After a decade working as an obstetrician-gynecologist, Marci Bowers thought she understood menopause. At any time when she noticed a affected person in her 40s or 50s, she knew to ask about issues reminiscent of sizzling flashes, vaginal dryness, temper swings, and reminiscence issues. And it doesn’t matter what a affected person’s concern was, Bowers nearly all the time ended up prescribing the identical factor. “Our reply was all the time estrogen,” she instructed me.
Then, within the mid-2000s, Bowers took over a gender-affirmation surgical apply in Colorado. In her new position, she started consultations by asking every affected person what they needed from their physique—a query she’d by no means been educated to ask menopausal girls. Over time, she grew snug mentioning difficult matters reminiscent of pleasure, want, and sexuality, and prescribing testosterone in addition to estrogen. That’s when she realized: Ladies in menopause had been getting quick shrift.
Menopause is a body-wide hormonal transition that impacts just about each organ, from pores and skin to bones to mind. The identical will be stated of gender transition, which, like menopause, is commonly referred to by medical doctors and transgender sufferers as “a second puberty”: a curler coaster of bodily and emotional modifications, incited by a dramatic shift in hormones. However medication has solely just lately begun connecting the dots. Previously few years, some medical doctors who usually deal with transgender sufferers—urologists, gender-affirmation surgeons, sexual-medicine specialists—have begun shifting into menopause care and bringing with them a brand new set of instruments.
“In some ways, trans care is mild years forward of ladies’s care,” Kelly Casperson, a urologist and authorized menopause supplier in Washington State, instructed me. Suppliers who do each are effectively versed within the results of hormones, attuned to issues about sexual perform, and empathetic towards individuals who have had their signs dismissed by suppliers. If the objective of menopause care isn’t simply to assist girls survive but additionally to permit them to reside their fullest life, suppliers would do effectively to borrow some insights from a subject that has been doing simply that for many years.
American girls’s relationship with estrogen has been a rocky one. Within the Nineteen Sixties, books reminiscent of Female Eternally, written by the gynecologist Robert A. Wilson, framed estrogen as a magical substance that might make girls as soon as once more enticing and sexually obtainable, rendering the menopausal “way more nice to reside with.” (The New York Occasions later reported that Wilson was paid by the producer of Premarin, the preferred estrogen remedy on the time.) Later, the pitch switched to lifelong well being. By 1992, Premarin was probably the most prescribed drug in the US. By the tip of the last decade, 15 million women had been on estrogen remedy, with or with out progesterone, to deal with their menopause signs.
Then, in 2002, a big medical trial concluded that oral estrogen plus progesterone remedy was linked to an elevated threat of stroke, coronary heart illness, and breast most cancers. The examine was an imperfect measure of security—it targeted on older girls slightly than on the newly menopausal, and it examined just one sort of estrogen—however oral-estrogen prescriptions nonetheless plummeted, from practically 1 / 4 of ladies over 40 to roughly 5 percent. Regardless of this blow to the hormone’s repute, proof has continued to pile up confirming that oral estrogen might help forestall bone loss and deal with sizzling flashes and night time sweats, although it could improve the chance of strokes for girls over 60. Topical estrogen helps tackle genital symptoms, together with vaginal dryness, irritation, and thinning of the tissues, in addition to urinary points reminiscent of continual UTIs and incontinence.
However estrogen alone can’t tackle each menopause symptom, partially as a result of estrogen will not be the one hormone that’s briefly provide throughout menopause; testosterone is simply too. Though researchers lack high-quality research on the position of testosterone in girls over age 65, they know that in premenopausal girls, it performs a job in bone density, coronary heart well being, metabolism, cognition, and the perform of the ovaries and bladder. A 2022 review concluded, “Testosterone is a crucial hormone in girls in sustaining sexual well being and performance” after menopause.
But for many years, commonplace menopause care largely ignored testosterone. A part of the reason being regulatory: Though estrogen has loved FDA approval for menopausal signs since 1941, the company has by no means green-lit a testosterone remedy for girls, largely due to scant analysis. Which means medical doctors need to be acquainted sufficient with the hormone to prescribe it off-label. And in contrast to estrogen, testosterone is a Schedule III managed substance, which suggests extra crimson tape. A few of Casperson’s feminine sufferers have had their testosterone prescription withheld by pharmacists; one was asked if she was present process gender transition.
The opposite hurdle is cultural. Today, suppliers reminiscent of Casperson, in addition to menopause-trained gynecologists, would possibly prescribe testosterone to menopausal girls experiencing problem with libido, arousal, and orgasm. Many ladies see enhancements in these areas after a number of months. However first, they need to get used to the thought of taking a hormone they’ve been instructed all their lives is for males, at simply the time when their femininity can really feel most tenuous (see: Female Eternally). Right here, too, expertise in trans care might help: Casperson has talked many transmasculine sufferers by way of comparable hesitations about utilizing genital estrogen cream to steadiness out the unwanted effects of their excessive testosterone doses. Taking estrogen, she tells these sufferers, “doesn’t imply you’re not who you wish to be,” simply as taking testosterone wouldn’t change a menopause affected person’s gender identification.
Many trans-health suppliers have additionally honed their expertise in talking frankly about sexuality. That’s very true for many who do surgical procedures that may have an effect on a affected person’s future intercourse life, Blair Peters, a plastic surgeon at Oregon Well being & Science College who performs phalloplasties and vaginoplasties, instructed me. Consultants I spoke with, together with urologists and gynecologists with coaching in sexual well being, stated that gynecologists can usually fall quick on this regard. Regardless of treating vaginas for a residing, they will usually be uncomfortable mentioning sexual issues with sufferers or inexperienced at treating points past vaginal dryness. They will additionally assume, inaccurately, that issues about vaginal discomfort all the time middle on penetrative intercourse with a male companion, Tania Glyde, an LGBTQ+ therapist in London and the founding father of the web site Queer Menopause, instructed me. A 2022 survey of OB-GYN residency applications discovered that lower than a 3rd had a devoted menopause curriculum.
Bowers, who’s herself transgender, instructed me she received snug speaking about sexuality in a medical setting solely after shifting into trans care. If she had been to return to gynecology in the present day, she stated, she would add some frank inquiries to her conversations with midlife sufferers who share that they’re having sexual points: “Inform me about your sexuality. Inform me, are you pleased with that? How lengthy does it take you to orgasm? Do you masturbate? What do you utilize?”
Menopause care has already benefited from many years of effort by queer folks, who’ve pushed medical doctors to pay extra consideration to a variety of experiences. Analysis courting way back to the 2000s that included lesbians going by way of menopause helped present that frequent menopause stereotypes, reminiscent of anxiety over remaining enticing to males and disconnect between members of a couple, had been removed from common. Trans folks, too, have benefited from advances in menopause care. As a result of each gender transition and menopause contain a pointy drop in estrogen, many transmasculine males who take testosterone additionally lose their interval, and expertise an analogous (although extra excessive) model of the genital dryness and irritation. Which means they will profit from remedies developed for menopausal girls, as Tate Smith, a 25-year-old trans activist within the U.Okay., realized when he skilled genital ache and recognizing after beginning testosterone at 20. After he discovered reduction with topical estrogen cream, he made an Instagram publish coining the time period trans male menopause to ensure extra trans males had been conscious of the connection.
The extra menopause and gender care are thought-about collectively in medical settings, the higher the outcomes might be for everybody concerned. But menopause research not often contemplate trans males and nonbinary folks, together with youthful girls and ladies who expertise menopause because of most cancers remedy, surgical procedure, or health conditions that have an effect on ovarian perform. Though these affected person populations symbolize a small proportion of the sufferers going by way of menopause, their experiences might help researchers perceive the results of low estrogen throughout a spread of our bodies. Siloing off menopause from different related fields of drugs means menopausal girls and trans folks alike can miss out on data and coverings that exist already.
Not like gender transition, menopause is usually not chosen. But it surely too will be a chance for an individual to make selections about what they need out of their altering physique. Not all girls in menopause are nervous about their libido or curious about taking testosterone. Like trans sufferers, they deserve suppliers who hearken to what they care about after which supply them a full vary of choices, not only a restricted choice primarily based on outdated notions of what menopause is meant to be.
