Menopause Under Researched in Transgender and Gender Diverse Individuals, Study Shows

The lack of understanding and agreement about menopause between the transgender and gender diverse communities (TGD) and medical professionals contributes to a lack of care for these individuals, according to an Australian study published this month in Menopause.

The study was led by co-authors Michelle Qian Lin Xin, M.D., from the department of general practice at Monash University in Melbourne, Australia and Riki Lane, Ph.D., a research fellow at Monash University in Melbourne, Australia.

“For cisgender women, menopause marks a significant transition with biopsychosocial impacts accompanying the cessation of menstrual periods and ovarian function,” Xin and Lane write in the study. “However, for TGD people, there are no evidence-based guidelines for diagnosing or addressing menopause or managing gender-affirming hormone treatment (GAHT) regimens in older TGD individuals.”

The number of TGD people is increasing globally. In the United States, approximately 1.3 million adults now identify as transgender, with 515,200 identifying as a transgender woman, 480,000 identifying as a transgender man and 341,800 reporting that they do not identify as either gender, otherwise known as non-binary.

To get a better understanding of the issues faced by these individuals during menopause, Xin and Lane interviewed three leaders within the transgender community and three medical professionals with experience in transgender healthcare. Specifically, one 55-year-old trans man, one 70-year-old trans woman, one 38-year-old non-binary person, one endocrinologist, one general practitioner and one psychiatrist. Participants were identified by a literature review of databases from sources such as PubMed, Medline and Embase.

The definitions of menopause within communities

The group did not reach a consensus on a definition of menopause in TGD communities.

The general practitioner said that the definition for menopause is “very complex” and suggested that for trans men assigned female at birth, menopause would be "similar to the way it's experienced by cisgender women," with symptoms such as hot flashes and mood swings.

The endocrinologist said that menopause in TGD is “not clinically relevant.”

Menopause experiences within the communities varies

The trans masculine person reported that they had “no negative emotion assigned to menopause at all” because “it represented getting rid of anything that was female.”

The non-binary person suggested that for non-binary individuals, menopause may represent a time of uncertainty and a time that they must choose to take either feminizing or masculinizing hormone therapy.

The endocrinologist reported that “trans people do not go through menopause

because they are on hormones,” and the general practitioner reported that menopause may be a source of gender dysphoria for trans men and that trans women may feel “left out” if they did not get to experience it.

Meanwhile, the psychiatrist, who identifies as “any” pronoun but was assigned male at birth, reported that cisgender women may have a negative association with the term menopause and that this may contribute to trans women not looking to induce it with hormone therapy.

Gender-affirming hormone regimen options for older adults

The general practitioner reported there are “lots of unanswered questions” about the potential long-term hormone therapy effects but offered three potential options: maintaining a patient’s current hormone dose, lowering their dose or taking them off it completely.

The male transgender participant expressed that reducing gender-affirming hormones to induce menopause may create gender presentation conflict, also called gender dysphoria.

Coping without community

Multiple participants discussed the lack of support within the TGD community when it comes to menopause, with the general practitioner citing the “natural comradery” and “strong network of peers” that menopausal cisgender women have.

The female transgender participant agreed, saying, “I think there's still a lot of stigma for those of us who are a bit older in terms of talking about some of these issues - I don't think we have a forum for that where it's easily done.”

The non-binary individual reported that it felt like asking TGD community members about menopause felt like a “faux pas to ask” because some members may find the topic upsetting.

This variety of opinion on the topic led Xin and Lane to advocate for greater education on the topic, achieved by awareness.

“As menopause for TGD people is under-researched, these experiences are likely under-acknowledged, explored, or addressed,” Xin and Lane write in the study. “Any current management approach to menopause in these patients needs to be individually tailored and guided by first principles with individual clinical expertise, given the absence of expert consensus for specific treatment decisions, such as changes to gender-affirming hormone treatment regimens in older TGD people.”