In her new role, she began consultations by asking each patient what they wanted from their body—a question she’d never been trained to ask menopausal women.
That’s when she realized: Women in menopause were getting short shrift.
But estrogen alone can’t address every menopause symptom, in part because estrogen is not the only hormone that’s in short supply during menopause; testosterone is too.
A 2022 review concluded, “Testosterone is a vital hormone in women in maintaining sexual health and function” after menopause.
These days, providers such as Casperson, as well as menopause-trained gynecologists, might prescribe testosterone to menopausal women experiencing difficulty with libido, arousal, and orgasm.
The more menopause and gender care are considered together in medical settings, the better the outcomes will be for everyone involved.
Siloing off menopause from other relevant fields of medicine means menopausal women and trans people alike can miss out on knowledge and treatments that already exist.
Not all women in menopause are worried about their libido or interested in taking testosterone.
Marci Bowers believed she understood menopause after ten years of practice as an obstetrician-gynecologist. She knew to inquire about hot flashes, vaginal dryness, mood swings, and memory issues whenever she saw a patient in her 40s or 50s. Bowers also nearly always prescribed the same medication, regardless of the patient’s concerns. “Estrogen was always our answer,” she informed me.
Bowers then acquired a gender-affirming surgical practice in Colorado in the middle of the 2000s. She asked each patient what they wanted from their body at the beginning of consultations in her new role, a question she had never been trained to ask menopausal women. She eventually became at ease discussing difficult subjects like pleasure, desire, and sexuality and giving both estrogen and testosterone prescriptions. She came to the realization that women going through menopause were being ignored at that point.
Every organ in the body, including the skin, bones, and brain, is impacted by the menopause, a hormonal shift. Similarly, gender transition is frequently described by medical professionals and transgender patients as “a second puberty”; it is a whirlwind of physical and psychological changes brought on by a sharp change in hormone levels. However, medicine has just lately started to make the connections. Some medical professionals who usually treat transgender patients—such as urologists, surgeons who perform gender affirmation surgery, and specialists in sexual medicine—have started to enter the menopause care field in recent years, bringing new resources with them.
Kelly Casperson, a certified menopause provider in Washington State and urologist, told me that trans care is “in many ways light-years ahead of women’s care.”. Professionals who do both are knowledgeable about hormone effects, sensitive to issues related to sexual function, and compassionate toward patients whose symptoms have been written off by other medical professionals. Providers would do well to take a cue from a field that has been doing just that for decades if the aim of menopause care is to enable women to live their lives to the fullest rather than just help them survive.
Estrogen has not always been a comfortable companion for American women. Books like Robert A. Feminine Forever, a gynecologist, were published in the 1960s. Wilson presented oestrogen as a miraculous drug that could restore women’s beauty and sexual arousal, making the menopausal woman “much more pleasant to live with.”. The maker of Premarin, the most widely used estrogen treatment at the time, reportedly paid Wilson, according to a later report in The New York Times. The pitch later shifted to lifetime health. Premarin was the most prescribed medication in the US by 1992. 15 million women were receiving estrogen therapy for menopause symptoms by the end of the decade, either in combination with progesterone or not.
Then, in 2002, a sizable clinical trial came to the conclusion that taking progesterone and estrogen orally was associated with a higher risk of breast cancer, heart disease, and stroke. Despite the study’s limitations as a safety measure (testing only one type of estrogen and focusing on older women rather than the recently menopausal), oral estrogen prescriptions fell, from nearly a quarter of women over 40 to about 5% of all women. Even though oral estrogen can raise the risk of strokes for women over 60, research has shown that it can help treat hot flashes and night sweats, prevent bone loss, and prevent bone loss. In addition to treating urinary problems like persistent UTIs and incontinence, topical estrogen also helps with genital symptoms like dryness, irritation, and tissue thinning in the vagina.
However, estrogen is not sufficient to treat all menopausal symptoms; testosterone is also depleted during this time. While high-quality studies on the effects of testosterone on women over 65 are scarce, premenopausal women are known to benefit from it in terms of bone density, heart health, metabolism, cognition, and the health of their ovaries and bladder. Testosterone is essential for women to maintain their sexual health and function after menopause, according to a review published in 2022.
But testosterone was largely disregarded in conventional menopause care for decades. A portion of the cause stems from regulatory factors: while estrogen has been approved by the FDA since 1941 to treat menopausal symptoms, testosterone treatments for women have never received agency approval, primarily due to a lack of research. Therefore, in order to prescribe the hormone off-label, doctors must have a sufficient understanding of it. Furthermore, testosterone is subject to additional regulations as a Schedule III controlled substance, in contrast to estrogen. Pharmacists have refused to fill some of Casperson’s female patients’ prescriptions for testosterone; one patient was questioned about whether or not she was going through a gender transition.
Culture is the other obstacle. Today, menopausal women who are having trouble with libido, arousal, and orgasm may be prescribed testosterone by healthcare professionals like Casperson and gynecologists who have received training in menopause management. After a few months, many women notice improvements in these areas. But first, at a time when their femininity can feel most shaky, they have to get used to the idea of taking a hormone that they have been told is only for men (see: Feminine Forever). Experience in transgender care can also be helpful in this situation. Casperson has helped numerous transmasculine patients overcome similar concerns about using genital estrogen cream to counteract the negative effects of high testosterone dosages. She explains to those patients that taking estrogen “doesn’t mean you’re not who you want to be,” just as taking testosterone wouldn’t alter a woman going through menopause’s gender identity.
Speaking candidly about sexuality is another skill that many trans-health providers have mastered. Blair Peters, an ORHS plastic surgeon who specializes in vaginoplasties and phalloplasties, told me that this is particularly true for surgeons who perform procedures that will have an impact on a patient’s future sexual life. When it comes to sexual health, gynecologists can often fall short, according to experts I spoke with, including urologists and gynecologists with training in the field. Even though they work in vaginal medicine, practitioners are frequently awkward discussing sexual issues with patients or lack experience in treating conditions other than vaginal dryness). Moreover, Tania Glyde, an LGBTQ+ therapist in London and the creator of the website Queer Menopause, told me that people might mistakenly believe that worries regarding vaginal discomfort are exclusively focused on having penetrative sex with a male partner. Per a survey conducted in 2022, fewer than one-third of OB-GYN residency programs had a specific curriculum on menopause.
Bowers, who identifies as transgender, informed me that it wasn’t until she entered trans care that she felt comfortable discussing sexuality in a professional setting. She added that if she were to go back to practicing gynecology today, she would ask her midlife patients who disclose that they are experiencing sexual problems blunt questions like, “Tell me about your sexuality.”. Tell me, are you content with that? Do you masturbate? What do you use? How long does it take you to have an orgasm?
Decades of work by queer people have already improved menopause care by forcing medical professionals to take a more comprehensive look at a range of experiences. Research on menopause-affected lesbians conducted as early as the 2000s helped dispel widespread misconceptions about menopause, such as the need to stay attractive to men and the disconnection between a couple’s members. The advancements in menopausal care have also benefited trans people. Due to the abrupt decrease in estrogen that occurs during both gender transition and menopause, many transmasculine men who take testosterone also miss their periods and have more severe cases of genital dryness and irritation. According to Tate Smith, a 25-year-old trans activist in the United States, this means they can profit from therapies created for menopausal women. KK. discovered when he started taking testosterone at the age of 20 and started to experience genital pain and spotting. In an effort to raise awareness among trans men, he coined the term “trans male menopause” on Instagram after using topical estrogen cream to treat his symptoms.
Results will be better for all parties if menopause and gender care are given equal consideration in medical settings. Yet, transgender and nonbinary individuals, as well as younger women and girls who go through menopause as a result of ovarian function-altering medical procedures or cancer treatment, are seldom taken into account in menopause studies. Their experiences can aid researchers in understanding the effects of low estrogen across a variety of bodies, even though these patient populations make up a small portion of menopausal patients. Menopausal women and trans people may lose out on existing knowledge and treatments if menopause is isolated from other pertinent areas of medicine.
Menopause is typically not chosen, unlike gender transition. However, it can also present a chance for an individual to decide what they want from their evolving physique. Not all women going through menopause are interested in taking testosterone or concerned about their libido. Similar to trans patients, they should receive care from medical professionals who pay attention to their concerns and then present them with all of their options, not just a select few based on antiquated ideas about what menopause is meant to be.
