Contraception in Gender Diverse Patients

Transgender, non-binary and gender diverse people who have a uterus and ovaries can become pregnant and may need contraception, including those taking masculinising hormone therapy. Care should use the patient's chosen name and pronouns, avoid assumptions, and be trauma-informed, because dysphoria and past discrimination affect engagement with pelvic care.

Testosterone is not contraception. Testosterone can cause amenorrhoea but does not reliably suppress ovulation, and pregnancy has occurred in patients on it. Testosterone is teratogenic and should not be continued in pregnancy, so reliable contraception is needed for anyone who has penetrative sex with a partner who produces sperm.

Assessment. Gender identity and goals, current and planned hormone therapy, surgical history (hysterectomy, oophorectomy), sexual practices and partners, bleeding and dysphoria related to menses or pelvic examination, mental health, smoking, blood pressure, BMI, venous thromboembolism risk, and pregnancy intention including future fertility.

Pregnancy exclusion. The usual criteria apply; amenorrhoea on testosterone does not exclude pregnancy, so a urine test is done when there is doubt.

Effectiveness. First-year pregnancies per 100 people with typical use: implants 0.05, intrauterine devices 0.2 to 0.8, injectables 3, combined pills 8.

Eligibility. The usual medical categories apply to patients with a uterus. No known interaction between testosterone and hormonal contraceptives changes the categories.

Method comparison.

• Levonorgestrel 52 mg device: reduces or stops bleeding, which can ease dysphoria; insertion may be distressing and should be planned with analgesia and a trauma-informed approach.

• Copper device: no hormones and no effect on gender-affirming therapy, but may increase bleeding and cramping.

• Implants: reduce or stop bleeding, no pelvic examination needed.

• DMPA: reliably suppresses menses and ovulation, with no pelvic examination needed; discuss bone and weight effects.

• Progestin-only pills: acceptable if the patient is comfortable with daily dosing.

• Combined methods: contain oestrogen, which may conflict with the patient's goals and adds thrombotic risk; offered only if the patient wishes and is eligible.

• Condoms: for STI and HIV protection with any method.

• Sterilisation: possible after counselling on future fertility, and often included in gender-affirming surgery.

Fertility. Testosterone and surgery can reduce future fertility; discuss oocyte preservation before starting therapy or before surgery.

Special groups. Adolescents need the usual assent and consent process. Patients on puberty-suppressing or masculinising therapy follow the same method rules.

Regimen lines.

• Etonogestrel 68 mg rod: 3 years; levonorgestrel two 75 mg rods: 5 years or 3 years by system; backup 7 days if inserted after day 7 of bleeding.

• Levonorgestrel 52 mg device: 5 years; copper T 380A: up to 12 years; insertion within 12 days of the start of bleeding or at any time if reasonably not pregnant; no backup.

• DMPA 150 mg intramuscularly every 13 weeks, up to 4 weeks late, or 104 mg subcutaneously every 13 weeks, up to 4 weeks late, with self-injection supported and up to 4 doses dispensed; backup 7 days if started after day 7 of bleeding.

• Progestin-only pill: one tablet daily without a break; late window 3 hours for the traditional pill, 12 hours for desogestrel and 24 hours for drospirenone; backup 2 days after a late or missed pill.

• Emergency contraception: levonorgestrel 1.5 mg within 120 hours, or the copper T 380A within 5 days.

Insertion planning. Offer self-insertion of the speculum, a smaller speculum, an experienced clinician of the patient's choice, a support person, topical or infiltration anaesthesia, and the option to stop at any time.

Following surgery. After hysterectomy and oophorectomy, contraception is no longer needed for pregnancy; condoms continue for STI protection.

Follow up. Review bleeding, dysphoria, mood, testosterone dosing, weight, blood pressure and method satisfaction at each visit.

Breakthrough bleeding on testosterone. Check adherence and dose, exclude pregnancy and infection, and add a progestin-only method if it is not already in use.

Atrophic symptoms and discomfort at examination. Local oestrogen, if acceptable to the patient, and gentle technique reduce discomfort.

Pregnancy. Offer all options, stop testosterone if the pregnancy continues, and arrange supportive antenatal care.

Mental health. Screen for depression, anxiety and suicidal thoughts at each visit and refer when needed.

Red flags. Suicidal thoughts, severe pelvic pain, signs of infection, missed bleeding with pain.

Referral and escalation. Refer pregnancy, suspected ectopic pregnancy, mental health crisis and gender-affirming surgery planning to the appropriate teams.