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Experiences with Menses in Transgender and Gender Nonbinary Adolescents

Published:February 02, 2022DOI:https://doi.org/10.1016/j.jpag.2022.01.015

      Abstract

      Study Objective

      To describe menstrual history, associated dysphoria, and desire for menstrual management in transgender male and gender diverse adolescents who were assigned female at birth

      Design

      Retrospective chart review

      Setting

      Tertiary care children's hospital

      Participants

      All patients seen in a multidisciplinary pediatric gender program from March 2015 through December 2020 who were assigned female at birth, identified as transgender male or gender nonbinary, and had achieved menarche

      Intervention

      None

      Main Outcome Measures

      Patient demographics, menstrual history, interest in and prior experiences with menstrual management, parental support, and concerns about menstrual management

      Results

      Of the 129 included patients, 116 (90%) identified as transgender male and 13 (10%) as gender nonbinary, with an average age of 15 (SD 1.6) years. Almost all (93%) patients reported menstrual-related dysphoria. Most (88%) were interested in menstrual suppression. The most common reasons for desiring suppression were achievement of amenorrhea (97%) and improvement of menstrual-related dysphoria (63%).

      Conclusions

      Most gender diverse patients assigned female at birth reported dysphoria associated with menses and desired menstrual suppression. This information can encourage physicians to raise this topic and offer menstrual management for gender diverse patients who experience distress related to menses, especially for those who are not ready for or do not desire gender-affirming hormonal treatment. Future research is needed to better understand patients’ experiences with menses and to determine the optimal menstrual management methods. This could be an important intervention to improve outcomes for this vulnerable population.

      Key Words

      Introduction

      Transgender and gender diverse youth have an increased incidence of mental health diagnoses, economic marginalization, social isolation, and physical abuse, all of which are associated with increased risk of self-harm, alcohol and drug use, and suicidality.
      • Rafferty J.
      Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents.
      • Almeida J
      • Johnson RM
      • Corliss HL
      • et al.
      Emotional distress among LGBT youth: the influence of perceived discrimination based on sexual orientation.
      • Perez-Brumer A
      • Day JK
      • Russell ST
      • et al.
      Prevalence and correlates of suicidal ideation among transgender youth in California: findings from a representative, population-based sample of high school students.
      • Day JK
      • Fish JN
      • Perez-Brumer A
      • et al.
      Transgender youth substance use disparities: results from a population-based sample.
      As nomenclature in this field is constantly evolving, we define the terms that will be used for this manuscript. Gender diverse individuals are those whose gender identity and expression are different from that typically associated with the sex they were assigned at birth.
      • Rafferty J.
      Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents.
      Transgender males are those who were assigned female at birth and identify as male. Gender nonbinary is an umbrella term for individuals who do not identify as a binary male or female. They might identify as neither gender, as both male and female at once, or as different genders at different times.
      • Richards C
      • Bouman WP
      • Seal L
      • et al.
      Non-binary or genderqueer genders.
      Gender dysphoria is distress or discomfort caused by the discrepancy between gender identity and sex assigned at birth.
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders.
      Those who are assigned female at birth and do not identify as female may present to gynecologists or reproductive health care providers for multiple reasons, including preventive care, menstrual issues, contraception, and mental health care, in addition to possible gender-affirming hormone therapy and treatments. Some adolescent or adult transgender male patients request therapeutic amenorrhea,
      • Pradhan S
      • Gomez-Lobo V
      Hormonal contraceptives, intrauterine devices, gonadotropin-releasing hormone analogues and testosterone: menstrual suppression in special adolescent populations.
      ,
      • Carswell JM
      • Roberts SA
      Induction and maintenance of amenorrhea in transmasculine and nonbinary adolescents.
      but little is known about this topic, especially in the pediatric population. Although there is known increased dysphoria related to puberty,
      • de Vries ALC
      • Cohen-Kettenis PT
      Clinical management of gender dysphoria in children and adolescents: the Dutch approach.
      there are minimal data on dysphoria associated with menses. One study described mixed attitudes toward menstruation in transmasculine adults,
      • Chrisler JC
      • Gorman JA
      • Manion J
      • et al.
      Queer periods: attitudes toward and experiences with menstruation in the masculine of centre and transgender community.
      and a qualitative study reported distress due to resumption of bleeding in transgender male adults who stopped gender-affirming hormonal treatment to pursue fertility preservation.
      • Armuand G
      • Dhejne C
      • Olofsson JI
      • et al.
      Transgender men's experiences of fertility preservation: a qualitative study.
      To our knowledge, there are no published reports on gender dysphoria, depression, anxiety, or other psychological symptoms or outcomes related to menses in the adolescent population. In our clinical experience, many transgender and gender diverse adolescents express significant distress related to menarche and menstruation.
      There is an even greater paucity of information about the experiences and treatment goals of gender nonbinary children and adolescents, but there are some data that nonbinary youth are at even higher risk of adverse mental health outcomes than their transgender peers.
      • Thorne N
      • Witcomb GL
      • Nieder T
      • et al.
      A comparison of mental health symptomatology and levels of social support in young treatment seeking transgender individuals who identify as binary and non-binary.
      ,
      • Newcomb ME
      • Hill R
      • Buehler K
      • et al.
      High burden of mental health problems, substance use, violence, and related psychosocial factors in transgender, non-binary, and gender diverse youth and young adults.
      The experience of nonbinary individuals who were assigned female at birth and undergo menstruation is unknown. It can be hypothesized that nonbinary persons are as similarly distressed by menses as transmasculine or transgender males because they also do not identify as female and thus menses could cause increased gender dysphoria. Conversely, gender nonbinary individuals might be more tolerant of menses because they do not identify as male. However, although many transgender males desire gender-affirming hormone therapy with testosterone, which often results in menstrual cessation,
      • Ahmad S
      • Leinung M
      The response of the menstrual cycle to initiation of hormonal therapy in transgender men.
      • Deutsch MB
      • Bhakri V
      • Kubicek K
      Effects of cross-sex hormone treatment on transgender women and men.
      • Pelusi C
      • Costantino A
      • Martelli V
      • et al.
      Effects of three different testosterone formulations in female-to-male transsexual persons.
      • Nakamura A
      • Watanabe M
      • Sugimoto M
      • et al.
      Dose-response analysis of testosterone replacement therapy in patients with female to male gender identity disorder.
      • Spratt DI
      • Stewart II
      • Savage C
      • et al.
      Subcutaneous injection of testosterone is an effective and preferred alternative to intramuscular injection: demonstration in female-to-male transgender patients.
      many gender nonbinary patients may not desire or use testosterone.
      • Cocchetti C
      • Ristori J
      • Romani A
      • et al.
      Hormonal treatment strategies tailored to non-binary transgender individuals.
      Therefore, knowledge about experiences with menstruation and desire for menstrual management or suppression in nonbinary youth might be even more important to guide long-term treatment options.
      Given that most transgender and gender nonbinary youth who are assigned female at birth will experience menstruation if puberty is not suppressed prior to menarche, their experiences around menstruation are an important and unexplored topic that could help facilitate conversations about the adolescents’ well-being and possible treatment options.
      • Olson J
      • Schrager S
      • Belzer M
      • et al.
      Baseline physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria.
      The objective of this study is to describe the characteristics, menstrual history, associated dysphoria, and desire for menstrual management in gender diverse adolescents and to assess for any differences in characteristics between those who identify as transgender males and those who identify as gender nonbinary. These data have the potential to identify gaps in medical treatment and new avenues to improve care for this vulnerable population.

      Materials and Methods

      This is a retrospective chart review of all patients who identified as transgender or gender nonbinary and who were seen by at least 1 provider at the Nemours Children's Hospital Delaware multidisciplinary Gender Wellness Program (GWP) between March 1, 2015, and December 17, 2020. The GWP is a multidisciplinary program. Patients and their parents or guardians are seen for a 4-session evaluation by a psychologist to assess mental health, family and community support, and readiness for medical transition. Patients are then followed by our psychologists for long-term gender-related care or transitioned to providers in the community. All patients are encouraged to see an endocrinologist and gynecologist when they are ready for information about gender-affirming medical treatments, as well as for menstrual management, counseling about fertility and fertility preservation, and reproductive health. A social worker meets with all patients initially and then as needed to provide support and resources. The GWP team meets regularly to discuss patients at all stages in the process of exploring gender identity and treatments. All new GWP patients are 17 years of age or younger. Once patients have established care, they can be followed by the program through age 20, at which time they are transitioned to adult care.
      Gender diverse patients were identified by electronic medical record (EMR) queries based on a combination of encounter types and diagnosis codes and confirmed by chart review. Inclusion criteria for this study were female sex assigned at birth, transgender male or gender nonbinary identity, and achievement of menarche. Included patients were seen by at least 1 of the GWP providers during the study period. Three patients with other gender identities (2 who identified as agender and 1 as a demi-boy) were excluded due to their very small numbers and because they did not fit into either of the other more well-defined gender identity subgroups.
      Data were abstracted from the EMR by 3 investigators using standardized Research Electronic Data Capture (REDCap) electronic data capture forms.
      • Harris PA
      • Taylor R
      • Thielke R
      • et al.
      Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support.
      The investigators met regularly as a team with the primary investigator to ensure consistent data collection and resolve questions or discrepancies through consensus. Abstracted data included patient demographic characteristics (age, race, ethnicity, insurance, sex assigned at birth, gender identity) and gender-affirming medical history and treatments. Gender identity was reported by patients with no predefined terms or lists. Information about behavioral health symptoms, psychiatric diagnoses, psychiatric admissions, contacts with a therapist and/or psychiatrist, and use of psychiatric medication was collected. Psychiatric diagnoses were made by psychologists or psychiatrists using Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria.
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders.
      Menstrual history (age at menarche; frequency, duration, and flow of menses; menstrual pain and other associated menstrual symptoms; mood symptoms; and dysphoria related to menses), sexual activity, and interest in and prior experiences with menstrual management, including goals for medication use and parental support and concerns about menstrual management, were also abstracted. Menstrual symptoms were considered present if reported by the patient, except for premenstrual dysphoria disorder (PMDD), which has clear diagnostic criteria.
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders.
      Information about sexual activity was also collected. Patients were considered to be sexually active if they engaged in vaginal or anal intercourse.
      Data were entered and managed using a REDCap electronic data capture tool hosted at Nemours Children's Hospital.
      • Harris PA
      • Taylor R
      • Thielke R
      • et al.
      Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support.
      Frequency counts and percentages and means and standard deviations were used to describe data for the entire study sample and by gender subgroup (transgender male, gender nonbinary). Data were compared between the 2 gender identity subgroups using 2-sample t tests for continuous variables and χ2 and Fisher exact tests for categorical variables. A P value of less than 0.05 was considered statistically significant. Statistical analyses were performed using SAS version 9.4.
      SAS® 9.4 Statements
      Reference.
      This study was approved by the Nemours Children's Health System Institutional Review Board.

      Results

      During the study period, 199 patients were seen by at least 1 GWP provider. Of these, 129 (65%) met the inclusion criteria for this study (Fig. 1). Demographic characteristics and sexual activity history for all patients and by gender identity subgroup are presented in Table 1. Mean age at initial presentation was 15 years (SD 1.6). Almost all patients were white (90%) and non-Hispanic (93%), and the majority (73%) were privately insured.
      Fig 1
      Fig. 1Flowchart of patients in the final analysis sample.
      Table 1Demographic Characteristics, Sexual Activity, and Testosterone Use of All Study Patients and by Gender Identity Subgroups
      Total n = 129Transgender male n = 116Gender nonbinary n = 13
      Age in years, mean (SD)
      P = .009.
      15.0 (1.6)15.1 (1.5)13.9 (1.8)
      Race, n = 121
      Asian1 (1)1 (1)0
      Black/African-American11 (9)10 (9)1 (8)
      White109 (90)97 (90)12 (92)
      Ethnicity, n = 128
      Hispanic or Latino9 (7)9 (8)0
      Not Hispanic or Latino119 (93)106 (92)13 (100)
      Type of health insurance, n = 128
      Private

      Public
      94 (73)

      34 (27)
      84 (73)

      31 (27)
      10 (77)

      3 (23)
      Ever sexually active
      Sexually active defined as engaging in vaginal or anal intercourse.
      , n = 104
      Yes12 (11)12 (13)0
      No92 (89)81 (87)11 (100)
      Current risk for pregnancy
      Risk for pregnancy defined as engaging in sexual activity that has the biological potential to result in pregnancy, ie, vaginal intercourse with a sperm-producing partner.
      , n = 104
      Yes5 (5)5 (5)0
      No99 (95)88 (95)11 (100)
      Current testosterone use, n = 128
      Yes7 (5)7 (6)0
      No121 (95)108 (94)13 (100)
      Data are presented as n (%), except where otherwise specified. Numbers do not all add up to total due to missing data.
      SD, standard deviation.
      low asterisk P = .009.
      Sexually active defined as engaging in vaginal or anal intercourse.
      Risk for pregnancy defined as engaging in sexual activity that has the biological potential to result in pregnancy, ie, vaginal intercourse with a sperm-producing partner.
      Only 12 (17%) had ever been sexually active, with only 7 patients currently sexually active and only 5 of these patients engaging in sexual activity that had the biologic potential to result in pregnancy. An additional 6 patients stated that they were considering becoming sexually active in the near future, although only 4 of these subjects intended to engage in vaginal intercourse. All sexually active patients were transgender males. A total of 17 (13%) patients reported a history of sexual abuse, with no patients experiencing current sexual abuse. Two of these patients also reported consensual sexual activity.
      Very few patients (n = 7, 5%) were using gender-affirming hormones (testosterone) at the time of their first GWP visit. Nearly 90% (n = 116) of patients identified as transgender male, and 10% (n = 13) identified as gender nonbinary. There was a significant difference in age at initial presentation between gender identity subgroups, with gender nonbinary patients presenting an average of 1 year earlier compared with transgender male patients (13.9 vs 15.1, P = .009). There were no other differences in demographic characteristics between these subgroups.

      Menstrual History

      The average age of menarche for all study patients was 11.5 years (SD 1.3) (Table 2). Most patients (n = 100, 85%) reported regular menstrual cycles. Almost three-quarters of patients had at least 1 associated menstrual symptom. The most common symptom was menstrual pain or cramping (n = 76, 66%), with a variety of other symptoms reported by a small number of patients. Of patients with reported menstrual pain, more than half required use of pain medication during periods. Almost all patients (n = 89, 93%) described increased gender dysphoria or distress related to menses. There were no significant differences in any menstrual characteristics or symptoms between patients identifying as transgender male and those identifying as gender nonbinary.
      Table 2Menstrual History of All Study Patients and by Gender Identity Subgroups
      Total n = 129Transgender male n = 116Gender nonbinary n = 13
      Age at menarche in years, mean (SD)11.5 (1.3)11.5 (1.3)11.0 (1.2)
      Menstrual history
      Regular periods, n = 117
       Yes100 (85)87 (84)13 (100)
       No17 (15)17 (16)0
      Cycle length (days), n = 102
       <212 (2)2 (2)0
       21-3489 (87)77 (86)12 (100)
       35-907 (7)7 (8)0
       >904 (4)4 (4)0
      Menstrual duration (days), n = 97
       <34 (4)4 (5)0
       3-783 (86)73 (84)10 (100)
       >710 (10)10 (11)0
      Menstrual symptoms and medication use
      Menstrual symptoms, n = 116
       None33 (28)30 (29)3 (23)
       Pain76 (66)67 (65)9 (69)
      Gastrointestinal (eg, nausea, vomiting, diarrhea)12 (10)11 (11)1 (8)
      Neurologic (eg, headaches, lightheadedness/dizziness)15 (13)14 (14)1 (8)
      Mood (eg, PMS, PMDD)4 (3)3 (3)1 (8)
      Other symptoms (eg, fatigue, acne)5 (4)4 (4)1 (8)
      Unspecified12 (10)9 (9)3 (23)
      Pain medication use during menses, n = 59
       Yes41 (69)37 (70)4 (67)
       No18 (31)16 (30)2 (33)
      Psychiatric symptoms associated with menses
      Mood changes prior to menses, n = 42
       Yes18 (43)16 (44)2 (33)
       No24 (57)20 (56)4 (67)
      Mood changes during menses, n = 56
       Yes35 (63)30 (61)5 (71)
       No21 (37)19 (39)2 (29)
      Gender dysphoria/distress related to menses, n = 96
       Yes89 (93)78 (92)11 (100)
       No7 (7)7 (8)0
      Data are presented as n (%), except where otherwise specified. Numbers do not all add up to total due to missing data.
      SD, standard deviation; PMDD, premenstrual dysphoric disorder; PMS, premenstrual syndrome.

      Menstrual Management

      One-quarter (n = 29, 24%) of patients reported previous use of a menstrual management method (MMM), with 19 (15%) currently using an MMM (Table 3). The most common prior method used was combined oral contraceptive pills (OCPs). Most patients were interested in starting menstrual management (n = 107, 88%). Of those who desired menstrual management, almost all (n = 104, 97%) patients cited a desire for amenorrhea as the reason for use. In addition, 63% (n = 67) of patients stated that reduction in menstrual-related dysphoria was a motivating reason. Only 5 (4%) patients stated that they desired contraception. All of these patients were currently sexually active. In fact, 66 (50%) subjects explicitly stated that their desire for hormonal medication was not for contraception.
      Table 3Prior Menstrual Management Method (MMM) Use and Interest in MMM for All Study Patients and by Gender Identity Subgroups
      Total n = 129Transgender male n = 116Gender nonbinary n = 13
      History of any prior MMM use, n = 119
       Yes29 (24)26 (25)3 (23)
       No90 (76)80 (75)10 (77)
      Current MMM use, n = 129
       Yes19 (15)17 (15)2 (15)
       No110 (85)99 (85)11 (85)
      Prior MMM used
      Among those who reported prior MMM use; multiple prior methods used possible.
      , n = 29
       Combined OCP13 (45)12 (46)1 (33)
       Progestin-only OCP1 (3)1 (4)0
       Norethindrone acetate9 (31)8 (31)1 (33)
       DMPA injections5 (17)4 (15)1 (33)
       Etonogestrel implant3 (10)3 (12)0
       Intrauterine device1 (3)1 (4)0
      Interest in starting MMM, n = 122
       Yes107 (88)95 (87)12 (92)
       No15 (12)14 (13)1 (8)
      Reasons for MMM desire/use
      For those interested in starting MMM; multiple reasons possible.
      , n = 107
       Amenorrhea104 (97)92 (97)12 (100)
       Less frequent periods1 (1)1 (1)0
       Improved bleeding3 (3)2 (2)1 (8)
       Improved menstrual-related pain8 (7)8 (8)0
       Improved menstrual-related moods7 (7)1 (1)0 (0)
       Improved menstrual-related dysphoria67 (63)58 (61)9 (75)
      Data are presented as n (%). Numbers do not all add up to total due to missing data.
      DMPA, depot medroxyprogesterone acetate; MMM, menstrual management method; OCP, oral contraceptive pill.
      low asterisk Among those who reported prior MMM use; multiple prior methods used possible.
      For those interested in starting MMM; multiple reasons possible.

      Parental Support

      Of the 51 patients for whom data were available from the EMR about parental support for menstrual management, almost three-quarters (n = 37) of parents were supportive of menstrual management (Fig. 2). Only 6 (12%) parents were explicitly not supportive of initiation of an MMM, with the remaining 8 (16%) reporting uncertainty or mixed feelings. There were no differences in parental support by gender identity subgroup. Regardless of whether parents voiced support for menstrual management, there were many reported parental concerns about its use. The most common concerns were adverse effects and long-term effects (Fig. 3).
      Fig 2
      Fig. 2Parental support of menstrual suppression.
      Fig 3
      Fig. 3Parental concerns about menstrual suppression, even if supportive of it.

      Discussion

      This study describes transgender and gender diverse adolescents’ experiences with menses. This is an issue that is anecdotally distressing to transgender and nonbinary patients who were assigned female at birth and do not identify as female. However, to our knowledge, there are no prior published data on this subject. Many adolescents might desire gender-affirming hormone treatment with testosterone in part to stop menses, but testosterone use might not be appropriate for some patients due to age, parental reluctance, or lack of desire for testosterone.
      Our data provide the first evidence that transgender and gender nonbinary adolescents are distressed by their periods. Their menstrual history and associated pain and other symptoms are consistent with those of the general adolescent population.
      • Elmaoğulları S
      • Aycan Z
      Abnormal uterine bleeding in adolescents.
      American College of Obstetricians and Gynecologists
      Committee Opinion No. 760: Dysmenorrhea and endometriosis in the adolescent.
      • Vichnin M
      • Freeman EW
      • Lin H
      • et al.
      Premenstrual Syndrome (PMS) in adolescents: severity and impairment.
      However, our patients report high rates of mood symptoms related to menses and significant gender dysphoria or distress that is caused or exacerbated by their periods. There is a strong desire for menstrual suppression in this population, with a primary goal of achieving amenorrhea. Desire for amenorrhea is different from menstrual goals for the general adolescent population, in which menstrual regulation or improvement is the typical request.
      • Altshuler AL
      • Hillard PJA
      Menstrual suppression for adolescents.
      This is especially important information because many patients are started on combined OCPs for menstrual suppression, and this method has lower rates of amenorrhea than other options.
      American College of Obstetricians and Gynecologists
      Committee Opinion No. 668: Menstrual manipulation for adolescents with physical and developmental disabilities.
      In addition, given our population's low rates of sexual activity and lack of interest in contraception, methods that have a high likelihood of resulting in amenorrhea might be more desirable to patients than traditional methods that are known to be used for contraception. The information from this study can help providers consider other menstrual management options, although more information is needed to determine the optimal MMMs in this population.
      We present data separately for transgender males and gender nonbinary patients because we suspect that they are similar but different populations, especially with respect to experiences with menstruation. Although no differences were seen between these subgroups, the small number of patients who identified as nonbinary might have obscured any potential differences. There was a significant age difference, with the nonbinary group presenting an average of 1 year younger than the transgender group. This might be of no clinical significance, but it also could be due to youth feeling more comfortable coming out as nonbinary at an earlier age. Importantly, all the nonbinary patients in our study population reported worsened gender dysphoria associated with menses. More research is needed on this subgroup of gender diverse patients, which could especially benefit from qualitative, patient-reported data on this topic.
      Given the age of this population, parental knowledge, support, and consent could be major factors in decisions about and initiation of treatment. Our patients’ parents were generally supportive of menstrual management or suppression, although they reported some concerns, especially about potential adverse effects. This is likely higher than the support for use of gender-affirming hormones, especially for younger patients, although there are no data on this topic. Possible reasons for the high acceptability of menstrual management are that many of these methods are familiar to parents for other reasons and are also completely reversible. Further research is needed to explore this topic.
      The strengths of this study are the relatively large sample size and the breadth of information available from patients seen at a multidisciplinary gender program. The main limitation of this study is its retrospective nature, which relies on adequate documentation of variables sometimes difficult to extract, and the resultant missing data. Although provider EMR templates were used to gather some of this information, there were not standardized questionnaires or tools. For those patients seen by a gynecologist in the GWP, there were likely more data available about menstrual history and menstrual management than for those who were not seen by this specialty. Another limitation is the smaller number of patients for whom information was available in the EMR about parental support and concerns related to menstrual suppression. This is new information that deserves further study. As almost all patients reported significant distress or increased gender dysphoria related to menses, this precluded any analyses of the effects of this factor on overall mental health. Lastly, this study might have limited generalizability. The fact that these patients were all seen in a specialized gender care clinic introduces a selection bias and could overestimate the degree of both gender dysphoria in general and distress related to menses. In addition, the patients who opted to see a pediatric gynecologist might be more distressed by menses and interested in menstrual management, although patients who did not see a gynecologist were also included in this study. Our patient population also has limited racial and ethnic diversity. Most patients were white, non-Hispanic, and privately insured. As there is no known national demographic information for adolescents who identify as transgender or gender diverse, it is difficult to know whether this information is generalizable to a broader population. However, the demographic composition of our population is significantly different from that of children and adolescents in the surrounding county and state, with a higher proportion of white (90% for our subjects vs 49% in the county and 52% in the state) and non-Hispanic (93% vs 86% for both the county and state) individuals in our population compared with these surrounding areas.

      U.S. Census Bureau: 2012-2016 American Community Survey five-year estimates. 2017, https://data.census.gov/mdat/#/

      The ways in which our population differs from the local community and the reasons for these differences deserve further study.
      This study provides new information about a significantly understudied area for the transgender population. These data highlight the importance of providers raising these topics and offering menstrual management for gender diverse patients who experience distress related to menses, especially for those who are too young, not currently ready for, or do not desire gender-affirming hormonal treatment. Future research is needed to obtain more information about patients’ experiences with menses and menstrual management, as well as to determine the optimal MMMs for this population to induce amenorrhea, improve menstrual-related moods, and help relieve gender dysphoria. This could be an important intervention to improve the mental health and overall health outcomes for individuals in this vulnerable population.

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