After working as an obstetrician-gynecologist for 10 years, Marcy Bowers thought she understood menopause. Every time she saw a patient in her 40s or her 50s, she knew to ask about things like hot flashes, vaginal dryness, mood swings, and memory problems. And no matter what a patient’s concerns were, Bowers almost always ended up prescribing the same thing. “Our answer has always been estrogen,” she told me.
Then, in the mid-2000s, Bowers took over a gender-affirming surgery clinic in Colorado. In her new role, she began her consultations by asking each patient what they wanted from their bodies. This was a question she had never been trained to ask menopausal women. Over time, she became more comfortable bringing up difficult topics such as her pleasure, desire, and sexuality, and she began to prescribe testosterone as well as estrogen. That’s when she realized that menopausal women were in short supply.
Menopause is a hormonal change throughout the body that affects nearly every organ, from the skin to the bones to the brain. The same can be said about gender reassignment. Gender change, like menopause, is often Referenced Doctors and transgender patients refer to the roller coaster of physical and emotional changes caused by dramatic changes in hormones as “second adolescence.” But only recently has medicine begun to connect the dots. In recent years, some doctors who typically treat transgender patients (urologists, gender-affirming surgeons, sexual medicine specialists) have shifted to treating menopause, bringing with them a new set of tools. .
“In many ways, transgender care is light years ahead of women’s care,” Kelly Casperson, a urologist and board-certified menopause specialist in Washington state, told me. Health care providers who do both are knowledgeable about hormonal effects, attuned to concerns about sexual function, and empathetic to people whose symptoms have been ignored by health care providers. If the goal of menopause care is not just to help women survive, but to enable them to live their fullest lives, health care providers have been working in a field that has been doing just that for decades. It would be good to borrow some insights from.
American women have had a rocky relationship with estrogen. In the 1960s, the following books were published: feminine foreverThis book, written by gynecologist Robert A. Wilson, describes estrogen as a magical substance that can make women attractive and sexually available again, making menopause “much better”. It has said. (new york times It was later reported that Wilson was receiving compensation from the manufacturer of Premarin, the most popular estrogen treatment at the time. ) His claims then switched to his lifelong health. By 1992, Premarin was the most commonly prescribed drug in the United States. By the end of the decade, 15 million women They were receiving estrogen therapy with or without progesterone to treat menopausal symptoms.
Then, in 2002, a large clinical trial concluded that oral estrogen and progesterone therapy was associated with an increased risk of stroke, heart disease, and breast cancer. The study had incomplete safety measures, focused on older women rather than newly menopausal women, and tested only one type of estrogen. However, oral estrogen prescriptions are still declining sharply, from nearly a quarter of women over 40 to around 40 women. 5 percent. Despite this blow to the hormone’s reputation, evidence continues to mount that oral estrogen can help prevent bone loss and treat hot flashes and night sweats, but estrogen may increase the risk of: There is. stroke For women over 60 years old.Topical estrogen helps address the genitals symptomsvaginal dryness, inflammation, tissue thinning, and even urinary problems such as chronic urinary tract infections and incontinence.
However, estrogen alone cannot address all menopausal symptoms. Part of the reason is that estrogen isn’t the only hormone that’s deficient during menopause. So is testosterone. Despite the lack of researchers, high quality research Regarding the role of testosterone in women over 65, we know that in premenopausal women, testosterone plays a role in bone density, heart health, metabolism, cognition, and ovarian and bladder function. 2022 review They conclude that “testosterone is an essential hormone in maintaining sexual health and function in postmenopausal women.”
But for decades, testosterone has been largely ignored in standard menopause care. Part of the reason is regulation. Estrogen has been FDA-approved for menopause since 1941, but the FDA has never given the green light for testosterone treatment for women, largely due to a lack of research. This means that doctors must be knowledgeable enough about hormones to prescribe them off-label. Also, unlike estrogen, testosterone is a Schedule III controlled substance, which means more red tape. Some of Casperson’s female patients have had their testosterone prescriptions withheld by pharmacists. one was Asked If she is undergoing a sex change.
Another hurdle is culture. These days, health care providers like Casperson and gynecologists trained in menopause may prescribe testosterone to menopausal women who are having trouble with sex drive, arousal, and orgasm. Many women see improvement in these areas after a few months. But first, you need to get used to the idea of taking hormones that you’ve been told all your life are for men, at a time when your femininity feels at its most tenuous (see below). feminine forever). Again, experience in transgender care is helpful. Casperson has spoken to many transmasculine patients who have similar hesitations about using genital estrogen creams to compensate for the side effects of high doses of testosterone. Just as taking testosterone doesn’t change a menopausal patient’s gender identity, she tells her patients that taking estrogen “doesn’t mean you’re not who you want to be.”
Many trans health providers are also honing their skills in speaking openly about sexuality. Blair Peters, a plastic surgeon who performs phalloplasty and vaginoplasty at Oregon Health & Science University, said that’s especially true for those performing surgeries that affect a patient’s future sex life. Experts I spoke to, including urologists and gynecologists trained in sexual health, said gynecologists often fall short in this regard. Despite making a living treating vaginas, in many cases, unpleasant If you bring up sexual concerns with your patient, or if you are inexperienced in treating problems other than vaginal dryness. Also, assumeAlthough inaccurate, concerns about vaginal discomfort have always centered around penetrative sex with male partners, Tania Glyde, a London-based LGBTQ+ therapist and founder of the website Queer Menopause, told me. Ta.a 2022 survey We found that less than one-third of obstetrics and gynecology training programs have a curriculum specifically for menopause.
Bowers, who is transgender herself, said it wasn’t until she moved into transgender care that she felt comfortable talking about sexuality in a clinical setting. If she were to go to the gynecologist again now, she said, she would add some candid questions to the conversation with middle-aged patients who share that they are having sexual problems. Ta. Tell me, are you satisfied with that? How long does it take to reach orgasm? do you masturbate? what do you use? “
Menopause care is already benefiting from decades of efforts by queer people who have urged doctors to pay more attention to diverse experiences. Research dating back to the 2000s that included lesbians going through menopause helped demonstrate common menopause stereotypes, including: anxiety To remain attractive to men, disconnect among the members of couple, it was far from universal. Transgender people are also benefiting from advances in menopause care. Because gender transition and menopause are accompanied by a rapid drop in estrogen, many trans men who take testosterone also stop having periods and experience similar (but more extreme) genital dryness and irritation. It was developed for menopausal women, as Tate Smith, a 25-year-old trans activist living in the UK, noticed when she experienced genital sores and spotting after she started taking testosterone at age 20. This means that patients can benefit from treatment.After discovering that topical estrogen cream relieved his symptoms, he posted on Instagram casting term trans male menopause To help more trans men recognize that connection.
The more menopause and gender care are considered together in medical practice, the better the outcome for everyone involved. However, research on menopause rarely takes into account trans men, non-binary people, or young women and girls who have experienced menopause due to cancer treatment, surgery, or treatment. health condition Those that affect ovarian function. Although these patient populations represent only a small portion of patients going through menopause, their experiences can help researchers understand the effects of low estrogen across the body. Separating menopause from other related fields of medicine means that menopausal women and transgender people alike may miss out on knowledge and treatments that already exist.
Unlike gender reassignment, menopause is generally not a choice. But it’s also an opportunity for people to choose what they want from their changing bodies. Not all menopausal women are concerned about their sex drive or interested in taking testosterone. Like trans patients, we listen to their concerns and offer them a full range of options, not just limited options based on outdated notions of what menopause should be like. You deserve a healthcare provider.
