well-being.
   • Feminizing hormones leads to redistribution of fats, softening of skin, decreased muscle mass and strength, breast development, and reduction in body hair growth.

   Masculinizing hormone therapy leads to an increase in body hair growth, voice deepening, growth of facial hair, and increase in muscle mass and strength.

   • Hormone therapy can have a significant impact on emotional and psychological effects leading to reduced gender dysphoria and improved sense of well-being.
   • Changes in physical appearance can influence how transgender individuals are perceived and treated in social settings.
   • Long-term effects of hormone therapy may affect bone health, cardiovascular health, and other aspects and this might need monitoring.

   Hormone therapy is a significant and often transformative aspect of the gender-affirming process. It can lead to positive changes in a person’s physical, emotional, and psychological well-being.

Transgender menopause is also known as transitional menopause. It is a term that is used to describe the unique experiences that transgender individuals go through as a result of gender-affirming hormone replacement therapy, particularly while undergoing masculinizing or feminizing hormone treatments.⁽¹⁾

Transgender undergo hormone therapy as a part of the gender-affirming process. This allows for the administration of estrogen and anti-androgens for transgender women and testosterone in transgender men.

There are various physical changes experienced as a result of hormone therapy, depending on whether they are undergoing feminizing or masculinizing hormone treatment.

Some of the potential physical changes include:

• Breast Development: Estrogen as a part of hormone therapy leads to breast development. The extent of it may vary from person to person.
• Redistribution of Fat: The fat distribution shifts towards a more feminine pattern with a decrease in the upper body and an increase in hip and thigh fat.
• Softer Skin: The skin of the individual becomes more softer and supple.
• Reduction in Body Hair Growth: Body hair gets finer and less dense, particularly in areas like the chest and back.
• Muscle Mass and Strength: There is a decrease in muscle mass, which leads to a softer and less muscular appearance.
• Changes in Genitalia: Due to hormone therapy there may be subtle changes in the size and function of the genitalia.

• Voice: There is a thickening of vocal cords leading to a lower-pitched voice.
• Hair Growth: There is a growth of facial and body hair, including beard and mustache.
• Muscle Mass and Strength: Testosterone in hormone therapy leads to an increase in muscle mass and overall physical strength.
• Fat Distribution: The fat tends to redistribute towards a more masculine pattern, with an increase in the upper body fat.
• Clitoral growth: The clitoris may enlarge but may not develop fully as a penis.
• Cessation of Menstruation: Transgender men undergo masculinizing hormone therapy also, experience amenorrhea due to hormonal changes.

• Fertility: Both male-to-female and female-to-male transformation individuals experience a loss of fertility as a result of hormone therapy.
• Emotional and Psychological Impact: The physical changes brought about by hormone therapy can have a significant emotional and psychological effect, leading to reduced dysphoria and improved sense of well-being.
• Skin Changes: Both types of transformation experience changes in skin texture, oiliness, and complexion.

The experiences an individual goes through with hormone therapy vary widely and not all individuals experience every listed changes. Also, the pace and extent of these changes can depend on various factors, including genetics, dosage, and duration of hormone therapy.

During gender-affirming hormone therapy in females, estrogen, androgen blockers, and progesterone are prescribed to help lower testosterone and increase estrogen levels.

There may be hormonal fluctuation in transgender females having hormone therapy making them experience symptoms cisgender females experience around menopause. This may result in premenstrual symptoms.

If a person decides to stop gender-affirming hormone therapy, the level of estrogen would drop leading to menopause-like symptoms. However, many people decide to continue the therapy for the rest of their life due to the life-affirming aspect of care.

Transgender females who receive gender-affirming hormone therapy are not likely to experience menopause-likes symptoms if they continue with therapy for the duration of their life.⁽²⁾ Also, transgender males who undergo gender-affirming hormone therapy will not likely experience menopause-like symptoms if they continue with therapy for the rest of their life.⁽³⁾

Individuals who are assigned female at birth and are not receiving gender-affirming hormone therapy might start menopause, following the final menstrual cycle as their estrogen level drops.

In gender-affirming surgery, the removal of ovaries can help prevent the occurrence of menopause in transgender males.  Also, transgender female who stops taking gender-affirming hormone replacement therapy may not experience menopause-like symptoms if their organs from birth are still intact and producing testosterone

Studies show that menopause may not be a significant concern for transgender females. A study done in 2019 on transgender females reported that they did not feel menopause was an issue due to the biological difference between transgender and cisgender females.⁽⁵⁾

One more study done in 2022 noted that transgender females often do not experience menopause due to lifelong continuation of gender-affirming hormone therapy.⁽⁴⁾ However, in this study, it was noted that other conditions such as cardiovascular disease were the concerns.

Research regarding menopause in transgender people is still lacking. In the coming years, the scientific community aims to learn more about gender-affirming hormone therapy, gender-affirming surgeries, and their influence on the transgender population.

Both medical and psychological considerations are crucial for transgender individuals undergoing hormone replacement therapy.

Before starting hormone therapy, individuals should undergo a comprehensive medical assessment by a qualified healthcare professional. Here medical history is reviewed and physical examination and lab tests are done. The choice of hormone and dosage is tailored according to individual goals, preferences, and health considerations. These decisions are made in collaboration with a knowledgeable healthcare provider.

The following health effects need to be monitored:⁽²⁾

• Monitor Hormone Levels: Regular blood tests are essential to monitor hormone levels and ensure they are under safe and effective ranges.
• Cardiovascular Health: Hormone therapy in higher doses can have implications for cardiovascular health. Regular monitoring of blood pressure, cholesterol levels, and cardiovascular markers is important.
• Bone Health: Reduced estrogen levels in transgender women and potential changes in physical activity can have an impact on bone density. Adequate calcium and vitamin D intake, along with weight-bearing exercises might be recommended.
• Reproductive Health: For individuals who want biological children in the future, discussions about fertility preservation options should take place before starting hormone therapy.
• Liver Functions: Liver function may be affected due to hormone therapy. Therefore, regular liver function tests may be recommended.
• Mental Health and Well-Being: The individuals should be monitored for mental health concerns including depression and anxiety. Hormone therapy can have

It is important for a healthcare provider to ensure that the individuals have a thorough understanding of the potential benefits, risks, and alternatives of hormone therapy. 

• Emotional Support and Counseling: The individuals should have access to mental health professionals who are knowledgeable about transgender experiences. This can be helpful for an individual to navigate the emotional changes that might arise during hormone therapy.
• Gender Dysphoria: Hormone therapy can alleviate gender dysphoria (distress experienced by individual due to mismatch between their gender identity.⁽⁶⁾ It is important to have regular discussions about emotional well-being and any persistent dysphoric feelings.
• Body Image and Self-Esteem: Hormone therapy can have a profound effect on body image and self-esteem. Addressing these issues with therapy or support groups can be beneficial.
• Managing Expectations: Setting realistic expectations about physical changes due to hormone therapy can help individuals navigate their journey.

Developing healthy coping mechanisms and resilience strategies can be invaluable as individuals navigate the challenges and triumphs of hormone replacement therapy.

Transgender people undergoing gender-affirming care are not likely to experience menopause. Gender-affirming care involves removing the reproductive organs that were present at birth and giving gender-affirming hormone replacement therapy.

Experiencing menopause would be due to stopping the gender-affirming therapies or still having sexual organs present since birth.

More research is needed to be done on the effect of gender-affirming hormone therapy on aging in transgender people.