THIEME

Review Article

Contraceptive Counseling for the Transgender

Patient Assigned Female at Birth
Aconselhamento contraceptivo para a pessoa
transgênera designada mulher ao nascimento
Sérgio Henrique Pires Okano1,2 Giovanna Giulia Milan Pellicciotta1 Giordana Campos Braga1,2

1 Universidade de Ribeirão Preto, Ribeirão Preto, SP, Brazil Address for correspondence Sérgio Henrique Pires Okano, Av.
2 Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Costábile Romano, 2201, 14096-900, Ribeirão Preto, SP, Brazil
Ribeirão Preto, SP, Brazil (e-mail: [email protected]).

Rev Bras Ginecol Obstet 2022;44(9):884–890.

Abstract Although almost 0.7% of the Brazilian population identifies as transgender, there is
currently no training for healthcare professionals to provide comprehensive care to
these patients, including the discussion of reproductive planning. The use of testos-
terone promotes amenorrhea in the first months of use; however, this effect does not
guarantee contraceptive efficacy, and, consequently, increases the risks of unplanned
pregnancy. The present article is an integrative review with the objective of evaluating
and organizing the approach of contraceptive counseling for the transgender popula-
tion who were assigned female at birth. We used the PubMed and Embase databases for
our search, as well as international guidelines on care for the transgender population.
Of 88 articles, 7 were used to develop the contraceptive counseling model. The model
follows the following steps: 1. Addressing the information related to the need for
contraception; 2. Evaluation of contraindications to the use of contraceptive methods
Keywords (hormonal and nonhormonal); and 3. Side effects and possible discomfort associated
► transgender with the use of contraception. The contraceptive counseling model is composed of 18
► contraception questions that address the indications and contraindications to the use of these
► testosterone methods, and a flowchart to assist patients in choosing a method that suits their needs.

Resumo Apesar de 0,7% da população brasileira se identificar como transgênera, não existe
treinamento para que o profissional de saúde realize um acolhimento de maneira
integral a estes pacientes, incluindo a discussão do planejamento reprodutivo. O uso de
testosterona promove a amenorreia nos primeiros 6 meses de uso; entretanto, este
efeito não garante eficácia contraceptiva, e, consequentemente, aumenta os riscos de
uma gravidez não planejada. O presente artigo é uma revisão integrativa com o
Palavras-chave objetivo de avaliar e organizar uma abordagem do aconselhamento contraceptivo na
► transgênero população transgênera que foi designada mulher ao nascimento. Para a estratégia de
► contracepção busca, foram pesquisados os bancos de dados PubMed e Embase, incluindo diretrizes
► testosterona internacionais sobre cuidados à população transgênera. De 88 artigos, 7 foram

received DOI https://doi.org/ © 2022. Federação Brasileira de Ginecologia e Obstetrícia. All rights
December 14, 2021 10.1055/s-0042-1751063. reserved.
accepted ISSN 0100-7203. This is an open access article published by Thieme under the terms of the
April 18, 2022 Creative Commons Attribution License, permitting unrestricted use,
published online distribution, and reproduction so long as the original work is properly cited.
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 Contraceptive Counseling for the Transgender Patient Assigned Female at Birth Okano et al. 885

utilizados para desenvolver o modelo de aconselhamento contraceptivo. O modelo

segue as seguintes etapas: 1. Abordagem das informações relacionadas à necessidade
de contracepção; 2. Avaliação das contraindicações ao uso dos métodos contraceptivos
(hormonais e não hormonais); 3. Efeitos colaterais e possíveis desconfortos associados
ao uso do contraceptivo. O modelo de aconselhamento contraceptivo é composto por
18 questões que abordam as indicações e contraindicações ao uso destes métodos e
um fluxograma que auxilia na escolha dentre os métodos permitidos ao paciente de
acordo com a sua necessidade.

Introduction undergoes these surgeries.9,10 However, family planning by

freezing gametes or embryos is a possible pretreatment of
A transgender person is someone whose gender identity fertility and should be offered to all TM prior to commencing
differs from their sex assigned at birth, regardless of their hormone therapy and surgery.5
undergoing gender affirmation body procedures.1 In Brazil,
the prescription of hormones for the acquisition of sexual Contraceptive Methods
characters of the experienced gender (cross-hormonaliza- Contraception must be discussed with all people who pres-
tion) should be performed according to the guidelines of the ent a risk of unplanned pregnancy.7,9–11 In Brazil, there is a
Transsexualization Process regulated by Ordinance higher prevalence of the use of oral pills (29.7%) by cisgender
2803/2013 of the Ministry of Health, and to the Resolution women, followed by tubal ligation (14%) and external con-
no. 2.265/19 of the Federal Council of Medicine.2,3 doms (10%).12
According to Spizzirri et al. (2021),4 0.69% (95% confi- Hormonal methods are divided into two groups: com-
dence interval [CI] ¼ 0.48–0.90) of the Brazilian population bined and progestogen-only contraceptives.13,14 Hormonal
identifies as transgender, and 1.19% (95%CI ¼ 0.92–1.47) methods act by inhibiting the luteinizing hormone (LH) peak
identify as nonbinary and are of reproductive age responsible for ovulation. They also alter the cervical mucus
(32.8  14.2 years old, 95%CI ¼ 28.5–37.1). Despite these to prevent the entry of spermatozoa into the uterine cavity,
numbers, the population faces several barriers to access impair the tubal motility of the fallopian tubes, preventing
health networks due to their lack of visibility. Comprehensive the egg from moving into the uterine cavity, and alter the
care, which should be based on health promotion, disease endometrial characteristics, making the uterus hostile to
prevention, the screening of clinical conditions, and possible implantation.15,16
treatments, is usually denied to this population, along with Combined contraceptives are a combination of estrogens
reproductive healthcare and, consequently, contraception.5 (either ethinyl estradiol or estradiol valerate) and proges-
People who are assigned female at birth may identify as togens, which ensure greater predictability of bleeding, acne
male or as any other nonbinary gender expression other than control, and hirsutism.16 However, the presence of estrogen,
female. Transgender men (TM) are understood to be those especially ethinyl estradiol, increases the chances of devel-
individuals who have a male gender identity but were oping thromboembolic diseases, which limits its use to a
assigned female at birth. The sexual orientation of transgen- restricted group of people.17 People with breast cancer or
der people is independent of their gender identity; that is, those who have been treated for it should not use any
TM can relate to people of male, female, and/or nonbinary hormonal contraception because of the increased risk of
identities, and can thus be subject to pregnancy when they recurrence.18,19
still have a uterus and ovaries and their fertile sexual partner Intrauterine devices (IUDs) do not act through mecha-
has a penis.6 A cohort study identified that transgender nisms based on altering the hypothalamic–pituitary–gonad-
people are at potential risk of pregnancy –only 20% of TM al axis. In users of copper IUDs, the liberation of ions, which is
used contraception, and more than half were not advised to spermicidal and prevents sperm capacitation, prevents
use contraception after starting hormone treatment.7 An- sperm from entering the uterus, while levonorgestrel-re-
other American survey showed that 24% of pregnancies in TM leasing intrauterine systems (LNG-IUD) follow the same
occur without planning, mainly due to a lack of guidance on mechanisms of combined methods, except for the inhibition
contraceptive methods and the false conception that testos- of the hypothalamic-pituitary-ovarian axis in most
terone has a contraceptive effect.8 users.20–22

Surgical Procedures and Contraception Testosterone Use and Contraception

Panhysterectomy and oophorectomy are procedures for The use of testosterone promotes the acquisition
patients who desire surgical gender affirmation. Since the of secondary male sexual characteristics such as gaining
organs essential to the reproductive process are removed, lean mass, muscular hypertrophy, the thickening of the
there is no need to discuss contraception with the TM who timbre of the voice, and the appearance and growth of

Rev Bras Ginecol Obstet Vol. 44 No. 9/2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. All rights reserved.
886 Contraceptive Counseling for the Transgender Patient Assigned Female at Birth Okano et al.

hair.23 Although it is not a contraceptive method, its use is to prepare the approach model (►Figure 1). The included
associated with amenorrhea in a massive portion of TM.9 For articles are shown in ►Table 1.
this reason, erroneously, 16.4 to 31% of TM believe that
testosterone is a contraceptive.7,10,24
Discussion
The presence of estrogen in contraceptive methods is one
of the factors that leads TM undergoing hormonization to the The discussion and construction of the approach model was
use of nonhormonal methods or of progestogen organized in three stages: 1. access to information related to
alone.9,10,25,26 Currently, there is no evidence of the influ- the need for contraception and the noncontraceptive bene-
ence of contraceptive use on the acquisition of secondary fits of hormonal methods; 2. evaluation of contraindications
male characteristics.9 There are also no studies that associate to the use of contraceptive methods (hormonal and nonhor-
thromboembolism with combined hormonal contracep- monal); and 3. side effects and possible discomfort associat-
tion.26 Therefore, caution is recommended in the prescrip- ed with the use of the method.
tion of estrogen due to the lack of data regarding its safety
and side effects in the transgender population.27 The pre- Accessing Information Related to the Need for
scription of contraceptive methods should, therefore, follow Contraception and the Noncontraceptive Benefits of
the same guidelines for contraception in cisgender women Hormonal Methods
proposed by the Center for Disease Control (CDC) and the Transgender men of fertile age who did not undergo a hyster-
World Health Organization (WHO).13,14,28 ectomy or oophorectomy and have sexual intercourse with
As such, the purpose of the present review is to evaluate people who have penises are at risk of getting pregnant, even if
and organize an approach to contraceptive counseling in the they are in amenorrhea due to the use of testosterone.8
transgender population who were assigned female at birth. Choosing a contraceptive method should be informed by an
understanding of the impact of the ovulatory cycle on the
quality of life of TM. Complaints such as bleeding, cramps,
Methods
symptoms of premenstrual tension syndrome (PMS), and pain
This is an integrative literature review with the purpose of associated with ovulation can result in physical and psycho-
organizing the existing evidence on the care and particular- logical discomfort.5 Symptoms related to the period before
ities of contraceptive counseling in TM, and of the develop- vaginal bleeding may exacerbate dysphoric features and
ment of an approach model based on this discussion. The should be treated, especially in patients who cannot yet
search was structured in four axes: indications and contra- make use of testosterone, such as patients < 16 years old.
indications to the use of contraceptives, the use of hormone
treatment with testosterone and interference with the use of Evaluation of Contraindications to the Use of
contraception, side effects of the use of contraception in TM Contraceptive Methods (Hormonal and Nonhormonal)
with or without the use of cross-hormone treatment, and All hormonal contraceptives are contraindicated in the pres-
possible discomfort related to the method and exacerbation ence of a history of breast cancer and hepatocarcinoma. In
of gender dysphoria. these conditions, the use of copper IUDs, behavioral meth-
The PubMed and Embase databases were searched along ods, spermicides, and barrier methods are acceptable con-
with the international guidelines on care for the transgender traceptive options.18,19 The use of combined methods
population from the University of California, the Internation- increases the risk of developing cardiovascular diseases,
al Society of Endocrinology, the World Professional Associa- lithiasis biliary disease, and hypertriglyceridemia. ►Annex 1
tion for Transgender Heath (WPATH), and the Family (Supplementary material) shows a model of anamnesis of the
Planning Society.23,25,27,29,30 The keywords transgender contraindications of these contraceptive methods based on the
and contraceptive were used to search the databases CDC and WHO guidelines for the use of contraceptive methods
(►Table 1 shows the search strategy). We considered reviews for cisgender women.13,14
that were published in the last decade, written in both The research model is composed of 5 core questions,
English and Portuguese, which evaluated contraception in containing a total of 18 “yes/no” subquestions. The first
TM, and which evaluated at least one of the outcomes related core question seeks to assess the need for contraception of
to contraception in this population. Relevant articles from the TM in attendance; any positive response indicates a
the bibliographic references of the selected articles were also contraception discussion. The core questions that follow
evaluated as needed. assess the absolute contraindications to contraception, hor-
monal contraceptive methods, combined hormonal con-
traceptive methods, and IUD use. A positive response
Results
contraindicates their use according to the condition
A total of 88 articles were found, 7 of which were excluded evaluated.
due to duplicity. Of the remaining 81 articles, 51 were For the preparation of ►Annex 1 (Supplementary
excluded for not containing information in the abstract about material), possibilities for the prescription of the clinical
the study questions, or whose abstract was unavailable or in conditions presented as categories 1 and 2 of the WHO
a language other than Portuguese or English. Twenty-five manuals were considered; the criteria classified as catego-
articles were used for the literature review, and 7 were used ries 3 and 4 were considered as contraindications to the use

Rev Bras Ginecol Obstet Vol. 44 No. 9/2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. All rights reserved.
 Contraceptive Counseling for the Transgender Patient Assigned Female at Birth Okano et al. 887

Table 1 Articles used for the literature review

Authors Year of Study Country Main Results

publication Design
Krempasky et al.9 2020 Review United States Transgender male patients deserve the same
comprehensive access to care as their cisgender female
peers. The most appropriate contraceptive is ultimately
the one chosen by the patient. After providing
introductory information, subsequent detailed
contraceptive counseling should be tailored to the options
of their interest. Those who desire contraception should
be offered a family-planning consultation in which skilled
clinicians may provide the service.
Montoya et al.31 2021 Review United States Understanding contraception, family building, and
gender-affirming care are important reproductive health
concerns for LGBTQI individuals. Appropriate gender-
affirming counseling allows providers to engage in
supportive, shared decision-making about contraception
with their transmasculine patients. Testosterone therapy
is not a substitute for contraception, even when
amenorrhea is achieved.
Nisly et al.32 2018 Review United States Nonhormonal intrauterine devices are frequently used;
therefore one should avoid not only the hormone effect
from hormonal birth control forms but also the perception
of the hormone effect, which can be frightening to a
transgender man who would not like to have estrogen or
progestogen effect. TM fear the effects associated with
estrogen or progesterone-containing contraception
methods, including reduction of clitoral size or breast
enlargement or masculinization reversal.
Gorton et al.33 2017 Review United States Hormone therapy provides significant benefits, allowing
many patients to live as male in society by 2 years of
treatment. No increased risks of malignancy or
cardiovascular end points with hormonal therapy are
demonstrated in the literature, although minor increases
might not be detectable at the current level of evidence.
Obedin-Maliver et al.34 2017 Review United States If there are no contraindications to combined oral
contraception, a continuous low-dose regimen can be
prescribed. Levonorgestrel-releasing intrauterine systems
are also an option, especially for patients who have a
contraindication to, or conceptual aversion to, estrogen-
containing compounds. Injectable medroxyprogesterone
acetate or daily oral progestin can also be considered for
persistent menses.
Mehringer et al.35 2019 Review United States Combined oral contraception can be used for both
contraception and menstrual suppression. Combined oral
contraceptives are less effective than long-acting
contraceptive methods. Estrogen may be perceived to be
a “feminine” hormone. Ring may be a less desirable option
for some transmasculine individuals who may not identify
with the anatomical location of insertion. Depot
medryprogesterone acetate is often a popular option for
menstrual regulation among transmasculine youth
because the progestin has a more androgenic effect
compared with other progestins. Intrauterine devices
contain no hormones, and, as a result do not provide
menstrual suppression. Bleeding patterns with the
hormonal intrauterine devices are variable. Bleeding
patterns of etonogestrel implants are very unpredictable,
and may include irregular prolonged bleeding or spotting,
amenorrhea, or increased frequency of bleeding.
Wilczynski et al.36 2014 Review United States Oral progestins (medroxyprogesterone) to decrease
androgen secretion. Oral contraceptives can be used to
stop menses.

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888 Contraceptive Counseling for the Transgender Patient Assigned Female at Birth Okano et al.

Some medications, such as medroxyprogesterone acetate

(DMPA), etonogestrel-releasing subdermal implants, and
LNG-IUD may be associated with an increased risk of spotting
and bleeding.40,41 Levonorgestrel-releasing intrauterine sys-
tems, despite promoting high contraceptive efficacy and
reduced uterine bleeding in the long term, does not block
ovulation in most cycles,22,34,42 thus promoting few benefits
related to PMS. Regarding the symptoms related to vaginal
bleeding and cramps, except for copper IUDs, all other
hormonal methods reduce colic during vaginal bleeding.
Transgender men may present resistance to the use of
estrogen in contraception.26,34 In cisgender women, the use
of ethinyl estradiol or estradiol valerate increases the pro-
duction of sex hormone-binding globulin (SHBG), leading to
the reduced bioavailability of testosterone; however, there
are no studies that evaluate this effect in transgender people,
neither other possible deleterious effects during hormonal
transition.9,31 Some surveys report that the use of exogenous
estrogen by this population may occasionally cause the
enlargement and development of the mammary glands.27
Since there are no studies that contraindicate the use of
estrogens associated with testosterone in TM, and the risk of
developing thrombosis is unknown in this situation, it is
prudent to initially offer the prescription of progestogens
alone to testosterone users.10,26,27 The use of combined
contraceptives may be offered when there is a desire for or
benefit from the association of this hormone for the testos-
terone-using patient, such as controlling bleeding patterns,
acne, or hair loss.9,35,36 For TM patients who are not on cross-
hormonalization, prescribing combined pills with 30 mcg
ethinyl estradiol or a vaginal ring in an extended fashion
(without breaks) can control unscheduled bleeding by 5 to
25%, while prescribing depot medroxyprogesterone can
promote amenorrhea in up to 80% of users.43–45 However,
the use of oral pills is associated with femininity, because in
Fig. 1. Flowchart. cisgender society only women use oral contraceptives; thus,
the use of oral contraceptives can be very dysphoric for TM.27
Depot medroxyprogesterone acetate affects lipid metab-
olism by reducing all its fractions.14,46 Two meta-analyses
of the methods. Conditions or periods such as postpartum evidenced that the use of testosterone by TM also reduces
were not considered, nor have behavioral and definitive high density lipoprotein-cholesterol (HDL).47,48 Despite this
(surgical) methods been discussed in the present article, side effect, data are still insufficient to assess whether this
although they can be oriented to this population.14 lipid modification would trigger higher mortality, infarction,
strokes, or venous thrombosis in TM.47 Thus, the association
Side Effects and Possible Discomfort Associated with of testosterone with depot medroxyprogesterone acetate
Contraceptive Use should be performed with caution in patients with a signifi-
The choice of contraceptive method should also consider cant reduction in HDL.
conditions associated with possible discomfort related to the ►Annex 2 (Supplementary material) shows a flowchart
use or insertion/withdrawal of the chosen method.31–37 The to assist in the choice of contraceptive methods based on the
genital exposure and pelvic manipulation can generate desire of the patient at three levels – first, addressing the
physical, psychological, and emotional discomfort.6,38 need for contraception, namely, controlling PMS symptoms
In some protocols, the association of testosterone with an and vaginal bleeding, or preventing pregnancy; second,
isolated progestogen method at the beginning of therapy is evaluating the risks and benefits of this association with
recommended to reduce possible unfavorable bleeding pat- testosterone; and third, evaluating the discomfort of the
terns.8,33,39 Krempasky et al.9 identified that the reduction or patient with genitopelvic evaluation or manipulation.
cessation of vaginal bleeding occurs mainly in users of This population should not be deprived from the choice of
progestogen alone and in users of combined methods on behavioral, barrier, or surgical methods. Transgender men
an extended basis (without breaks). who do not care about bleeding patterns, who have

Rev Bras Ginecol Obstet Vol. 44 No. 9/2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. All rights reserved.
 Contraceptive Counseling for the Transgender Patient Assigned Female at Birth Okano et al. 889

complaints related to their ovulatory cycle, or who simply do 7 Abern L, Maguire K. Contraception knowledge in transgender
not want to use combined contraception may be candidates individuals: are we doing enough? Obstet Gynecol. 2018;131:65S.
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8 Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender
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men who experienced pregnancy after female-to-male gender
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proach model that is yet to be tested. A limitation to the 9 Krempasky C, Harris M, Abern L, Grimstad F. Contraception across
theme is the small number of prospective and randomized the transmasculine spectrum. Am J Obstet Gynecol. 2020;222
(02):134–143. Doi: 10.1016/j.ajog.2019.07.043
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10 Light A, Wang LF, Zeymo A, Gomez-Lobo V. Family planning and
Studies on contraceptive use and contraindications to meth-
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12 United Nations. Department of Economic and Social Affairs.
Conclusion Population Division. Estimates and projections of family planning
indicators 2019. New York: United Nations; 2019
Both gynecologists and general practitioners have questions 13 Curtis KMUS, Tepper NK, Jatlaoui TC, Berry-Bibee E, Horton LG,
about the particularities of contraceptive prescriptions for Zapata LB, et al. medical eligibility criteria for contraceptive use,
the TM population. The use of this objective, semistructured, 2016. MMWR Recomm Rep. 2016;65(03):1–103. Doi: 10.15585/
mmwr.rr6503a1
and easily applied instrument can assist in the discussion
14 World Health Organization. Medical eligibility criteria for con-
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Braga G. C. Data collection or analysis, and interpretation Løkkegaard E. Risk of venous thromboembolism from use of
of data; Okano S. H. P., Braga G. C. Writing of the article or oral contraceptives containing different progestogens and oes-
critical review of the intellectual content: Okano S. H. P. trogen doses: Danish cohort study, 2001-9. BMJ. 2011;343:d6423.
Doi: 10.1136/bmj.d6423
and Pellicciotta G. G. M. Final approval of the version to be
18 Gompel A, Ramirez I, Bitzer JEuropean Society of Contraception
published: Okano S. H. P. and Braga G. C. Expert Group on Hormonal Contraception. Contraception in
cancer survivors - an expert review Part I. Breast and gynaeco-
Conflict of Interests logical cancers. Eur J Contracept Reprod Health Care. 2019;24
The authors have no conflict of interests to declare. (03):167–174. Doi: 10.1080/13625187.2019.1602721
19 Cagnacci A, Ramirez I, Bitzer J, Gompel A. Contraception in cancer
survivors - an expert review Part II. Skin, gastrointestinal, haemato-
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