By Katherine Rivlin, MD, MSc
Associate Professor, Department of Obstetrics and Gynecology, University of Chicago
SYNOPSIS: In a retrospective chart review of transgender and gender-diverse adolescents at a single institution seeking menstrual suppression methods, most individuals had high rates of method continuation, amenorrhea, improved bleeding, and a reduction in dysphoria and mood symptoms.
SOURCE: Schwartz BI, Bear B, Short VL, Kazak AE. Outcomes of menstrual management use in transgender and gender-diverse adolescents. Obstet Gynecol 2023;141:748-755.
For transgender and gender-diverse individuals, the onset of menses can either trigger or exacerbate gender dysphoria. In this context, patients may seek care to manage or suppress menses. Although the field of OB/GYN has extensive data regarding the use of hormones to suppress or manage heavy or bothersome menses, little data exist in the context of gender-affirming care. Adolescents are a particularly vulnerable group to menses-related gender dysphoria, since they are closer to menarche, may be new to seeking gender-affirming care, may not yet feel certain about initiating gender-affirming hormones, or may not have access to gender-affirming care as the result of a lack of parental support or the increasing barriers imposed by legislative bans. Menstrual management using progestin or combined estrogen/progestin therapies can, therefore, provide an alternative to gender-affirming therapies for alleviating dysphoria symptoms related to menses. This study sought to describe and compare various menstrual management methods over the first year of use in transgender and gender-diverse adolescents.
This retrospective chart review of all patients seen by at least one healthcare professional in a single children’s hospital between March 2015 and December 2020 included all patients who desired menstrual management or contraception. All patients received counseling from a single gynecologist who used a shared decision-making approach to determine which menstrual suppression medication to initiate. Participants were identified through the electronic medical record (EMR) based on encounter types and diagnosis codes. Inclusion was confirmed using chart review. The study included those patients assigned female at birth who already had achieved menarche and who used a menstrual management method during the study period. Patients using testosterone were included, since the study assumed that individuals seeking additional hormonal therapy had not achieved sufficient menstrual regulation with testosterone alone. Testosterone was not considered a menstrual management hormone in the study. The study excluded those participants using gonadotropin-releasing hormone (GnRH) agonists.
The team abstracted data from the EMR, including demographics, gender-affirming hormone use, and type of menstrual management method. They also collected information on method continuation, bleeding patterns, effects on mood and dysphoria, and method satisfaction at two follow-up time points: the first at one to three months after method initiation for the levonorgestrel intrauterine system (LNG-IUS) and the etonogestrel-containing arm implant and two to six months after all other method initiation, and the second at one year or at nine to 18 months after initiation. Subjective outcomes, such as method satisfaction, were abstracted from the EMR when documented by the provider.
Of all charts reviewed, 101 patients met inclusion. Most participants (70%) used oral norethindrone acetate (NETA), initiated at a dose of 5 mg daily and adjusted as needed, followed by the LNG-IUS (20%), and combined estrogen-progestin containing oral contraceptive pills (6%). The remainder of participants used the depot-medroxyprogesterone acetate injection (2%), the etonogestrel-containing implant (1%), and the progestin-only oral contraceptive pill (1%). The continuation rate for all methods was 84% at time point one (T1) and 76% at time point two (T2). The amenorrhea rate for all methods was 80% at T1 and 93% at T2. Overall satisfaction rates were high for all methods, with 78% of participants reporting feeling very satisfied at T1 and 97% of participants feeling satisfied at T2. At T2, all participants reported improvement in menstrual bleeding, pain, other menstrual symptoms, mood, and dysphoria associated with menses. Because 90% of participants in the study used NETA or the LNG-IUS, the team compared outcomes between the two methods and found very few differences at T1 and none by T2. Only four included participants were using testosterone at their initial visit. Each of these participants added menstrual suppression methods for breakthrough bleeding. During the study period, 38 additional participants initiated gender-affirming hormones. Most of these participants remained on menstrual suppression hormones either for contraception or for the continued menstrual suppression. Only seven discontinued their menstrual suppression method.
COMMENTARY
Because dysphoria with menses is common, menstrual suppression can play an important role in an individual’s gender-affirming healthcare plan. In addition, because testosterone alone does not reliably suppress ovulation, patients using testosterone who wish to avoid pregnancy should be counseled on contraceptive options.1
This study fills a necessary gap in the literature regarding the use of hormonal menstrual suppression therapies in transgender and gender-diverse adolescents. The study team found high continuation rates, high amenorrhea rates, and high satisfaction rates among study participants. Each of these outcomes improved over time, which can inform provider counseling and anticipatory guidance. That most patients in the study using testosterone still sought or continued to use menstrual suppression methods highlights the important role of these therapies in gender-affirming care, both on their own and as an adjuvant to gender-affirming hormones.
This study also provides necessary data to support the use of the LNG-IUS in gender-diverse adolescents. Minimal data have existed to this point, but the LNG-IUS can be an important tool for both contraception and management of unwanted menses and pelvic pain in this patient population. The localized progestin effect may be particularly beneficial for reducing systemic side effects, including hormonally triggered dysphoria. The authors highlighted, however, that patients may hope to avoid or not tolerate insertion and that placement under sedation should be considered.
Clinicians should note the lower utilization rates for combined birth control pills, the contraceptive injection, and progestin-only pills in this study. The authors stated that many of these methods make menstrual control more challenging and that, anecdotally, gender-diverse youth may hope to avoid estrogen use. Although these methods may be less preferred in this patient population, the low utilization rates also may reflect counseling practices at this institution. Providers always should use a shared decision-making approach to contraceptive counseling and center the patients’ needs and preferences.2 For example, the ease of insertion of the contraceptive implant may be preferred by individual patients compared to the LNG-IUS insertion.
Method satisfaction was high in this study, higher than commonly is reported for oral contraceptives. These differences may reflect differing goals of therapy. Individuals who use oral contraceptives for pregnancy prevention may have different goals or expectations than adolescents experiencing gender dysphoria. Very few of the study’s participants were sexually active or seeking contraception. In addition, the study’s measurement of method satisfaction was not patient reported. Instead, providers documented patient satisfaction in the EMR. High levels of method satisfaction could reflect provider bias rather than user experiences.
Gender-diverse youth experience higher rates of discrimination, psychological diagnoses, and a lack of access to healthcare services when compared to their cis-gendered peers.3 Access to all gender-affirming healthcare and therapies is necessary to reducing healthcare disparities and improving outcomes. Menstrual suppression methods can serve as an adjunct to gender-affirming care for individual patients, can reduce dysphoria as patients determine their long-term goals, or can provide an alternative when gender-affirming care is unavailable either because of a lack of parental support or legislative restrictions. Physicians should continue to advocate for access to and coverage for necessary services for individuals seeking gender-affirming care and oppose bans or restrictions to these services.1 This study adds to the growing body of evidence to support the safety and benefit of gender-affirming care.
REFERENCES
- [No authors listed]. ACOG Committee Opinion No. 823, Health care for transgender and gender diverse individuals: Correction. Obstet Gynecol 2022;139:345.
- American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women, Contraceptive Equity Expert Work Group, and Committee on Ethics. Patient-centered contraceptive counseling: ACOG Committee Statement Number 1. Obstet Gynecol 2022;139:350-353.
- Rafferty J; Committee on Psychosocial Aspects of Child and Family Health; Committee on Adolescence; Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics 2018;142:e20182162.
