Experiences with Menses in Transgender and Gender Nonbinary Adolescents

Uterine changes in transgender men receiving testosterone therapy

OBJECTIVES

Despite regular gender-affirming hormone therapy (GAHT), the presence of uterine bleeding can occur occasionally and cause profound discomfort. This study aimed to evaluate the histologic features and immunohistochemical expression of estrogen (ER), progesterone (PR), and androgen receptors (AR) in the endometrium and myometrium of transgender men receiving testosterone therapy and relate them to clinical and hormonal characteristics.

DESIGN

Retrospective cross-sectional study.

METHODS

Thirty-four transgender men undergoing gender-affirming surgery were included. Clinical, sociodemographic, and laboratory data as well as anatomopathological and immunohistochemical findings were evaluated.

RESULTS

The participants' mean age was 42.35 (SD, 10.00) years, and body mass index was 28.16 (SD, 5.52) kg/m2. The mean GAHT duration before surgery was 5.36 (SD, 3.24) years. The mean testosterone levels were 814.98 (SD, 407.13) ng/dL, and estradiol levels were 55.22 (SD, 25.27) pg/mL. The endometrium was atrophic in 61.8%, proliferative in 17.6%, and secretory in 20.6%. Immunohistochemical receptor analysis revealed that endometrial epithelial cells expressed ER (90%) and PR (80%), with a lower expression of AR (30%). In stromal tissue, the median ER, PR, and AR expression was lower than that in the epithelium (60%, 70%, and 25%, respectively). The myometrium showed high expression of PR (90%) and ER (70%), with the highest expression of AR (65%) being localized to this region.

CONCLUSIONS

In the present study, GAHT induced an atrophic condition of the endometrium in two-thirds of the transgender men, with a limited AR expression in the endometrial region. The present results suggest that testosterone-based GAHT for a mean of 5 years is safe in transgender men achieving amenorrhea.

Evaluation and medical care of intersex and gender diverse youth

While there is considerable overlap in the treatment of patients with intersex traits and differences in sex development (I/DSD) with transgender and gender diverse (TGD) youth, the initial medical evaluation varies significantly. I/DSD youth often present due to differences in genitalia development in infancy or pubertal development in adolescence, and this leads to comprehensive biochemical, radiologic, and genetic evaluation. TGD youth, however, tend to have typical development noted at birth and during puberty, but present with a gender identity that does not align with their sex assigned at birth and do not require evaluation for underlying pathology. For both I/DSD and TGD youth, the mainstays of treatment are to better align one's physical appearance to their gender identity. This review discusses the non-medical and medical interventions utilized in gender affirming care. A multidisciplinary team of mental health providers, pediatric medical providers, and surgeons is recommended for providing gender affirming care to both I/DSD youth and TGD youth and their families. Radiologists have an important role in initial evaluation of I/DSD youth and in ongoing monitoring of growth and bone mineral density during puberty induction in I/DSD and TGD youth.

Management of breakthrough bleeding in transgender and gender diverse individuals on testosterone

BACKGROUND

While many transgender and gender diverse individuals rapidly achieve amenorrhea on testosterone, emerging data have identified that breakthrough bleeding can occur in up to one-third of individuals with long-term use. Breakthrough bleeding can worsen dysphoria and patients may seek management to reattain amenorrhea. Because of this, there is a need to assess efficacy of management approaches.

OBJECTIVE

The primary aim of the study was to evaluate methods used by patients and their providers to manage breakthrough bleeding which arises after 1 year of testosterone use. Secondary aims included describing the diagnostic approaches to breakthrough bleeding, and proposing an algorithm for classification and management of breakthrough bleeding in this patient population.

STUDY DESIGN

This was an institutional review board-approved single tertiary center, retrospective chart review of transgender and gender diverse individuals on testosterone gender affirming hormone therapy who experienced breakthrough bleeding after 1 year of use. Charts were reviewed to determine patient characteristics, testosterone use, and breakthrough bleeding management approaches.

RESULTS

Of the 96 individuals who had been on testosterone for 1 year and experienced breakthrough bleeding, 97% (n=93) engaged in at least 1 approach to management. The mean age at initiation of testosterone was 21.9 (standard deviation 5.4) and the median duration of time on testosterone was 54.5 months (interquartile range 33.5, 82). Only 16% (n=15) were using menstrual suppression at the time of their breakthrough bleeding episode. Breakthrough bleeding was successfully managed in 77 (79%), following between 1 and 4 attempted approaches. More than half of management attempts (63%) were successful on the first try. When management approaches were analyzed independently, the range of success associated with any particular approach was between 33% and 100%. Other than hysterectomy, which was fully successful at managing breakthrough bleeding, no approach was significantly better than no intervention. This was true both for individuals who did and did not bleed with missed testosterone doses. Regardless of what approach was used, after a failed attempt, the next attempt was successful in more than half of individuals. Of the 16 who underwent hysterectomy, 1 did so in part as a first line approach to manage breakthrough bleeding.

CONCLUSION

In this study, use of medical management methods was not found to be superior to observation alone in the management of breakthrough bleeding. In the absence of data supporting superiority of any method, we recommend tailoring method attempts to patients' goals.

Degendering Menstruation: A Scoping Review Exploring the Experiences of Transgender and Non-Binary People

Menstruation is a biological process experienced by up to 800 million people on any given day. Historically, menstruation has been studied from the female perspective. However, it should be considered that not all who menstruate are women. Therefore, the purpose of this research was to determine the status of evidence on transgender and non-binary individuals' experiences with menstruation. Arksey and O'Malley's (2005) framework for conducting a scoping study was used to guide this review. The authors used five steps of the six-step process to identify the research problem and search strategy, select studies based on defined inclusion and exclusion criteria, extract key information from five selected studies, and chart, summarize, and report the results as themes. The analysis resulted in the identification of four themes: (1) gender dysphoria and the influence on identity; (2) menstrual management and transformation as a turning point; (3) managing menstruation in precarious spaces; and (4) moving toward an open dialogue. Findings suggest a need for awareness of diverse and inclusive menstrual experiences. Inclusive advertising and menstrual products are needed to support transgender and non-binary people and reduce gender dysphoria. Policy initiatives should support the reconceptualization of infrastructure so that bathrooms are safe and comfortable places. Future opportunities for research exploring menstrual management within transgender and non-binary populations with emphasis on global research with diverse cultures and social structures is necessary to address gaps in the existing literature.

Factors Predicting Removals of the Levonorgestrel-Releasing Intrauterine System in an Adolescent Cohort

OBJECTIVE

Use of 52-mg levonorgestrel intrauterine system (LNG-IUS) in adolescents for heavy menstrual bleeding (HMB), dysmenorrhea, and contraception has increased, yet little is known about the factors predicting removal and dissatisfaction in adolescents. The aim of this study was to identify factors predicting LNG-IUS removal in adolescents.

METHODS

This was a retrospective cohort study including all adolescents (9-19 years) who underwent LNG-IUS insertion between 2012 and 2021 (n = 536). A medical record review was conducted and data were collated on medical and gynecological history, age, indications for insertion, complications, expulsions, and removals. The data were analyzed using χ2 tests.

RESULTS

Indications for LNG-IUS insertions (n = 536) among 517 individual patients (n = 517) included menstrual management (n = 142), HMB alone (n = 118), HMB and pelvic pain/dysmenorrhea (n = 105), dysmenorrhea/pelvic pain alone (n = 47), and contraception (n = 16). Associated diagnoses included intellectual disability (44.29%, 229/517), chronic pain conditions (12.77%, 66/517), and additional mental health concerns (24.37%, 126/517). Patient dissatisfaction with LNG-IUS led to removal in 61 (11.38%), mostly for pain or persistent bleeding. Higher removal rates occurred in those with associated chronic pain conditions (46.97%, χ2 = 55.9, P < .05), mental health concerns (16.67%, χ2 = 5.06, P < .05), and bleeding disorders (26.32%, χ2 = 5.09, P < .05). Among the cohort with an intellectual disability, lower rates of removal occurred (5.7%, χ2 = 11.2, P < .05). Whereas the LNG-IUS removal rate among gender-diverse youth was 23.07%, this was not statistically significant. Younger age was also not associated with a statistically significant increase in removals (13.72%, χ2 = 0.73, P > .05).

DISCUSSION

Adolescents have a low dissatisfaction and removal rate (11.38%) of LNG-IUS. Chronic pain, bleeding tendency, and mental health concerns are associated with higher removal rates and intellectual disability with lower rates. These findings are useful in counselling patients and families about LNG-IUS.

Menstruation in the USA

Purpose of review

Menstruation touches all spheres of human society, including psychology, education, business, policy, race, and religion. This narrative review aims to describe the relationship menstruation holds with these spaces.

Recent findings

First, menstruation plays many roles in psychology - premenstrual syndrome affects psychological wellbeing and in turn, psychological stress impacts menstruation. Functional hypothalamic amenorrhea can result when stress hormones inhibit the Hypothalamus-Pituitary-Ovarian axis. Furthermore, menstruation has many implications for all aged individuals, especially adolescents and those who are menopausal. These implications underscore the importance of proper education surrounding menstruation, which can be achieved via social media, school systems, family, and clinicians. However, menstrual health education is highly variable depending on the state and family that someone is raised in. Additionally, menstruation can pose a financial burden as menstrual products can be expensive and access to these products is limited for those who are homeless, incarcerated, and low-income. Recent public policy measures in various states have aimed to achieve "menstrual equity," by requiring public schools to supply free menstrual products in bathrooms. Furthermore, racial disparities exist with menstrual disorders. Uterine fibroids occur more frequently in Black menstruators compared to White menstruators, and Black women experience worse outcomes overall with fibroids and endometriosis management. Finally, analysis of religion and its relationship to menstruation underscores the immense stigma and "impurity" associated with menstruation.

Summary

Overall, this review highlights the universality of menstruation in society. As a "fifth vital sign", there is significant room for improvement in terms of education, research, and cultural acceptance of menstruation. Future research should explore interventions to reduce these gaps.

Through Their Eyes: Youth Perspectives on Sexual and Reproductive Health Barriers and Facilitators in Baltimore, Maryland

PURPOSE

Youth face barriers to sexual and reproductive health (SRH). Few states require the delivery of comprehensive sex education in schools, and youth report challenges with accessing clinical care. We sought to identify youth's perceived barriers and facilitators to SRH in their communities.

METHODS

We utilized photovoice, a community-based participatory research methodology. Youth were recruited from high schools in Baltimore, Maryland. Participants were given a tutorial on Photovoice methodology and photography. In groups of 5-7 participants, youth brainstormed questions relevant to their perspective of SRH. Three months were allocated to taking photographs. Participants wrote brief narratives to accompany their photographs, and group level assessment was used for participants to comment on others' photographs. Participants discussed the narratives and comments, created themes, and generated action steps to address barriers to SRH. Further thematic analysis was conducted using NVivo.

RESULTS

There were 30 participants aged 14-19 years with 26 self-identifying as female and four nonbinary. Self-identified race/ethnicity included 50% Black/African American, 30% Asian American, and 20% White or Hispanic/Latino. Four domains emerged: desire for societal-level change, community-level change, peer-level change, and positive examples of SRH within their communities (e.g., gender-inclusive spaces and free menstrual products).

DISCUSSION

Youth photographs shed light on a strong desire for an improved school environment, in terms of safety, cleanliness, gender-inclusivity, menstrual product access, and SRH education.

Long-acting reversible contraception in gender-diverse adolescents and young adults: Outcomes from a multisite collaborative

OBJECTIVES

This study aimed to describe the clinical experience of gender-diverse adolescents and young adults receiving long-acting reversible contraception (LARC).

STUDY DESIGN

This was a secondary analysis of prospectively collected quality improvement data among gender-diverse adolescents and young adults receiving LARC in four adolescent medicine clinics.

RESULTS

Most attempted insertions (59/63) were successful. A majority (54%) chose LARC for both contraception and menstrual management. Pelvic pain/cramping and unsatisfactory bleeding were reported side effects. One known expulsion and six known LARC removals occurred.

CONCLUSIONS

Gender-diverse adolescents and young adults had high rates of successful LARC insertion and demonstrated a side effect profile similar to a broader adolescent and young adult population seeking LARC care.

IMPLICATIONS

LARC is an important and well-tolerated method of menstrual management and contracention in gender-diverse adolescents and young adults, although more investigation is needed to understand how gender-affirming testosterone therapy may impact the LARC experience in this population.

Characteristics of Menstrual Suppression and Its Association With Mental Health in Transgender Adolescents

OBJECTIVE

To investigate the prevalence, nature, and effectiveness of menstrual suppression in transgender and gender-diverse (TGD) adolescents, and to explore whether there is an association between menstrual suppression and mental health in this population.

METHODS

A cross-sectional study was performed of TGD adolescents assigned female at birth attending their first appointment at a specialist pediatric gender service between February 2017 and December 2021. Demographic and mental health data were collected using a questionnaire at the time of first visit, and information regarding menstrual suppression at this time was retrieved from the medical record.

RESULTS

A total of 530 TGD individuals were included; 131 (24.7%) were on menstrual suppression at their initial visit, mainly to help alleviate gender dysphoria. Combined oral contraceptive pills were the most common agent used (n=61, 46.6%), followed by norethindrone (n=39, 29.8%) and intramuscular medroxyprogesterone (n=19, 14.5%). Rates of effectiveness (in stopping menstruation) and patient satisfaction were high. Among the 399 individuals not on menstrual suppression, there was strong interest in starting this treatment. No differences in the risk of gender dysphoria, depression, or anxiety were observed between those who were receiving menstrual suppression and those who were not.

CONCLUSION

Effectiveness of and satisfaction with menstrual suppression were high in TGD adolescents receiving this treatment. These findings support the routine exploration and management of menstrual health in TGD adolescents. However, menstrual suppression was not associated with any difference in gender dysphoria, depression, or anxiety symptoms in this cross-sectional study, and longitudinal studies are required to better investigate this.

MANstruation: A cyberethnography of linguistic strategies of trans and nonbinary menstruators

Trans and nonbinary experiences of menstruation are subject to menstrual discourse that is deeply gendered. Terms such as "feminine hygiene" and "women's health" make trans and nonbinary people acutely aware that they fall outside of the ideal of the default menstruator. To better understand how such language affects menstruators who are not cis women and what alternative linguistic strategies they adopt, we conducted a cyberethnography of 24 YouTube videos created by trans and nonbinary menstruators, along with their 12,000-plus comments. We observed a range of menstrual experiences-dysphoria, tensions between femininity and masculinity, and transnormative pressures. Using grounded theory, we identified three distinct linguistic strategies vloggers adopted to navigate these experiences: (1) avoiding standard and feminizing language; (2) reframing language through masculinization; and (3) challenging transnormativity. The avoidance of standard and feminizing language, coupled with a reliance on vague and negative euphemisms, revealed feelings of dysphoria. Masculinizing strategies, on the other hand, navigated dysphoria through euphemisms-or even hyper-euphemisms-that showed an effort to reclaim menstruation to fit within the trans and nonbinary experience. Vloggers responded through tropes of hegemonic masculinity, using puns and wordplay, and sometimes relying on hypermasculinity and transnormativity. Transnormativity, however, can be polarizing, and vloggers and commenters who rejected stratification of trans and nonbinary menstruation challenged it. Taken together, these videos not only uncover an overlooked community of menstruators who demonstrate unique linguistic engagement with menstruation, but they also reveal destigmatization and inclusion strategies that can inform critical menstruation activism and research as a whole.

Outcomes of Menstrual Management Use in Transgender and Gender-Diverse Adolescents

OBJECTIVE

To describe and compare the outcomes of various menstrual-management methods, including method choice, continuation, bleeding patterns, amenorrhea rates, effect on moods and dysphoria, and side effects, in transgender and gender-diverse adolescents.

METHODS

This was a retrospective chart review of all patients seen in a multidisciplinary pediatric gender program from March 2015 to December 2020 who were assigned female at birth, had achieved menarche, and used a menstrual-management method during the study period. Data were abstracted on patient demographics and menstrual-management method continuation, bleeding patterns, side effects, and satisfaction at 3 months (T1) and 1 year (T2). Outcomes were compared between method subgroups.

RESULTS

Among the 101 included patients, 90% chose either oral norethindrone acetate or a 52-mg levonorgestrel (LNG) intrauterine device (IUD). There were no differences in continuation rates for these methods at either follow-up time. Almost all patients had improved bleeding at T2 (96% for norethindrone acetate and 100% for IUD users), with no difference between subgroups. Amenorrhea rates were 84% for norethindrone acetate and 67% for IUD at T1 and 97% and 89%, respectively, at T2, with no differences at either point. The majority of patients had improved pain, menstrually related moods, and menstrually related dysphoria at both follow-up points. There were no differences in side effects between subgroups. There were no differences in method satisfaction between the groups at T2.

CONCLUSION

Most patients chose norethindrone acetate or an LNG IUD for menstrual management. Continuation, amenorrhea, and improved bleeding, pain, and menstrually related moods and dysphoria were high for all patients, indicating that menstrual management is a viable intervention for gender-diverse patients who experience increased dysphoria related to menses.

Postoperative Vaginal Bleeding Concerns after Gender-Affirming Hysterectomy in Transgender Adolescents and Young Adults on Testosterone

STUDY OBJECTIVE

This study aimed to characterize the incidence and management of postoperative vaginal bleeding concerns experienced by transgender adolescents and young adults (AYA) on testosterone hormone therapy after gender-affirming hysterectomy (GAH).

METHODS

This was a retrospective cohort of transgender AYA, 18 years and older, using testosterone therapy who underwent a GAH between July 2020 and September 2021 at a tertiary care children's hospital. The incidence of patient-reported postoperative vaginal bleeding concerns and management of bleeding are described.

RESULTS

Patient ages ranged between 18 and 33 years. Among 25 patients who met the inclusion criteria, 13 (52.0%) reported vaginal bleeding concerns. No modifiable patient or operative characteristics reached statistical significance in association with postoperative bleeding concerns. Among patients with bleeding concerns, 10 (76.9%) experienced such concerns during the first 2 weeks after surgery, and 6 (46.2%) had resolution of bleeding without intervention. Among 11 patients who underwent an exam for evaluation of bleeding, findings included granulation tissue (n = 5, 45.5%), vaginal atrophy (n = 4, 36.4%), bleeding vessel (n = 1, 9.1%), mucosal separation (n = 1, 9.1%), or no cause of bleeding identified (n = 4, 36.4%).

CONCLUSIONS

Over half of transgender AYA on testosterone therapy in this cohort reported postoperative vaginal bleeding concerns that were most often secondary to atrophy and granulation tissue, suggesting possible susceptibility to vaginal tissue trauma at the time of GAH and granulation-susceptible healing in patients on testosterone. As vaginal bleeding could worsen gender dysphoria, these findings support the need for patient counseling on postoperative bleeding expectations and identification of interventions to reduce vaginal bleeding after GAH.

Menstrual Management Choices in Transgender and Gender Diverse Adolescents

PURPOSE

Transgender and gender diverse patients who are assigned female at birth may request menstrual management to alleviate an increased dysphoria due to menses. The objective of this study is to describe the initiation and use over time of menstrual management methods (MMMs) in transgender and gender diverse adolescents.

METHODS

A retrospective chart review was conducted of patients in a multidisciplinary pediatric gender program from March 2015 to December 2020 who were assigned female at birth, identified as transgender or gender diverse, and had achieved menarche. A descriptive statistical analysis was performed.

RESULTS

Of 133 patients, 119 (90%) identified as transgender male, 11 (8%) as gender nonbinary, and 3 (2%) as another gender identity. Mean age was 15 (standard deviation 1.6) years. Only 12 (9%) patients had ever been sexually active. During the study period, 48 (36%) used gender-affirming testosterone. At the initial visit, 114 (86%) patients were not using an MMM. Of 80 patients who initiated a new MMM, 3 (4%) chose continuous oral contraceptive pills, 65 (83%) used norethindrone acetate (NETA), and 9 (11%) planned levonorgestrel intrauterine device (IUD) insertion. At 1 year, 56 patients were using NETA and 20 had an IUD in place.

DISCUSSION

This study provides data on MMM choice in transgender and gender diverse adolescents using these methods almost exclusively for menstrual management and not contraception. Although few patients were using an MMM at baseline, most opted to start a method when given the opportunity. The most common methods were NETA or an levonorgestrel IUD.

Reversible interventions for menstrual management in adolescents and young adults with gender incongruence

The newly released World Professional Association for Transgender Health Standards of Care, 8th Edition specify that adolescents should be offered menstrual suppression as part of their treatment plans to suppress menses and alleviate dysphoria, provide contraception, or improve irregular bleeding on testosterone therapy. This is a review of current evidence-based options for reversible interventions for menstrual suppression in adolescents with gender dysphoria or incongruence. Shared decision-making should be used by the clinician at all times, and the clinician should be intentional in prioritizing the patient's stated needs and desires when offering interventions. No method should be withheld due to the experience of gender incongruence alone. Contraceptive options offering menstrual suppression include depot-medroxyprogesterone acetate, levonorgestrel intrauterine systems, progestin-only contraceptive pills, and combined hormonal contraceptives. Non-contraceptive options include norethindrone acetate, oral medroxyprogesterone acetate, gonadotropin-releasing hormone analogues/agonists, and danazol. Certain patients may also benefit from non-pharmacologic interventions, such as specialty menstrual underwear.

Plain language summary

Using medicine to stop Menstrual periods in teens with gender incongruence Summary: Newly released recommendations for the care of teens and young adults with gender dysphoria or incongruence specifically recommend using medications to get rid of menstrual periods if desired or medically necessary. Patients may ask for this to help improve dysphoria, as a feature they want in birth control, or simply because they do not want to have periods. Because temporarily getting rid of periods is something that doctors can do for any patient old enough to have periods, patients with gender dysphoria should also be able to have their periods temporarily stopped using medications if requested. Doctors should ensure that they always help the patient make a decision that is right for them instead of prescribing what they think is right without considering the patient's input. Options for temporarily getting rid of periods can include birth control, such as oral contraceptive pills, patches, or rings; intrauterine devices; or shots, and it can also be done with things that are not birth control, such a progesterone pills or puberty blockers. Finally, some patients may only need improved period hygiene with period underwear to feel better in their bodies.