7. Special Populations and Emerging Topics
Pedagogy: This lesson uses inclusive-practice framing — building awareness and communication skills for managing menopause in transgender and gender-diverse individuals with sensitivity and clinical accuracy.
Learning Objectives
- Recognise that trans men and non-binary people (assigned female at birth) may experience menopausal symptoms
- Describe how prior gender-affirming hormone therapy affects the menopausal transition
- Apply NICE NG23 (2024) recommendations for this population
- Demonstrate sensitive history-taking and inclusive language
Key Facts
Who Is Affected?
Trans men and non-binary individuals assigned female at birth who have functioning ovaries may experience menopause. Those who have taken gender-affirming testosterone therapy may experience symptoms if testosterone is stopped. Those who undergo bilateral oophorectomy experience surgical menopause (1).
NICE NG23 (2024) Recommendations
The 2024 update includes specific recommendations: menopause-specific CBT is recommended for VMS, sleep difficulties, or depressive symptoms in trans men and non-binary people. Sensitive history-taking using inclusive language is essential. Consider the individual's hormone history and current gender-affirming treatment when planning menopause management (1).
Clinical Considerations
Testosterone therapy may mask some menopausal symptoms but does not prevent bone loss from oestrogen deficiency. After oophorectomy without oestrogen replacement, cardiovascular and bone risks increase. Management should be coordinated with the gender identity service where applicable (1).
Clinical Pearl Not all people who experience menopause identify as women. Using inclusive language ('people experiencing menopause') in clinical documentation and patient-facing materials is recommended by NICE (2024).
Clinical Pearl Trans men on testosterone who undergo oophorectomy may need oestrogen replacement for bone and cardiovascular protection — even if they do not experience VMS. Coordinate with gender identity services.
Case-Based Examples
Case 1: Trans man with VMS after stopping testosterone
Presentation: A 52-year-old trans man who stopped testosterone 6 months ago reports severe hot flushes and low mood. He has intact ovaries. He does not want oestrogen therapy.
Question: What options are available?
Model Answer: Respect his preference against oestrogen. Options: (1) Fezolinetant for VMS (non-hormonal, no oestrogenic effect); (2) Menopause-specific CBT (NICE NG23 recommended for this population); (3) Discuss resuming testosterone — this may suppress VMS; coordinate with gender identity service. If bone/cardiovascular protection is a concern: assess FRAX, check vitamin D, recommend exercise. If he reconsiders oestrogen in future: low-dose transdermal would be an option.
Case 2: Non-binary individual post-oophorectomy
Presentation: A 45-year-old non-binary person (assigned female at birth) underwent bilateral oophorectomy as part of gender-affirming surgery 1 year ago. They are not on any hormone therapy and present with joint pain, poor sleep, and vaginal dryness.
Question: How would you assess and manage this presentation?
Model Answer: Surgical menopause at 45 = early menopause with significant long-term health risks if untreated. Assess: symptom domains (VMS, GSM, mood, MSK, sleep), FRAX, cardiovascular risk. Management depends on the individual's goals and hormone preferences. Options: (1) Low-dose transdermal oestradiol for bone/CV protection and GSM — discuss carefully, as some non-binary individuals may be uncomfortable with oestrogen therapy; (2) Vaginal oestrogen for GSM (local, minimal systemic effect); (3) Testosterone continuation/initiation via gender identity service may provide some bone protection. (4) Bisphosphonate if declining all hormones and FRAX indicates risk. Coordinate with gender identity service. Use preferred name and pronouns throughout.
Self-Assessment Questions
PLAB/MLA NICE recommendation for trans individuals
What does NICE NG23 (2024) recommend for VMS in trans men and non-binary people?
A. No specific recommendations exist
B. Menopause-specific CBT is recommended for VMS, sleep, and mood
C. Only oestrogen therapy is recommended
D. Menopause management is not needed in this population
Answer: B. NICE NG23 (2024 update) specifically recommends menopause-specific CBT for VMS, sleep, and depressive symptoms in trans men and non-binary people.
MRCGP Bone protection after oophorectomy in a trans man
A 40-year-old trans man on testosterone undergoes bilateral oophorectomy. What bone protection consideration is essential?
A. Testosterone alone provides full bone protection
B. Oestrogen deficiency post-oophorectomy increases bone loss risk; assess FRAX, consider whether low-dose oestrogen or bisphosphonate is needed alongside testosterone
C. No bone assessment is needed under age 50
D. DEXA is contraindicated in trans individuals
Answer: B. Testosterone provides some bone protection but does not fully replace oestrogen's role. After oophorectomy, oestrogen deficiency accelerates bone loss. FRAX assessment and DEXA if indicated are appropriate regardless of gender identity.
Professor Evidence gaps in transgender menopause management
Critically evaluate the evidence base for menopause management in transgender and gender-diverse individuals.
A. Extensive RCT data are available
B. The evidence base is extremely limited — NICE 2024 recommendations are based on expert consensus and extrapolation from cisgender data; no RCTs exist in this population; clinical practice relies on case series and gender identity clinic experience
C. All cisgender data are directly applicable
D. No evidence of any kind exists
Answer: B. This is one of the most significant evidence gaps in menopause medicine. NICE 2024 recommendations are based on consensus and indirect evidence. Unique challenges: hormone histories are complex; standard HRT may conflict with gender identity; bone and CVD risk assessment tools (FRAX, QRISK3) were validated in cisgender populations. Research priorities include prospective cohort studies of bone/CVD outcomes post-oophorectomy in trans men, and co-designed studies with the transgender community.
Take-Away Messages
- Trans men and non-binary individuals (assigned female at birth) may experience menopause
- NICE NG23 (2024) recommends CBT for VMS, sleep, and mood in this population
- Testosterone does not fully replace oestrogen's bone-protective effects after oophorectomy
- Coordinate menopause management with gender identity services
- Use inclusive language and preferred pronouns — clinical respect supports engagement