Vaginal bleeding and spotting in transgender men after initiation of testosterone therapy: A prospective cohort study (ENIGI)

Abstract

Background: Previous studies have cross-sectionally described amenorrhea in cohorts of transgender men on intramuscular or subcutaneous testosterone injections. It remains uncertain which testosterone preparations most effectively suppress vaginal bleeding and when amenorrhea occurs after testosterone initiation.

Aim:To investigate the clinical effects of various testosterone preparations on vaginal bleeding and spotting in transgender men.

Methods: This prospective cohort study was part of the European Network for the Investigation of Gender Incongruence (ENIGI). Data on the persistence and intensity of vaginal bleeding and spotting, serum sex steroid levels and body composition were prospectively and cross-sectionally assessed in 267 transgender men during a three-year follow-up period, starting at the initiation of various testosterone preparations.

Results: After three months of testosterone, 17.9% of transgender men reported persistent vaginal bleeding and 26.8% reported spotting. The percentages reporting vaginal bleeding and spotting decreased over the first year of testosterone (bleeding 4.7% and spotting 6.9% at 12?months, respectively), with no participants reporting vaginal bleeding or spotting after 18?months of testosterone. Factors associated with vaginal bleeding or spotting included lower serum testosterone levels and being on testosterone gel as compared to injections (e.g., esters or undecanoate preparations). If vaginal bleeding persisted, starting progestogens at three months resulted in a decrease in the intensity of vaginal bleeding and spotting.

Discussion: Transgender men and hormone-prescribing providers can be reassured that vaginal bleeding and spotting usually stop within three months after testosterone initiation. If not, serum testosterone levels should be measured and testosterone dose adjusted to achieve serum testosterone levels in the physiologic male range. Adding a progestin can be considered after three to six months if bleeding persists. Providers should be aware that cessation of bleeding can be more difficult to achieve in transgender men with lower serum testosterone levels or those on testosterone gel.     

Engaging with Cultural Sport Psychology to Explore Systemic Sexual Exploitation in USA Gymnastics: A Call to Commitments

In this article, we engage with cultural sport psychology (CSP) to explore sexual exploitation in USA Gymnastics. Specifically, using critical reflexivity on the Larry Nassar case, we bring to life how systemic abuse in sport is more than a tragedy. We argue that perpetration of abuse persists in sport spaces largely because athletes train and compete in relations of force that privilege structures and practices to which athletes are subordinate. A return to recenter discussions on the significance of oppression and power in the larger discourse and ethical practice of CSP became imperative with the news of U.S. doctor Larry Nassar’s sexual predation. As tools in our advocacy for the reduction of sport sexism and sexual exploitation and abuse, we offer four ethical commitments to the field as we examine the ways systemic gendered violence and oppressions in sport are perpetrated in systems, decision-making, and every practices. We invite CSP scholars and sport psychology practitioners to interrogate and disrupt systemic intersectional disempowerment and cultures of sexual exploitation.