Menstrual suppression for AFAB patients
The term trans masculine is used in reference to trans people who were assigned female at birth, but who identify more with masculinity than femininity. This may include non-binary people as well as binary trans men11.
Some (but by no means all) trans masculine people find menstruation distressing and seek advice from their GP.
For people on standard dose testosterone therapy, this alone is usually sufficient to suppress menstruation after 3-6 months of treatment. The oral progestin Provera used at high dose can offer short term arrest of bleeding as a short-term measure while serum testosterone reaches optimum range and stabilises.*
For people using either low-dose testosterone or no testosterone at all, a long-term approach to menstrual suppression will be required. High-dose Provera is very effective, but specialist guidance is recommended for longer treatment courses.
Alternatives in this context include progesterone-only contraceptive preparations including the progesterone-only pill, depot progestin, and the LNG-IUS. However, they can cause irregular spotting which may cause more dysphoria than a predictable monthly bleed, so the pros and cons should be discussed carefully with each patient. The combined oral contraceptive pill is counterproductive for patients using testosterone, and for others, taking a ‘female’ hormone might not be a desirable treatment option. However, it is not contraindicated and could theoretically be used continuously with biennial ultrasound monitoring if acceptable to the patient12.
Unexplained vaginal bleeding in trans masculine people requires investigation as you would for any patient with a female reproductive tract. If they are using testosterone, it is prudent to check their serum level as when supraphysiological, testosterone is aromatised to estrogen and this can stimulate endometrial proliferation producing bleeding. Equally, menses can resume if the testosterone dose is insufficient and serum levels fall.
* Where Provera treatment fails, and serum testosterone levels are adequate, a GnRH agonist will very effectively shut down the hypothalamic-pituitary-gonadal axis and arrest menstrual cycling (as for endometriosis)
