A Retrospective Analysis of Progestogen Use in Transgender Women

Abstract

Abstract Background: Many transgender women seek progestogens as part of their feminizing gender-affirming hormone treatment (GAHT), particularly to address breast development, body composition, mood stabilization, and changes in sexual desire and sleep. However, there are few studies that evaluate the role of progestogen use in feminizing GAHT. Reasons for initiating and continuing progestogen therapy have been mostly anecdotal to date, dependent on patient preference and provider practice style, and data about effects remain scarce. Objective: To characterize progestogen use patterns in transgender women at one academic center; identify reasons for initiation and continuation of its use; and determine perceived related benefits and adverse events. Methods: Retrospective analysis of transgender women prescribed feminizing GAHT at Stanford Health Care (SHC) between 2014-2020. Those using either combination estrogen + micronized progesterone or combination estrogen + medroxyprogesterone acetate (MPA) were included in our sample. Twenty-five consecutive charts were reviewed in detail for patterns of progestogen use, reasons for initiation and continuation, and its perceived effects. Results: 410 transgender women sought care at SHC between 2014-2020. Ninety-six patients (23%) were prescribed micronized progesterone and 15 patients (4%) MPA at some point in their care, in addition to estrogen use. Of the 25 patient charts reviewed in detail (median age 30 years, IQR 25-42), 32% (n = 8) had clear documentation in the medical record of why progestogen was started and 25% (n = 6) included a description of the patient’s perceived effects with progestogen therapy. The most common reason to start progestogen was improved breast development (20%, n = 5). Three individuals reported improved nipple/breast growth. Median duration of progestogen use was 34.4 months (IQR 22.3-47.4) with 22 out of 25 patients still on progestogen therapy at time of chart review. Median duration of estrogen use prior to initiation of progestogen use was 14.2 months (IQR 7.1-35.8). No cardiovascular or thromboembolic events were noted in the reviewed patients on progestogen therapy. Discussion: Over one in four transgender women seeking feminizing GAHT received a form of progestogen therapy as part of their overall GAHT. Most patients on progestogens lack documentation of why it was started or whether the patient seems to benefit from its addition. Given the continued paucity of data supporting or against progestogen use in feminizing GAHT, gender-affirming hormone providers may benefit from further education on how to counsel patients about progestogen use and how to assess for potential progestogen-associated effects over time. Finally, more consistent documentation in the electronic medical record will allow for more definitive conclusions regarding the benefits and risks of progestogen therapy in the future.