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Data unclear on pregnancy risk in transmasculine individuals on testosterone

2019; Elsevier BV; Volume: 222; Issue: 4 Linguagem: Inglês

10.1016/j.ajog.2019.12.014

1097-6868

Finn D. Schubert, Jeanne Carey,

Reproductive Health and Contraception

Although we were pleased to see the article by Krempasky et al1Krempasky C. Harris M. Abern L. Grimstad F. Contraception across the transmasculine spectrum.Am J Obstet Gynecol. 2020; 222: 134-143Abstract Full Text Full Text PDF Scopus (61) Google Scholar on the contraceptive needs of transmasculine individuals, we have serious concerns about their scientific interpretation regarding pregnancy risk in transmasculine individuals on testosterone. Although Krempasky et al state that the 2014 study by Light et al2Light A.D. Obedin-Maliver J. Sevelius J.M. Kerns J.L. Transgender men who experienced pregnancy after female-to-male gender transitioning.Obstet Gynecol. 2014; 124: 1120-1127Crossref PubMed Scopus (299) Google Scholar found that 20% of transmasculine individuals who became pregnant did so while amenorrhoeic on testosterone, this number actually reflects those who were amenorrhoeic from the effects of recent testosterone exposure, including those who had stopped taking testosterone as prescribed. Similarly, in 2018 Light et al3Light A. Wang L.-F. Zeymo A. Gomez-Lobo V.J.C. Family planning and contraception use in transgender men.Contraception. 2018; 98: 266-269Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar examined 60 pregnancies among transmasculine individuals and did not report any that occurred in individuals who were consistently taking testosterone, with only 1 pregnancy in an individual who had been taking testosterone inconsistently at the time of conception. Instead of acknowledging the lack of high-quality data regarding testosterone's effects on fertility, Krempasky et al1Krempasky C. Harris M. Abern L. Grimstad F. Contraception across the transmasculine spectrum.Am J Obstet Gynecol. 2020; 222: 134-143Abstract Full Text Full Text PDF Scopus (61) Google Scholar draw questionable conclusions based on small, ambiguous studies and inappropriate clinical comparisons. The authors present data from cisgender women with congenital adrenal hyperplasia and polycystic ovary syndrome, which is not an appropriate comparison, and studies that were designed to evaluate hormone levels in the context of bone mineral density. There is a need for large-scale studies that examine pregnancies by person-months on testosterone in the context of appropriately dosed and monitored testosterone levels without menstruation or abnormal uterine bleeding. Much existing literature, including the article by Krempasky et al,1Krempasky C. Harris M. Abern L. Grimstad F. Contraception across the transmasculine spectrum.Am J Obstet Gynecol. 2020; 222: 134-143Abstract Full Text Full Text PDF Scopus (61) Google Scholar unfortunately conflates pregnancy risk among transmasculine individuals who are and are not maintained at appropriate testosterone levels. The evidence presented does not support adequately the assertion that breakthrough ovulation is a substantial concern for transmasculine patients who are maintained at appropriate testosterone levels. Overstating the risk of pregnancy for such individuals could increase barriers to hormone therapy (ie, providers who perceive the risk of pregnancy to be high may decline to prescribe testosterone to transmasculine individuals who do not agree to use a contraceptive method, and patients may agree to accept contraceptive methods that they find undesirable to maintain access to testosterone). When counseling transmasculine patients on testosterone regarding contraception, we favor a shared decision-making model that acknowledges the gaps in evidence and supports the patient in making a decision that is aligned with their values and preferences. Krempasky et al's1Krempasky C. Harris M. Abern L. Grimstad F. Contraception across the transmasculine spectrum.Am J Obstet Gynecol. 2020; 222: 134-143Abstract Full Text Full Text PDF Scopus (61) Google Scholar thorough review of contraceptive considerations will be helpful in counseling transmasculine individuals who desire contraception, including those who are not using testosterone, who are using testosterone irregularly or at low doses, or who are maintained on testosterone who desire the use of a contraceptive method. Contraception across the transmasculine spectrumAmerican Journal of Obstetrics & GynecologyVol. 222Issue 2PreviewThe field of transgender health continues to expand rapidly, including research in the area of family planning. While much attention has been given to fertility preservation and the parenting intentions of transgender individuals, far less has been paid to pregnancy prevention and contraceptive needs of people along the transmasculine gender spectrum (transgender men and gender-nonbinary persons who were assigned female at birth). Existing research illustrates that many clinicians and transmasculine individuals falsely believe that there is no risk of pregnancy while amenorrheic. Full-Text PDF