(80) Management of Heavy Menstrual Bleeding in Transgender and Gender Diverse Adolescents and Young Adults

Background: Transgender and gender diverse (TGD) individuals assigned female at birth (AFAB) often desire menstrual suppression due to dysphoria related to menses. Achieving amenorrhea may be more difficult in the setting of heavy menstrual bleeding (HMB) or a bleeding disorder (BD). The aim of this study was to investigate management patterns and rates of amenorrhea in TGD AFAB individuals with diagnoses of HMB and/or a BD. A secondary aim was to examine the influence of testosterone (T) on achieving amenorrhea.

Methods: A retrospective chart review was performed at a single academic center. IRB exemption was obtained. AFAB patients aged 10-21 who identified as TGD and had a diagnosis of HMB and/or a BD were identified with ICD-10 codes and using an Electronic Medical Record Search Engine (EMERSE). Variables collected are listed in Tables 1 and 2. Data was analyzed using t-tests and chi-squared tests.

Results: 121 patients met inclusion criteria. 16 (13.9%) patients had a diagnosed BD. 54 (44.6%) patients had a history of anemia, and 63 (52.1%) had iron deficiency. Patients with a known BD achieved amenorrhea at similar rates to patients without (62.5% vs 65.7%, p=0.78), regardless of T use. Patients that identified as male were more likely to achieve amenorrhea than nonbinary patients or any non-male gender identity ((p = 0.003), p = 0.004) (Table 1). 31 (26.7%) patients achieved amenorrhea with the first medication prescribed. 82 (67.8%) used an estrogen-containing medication for menstrual suppression.

76 (62.8%) patients ever achieved amenorrhea with any combination of hormonal medication. Of patients who achieved amenorrhea, 63 (82.9%) achieved amenorrhea on a single agent, and 12 (15.8%) required 2 agents. The most common agent used that resulted in amenorrhea was continuous oral contraceptive pills (COCs), and the most common combination used to achieve amenorrhea was T and norethindrone acetate (NETA).

55 (45.5%) patients were prescribed T for gender affirmation, and 42 (77.8%) patients achieved amenorrhea during the study period while on T. (Table 2) Of the patients who achieved amenorrhea with T, 44.4% required the use of a second agent, most commonly NETA. Individuals who used T at any point achieved significantly higher rates of amenorrhea than those who did not use T (76.3% vs 43.9%, p<.001) .

Conclusions: BD diagnosis did not influence rates of amenorrhea, regardless of the use of T. TGD adolescents on T with HMB had lower rates of amenorrhea when compared to prior studies looking at all TGD individuals on T. In addition, almost half of the patients on T also required the use of a second agent to achieve amenorrhea.