Skip to main content
Top
Published in:

09-06-2024 | Testosterone | Review

Management of Abnormal Uterine Bleeding in Transmasculine Individuals

Authors: Frances W. Grimstad, Ava Scatoni, Elizabeth R. Boskey

Published in: Current Obstetrics and Gynecology Reports | Issue 3/2024

Login to get access

Abstract

Purpose of Review

Transmasculine individuals, those who identify as men, transgender men, and non-binary individuals who are sex assigned female at birth, may present to gynecologic care for the management of abnormal uterine bleeding (AUB). The purpose of this review is to better understand the epidemiology, etiology, evaluation of, and management of AUB in transmasculine patients.

Recent Findings

There have been a series of single institution studies on AUB in transmasculine patients done in recent years. However, to our knowledge, no reviews have been conducted on this topic.

Summary

Causes of AUB can include the same age related causes that may occur in cisgender individuals who are not on testosterone, as well as breakthrough bleeding (BTB) in individuals on testosterone. Options for management of testosterone-related to BTB include adjustments to testosterone dosing and preparation, initiation or discontinuation of a secondary menstrual suppression agent, or surgical approaches. Observation is also an option. Decisions around approach should be patient-centered, and both evaluation and management should proceed with a trauma-informed and gender-affirming lens. Using existing data regarding AUB in transmasculine individuals and best practice guidelines for the provision of gynecologic care of the transgender community, gynecologists can offer a holistic and welcoming approach to caring for patients who present with these concerns.
Literature
1.
go back to reference ACOG Committee on Gynecologic Practice, ACOG Committee on Health Care for Underserved Women. Health Care for transgender and gender diverse individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021;137(3):e75–88.CrossRef ACOG Committee on Gynecologic Practice, ACOG Committee on Health Care for Underserved Women. Health Care for transgender and gender diverse individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021;137(3):e75–88.CrossRef
2.
go back to reference Ferrando CA. Gynecologic care of transgender and gender-diverse people. Obstet Gynecol. 2024;143(2):243–55.CrossRefPubMed Ferrando CA. Gynecologic care of transgender and gender-diverse people. Obstet Gynecol. 2024;143(2):243–55.CrossRefPubMed
3.
go back to reference Grimstad F, McLaren H, Gray M. The gynecologic examination of the transfeminine person after penile inversion vaginoplasty. Am J Obstet Gynecol. 2021;224(3):266–73.CrossRefPubMed Grimstad F, McLaren H, Gray M. The gynecologic examination of the transfeminine person after penile inversion vaginoplasty. Am J Obstet Gynecol. 2021;224(3):266–73.CrossRefPubMed
4.
go back to reference Grimstad FW, Boskey ER, Clark RS, Ferrando CA. Prevalence of pelvic pain in transgender individuals on testosterone. J Sex Med. 2023;20(12):1459–65. First paper to describe the prevalence of pelvic pain in individuals on testosterone and how that relates to prevalence prior to testosterone use.CrossRefPubMed Grimstad FW, Boskey ER, Clark RS, Ferrando CA. Prevalence of pelvic pain in transgender individuals on testosterone. J Sex Med. 2023;20(12):1459–65. First paper to describe the prevalence of pelvic pain in individuals on testosterone and how that relates to prevalence prior to testosterone use.CrossRefPubMed
5.
go back to reference 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(5):706–16. First paper to describe long term breakthrough bleeding in transgender adolescents on testosterone and identify GnRHa use as a possible alleviator.CrossRefPubMed 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(5):706–16. First paper to describe long term breakthrough bleeding in transgender adolescents on testosterone and identify GnRHa use as a possible alleviator.CrossRefPubMed
6.
go back to reference Grimstad FW, Boskey ER, Clark RS, Ferrando CA. Incidence of breakthrough bleeding in transgender and gender diverse individuals on long-term testosterone. Am J Obstet Gynecol. 2024;S0002–9378(24):00002–4. Grimstad FW, Boskey ER, Clark RS, Ferrando CA. Incidence of breakthrough bleeding in transgender and gender diverse individuals on long-term testosterone. Am J Obstet Gynecol. 2024;S0002–9378(24):00002–4.
7.
go back to reference American College of Obstetricians and Gynecologists. ACOG committee opinion 557: management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol. 2013;121(4):891–6.CrossRef American College of Obstetricians and Gynecologists. ACOG committee opinion 557: management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol. 2013;121(4):891–6.CrossRef
8.
go back to reference Munro MG, Critchley HOD, Fraser IS, FIGO Menstrual Disorders Committee. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet. 2018;143(3):393–408.CrossRefPubMed Munro MG, Critchley HOD, Fraser IS, FIGO Menstrual Disorders Committee. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet. 2018;143(3):393–408.CrossRefPubMed
10.
go back to reference Vitale SG, Watrowski R, Barra F, D’Alterio MN, Carugno J, Sathyapalan T, et al. Abnormal uterine bleeding in Perimenopausal women: the role of Hysteroscopy and its impact on quality of life and sexuality. Diagnostics (Basel). 2022;12(5):1176.CrossRefPubMed Vitale SG, Watrowski R, Barra F, D’Alterio MN, Carugno J, Sathyapalan T, et al. Abnormal uterine bleeding in Perimenopausal women: the role of Hysteroscopy and its impact on quality of life and sexuality. Diagnostics (Basel). 2022;12(5):1176.CrossRefPubMed
11.
go back to reference Nakamura A, Watanabe M, Sugimoto M, Sako T, Mahmood S, Kaku H, et al. Dose-response analysis of testosterone replacement therapy in patients with female to male gender identity disorder. Endocr J. 2013;60(3):275–81.CrossRefPubMed Nakamura A, Watanabe M, Sugimoto M, Sako T, Mahmood S, Kaku H, et al. Dose-response analysis of testosterone replacement therapy in patients with female to male gender identity disorder. Endocr J. 2013;60(3):275–81.CrossRefPubMed
12.
13.
go back to reference Pelusi C, Costantino A, Martelli V, Lambertini M, Bazzocchi A, Ponti F, et al. Effects of three different testosterone formulations in female-to-male transsexual persons. J Sex Med. 2014;11(12):3002–11.CrossRefPubMed Pelusi C, Costantino A, Martelli V, Lambertini M, Bazzocchi A, Ponti F, et al. Effects of three different testosterone formulations in female-to-male transsexual persons. J Sex Med. 2014;11(12):3002–11.CrossRefPubMed
16.
go back to reference Grimstad FW, Fowler KG, New EP, Ferrando CA, Pollard RR, Chapman G, et al. Uterine pathology in transmasculine persons on testosterone: a retrospective multicenter case series. Am J Obstet Gynecol. 2019;220(3):257.e1–257.e7.CrossRefPubMed Grimstad FW, Fowler KG, New EP, Ferrando CA, Pollard RR, Chapman G, et al. Uterine pathology in transmasculine persons on testosterone: a retrospective multicenter case series. Am J Obstet Gynecol. 2019;220(3):257.e1–257.e7.CrossRefPubMed
17.
18.
go back to reference Hawkins M, Deutsch MB, Obedin-Maliver J, Stark B, Grubman J, Jacoby A, et al. Endometrial findings among transgender and gender nonbinary people using testosterone at the time of gender-affirming hysterectomy. Fertil Steril. 2021;115(5):1312–7. Most recent paper adding to past data providing reassurance of endometrial findings in individuals on testosterone.CrossRefPubMed Hawkins M, Deutsch MB, Obedin-Maliver J, Stark B, Grubman J, Jacoby A, et al. Endometrial findings among transgender and gender nonbinary people using testosterone at the time of gender-affirming hysterectomy. Fertil Steril. 2021;115(5):1312–7. Most recent paper adding to past data providing reassurance of endometrial findings in individuals on testosterone.CrossRefPubMed
19.
go back to reference Gill S, Anderson M, Neveu J. Endometrial Cancer in a Transgender Man with Prolonged Exogenous Testosterone Use. Obstet Gynecol. 2024. Gill S, Anderson M, Neveu J. Endometrial Cancer in a Transgender Man with Prolonged Exogenous Testosterone Use. Obstet Gynecol. 2024.
20.
go back to reference Yoshida H, Uno M, Ogimoto K, Kobayashi-Kato M, Tanase Y, Ishikawa M, et al. Endometrioid endometrial carcinoma with NKX3.1 expression in a Transgender Man: a Case Report. Int J Gynecol Pathol. 2023;42(3):308–14.CrossRefPubMed Yoshida H, Uno M, Ogimoto K, Kobayashi-Kato M, Tanase Y, Ishikawa M, et al. Endometrioid endometrial carcinoma with NKX3.1 expression in a Transgender Man: a Case Report. Int J Gynecol Pathol. 2023;42(3):308–14.CrossRefPubMed
21.
go back to reference Ferrando CA, Chapman G, Pollard R. Preoperative pain symptoms and the incidence of endometriosis in transgender men undergoing hysterectomy for gender affirmation. J Minim Invasive Gynecol. 2021;28(9):1579–84. Describes how common pain and endometriosis are in individuals undergoing gender affirming hysterectomy.CrossRefPubMed Ferrando CA, Chapman G, Pollard R. Preoperative pain symptoms and the incidence of endometriosis in transgender men undergoing hysterectomy for gender affirmation. J Minim Invasive Gynecol. 2021;28(9):1579–84. Describes how common pain and endometriosis are in individuals undergoing gender affirming hysterectomy.CrossRefPubMed
22.
go back to reference Cipres DT, Shim JY, Grimstad FW. Postoperative vaginal bleeding concerns after gender-affirming hysterectomy in transgender adolescents and young adults on testosterone. J Pediatr Adolesc Gynecol. 2022;S1083–3188(22):00291–1. Cipres DT, Shim JY, Grimstad FW. Postoperative vaginal bleeding concerns after gender-affirming hysterectomy in transgender adolescents and young adults on testosterone. J Pediatr Adolesc Gynecol. 2022;S1083–3188(22):00291–1.
23.
go back to reference Sbragia JD, Vottero B. Experiences of transgender men in seeking gynecological and reproductive health care: a qualitative systematic review. JBI Evid Synth. 2020;18(9):1870–931.CrossRefPubMed Sbragia JD, Vottero B. Experiences of transgender men in seeking gynecological and reproductive health care: a qualitative systematic review. JBI Evid Synth. 2020;18(9):1870–931.CrossRefPubMed
24.
go back to reference UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People [Internet]. 2nd ed. Deutsch MB, ed. 2016. Available from: https://transcare.ucsf.edu/guidelines. UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People [Internet]. 2nd ed. Deutsch MB, ed. 2016. Available from: https://​transcare.​ucsf.​edu/​guidelines.
25.
go back to reference Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017;102(11):3869–903.CrossRefPubMed Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017;102(11):3869–903.CrossRefPubMed
26.
go back to reference Hoffman BL, Schorge JO, Bradshaw KD, Halvorson LM, Schaffer JI, Corton MM. Williams gynecology (3rd ed.). McGraw Hill Professional. 2016. Hoffman BL, Schorge JO, Bradshaw KD, Halvorson LM, Schaffer JI, Corton MM. Williams gynecology (3rd ed.). McGraw Hill Professional. 2016.
27.
go back to reference Tordoff DM, Lunn MR, Chen B, Flentje A, Dastur Z, Lubensky ME, et al. Testosterone use and sexual function among transgender men and gender diverse people assigned female at birth. Am J Obstet Gynecol. 2023;229(6):669.e1–669.e17.CrossRefPubMed Tordoff DM, Lunn MR, Chen B, Flentje A, Dastur Z, Lubensky ME, et al. Testosterone use and sexual function among transgender men and gender diverse people assigned female at birth. Am J Obstet Gynecol. 2023;229(6):669.e1–669.e17.CrossRefPubMed
28.
go back to reference Baldassarre M, Giannone FA, Foschini MP, Battaglia C, Busacchi P, Venturoli S, et al. Effects of long-term high dose testosterone administration on vaginal epithelium structure and estrogen receptor-α and -β expression of young women. Int J Impot Res. 2013;25(5):172–7.CrossRefPubMed Baldassarre M, Giannone FA, Foschini MP, Battaglia C, Busacchi P, Venturoli S, et al. Effects of long-term high dose testosterone administration on vaginal epithelium structure and estrogen receptor-α and -β expression of young women. Int J Impot Res. 2013;25(5):172–7.CrossRefPubMed
29.
go back to reference Bachmann GA, Nevadunsky NS. Diagnosis and treatment of Atrophic Vaginitis. AFP. 2000;61(10):3090–6. Bachmann GA, Nevadunsky NS. Diagnosis and treatment of Atrophic Vaginitis. AFP. 2000;61(10):3090–6.
30.
go back to reference Krakowsky Y, Potter E, Hallarn J, Monari B, Wilcox H, Bauer G, et al. The effect of gender-affirming Medical Care on the vaginal and neovaginal microbiomes of transgender and gender-diverse people. Front Cell Infect Microbiol. 2021;11:769950. Describes the changes in the vaginal microbiome on gender affirming hormone therapy.CrossRefPubMed Krakowsky Y, Potter E, Hallarn J, Monari B, Wilcox H, Bauer G, et al. The effect of gender-affirming Medical Care on the vaginal and neovaginal microbiomes of transgender and gender-diverse people. Front Cell Infect Microbiol. 2021;11:769950. Describes the changes in the vaginal microbiome on gender affirming hormone therapy.CrossRefPubMed
31.
go back to reference Ruiz MJ, Chisholm B, de Martelly V, Chor J. Sexual and gender minority patients’ first pelvic examination experiences: what clinicians need to know. J Pediatr Adolesc Gynecol. 2023;S1083–3188(23):00447–3. Ruiz MJ, Chisholm B, de Martelly V, Chor J. Sexual and gender minority patients’ first pelvic examination experiences: what clinicians need to know. J Pediatr Adolesc Gynecol. 2023;S1083–3188(23):00447–3.
32.
go back to reference Masek BJ, Arora N, Quinn N, Aumakhan B, Holden J, Hardick A, et al. Performance of three nucleic acid amplification tests for detection of Chlamydia trachomatis and Neisseria gonorrhoeae by use of self-collected vaginal swabs obtained via an internet-based screening program. J Clin Microbiol. 2009;47(6):1663–7.CrossRefPubMedPubMedCentral Masek BJ, Arora N, Quinn N, Aumakhan B, Holden J, Hardick A, et al. Performance of three nucleic acid amplification tests for detection of Chlamydia trachomatis and Neisseria gonorrhoeae by use of self-collected vaginal swabs obtained via an internet-based screening program. J Clin Microbiol. 2009;47(6):1663–7.CrossRefPubMedPubMedCentral
35.
go back to reference Timor-Tritsch IE, Monteagudo A, Rebarber A, Goldstein SR, Tsymbal T. Transrectal scanning: an alternative when transvaginal scanning is not feasible. Ultrasound Obstet Gynecol. 2003;21(5):473–9.CrossRefPubMed Timor-Tritsch IE, Monteagudo A, Rebarber A, Goldstein SR, Tsymbal T. Transrectal scanning: an alternative when transvaginal scanning is not feasible. Ultrasound Obstet Gynecol. 2003;21(5):473–9.CrossRefPubMed
36.
go back to reference Committee on Practice Bulletins—Gynecology. Practice bulletin 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol. 2012;120(1):197–206.CrossRef Committee on Practice Bulletins—Gynecology. Practice bulletin 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol. 2012;120(1):197–206.CrossRef
37.
go back to reference Chan KJ, Jolly D, Liang JJ, Weinand JD, Safer JD. Estrogen levels do not rise with Testosteroen Treatmetn for Transgender men. Endocr Pract. 2018;24(4):329–33.CrossRefPubMed Chan KJ, Jolly D, Liang JJ, Weinand JD, Safer JD. Estrogen levels do not rise with Testosteroen Treatmetn for Transgender men. Endocr Pract. 2018;24(4):329–33.CrossRefPubMed
38.
go back to reference Pastuszak AW, Mittakanti H, Liu JS, Gomez L, Lipshultz LI, Khera M. Pharmacokinetic evaluation and dosing of subcutaneous testosterone pellets. J Androl. 2012;33(5):927–37.CrossRefPubMed Pastuszak AW, Mittakanti H, Liu JS, Gomez L, Lipshultz LI, Khera M. Pharmacokinetic evaluation and dosing of subcutaneous testosterone pellets. J Androl. 2012;33(5):927–37.CrossRefPubMed
40.
go back to reference Carel JC, Eugster EA, Rogol A, Ghizzoni L, Palmert MR, ESPE-LWPES GnRH Analogs Consensus Conference Group. Consensus statement on the use of gonadotropin-releasing hormone analogs in children. Pediatrics. 2009;123(4):e752–762. Carel JC, Eugster EA, Rogol A, Ghizzoni L, Palmert MR, ESPE-LWPES GnRH Analogs Consensus Conference Group. Consensus statement on the use of gonadotropin-releasing hormone analogs in children. Pediatrics. 2009;123(4):e752–762.
41.
go back to reference Grimstad F, Boskey ER, Taghinia A, Ganor O. Gender-affirming surgeries in transgender and gender diverse adolescent and young adults: a pediatric and adolescent gynecology primer. J Pediatr Adolesc Gynecol. 2021;34(4):442–8.CrossRefPubMed Grimstad F, Boskey ER, Taghinia A, Ganor O. Gender-affirming surgeries in transgender and gender diverse adolescent and young adults: a pediatric and adolescent gynecology primer. J Pediatr Adolesc Gynecol. 2021;34(4):442–8.CrossRefPubMed
42.
go back to reference Grimstad FW, Fraiman E, Garborcauskas G, Ferrando CA. Retrospective review of changes in testosterone dosing and physiologic parameters in transgender and gender-diverse individuals following hysterectomy with and without oophorectomy. J Sex Med. 2023;20(5):690–8.CrossRefPubMed Grimstad FW, Fraiman E, Garborcauskas G, Ferrando CA. Retrospective review of changes in testosterone dosing and physiologic parameters in transgender and gender-diverse individuals following hysterectomy with and without oophorectomy. J Sex Med. 2023;20(5):690–8.CrossRefPubMed
43.
go back to reference Alkatout I, Mettler L, Peters G, Noé G, Holthaus B, Jonat W, et al. Laparoscopic hysterectomy and prolapse: a Multiprocedural Concept. JSLS. 2014;18(1):89–101.CrossRefPubMedPubMedCentral Alkatout I, Mettler L, Peters G, Noé G, Holthaus B, Jonat W, et al. Laparoscopic hysterectomy and prolapse: a Multiprocedural Concept. JSLS. 2014;18(1):89–101.CrossRefPubMedPubMedCentral
44.
go back to reference Committee on Ethics. Committee Opinion 695: sterilization of women: ethical issues and considerations. Obstet Gynecol. 2017;129(4):e109–16.CrossRef Committee on Ethics. Committee Opinion 695: sterilization of women: ethical issues and considerations. Obstet Gynecol. 2017;129(4):e109–16.CrossRef
45.
go back to reference ACOG Practice Bulletin No. Endometrial ablation. Obstet Gynecol. 2007;81(5):1233. ACOG Practice Bulletin No. Endometrial ablation. Obstet Gynecol. 2007;81(5):1233.
46.
go back to reference Krempasky C, Harris M, Abern L, Grimstad F. Contraception across the transmasculine spectrum. Am J Obstet Gynecol. 2020;222(2):134–43.CrossRefPubMed Krempasky C, Harris M, Abern L, Grimstad F. Contraception across the transmasculine spectrum. Am J Obstet Gynecol. 2020;222(2):134–43.CrossRefPubMed
47.
go back to reference 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 Women’s Health. 2021;66(6):772–7.CrossRef 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 Women’s Health. 2021;66(6):772–7.CrossRef
Metadata
Title
Management of Abnormal Uterine Bleeding in Transmasculine Individuals
Authors
Frances W. Grimstad
Ava Scatoni
Elizabeth R. Boskey
Publication date
09-06-2024
Publisher
Springer US
Published in
Current Obstetrics and Gynecology Reports / Issue 3/2024
Electronic ISSN: 2161-3303
DOI
https://doi.org/10.1007/s13669-024-00396-9

Women’s health knowledge hub

Elevate your patient care with our comprehensive, evidence-based medical education on women's health. Designed to help you provide exceptional care for your female patients at every stage of life, we provide expert insights into topics such as reproductive health, menopause, breast cancer and sex-specific health risks and precision medicine.

Read more

Keynote series | Spotlight on menopause

Menopause can have a significant impact on the body, with effects ranging beyond the endocrine and reproductive systems. Learn about the systemic effects of menopause, so you can help patients in your clinics through the transition.   

Prof. Martha Hickey
Dr. Claudia Barth
Dr. Samar El Khoudary
Developed by: Springer Medicine
Watch now
Video