An Update on Contraception for Transgender, Non-binary, and Gender-expansive Individuals

Purpose of ReviewThe goal of this review is to summarize the current understanding of how exogenous testosterone and estrogen affects fertility in transgender, non-binary, and gender-expansive (TGE) individuals, and what contraceptive options are available for this population.Recent FindingsRecent studies have shown conflicting findings with regards to the effects of exogenous testosterone on ovulation and the endometrium; however, the overarching conclusion continues to be that it cannot be viewed as a contraceptive. Survey studies conducted in the past 5 years have repeatedly shown disparities in the rates of contraceptive use among TGE individuals compared to their cisgendered peers, with condoms being the most commonly used contraceptive among this population, followed by the pill and long-acting reversible contraceptives. Studies on the effects of exogenous estrogen use on testicular structure and spermatogenesis have shown findings suggestive of reduced fertility; however, no long-term data is available and further investigation is needed. Contraceptives need to be recommended for these individuals to avoid unintended pregnancies due to incomplete suppression of spermatogenesis. Data shows condoms are the first-line option.SummaryDespite the need for healthcare providers to discuss contraception with TGE individuals, research and guidance on this topic remains limited. Advancements have been made in understanding how exogenous testosterone or estrogen taken as part of gender-affirming hormone therapy (GAHT) can affect fertility, but there remain significant gaps in knowledge beyond the understanding that these therapies are not sufficient to prevent pregnancy and contraception is required to avoid unintended pregnancies. There remain disparities in contraceptive use among TGE individuals, and between TGE individuals and their cisgendered peers. This literature review will focus primarily on new publications related to the contraceptive needs and options for the TGE community to help inform healthcare providers of specific considerations for their TGE patients. By creating a trusting, gender-inclusive environment, reproductive healthcare providers can engage in shared decision-making with TGE patients to select the most appropriate contraceptive for each specific patient.