The Trans Directory

FTM Periods and Fertility

9 min read

What testosterone does (and doesn’t do) to periods, fertility, and pregnancy risk is one of the biggest questions for trans men and transmasculine people. The short version: periods usually stop, fertility usually comes back if you stop T, and testosterone is not birth control.

Periods on T

Most people’s periods stop within 1-6 months. The Endocrine Society’s expected-effects table lists cessation of menses (periods stopping) at 1-6 months, and WPATH SOC8 says T “usually results in cessation of both menses and ovulation, often within a few months of initiating therapy.”12 Reported rates of amenorrhea (no periods) at 6 months vary widely between studies (~55-96%), around 90% is a reasonable expectation, but roughly 1 in 10 people still bleed beyond 6 months.34

Breakthrough bleeding (bleeding that shows up despite being on T) is common even later on. In the largest cohort of trans adolescents and young adults, 25% had at least one episode of breakthrough bleeding after more than a year on T, starting on average about 2 years in and 79% had no identifiable cause.5 With long-term use, up to one-third of people may experience it.6

When bleeding needs checking

Get reviewed if bleeding: persists beyond ~6 months when starting T, returns after a long stretch of no periods, is much heavier than before, or comes with unusual pain or other symptoms. First steps are usually checking your testosterone level and adherence (missed doses are a known trigger), and ruling out pregnancy if you have sex that could cause it. Unexplained persistent bleeding warrants an exam and possibly ultrasound or biopsy. every published case of endometrial cancer (cancer of the womb lining) in a trans man presented with vaginal bleeding, so don’t ignore it.47

If bleeding won’t stop: clinicians commonly add a progestin (a progesterone-like hormone) or a GnRH agonist (a medication that switches off the ovaries’ hormone signals). Honest caveat: no medical approach has been proven superior to simple observation, only hysterectomy (surgery to remove the uterus) is 100% definitive.6 Amenorrhea is also dose-dependent: persistent bleeding is more common on gel and at lower T levels, so an under-range level is worth ruling out (see FTM Dosages and FTM Target Ranges).

Testosterone is NOT contraception

You can get pregnant on T even with no periods

A 2024 study of ovarian tissue found 33% of people on adequate testosterone (>=1 year) whose periods had stopped showed signs of recent ovulation, no correlation with dose, level, or formulation.8 In the key pregnancy survey, 20% of trans men who had used T before conceiving got pregnant while their periods were stopped.9 Ovulation on T is invisible, your bleeding pattern tells you nothing reliable about it.10 If you have sex that could cause pregnancy and don’t want to be pregnant, you need real contraception. Every major guideline agrees on this.11

This matters because the misconception is common: in one 2016 survey, 16% of trans men were relying on T as their contraception, some on a provider’s advice.10 And 54% of pregnancies in one national survey of trans and gender-diverse people were unintended.11

Contraception that works with T

  • Progestin-only methods (pill, implant, DMPA injection, levonorgestrel IUS) and the copper IUD (a small hormone-free device placed in the uterus for contraception) are the usual first-line recommendations, they’re not thought to interfere with masculinization, and injectables/the hormonal IUS have the bonus of reducing or stopping bleeding.12
  • Estrogen-containing methods are an unknown. ACOG and the Society of Family Planning say combined methods are not contraindicated (not ruled out as unsafe) on T and cause little change in masculinization; the UK’s FSRH advises against them (estrogen may counteract masculinization) and NHS Scotland advises avoiding them (blood clot risk).1213 No study has ever directly measured the interaction, all positions are extrapolations. If you want an estrogen-containing method I’d recomend discussing more with a medical professional.
  • Emergency contraception (levonorgestrel, ulipristal, copper IUD) is fine on T.12
  • Hormonal contraceptive efficacy on T has never been systematically studied effectiveness estimates come from cisgender-women data.10

Pregnancy and testosterone

Testosterone is teratogenic (can harm a developing pregnancy)

T can virilize a fetus (cause a developing baby’s genitals to masculinize). Pregnancy is an absolute contraindication to testosterone: stop before trying to conceive and stay off for the whole pregnancy.1314 The optimal washout interval (how long T takes to clear your system) is genuinely unknown, UCSF and SOC8 both say so, so plan the timing with a clinician rather than guessing.214 If an unintended pregnancy happens on T: you’ll be counseled on all options; if continuing the pregnancy is on the table, stop T immediately.15

In the landmark Light 2014 survey of 41 trans men who had been pregnant after transition, prior T use did not worsen pregnancy, delivery, or birth outcomes, and most conceived within 6 months of stopping.9 Pregnancy can cause dysphoria and isolation for some people, SOC8 recommends preconception and prenatal care in gender-affirming settings, with mental-health support and a plan for delivery, feeding, and when to stop/resume T.2

Fertility preservation and stopping T

Think about fertility before starting T every major guideline recommends it, even if it feels irrelevant right now.216 (UCSF has a plain-language fertility page that walks through the options.) Options for people with ovaries:

  • Egg (oocyte) freezing or embryo freezing involves ~2 weeks of daily hormone injections, monitoring ultrasounds, and a sedated retrieval procedure. All of this can be dysphoria-inducing; good clinics will plan around that with you.16
  • Ovarian tissue cryopreservation (freezing ovarian tissue to use later) can be done at the time of gender-affirming surgery without hormone stimulation (still the more experimental route).16
  • Do you have to stop T, and for how long? Traditional protocols stopped T until menses returned (~3-6 months in published cohorts). Newer case reports show successful egg retrieval after only ~3.5 weeks off T and a few with no cessation at all, though outcome data is sparse.17 Egg yields and outcomes after stopping look comparable to cis women of the same age across several small cohorts.17

What stopping T involves: fertility usually returns, in Light 2014, ~80% resumed menses within 6 months of stopping (most within 3), and some conceived before their first period.914 But it’s not guaranteed: permanent loss is possible, and some people need assisted reproduction (treatments like IVF). Plan both ways, and see FTM Effects for what else reverts and what doesn’t. Whether long-term T affects egg quality or future children is unknown, SOC8 flags this as a major knowledge gap.2

Vaginal and urinary comfort

Vaginal/urogenital atrophy is common on T (dryness, irritation, pain or spotting with penetration; also urinary urgency and more frequent UTIs), starting 1-6 months in.18 It’s treatable:

  • Lubricants and vaginal moisturizers first-line of defense, no hormones.
  • Low-dose topical (vaginal) estrogen cream, tablet, or ring. Recommended across trans-care guidelines because very little is absorbed into the bloodstream at low doses, and it’s believed not to undermine masculinization. Keep in mind it has never been studied specifically in transmasculine people, efficacy and any feminizing effect are extrapolated from postmenopausal cis-women data.18 See FTM Evidence Gaps.
  • Pelvic floor physiotherapy for pain. pelvic pain on T is real, common, and was community knowledge years before guidelines caught up (see FTM Community Knowledge).

Chestfeeding

Chestfeeding is possible and commonly chosen, including for many who’ve had top surgery (in the MacDonald 2016 qualitative study, 16 of 22 participants chestfed; some post-surgery participants had chest-tissue regrowth).19 Small amounts of testosterone do pass into milk, and effects on the infant are unknown, so official guidance (SOC8, ACOG) is to delay restarting T until chestfeeding ends; it can be resumed afterward.213 Lactation suppression (medication such as cabergoline that stops milk production) can be offered if you want it.13

Further reading

No single website, this one included, should be your only source; these are reputable places to keep reading.

Related pages: FTM HRT | FTM Effects | FTM Low-Dose and Nonbinary | FTM Long-Term Health | FTM Myths and FAQ | Surgeries | FTM Resources

Footnotes

  1. Endocrine Society Clinical Practice Guideline (Hembree et al., 2017), effects time-course table - https://academic.oup.com/jcem/article/102/11/3869/4157558 ↩

  2. WPATH Standards of Care v8 (Coleman et al., 2022), Chapters 12 & 16 - https://pmc.ncbi.nlm.nih.gov/articles/PMC9553112/ ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  3. Contraception Considerations in Transmasculine and Gender Diverse Adolescents & Young Adults (review, 2025) - https://pmc.ncbi.nlm.nih.gov/articles/PMC12192487/ ↩

  4. Leeds & York Partnership NHS FT - How to Approach Vaginal Bleeding for Transmen and Non-Binary Individuals (v5, 2023) - https://www.leedsandyorkpft.nhs.uk/our-services/wp-content/uploads/sites/2/2023/05/How-to-Approach-Vaginal-Bleeding-for-Transmen-and-Non-Binary-Individuals-GIS-v5-April23.pdf ↩ ↩2

  5. Grimstad F et al., Breakthrough Bleeding in TGD Adolescents and Young Adults on Long-Term Testosterone, J Pediatr Adolesc Gynecol 2021 - https://pubmed.ncbi.nlm.nih.gov/33910088/ ↩

  6. Grimstad FW et al., Management of breakthrough bleeding in TGD individuals on testosterone, AJOG 2024 - https://pubmed.ncbi.nlm.nih.gov/38876414/ ↩ ↩2

  7. Seay et al., endometrial cancer case report + literature review (2023) - https://pmc.ncbi.nlm.nih.gov/articles/PMC10209109/ ↩

  8. Asseler JD et al., One-third of amenorrheic transmasculine people on testosterone ovulate, Cell Reports Medicine 2024 - https://pmc.ncbi.nlm.nih.gov/articles/PMC10982961/ ↩

  9. Light AD et al., Transgender men who experienced pregnancy after female-to-male gender transitioning, Obstet Gynecol 2014 - https://pubmed.ncbi.nlm.nih.gov/25415163/ ↩ ↩2 ↩3

  10. Society of Family Planning clinical recommendations - contraceptive counseling for TGD people AFAB (Bonnington et al., 2020) - https://www.everybodytexas.org/uploads/images/general/43Society-of-Family-Planning-clinical-recommendations-Contraceptive-counseling-for-transgender-and-gender-diverse-people-who-were.pdf ↩ ↩2 ↩3

  11. CDC U.S. Selected Practice Recommendations for Contraceptive Use - Testosterone Use and Risk for Pregnancy (2024) - https://www.cdc.gov/contraception/hcp/usspr/testosterone-pregnancy-risk.html ↩ ↩2

  12. FSRH Clinical Effectiveness Unit - Contraceptive Choices and Sexual Health for Transgender and Non-binary People (2017) - https://www.cosrh.org/Common/Uploaded%20files/documents/contraceptive-choices-and-sexual-health-for-transgender-non-binary-people-oct-2017.pdf ↩ ↩2 ↩3

  13. ACOG Committee Opinion 823 - Health Care for Transgender and Gender Diverse Individuals (2021) - https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2021/03/health-care-for-transgender-and-gender-diverse-individuals ↩ ↩2 ↩3 ↩4

  14. UCSF Transgender Care - Fertility options for transgender persons - https://transcare.ucsf.edu/guidelines/fertility ↩ ↩2 ↩3

  15. Rainbow Health Ontario - Guidelines for gender-affirming primary care (4th ed., 2023 updates) - https://www.rainbowhealthontario.ca/wp-content/uploads/2021/09/Guidelines-FINAL-4TH-EDITION-With-2023-Updates.pdf ↩

  16. Choi JY et al., Fertility Preservation and Reproductive Potential in Transgender and Gender Fluid Population (review, 2022) - https://www.mdpi.com/2227-9059/10/9/2279 ↩ ↩2 ↩3

  17. Fertility preservation in a transgender man without prolonged discontinuation of testosterone (case report + literature review, Fertil Steril) - https://pmc.ncbi.nlm.nih.gov/articles/PMC8244337/ ↩ ↩2

  18. The Effect of Gender-Affirming Medical Care on the Vaginal and Neovaginal Microbiomes (review, 2022) - https://pmc.ncbi.nlm.nih.gov/articles/PMC8814107/ ↩ ↩2

  19. MacDonald T et al., Transmasculine individuals’ experiences with lactation, chestfeeding, and gender identity, BMC Pregnancy Childbirth 2016 - https://pubmed.ncbi.nlm.nih.gov/27183978/ ↩

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