Introduction

Balancing contraceptives and masculinising hormone therapy is a critical consideration for transgender men, non-binary people and individuals assigned female at birth (AFAB) who are undergoing gender-affirming care.

Masculinising Hormone Therapy

Masculinising hormone therapy typically involves the use of testosterone to induce the development of male secondary sexual characteristics. While this process aligns with an individual’s gender identity, it also has implications for reproductive health.

Effects on Menstruation and Fertility

• Testosterone therapy often leads to amenorrhea (the absence of menstruation) in individuals who still have a uterus.
• Ovarian function may not cease immediately, and individuals may experience irregular menstruation before it stops entirely.
• Fertility preservation may be a consideration for those who wish to have biological children in the future.

Contraceptives and Reproductive Health

Masculinising therapy cannot be relied on for contraception, however after a prolonged period of absent periods, fertility can be presumed to be reduced. Individuals on masculinising therapy who are having receptive vaginal sex should consider their contraceptive options to prevent unintended pregnancy. Some contraceptive methods are compatible with testosterone therapy, while others may have interactions or considerations to keep in mind.

Birth Control Options

• Barrier Methods: Condoms, diaphragms, and cervical caps are safe options as they do not involve hormonal interventions.
• Intrauterine Devices (IUDs): Hormone-free IUDs, such as the copper IUD, are effective and suitable for individuals on masculinising therapy. The IUS is an intrauterine device that releases progesterone. This can stop menstruation and very little is absorbed into the blood stream.
• Progestin-Only Contraceptives: Progestin-only methods like the mini-pill, contraceptive implant, or progestin-only IUDs are considered safe with testosterone therapy, however progesterone is a prominent female hormone which causes feminising effects and an alternative may be better.
  • eg: Norethindrone, Desogestrel, Norgestrel, Levonorgestrel, Norethisterone, Drospirenone, Medroxyprogesterone acetate (MPA), Dienogest, Ethynodiol diacetate, Norgestimate, Orgametril
• Combined Hormonal Contraceptives: The combination of estrogen and progestin is generally discouraged for those on testosterone, as it can counteract the hormone therapy’s effects, and estrogen is a powerful female hormone.
  • eg: Yasmin, Microgynon, Loestrin, Marvelon, Ortho Tri-Cyclen, Yaz, Femodene, Cilest, Mercilon, Alesse, Ridegivon

Stopping Contraceptives

Some individuals use contraceptive methods primarily to suppress menstruation rather than for their contraceptive effects. Testosterone therapy alone will eventually lead to the cessation of menstruation, but the timeline for this varies among individuals and the dose being prescribed.

When someone decides to discontinue contraceptive use while on testosterone therapy, there will be at least one more withdrawal bleed as the lining of the womb is shed. This is a normal physiological response to the change in hormonal balance. Spotting and irregular bleeding can continue until it eventually stops.

Individuals should be aware that alternative contraceptive options will be needed if they are having vaginal penetration with a penis.

Fertility Preservation

For those interested in preserving their fertility before starting hormone therapy, options such as egg or embryo freezing may be explored. It’s essential to consider these options before beginning masculinising therapy.

Additional Note on Pregnancy and Testosterone

If an individual on testosterone were to become pregnant, there could be potential risks to the developing fetus. Testosterone is known to masculinise a fetus during pregnancy, which can have significant implications for the child’s development. Therefore, effective contraceptive measures and diligent family planning are absolutely crucial for individuals while on testosterone therapy. Open and transparent discussions with healthcare providers about contraception and reproductive health goals are essential components of comprehensive gender-affirming care.

Return of Fertility

For individuals who are undergoing masculinising hormone therapy who wish to conceive, discontinuing treatment can lead to the return of fertility. In many cases, the resumption of regular ovulatory menstrual cycles and the potential for pregnancy will occur after stopping testosterone therapy. The timeline for the return of fertility can vary widely among individuals. Some may experience a relatively rapid return of fertility, while others may require more time.

Conclusion

Navigating contraceptives and masculinising hormone therapy is a complex but manageable aspect of gender-affirming care. By seeking guidance from knowledgeable healthcare providers and understanding the contraceptive methods compatible with testosterone therapy, individuals can make informed decisions that align with their reproductive health and gender-affirming goals.

Further Reading

https://www.fsrh.org/documents/fsrh-ceu-statement-contraceptive-choices-and-sexual-health-for/