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

Publisher: Lippincott Williams & Wilkins Country of Publication: United States NLM ID: 0401101 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1873-233X (Electronic) Linking ISSN: 00297844 NLM ISO Abbreviation: Obstet Gynecol Subsets: MEDLINE

Publication: 2004- : Hagerstown, MD : Lippincott Williams & Wilkins
Original Publication: New York.

Contraceptive Agents, Female*/adverse effects ; Intrauterine Devices, Medicated*/adverse effects ; Transgender Persons*; Adolescent ; Child ; Female ; Humans ; Amenorrhea/chemically induced ; Amenorrhea/drug therapy ; Hemorrhage/etiology ; Levonorgestrel/adverse effects ; Norethindrone Acetate ; Pain/etiology ; Retrospective Studies ; Male

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.
Competing Interests: Financial Disclosure Beth I. Schwartz disclosed that this article discusses off-label use of norethindrone acetate for menstrual suppression. The authors did not report any potential conflicts of interest.
(Copyright © 2023 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Schwartz BI, Effron A, Bear B, Short VL, Eisenberg J, Felleman S, et al. Experiences with menses in transgender and gender non-binary adolescents. J Pediatr Adolesc Gynecol 2022;35:450–6. doi: 10.1016/j.jpag.2022.01.015. (PMID: 10.1016/j.jpag.2022.01.015)
Pradhan S, Gomez-Lobo V. Hormonal contraceptives, intrauterine devices, gonadotropin-releasing hormone analogues and testosterone: menstrual suppression in special adolescent populations. J Pediatr Adolesc Gynecol 2019;32:S23–9. doi: 10.1016/j.jpag.2019.04.007. (PMID: 10.1016/j.jpag.2019.04.007)
Schwartz BI, Alexander M, Breech LL. Intrauterine device use in adolescents with disabilities. Pediatrics 2020;146:e20200016. doi: 10.1542/peds.2020-0016. (PMID: 10.1542/peds.2020-0016)
Carswell JM, Roberts SA. Induction and maintenance of amenorrhea in transmasculine and nonbinary adolescents. Transgend Health 2017;2:195–201. doi: 10.1089/trgh.2017.0021. (PMID: 10.1089/trgh.2017.0021)
Kanj RV, Conard LAE, Corathers SD, Trotman GE. Hormonal contraceptive choices in a clinic-based series of transgender adolescents and young adults. Int J Transgend 2019;20:413–20. doi: 10.1080/15532739.2019.1631929. (PMID: 10.1080/15532739.2019.1631929)
Light A, Wang LF, Zeymo A, Gomez-Lobo V. Family planning and contraception use in transgender men. Contraception 2018;98:266–9. doi: 0.1016/j.contraception.2018.06.006. (PMID: 0.1016/j.contraception.2018.06.006)
Akgul S, Bonny AE, Ford N, Holland-Hall C, Chelvakumar G. Experiences of gender minority youth with the intrauterine system. J Adolesc Health 2019;65:32–8. doi: 10.1016/j.jadohealth.2018.11.010. (PMID: 10.1016/j.jadohealth.2018.11.010)
Guss CE. Intrauterine devices in gender minority youth: an option to decrease dysphoria and unintended pregnancies. J Adolesc Health 2019;65:3–4. doi: 10.1016/j.jadohealth.2019.04.012. (PMID: 10.1016/j.jadohealth.2019.04.012)
Lynch MM, Khandheria MM, Meyer WJ. Retrospective study of the management of childhood and adolescent gender identity disorder using medroxyprogesterone acetate. Int J Transgend 2015;16:201–8. doi: 10.1080/15532739.2015.1080649. (PMID: 10.1080/15532739.2015.1080649)
Abern L, Krempasky C, Diego D, De Guzman G, Kiely K, Cook J, et al. The intrauterine device experience among transgender and gender-diverse individuals assigned female at birth. J Midwifery Womens Health 2021;66:772–7. doi: 10.1111/jmwh.13310. (PMID: 10.1111/jmwh.13310)
Belsey EM, Farley TM. The analysis of menstrual bleeding patterns: a review. Contraception 1988;38:129–56. doi: 10.1016/0010-7824(88)90035-2. (PMID: 10.1016/0010-7824(88)90035-2)
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research Electronic Data Capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377–81. doi: 10.1016/j.jbi.2008.08.010. (PMID: 10.1016/j.jbi.2008.08.010)
SAS Institute Inc. SAS® 9.4. SAS Institute; 2013.
Almeida J, Johnson RM, Corliss HL, Molnar BE, Azrael D. Emotional distress among LGBT youth: the influence of perceived discrimination based on sexual orientation. J Youth Adolesc 2009;38:1001–14. doi: 10.1007/s10964-009-9397-9. (PMID: 10.1007/s10964-009-9397-9)
Day JK, Fish JN, Perez-Brumer A, Hatzenbuehler ML, Russell ST. Transgender youth substance use disparities: results from a population-based sample. J Adolesc Health 2017;61:729–35. doi: 10.1016/j.jadohealth.2017.06.024. (PMID: 10.1016/j.jadohealth.2017.06.024)
Perez-Brumer A, Day JK, Russell ST, Hatzenbuehler ML. Prevalence and correlates of suicidal ideation among transgender youth in California: findings from a representative, population-based sample of high school students. J Am Acad Child Adolesc Psychiatry 2017;56:739–46. doi: 10.1016/j.jaac.2017.06.010. (PMID: 10.1016/j.jaac.2017.06.010)
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. doi: 10.1542/peds.2018-2162. (PMID: 10.1542/peds.2018-2162)
Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgend Health 2022;23:S1–259. doi: 10.1080/26895269.2022.2100644. (PMID: 10.1080/26895269.2022.2100644)
Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Hassan Murad M, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2017;102:3869–903. doi: 10.1210/jc.2017-01658. (PMID: 10.1210/jc.2017-01658)
Huvinen E, Holopainen E, Heikinheimo O. Norethisterone and its acetate: what's so special about them? BMJ Sex Reprod Health 2021;47:102–9. doi: 10.1136/bmjsrh-2020-200619. (PMID: 10.1136/bmjsrh-2020-200619)
Dean J, Kramer KJ, Akbary F, Wade S, Hüttemann M, Berman JM, et al. Norethindrone is superior to combined oral contraceptive pills in short-term delay of menses and onset of breakthrough bleeding: a randomized trial. BMC Womens Health 2019;19:70. doi: 10.1186/s12905-019-0766-6. (PMID: 10.1186/s12905-019-0766-6)
Varma R, Sinha D, Gupta JK. Non-contraceptive uses of levonorgestrel-releasing hormone system (LNG-IUS): a systematic enquiry and overview. Eur J Obstet Gynecol Reprod Biol 2006;125:9–28. doi: 10.1016/j.ejogrb.2005.10.029. (PMID: 10.1016/j.ejogrb.2005.10.029)
Lethaby A, Hussain M, Rishworth JR, Rees MC. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. The Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD002126. doi: 10.1002/14651858.CD002126.pub3. (PMID: 10.1002/14651858.CD002126.pub3)
Schwartz BI, Alexander M, Breech LL. Levonorgestrel intrauterine device use for medical indications in nulliparous adolescents and young adults. J Adolesc Health 2021;68:357–63. doi: 10.1016/j.jadohealth.2020.05.041. (PMID: 10.1016/j.jadohealth.2020.05.041)
Kebodeaux CA, Schwartz BI. Experience with intrauterine device insertion in never sexually active adolescents: a retrospective cohort study. Am J Obstet Gynecol 2018;219:600.e1–7. doi: 10.1016/j.ajog.2018.09.033. (PMID: 10.1016/j.ajog.2018.09.033)
Kailasam C, Cahill D. Review of the safety, efficacy and patient acceptability of the levonorgestrel-releasing intrauterine system. Patient Prefer Adherence 2008;2:293–302. doi: 10.2147/PPA.S3464. (PMID: 10.2147/PPA.S3464)
Hidalgo M, Bahamondes L, Perrotti M, Diaz J, Dantas-Monteiro C, Petta C. Bleeding patterns and clinical performance of the levonorgestrel-releasing intrauterine system (Mirena) up to two years. Contraception 2002;65:129–32. doi: 10.1016/s0010-7824(01)00302-x. (PMID: 10.1016/s0010-7824(01)00302-x)
Villavicencio J, Allen RH. Unscheduled bleeding and contraceptive choice: increasing satisfaction and continuation rates. Open Access J Contracept 2016;7:43–52. doi: 10.2147/oajc.S85565. (PMID: 10.2147/oajc.S85565)
Menstrual manipulation for adolescents with physical and developmental disabilities. Committee Opinion No. 668. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e20–5. doi: 10.1097/AOG.0000000000001585. (PMID: 10.1097/AOG.0000000000001585)
LLC PUC. Depo-Provera CI: full prescribing information. 2017. Accessed October 27, 2022. https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/020246s036lbl.pdf.
Darney P, Patel A, Rosen K, Shapiro LS, Kaunitz AM. Safety and efficacy of a single-rod etonogestrel implant (Implanon): results from 11 international clinical trials. Fertil Steril 2009;91:1646–53. doi: 10.1016/j.fertnstert.2008.02.140. (PMID: 10.1016/j.fertnstert.2008.02.140)
Divasta AD, Laufer MR, Gordon CM. Bone density in adolescents treated with a GnRH agonist and add-back therapy for endometriosis. J Pediatr Adolesc Gynecol 2007;20:293–7. doi: 10.1016/j.jpag.2007.04.008. (PMID: 10.1016/j.jpag.2007.04.008)
U.S. Census Bureau. 2012–2016 American community survey five-year estimates. 2017. Accessed October 27, 2022. https://data.census.gov/all?q=2012-2016+ACS+5-year+Estimates.
Grimstad F, Kremen J, Shim J, Charlton BM, Boskey ER. Breakthrough bleeding in transgender and gender diverse adolescents and young adults on long-term testosterone. J Pediatr Adolesc Gynecol 2021;34:706–16. doi: 10.1016/j.jpag.2021.04.004. (PMID: 10.1016/j.jpag.2021.04.004)
Zigler RE, McNicholas C. Unscheduled vaginal bleeding with progestin-only contraceptive use. Am J Obstet Gynecol 2017;216:443–50. doi: 10.1016/j.ajog.2016.12.008. (PMID: 10.1016/j.ajog.2016.12.008)

0 (Contraceptive Agents, Female)
5W7SIA7YZW (Levonorgestrel)
9S44LIC7OJ (Norethindrone Acetate)

Date Created: 20230310 Date Completed: 20230328 Latest Revision: 20241231

20250101

PMC10026956

10.1097/AOG.0000000000005123

36897186