It’s not hard to be a medical expert – just answer ‘we need more research’ to any question and you’ll be correct 90% of the time.
This is especially true of conditions that affect people who aren’t young white cis men. This demographic has traditionally been the focus of research for the sake of safety, simplicity, and sexism, but it means that medicine has a lot of catching up to do when it comes to the rest of us.
We know that a lot of diseases and medications affect men and women differently. But what happens when a person goes through a gender transition? How does that affect a person’s experience of pre-existing conditions, or risk of developing them? How do the risks change when your chromosomes say one thing but your hormones, body composition, biochemistry, and everyday experience say another?
What does HRT do to you biochemically?
Trans people are like ducks – they’re cute, they like bread, and they have a lot going on beneath the surface. While it can take years to see external changes after starting HRT, internal changes happen much faster.
“We compared the protein profile in trans women – more than 5000 blood proteins – to the UK Bio Bank, [which has a database of] more than 50,000 cisgender women. The blood protein profile of trans women shifted after only 6 months [after taking hormonal replacement therapy] to a position more associated with cis women” says Ada Cheung, award-winning endocrinologist at Austin Health and a NHMRC & Dame Kate Campbell Research Fellow at The University of Melbourne.
Blood proteins are busy workers that perform a huge range of tasks in the body, from ferrying hormones and vitamins around, to helping out with immune responses, coagulating blood and regulating genes. It’s why plasma donation (which contains blood proteins) is just as important as blood donation.
This means that while trans women might still appear duck-like on the outside, they’re rapidly transforming into swans from the inside. And these changes don’t just affect blood proteins, but also muscle mass and strength, amount and distribution of fat tissue, libido, metabolism, and the brain.
One trans woman I spoke to said that a few days after starting HRT, her emotions made sense for the first time. Another said that living with their libido before HRT was like living with an annoying stranger.
But with all these molecular changes bubbling away, how does this interact with pre-existing conditions?
PMOS and Endometriosis
“There’s not a lot of research in this space” confirms Ada, “[but] PCOS [now renamed PMOS] is really common. Maybe about 10% in the general population.”
“People with PCOS may have irregular periods. I find that most people who start testosterone don’t want periods [at all]. They want menstrual suppression.”
“There’s also a higher risk of insulin resistance and cardiometabolic risk with PCOS so that needs consideration, but we don’t think testosterone exacerbates that. It will need proactive monitoring, but it’s something we’d monitor in everyone anyway.”
PMOS affects hormones and can cause masculine facial and body hair growth, and fewer, irregular periods. Many transmasc people want these effects to happen anyway, so hormone replacement therapy with testosterone just boosts what’s already happening.
In terms of endometriosis, Ada is similarly sanguine.
“[Testosterone] tends to make endometriosis better. Pain is one of the most common symptoms of endometriosis, typically related to the menstrual cycle. There’s not a lot of research in this space, but based on first principles if testosterone is causing menstrual suppression, it should make endometriosis better.”
Because endo causes awful pain during periods, and testosterone stops your periods, testosterone should be pretty helpful. And of course if trans men or transmasc nonbinary people get a hysterectomy, either as a gender affirming surgery in itself or in preparation for genital surgery, an experienced gynaecological surgeon will remove the endometriosis tissue as well.
Do trans people go through menopause?
“It all depends on whether someone is using gender affirming hormone therapy,” says Ada.
“If someone who’s gender diverse is not using hormone therapy, then they will [physically] experience menopause similar to cisgender people. However, if people are on gender affirming hormonal therapy, then it’s very different. Because essentially they’re on HRT already.”
“The type of estrogen we use for gender affirming hormone therapy are the same types of estrogen we use for menopausal hormone therapy. Exactly the same,” explains Ada – the only difference is the dose.
“For people recorded male at birth who are using estradiol-based hormone therapy, typically menopause doesn’t occur because they continue the same dose [throughout their 50s]. There’s no need or evidence to reduce estrogen doses in later life.”
However, menopause tends to happen when you get older, and it’s the getting older part that doctors worry about.
“Generally we would recommend transdermal [gel] options of estadiol instead of oral [pills] in older trans people, as oral tends to increase thrombotic [blood clotting] risk. We would generally do that for all people taking estrogen as they age.”
“Osteoporosis is something we worry about at menopause, but that is largely related to the drop in estrogen that happens to cisgender women. If [trans people] have adequate estrogen levels, we would give the usual recommendations to optimise bone health, like making sure people are exercising and not smoking and that their vitamin D and calcium levels are adequate.”
“If they’ve had periods of time when they haven’t had adequate estrogen replacement, we’d consider further evaluating their bone health at that point.”
Even after everything trans people have gone through, we still can’t escape a fundamental biological truth – exercise and a healthy diet are good for you.
For trans men and trans mascs, menopause is a little more complicated – it it happens at all.
“For people who are taking testosterone, hormone therapy will lead to menstrual suppression, and so it can be difficult to tell when menopause occurs,” says Ada.
It’s even harder because people taking testosterone can experience similar symptoms to menopause at any time during their treatment – things like genital dryness, hairiness, or aches and pains.
Those symptoms in menopause are caused by the sudden decrease in estrogen as the ovaries wind down, while the same symptoms in trans people are caused by the sudden increase in testosterone. It’s the dramatic change, rather than the specific hormones or levels of hormones, that lead to these effects. This means that if people take testosterone consistently throughout their 40s and 50s, any menopause symptoms will be suppressed or masked.
“[People taking testosterone] only have a small drop in their estrogen levels [when they start HRT],” says Ada. “If they have ovaries, their ovaries will still convert some of that testosterone to estradiol. That’s why they don’t have a big drop in estrogen. The data shows that their bones are protected because they’ve got adequate amounts of hormones.”
Do trans men go balder faster than cis men?
Internet rumour has it that since baldness is caused by the X chromosome, and trans masculine people generally have two X chromosomes, they get super-powered baldness.
“I hear this a lot,” says Ada. “Baldness in transmen is very common, but it’s not because they have two X chromosomes. We don’t know why. We don’t [even] know if it’s more common [in trans masculine people] than in cis men.”
However, this is one area in which research has been done. In fact, Ada’s team have just completed a randomised, controlled trial into minoxidil, a hair loss medication.
They found the participants who had been taking minoxidil grew more hair, felt happier with their hair, and didn’t get any serious side effects.
“There was previously almost no good evidence to guide hair loss treatment for trans people on testosterone. Now there is,” says Ada.
“These findings can help doctors here and overseas offer minoxidil with more confidence, and they give the trans community solid information instead of guesswork.
Her team’s next project is to find out what happens when trans people use one of the most common anti-baldness medications, finesteride, a treatment that works by blocking some hormonal actions.
“We want to do some further research in that space. One of the key treatments of baldness in cisgender men is 5-alpha-reductase inhibitors [finesteride], which prevent the conversion of testosterone into dihydrotestosterone. We don’t know the effect of giving that testosterone blocker [to trans people who are taking testosterone].”
Dihydrotestosterone (DHT) has a role in body hair growth and head hair loss, the onset of puberty, and is thought to influence penis growth, so it’s a bit of a mystery what happens when an adult person taking testosterone also takes a DHT blocker.
Does HRT cause cancer?
Ada is very sure about this one.
“Based on limited research, there is no evidence that gender affirming hormone therapy increases risks of any cancers.”
“Screening should be as per the general population, depending on what organs you have. But screening uptake needs to be targeted to ensure that trans people take up the screening [at the same rate] like anyone else”
Trans people may not get more cancer or different types of cancer than cis people, but they can still miss out on care. Things like the gender dysphoria caused by a pap smear, or stigma experienced when going for a breast screen, can make it harder to access services.
The most important part of trans people’s healthcare
The most important thing to keep in mind about trans people and healthcare is that trans people are people and deserve healthcare.
“Gender diversity is just a normal part of human variation. Trans people are people and need to be accepted – and whatever happens with their hormone therapy is an issue for individuals and their clinicians,” says Ada.
Like literally every other part of medicine, HRT and surgery have their benefits and their detriments. That’s why Ada emphasises that decisions should only be made by individuals in the context of their own medical and life history, with help from their treating doctor.
“Treatment needs to be individual,” she stresses.
“If you’ve got health conditions, you need to have a chat with your treating doctor. The main thing is taking an interest in your health, having a proactive approach, and engaging with a GP who you trust.”
