The care of Transgender and Gender Nonbinary Adolescents and Young Adults.

Transgender and gender nonbinary (TGNB) adolescents and young adults (AYA) may present to clinicians with reproductive health expertise for the spectrum of gynecologic, sexual, and reproductive care. As such, clinicians should be knowledgeable in the many facets of gender-affirming care. This clinical opinion reviews language associated with gender diversity and gender-affirming care; current clinical, social, and political barriers faced by TGNB AYA; and the creation of welcoming and inclusive clinical spaces for TGNB AYA. It discusses social, medical, and surgical affirmation processes, and focuses on gynecologic care topics which may arise in the care of TGNB AYA, including those who undergo medical or surgical therapies. This includes menstrual suppression, breakthrough bleeding on testosterone, sexual health, fertility, and the pelvic care of individuals following gender affirming vulvovaginoplasty.

Danazol's use for menstrual suppression in transgender individuals: A retrospective multi-site cohort study.

BACKGROUND: Danazol is a synthetic progestin with androgenic effects that is approved by the Food and Drug Administration for treatment of endometriosis, benign fibrocystic breast disease, and hereditary angioedema. In recent years, increasing numbers of transgender and nonbinary individuals seeking menstrual suppression have been offered danazol due to its potential to both induce amenorrhea and cause reversible androgenic side effects including pigmentation of vellus hairs and voice changes, which may be desirable in this population. There are currently no studies assessing use of danazol within the transgender population for menstrual suppression. OBJECTIVE: This study's primary aim was to evaluate the use of danazol as a menstrual suppression agent in transgender patients. DESIGN: This was a retrospective multisite cohort study of all individuals who had been on danazol at two tertiary care centers between 2000 and 2022. METHODS: All patients prescribed danazol were identified using a search of the electronic medical records. For demographic purposes, comparisons were made between those who did and did not use danazol for the purpose of menstrual suppression. A detailed chart review was then performed to analyze the experiences of menstrual suppression in transgender and nonbinary patients. RESULTS: Most transgender and nonbinary patients on danazol for menstrual suppression remained on it at their most recent follow-up visit, and many charts noted improvements in gender dysphoria, pelvic pain, dysmenorrhea, endometriosis, and heavy menstrual bleeding. Most transgender patients achieved amenorrhea. CONCLUSION: Danazol may be a reasonable option for menstrual suppression in transgender and nonbinary patients. Our findings show its potential to not only induce amenorrhea but cause desired androgenic symptoms and improve gender dysphoria, pelvic pain, dysmenorrhea, endometriosis, and heavy bleeding. While the androgenic effects of danazol are less desirable in cisgender populations, it is an attractive option for menstrual suppression in transgender and nonbinary patients.

Using danazol to stop periods in transgender individualsDanazol has previously been used to help treat pain and bleeding related to endometriosis. However, danazol can have certain androgenic side effects (acne, deepening of the voice) that cisgender women (individuals who were assigned female at birth and identify with the female gender) often find undesirable, but that could be desirable in transgender patients seeking to affirm their gender by stopping periods. Our study looked at danazol use for period suppression, as well as for other reasons. We found that most transgender patients using danazol for period suppression found it to be successful and remained on it at follow-up appointments, and that many transgender patients saw improved gender dysphoria, pelvic pain, pain during periods, endometriosis, and heavy period bleeding. These findings suggest that danazol may be a good option for menstrual suppression in transgender individuals as any experienced androgenic effects may help with gender dysphoria, whether individuals are not yet ready to start testosterone or do not desire testosterone therapy at all.

Adult endocrinologists' perspectives on transitioning adolescent patients with congenital adrenal hyperplasia.

OBJECTIVES: The study aimed to evaluate adult endocrinologists' perspectives on caring for patients with congenital adrenal hyperplasia (CAH) and views on their transition from pediatric to adult care. METHODS: An online survey was conducted among adult clinical endocrinologists at Harvard Medical School-affiliated hospitals from March to October 2022. RESULTS: Most participants (25/34, 73.5 %) treat patients with CAH and expressed moderate to high confidence (23/32, 71.9 %) in their care. Those that did not treat or accept referrals cited insufficient expertise, knowledge, and resources as reasons. Only half of respondents correctly answered at least 50 % of standard of care questions. The main transition of care barrier identified was the absence of standardized policies (12/34, 35.3 %). CONCLUSIONS: Participants, though involved in care of patients with CAH, had varied responses to standard of care questions and transition of care barriers, emphasizing the need for standardized transition protocols and additional training to ensure up-to-date clinical knowledge.

Management of breakthrough bleeding in transgender and gender diverse individuals on testosterone.

BACKGROUND: 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. Because of this, there is a need to assess efficacy of management approaches. OBJECTIVE: The primary aim of the study was to evaluate methods used by patients and their providers to manage breakthrough bleeding which arises after 1 year of testosterone use. Secondary aims included describing the diagnostic approaches to breakthrough bleeding, and proposing an algorithm for classification and management of breakthrough bleeding in this patient population. STUDY DESIGN: This was an institutional review board-approved single tertiary center, retrospective chart review of transgender and gender diverse individuals on testosterone gender affirming hormone therapy who experienced breakthrough bleeding after 1 year of use. Charts were reviewed to determine patient characteristics, testosterone use, and breakthrough bleeding management approaches. RESULTS: Of the 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. The mean age at initiation of testosterone was 21.9 (standard deviation 5.4) and the median duration of time on testosterone was 54.5 months (interquartile range 33.5, 82). Only 16% (n=15) were using menstrual suppression at the time of their breakthrough bleeding episode. Breakthrough bleeding was successfully managed in 77 (79%), following between 1 and 4 attempted approaches. More than half of management attempts (63%) were successful on the first try. When management approaches were analyzed independently, the range of success associated with any particular approach was between 33% and 100%. Other than hysterectomy, which was fully successful at managing breakthrough bleeding, no approach was significantly better than no intervention. This was true both for individuals who did and did not bleed with missed testosterone doses. Regardless of what approach was used, after a failed attempt, the next attempt was successful in more than half of individuals. Of the 16 who underwent hysterectomy, 1 did so in part as a first line approach to manage breakthrough bleeding. CONCLUSION: In this study, use of medical management methods was not found to be superior to observation alone in the management of breakthrough bleeding. In the absence of data supporting superiority of any method, we recommend tailoring method attempts to patients' goals.

Approach to the Patient: Navigating Body Mass Index Requirements for Gender-Affirming Surgery.

Body mass index (BMI) requirements for gender-affirming surgeries (GAS) present an obstacle to gender transition for many transgender and gender diverse (TGD) people. Furthermore, TGD people have unique barriers and preferences in managing their weight that must be considered. TGD patients frequently present to their endocrinologists for individualized, gender-affirming support to meet BMI cutoffs for GAS. This Approach to the Patient article combines expertise from several disciplines, including gender-affirming hormone management, weight management, mental health, gynecology, and plastic surgery. Multidisciplinary management considerations are offered for clinicians to assist TGD patients with obesity navigate BMI requirements to access GAS.

Peri-surgical imaging of intersex and gender diverse youths.

This publication provides an overview of current imaging indications and practices for patients undergoing gender-affirming surgery, with an emphasis on the importance of tailored, patient-specific care. Gender-affirming surgeries are performed with personalized approaches at various stages of life for those with intersex traits or differences in sex development (I/DSD) and transgender and gender diverse (TGD) individuals. For I/DSD patients, ultrasound, genitography, or MRI occurs during infancy and puberty to evaluate genital and gonadal anatomy. Facial harmonization involves bony and soft tissue modifications, guided by maxillofacial computerized tomography (CT) with three-dimensional reconstruction. Ultrasound is the main modality in assessing hormone-related and post-surgical changes in the chest. Imaging for genital reconstruction uses cross-sectional images and fluoroscopy to assess neoanatomy and complications.

Overview of gender-affirming surgery.

This publication will discuss the diversity of procedures that are common to those with intersex traits,/differences of sex development (I/DSD), and transgender and gender diverse (TGD) patients. It will address how these procedures are performed, and common after care and long-term considerations which are relevant to the pediatric radiologist. Some surgeries offered to these patient populations have shared surgical approaches and radiographic considerations. With the growth of TGD procedures as a field, more pediatric subspecialties are performing these procedures, and the approaches are informing the surgical care of the growing number of I/DSD individuals who are seeking surgery in adolescence and young adulthood. Surgeries discussed will include procedures to masculinize or feminize breast/chest tissue, facial bony contours, as well as internal and external genital structures. Patients are diverse and this includes their embodiment goals. As such, not all TGD and I/DSD patients will desire to undergo these procedures. It is important for radiologists to have a foundational understanding of this heterogenous set of procedures so they can provide optimal care for these patient populations.

Use of the Drospirenone-Only Contraceptive Pill in Adolescents with Endometriosis.

STUDY OBJECTIVE: To evaluate the efficacy and tolerability of a progestin-only pill containing 4 mg drospirenone (DRSP) as a hormonal therapy for the management of endometriosis-associated symptoms in adolescents and young adults. DESIGN: Retrospective cohort study. METHODS: A retrospective chart review was performed of all adolescents who were prescribed DRSP continuously (without placebo) for treatment of endometriosis at a single pediatric tertiary care center between 2019 and 2022. Electronic medical records were reviewed to obtain demographics and clinical characteristics of the patients. Measured outcomes included symptom resolution and medication discontinuation. The study was deemed IRB exempt. RESULTS: A total of 61 patients with endometriosis were prescribed DRSP during the study period, with a median age of 18.9 years (SD 2.3). The majority (97%) were laparoscopically confirmed to have endometriosis, and 85% had stage I disease. Before DRSP use, the most common medications trialed were norethindrone (57%) and norethindrone acetate (68%), and 56% had at least one medical contraindication to receiving estrogen-containing therapy. Of those with follow-up, 52% established an absence of bleeding/spotting, and 67% reported less pain at follow-up. One in 4 patients discontinued DRSP during the study period, most commonly due to breakthrough bleeding. CONCLUSION: DRSP is a well-tolerated and effective option for the treatment of endometriosis-associated symptoms in adolescents and young adults.

Incidence of breakthrough bleeding in transgender and gender-diverse individuals on long-term testosterone.

BACKGROUND: Little is known about the maintenance of amenorrhea among transgender and gender-diverse individuals with uteri who are using long-term testosterone gender-affirming hormone therapy. Emerging data describe breakthrough bleeding among adolescents on long-term testosterone therapy and among adults who are seeking a gender-affirming hysterectomy. More studies are needed to better understand breakthrough bleeding patterns among transgender and gender-diverse individuals with uteri who are using testosterone, including the frequency, timing, and etiology of bleeding and how these patterns may differ between adults and younger populations. OBJECTIVE: The primary aim of this study was to characterize the incidence and patterns of breakthrough bleeding in a cohort of transgender and gender-diverse individuals who had been on testosterone for longer than 12 months and who had uteri in situ. Secondary aims included identifying the time to first bleed for those who experienced breakthrough bleeding and the risk factors associated with breakthrough bleeding while on testosterone therapy. STUDY DESIGN: This was an institutional review board-approved, single tertiary center, retrospective chart review of transgender and gender diverse individuals who had been on testosterone for at least 1 year. A primary survival analysis that evaluated the incidence of bleeding was combined with descriptive analyses and an evaluation of the factors associated with bleeding. RESULTS: Of the 279 patients included in the analysis, the median age of testosterone initiation was 22 years (interquartile range, 19-41), and the median follow-up time was 34 months (range, 12-278). The absolute proportion of individuals who ever experienced breakthrough bleeding on testosterone was 34% (n=96; 95% confidence interval, 29-40). Patients who experienced breakthrough bleeding initiated testosterone at a younger age (20.5 vs 22.0 years; P=.04), had lower mean serum testosterone levels (389.14 vs 512.7 ng/dL; P=.001), were more likely to have a mean testosterone level <320 ng/dL (52% vs 48%; P=.001), and had higher mean estradiol levels (62% vs 49%; P=.003). Survival analyses estimated a breakthrough bleeding incidence rate of 0.09 per year (95% confidence interval, 0.07-1.0). Although 58 people underwent a hysterectomy during the follow-up period, 64% of the cohort who maintained a uterus eventually experienced breakthrough bleeding. The median time to the initial bleeding episode was 22 months (interquartile range, 12-201) after testosterone initiation. CONCLUSION: These results suggest that a substantial fraction of transgender and gender-diverse individuals who are using testosterone will experience at least 1 episode of breakthrough bleeding even after their initial year of testosterone use. We recommend that clinicians inform all patients that breakthrough bleeding is a common occurrence even after the first year on testosterone therapy.

Preventive Practices and Knowledge of Human Papillomavirus in Mayer-Rokitansky-Küster-Hauser Syndrome Individuals.

ABSTRACT: Mayer-Rokitansky-Küster-Hauser syndrome is a congenital disorder typified by an underdeveloped female reproductive tract. An exploratory online survey of adults with Mayer-Rokitansky-Küster-Hauser syndrome found that many did not recall receiving the human papillomavirus vaccine, and answers to knowledge questions suggested inadequate human papillomavirus counseling. However, recalled vaccine counseling was associated with improved uptake.

How Do Prescribing Clinicians Obtain Consent to Initiate Gender-Affirming Hormones?

Purpose: Multiple consent models exist for initiating gender-affirming hormone therapy (GAHT). Our study aim was to examine the variety of approaches utilized by clinicians. Methods: Online and in-person recruitment of clinicians involved in gender-affirming care was undertaken from June 2019 through March 2020. Participants completed an online survey. Results: Of the 175 respondents, 148 prescribed GAHT. Sixty-one (41.2%) prescribed to adults only, 11 (7.4%) to minors only, and 76 (51.4%) prescribed to adults and minors. Of those who prescribed to adults, more than half (n=74, 54.4%) utilized a written consent model, one-fourth only verbal consent (n=33, 24.3%), and one-fifth required an additional mental health assessment (MHA) (n=29, 21.3%). Of those prescribing to minors, most required either written consent (n=39, 44.8%) or an additional MHA (n=35, 40.2%). Only 11 (12.6%) utilized only verbal consent for minors. Rationales provided for requiring an additional MHA in adults included protection from litigation, lack of competence in assessing psychosocial readiness for GAHT, and believing that this is the best way to ensure the patient has processed the information. Practicing in multidisciplinary clinics was associated with not requiring an MHA for adult GAHT. Conclusion: Clinicians across fields are utilizing different models to provide the same treatment, with varying rationales for the same model. As a result, patients receive nonstandard access to care despite similar clinical presentations. Our study highlights an important area for further improvement in GAHT care.

Prevalence of pelvic pain in transgender individuals on testosterone.

BACKGROUND: Pelvic pain has been reported in transmasculine individuals taking testosterone. There is a need for further investigation to increase understanding of the prevalence and risk factors of this pain. AIM: We sought to determine the prevalence of pelvic pain reported by transmasculine individuals who had both a uterus and ovaries and were taking testosterone. METHODS: We conducted an institutional review board-approved retrospective study of all transmasculine individuals who had been taking testosterone for at least 1 year and had a uterus and ovaries at the time of testosterone initiation. Charts of participating patients were reviewed to determine patient characteristics, testosterone use, and pelvic pain symptoms both before and after initiation of testosterone. OUTCOMES: Patients reported experiences of pelvic pain while on testosterone. RESULTS: Of 280 individuals who had been on testosterone for at least 1 year, 100 (36%) experienced pelvic pain while on testosterone. Of those patients, 71% (n = 71) had not experienced pelvic pain prior to starting testosterone. There were 42 patients (15%) who had pelvic pain prior to starting testosterone, 13 (31%) of whom no longer experienced pain once starting testosterone. The median (IQR) age at initiation of testosterone was 22 (19-41) years and duration of testosterone treatment was 48 (27-251) months.Those patients who experienced pelvic pain while on testosterone were significantly more likely to have also reported pelvic pain prior to starting testosterone (29% vs 7%, P < .001). These patients were also more likely to have a pre-existing diagnosis of dysmenorrhea (27% vs 7%, P < .001), endometriosis (6% vs 2%, P = .049), or ovarian cysts and/or masses (12% vs 2% P < .001). Patients with pelvic pain were also more likely to have been on a menstrual suppression agent prior to and overlapping testosterone initiation (22% vs 12%, P = .03) and to have used menstrual suppression for longer durations (median [IQR] 18 [6-44] vs 8 [4-15] months, P = .04). CLINICAL IMPLICATIONS: Pelvic pain is common in transmasculine individuals who are initiating testosterone treatment, although testosterone has both positive and negative effects on pelvic pain in different individuals. STRENGTHS AND LIMITATIONS: The major strengths of this study included large numbers of patients, ability to assess for documentation of pelvic pain prior to testosterone, and ability to determine an actual prevalence of pelvic pain. Major limitations included the study being a retrospective analysis in a single tertiary care center, the limitations of clinical documentation, and the lack of a standard pelvic pain evaluation process. CONCLUSION: More than one-third of transmasculine patients with a uterus and ovaries had pelvic pain while on testosterone, with the majority reporting onset of pain after initiating testosterone.

A randomized trial comparing perioperative pelvic FLOor physical therapy to current standard of care in transgender Women undergoing vaginoplasty for gendER affirmation: the FLOWER Trial.

INTRODUCTION AND HYPOTHESIS: There are sparse data on the use of postoperative pelvic floor physical therapy (PFPT) in patients undergoing vaginoplasty. The primary objective of this study was to compare the impact of PFPT on the ease of vaginal dilation after vaginoplasty in transgender women. We hypothesized that patients undergoing PFPT would report better ease of vaginal dilation following surgery. METHODS: This was a randomized trial of transgender women undergoing vaginoplasty. Patients were randomized to either no PFPT or PFPT 3 and 6 weeks following surgery. Subjects completed the Pelvic Floor Disorders Inventory and the Pelvic Floor Impact Questionnaire at baseline and at 12 weeks. At 12 weeks, subjects underwent vaginal length measurement and completed the Patient Global Impression of Improvement and a visual analogue scale (0-10) for ease of vaginal dilation and pain with dilation. A total of 17 subjects in each arm were needed to detect a significant difference in ease of dilation between the two groups. RESULTS: Forty-one subjects were enrolled and 12-week data were available for 37 subjects (20 PFPT, 17 no PFPT). Mean age and BMI were 31 ± 13 years and 24.9 (± 4.0) kg/m2. Subjects were on hormone therapy for a median of 39 (20-240) months and 5 (13.5%) patients had undergone previous orchiectomy. At 12 weeks, the median vaginal length was 12.5 (10-16) cm, reported mean ease of dilation was 7.3 (± 1.6), and pain with dilation was 2.4 (± 1.7). There were no differences in these outcomes or in pelvic floor symptoms between the groups. CONCLUSIONS: In this study, routine postoperative PFPT did not improve outcomes in patients undergoing vaginoplasty.

Desire for genetically related children among transgender and gender-diverse patients seeking gender-affirming hormones.

Objective: To assess predictors of desire for genetically related children among a national cohort of reproductive-age transgender and gender-diverse patients aged 18 to 44 years initiating gender-affirming hormone therapy for the first time. Design: Cross-sectional study. Setting: National telehealth clinic. Patients: A cohort of patients from 33 US states initiating gender-affirming hormone therapy. A total of 10,270 unique transgender and gender-diverse patients-aged 18 to 44 years (median age 24 years), with no prior use of gender-affirming hormone therapy-completed clinical intake forms between September 1, 2020, and January 1, 2022. Interventions: Patient sex assigned at birth, insurance status, age, and geographic location. Main Outcome Measures: Self-reported desire for children using own genetic material. Results: Transgender and gender-diverse patients seeking gender-affirming medical treatments who are open to having genetically related children are an important population to identify and appropriately counsel. Over one quarter of the study population reported being interested in or unsure about having genetically related children, with 17.8% reporting yes and 8.4% unsure. Male-sex-assigned-at-birth patients had 1.37 (95% confidence interval: 1.25, 1.41) times higher odds of being open to having genetically related children compared with female-sex-assigned-at-birth patients. Those with private insurance had 1.13 (95% confidence interval: 1.02, 1.37) times higher odds of being open to having genetically related children compared with those without insurance. Conclusions: These findings represent the largest source of self-reported data on the desire for genetically related children among reproductive-age adult transgender and gender-diverse patients seeking gender-affirming hormones. Guidelines recommend that providers offer fertility-related counseling. These results indicate that transgender and gender-diverse patients, particularly male-sex-assigned-at-birth individuals and patients with private insurance, could benefit from counseling regarding the impacts of gender-affirming hormone therapy and gender-affirming surgeries on fertility.

How Should Clinicians Navigate Decision Making About Genital Reconstructive Surgeries Among Intersex and Transgender Populations?

Genital reconstructive surgeries (GRS) are available for a variety of indications and populations, including transgender and gender diverse (TGD) individuals and those with intersex traits/differences in sex development (I/dsd). Despite the common outcomes of GRS for TGD and I/dsd individuals, decision making about this surgical care differs between these populations and across the lifespan. Sociocultural perspectives on sexuality and gender dominate the ethics of GRS, and reform is needed within clinical ethics to center the autonomy of TGD and I/dsd individuals in informed consent processes. Such changes are necessary to ensure justice in health care for all sex and gender diverse individuals across the lifespan.

Success in Accessing Fertility Preservation Appointments for Egg-Producing Transgender and Gender-Diverse Patients: A Mystery Caller Study.

Purpose: This study aimed to evaluate access to fertility preservation appointments for egg-producing transgender and gender-diverse patients. Methods: Fertility clinics nationwide were identified through the 2018 National Assisted Reproductive Technology Surveillance System dataset of the Centers for Disease Control and Prevention. Using a mystery caller approach with a standardized, community-developed script, three researchers called 456 clinics between July and December 2020 identifying themselves as a transgender man seeking oocyte cryopreservation. Information was collected regarding access to fertility preservation for the caller. Univariate and multivariable logistic regression analysis were used to compare call outcomes by geographic region and clinic demographics. Results: Of 369 clinics included in the final analysis, 90.2% of clinics offered an initial appointment. A clinic that offered an appointment was four times more likely to be located on the West Coast (95% confidence interval [CI] 1.33-12.7; p = 0.014). Notably, endorsement of prior experience caring for transgender patients was most strongly associated with an appointment being offered (odds ratio = 7.31; 95% CI: 3.44-15.5; p < 0.001). Themes across some calls included a lack of knowledge about transgender identities and care models (e.g., requiring a letter of support) leading to additional steps (e.g., having to explain anatomy or being transferred to another staff member) before accessing an appointment. Conclusion: The majority of clinics offered an initial appointment to a caller identifying as a transgender man seeking oocyte cryopreservation, suggesting access to an initial appointment is not a major barrier.

Retrospective review of changes in testosterone dosing and physiologic parameters in transgender and gender-diverse individuals following hysterectomy with and without oophorectomy.

BACKGROUND: As more transgender and gender-diverse patients undergo hysterectomy, gaps in knowledge remain about how testosterone dosing or other physiologic parameters change following surgery and how these are influenced by concomitant oophorectomy. AIM: The aims of this study were to determine the incidence of testosterone dosing change after gender-affirming hysterectomy and to compare this incidence between patients who underwent oophorectomy and ovarian preservation. METHODS: This multicenter retrospective cohort study consisted of transmasculine patients who underwent hysterectomy for gender affirmation. OUTCOMES: Outcome measures included testosterone dosing changes at least 3 months following hysterectomy, as identified by clinical documentation, as well as clinical and laboratory parameters assessed for a change after hysterectomy: free and total testosterone, estradiol, hemoglobin, hematocrit, total cholesterol, weight, and blood pressure. RESULTS: Of the 50 patients, 32 (64%) underwent bilateral oophorectomy, 10 (20%) unilateral oophorectomy, and 8 (16%) maintained both ovaries. Eight percent (n = 4) changed testosterone dosing following hysterectomy. Those who underwent bilateral oophorectomy were no more likely to change their testosterone dose than those who did not (P = .09). Those who also used menstrual suppression were 1.31 times more likely to change doses of testosterone after hysterectomy (95% CI, 1.09-1.82; P = .003). For those who had pre- and posthysterectomy laboratory and clinical values, the majority saw no clinically significant change. However, among patients who underwent bilateral oophorectomy, the calculated free testosterone increased by 90.1 ± 288.4 ng/dL (mean ± SD), and estradiol dropped by 20.2 ± 29.0 pg/mL. CLINICAL IMPLICATIONS: In a field where access to care can be a significant barrier, there is unlikely to be a need for routine reassessment of testosterone dose or laboratory parameters following hysterectomy, whether or not a bilateral oophorectomy occurs. STRENGTHS AND LIMITATIONS: Limitations of the study include its retrospective nature and the lack of consistent clinical laboratory testing, which resulted in limited data about any given hormonal change. The heterogeneity of our population limited the number of patients undergoing or not undergoing oophorectomy; however, it allowed our study to more truly reflect a clinical environment. CONCLUSION: In a multisite cohort of individuals who underwent hysterectomy for gender affirmation, few patients changed testosterone dosing after surgery. In addition, dosing change was not associated with the presence or absence of bilateral oophorectomy, and most measured laboratory values remained consistent following hysterectomy.

Assessing and Addressing the Risk of Venous Thromboembolism Across the Spectrum of Gender Affirming Care: A Review.

OBJECTIVE: Accumulating evidence demonstrates that gender affirming hormone therapy (GAHT) improves mental health outcomes in transgender persons. Data specific to the risks associated with GAHT for transgender persons continue to emerge, allowing for improvements in understanding, predicting, and mitigating adverse outcomes while informing discussion about desired effects. Of particular concern is the risk of venous thromboembolism (VTE) in the context of both longitudinal GAHT and the perioperative setting. Combining what is known about the risk of VTE in cisgender individuals on hormone therapy (HT) with the evidence for transgender persons receiving HT allows for an informed approach to assess underlying risk and improve care in the transgender community. OBSERVATIONS: Hormone formulation, dosing, route, and duration of therapy can impact thromboembolic risk, with transdermal estrogen formulations having the lowest risk. There are no existing risk scores for VTE that consider HT as a possible risk factor. Risk assessment for recurrent VTE and bleeding tendencies using current scores may be helpful when assessing individual risk. Gender affirming surgeries present unique perioperative concerns, and certain procedures include a high likelihood that patients will be on exogenous estrogens at the time of surgery, potentially increasing thromboembolic risk. CONCLUSIONS AND RELEVANCE: Withholding GAHT due to potential adverse events may cause negative impacts for individual patients. Providers should be knowledgeable about the management of HT in transgender individuals of all ages, as well as in the perioperative setting, to avoid periods in which transgender individuals are off GAHT. Treatment decisions for both anticoagulation and HT should be individualized and tailored to patients' overall goals and desired outcomes, given that the physical and mental health benefits of gender affirming care may outweigh the risk of VTE.

Young Adult Patients with Testosterone Management Concerns after Gender-Affirming Hysterectomy and Bilateral Oophorectomy: A Case Series.

Many transgender and gender diverse adolescents and young adults will pursue hysterectomy for the purpose of gender affirmation. This procedure often includes bilateral salpingo-oophorectomy (BSO), which has potential implications for long-term health should individuals choose to stop, or lose access to, exogenous testosterone. Although most of these individuals intend to remain on testosterone indefinitely, not all do, and little information exists on such cases following bilateral oophorectomy to guide counseling and practice. This case series documents 3 individuals who had interruptions in their testosterone use after hysterectomy with BSO for reasons including external barriers, internal barriers, and concerns about side effects. Patients should be appropriately counseled on hysterectomy options as bilateral oophorectomy is not required in the absence of specific indications.

Postoperative Vaginal Bleeding Concerns after Gender-Affirming Hysterectomy in Transgender Adolescents and Young Adults on Testosterone.

STUDY OBJECTIVE: This study aimed to characterize the incidence and management of postoperative vaginal bleeding concerns experienced by transgender adolescents and young adults (AYA) on testosterone hormone therapy after gender-affirming hysterectomy (GAH). METHODS: This was a retrospective cohort of transgender AYA, 18 years and older, using testosterone therapy who underwent a GAH between July 2020 and September 2021 at a tertiary care children's hospital. The incidence of patient-reported postoperative vaginal bleeding concerns and management of bleeding are described. RESULTS: Patient ages ranged between 18 and 33 years. Among 25 patients who met the inclusion criteria, 13 (52.0%) reported vaginal bleeding concerns. No modifiable patient or operative characteristics reached statistical significance in association with postoperative bleeding concerns. Among patients with bleeding concerns, 10 (76.9%) experienced such concerns during the first 2 weeks after surgery, and 6 (46.2%) had resolution of bleeding without intervention. Among 11 patients who underwent an exam for evaluation of bleeding, findings included granulation tissue (n = 5, 45.5%), vaginal atrophy (n = 4, 36.4%), bleeding vessel (n = 1, 9.1%), mucosal separation (n = 1, 9.1%), or no cause of bleeding identified (n = 4, 36.4%). CONCLUSIONS: Over half of transgender AYA on testosterone therapy in this cohort reported postoperative vaginal bleeding concerns that were most often secondary to atrophy and granulation tissue, suggesting possible susceptibility to vaginal tissue trauma at the time of GAH and granulation-susceptible healing in patients on testosterone. As vaginal bleeding could worsen gender dysphoria, these findings support the need for patient counseling on postoperative bleeding expectations and identification of interventions to reduce vaginal bleeding after GAH.