Menopause management for transgender and genderdiverse people

Abstract

For most transgender and genderdiverse people terms like the menopause and andropause only apply in a figurative sense. Under well-adjusted gender affirmative treatment it is unlikely to get climacteric’ symptoms. More frequently dosage adaptation in elderly transpersons due to concurrent chronic diseases leads to problems and may wrongly be considered ‘menopausal’. If complaints remain for a longer period a laboratory check of the sex steroids involved may be indicated. In case lab results do not show conspicious features, it is recommendable to consider absorption problems as transfemale persons are more prone to skin irritation caused by transdermal hormone patches compared to cisgender women. A switch to estrogen gels or sprays is recommended, but not oral administration. There is robust evidence that oral estrogen in elderly transfemale persons significantly increases the risks for CVD, and in particular for VTE. That is why guidelines from authoritative societies like WPATH or the Endocrine Society recommend to refrain from oral estrogen treatment, at least from the age of 50 or even earlier in case of concurrent chronic diseases or risky lifestyle habits. Some transfemales embrace complaints with a strong female connotation, e.g. PMS or some perimenopausal symptoms, to accentuate their femininity. This may be seen as a desperate attempt to overcome gender bounderies and should not be subjected to ridicule but regarded a last cry for help. Also transmale persons may suffer from climacteric complaints but it would be more appropriate to use the term ‘andropause’. Globally, the majority of transmale persons does not undergo genital surgery and are in need of adequate care in case of complaints irrespective of a male outer appearance. This situation may be challenging for healthcare providers not used to encounter transpeople. Even worse is the fact that transmale persons without gender-affirmative surgery often ignore genital complaints, potentially worsening the situation only because the genital organs left in situ are not regarded part of oneself. Healthcare providers need to proactively address possible complaints rather than waiting for the patient expressing his suffering. Medical management of elderly transpeople is a time-consuming challenge as social, emotional and physical well-being are tightly interwoven and also needs an understanding for life concepts beyond the traditional binary.