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

Among gender-diverse patients who used medical menstrual management, we found improved bleeding, pain, dysphoria, and moods related to menstruation and high continuation and amenorrhea rates.

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.

The onset of menses may exacerbate gender dysphoria in those who do not identify as female. Many transgender and gender-diverse adolescents desire menstrual management to alleviate this increased dysphoria-related menses.¹ Menstrual management, also called menstrual manipulation or suppression, is the use of hormonal medication to improve or stop periods. Menstrual manipulation may be used because children or adolescents are not old enough, ready for, or desiring of gender-affirming hormone therapy or because they may not be able to access other gender-affirming care owing to lack of parental support or increasing policies and laws banning affirming medical treatments.

Menstrual management is used in other populations, including for menstrual concerns and in patients with disabilities,^1–3 but it is unknown whether goals of treatment, method use, and outcomes are the same for these populations as for gender-diverse patients and gender-diverse youth specifically. In addition, menstrual manipulation is often described or recommended in these situations without data on outcomes of use. Although there are minimal published reports about menstrual-management and contraceptive methods in transgender adolescents or adults, this information is very limited and purely descriptive.^4–10 There are no known data on outcomes of different menstrual-management methods in gender-diverse patients, including continuation rates, bleeding patterns, and side effects (Ovid, PubMed, CINAHL, and SCOPUS database searches for articles published 2000–2022 using keywords including menses, menstruation, and contraception; full search available on request). This information is crucial for counseling patients and helping them choose appropriate options.

Because gender-diverse children and adolescents are increasingly presenting to medical care while gender-affirming care is simultaneously being villainized in some places, there is a need to identify potential alternative opportunities to improve outcomes in this population. Menstrual management is a possible intervention to help alleviate dysphoria in transgender youth. The objective of this study is to describe and compare the outcomes of various menstrual-management methods over the first year of use in transgender and gender-diverse adolescents.

METHODS

This was a retrospective chart review of all patients who identified as transgender or gender diverse and who were seen by at least one health care professional at the Nemours Children's Hospital Delaware Gender Wellness Program between March 2015 and December 2020. The Gender Wellness Program is a multidisciplinary program that includes a psychologist, endocrinologist, gynecologist, and social worker. There is a single Gender Wellness Program gynecologist whose role is to discuss reproductive and sexual health, menses, and fertility and fertility preservation.

If patients desire menstrual management or contraception, they are counseled on options with a shared decision-making approach using a handout that includes amenorrhea rates compiled from studies in different populations (Table 1). Parents are typically present at gynecology visits and participate in decision making. However, patients at our institution can receive confidential reproductive care, and minors can consent to contraception, although visits, medications, and procedures are billed to their insurance.

Table 1.

Menstrual-Management and Contraceptive Methods Discussed in Our Program

Gender-diverse patients were identified by electronic medical record (EMR) queries based on a combination of encounter types and diagnosis codes and confirmed by chart review. Inclusion criteria were female sex assigned at birth, achievement of menarche, and use of a menstrual-management method during the study period. Patients were seen by at least one Gender Wellness Program health care professional during the study period. Use of testosterone for gender-affirming hormone therapy was not considered a menstrual-management method, but patients who used both a menstrual-management method and testosterone were included because it was assumed that patients who used a menstrual-management method while on testosterone did not have adequate menstrual suppression on testosterone alone. Patients on gonadotropin-releasing hormone (GnRH) agonists were excluded because almost all were premenarchal.

We conducted a chart review for all patients who met inclusion criteria. Data were abstracted from standardized health care professional EMR note templates by three investigators, who met regularly with the primary investigator to ensure consistent data collection and to resolve questions or discrepancies through consensus. Abstracted data included patient demographics (age, race, ethnicity, type of health insurance, sex assigned at birth, gender identity, sexual activity), gender-affirming hormone use, and prior use and type of menstrual-management method. Sexual activity was defined as ever engaging in vaginal or anal intercourse because of the risk for pregnancy or infection with these activities. Information on method continuation, bleeding patterns, effects on moods and dysphoria, method side effects, and satisfaction was gathered at two follow-up visit time points, as documented on standardized EMR templates. The initial clinical follow-up visit (T1) occurred at 1–3 months for intrauterine device (IUD) and implant users and at 2–6 months for users of other methods because of the variability of typical clinical practice. The second follow-up visit (T2) occurred at 1 year for all patients, with data available from 9 to 18 months used for this time point.

We abstracted information on menstrual-management method choice at the baseline visit, menstrual-management method continuation from baseline to follow-up visits, menstrual bleeding pattern, amenorrhea, abdominal and pelvic pain, and other menstrual symptoms, including mood changes and dysphoria related to menses at T1 and T2. We determined bleeding to be improved at follow-up visits if amenorrhea was present or bleeding was less frequent, of shorter duration, or lighter in flow. Amenorrhea was defined as the complete absence of menstrual bleeding for 3 months, as defined by the World Health Organization and used in many contraception trials.¹¹ At T1, patients were also considered to be amenorrheic if they had not had any menstrual bleeding since method initiation. We deemed menstrual pain and other symptoms to be improved if those symptoms were explicitly documented as improved or resolved. We also recorded the presence and details of all reported side effects. Subjective method satisfaction (eg, very happy, somewhat happy, unhappy, unsure, mixed feelings) is included in the standardized EMR templates and was abstracted when documented.

Data were entered and managed using a REDCap (Research Electronic Data Capture) tool hosted at Nemours Children's Hospital Delaware.¹² Frequency counts, percentages, means, and SDs were used to describe the patient population and outcomes related to menstrual management. Method continuation, bleeding patterns, side effects, and satisfaction were compared between method subgroups at both T1 and T2 with χ² and Fisher exact tests. Missing data were excluded from analysis of individual variables. P<.05 was considered statistically significant. Statistical analyses were performed with SAS 9.4.¹³ This study was approved by the Nemours Children's Health IRB.

RESULTS

In total, 101 patients met the inclusion criteria for this study (Fig. 1). Demographic information is presented in Table 2. The distribution of menstrual-management method use during the study period is shown in Figure 2. The continuation rate for all methods was 84% at T1 and 76% at T2. The rate of amenorrhea for those still using a menstrual-management method was 80% at T1 and 93% at T2.

Fig. 1. Flowchart of the study population.

Schwartz. Menstrual Management in Transgender Adolescents. Obstet Gynecol 2023.

Table 2.

Demographic Characteristics of the Study Population (N=101)

Fig. 2. Menstrual-management method use during the study period.

Schwartz. Menstrual Management in Transgender Adolescents. Obstet Gynecol 2023.

Because 90% of patients (n=80) chose either oral norethindrone acetate or a 52-mg levonorgestrel (LNG) IUD as their initial menstrual-management method, patient experiences and outcomes with these two methods were compared (Table 3). Follow-up data were available for 75 patients (94%) at T1 and 68 patients (85%) at T2. There were no differences in continuation at either time point, although it is notable that all patients who chose an IUD still had it in place at 1 year. Although more patients with IUDs required intervention at or before T1, this difference was no longer significant at T2. Similarly, although more norethindrone acetate than IUD users reported improved bleeding at T1, almost all patients had improved bleeding and high rates of amenorrhea at T2, with no significant differences between the groups.

Table 3.

Comparison of Experiences With Norethindrone Acetate and Levonorgestrel Intrauterine Devices at the First and Second Follow-up Visits

The majority of patients with available follow-up data in both groups reported improved pain, menstrually related moods, and menstrually related dysphoria, but data available in the EMR were limited for this information because it was collected with an open-ended question rather than individually queried. More patients using norethindrone acetate than IUDs reported side effects, but there were no significant differences between the groups.

Overall reported satisfaction with menstrual-management method was high. At T2, no patients reported dissatisfaction with their method. Although those using norethindrone acetate were more likely to be satisfied with their chosen method at T1 than those with an IUD, there were no differences in satisfaction between groups at T2 (Table 3). When all menstrual-management methods were included, 78% of patients still using a menstrual-management method were very satisfied with their method at T1 and 97% were very satisfied at T2. Of note, at T2, 97% of the very or somewhat satisfied patients were amenorrheic, with all patients reporting improved menstrual bleeding, pain, other menstrual symptoms, menstrually associated moods, and menstrually associated dysphoria.

Only four patients were using gender-affirming hormone therapy at their initial visit. These patients all started a menstrual-management method as a result of persistent breakthrough bleeding or cramping. During the study period, an additional 38 patients initiated gender-affirming hormone therapy. Most patients who used testosterone at any time (n=38/42, 90%) were on a menstrual-management method before starting testosterone: 36 for menstrual suppression, five for improved periods, and two for contraception, with some overlap between reasons. Thus, more than half of the patients (n=25/42, 60%) were amenorrheic before starting testosterone. An additional seven patients became amenorrheic after starting testosterone. The majority of patients continued their menstrual-management method after gender-affirming hormone initiation, with only seven patients stopping their menstrual-management method after starting testosterone.

DISCUSSION

Gender-diverse youth have an increased prevalence of discrimination and psychological diagnoses and adverse outcomes compared with their cisgender peers.^14–17 However, gender-affirming care can improve mental health symptoms and outcomes.^18,19 Because gender-diverse patients frequently report increased dysphoria with menses and desire amenorrhea,¹ menstrual management is an important component of gender-affirming care. Limited prior data on hormonal medication use in this population do not focus specifically on menstrual suppression, and there are no previous reports on outcomes of menstrual management.^4–6,10 This study provides the first known data on outcomes of menstrual management use in transgender and gender-diverse adolescents.

Most of our patients chose oral norethindrone acetate or LNG IUD. Continuation rates of both norethindrone acetate and IUDs were very high, and no patients underwent IUD removal. Although amenorrhea rates were higher in patients using norethindrone acetate, this difference was not significant. More important, 95% of patients in both groups were amenorrheic at 1 year. Because a recent study identified that amenorrhea is the primary goal of menstrual management in gender-diverse adolescents,¹ this information is important for counseling patients on options. The fact that improved bleeding and amenorrhea rates increased over time, especially in the IUD group, will also allow better education of patients about the natural course of breakthrough bleeding and amenorrhea with these methods. Although some of the improved bleeding could be attributed to initiation of gender-affirming hormone therapy, most patients were already amenorrheic before starting testosterone, and only seven patients became amenorrheic after starting testosterone. Almost all patients who were satisfied with their menstrual-management method were amenorrheic. Further research is needed to determine whether amenorrhea, improved bleeding, or other factors drive patient satisfaction with their method. The effects of improved bleeding on overall gender dysphoria and mental health should also be examined, taking gender-affirming hormones into consideration as a possible confounding factor.

Many hormonal medications can be used for menstrual suppression. Norethindrone acetate is a high-dose oral progestin with amenorrhea rates exceeding 90%.^20,21 Dosing can be titrated to induce amenorrhea. We start at a dose of 5 mg daily and adjust it as needed. We inform our patients that norethindrone acetate is not currently approved for contraception. Although we do not restrict its use on the basis of sexual activity, patients are counseled to use condoms consistently or to consider a different method if they are or become sexually active.

We also use 52-mg LNG IUDs for noncontraceptive indications, including heavy menstrual bleeding and dysmenorrhea,^22,23 and are increasingly using them in adolescents for both contraceptive and medical indications.^24,25 A study on LNG IUD use for menstrual suppression in adolescents with disabilities reported high continuation rates and amenorrhea rates of about 60%.³ Our 1-year amenorrhea rate was higher than this. Although some of this could be attributed to concomitant testosterone use, most of our patients were amenorrheic before starting testosterone. This may be attributable to increased intervention for initial bothersome breakthrough bleeding, for which we typically use a short course of norethindrone acetate.

There are minimal data on IUD use in transgender populations. Transgender and gender-diverse adults who were using an IUD were surveyed about their reasons for IUD use. The most common reason for selecting a 52-mg LNG IUD was for menstrual suppression.¹⁰ Another study reported the use of LNG IUDs in gender-minority youth, with 80% endorsing a reduction in menstrual distress after IUD insertion.⁷ An LNG IUD may also be an attractive menstrual-management method for transgender youth because its hormonal effects are localized with minimal systemic absorption, side effects, or interactions with other medications.²⁶ Side effects were lower in our patients with IUDs compared with those taking norethindrone acetate, although not significantly, with no IUD users reporting any hormonal side effects. Therefore, an IUD is a viable option for patients who are concerned about the possibility of side effects or who have experienced side effects with other methods. A drawback to IUD use in this population is that patients may not want to undergo office insertion because of increased anxiety or dysphoria. If this is the case, insertion can be performed under sedation, as it was for about three quarters of our patients who chose an IUD.

The amenorrhea rates of our patients using norethindrone acetate or a 52-mg LNG were higher than in other studies.^3,20,21,27 Although the amenorrhea rate was higher for patients using norethindrone acetate than an IUD at the initial follow-up visit, there was no difference in bleeding, amenorrhea, or satisfaction between the groups at 1 year. This is important information for both preprocedural counseling and reassurance over the first few months after IUD insertion.

It is also notable that norethindrone acetate and IUDs were the most commonly chosen methods by our patients; limited prior data on hormonal medication use in this population show that combined oral contraceptive pills are the most commonly used methods.⁵ Although combined estrogen-progesterone medications are used for menstrual regulation and improvement in menses and associated symptoms, it may be more difficult to achieve amenorrhea with oral contraceptive pills.²⁸ Irregular bleeding is common with initiation.²⁹ Although breakthrough bleeding improves with time,²⁸ this may be distressing to patients who have worsened dysphoria with menstrual bleeding. In addition, some transgender adolescents anecdotally are uncomfortable with using a medication that contains estrogen because of perceived feminine side effects or interactions with current or future gender-affirming hormone use.

Other methods chosen by very few of our patients included depot medroxyprogesterone injections and the etonogestrel hormonal implant. Depot medroxyprogesterone results in amenorrhea rates exceeding 50% at 1 year and 70% at 2 years, but it is associated with high rates of initial irregular bleeding,³⁰ which may not be tolerated well by patients who have increased dysphoria with menstrual bleeding. Etonogestrel hormonal implants are associated with only a 20–30% amenorrhea rate,³¹ so they are not typically recommended for menstrual suppression.²⁹ However, they may be appropriate for some sexually active patients given their very high contraceptive efficacy. Gonadotropin-releasing hormone agonists can also be used for menstrual suppression. Our program does not use GnRH agonists solely for this purpose because of the availability of other menstrual suppression options that do not cause potential irreversible decreased bone mineral density.³² In addition, GnRH agonists are very expensive, especially compared with menstrual-management methods, and are not always covered by insurance.

Strengths of this study are the relatively large sample size and the focus on menstrual management rather than contraception. Our study reports the outcomes of menstrual-management methods, including amenorrhea rates, changes in menstrual bleeding, abdominal or pelvic pain, and mental health symptoms. The main limitation is its retrospective design, which relies on adequate documentation and resulted in missing data. Although EMR templates were used to gather this information, there were no standardized patient questionnaires or tools. Although having a single Gender Wellness Program gynecologist ensured that patients were counseled consistently, this introduces potential bias of this counseling. The presence of parents at most visits and the fact that all visits and medications were billed to insurance may have biased menstrual-management method choice, but this is a reality of most adolescent reproductive care. Anecdotally, parents were generally supportive of menstrual management and their children's choices specifically, although they sometimes voiced their own preferences and opinions. Another limitation is that we did not control for the effects of gender-affirming hormone or other treatments on dysphoria. Therefore, the improved menstrual dysphoria in those with amenorrhea may be confounded by testosterone use or other factors. This study may also be underpowered to detect some differences between the groups, but this is a first step in determining outcomes for this population.

This study may also have limited generalizability; these patients were all seen in a specialized gender clinic, and the majority had a dedicated visit with a pediatric gynecologist, which introduces selection bias and may overestimate the degree of gender dysphoria in general, as well as distress related to menses, because those who did not have increased dysphoria with menses may have declined to see a gynecologist or to start menstrual management. In addition, the low prevalence of sexual activity in our population may have biased the menstrual-management method choice, but this would not affect the outcomes of the methods. Last, the majority of our patients were White and non-Hispanic and used private health insurance. Although there is no known national demographic information on gender-diverse adolescents, our patient demographics are different from those of the surrounding county and state.³³

This exploratory study describes an understudied area of treatment for transgender and gender-diverse patients who experience increased distress and dysphoria related to menses. Most of our patients achieved amenorrhea, or at least improved menstrual bleeding, as well as improved menstrually related dysphoria, with fairly low rates of side effects. These data can be used to counsel patients about the effects of different menstrual-management methods. Menstrual management has the potential to be an important intervention for gender-diverse patients, especially as an initial treatment in those who are too young for, do not desire, or are unable to access gender-affirming hormone therapy. Further research is needed to prospectively evaluate the effects of different menstrual-management methods on menstrual bleeding, side effects, and effect on gender dysphoria and mental health outcomes in this medically and psychologically vulnerable population.