Gender Diversity and Perimenopause and Menopause

I had the pleasure of sitting down and recording a podcast with the wonderful Dr Peter Hammond – the endocrinology lead for the Leeds Regional Gender Identity Service in the UK.

Connecting over the lack of information and support available to transmasculine and non-binary persons experiencing symptoms of perimenopause and menopause, Dr Hammond and I wanted to produce a podcast episode that could be used as a signposting resource for those seeking care, as well as those wanting to learn more about supporting gender diverse patients navigating this stage of life.

Dr Hammond spends time explaining the changing landscape of Gender Affirming Care (GAC) and pays attention to the importance of recognizing non-binary and transmasculine persons as an often excluded group from conversations about perimenopause and menopause. We highlight how perimenopause and menopause for gender diverse people can be a dysphoric and difficult experience, emphasizing the importance of learning more about how best to offer support.

If you enjoy this podcast and the format, be sure to let us know so we are able to produce more resources like this! Spotlighting and uplifting the experiences of transmasculine and non-binary persons navigating perimenopause and menopause is so important. This cohort remains underserved and often marginalized in conversations about perimenopause and menopause.

As we touch on in our conversation the support that is currently needed within gender diverse communities is not labor intensive. It is a willingness from healthcare providers to listen, learn and signpost. Equally, it is reminding ourselves that perimenopause and menopause affects over 50% of the population. So, help be a hormone ally and share this with professionals that may interested in upskilling their knowledge of caring for this cohort, or people you know that may be searching for support as part of their GAC.

Happy podcasting and happy pride everyone.

Lauren: We often hear that over 50% of the population will experience symptoms of the perimenopause and menopause. But what does this statistic really mean? In essence, it suggests that the significant hormonal changes that occur during the perimenopause and menopause, can affect a wider community than some of us may realize. And, it is important that we remain aware of this when thinking about who may suffer with symptoms associated with the perimenopause and menopause. In particular, is the importance of recognizing and accounting for the experiences of the trans and non binary community when discussing the perimenopause and menopause.

Joining me on the podcast today to help explore this topic in greater detail is Dr Peter Hammond. Dr Hammond is a consultant endocrinologist and is the endocrinology lead for the Leeds Regional Gender Identity Service and has been in post since 2007. He’s also on the gender recognition panel’s list of gender specialists. Hi, Peter. Thank you so much for agreeing to take part in the podcast today; I wondered if we could just start with you introducing yourself to those listening and telling us a little bit more about the work that you do.

Peter: Yes. Thanks, Lauren. Well, thank you very much for inviting me. So I’m an endocrinologist in Harrogate in North Yorkshire. I’ve been a consultant since 1996, having done most of my training in London, I started working in the gender service in Leeds in around 2007, and I’ve been the endocrinology lead for that service ever since.

The service has grown hugely. So in terms of the numbers coming through our service, it’s increased almost tenfold over that period of time, sadly, with long waiting lists associated with that. So I think looking back 15 years or so, we saw mostly people with a binary gender identity. But now increasingly, we see people with non binary gender identities. And I think you’re right to have highlighted those as a group who may have particular issues when it comes to the menopause.

Lauren: Yeah. And one of the things I think it’s important for us to clarify really to those listening is that not every trans or non binary person will take hormones and that a person can obviously change their gender expression without medical intervention. But for those that do take hormones, it will usually involve using estrogen along with testosterone blockers to feminize and testosterone along with estrogen blockers to masculinize.

And in the context of this and thinking about those affected by perimenopausal and menopausal symptoms that are trans, this conversation would primarily implicate trans men. Is that correct?

Peter: Yes. So I think, obviously, trans men who don’t have surgery will still have intact ovaries. But if they have lower surgery so when they get to menopausal age, if they’re on adequate levels of testosterone, then that would suppress the function of the ovaries and they wouldn’t be expected to have menopausal symptoms then they potentially could go through or experience menopausal symptoms if they’re not treated adequately with testosterone. So they’re the group who would have gone through the menopause where the hormone treatment is important to that. Whereas with trans females, they wouldn’t be expected to experience menopausal symptoms, but we have to be conscious of the fact that their hormone requirements may change with age. So the feminizing hormones that they require may the doses, the levels that you’re wanting to try and achieve with feminizing hormones aren’t perhaps the same as they would be for a younger person.

Lauren: Yeah. And I wonder if you could tell us a little bit more on that as to why or how perimenopausal or menopausal symptoms could arise and impact transmasc persons and what effects this can have for the individual when that occurs.

Peter: So, really, with a transmasculine individual, if they are wanting standard testosterone treatment, you mentioned possibly with a blocker to down regulate the ovaries. Although the reality is that the vast majority, testosterone alone completely suppresses ovarian function. So usually, menstruation stops with testosterone treatment for a a trans man usually within 6 months.

So 90% of the time, they would stop having cycles within 6 months. And if you then maintain that testosterone treatment and they continue to have masculine testosterone levels, so we would be aiming for depending on how they have the testosterone treatment levels around the middle of the reference range, then ovarian function will remain suppressed, and they wouldn’t be expected to have menopausal symptoms because we would continue testosterone treatment in effect lifelong. I mean, we certainly wouldn’t be thinking about reducing testosterone levels or adjusting the treatment until someone was perhaps into their seventies or beyond. And by that stage, they’ll be being looked after in primary care anyway. I think where people may have issues is particularly we see people who either they get the masculinizing effects of testosterone treatment early on, which is what you’d expect.

So the masculinizing changes from testosterone treatment occur within the first 3 to 5 years of testosterone treatment and the level then levels off. And some people who are transmasculine, but particularly people who have a non binary identity, may not particularly want some of those masculinizing effects. So, particularly, I think most people don’t want scalp hair recession. And I think that’s true whether they’re, you know, have a binary or a non binary identity. Whereas some people, again, more so with a non binary identity, might not want a lot of facial and body hair growth.

They may want things like voice deepening and perhaps some androgenization of their body perhaps, but they don’t want more effects than that. So what some people ought to do is either maintain their changes with low dose testosterone or indeed come off testosterone completely. So they might have 5 to 10 years of testosterone treatment and then stop. One of the trade offs for doing that is obviously, particularly if they come off, but even if they’re on low dose, the variant function may restart, and they may end up having cycles again.

Lauren: Mhmm.

Peter: And so sometimes they may choose to either combine that with a blocker and have a low dose of testosterone, and that keeps any potential menopausal symptoms related to blocker treatment at bay, or they may come off treatment completely and accept that they’ll then have cycles and will have some estrogenic activity, but will continue to experience some of those masculinized effects, particularly around voice deepening that they’d experienced before. So those people who are either transmasculine or or have a  nonbinary transmasculine identity and who are then either on low dose testosterone or have stopped treatment completely will potentially go through the menopause at a later date.

Lauren: Yeah. And I wondered with that, obviously, something you’ve talked about is sort of use of hormones either throughout the life time or for a shorter period of time. And I know that something we discussed prior to this recording is how, you know, if you’re using hormones, you will have regular health checks to ensure that levels are stable.

But there are factors that can affect the regularity of these health checks. And, I mean, you mentioned the long waiting lists. And this would mean that hormone levels,  I imagine, are not necessarily monitored as well and, in turn, can actually lead to a destabilization of hormone levels and therefore kind of the recurrence of perimenopausal and menopausal symptoms within that?

Peter: Yeah. The nature of the way that the specialist service is commissioned in England is that it’s a time limited service.

So the individual will go into the service. They will have their assessment. They’ll get their diagnosis of a gender identity disorder. They will have the treatments appropriate to that disorder and any treatments that may help them change physically. So that may be things like laser hair removal, or surgery. For both trans men and trans women. But once they’ve essentially completed that pathway, they’re established on hormone treatment, they’ve had any additional treatments that they might wish to have, they’re then discharged from that service. So the service user will usually remain within the service for, say, somewhere between 3, perhaps 7 years, and then they’ll be discharged into primary care with a a long term package if you like. You know, this is we will send them out with advice to the GPs about how to manage it, but then it’s very much down to the individual.

Perhaps they might move around. And, of course, one of the things that we’re very conscious of and that we we want to support them with is to essentially change that identity so that their health record is changed and they start with the new health record. And so if you move general practice, to all intents and purposes, you are your new gender. And it might be we’ve certainly had situations where hormone treatment is being stopped or overlooked or not monitored. So there are potentially a lot of things that can happen.

And as we see people coming through our services at younger age, I mean, again, I mentioned the, perhaps, the change in identity. We see more people with non binary than we used to, but also the age at which people seek help from the regional GEM Services has changed a lot. You know, 10 or 15 years ago, we saw a lot of people in middle age. Now we see far more younger people, and I think that’s obviously a really good thing for those people. But it does mean that they’re in our service at a much younger age and being discharged with a much longer length of follow-up so that.

You know, potential for going through the menopause for those trans men is 20 odd years after they’ve been discharged from our service. And you’re quite right to flag up the fact that if the monitoring that they get is not adequate and they’re not being maintained with sufficient testosterone, then they could potentially go through a menopause as anyone else would.

Lauren: And I suppose in the context of transmasc or non binary people navigating care, this is sort of made challenging in a different way, the detrimental impact menopausal symptoms can have over your sense of identity. People often describe a sense of losing sight of who they are. It must resurface for some very extreme dysphoric feelings. And I wondered if you might be able to talk a little bit about that and what the impact of that may be.

Peter: I think you’re absolutely right. I mean, for somebody who’s got a trans masculine identity to be experiencing symptoms which are clearly related to being female. I think that is really distressing for them to experience those. And I think, you know, those symptoms are distressing potentially for anybody, but I think particularly distressing in that context.

And it’s also a challenge then because they have to make a decision about how they want to manage those. So I think if you’ve got a binary transmasculine identity and it’s just that you’ve been getting inadequate testosterone exposure, then hopefully, that’s fairly easy to address that you can be given increased levels of testosterone through whatever route of administration you’re you’re getting your testosterone. Hopefully, that should address those symptoms you’ve been experiencing. But if you’ve got a non binary transmasculine identity and you don’t really want to increase your exposure to testosterone, but you almost certainly don’t want equally to have estrogen to treat those symptoms. I think that is very challenging. How do you go about managing those symptoms in a way that fits with your identity and with your hormone requirements.

Lauren: Absolutely. You currently prescribe what’s termed bridging hormones to patients, and I feel like this is we’re hearing a lot more about bridging hormones. And I wondered if you could talk us through a little bit about what this term actually means and why it’s important as well.

Peter: So I think, as I mentioned earlier, the waiting list for the regional gender services across the country is that I mean, they they are long waiting lists. So ours is around 4 years. They range from probably about 3 to 6 years. COVID has had a big impact on those waiting lists. There are some pilot schemes, pilot clinics around the country based more in primary care than in a secondary care setting, which are hopefully going to impact on those waiting lists.

And there are some good models out there, so, hopefully, things should improve. But for somebody who’s got a gender identity disorder, obviously, very distressing, you know, I think can cause significant mental health problems and for some of them can make them suicidal. The the need to access hormone treatment in order to alleviate the dysphoria and improve their mental health is very great. And so what a lot of them will be looking for is to be able to access hormone treatment even though they haven’t had the formal assessment within a gender service. And so there is this concept of bridging hormone prescriptions, which really is a concept of a GP who has referred someone into a regional gender service, they’re on the waiting list being able to prescribe hormones until such time as they’re formally assessed and given a prescription through the regional service.

What I try to do is provide support to general practitioners prepared to do that. So some general practitioners are happy to do that, and they’ll do that without any support. But others would not want to do that, but are prepared to do that with support from an endocrinologist. So that’s really what I’m there to provide. And, you know, I think it is for a lot of people, that’s a crucial way of helping them to manage that phase before they are seen in the regional gender service.

Lauren: And so that would be sort of you’d start on hormone treatment before seeing an identity specialist. And I suppose as you’re saying with the waits of 3 to 6 years, that makes complete sense for people not to have to suffer for that period of time.

Peter: Yeah. And I think, to me, it’s important that we provide that in a proper clinical setting. You know, there there’s a danger that people will go off otherwise and purchase them online or go to private providers that perhaps don’t have the clinical expertise and the governance structures that we have in place.

So I think it’s important that it’s done within the right framework, really. So, you know, it’s just meeting an unmet need, which hopefully will be a temporary thing until such time as, you know, we have a a service in this country that allows people to be seen in a more timely way.

Lauren: Yeah. Absolutely. And that was actually going to be my follow on question to that, really, to mention that, obviously, as wait times are as long as they are to see a gender identity specialist. I wondered what your thoughts are, and I imagine that many trans persons and non binary persons are perhaps privately seeking treatment or taking measures into their own hands, and what really the dangers would be involved in this, and what we can do within the wider medical community to support in the interim period while a person is awaiting a consultation with a gender specialist. And I guess, really, at the other part of that would be if there was anybody listening that wanted to learn more about bridging hormones and how to provide that and what they can do, where they could go really to learn.

Peter: So the websites for the regional services all have information about hormone prescribing. So, for example, on our website, we have for the Leeds gender service, there’s guidance for general practitioners on hormone prescribing, which talks about initiation, monitoring hormone titration.

So there is information there. I know that other sites, the Exeter service, Newcastle service all have similar information there. I think the crucial thing that you get through an NHS service or private providers who also work in NHS clinics is that, you know, what you’re getting is safe treatment, so safe hormone treatment. I think the issue with private providers or getting it online is that you get nonstandard treatment. Sometimes you don’t know where the treatment’s coming from.

So with some of the online suppliers, you’re never quite sure what you’re getting. I was talking to someone the other day who has been giving themselves injectable estrogen. Now we don’t use injectable estrogen in the UK. It’s used in the US, and it is a recognized way of giving estrogen. But the dosing is more complex, more difficult to monitor, and this person was actually obtaining online an unlabelled vial.

So just a clear vial with, apparently, with estrogen in it, but not really knowing what the concentration of the estrogen was or you know, so not really sure exactly what they were giving, and are monitoring with very high estrogen levels. So I think that’s the difficulty. And there are some providers out there who use treatments that are perhaps not standard treatments. You mentioned progesterone earlier. I wouldn’t say that’s a nonstandard treatment, but isn’t used in every by every endocrinologist working in the field, and there is controversy about progesterone.

There are some of the testosterone blockers. So some of the tablets they’re used for testosterone blockage. Again, it’s controversial whether some of them should or shouldn’t be used. So I think it’s those kind of issues that if you’re accessing the treatment from nonstandard private prescribers or just, you know, buying it off the internet, what are you actually getting? And is it a standard treatment, or is it something a bit rogue if you like?

Lauren: Yeah. Absolutely. And I suppose in line with that and the conversation that we’ve had about the possibility of providing bridging hormones, I suppose it would be really encouraging people to continue to talk to their general practitioner even if they are waiting to see a specialist about their distress as opposed to seeking hormones, you know, online or elsewhere.

Peter: Yeah. I think that’s absolutely right. I mean, it’s interesting that the GMC provide guidance for GPs on bridging hormone prescriptions, and that’s very much the context that they offer that advice about what GP should do. But this is about harm reduction strategy. Yes. That by having such a long wait to get a diagnosis and access hormone treatment, that is potentially harmful to that individual, particularly, obviously, in terms of their mental health. So as part of a harm reduction strategy, that’s where the GP comes into that and the potential for offering a bridging hormone prescription.

Lauren: In terms of, you know, health care professionals that are coming into contact with, you know, with requests for support and with requests, really, to provide information around any reoccurrence of symptoms around perimenopause or menopause. Where do you think people could go to gain access about this information? Because I found it interesting, you know, in in preparation for the podcast. I’ve just felt there are very limited resources talking about this. So I suppose it would be any general points that you have to bear in mind and then also, yeah, where people might be able to go to access that support.

Peter: I think you’re absolutely right. I mean, I think that is a challenge. I think you can contact the gender services.

The standard response I mean, certainly, our standard response used to be, I’m sorry. This person’s been discharged from the service. You know, they’re well beyond that 12 months after completing their transition, and we can’t give advice. I think we’ve recognized that there is a need for advice. So even if the gender service itself can’t give advice, it might be able to direct you to somebody who can.

I think the challenge is that I think the people who should be doing that are your local endocrinologists. So I think the endocrinologist, you know, there’ll be 1 in every hospital around the country. In an ideal world, they would be giving that advice, but I think it’s fair to say that a lot of my endocrinology colleagues don’t feel comfortable giving advice for trans individuals and their hormone treatment. And so what I often find is that I’m getting people referred into my general endocrinology clinic in Harrogate rather than through the gender servicing leads from all around the country because there isn’t that support out there. So it is difficult, I think, to know quite what the best advice to give.

Again, it’s one of those things that I think we are actively trying to improve that situation. We now have gender endocrinology as part of the competencies that our trainees are supposed to gain so that once they get to consultant level, that they will have some knowledge of gender endocrinology, and then they should be able to give that advice and support. So I’m hoping that over the next few years, that situation will change. But at the moment, the best bet is to try and find an endocrinologist who has got an interest and will give that advice. And for yourself, if you were coming into contact with transmasc patients or non binary patients who were sort of experiencing this resurgence of perimenopausal and menopausal symptoms, what would your course of action be?

What would your treatment process, I guess, look like if this was an individual that had either previously transitioned sometime before or had, as you said, only been using hormones to affect some masculine changes, but not full transition? I think it’s very much I mean, as I think managing the menopause is generally, I think it’s individualizing the treatment. I think it’s assessing what the symptoms are that that person’s getting and how best to manage that, ideally, with hormones. So, ideally, with either adjusting testosterone treatment to alleviate symptoms or in a non binary individual who’s perhaps either on a low dose of testosterone or stopped it completely, Can you get some kind of balance between testosterone and estrogen that does allow you to do that? I I saw someone a few weeks ago who was in exactly that situation where we were trying to balance a dose of estrogen gel, a dose of testosterone gel to give them that symptom relief from those deficiency symptoms whilst at the same time, they didn’t want too much testosterone.

So I think it is very much individualizing the treatment to that individual. And, obviously, where perhaps hormone treatment isn’t well, we can’t achieve what they want with hormone treatment. Are there adjunctive treatments where you can use to alleviate the particular symptoms that they’re getting?

Lauren: And, I mean, I think there’s something fascinating in that as well that I feel the immediate course of action that most people would think is just increase the testosterone as opposed to actually going, this is a really complex balancing act of finding out how we can allow these hormones to exist in conversation and help one another as well.

Peter: Yeah. Absolutely. And, I mean, probably for most people, it will be actually straightforward and a question of increasing testosterone levels by altering, you know, injection frequency or gel dose or whatever it is. But, yes, there will be a proportion of people in that scenario where that isn’t the right answer, and it’s more I liked your your way of describing that, the conversation between the different hormones that you’re trying to get that balance right.

Lauren: Yeah. Absolutely. And I suppose really just emphasizing for anybody listening that may be experiencing that resurgence of symptoms, that it is important to go and, you know, talk to your practitioner, your primary practitioner about that because I think there can also be and I thought it was interesting what you were saying about with identity itself. If your identity has been changed, it may also feel difficult to go and have that conversation and almost have to identify as trans as opposed to just being who you are in that moment. Yeah.

Peter: Yes. And I think you highlight something else that’s quite interesting there that I think one of the reasons that we didn’t see a lot of people presenting as non binary, in fact, very rarely, 15 years ago was that the way that gender identity was constructed from a health care point of view was very much a binary gender identity. And I I know that we had people who accessed our services 15, 20 years ago who now would see themselves as nonbinary.

But in those days, in order to access hormone treatment and surgery, were expected to present with a binary gender identity. And so there may well be people who, back then, presented with a binary gender identity who now actually see themselves as having a non binary identity. And I I’ve seen some of those in my general endocrinology clinic as I say referred from far and wide, who have changed that perception of their identity. So they no longer want either they don’t want testosterone or they don’t want, you know, as much testosterone. And so there will be people who potentially are coming to that view of their own identity that it has evolved over time and therefore coming into the age at which they might get menopausal symptoms, maybe looking at a different hormone profile for themselves, which will alter their identity, how this conversation is ongoing and so important to be had because we are seeing those changes, as you say, that even 15 years ago, even the category of non binary was not even really, you know, involved in conversation.

Lauren: Yes. Absolutely. Yeah. I think, sadly, that’s all we’ve got time to talk about today, Peter, and I want to thank you for what’s been a truly fascinating conversation for me, and I I really appreciate the time. I tend to end these podcasts with just really asking our guests if they have any take home messages they’d like to share with those listening around the topic that we’ve discussed today or just anything that you’d like to emphasize.

Peter: I think the thing that I would emphasize is that I think our discussion today about menopausal symptoms in trans individuals just highlights the fact that we do need to be thinking about longer term health issues for trans individuals that, as I say, increasingly now, they’re within our services at relatively young age and then discharged to primary care for that long term follow-up. And it’s very important, a, that that long term follow-up is robust, that they do get annual checks of hormone levels and treatment adjusted if needed, but also that the primary care practitioners are conscious of their needs around things that happen to us in later life. So I I think that’d be my take home message.

Lauren: Yeah. And, I mean, I think it’s been fascinating for me as well to learn more about bridging hormones and for any, you know, GPs that are listening to know that it is possible for you to provide that and there is a support available if that’s something that, you know, you’d be interested in learning more about that it clearly, you know, with waiting lists of 3 to 6 years shows that that’s a a real need.

Peter: And I think, yes, just following on from that that we need to provide that education and support for primary care. So if there are people who want that kind of information or us to come out and talk to them, then then we’d be very, very happy to do that.

Lauren: Absolutely. Well, that’s great. Thank you so much for joining me, Peter, and I look forward to talking to you again soon.

Peter: Pleasure. Thank you, Lauren