The default assumption that “menopause is only a women’s issue” makes it hard for trans and gender-nonconforming people to seek menopause care.
“If you even take a look for providers or services in directories, in hospitals, group practices, and menopause centers, you will quickly see that almost all of it says ‘women’ and doesn’t make room for anyone else,” says sex educator Heather Corinna, author of the inclusive menopause guide What Fresh Hell Is This?
And though finding a trans-competent doctor can be challenging in any circumstances, finding a trans-competent doctor with expertise in menopause care is even more difficult.
“Although this is rapidly changing, many primary care clinicians were not trained in medical school about how to ask a patient whether they identify as trans or nonbinary, how to ask about what organs or body parts a trans person has or doesn’t have, or how to manage hormone therapy,” says Dr. Stephanie Nothelle, assistant professor at Johns Hopkins University School of Medicine specializing in geriatric medicine.
What you need to know about symptoms
“We know, as a medical field, very little about trans sexuality, and have tons of preconceived notions,” says Dr. Iris Romero, a professor in the department of obstetrics & gynecology and dean of diversity and inclusion at the University of Chicago. In this absence of dependable healthcare infrastructure, it can be vitally important to know how to be proactive about your own health and request the care you need.
For example, trans men going through menopause can experience vaginal dryness and atrophy, just like menopausal cis women, but it’s much more likely to go undiagnosed and unaddressed. Because doctors may assume that trans men don’t have vaginal sex, they may not even think to ask about discomfort or difficulty with penetration. The good news is that topical estrogen is effective at treating vaginal dryness and isn’t absorbed systemically, so it shouldn’t cause any side effects that run counter to your transition goals.
For trans men who retain their uterus and ovaries, it’s also important to be aware of potential health risks to those organs and to discuss any symptoms you’re experiencing in that area with your provider. If you have uterine bleeding after a long time without a period (due to menopause or testosterone), be sure to mention it to your doctor, as it can be a warning sign of uterine cancer.
Understanding HRT
While women without an ovarian system don’t experience many of the symptoms of menopause, they are still affected by hormonal changes. Unfortunately, there’s very little data on the effects of long-term HRT for trans people, or its effects on aging.
It used to be more commonly recommended that trans women stop HRT around the age cis women experience menopause, without much rationale behind it (beyond, perhaps, a desire to share the misery). Although there’s some evidence that long-term HRT is associated with an elevated risk of stroke and heart disease, those risks can be mitigated in other ways and are generally considered to be outweighed by the benefits of gender-affirming care. For trans women who retain their testicles, going off estrogen can result in a recurrence of unwanted masculine features and associated dysphoria — the last things you want while simultaneously experiencing hormonal mood swings.
Some doctors still recommend that trans women reduce their dosage of estrogen as they age, but it’s worth being aware that a sudden reduction in estrogen can result in menopause symptoms including hot flashes (they do like to show up everywhere, don’t they?), sleep disruption, and bone loss. Jennifer Potter, MD, director of LBGT Population Health Program and co-chair of the Fenway Institute, says that adjusting your dosage very gradually should mitigate the effects and that: “Abrupt changes are more likely to cause symptoms.”
Of course, many trans people don’t take HRT or have gender-affirming surgeries. If you have an ovarian system, menopause symptoms are likely to be the same as those of cis women, which is to say they run the gamut from mild to miserable.
It's also important to remember that while menopause symptoms like hot flashes are commonly associated with aging, it’s possible to experience them at other points, too. People assigned female at birth who go on testosterone may experience menopause symptoms such as hot flashes, mood swings, and disrupted sleep disruptions regardless of how old they are. Hot flashes can also be a side effect of oophorectomy (removal of the ovaries), even for men who have been on testosterone for a long time.
Getting the care you need
Menopause care, often inaccessible to begin with, is even harder to find for trans and gender-nonconforming people. “It's hard enough to be having a hard time in perimenopause or with menopause, but being misgendered as a rule, including after you correct people, given information that itself misgenders you, having care providers so generally unwilling to accommodate something as simple as your correct pronouns or gender, is not even adding insult to injury so much as injury to injury,” says Corinna, who is agender. This lack of consideration for menopause experiences beyond cis women’s creates a huge barrier to care for many people.
Around midlife and during menopause, health risks increase for everyone, trans and cis. It’s important to be on the lookout for heart disease, cancer, mental illness, and other conditions that tend to become issues that become more prevalent as you age. For trans people, it’s especially vital to have a medical provider who’s familiar with your history and knows what kind of preventative care you might need, such as cervical cancer screenings for trans men or prostate cancer screenings for trans women. Trans people on HRT, both men and women, are also at an increased risk of heart attack when compared to cis people.
Because every transition, every body, every aging process is different, there is no one-size-fits-all medical advice. Unfortunately, transphobia — especially where it intersects with other forms of marginalization, like racism and poverty — makes it exponentially more difficult to establish and maintain a consistent relationship with a healthcare provider. Provider directories like those compiled by GLMA and WPATH can help, and you can also reach out to your social network for their recommendations.
Although in a perfect world, trans-competent care for menopause and midlife health issues would be affordable and accessible to everyone, in this world, it’s often necessary to do a little — or a lot — of extra legwork to find a doctor you trust. “I think it’s fair to say mutual aid and community-sourced information or care from one’s peers is easier for everyone to find,” says Corinna. Ultimately, trans people and those who love and support them must be prepared to advocate for respectful, affirming healthcare, at midlife, menopause, and beyond.
By Lindsay King-Miller
Lindsay King-Miller is the author of Ask A Queer Chick: A Guide to Sex, Love, and Life for Girls who Dig Girls (Plume, 2016). Her writing has appeared in Bitch, Glamour, Vice, The Hairpin, and numerous other publications. She lives in Denver with her partner and their two children.
