Options for Menstrual Suppression (Mak, 4/16/25)

 A recording of this presentation is available HERE.  

Thanks to Dr. Ray Mak for a good refresher on menstrual suppression. A reminder from Dr. Mak up front that there are varied reasons that people with a uterus prefer to suppress their menstruation -- from personal preference to medical indications, and we can and should know how to counsel them on how to safely do so.

Check out this table that outlines some of the reasons for menstrual suppression. Not included in the table are financial reasons (people spend $6000-$18,000 over their lifetime for menstrual products) or cancer risk reduction. 

Patient preference		Challenges with menstrual hygiene	Intellectual or developmental delay Limited dexterity or mobility
Gynecologic	Dysmenorrhea Endometriosis-related pain and bleeding Menorrhagia PMS Abnormal uterine bleeding	Work or social indications	Military deployment or space travel Athletes Camping or wilderness experience
Hematologic	Anemia Coagulation disorder Malignancy Chemotherapy	Other conditions worsened by menses	Irritable bowel syndrome Asthma Postural tachycardia syndrome Migraines

Combined oral contraceptives

The most commonly accepted and practices way to ensure menstrual suppression comes via continuous Combined oral contraceptives (COCPS)

-efficacy is 49%, 68% and 88% are 2, 6 and 12 cycles respectively

-monophasic OCPs are preferred 

-breakthrough bleeding (BTB) is the most common side effect and decreases with time

-lower estrogen levels in OCPs is associated with more BTB

-a hormone free break of 3-4 days is usually sufficient to manage BTB

-see two images below from the AAFP with guidelines on management of BTB

 

Additionally, menstrual suppression can occur using alternative contraceptive modes, including:

• vaginal ring (skipping ring-free week)>> amenorrhea 89% at 6 months, BTB more common early and diminishes with time (NSAIDs may help, no studies on adding estrogen)
• contraceptive patch (skipping patch-free week), not as well studied, no long term data, higher estrogen exposure, similar issues with BTB
• hormonal IUD (Mirena, Liletta)>> amenorrhea 50% at 1 year, 60% at 5 years; lower dose IUD not effective at attaining amenorrhea, can uses NSAID/estrogen or OCPs for BTB
• depo provera injections>> amenorrhea 50-75% at 1 year, increases with prolonged use; concerns about decreased bone density over time, also weight gain/mood changes. For BTB: NSAID, estrogen, cOCPs, decreasing injection interval (e.g. 2 months)
• etonogestrel implant>> 22% amenorrhea at 1 year, improved with prolonged use, irregular BTB is common

Aside from using contraceptive methods to induce menstrual suppression, other medications can be used, including:

• norethindrone acetate 5mg daily, not approved for contraception>> 76% amenorrhea at 2 years, can titrate up to 15mg daily (for BTB), different than norethindrone mini-pill (0.35)
• testosterone therapy for trans and gender diverse patients >> testosterone therapy usually suppresses by 3-6 months, transmen generally prefer to avoid estrogen  (because of desire for masculinization)
• GnRH agonists (puberty blockers), fast onset 4-6 weeks, high efficacy 96%, no increased prothrombotic use (often used in oncologic patients)
• Danazol

Menstrual suppression considerations for people with disabilities:

• can they swallow pills?
• can they tolerate invasive procedure?
• caution: bone density, weight gain, VTE risk in pts with decrease mobility at baseline
• scheduled withdrawal bleeding may be preferred over random BTB

Don't forget this chart:

LGBTQ+ Fertility and Preconception Counseling (Lopez 4/5/2022)

Many thanks to Dr. Julissa Lopez for her important Grand Rounds presentation on LGBQT+ Fertility and Preconception Counseling. Key take home message up front: primary care physicians SHOULD be helping LGBQT+ patients pursue the families they desire. It's definitely within our scope.

If you would like to watch, the presentation is available HERE. 

Dr. Lopez started with a reminder of the wide range of gender and gender identities that we may encounter. Refer to the Flying Gender Unicorn graphic below as often as you need to to remind you of the range of gender identity, gender expression, gender expression at birth, sexual identity, etc (and to help your patients and you better understand themselves). 

Dr. Lopez' 3-part framework for gender identity considerations

• Biology>>sex>>chromosomes and anatomy
• Psyche>>gender>> identity and expression
• Interpersonal>>sexuality, sexual orientation, attraction

Important reminder for all of us who care for childbearing age patients of all genders and gender identities: Do NOT assume that LGBQT+ do not desire pregnancy. 

In fact, since the early 2000s, there has been a "Gayby Boom"

• 2002: 41% of Lesbians and 52% of gay men expressed an interest in having children
• 2013: 51% of LGBT are parents or want to be
• 2017: 49% of lesbians and bisexual women have had a child (through previous relationship, reproductive technology, adoption, etc)

There is growing consensus that LGBTQ+ community have a right to pathways to parenthood. This includes an increasing number of state laws that protect fostering and adoptive parents. Information on state laws and protections are available HERE via the Movement Advancement Project, where maps like this live:

https://www.lgbtmap.org/equality-maps/foster_and_adoption_laws

The remainder of Dr. Lopez' presentation focused on ways in which primary care clinicians care for persons with ovaries not on gender affirming hormone therapy (GAHT) and persons with testicles not on GAHT achieve biologic parenthood.

1) Preconception care: this is similar to care for any patient who desires children. Goal is to plan for family building: optimize fertility and minimize pregnancy complications

• Risk assessment and counseling
• Cost: home insemination w/fresh semen (cheapest), genetic and STI testing can cost updwards of $3-4K, sperm is $700-$1500/vial
• Optimize health: routine screening, alcohol and substance use screening, prenatal vitamins, medical conditions (DM, BMI, stress)
• Social and legal considerations (depending on state of residence)
• Outcomes counseling: typically families achieve pregnancy with 3 cycles of IUI (this is much higher than other IUI populations because you are not dealing with someone with fertility challenges), increased rates when both (vs. one) partner attempt pregnancy

2) Deciding origin of sperm

• known vs. anonymous donor
• frozen vs. fresh (more effective)
• sperm banks provide STI and genetic testing (could be more desirable but more expensive)
• washed vs. unwashed (i.e. processed-- removing prostaglandins for IUI)
• West Cost sperm banks have online donor searches vs. direct contact
• differences in $$
• Local sperm banks: California Cryobank (LA), The Sperm Bank of California (Berkeley), California Sperm Bank (SF), Seattle Sperm Bank (Seattle, Tempe, San Diego)

3) Preparation for insemination: mapping out reproductive cycle (we definitely know how to do this)

• 28 day cycle: ovulation occurs 14 days before first day of menses
• educate on use of home ovulation kit: LH surge, cycles day 10-12
• frozen sperm has a short life span, so should be inserted 24 ours after LH surge (right before ovulation); there is no benefit to repeated insemination

4) Assisted Reproductive technology i.e. intrauterine insemination (IUI) in the office

IUI is more effective than transvaginal (home syringe method) and can (and should) be done by PCP in the office. Using the reproductive cycle above.

• 1cc syringe
• 18cm polyethylene catheter (available online)
• Speculum
• No other medications needed
• Patient lies down for 10-15 minutes after insemination

https://www.obgynofatlanta.com/iui

***

In contrast with above, for persons contributing sperm (i.e. men), the needs are different and always require a fertility clinic/specialist (i.e. cannot be managed by PCP alone) because they must involve an ovum donor and a surrogate (or both in one)

Things to consider in discussions as you refer folks to fertility centers:

• intentional unknowing (mixing sperm to fertilize ovum)
• genetic fatherhood in turns
• genetic vs. gestational surrogacy (different ovum donor from who carries the pregnancy)

Local Fertility Centers: Southern California Reproductive Center, CCRM Fertility (SF and Orange County)

Gender Affirming Healthcare: Beyond Pronouns and Hormones (Kohli, 11/10/2021)

 Many thanks to local expert, Dr. Arunima Kohli, for her excellent Grand Rounds this week on Gender Affirming Care: Beyond Pronouns and Hormones. 

A recording of her presentation can be found HERE.

My notes:

Transgender Awareness Week, observed November 13th to November 19th, is a one-week celebration leading up to the Transgender Day of Remembrance (TDoR), which memorializes victims of transphobic violence. In Santa Rosa, TDoR will be honored during an event at Brew Coffee House Saturday 11/20/21 5pm. More information click HERE.  All are welcome.

Of note, in talking about gender affirming care it is important to acknowledge who we are and what our biases are.

No lecture on gender affirming care is complete without going over terminology and definitely not a presentation without the Gender Unicorn. Take a look at the unicorn and try to identify where you would place yourself. 

• gender is a construct AND a spectrum
• gender identity is different than gender expression, physical and emotional attraction are also separate (sexual orientation)

In addition to the gender unicorn, Dr. Kohli likes to think of gender as a multi-dimensional ball-- everybody is kind of fluid-- we are all constantly figuring out our identity, especially when we are younger. This is not isolated to people who identify as trans.  

Language keeps evolving in this field. Very quickly.

• gender diversity and gender expansiveness: umbrella terms that capture the full spectrum (including gender binary people)
• transgender: person whose gender does not correspond to sex assigned at birth based on traditional expectations
• cisgender: person whose gender does correspond to sex assigned at birth
• non-binary (enby): person whose gender does not fit into typical binary norms, based on traditional expectations
• intersex: people with unique variations in reproductive/sexual anatomy, may or may not need to talk about hormones, pronouns, etc

Terms to avoid: transgendered, transgenderism, trans-sexual, biologically/genetically/born as, gender reconstruction surgery. Instead use assignation, designation, and socialization. 

What is gender affirming care? "Health care that holistically attends to transgenders people physical, mental and social needs and well being while respectfully affirming their gender identity."

• social: pronouns, clothing, gender expression, community support
• legal: name change, sex designation, gender marker or legal documents
• medical: gender affirming HRT, surgery, laser tx, voice therapy, pelvic floor therapy
• mental: medication management, mental health service

Professional Guidelines for gender affirming care

• World Professional Association Transgender Healthcare Standards of Care (v7, 2013, v8 may be coming soon)
• UCSF Guidelines for Primary and Gender Affirming Care of Transgender and Gender non-binary People (good for hormone doses, lab monitoring, etc)
• Endocrine Society: Endocrine Treatment of Gender Dysphoric/Gender Incongruent People: Clinical Practice Guidelines (2017)

Health disparities in the gender expansive population are marked

• 1/2 of trans people had to teach their healthcare provider about trans care
• 20% of people don't access health care for fear of mistreatment
• 62% (or more) of gender expansive people suffer depression
• High rates smoking and alcohol
• Higher rates of HIV infection, particularly in black trans women population

Data specific to teens (CDC data)

• Nearly 2% of high schoolers identify as transgender (number increasing)
• 27% of trans-identified high schoolers feel unsafe at school
• 35% of trans-identified high schoolers report being bullied at school
• 35% of trans teenagers attempt suicide
• Higher rates of early sex, multiple partners, having sex without contraception or STD prevention

cdc mmwr 2017

It is INCREDIBLY effective to have supportive parents for trans kids. Check out this graphic to understand why! Markedly improved rates of depression, suicide attempts. . .

https://transstudent.org/graphics/youthsupport/

Gender affirming care is life saving care

• Well documented improved mental health in adults and children with gender affirming care (including psychotherapy, gender affirming surgery, hormones, even proper use of pronouns)
• decreased depression, anxiety, SI
• Decreased rates of suicide attempts by 40% if there is ANY gender affirming person in a trans person's life
• increased engagement with health care system
• improved school performance, improved social skills

. . .But affirmation isn't everything. 

Discrimination

• 65% of trans-people experience discrimination (DMV, nursing homes, gym/health club)
• 59% of trans people avoid using public restroom because of fear of discrimination, 1/3 limit food and drink so they can avoid bathrooms
• 3x higher unemployment rate, worse in BIPOC
• 2/3 of states coverage cover gender affirming hormone therapy
• Few states have Medicaid protections for transgender people
• Being undocumented is additional risk factor; high rates of anti-trans violence in Latin America, have 
• Higher rates of incarceration, higher rates of assaults in prisons, many denied medically necessary gender affirming healthcare while incarcerated

Safety is a real issue

• Sexual assault, sexual violence
• 2021 

https://transrespect.org/en/tmm-update-tdor-2021/

What do we do as health care providers?

• Advocate for change in health systems
• EMR
• Ask EVERY one who comes into your system SOGI (sexual orientation, gender identity), not just those who you assume are different
• organ inventories (so you don't assume gender tells you screening needs)
• formulary
• education and trainings for staff
• hiring people who are transgender
• Do the work before you signal you are safe!
• Learn the language and vocabulary
• Learn insurance rules: sometimes insurance will initially decline but they are not allowed
• Think beyond your own panel
• specialists, other providers--> improve access 
• In CA, all medically necessary care MUST be covered for transition (this includes everything in WPATH of what is medical necessity and what procedures, e.g. laser, body contouring)
• Know your State and National Laws, Legal rights about restroom, Sports participation, etc
• Know local referral providers (e.g. surgeons for gender affirming surgeries)
• Advocacy with schools and workplaces

Additional resources

WPATH Global Education Institute

Transline

Fenway Institute

U Michigan OB/Gyn modules

Trans Student Educational Resources (TSER)
William's Institute UCLA