Urological and Gynaecological Considerations for the Use of Gonadotropin-releasing Hormone Analogues in Transgender and Nonbinary Adolescents: A Narrative Review

Wai Gin Lee; Gary Butler; Polly Carmichael; Tina Rashid; Ephia Yasmin; Roland Morley; James Barrett; Nim Christopher; Pippa Sangster

doi:10.1016/j.euf.2022.11.002

Urological and Gynaecological Considerations for the Use of Gonadotropin-releasing Hormone Analogues in Transgender and Nonbinary Adolescents: A Narrative Review

Eur Urol Focus. 2023 Jan;9(1):35-41. doi: 10.1016/j.euf.2022.11.002. Epub 2022 Nov 14.

Authors

Wai Gin Lee¹, Gary Butler², Polly Carmichael³, Tina Rashid⁴, Ephia Yasmin⁵, Roland Morley⁶, James Barrett³, Nim Christopher⁷, Pippa Sangster⁷

Affiliations

¹ University College London Hospitals NHS Foundation Trust, London, UK; St Peter's Andrology Centre, London, UK. Electronic address: waigin.lee@nhs.net.
² University College London Hospitals NHS Foundation Trust, London, UK; UCL Great Ormond Street Institute of Child Health, London, UK; The Tavistock and Portman NHS Foundation Trust, London, UK.
³ The Tavistock and Portman NHS Foundation Trust, London, UK.
⁴ Imperial College Healthcare NHS Trust, London, UK; Parkside Private Hospital, London, UK.
⁵ University College London Hospitals NHS Foundation Trust, London, UK.
⁶ Imperial College Healthcare NHS Trust, London, UK.
⁷ University College London Hospitals NHS Foundation Trust, London, UK; St Peter's Andrology Centre, London, UK.

PMID: 36396559
DOI: 10.1016/j.euf.2022.11.002

Abstract

Context: Gonadotropin-releasing hormone analogues (GnRHAs) delay the progression of puberty in transgender and nonbinary (TGNB) adolescents and reduce the impact of dysphoria due to ongoing physical development. The intervention remains contentious despite growing evidence to support this practice.

Objective: To stimulate discussion on this topical issue in the urological and gynaecological community given potential ramifications for future fertility, physical development, and options for gender affirmation surgery (GAS).

Evidence acquisition: We conducted searches of the MEDLINE (from 1946) and Embase (from 1974) databases for the benefits and potential challenges of hormone blockade in TGNB adolescents on February 1, 2022. Evidence with a primary focus on clinical issues of interest to urologists and gynaecologists was objectively synthesised and reported.

Evidence synthesis: The onset of puberty represents a period of distress for TGNB adolescents as secondary sexual characteristics develop. GnRHAs are prescribed to inhibit sex hormone production, but the decision to treat should be balanced against the known (and unknown) adverse effects. Fertility preservation is more likely to be successful if GnRHA treatment is delayed for as long as possible. Some adolescents may decide to stop GnRHA use to harvest spermatozoa or oocytes before starting gender-affirming hormone treatment. Transfeminine individuals should consider that options for genital GAS may become more limited, as vaginoplasty with penile skin inversion requires an adequate stretched penile length. Transmasculine individuals may no longer require chest reconstruction for breast development.

Conclusions: Offers of GnRHA treatment to TGNB adolescents should be balanced by careful preparation and counselling. Urologists and gynaecologists can complement the expertise of specialist psychosocial and adolescent endocrinology teams, and should be involved early in and throughout the treatment pathway to maximise future functional and surgical outcomes.

Patient summary: Puberty blockers for transgender and nonbinary adolescents have benefits, but timing is important to preserve fertility and surgical options.

Keywords: Fertility; Gender dysphoria; Gonadotropin-releasing hormone analogues; Hormone blockers; Transgender.

Publication types

Review

MeSH terms

Gender Dysphoria*
Gonadotropin-Releasing Hormone / therapeutic use
Humans
Male
Sex Reassignment Surgery*
Sexual Maturation
Transgender Persons*

Substances

Gonadotropin-Releasing Hormone