Late Diagnosis of Pregnancy in a Transmasculine Patient on Testosterone: A Case Report and Patient Perspective

Testosterone therapy can be an important component of care for transgender and gender-diverse (TGD) patients assigned female at birth (AFAB) who wish to pursue hormonal transition. While testosterone often leads to menstrual suppression, it is not a reliable source of contraception and can be teratogenic. Our patient presented to the clinic at age 18 to establish care and resume gender-affirming hormone therapy with testosterone (GAHT-T). The patient's first visit, typically a comprehensive intake conducted to understand patients' general health and transition-related goals, which includes discussion surrounding sexual health and family planning, was truncated due to time constraints. However, a joint decision was made to restart GAHT-T given its importance for the patient's health and transition. Routine labs to assess hormone levels were conducted at follow-up and incidentally showed rising estradiol levels, which are unusual for patients on GAHT-T, and triggered concern and evaluation for a possible underlying endocrine tumor. The patient was ultimately determined to have a single intrauterine pregnancy at 35 weeks of gestation. Understanding patients' comprehensive health and transition-related goals and routinely engaging in shared decision-making can optimize options, autonomy, well-being, and health outcomes for TGD patients. Providers should be skilled in sensitively and meaningfully engaging patients in conversations surrounding overall health, sexual health, contraception counseling, family planning, fertility preservation, and options when there is a late diagnosis of pregnancy. Our patient shares insight on the physical and psychological impact of their journey and the significance of open and safe patient-provider relationships in supporting whole health for patients.