By Dr Yvette Pyne, GP and NIHR In-Practice Research Fellow, Centre for Academic Primary Care, University of Bristol

Coinciding with the 15th World Menopause Day on 18 October 2024, I am planning my travel to Birmingham for a screening of a film which describes the experiences of LGBTQ+ people going through menopause. As a clinician and an LGBTQ+ menopausal person myself, I was fortunate to be involved in this amazing project and to meet people passionate about providing better information and visibility around this topic. I’m a GP working both in menopause and trans healthcare (with the Welsh Gender Service), and I’m keen to hear and raise the voices of menopausal trans people who are currently not represented by the general discourse about this life stage.

Menopause and perimenopause: some facts

Menopause, which will happen to anyone who was born with ovaries, can occur at any time and for a variety of reasons. It is when a person’s ovaries stop releasing eggs and they experience their final menstrual cycle. It typically happens around the age of 51 but can also happen much earlier either naturally, or due to surgery or medicine (such as chemotherapy). Perimenopause, is the time before this when your changing hormone levels – oestrogen being the key one – produce a wide array of symptoms from the classic ‘hot flushes’ through to problems with your memory and your mood, as well as vaginal symptoms and joint aches.

Trans men, trans masculine people, and nonbinary people assigned female at birth (AFAB) are commonly born with ovaries, and may experience symptoms depending on what surgery they might have had and what medications they are or are not taking. For trans people, their experiences of menopause and perimenopause can be as complex and difficult as cis people with added elements of dysphoria and erasure to manage as well.

Menopause and perimenopause for trans individuals

There are so many overlaps in my medical care of menopausal patients and trans patients of all ages; both groups are looking for exogenous (from outside the body) hormones to ease their distress. This distress can be psychological – in terms of low mood or anxiety, physical – in terms of hot flushes for menopausal people or desiring physical changes to their body for trans people, and even social – in terms of how they are perceived by others and their ability to work.

We know that perimenopause is often underdiagnosed and misdiagnosed in the cis population, so we can only imagine how often it is missed in the trans population. As well as potentially experiencing the same difficult symptoms as cis women, trans men and nonbinary face the additional lack of representation and clinician awareness of their particular needs. They are also woefully under-represented in medical guidelines related to menopause. I am delighted to see that the draft of new NICE guidelines regarding menopause (due for publication on 7 November 2024) will include wording and research suggestions for trans and nonbinary people; I am hopeful that other national and international guidelines will follow this example.

Trans men and nonbinary people who have chosen to use gender affirming hormone therapy (GAHT) typically in the form of testosterone, may find that the onset of perimenopause with its more erratic hormone changes means their previously stable dosing of testosterone needs to be reviewed and changed. I have also personally seen cases where someone is on a ‘low dose’ of testosterone insufficient to support their perimenopausal symptoms, not through choice but it has been prescribed as a temporary measure by a GP too worried, unsupported or insufficiently knowledgeable to feel confident to prescribe a full bridging prescription while the patient waits on the endless waiting list for care in the English Gender Service.

Trans men and nonbinary people who have chosen not to take GAHT may experience perimenopause symptoms. For the people who are using progesterone as their preferred form of menstrual suppression, the increasingly irregular and heavy bleeding associated with perimenopause may lead to ‘breakthrough bleeds’ which can be a particularly distressing source of dysphoria. They may find themselves unsure if they are expected to take oestrogen (which is not gender affirming) or they may want to consider testosterone – which they have previously chosen not to take. There are non-hormonal options to manage menopausal symptoms for people who do not wish to use any hormone therapy, but these typically have lower efficacy, narrower symptom coverage, and no long-term benefits for osteoporosis or cardiovascular protection.

What’s available?

What options are open to trans people experiencing perimenopause and menopause? The same lifestyle measures that apply for cis people are relevant for trans people as well. Even within this, there may be some elements that can be harder to access for trans people. While some trans men find their chest dysphoria (and the binding and taping they often undertake to manage this) limits their exercise options, there may be types of exercise that can work and are more likely to be compatible with binding such as tai-chi or yoga. Additionally, eating healthily, stopping smoking, and having good sleep hygiene will all help as well.

With regards to hormonal medication, while there is a lack of formal research, there is enough anecdotal evidence that trans men and nonbinary people who wish to, can take testosterone in place of oestrogen to give similar relief from perimenopausal symptoms. A common side-effect of both testosterone for trans people and an effect of menopause is vaginal dryness. I offer the same option to anyone with that symptom – vaginal oestrogen. The local application of oestrogen has very limited body-wide absorption, so it is can be an effective and safe option for trans men and nonbinary people.

It is important to remember that there are also non-hormonal medication options for menopausal symptoms which might be the right option for some people. These include SSRIs and SNRIs (types of antidepressant medication) which can help with mood and also with hot flushes and some newer groups of medications known as Neurokinin-3 Receptor (NK3R) Antagonists such as Fezolinetant that focus on reducing hot flushes and night sweats.

There are very few support organisations that focus on both older people and LGBTQ+ people. More generally, there are lots of support organisations that can be found through ‘TranzWiki’. In Wales, I encourage people to reach out to excellent support organisations such as Umbrella Cymru. There are also individuals such as Tania Glyde who are doing important work specifically in this area of Queer Menopause which I have to believe will be a growing area of interest.

But we must do better

There is a lack of research and awareness related to trans people’s experience of menopause in healthcare settings and beyond. This needs to be addressed and organisations and leaders who can influence what research gets funded need to “be brave” and recognise that trans identities need better clinical care and this will be partly through research.

In the clinical setting, doctors, other healthcare practitioners, and anyone who interacts with patients urgently need training on how to support trans people including those experiencing menopause. Trans people often have poor healthcare experiences and the menopause can be a time of vulnerability and confusion which can be compounded by insensitive care. There are plenty of people (including myself) who are passionate about providing training and there are plentiful and free resources to better educate ourselves. We need to improve access and reduce the chance of further stigmatising and traumatising a group of people who are already marginalised.

More widely in the community, it must not be up to trans people to advocate for their right to accurate information about the menopause in their community alone; everyone must choose kindness and humility to learn about and from trans people and they must demand that leaders change laws and fund clinical care for this underserved community.

What next?

Menopause in trans men and nonbinary people is not a niche issue; estimates of the size of the trans population are between 0.5% and 3% and are likely to be at the higher end of this estimate with increased visibility in society. This means that potentially at least 1% of the population are trans masculine or nonbinary people who will experience menopause – a similar percentage of people who have epilepsy or rheumatoid arthritis, for example; conditions for which we have extensive research and clinical expertise.

So back to that film screening I am a panel member for; while there are tickets available for the screening, the creators have expressed a worry about sharing it more widely. They are fearful of the backlash that they will get from transphobic agitators and this trepidation is far from unfounded. There are reports of increases in hate crimes occurring and even high-profile medical organisations seem to be moving away from affirming gender care in light of the recent Cass Review. However, these voices are beginning to be heard, and I want to give them a further much-needed boost on 18 October. I plan to be part of the creation of a truly inclusive menopause research and clinical network that listens to and learns from everyone.