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Persistent vaginal bleeding during gender-affirming hormone therapy in transgender men

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Abstract

Purpose

While it is common for menstrual cycles to cease within the initial 6 months of treatment, there are instances where some transgender men may not experience this cessation. We analyzed transgender men undergoing gender-affirming hormone therapy (GAHT) with testosterone who experienced breakthrough bleeding in order to identify the factors associated with this condition.

Methods

In this case–control study, 24 transgender men in the case group and 48 in the control group were assessed for clinical, sociodemographic, hormonal, and body composition variables using dual-energy X-ray absorptiometry. All participants had been on GATH for at least 6 months.

Results

A few transgender men experienced persistent breakthrough bleeding, which was associated with decreased testosterone levels and free androgen index (FAI) compared with controls (p = 0.002 and p = 0.008, respectively). Among individuals with breakthrough bleeding, 50% had testosterone levels below the lowest tertile calculated for the sample, compared with 18.8% on controls (p = 0.007). After therapy adjustment, testosterone levels increased compared with the values obtained in the initial bleeding episode (p = 0.031). Eight transgender men required the addition of an oral progestogen to achieve amenorrhea, and these individuals had higher BMI than those in whom the adjustment of the parenteral testosterone dose was adequate (p = 0.026). A univariate prevalence ratio analysis revealed a negative association of persistent bleeding with testosterone levels (p = 0.028) and FAI levels (p = 0.019).

Conclusion

Higher BMI and lower levels of testosterone and FAI were the main factors associated with breakthrough bleeding in transgender men.

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Data availability

Data are available after request directly to the authors.

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Funding

This work was funded by the National Council for Scientific and Technological Development (grant number INCT/CNPq 465482/2014-7) and Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul (grant INCT/FAPERGS: 17/2551-0000519-8). The funding source had no role in the collection, analysis, interpretation of data and in the writing of the report or in the decision to submit the article for publication.

Author information

Authors and Affiliations

  1. Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90035 003, Brazil

    E. D. da Silva, P. M. Spritzer & T. M. Fighera

  2. Postgraduate Program in Endocrinology, Medicine School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil

    E. D. da Silva, P. M. Spritzer & T. M. Fighera

  3. Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil

    E. D. da Silva, P. M. Spritzer & T. M. Fighera

  4. Department of Internal Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil

    T. M. Fighera

  5. Department of Physiology and Postgraduate Program in Physiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil

    P. M. Spritzer

Authors
  1. E. D. da Silva
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Contributions

EDS contributed to study design, acquisition of data, analysis and interpretation of data, drafting the manuscript, and final review. TMF and PMS contributed to conception and study design, acquisition of data, analysis and interpretation of data, and final review of the manuscript. All authors approved the final version of the manuscript.

Corresponding author

Correspondence to P. M. Spritzer.

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Conflict of interest

None declared.

Research involving human participants and/or animals

This study was approved by the Ethics Committee of Hospital de Clínicas de Porto Alegre, project number 2014-0608, and all participants signed an informed consent form and complies with the guidelines of the Declaration of Helsinki.

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All patients have provided their written informed consent to participate to the study.

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da Silva, E.D., Spritzer, P.M. & Fighera, T.M. Persistent vaginal bleeding during gender-affirming hormone therapy in transgender men. J Endocrinol Invest (2024). https://doi.org/10.1007/s40618-023-02296-w

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