Use of medical management methods was not found to be superior to observation alone in the management of breakthrough bleeding in transgender and gender diverse individuals on testosterone, and in the absence of data supporting superiority of any method, the authors recommend tailoring method attempts to patients' goals.
Key Findings
Results
Breakthrough bleeding was successfully managed in 79% of individuals who experienced it after 1 year of testosterone use.
Of 96 individuals who had been on testosterone for 1 year and experienced breakthrough bleeding, 97% (n=93) engaged in at least 1 approach to management.
Breakthrough bleeding was successfully managed in 77 (79%) individuals, following between 1 and 4 attempted approaches.
More than half of management attempts (63%) were successful on the first try.
After a failed attempt, the next attempt was successful in more than half of individuals, regardless of what approach was used.
Results
No medical management approach was significantly better than no intervention for managing breakthrough bleeding.
When management approaches were analyzed independently, the range of success associated with any particular approach was between 33% and 100%.
This finding was true both for individuals who did and did not bleed with missed testosterone doses.
Other than hysterectomy, which was fully successful at managing breakthrough bleeding, no approach was significantly better than no intervention.
Results
Hysterectomy was the only fully successful approach for managing breakthrough bleeding.
Of the 16 who underwent hysterectomy, 1 did so in part as a first line approach to manage breakthrough bleeding.
Hysterectomy achieved 100% success at managing breakthrough bleeding.
The remaining individuals who underwent hysterectomy did so after other management attempts.
Results
Only a minority of individuals experiencing breakthrough bleeding were using menstrual suppression at the time of their breakthrough bleeding episode.
Only 16% (n=15) were using menstrual suppression at the time of their breakthrough bleeding episode.
The mean age at initiation of testosterone was 21.9 years (standard deviation 5.4).
The median duration of time on testosterone was 54.5 months (interquartile range 33.5, 82 months).
Background
Breakthrough bleeding can occur in up to one-third of transgender and gender diverse individuals with long-term testosterone use.
While many transgender and gender diverse individuals rapidly achieve amenorrhea on testosterone, emerging data have identified that breakthrough bleeding can occur in up to one-third of individuals with long-term use.
Breakthrough bleeding can worsen dysphoria and patients may seek management to reattain amenorrhea.
The study was a single tertiary center, retrospective chart review of individuals on testosterone gender affirming hormone therapy who experienced breakthrough bleeding after 1 year of use.
Results
The authors propose an algorithm for classification and management of breakthrough bleeding in transgender and gender diverse individuals on testosterone.
Secondary aims of the study included describing the diagnostic approaches to breakthrough bleeding and proposing a management algorithm.
In the absence of data supporting superiority of any method, the authors recommend tailoring method attempts to patients' goals.
This was an institutional review board-approved single tertiary center retrospective chart review with 96 individuals included.
Grimstad F, Boskey E, Clark R, Ferrando C. (2024). Management of breakthrough bleeding in transgender and gender diverse individuals on testosterone.. American journal of obstetrics and gynecology. https://doi.org/10.1016/j.ajog.2024.06.004