Transgender and nonbinary individuals have faced prejudice, discrimination, and healthcare professionals who lack education on transgender healthcare. These have in turn caused adverse health effects to trans and nonbinary people. Because of this, it is important for OB/GYNs to provide sensitive, informed, gender-affirming medical care to this vulnerable patient population.
This particular article focuses on gynecologic care in a gender-affirming manner for transgender men and gender nonbinary individuals with irregular bleeding.
Understanding Irregular Bleeding in the Transgender Patient
The majority of transgender men receiving gender-affirming hormone therapy will have cessation of menses by six months of continuous therapy, according to a commentary in Obstetrics & Gynecology. "Bleeding beyond this interval warrants measurement of hormone levels and further evaluation," the authors write.
The initial approach is to measure testosterone levels and adjust testosterone dose to achieve serum testosterone levels in the physiologic male range, according to a study in the International Journal of Transgender Health. If bleeding persists after this adjustment, physicians can consider the addition of a progestin.
Diagnostic Approaches
When a transgender man or nonbinary person presents to their gynecologist with irregular bleeding, the first step should be a thorough history, including medications, medical comorbidities, hormonal treatments and their duration, surgical history, sexual history, and any previous vaginal bleeding.
A clinician should evaluate serum testosterone and estradiol levels. They should also consider pregnancy in sexually active transgender men who have sexual partners who produce sperm. Clinicians can rule out polyps, adenomyosis, leiomyomas, and other possible causes of abnormal uterine bleeding in differential diagnosis.
"In evaluation of structural causes of abnormal uterine bleeding, a special consideration for this patient population includes an understanding that undergoing a transvaginal ultrasound examination can promote gender dysphoria," write the authors of a commentary in Obstetrics & Gynecology. Transvaginal ultrasound is part of the diagnostic workup for abnormal bleeding, but in transgender or nonbinary patients, clinicians may consider transabdominal imaging if they can adequately visualize the uterus. If a transvaginal ultrasound is needed, the patient should receive counseling, and the person performing the exam must be trained in providing "competent, gender-affirming care," write the authors. Another study suggests that MRI is a valid alternative imaging modality to consider in these patients.
Abnormal bleeding in a transgender person with a uterus should include an evaluation for endometrial malignancy even though cohort studies have not shown an increased risk of endometrial carcinoma. Clinicians should also rule out infectious causes.
Treatment Options and Management Strategies
Management strategies depend on the cause of bleeding. In the case of fibroids that may resist medical therapy or bleeding that cannot be managed with medication, clinicians should discuss surgery. Hysterectomy is a viable option in patients who desire gender-affirming surgery. Endometrial ablation is another option to decrease bleeding if the patient does not plan to have children and for those who decline or cannot have a hysterectomy.
Challenges and Considerations
Transgender and nonbinary people experience double the poverty rate and nine times the rate of attempted suicide. Transgender individuals are frequently targeted with harassment and violence. Less than 40% of transgender people receive routine medical care, and many of them report fear of mistreatment as the main reason they do not seek healthcare.
In the United States, a survey found that only about one-third of gynecologists felt comfortable treating transgender men. Eighty percent reported that they received no training whatsoever in transgender patient care.
Patient-Centered Care and Communication
Many transgender patients have experienced discrimination in the healthcare setting, combined with the dysphoria that can occur when addressing anatomy related to their assigned sex at birth. Using the patient's preferred name and pronouns, asking patients what they prefer to use to refer to their own anatomy, and using gender-neutral terms can all help affirm gender identity.
Pelvic examination can worsen gender dysphoria. Healthcare providers should be aware of any past trauma history. Testosterone therapy can cause vaginal atrophy and decreased lubrication, so clinicians must take care during pelvic exams to make patients as comfortable as possible.
A welcoming care environment includes not only the physician, but also office staff, nurses, and ultrasonographers being trained on transgender healthcare barriers and inclusive practices. With attention to these details, physicians can build a gender-affirming practice where patients feel affirmed throughout their care.
