Images illustrated by Leo Mateus. This article has been clinically reviewed by Haley Collins, NP.
Cisgender women aren’t the only ones who menstruate. Transgender men, nonbinary people, and other gender variant people can menstruate, too. Gender identities and bodies beyond these ones also can experience premenstrual syndrome (PMS) symptoms as well.
Gender affirming hormone therapy (GAHT), also referred to as hormone replacement therapy (HRT), can impact menstrual periods and cycles overall. People on testosterone GAHT/HRT may stop bleeding every month as a result of taking HRT. Additionally, those on estrogen GAHT/HRT (or anti-androgens such as progesterone) may experience PMS symptoms, despite not bleeding.
Read on for what you need to know when it comes to menstruation and transgender health.
What is menstruation?
For those who have uterus, menstruation is described as the monthly shedding of your uterine lining. This monthly cycle typically includes bleeding for anywhere from two to seven days.
Some may experience irregular periods with extreme cramping, bleeding for over a week, and other symptoms. Because of cultural stigma and misogyny within the medical industrial complex, those who bleed either a) don’t talk about their symptoms openly or b) are dismissed when they do share their symptoms. If either is true for you, know there are options for managing painful periods.
Those on testosterone GAHT might have other gender transition goals—such as deepening their voice and growing facial hair—but may also benefit from testosterone’s ability to manage painful PMS symptoms by stopping their periods entirely. If you’re a cis woman on testosterone HRT, testosterone can also help you manage painful periods.
Some people not on testosterone HRT, including cisgender women, might seek contraception to manage related pain. More specifically, progesterone contraceptive pill, nexplanon/birth control implant, non-hormonal IUD, or combined contraceptive methods to help reduce periods. Additionally, those who are already on testosterone can also choose from the mentioned options if they want to further manage painful periods. Know that anyone and everyone with a rough period can seek help managing their symptoms!
Having a period on testosterone HRT
Everyone experiences their hormone replacement therapy journey differently. Likewise, there is a general, loose timeline of anticipated physical effects you can anticipate on testosterone GAHT. Within your first year, you can expect your period to stop altogether. However, dosage will play a factor.
“Most people on average doses of testosterone should have a suppressed period within six months,” explains FOLX clinician and Nurse Practitioner, Haley Collins.
Since hormones impact every individual body differently, you may continue to bleed while on HRT, even after six months. FOLX members should check in with their clinician if stopping bleeding is a desired transition goal and it has yet to be reached. A potential solution could look like increasing your dosage or switching from gel to injections; however, your clinician will have the best recommendations suited for your health needs and transition goals.
Additionally, it’s important to note that cis women on testosterone HRT can also experience their period stopping.
HRT phantom periods
Others who have stopped bleeding monthly may experience HRT phantom periods on testosterone. Especially for those with more severe PMS symptoms, you may experience cramping, mood swings, acne, and more that go along with a typical bleeding menstrual period.
“If there is a history of heavy periods, fibroids, or frequent cycles, they may have a harder time suppressing their period,” explains Collins. “Some people may continue to experience PMS symptoms after their cycle has ceased. Particularly, if there is a history of polycystic ovary syndrome (PCOS), endometriosis, and/or premenstrual dysphoric disorder (PMDD), it seems to be more common.”
Because cyclic PMS symptoms can happen to anyone with or without ovaries, HRT phantom periods can also happen for those on estrogen GAHT.
“For those on estrogen, they may experience all of the typical PMS symptoms of a period: bloating, cramping, mood swings, chest tenderness just without the bleed,” adds Collins. “The assumption is these changes are caused by cyclic hormonal fluctuations; however, there are no medical studies on the subject.”
If you experience phantom periods or PMS symptoms, Collins recommends practicing self-compassion. Be kind to yourself and practice self-care. If menstrual symptoms cause gender dysphoria for you, we recommend you seek out mental health support from friends, family, and/or a therapist. If you need help finding a therapist, check out our guide on how to find a trans-competent therapist.
“You can treat your symptoms the same as anyone else,” Collins adds. “It is perfectly okay for anyone and everyone to take Midol for their cramps, do some meditation for their mood swings, and take a long bath to relax during this time.” Additionally, if you have menstruation-related cramps, you can also use a heating pad or hot water bottle over your abdominal area.
Fertility and menopause
“Being on testosterone can give you similar symptoms of menopause, like hot flashes, night sweats, and genital atrophy,” Collins explains. “This can especially happen post-hysterectomy.”
There are both hormonal and non-hormonal medications to treat menopausal symptoms associated with testosterone GAHT. If you suspect you are having menopausal symptoms, we recommend checking in with your FOLX clinician.
“Local topical estrogen can be given to help with genital atrophy, it is not absorbed systemically and is safe to prescribe alongside testosterone therapy,” Collins adds. “There are also non-hormonal medications often prescribed off-label to reduce hot flashes and night sweats.”
While you may experience menopausal symptoms on top of not bleeding, this does not necessarily mean that you have stopped ovulating. Testosterone isn’t birth control. If you’re sexually active with a partner (or partners) and having the types of sex where you can get pregnantand want to learn more about your contraception options, check out our library article, HRT and Birth Control. Those who want to learn more about family-building options can read our article, Queer and Transgender Fertility 101.
Endometrial hyperplasia and uterine cancer
If you experience Irregular bleeding, pay attention and make note of it. Irregular bleeding can look like bleeding after not having bled for an entire calendar year. While there can be several reasons for irregular bleeding, endometrial hyperplasia could be the culprit.
“Endometrial hyperplasia is basically a ‘buildup’ of the endometrial (uterine) lining. If left untreated, this could then lead to cancer. Testosterone administration may lead to unopposed estrogen, from aromatization of testosterone to estrogen. This creates a theoretical risk of endometrial hyperplasia. While there have not been many studies on this possibility, anytime someone has unexplained bleeding (whether on hormone therapy or not) after they have been without a period for over a year it is worth working up. Sometimes this workup can include an ultrasound, but not always. There is no current recommended prevention for endometrial hyperplasia.”
Based on current evidence, there is no increased risk of endometrial cancer in people using average doses T HRT compared to cis women.
If you experience irregular bleeding, haven’t changed your dosage or route of delivery (such as from injectables to gel or vice versa), and haven’t forgotten to take medication for significant time, please contact your FOLX clinician. To further investigate your symptoms, a clinician may want to get a blood test to check your testosterone levels. They may also want to monitor bleeding/symptoms (such as noting the difference spotting versus heavy bleed) and may recommend a further evaluation by an OBGYN.
Our team of LGBTQ+ specialized clinicians are here to support you. Existing FOLX members are encouraged to reach out to their clinician in their Athena PatientPortal if they’re experiencing difficulty with symptoms or side effects of their HRT. For those looking for more healthcare support, you can schedule a virtual care visit with a FOLX clinician today.