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HRT and Birth Control: What You Need to Know, Explained by FOLX

Gender affirming hormone therapy (GAHT)— neither testosterone nor estrogen—cannot be a substitute for birth control. But rest assured: there are many options for birth control while on HRT!

Choosing  birth control for you and your partner on HRT

Make no mistake: birth control is not exclusively a women's health topic. Cisgender women are not the only people who utilize or need birth control. Plenty of people across the gender spectrum, including transgender men, transgender women, non-binary and intersex people, and many other people of varying genders belong in conversations about reproductive health, wellness, and access.

While there are many other uses for birth control other than pregnancy prevention, it should be noted that hormone replacement therapy (HRT) is not and cannot be a replacement for birth control as a method of pregnancy prevention. This is true regardless of whether you're on a high or low dose of testosterone or estrogen. In this article, we will be specifically referring to the type of sex where sperm can enter the uterus of a person with ovaries. If this is the type of sex you might be having, and you are on HRT or considering HRT, keep reading for necessary sexual health information regarding this topic.

If you’re using birth control to prevent pregnancy, determining which route to take depends on your preference.

Those on testosterone hormone therapy, who choose to go on hormonal birth control, will often decide on a progesterone-only birth control method since they typically don’t want to add more estrogen into their bodies. Taking birth control with estrogen (such as oral contraceptives) may cause some unwanted side effects at the beginning such as chest tenderness or mood swings. It’s important to know that the estrogen in birth control pills is synthetic, not bio-identical (such as the type used in HRT). However, it’s important to know that an estrogen contraceptive shouldn’t alter or decrease testosterone's effect on your body.

If someone on testosterone therapy doesn’t want to put (more) estrogen in their body, there are many options, including hormone-free options. If someone initially utilized contraceptive methods for reasons aside from preventing pregnancy—like controlling bleeding or cramps related to menstruation, after being on T for a while, it may be worth reassessing the need for using contraception. For those taking estrogen—with or without anti-androgens—while estrogen HRT may lower sperm count, it’s important to know that it may still be possible to get someone pregnant.

Birth control options

There are hormonal contraception options as well as hormone-free options; some forms of birth control are more immediate while others are long-term and they all have different efficacy rates. Each person should choose the type of birth control that feels best for them. Fertility tracking methods are often not reliable while using testosterone HRT, as the timing of ovulation may vary.

Immediate methods of birth control that are only needed at the time of sex (primarily to prevent pregnancy) include: 
  • External condom worn on the penis (which can also prevent STIs)
  • Internal condom inserted in the vagina/front hole (which can also prevent STIs)
  • Diaphragm (with the use of spermicide) or cervical cap inserted in the vagina/front hole
  • Spermicide alone inserted in the vagina/front hole
  • Withdrawal method (pulling the penis out of vagina/front hole before ejaculation)*
  • Plan B/Ella emergency contraception, to be taken up to five days after

*It should be noted that this is a method with low efficacy (may have lower pregnancy rates than not withdrawing, but much higher pregnancy rates than a barrier method or other methods)

Short-acting methods, to be taken daily, that have other added benefits beyond preventing pregnancy include: 
  • The Pill (contains estrogen), which can also improve bleeding/cramps and acne for some
  • Progestin-only birth control pills, which can also improve bleeding/cramps and acne for some
Medium-acting methods that require weekly or monthly attention include:
  • A shot every three months (i.e. Depo-provera)
  • The Patch (contains estrogen), applied three weeks in a row, followed by one week off, can also improve bleeding/cramps and acne for some (i.e. Xulane)
  • The Ring (contains estrogen), inserted into the vagina and changed monthly or yearly (i.e. Nuvaring, Annovera)
Long-acting methods that require a healthcare provider to place or remove
  • Copper IUD (contains no hormones) placed in the uterus and may be left in place up to 12 years (i.e ParaGard)
  • Progestin IUD placed in the uterus and may be left for three to seven years (i.e. Liletta, Mirena, Kyleena, Skyla)
  • An implant placed under the skin of the arm by a healthcare provider (i.e. Nexplanon) can be left in for four years*

*Nexplanon is not currently FDA approved for use up to four years—the current recommendation is three years. Although studies do support use up to five years, the FDA has not yet updated the label.

What about menopause?

Typically, the average age where a cisgender woman starts experiencing menopause (a complete year of not having a menstrual period) is between 51 and 52 years old, according to the Cleveland Clinic. Likewise, early menopause can happen to cisgender women before the age of 45 and premature menopause can happen before the age of 40. Perimenopause (a time "around menopause" during which your body transitions into the end of reproductive years) can happen to those in their mid-30s.

Why is this important for non-cisgender people to know?

Since we recognize more than cisgender women experience menopause, transgender, non-binary, intersex, and other gender-variant people can also go through menopause and therefore may not need hormonal treatment to prevent pregnancy. Please consult with your healthcare provider if you believe you're experiencing menopausal symptoms, which can include hot flashes, vaginal / front hole dryness, difficulty sleeping, night sweats, etc.

Birth control is fully up to the decision of the person whose body it is depending on the types of sex they want to have. FOLX clinicians are available for any further questions to find the right combination of birth control and HRT for each person.‍

For those interested in longer-term family planning, there’s more to read about in the articles Testosterone and Fertility and Estrogen and Fertility. For FOLX members with questions about birth control options, follow up with your provider by scheduling an appointment with a clinician. For anyone who isn't a FOLX member, drop us a line at support@folxhealth.com!