Myth busting

Gender-affirming hormone therapies (both testosterone and estrogen-based) are not considered birth control. 

People who are using testosterone, have uteruses, and are having sex with pregnancy potential (sex where sperm gets near the uterus) should use birth control to prevent pregnancy. People whose periods have stopped with testosterone use have become pregnant while taking testosterone. Testosterone should not be used during pregnancy (due to effects on the fetus). 

Use of birth control by people who could get pregnant is recommended if they are having sex with pregnancy potential with someone who is using estrogen-based hormone therapy unless pregnancy is desired.

Using testosterone is not a contraindication to the use of any form of hormonal birth control. Use of birth control is recommended for all people using testosterone who are having sex with pregnancy potential. While research is limited, we do not think that hormonal birth control (including estrogen-containing methods) have a significant negative impact on the effects of testosterone. Said another way, this means people using testosterone can use birth control pills, patches, and rings to prevent pregnancy.

We support people of all genders in achieving their family planning goals. At this time there is limited data on the long-term impact of testosterone on fertility and pregnancy outcomes. However, the available data generally suggests that people can get pregnant and carry a healthy pregnancy after using testosterone. Testosterone should not be used during pregnancy (due to effects on the fetus). There may be some impact of long-term testosterone use on gametes (eggs) or future pregnancies, but existing data is limited. Some people pursue gamete (egg) banking (oocyte cryopreservation) prior to or during testosterone use. This process involves taking hormones to stimulate the ovaries to make eggs and then undergoing a needle guided procedure to harvest the eggs. This is not a service PPMI offers. If this is something you are considering, we are happy to provide resources for exploring these services.

We support people of all genders in achieving their family planning goals. At this time there is limited data on the long-term impact of estrogen-based therapy on fertility. However, the available data suggests that estrogen-based therapy likely has a long-term negative impact on the quality and quantity of gametes (sperm). It is possible (and likely) that decreased fertility persists even after stopping estrogen-based therapy. Some people pursue gamete (sperm) banking (semen cryopreservation) prior to or during estrogen-based therapy. This process involves banking ejaculated semen with a fertility lab. This is not a service PPMI offers. If this is something you are considering, we are happy to provide resources for exploring these services.

Testosterone-based therapies do not appear to increase the risk of either uterine or ovarian cancer. Studies are limited at this time, but researchers and clinicians do not think there is a link between testosterone use and uterine or ovarian cancer.

No. Removal of the uterus and/or ovaries is medically necessary for gender dysphoria for some transmasculine and nonbinary people, but use of testosterone does not mean that someone needs to proceed with any particular surgeries.

If you have a cervix (the bottom portion of the uterus) and are between the ages of 21 and 65 years old, cervical cancer screening is recommended. Use of testosterone does not change cervical cancer screening guidelines.  Depending on your age, type of screening, and your results, Pap tests may be needed every 1 to 5 years. People using testosterone should be aware that testosterone increases the risk that cervical cancer screening samples may be “unsatisfactory”; this result occurs approximately 10% of the time for people using testosterone, and repeat testing is recommended following this result. People may experience spotting (light bleeding) after a Pap test.

Yes. Currently, PPMI does not use self-swab testing technology. Cervical cancer screening at PPMI requires a pelvic exam with a speculum. If you have concerns about pelvic exams, please speak with your clinician about ways in which we may be able to best support you to facilitate an exam when you are ready.

You may. In general, breast cancer screening may be recommended for transfeminine and nonbinary people who have been on estrogen-based therapy for at least 5–10 years and are at least 50 years old. Additionally, we always recommend letting a clinician know if you have a breast or chest concern.

Yes, people assigned male sex at birth retain their prostate tissue even if they undergo a vaginoplasty procedure (construction of the vagina). PPMI clinicians do not perform prostate exams. People using estradiol should speak with their primary care doctor about prostate cancer screening. In people who have had a vaginoplasty procedure, the prostate sits in front of the vagina and exams of the prostate are typically best performed by placing a finger in the vagina rather than the rectum.

Some sexually transmitted infection screening, such as hepatitis, syphilis, and HIV, are completed using blood samples. Other testing, like gonorrhea and chlamydia, are done using swabs or urine. The type of testing recommended depends both on the part of the body you have and how you engage in sex. Our health center staff can help recommend screening based on your specific practices. However, in general, for people who have had a vaginoplasty and use their vagina for sex, urine STI screening is recommended rather than vaginal swabs.

We encourage you to discuss any concerns you may have related to sexual pleasure or function with a clinician. 

Testosterone can increase libido, genital sensitivity, and can change lubrication; some people with uteruses also experience uterine cramps intermittently or with orgasm for reasons that are not well understood. Depending on one’s symptoms and goals, additional lubrication, dilator use, pelvic floor physical therapy, ibuprofen use for cramping, an exam, and/or resources for sex therapy may be recommended. Some people have a hysterectomy if symptoms of uterine cramping persist and cannot be well controlled and if having the uterus removed aligns with their needs and goals.

Estrogen-based therapy can cause spontaneous erections to stop or decrease significantly and may decrease or change libido; erections may be less firm and orgasms may take longer to achieve on estrogen-based therapy. Of note, orgasms can occur without erections. Some people using estrogen-based therapy who desire assistance with erections may use medications marketed for erectile dysfunction; PPMI does not prescribe erectile dysfunction medications but encourages folks who are interested to speak with their primary care doctor. Sex therapy may also be helpful; we are happy to provide resources!