How to eliminate menstruation in a 28-year-old transgender patient transitioning from female to male who is currently on testosterone (intramuscular injections of testosterone cypionate or enanthate)?

Eliminating Menstruation in Transgender Men on Testosterone Therapy

For transgender men on testosterone therapy who still experience menstruation, adding a progestin to their hormone regimen is the most effective approach to eliminate menstruation while maintaining quality of life and minimizing health risks. 1, 2

Current Testosterone Status and Menstruation

Testosterone therapy alone often suppresses menstruation in transgender men, but breakthrough bleeding may still occur. This is important to address as continued menstruation can significantly worsen gender dysphoria and negatively impact mental health.

Optimizing Testosterone Therapy First

Before adding additional medications:

1. Verify adequate testosterone levels:

   • Target serum testosterone levels should be in the cisgender male reference range (300-1000 ng/dL) 2
   • Measure testosterone levels midway between injections for injectable formulations 2
   • Standard dosing for testosterone cypionate is 50-400 mg intramuscularly every 2-4 weeks 3, 4

2. Assess administration technique and schedule:

   • Ensure injections are given deep in the gluteal muscle 3, 4
   • Consider more frequent dosing (every 1-2 weeks) to maintain stable levels and reduce breakthrough bleeding

Adding Progestin Therapy

If optimizing testosterone alone doesn't eliminate menstruation:

1. First-line option: Add a progestin

   • According to the Mayo Clinic, progestins are often co-administered with testosterone to halt menstruation in transgender men 1
   • Options include:
     • Medroxyprogesterone acetate (oral or depot injection)
     • Norethindrone acetate
     • Levonorgestrel IUD (provides local effect with minimal systemic absorption)

2. Dosing considerations:

   • Start with standard doses used for menstrual suppression
   • Monitor for 2-3 months to assess effectiveness
   • Adjust dosing as needed based on response

Monitoring and Follow-up

1. Regular laboratory monitoring:

   • Check testosterone levels every 3 months during the first year, then every 6-12 months 2
   • Monitor hematocrit/hemoglobin (increases within 3 months of starting testosterone) 2
   • Check lipid profiles (HDL may decrease) 1, 2

2. Physical assessment:

   • Track menstrual patterns to confirm cessation
   • Monitor for side effects of combined therapy

Important Considerations and Potential Risks

1. Cardiovascular considerations:

   • Testosterone therapy may increase risk of myocardial infarction 1
   • Consider transdermal testosterone preparations if cardiovascular risk factors are present 1

2. Hematologic monitoring:

   • Watch for polycythemia, which is a common side effect of testosterone 1, 2
   • If hematocrit rises above reference range, consider temporarily withholding therapy, reducing dosage, or phlebotomy if severely elevated 2

3. Gynecological considerations:

   • Be aware that testosterone can cause pelvic pain and genital dryness 1
   • Regular gynecological care remains important

Alternative Options if Progestin is Contraindicated

If progestins are contraindicated or ineffective:

1. GnRH analogs (puberty blockers):

   • These can be used in adults as well as adolescents 1
   • Effectively suppress menstruation by inhibiting the hypothalamic-pituitary-gonadal axis
   • More expensive than progestins and may require prior authorization

2. Surgical options:

   • Hysterectomy with bilateral salpingo-oophorectomy is definitive
   • Consider if medical management fails or if the patient desires permanent solution
   • This approach eliminates need for progestin therapy

Common Pitfalls to Avoid

1. Don't assume testosterone alone will eliminate menstruation in all patients

   • Up to 20% of transgender men on testosterone continue to have some menstrual bleeding

2. Don't ignore breakthrough bleeding

   • Persistent bleeding can significantly worsen dysphoria and requires prompt management

3. Avoid abrupt discontinuation of testosterone

   • Never discontinue testosterone abruptly without medical supervision 2
   • Maintain regular follow-up appointments even when feeling well

4. Don't overlook the importance of chest binding considerations

   • While not directly related to menstruation, proper binding techniques are important for overall well-being 1
   • Recommend removing binders before anesthesia if surgery is planned 1

By following this approach, you can effectively eliminate menstruation in transgender men while maintaining their overall health and improving quality of life.