REPRODUCTIVE HEALTH IN TRANS AND GENDER DIVERSE PATIENTS: Contraception considerations in transmasculine and gender diverse adolescents and young adults.

There continues to be a need to assess contraception use and preferences in TGD adolescent and young adults. TGD AYA patients may seek contraception care that is discrete, avoids estrogen, helps alleviate gender dysphoria, and potentially leads to amenorrhea. Given the paucity of national data and lack of inclusion of gender identity on large, sampled data sets, most data in this population comes from smaller, cohort or convenient sampling techniques. While still informative, it is critical for us to better understand this population’s needs. Furthermore, many of the studies focusing on TGD patients are predominantly in white and higher socioeconomic status (SES) individuals and not encompassing the intersectionality appreciated with TGD persons of color or lower SES. Future studies could include larger cohorts and continued qualitative studies among TGD AYA that may help better inform providers of TGD AYA and aid in contraception counseling.

Contraception is an important aspect of comprehensive gender affirming care for transgender and gender diverse adolescents and young adults (AYA) ( S. Pradhan, V. Gomez-Lobo, 2019 ). While these patients may seek contraceptive care for very similar reasons to cisgender persons, there are unique considerations and concerns in this population that providers should understand and consider. Gender refers to a person’s own sense of inner self and gender dysphoria refers to distress caused by feeling that one’s identity does not align with one’s sex at birth. Throughout this narrative review, we will utilize the term transgender and gender diverse (TGD) persons to refer to those whose gender identity is transmasculine, non-binary, or gender diverse and were assigned female sex at birth. There continues to be gaps in research and now increasing limitations placed on clinicians caring for this population. Gender care includes affirming one’s sense of gender identity through social, medical, and surgical steps. Each person’s journey is unique and often nonlinear, and the role of the clinician is to support patients in their transition ( E. Coleman, A.E. Radix, et al., 2022 ). Social transition refers to the steps that a person takes to affirm one’s gender identity through gender expression and can occur at varying points in their lives ( J.L. Turban, D. King, et al., 2021 ). Medical transition can include puberty suppression often with gonadotropin releasing hormone agonists (GnRHa) when a young person is Tanner Stage 2 or gender affirming hormone therapy (GAHT or testosterone therapy) ( E. Coleman, A.E. Radix, et al., 2022 ). Surgical transition is a step that some TGD chose to take and for transmasculine patients can include top surgery (e.g., mastectomy), gender affirming hysterectomy, salpingectomy, oophorectomy, or bottom surgery (e.g., metoidioplasty, phalloplasty, or vaginectomy). There is limited prospective data evaluating contraception preferences, continuation rates, and amenorrhea rates in the TGD AYA population; however, several studies have evaluated current and past contraception use in this population. A 2019 cross-sectional survey study of contraceptive use for the purpose of contraception in 150 TGD (mean age of 27), noted that 24% used condoms, 8% intrauterine device (IUD), 2.7% a pill (unspecified type – estrogen and progestin versus progestin only) ( B. Stark, J.M. Hughto, 2019 ). Within this same study, the lifetime use of oral contraceptives was quite high at 50% and lifetime IUD use of 10%. Additionally, qualitative data looking at contraception use in this same population noted that the most common reasons for use were for prevention of sexually transmitted infections and pregnancy. In TGD adults, a 2018 questionnaire study noted that the majority of TGD persons used condoms, combined oral contraceptives (COCs), or progestin only pills (POPs) ( A. Light, et al., 2018 ). Similar to the cisgender AYA population, pills and condoms are commonly utilized for pregnancy and sexually transmitted infection (STI) prevention respectively and many reported that they preferred external condoms and implants because these methods provided fewer reminders of their natal anatomy and were not perceived as interfering with testosterone use ( A. Light, et al., 2018 , M. Agénor, et al., 2020 ). These studies also help illustrate that there is a diverse use of contraception in this population and that there is some acceptability of combined oral contraceptives although lower than in the cisgender female population ( K. Hall, et al., 2012 ). Several studies on current contraceptive use reveal that a significant number of TGD individuals utilize contraception for the purpose of menstrual suppression in addition to other non-contraceptive methods of menstrual suppression. For example, a 2020 study among young TGD adults (ages 18 to 29) noted that participants chose their contraceptive method mainly for menstrual suppression or addressing their gender dysphoria ( M. Agénor, et al., 2020 ). Another 2023 study of contraception use in over 500 TGD AYA, noted that 24.7% were on menstrual suppression at their initial visit to a gender service specialist. Combined oral contraceptive pills use was the most common method used for menstrual suppression (46.6%), followed by norethindrone (29.8%), and depot medroxyprogesterone (14.5%) ( D. Moussaoui, et al., 2023 ). Another retrospective cohort study of over 100 TGD AYA at a single gender affirming clinic focusing on menstrual suppression reported that the most utilized methods were norethindrone acetate (70%, a progestin pill that is not a contraceptive method) and the levonorgestrel IUD (20%) ( B. Schwartz et al., 2023 ). Other methods in this study included combined oral contraceptive pill (6%), progestin-only oral contraceptive pill (1%), the etonogestrel implant (1%). The differences in method preference in these studies may reflect provider counseling including comfort with more invasive methods or differences in sub-populations and underlying goals of the patient. Contraception counseling should aim to be gender affirming, patient goal oriented, and limit provider bias ( A. Bonnington, et al., 2020 , J.L. Manzer, A.V. Bell, 2021 ). Specifically, for TGD AYA, it is important to determine a thorough surgical and menstrual history that will inform contraceptive needs. In addition, the clinician should understand the patient’s goals of contraception. This could include possible prevention of pregnancy (exposure to sperm and ability to become pregnant), reduction in gender dysphoria related to menses, achieving amenorrhea to avoid menstrual care in public restrooms, treatment for breakthrough bleeding on testosterone therapy, or for another patient desired reason. By assessing the patient’s goals, the clinician will be able to better counsel and provide patient-oriented options. It is important to assess medical history for any absolute or relative contraindications to contraceptive methods. The Centers for Disease Control and Prevention (CDC) Medical Eligibility Criteria (MEC) provides an overview of the impact of potential diseases on contraception choice ( K. Curtis, et al., 2016 ). It is also important to inquire about medical problems that could impact disease severity or increase the risk of side effects. For example in lupus, estrogen containing contraceptives are contraindicated if positive antiphospholipid testing is noted ( D.S. Reddy, 2017 , ACOG, 2020 ). Currently, there is no clear consensus on the effect of contraception on mental health diagnoses. Large datasets in the broader population have shown increased rates of depression and even suicidality ( C.W. Skovlund, et al., 2016 , S. Zettermark, et al., 2018 , M.E. Newcomb, et al., 2020 ). However, while TGD AYA are at higher risk of mental health disorders such as depression, anxiety, and suicidal ideation ( IOM, 2011 , Connolly, et al., 2016 ), this must also be balanced with the benefits of menstrual suppression and pregnancy prevention and should not be considered a barrier to desired contraceptive care. There are two major categories of contraceptives: (1) hormonal and (2) non-hormonal. To help facilitate shared decision making with TGD AYA patients and their clinicians we have summarized potentially relevant factors relating to contraception in Figure 1 . There are no absolute contraindications to any form of contraception for TGD AYA. Some TGD individuals have reported preferring non-hormonal forms of contraception as both estrogen and progestin are considered “female” hormones ( D. Boudreau, R. Mukerjee, 2019 ). In our experience, progesterone therapy is more often accepted especially given the availability of methods that have very low systemic hormone levels such as the hormonal intra-uterine device (IUD). While hormonal contraception with estrogen is often not prescribed given concern for utilizing a “feminizing” hormone and possible contribution to gender dysphoria, it is unlikely to have significant physical effects such as breast growth or reversal of masculining effects ( D. Boudreau, R. Mukerjee, 2019 , C. Krempasky, et al., 2020 ). A 2019 cross-sectional study (PRIDE study) notes younger participants (19–24 years old) and those who want to avoid estrogen therapy are more interested in over-the-counter progestin-only pill usage ( Grindlay, et al., 2024 ). Another consideration is a theoretical increased risk for VTE events in patients on testosterone compared to cisgender females, but there is no clear clinical data to support this speculation ( D. Boudreau, R. Mukerjee, 2019 , M. Oakes, et al., 2021 ). Hormonal contraception options can contain both estrogen and progestin or progestin only methods. These options include two steroid-based sex hormones, estrogen (most often ethinyl estradiol) and progestin (synthetic progesterone with many available types). The method of delivery includes a pill taken daily, a patch placed weekly, or a ring placed vaginally monthly. When the combined oral contraceptive pill was initially designed by John Rock in the 1950’s, it was given cyclically with seven days of a placebo which led to a progestin withdrawal bleed to mimic typical menses and improve acceptability. Skipping this hormone free interval or continuous use of the hormonal method can lead to fewer menstruating days annually and is often preferred by TGD youth ( A. Edelman, et al., 2005 ). In this approach, the method is continued until bothersome breakthrough bleeding occurs at which time the patient is counseled to skip the methods for 4 days to allow for a full withdrawal bleed. This strategy of extended cycling (allowing for withdrawal bleeding every 2–3 months) or continuous cycling (no withdrawal bleed) can be utilized for the patch and ring as well. These contraceptive methods include a variety of different options with varying routes of use, dosing, and types of progestin. There are progestin only daily pills (POPs including norethindrone or drospirenone), every three-month intramuscular injection (e.g., medroxyprogesterone acetate), arm implant (e.g., etonogestrel implant), or intrauterine device (e.g., levonorgestrel IUD). Pregnancy prevention efficacy varies, but overall progestin only methods are very effective with the progestin-only pill at 93% to the etonogestrel implant at 99.95% with typical use ( L.E. Britton, et al., 2020 ). These methods are associated with varying rates of breakthrough bleeding which can be bothersome to patients (implant ~25–40%, IUD, ~39% spotting first 3 months of insertion, see Figure 1 for amenorrhea rates) ( D. Mansour, et al., 2019 , L.Y. Maldonado, et al., 2020 ). In the above stated retrospective study of TGD AYA individuals, the amenorrhea rate at 1 year was 89% with the levonorgestrel IUD ( B. Schwartz et al., 2023 ). This amenorrhea rate did not differentiate between those on testosterone therapy. An additional retrospective study in TGD noted an amenorrhea rate of 50% for those with placement of IUD after breakthrough bleeding on testosterone therapy, but the sample size was limited ( Grimstad et al., 2024 ). Larger, prospective studies are needed to help better counsel patients about amenorrhea and breakthrough bleeding management. An additional consideration is that IUD insertion can be very uncomfortable both emotionally and physically (possibly secondary to gender dysphoria, genital atrophy secondary to testosterone therapy, or differences in sexual practices). For young never sexually active TGD individuals or those desiring more pain management, IUD insertion can be performed under sedation or anesthesia in the operating room. For those interested in office placement, the provider should discuss pain management modalities and utilize trauma informed care for all pelvic exams and procedures. For non-hormonal contraception, there are both reversible and irreversible options. These methods include as needed barrier methods such as external and internal condom, diaphragm, spermicide, and cervical cap. These methods are utilized at time of sexual encounter. Condoms are the only method that provide the additional benefit of preventing STI transmission. A copper IUD is also a non-permanent non-hormonal option with high efficacy but has a side effect profile of heavy menstrual bleeding and dysmenorrhea ( G. Farr, R Amayta, 1994 ). Some copper IUD data suggests that these intermenstrual side effects (bleeding and pain) do decrease over 12-month use ( D. Hubacher, et al., 2009 ). Sterilization or permanent contraception involves surgical intervention to damage or remove reproductive structures to prevent pregnancy. They are considered non-reversible and include bilateral tubal ligation or salpingectomy, hysterectomy, and/or bilateral oophorectomy. As these options may be an important part of a TGD person’s journey or necessary prior to other surgical interventions, they may be offered in patients who are of the age of majority and who desire this surgical intervention. We also would consider the involvement of a specialized gender mental health care provider when counseling or offering gender affirming surgical interventions to AYA (S.E. James, et al., 2015, C.A. Ferrando, 2024 ). There are also varying forms of emergency contraception (EC) or contraception that can be utilized after unprotected intercourse or exposure to sperm has taken place. TGD AYA can utilize hormonal options including the levonorgestrel IUD, oral levonorgestrel, or oral ulipristal acetate and there are no contraindications to these methods ( Salcedo, et al., 2023 ). Both the copper and levonorgestrel IUD is effective in preventing pregnancy if inserted within 5 days of intercourse ( Salcedo, et al., 2023 ). Oral levonorgestrel and ulipristal acetate work within 96 hours and 120 hours respectively after unprotected sex by preventing or delaying ovulation. There may be additional barriers to use of emergency contraception in TGD individuals such as access to a gender inclusive gynecologist within a short time frame of unprotected sex or fear or inability to access behind the counter medications given gender expression. Providers of TGD AYA who may have unprotected sex can consider discussing a prescription of oral EC prior to unprotected sex to help alleviate these barriers. Additionally, they can provide counseling and guidance about same day or next day delivery through a variety of different online prescribers ( Salcedo, et al., 2023 ). Any person who can become pregnant should be counseled regarding fertility goals. If they do not want to be pregnant, contraception counseling utilizing the CDC’s MEC criteria and a knowledge of gender affirming care is critical ( K.M. Curtis, et al., 2016 ). There are multiple studies showing that both patients and clinicians believe that TGD patients on testosterone who are amenorrheic are not able to become pregnant ( A. Gomez, et al., 2016 , L. Abern, K. Maguire, 2018 , A. Light, et al., 2018 , C. Krempasky, et al., 2020 ). Depending on data utilized, approximately 16–31% of TGD adults believe that testosterone is a form of contraception ( A. Light, et al., 2018 , C. Krempasky, et al., 2020 ). One small, mixed methods study of AFAB individuals who experienced pregnancy after transition (with a mean age of 25 years old) noted that patients on testosterone were less likely to report hormonal contraceptive use compared to those not on testosterone; however, exposure to sperm during contraception use was not clearly defined ( A.D. Light, 2014 ). That same study found that 20% of participants became pregnant while amenorrheic. While there is likely suppression of the hypothalamic pituitary ovarian axis with exogenous testosterone use, and testosterone leads to at least partial endometrial quiescence, one study demonstrates that up to one-third of TGD on testosterone ovulate ( J.D. Asseler, et al., 2024 ). Additionally, there is limited data looking at abortion in this population. However, a large, sampled survey of young TGD adults less than 30 years old found that among those who experienced a pregnancy, 21% had an abortion ( H. Moseson, et al., 2021 ). This underlines the continued importance of contraception counseling in this population. TGD AYA patients can become pregnant while amenorrheic and on testosterone therapy and there is a continued need to assess fertility goals within this population. Some patients and families opt to initiate a GnRH (gonadotrophin releasing hormone) agonist to stop the progression of puberty at Tanner stage 2 and prior to menarche. There is evidence that the gonadotropins are suppressed similarly in TGD AYA patients as to patients with precocious puberty ( J.D. Mejia-Otero, et al., 2021 ). There are reported cases of unintended pregnancy after administration of GnRH agonists for patients with infertility and endometriosis ( H. Wu, et al., 2021 ), thus it should not be considered a form of contraception. Furthermore, when there is a discussion of testosterone hormone therapy, it is important to reinitiate a conversation about sexual activity, pregnancy potential, fertility goals, and contraception use. Although a TGD AYA patient may request contraception, they may be interested in future fertility. The Endocrine Society Guidelines and WPATH both recommend that TGD individuals be counselled about the possible effects of gender affirming hormone therapy on future fertility. The contraceptive visit may be an ideal time to discuss family planning wishes, effects of gender affirming therapy, and possible fertility preservation options ( E. Coleman, A.E. Radix, et al., 2022 ). Unfortunately, there are no large, prospective studies assessing the long-term effect of testosterone use on ovarian reserve and reproductive potential. Smaller studies have confirmed that there is a resumption of menses after discontinuing testosterone therapy and there are also reports of patients becoming pregnant without resumption of menses ( A.D. Light, 2014 ). Several case series report successful ovulation induction in individuals who achieved menarche and subsequently were treated with testosterone. The effect of GnRH agonists followed by testosterone on fertility is unknown. There are a few case reports of successful ovarian stimulation success following GnRH agonists, but there is no published outcomes data for ovulation induction in those who received testosterone therapy following GnRH agonists ( A. Ghofranian, et al., 2023 , M. Slonim, et al., 2023 ). As clinicians, it is important to discuss future fertility interests and goals, limitations in current data, and assessment of pregnancy potential. When a patient expresses a desire for future fertility, they should be referred to a fertility specialist and offered fertility preservation options. As mentioned above, one reason that a TGD AYA may seek contraceptive care is to achieve amenorrhea, lighten menstrual bleeding, or minimize menstrual symptoms. This could be due to several different reasons such as primary dysmenorrhea, endometriosis, heavy menstrual bleeding, polycystic ovarian syndrome, or gender dysphoria. There is an association between chronic pelvic pain and initiation of testosterone therapy most notably in the first six months and perhaps secondary to uterine contractions or pelvic floor dysregulation ( S. Zwickl, et al., 2023 ). There is also a unique need or concern in this population to avoid heavy or regular menstrual bleeding due to considerations of harm or harassment about menstrual care in public restrooms ( J. Chrisler, et al., 2016 ). There are multiple studies suggesting that rates of amenorrhea in TGD persons on testosterone is high but variable (55–96% at 6 months dependent on the referenced study) ( A. Nakamura, et al., 2013 , S. Ahmad, et al., 2017 ). Furthermore, despite high rates of amenorrhea, there is also a high rate (25–27%) of breakthrough bleeding in these patients two years after initiation of therapy ( J. Defreyne, et al., 2020 , F. Grimstad, et al., 2021 ). A recent study in 2024 by Grimstad et al . reports amenorrhea rates for TGD on testosterone therapy and rates of amenorrhea after initiating varying options for menstrual suppression, ensuring compliance with testosterone therapy, changing testosterone formulation, and discontinuing current menstrual suppression method ( Grimstad, et al., 2024 ). Given this, it is important for clinicians caring for TGD AYA on testosterone therapy to discuss role of contraceptives in achieving amenorrhea or treating breakthrough bleeding ( J. Defreyne, et al., 2020 , F. Grimstad, et al., 2024 ). Testosterone is peripherally aromatized to estrogen and is often associated with anovulation and lack of progesterone, and thus, some have speculated that testosterone may be associated with endometrial hyperplasia over the long term ( M. Hawkins, et al., 2021 ). Androgen receptors on the endometrium play a key role in the late luteal phase and decidualization in the event of pregnancy ( I. Simitsidellis, et al., 2018 ). Data suggests that the endometrium remains active in 40–69% of patients on testosterone therapy despite often being amenorrheic ( H.P. Crissman, et al., 2021 , F. Grimstad, et al., 2021 , M. Hawkins, et al., 2021 ). Other studies dispute this finding and have noted that the endometrium is in fact inactive in those on testosterone therapy ( A.M. Perrone, et al., 2009 ). Hormonal contraception containing progesterone is known to protect against endometrial hyperplasia/cancer and may reassure the provider and patient of endometrial protection especially for those on long term testosterone use and are not planning hysterectomy ( L.K. Nees, et al., 2022 , S. Uccella, et al., 2022 ). Given this conflicting data and lack of long-term studies, there is no current recommendation for endometrial protection in patients who are on testosterone therapy.