Gynecological care for trans men

Comprehensive healthcare for transgender men includes gynecological care. This care is particularly important for those who have not had gender-affirming surgery.

Some trans men have trouble finding a healthcare professional who understands their needs. Look for a healthcare professional who is familiar with transgender health. Your care professional should be someone who is respectful of you and your concerns, and with whom you feel comfortable. A number of trans-focused organizations offer guidance in finding care professionals, including the World Professional Association of Transgender Health.

Try not to let negative interactions with healthcare professionals in the past or the fear of negative reactions prevent you from getting the care you need. You deserve to receive healthcare from someone who is inclusive and competent in providing transgender care.

Once you've established a relationship with your healthcare professional, it's important to share your medical history to ensure that you receive the right care for you. That includes information about surgeries, hormone therapy and other gender-affirming care you've had. Ask about tests recommended for trans men in your age group. Also ask about screenings, which are tests that look for certain diseases. Talk with your healthcare professional about any specific health concerns you may have.

Breast tissue health

Everyone has breast tissue. Even trans men who have had top surgery to create a male-contoured chest, called masculinizing chest surgery, still have some breast tissue. While the risk is much lower after that procedure, breast cancer still can develop.

Take these steps:

• Tell your healthcare professional if any family members have had breast cancer.
• Become familiar with the look and feel of your chest. Ask your healthcare professional what changes to look for that might be signs of a problem. Tell your healthcare professional if you see any changes.
• Talk to your healthcare professional about the cancer screenings you may need.

In general, breast cancer screenings for trans men who haven't had top surgery are based on guidelines for women who are not trans, also called cisgender women. But screening recommendations for breast cancer can vary depending on your situation.

If you've had top surgery and a mammogram isn't possible, you might have an MRI or ultrasound to check your breast tissue, depending on your cancer risk.

If you use a binder or other chest compression, tell your healthcare professional. Your care professional can help ensure that you're using it safely and offer guidance on how to avoid problems, such as developing a rash or a yeast infection of the skin.

Pelvic health

You might be at risk of cancer of the cervix, ovaries or uterus if you have not had surgery to remove them. This is true whether or not you take testosterone. Testosterone therapy doesn't change your risk of these cancers.

For good pelvic health, your care professional may suggest the following exams and tests. Your comfort during these exams is important. Talk with your healthcare professional about what would help put you at ease.

• A pelvic exam. This exam checks for problems with the uterus, vagina, ovaries and cervix. During a pelvic exam, a care professional looks at the genitals, feels inside the vagina, and looks at the vagina and cervix. If you are not comfortable having a pelvic exam, tell your care professional. You may have the option of having the procedure while you are under sedation.
• Pap test. For this test, a healthcare professional uses a small, soft brush to collect cells from the cervix. The cells are studied under a microscope to look for changes that could be signs of cancer. In many cases, a test for types of the human papilloma virus (HPV) that could put you at high risk of cervical cancer is done at the same time.
• Sexually transmitted infection tests. You can get a sexually transmitted infection from oral, anal or vaginal sex. These infections include chlamydia, gonorrhea, syphilis, herpes and hepatitis. HPV and the human immunodeficiency virus (HIV) also can be passed during sex. Depending on your situation, your healthcare professional might suggest that you have regular screenings for HIV and other sexually transmitted infections.

To protect your health:

• Use a condom or other barrier protection. Use a new condom every time you have vaginal or anal sex. During digital penetration, think about using a latex glove. During oral sex, use a latex barrier, also called a dental dam. Use only water-based lubricants. Do not use petroleum jelly, hand lotion, cold cream or oil-based products. They can weaken latex condoms and cause them to break.

• Get tested and have your partner get tested. Do not have unprotected sex unless you are sure you and your partner are not infected with a sexually transmitted infection. Testing is important because many people do not know they are infected. And some might not be honest about their health.

  Keep in mind that a person may be infected with HIV and have a negative test result. It can take up to three months after being infected with HIV for a blood test to become positive. You and your partner may want to be retested after three months from a possible exposure to HIV.

• Treat sexually transmitted infections. If you have an infection, follow the treatment plan your healthcare professional gives you. To help prevent repeat infections, ask that you and your partner or partners get treatment at the same time.

• Take steps to prevent and treat HIV. If you are concerned about HIV, talk to your care professional about medicines that may help prevent it. Some medications may help prevent HIV even if you have unprotected sex with someone who has HIV.

  If you are at high risk of exposure to other people who have HIV, your healthcare professional may recommend preexposure prophylaxis (PrEP). You take one or more medicines daily. Post-exposure prophylaxis (PEP) consists of one or more medicines that you take soon after a possible exposure to HIV. If you or your partner or partners have HIV, follow the plan your care professional gives you for how to treat and monitor the infection.

• Get vaccinated. Vaccines can protect you from hepatitis A and hepatitis B. These serious liver infections can spread through sexual contact. HPV also can be passed to you during sex. HPV can cause cancer of the cervix. The HPV vaccine can help prevent most types of cervical cancer and genital warts. It is available to children, teens and young adults.

Not all sexually transmitted infections are prevented by vaccines. For example, there are no vaccines for hepatitis C, HIV, herpes, gonorrhea or chlamydia.

• Know the risks of sexual settings. Sexual settings such as those found through the internet can make it easy to have many sexual partners and to have sex with people you do not know. Some people who have a sexually transmitted infection may not tell you about it.
• Practice safer sex. Do not share sexual devices. Protect them with a condom and clean them with soap and water before and after every use.

Fertility and fertility preservation

Some trans men wish to have children. Others do not. The choice is a personal one. If you think you'd like to have children, ask your healthcare professional about the options available to you. No matter what you choose to do, it's a good idea to plan ahead. If possible, make decisions about children before you start hormone therapy or have gender-affirming surgery.

If you have a uterus and ovaries, you can get pregnant if you have vaginal sex with a person who can produce sperm. This is true even if you take testosterone or have irregular menstrual cycles or no menstrual cycles. Although testosterone might lessen your chance of pregnancy, don't rely on testosterone therapy for birth control. Pregnancy remains possible until menopause.

Birth control options include:

• Barrier methods. Condoms and other barrier forms of birth control help prevent pregnancy and sexually transmitted infections.
• Intrauterine device (IUD). An IUD that contains the hormone progestin (Mirena, Liletta, Skyla) can serve as birth control and decrease menstrual bleeding.
• Hormone birth control. Many trans men prefer not to take estrogen. But progestin-based pills are an option for those who would like a pill form of birth control.
• Permanent birth control. Permanent birth control options include tubal ligation, a surgery that permanently blocks the fallopian tubes, and complete removal of the fallopian tubes, a procedure called salpingectomy.

If you want to become pregnant, talk to your healthcare professional. If you take testosterone, you'll need to stop. Talk to your healthcare professional about how hormone use may affect your fertility. Procedures are available that make it possible to carry a pregnancy or to collect and freeze unfertilized eggs or ovarian tissue for future use. This might involve medicine or surgery. Typically, these procedures are available at specialized fertility centers. They can be expensive.

Testosterone use

Taking testosterone can increase your sex drive. Sexual arousal may come unexpectedly and more often than before you started taking testosterone. The hormone can also make your clitoris larger and your vaginal walls thin. If you have receptive sex, you might bleed or have pain. Using a water-based lubricant during sex can help. If the discomfort continues, your healthcare professional might prescribe a topical cream that can help ease symptoms.

Menstrual cycles usually stop within three or four months of starting testosterone. If they continue beyond four months, or if they start again after stopping, tell your healthcare professional. You may need an evaluation to make sure there isn't another medical condition causing the bleeding. If there isn't an underlying medical concern, your care professional may recommend a three-month course of progesterone to stop menstrual cycles long term.

Body image

A positive body image is important for self-esteem and sexual health. Many trans men face challenges with their body image. You may feel pressure to look a certain way. This can be due to cultural or family background or stereotypes promoted in the media.

Body shapes vary. There's no one "right" way to look. Talking about your body image with a trusted friend, family member or therapist might help you feel better. Consider what you like about the way you look. You might also consider using gender-affirming devices, such as a chest-binder, genital packer or stand-to-pee device.

Some trans men have hormone therapy or surgery to change their bodies to match their gender identity more closely. Surgery may include top surgery to create a more male-contoured chest. It also may include bottom surgery. Bottom surgery can be done to increase the length of the clitoris, called metoidioplasty; create a penis, called phalloplasty; or create a scrotum, called scrotoplasty. Ask your care professional for detailed information before you take hormones or have any surgery. Discuss the potential benefits, side effects and risks of these options.

If you have body image concerns, ask your healthcare professional about resources that may help. Seeking counseling or attending a support group might be useful.

For questions or concerns about your gynecological health, talk to your healthcare professional. Together, you can create a plan that best meets your needs.