Approaches to Vaginal Bleeding and Contraceptive Counseling in Transgender and Gender Nonbinary Patients

The transgender community has faced a long-standing history of prejudice and discrimination that has negatively affected their health. A lack of health care provider education and comfort with transgender medicine further challenges the ability of this population to obtain competent, gender-affirming medical care. As with all patients, a thorough patient history with avoidance of assumptions of sexual orientation based on gender identity is integral to providing appropriate care for transgender individuals. Vaginal bleeding in transgender men should be evaluated in a similar manner to natal women, and with knowledge of the individual's present reproductive organs. The majority of transgender men receiving gender-affirming hormone therapy will have cessation of menses by 6 months of continuous use; thus, bleeding beyond this interval warrants measurement of hormone levels and further evaluation. Progesterone-only contraceptive methods including progesterone-only pills, medroxyprogesterone acetate, or a levonorgestrel intrauterine device can be used in transgender men and nonbinary patients with continued menses despite physiologic testosterone levels, or to act as a bridge method for menstrual cessation at the time of testosterone initiation. For bleeding refractory to progesterone methods, health care providers should discuss surgical options or the use of aromatase inhibitors with their patients. Counseling on fertility desires and family planning is integral to improving the reproductive care of transgender patients. Contraceptive counseling for transgender patients should include not only the efficacy and ease of use of available methods, but also discussion of advantages and disadvantages of contraceptive options with regard to the patient's gender identity.