Hormone Therapy and Contraceptive Surgery in Transgender Men

Know the myths and pitfalls before prescribing

Transgender men (persons born female who identify as men) who have not undergone gender reassignment surgery can be surprised by unintended pregnancy. For many, the event can worsen gender dysphoria and trigger pre- or postpartum depression.

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Too often among transgender men, unintended pregnancy is the result of myths or incomplete information about the effects of testosterone therapy on fertility. According to Cecile Unger, MD, MPH, a gynecologic surgeon at Cleveland Clinic’s Center for LGBT Care, accurate understanding of these myths and practices can help gynecologists provide proper guidance for these patients.

Myths about testosterone

Transgender men may choose to initiate testosterone therapy to help make their physical appearance concordant with their gender identity. However, they are often mistaken about the contraceptive properties of testosterone.

“Some transgender men have male partners and engage in penile-vaginal intercourse. They may believe that testosterone is also a contraceptive,” says Dr. Unger. “While testosterone may affect fertility, transgender men who take testosterone are not always amenorrheic and may ovulate. Also, they may become pregnant if they discontinue testosterone.”

Many TM do not use contraception. Reasons for not using contraception can include fear that the modalities will feminize them and compromise their identity, and clinician’s assumptions the patient is not a candidate for female hormone therapy.

Hormone therapy options and monitoring standards can be found in an expert review, “Care of the Transgender Patient: The Role of the Gynecologist,” by Dr. Unger in the American Journal of Gynecology.

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“An important step in the initiation of hormonal therapy is ensuring the patient does not have a history of a comorbid condition, such as breast cancer or migraine with aura,” says Dr. Unger.

Oophorectomy and hysterectomy

 In some transgender men, hysterectomy or oophorectomy may be an appropriate surgical procedure to prevent conception. Additionally, hysterectomy may be performed in preparation for the transition to self-affirmed gender.

 “Patients who do not want a genetic child are candidates for oophorectomy. Those who want to become a parent, but don’t want to carry a child, are candidates for hysterectomy. Those who do not want to preserve their fertility are candidates for oophorectomy with hysterectomy, if they meet the World Professional Association for Transgender Health (WPATH) criteria for surgery,” says Dr. Unger.

Dr. Unger discusses these criteria, as well as those for all gynecologic surgical procedures in transgender patients, in an article, “Caring for the Transgender Patient: The Role of the Gynecologist,” in the June 2017 issue of OBG Management.

When hysterectomy is indicated, the American College of Gynecologists recommends vaginal hysterectomy for limited complications and morbidity and maximum cost effectiveness. Dr. Unger does not necessarily agree.

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“I believe in using the operative route most comfortable for the surgeon,” she says.

 Vaginectomy

Patients with severe gender dysphoria and no vaginal penetration may request vaginectomy. According to Dr. Unger, there is no standard of care for this procedure and no guidelines for stopping or continuing testosterone perioperatively.

“It is important to remember that a portion of vaginal epithelium is sometimes used in certain phalloplasty procedures, so if they want future genital reconstruction, leave the vagina alone. Also, the vaginal cuff should be closed in two layers to avoid evisceration,” she says.