For a transgender man on testosterone therapy who still has menstrual periods, what is the most appropriate birth control method?

Best Birth Control for Transgender Men on Testosterone with Persistent Menses

For a transgender man on testosterone therapy who continues to menstruate, the levonorgestrel intrauterine system (LNG-IUS) or depot medroxyprogesterone acetate (DMPA) are the most appropriate contraceptive options, as they provide highly effective pregnancy prevention while promoting amenorrhea without introducing estrogen that could counteract testosterone's masculinizing effects.

Critical Understanding: Testosterone Is NOT Contraception

Despite inducing amenorrhea in many transmasculine individuals, testosterone does not reliably inhibit ovulation and pregnancy remains possible 1, 2. Approximately 23% of transgender men on testosterone continue to menstruate beyond 6 months of therapy 3. This makes dedicated contraception essential for anyone engaging in sexual activity with reproductive potential.

Recommended Contraceptive Options

First-Line Methods

Levonorgestrel Intrauterine System (LNG-IUS)

• Provides highly effective contraception with typical use failure rate <1%
• Promotes amenorrhea in 22-34% of users within the first year 4
• Requires minimal healthcare interaction after insertion
• No estrogen to counteract testosterone effects
• Can be inserted at any time if reasonably certain patient is not pregnant 4
• Requires backup contraception for 7 days after insertion if placed >5 days since menstrual bleeding started 4

Depot Medroxyprogesterone Acetate (DMPA)

• Injectable progestin-only method with 6% typical use failure rate
• Amenorrhea common after ≥1 year of continuous use 4
• No estrogen exposure
• Can be started within first 5 days of menstrual bleeding without backup contraception; if started later, requires 7 days of backup contraception 4
• Addresses both contraception and menstrual suppression goals

Alternative Options

Etonogestrel Implant

• Highly effective (failure rate <1%)
• 22% of users experience amenorrhea, 34% have infrequent spotting 4
• Progestin-only formulation
• Requires backup contraception for 7 days after insertion if placed >5 days since menstrual bleeding started 4

Progestin-Only Pills (POPs)

• No estrogen exposure
• Requires strict daily adherence
• Higher failure rate than LNG-IUS or implant
• May help consolidate amenorrhea 5, 6

Methods to Generally Avoid

Combined Hormonal Contraceptives (Pills, Patch, Ring)

• Contain estrogen which may counteract testosterone's masculinizing effects
• Can exacerbate gender dysphoria 1, 6
• Increased VTE risk, particularly concerning given testosterone's potential cardiovascular effects 7
• Should not be used in first 3 weeks postpartum (if applicable) due to VTE risk 4

Important Clinical Considerations

Addressing Persistent Menstruation

• If menstruation persists >6 months on testosterone, consider:
  • Testosterone formulation: Injectable forms more effective at inducing amenorrhea than gels/creams (OR = 11.3 for persistent menses with gels) 3
  • BMI ≥30 kg/m² associated with lower odds of persistent menstruation 3
  • Adding progestin-only contraception specifically for menstrual suppression

Contraceptive Counseling Approach

• Use shared decision-making prioritizing patient's stated needs 2, 5
• Discuss dual goals: pregnancy prevention AND menstrual suppression
• Address that some patients mistakenly rely on testosterone as contraception 8
• No method should be withheld due to gender incongruence alone 5

Timing and Backup Contraception

• Most methods can be started immediately if reasonably certain patient is not pregnant 4
• If started >5 days since menstrual bleeding began, use backup contraception (condoms or abstinence) for 7 days 4
• Emergency contraception (ulipristal acetate or levonorgestrel) should be discussed and potentially provided in advance 4

Common Pitfalls to Avoid

1. Assuming testosterone provides contraception - It does not reliably prevent ovulation 1, 2
2. Defaulting to estrogen-containing methods - These can worsen dysphoria and counteract testosterone effects 1, 6
3. Not discussing menstrual suppression as a separate goal - Many transmasculine patients seek contraception specifically for amenorrhea 2, 5
4. Requiring unnecessary pregnancy testing - Consider serum β-hCG instead of urine testing to reduce dysphoria 9

Special Considerations

If Using Sugammadex or Aprepitant

• Counsel that these medications reduce oral contraceptive efficacy
• Sugammadex: 1 week of reduced efficacy
• Aprepitant: 1 month of reduced efficacy 9
• This applies to transmasculine patients on oral contraceptives, not to transfeminine patients on estrogen

Fertility Preservation

• Contraceptive counseling visits provide opportunity to discuss fertility goals and preservation options 2