Gynecologic care considerations for transmasculine people

Transgender and nonbinary people need access to high-quality sexual and reproductive healthcare. For transmasculine people—transgender men, and nonbinary people, whose sex assigned at birth was female—ob/gyns are ideally positioned to provide such care.

Transgender and nonbinary people face disproportionate rates of stigma and discrimination in seeking healthcare—and may encounter additional unique barriers in attaining gynecologic and reproductive care.¹

Even in the absence of overt discrimination, transgender and nonbinary people face challenges related to structural discrimination, or cisnormativity – the assumption that all individuals are cisgender and the ways in which the social world is constructed to address the needs of cisgender people and to encourage conformity with such norms.²

For example, providers and staff often make assumptions about gender identity or expression of patients in a “women’s health” clinic; many providers lack cultural competence in caring for transgender and nonbinary patients; and transgender and nonbinary people may encounter unique challenges in accessing insurance coverage.^1,3,4

Given the negative and traumatic experiences that many transgender and nonbinary people have had when accessing care, many avoid necessary care.¹

The American College of Obstetricians and Gynecologists (ACOG) has called on ob/gyns to assist gender-diverse individuals in obtaining routine treatment and screening, as well as gender-affirming care needs.⁵

In their article, “Opening the OBGYN door for sexual and gender minority patients” in 2019, Drs. Light and Obedin-Maliver reviewed practices to ensure a welcoming environment for transgender and nonbinary people in ob/gyn clinics.

In this article, we will discuss ways ob/gyns can provide high quality gynecologic and reproductive health care for transgender and nonbinary people assigned female sex at birth.

Creating a structurally affirming environment

Clinics can build patient trust and reduce patient anxiety even before a patient enters an exam room.

Several steps clinics can take to create a safe, supportive, and welcoming environment for transgender and nonbinary people include training frontline staff in cultural competency training such as pronouns and names used (“preferred”), ensuring intake forms avoid cisgender assumptions, having gender-neutral bathrooms, and posting lesbian-, gay-, bisexual-, transgender-, queer-positive friendly signage.^2,6

Avoiding cisgender assumptions on gynecology intake forms, for example, may involve the use of survey branch points such as: “if you were born with a uterus” before sections of the form regarding menses, pregnancy, Pap smears and contraception.⁶

Special considerations for pelvic exams

Pelvic exams can be particularly difficult or traumatic for transgender and nonbinary individuals.

Many transgender and nonbinary people avoid exams due to fear, secondary to personal or collective trauma in healthcare settings. Nearly one-quarter of transgender and nonbinary individuals report avoiding seeking healthcare due to fear of being mistreated due to their gender.¹

In addition, nearly 50% of transgender and nonbinary people are survivors of sexual abuse or assault, which may contribute to fear in seeking sexual and reproductive healthcare.¹ Finally, many transmasculine individuals find pelvic exams triggering of their dysphoria.

Building patient trust, at times over several visits, may help patients. Providers are encouraged to use a trauma-informed care approach to exams; this includes explaining the steps of the exam in advance, empowering the patient to stop the exam at any time by saying “stop” or raising their hand, and asking the patient what terms they feel most comfortable with using for their anatomy prior to the exam.

For example, some patients use the term “front hole” to refer to the vagina and find this term less dysphoria. Use of a narrow Pederson speculum should be considered and patients should be offered the opportunity to self-insert the speculum.

Occasionally, individuals who have used testosterone for prolonged periods of time may develop vaginal atrophy, although in our experience, this is not common.

For such individuals, use of vaginal estrogen for 1 to 2 weeks in advance of a planned speculum exam may also be useful if acceptable to the patient. For individuals with severe anxiety, pre-medication with a benzodiazepine can be considered, as well as patient application of topical lidocaine to the perineum prior to the exam.

Some people may find it helpful to have a support person in the room for an exam, or to use headphones for music or meditation guidance during the exam. For patients with particularly severe anxiety, moderate or deep sedation may be required if an exam is necessary.

Pap smears

Transgender men are less likely to be up to date on cervical cancer screening than cisgender women, in part due to anxiety about exams, as well as barriers to general reproductive and sexual healthcare as discussed previously.^7,8

Most transgender and nonbinary people assigned female sex at birth have a cervix and uterus; in a 2015 survey of almost 28,000 transgender individuals in the United States, 14% of transgender men reported having had a hysterectomy.¹ Gender minority people who have a cervix should receive the same cervical cancer screening as cisgender women.

When Pap smears are performed on individuals taking testosterone there is an increased risk of unsatisfactory results. In one study, cervical cytology specimens were approximately 10 times more likely to be unsatisfactory among individuals using testosterone compared to those not using testosterone.⁹

Prior to performing a Pap smear on patients taking testosterone, they should be informed that there is an approximately 10% risk of inadequate screening and need for follow-up testing.⁹

In general, as with cisgender females, unsatisfactory cytology should prompt repeat cytology testing in 2-4 months.

Read more: A slideshow presenting terms and definitions for ob/gyns to know when treating transgender and non-binary patients

Research on postmenopausal cisgender women suggests that 5 days of vaginal estrogen pre-treatment may reduce unsatisfactory results in the setting of atrophic changes, which has led some to consider this approach with transgender and nonbinary individuals returning for repeat cytology following unsatisfactory results.¹⁰

While human papillomavirus (HPV) testing alone can be considered for individuals 25 years and older, patients should be aware that this strategy has been associated with higher false-positive and colposcopy rates than cytology alone in population level studies; there has not been transgender and nonbinary-specific research on HPV-alone screening strategies.¹¹

Some transgender and nonbinary people in need of Pap smears may have their sex listed as male with their insurance company. For individuals with sex listed as male, prior authorization for Pap smears should be obtained to avoid patients receiving unexpected denial of coverage for these services.

In addition, a KX modifier can be used to alert the insurance carrier that sex-specific editing may apply and that the service should be allowed to continue with normal processing.

As with other hormonal medications such as contraception, gender-affirming hormone therapy should not be withheld or postponed because a patient is not current on their cervical cancer screening or has not had a pelvic exam.

Contraception

Like cisgender people, transgender and nonbinarypeople are diverse in their sexuality and sexual practices. Limited data suggest that more than 50% of transmen engage in sexual practices with pregnancy potential (penile-vaginal intercourse).12

Approximately one-quarter to one-half of transgender individuals want to use their natal reproductive capacity, including use of gametes and carrying pregnancies.¹³ Thus access to the range of reproductive care—including preconception, obstetric, abortion, pregnancy loss, and fertility care for transmasculine people—is essential.

Here we will focus on contraceptive needs.

Gender-affirming hormones are not recommended or approved as contraception. While male physiologic levels of testosterone likely cause hypothalamic-pituitary-ovarian suppression and anovulation in most individuals, a recent study of 20 individuals showed that breakthrough ovulation does occur.¹⁴

While there is currently a lack of data regarding conception rates while using testosterone, pregnancies in the setting of testosterone-induced amenorrhea have been reported.¹⁵

Testosterone is a known teratogen and should be discontinued prior to conception. Several studies note that a small number of transgender and nonbinaryindividuals assigned female sex at birth believe that testosterone is an adequate contraceptive—and that some have unfortunately received this misinformation from their doctors.

Ob/gyns should make sure their transgender and nonbinarypatients on testosterone are aware that testosterone is not adequate contraception and should provide contraceptive counseling for transgender and nonbinaryindividuals engaged in sex with pregnancy potential who are taking testosterone or not looking to conceive.

Condoms appear to be the most common form of contraception among transgender and nonbinarypeople assigned female sex at birth.¹⁶

However, testosterone use is not a contraindication to any form of hormonal or non-hormonal birth control, emergency contraception, or medication abortion. Transgender and nonbinaryindividuals in need of contraception should be offered the full scope of contraceptive options, including combined hormonal contraception.¹⁷

Clinicians should be aware that transgender and nonbinarypeople experience gender dysphoria differently, and for some, the act of taking medications or using contraceptive devices generally associated with cisgender women, or requiring a pelvic exam for placement, will be associated with dysphoria.

While robust research on hormonal contraception in the setting of masculinizing hormone use is lacking, estrogen in combined hormonal contraception is not likely to significantly prevent masculinization. It may be useful to counsel patients regarding contraceptive side effects that may cause dysphoria or distress, such as potential chest/breast tenderness with hormonal contraception initiation.¹⁷

For patients interested in non-hormonal options, a small case series suggests that transmen with amenorrhea on testosterone may continue to have amenorrhea with coppers intrauterine devices (IUDs); however, all individuals should be aware spotting immediately after IUD insertion is expected and might require use of menstrual hygiene products.

There are currently no data on effects of various progestin contraceptive options on amenorrhea among patients taking masculinizing testosterone.

In our clinical experience, medroxyprogesterone acetate, norethindrone acetate, or drospirenone may be superior to the etonogestrel implant for maintaining amenorrhea and avoiding irregular bleeding or spotting.

Abnormal bleeding on testosterone

Most transgender and nonbinary individuals assigned female sex at birth who use exogenous testosterone achieve amenorrhea, typically within 2 to 4 months of treatment initiation. Individuals on lower doses of testosterone, such as nonbinary individuals who choose to use low-dose testosterone, are less likely to be amenorrheic.

A common cause of continued menses or irregular bleeding on testosterone is inappropriate dosing. An initial evaluation should include total testosterone and estradiol levels, and evaluation for any missed doses or trouble obtaining their testosterone medication.¹⁸

Of note, in patients using injectable testosterone, testosterone levels should be obtained approximately halfway between injections. In patients who continue to have menses, with serum testosterone on the lower end of the male physiologic spectrum, a modest increase in testosterone will often result in resolution of bleeding; theoretically, this may result from improved suppression of ovulation.¹⁸

In patients with serum testosterone on the higher end of the spectrum, or supraphysiologic levels, excess testosterone levels may be aromatized, leading to elevation of estradiol levels; in these cases, a decrease in testosterone level may cause cessation of bleeding.¹⁸

In addition, individuals on androgen gels may be more likely to receive insufficient dosing, compared to those using injectable testosterone, and may anecdotally be more prone to breakthrough bleeding.

Individuals may also have bleeding while on testosterone for structural and non-structural reasons, just as with cisgender women. Bleeding that is not explained or resolved with optimization of gender-affirming hormones should be evaluated with an exam with consideration of endometrial assessment using pelvic ultrasound or endometrial biopsy.

Related: Additional resources for consideration

When ordering a pelvic ultrasound, if transvaginal ultrasonography is requested, the patient should be aware of this recommendation and of the rationale for transvaginal versus transabdominal imaging. If referring to radiology, including the patient’s gender and pronouns in the scheduling comments may help ensure that the radiology team is gender-affirming.

In a practice that does not see transmasculine patients often, a preliminary conversation with the radiology team can help ensure that the patient receives appropriate, respectful, and affirming care.

Progestins can be used to manage abnormal bleeding in individuals on testosterone. It is important to note that despite amenorrhea, the majority of transmasculine people on testosterone appear to have active proliferative endometrium on histopathology.¹⁹ Thus, progestin therapies for endometrial stabilization are commonly used for bleeding management in transgender and nonbinary patients on testosterone.

Risk of endometrial cancer in transgender and gender-nonbinary individuals on testosterone appears to be similar to the baseline population risk among cisgender women.¹⁹

Gender-affirming hysterectomies and oophorectomies

Many transgender and nonbinary people assigned female sex at birth feel dysphoria related to their uterus, fallopian tubes, ovaries, and/or vaginas—with approximately 50% of individuals having had or in need of a hysterectomy in the future.¹ There is broad consensus in the medical community that gender-affirming surgeries, like hormones, are a medical necessity rather than elective.

While some guidelines require that patients universally acquire letters of support from two mental health providers prior to undergoing gender-affirming genital surgeries, including hysterectomies, there are several ethical and practical concerns with these guidelines.

In our practice, we use a shared decision-making model in discussing surgery and obtaining informed consent for hysterectomies and oophorectomies for patients of all genders.

Surgeons should be aware, however, that some insurance companies may require letters of support from mental health providers for hysterectomies with “gender dysphoria” as the primary indication.

Whereas the ovaries are typically preserved in young cisgender women undergoing hysterectomy for benign indications, bilateral oophorectomies are appropriate for transgender and nonbinary individuals committed to longstanding gender-affirming hormone therapy and who do not intend to proceed with gamete harvesting or carrying a pregnancy.²⁰

Concerns regarding lower parity on average compared to cisgender women, atrophic vaginal walls, and in some individuals a more narrow vaginal caliber, as well as ensuring ability to complete a concurrent bilateral salpingectomy (with or without oophorectomy), have led many clinicians to favor laparoscopic approaches over vaginal approaches.²¹

Vaginal hysterectomy, however, has been proven feasible for transgender men, and providers are encouraged to consider the potential appropriateness of a vaginal approach for hysterectomy for transgender and nonbinary patients.²²

Patients may also consider concurrent vaginectomy, which is typically recommended prior to proceeding with genital construction surgeries (phalloplasty or metoidioplasty); however, coordination with the physician planning to perform the phalloplasty or metoidioplasty is recommended as some may use vaginal epithelium for urethral reconstruction.

Summary

Ob/gyns have the opportunity to play a significant role in improving access to quality gynecologic and reproductive care for transgender and nonbinary people.

This can be done with relative ease, with compassion, gender-inclusive practices, sensitivity to patients’ lived experiences, and a modest expansion of the traditional baseline knowledge regarding hormones and gender-affirming medical interventions.

The needs of transgender and nonbinary people relevant to ob/gyns extend beyond the scope of this article, and include endocrinological management of gender-affirming hormones, pre-conception, prenatal, fertility, obstetric, abortion, lactation, general gynecologic and specialty care—creating and opportunity and need for all ob/gyns to provide gender-inclusive care to ensure all people receive excellent gynecologic and reproductive healthcare regardless of gender.

Stay tuned for a video interview and podcast with Drs. Crissman and Stroumsa where they will expand upon what they have covered in this article.

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References

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