Approaches to Vaginal Bleeding and Contraceptive Counseling in Transgender and Gender Nonbinary Patients

Abstract

The transgender community has faced a long-standing history of prejudice and discrimination that has negatively affected their health. A lack of health care provider education and comfort with transgender medicine further challenges the ability of this population to obtain competent, gender-affirming medical care. As with all patients, a thorough patient history with avoidance of assumptions of sexual orientation based on gender identity is integral to providing appropriate care for transgender individuals. Vaginal bleeding in transgender men should be evaluated in a similar manner to natal women, and with knowledge of the individual's present reproductive organs. The majority of transgender men receiving gender-affirming hormone therapy will have cessation of menses by 6 months of continuous use; thus, bleeding beyond this interval warrants measurement of hormone levels and further evaluation. Progesterone-only contraceptive methods including progesterone-only pills, medroxyprogesterone acetate, or a levonorgestrel intrauterine device can be used in transgender men and nonbinary patients with continued menses despite physiologic testosterone levels, or to act as a bridge method for menstrual cessation at the time of testosterone initiation. For bleeding refractory to progesterone methods, health care providers should discuss surgical options or the use of aromatase inhibitors with their patients. Counseling on fertility desires and family planning is integral to improving the reproductive care of transgender patients. Contraceptive counseling for transgender patients should include not only the efficacy and ease of use of available methods, but also discussion of advantages and disadvantages of contraceptive options with regard to the patient's gender identity.

Breakthrough Bleeding in Transgender and Gender Diverse Adolescents and Young Adults on Long-Term Testosterone

“…Because experiencing breakthrough bleeding can worsen patient dysphoria/distress, an understanding of risk factors for bleeding is essential to improving care for TGD AYA patients using testosterone. 13 Common causes of breakthrough bleeding in patients using medical therapies that suppress menstruation (eg, combined oral contraceptives or a levonorgestrel IUD) ( Fig. 4 ) must be considered in the evaluation of patients experiencing genital bleeding while on T-GAHT.…”

Southern African HIV Clinicians Society gender-affirming healthcare guideline for South Africa

“…66 In a client taking masculinising HT, an increase in sexual desire and activity is often reported 66 , and clitoral enlargement is likely to occur. 67 Vaginal atrophy may occur because of the hypoestrogenic effect that testosterone has on vaginal tissues 68 and can be ameliorated with lubricants.…”

Gender dysphoria in the field of obstetrics and gynecology

“…The OB/GYN clinician's role regarding the challenging needs of a GD patient GD individuals frequently experience healthcare discrimination, leading them to ''avoid using the healthcare system.'' 11 Knowledge of guidelines and validated screening tools, as well as up-to-date training, poses great challenges for clinicians. The OB/GYN clinician's role should entail the following: (1) identification and evaluation of GD and possible mental comorbidities, (2) explanation of terminology and management options available, (3) education of the patient's family and social groups regarding GD, (4) collaboration and consultation with a multi-disciplinary team (MDT), ( 5) timely referrals to specialists and qualified mental health professionals, and (6) follow-up services.…”

“…12 Clinical examination, especially pelvic exams, should be performed when necessary (e.g., vaginal bleeding, suspected endometrial cancer), while keeping in mind that such individuals could experience disproportionately high discomfort. 11,13 Further steps to a holistic approach Access and availability (equity of access) to gender clinics as well as the level of knowledge, awareness, qualification, and expertise of the MDT May be the lead clinician. The presence of some mental disorders may cofound with the gender dysphoria diagnosis.…”

“…12 The OB/ GYN clinician should bear in mind that an unplanned pregnancy could significantly exacerbate GD feelings. 11 Interestingly, it is reported that women who mainly choose to have sex with women make inadequate use of contraceptive methods should they occasionally choose to have sex with men. Even greater attention is needed when fertility and contraception options are provided to DSD individuals; such patients may additionally warrant genetic counselling.…”