Pelvic pain common for people using gender-affirming testosterone therapy

Nearly three-quarters of people using testosterone therapy for gender affirmation reported pelvic pain, according to findings of an online survey published in LGBT Health.

“As clinicians (gynecologists, endocrinologists and physiotherapists), we have seen increasing numbers of trans individuals on testosterone seeking assistance to relieve symptoms of pelvic pain,” Sav Zwickl, PhD, a trans health research fellow in the department of medicine at the University of Melbourne in Australia, and colleagues wrote. “However, there is a paucity of data regarding pelvic pain in trans individuals using testosterone gender-affirming hormone therapy.”

Zwickl and colleagues recruited participants from the longitudinal Australian transgender health study TRANSform who reported using testosterone therapy for gender affirmation. From Aug. 28 to Dec. 31, 2020, the researchers administered an online survey assessing pelvic pain, menstruation history and other gynecologic, sexual and mental health symptoms related to testosterone therapy.

In total, 486 people completed the survey, of whom 351 (72.2%) reported experiencing pelvic pain after starting testosterone therapy.

Of those reporting pelvic pain, 345 (98.3%) reported experiencing pelvic pain prior to starting testosterone therapy. Additionally, 316 (90%) reported “sometimes” experiencing pelvic pain, and 35 (10%) reported “always or almost always” experiencing pelvic pain.

Participants most frequently described this pain as cramping (72.6%), aching (58.1%), stabbing (39.9%) and sharp (33.9%), and reported it occurred in the hypogastric region (87.2%).

In response to a question about the difference in the pelvic pain experienced before and after starting testosterone therapy, the median score was 4.3 on a scale of 0 to 10, where 0 corresponded with “much less severe,” 5 corresponded with “about the same” and 10 corresponded with “much more severe.”

The odds of reporting pelvic pain after starting testosterone therapy were greater with persistent menstruation (OR = 4.46; 95% CI, 1.33-14.97), current or previous PTSD (OR = 2.5; 95% CI, 1.07-5.85) and pain with orgasm (OR = 32.72; 95% CI, 10.65-100.52).

For treatment of pelvic pain, painkillers (56.7%) and heat (45.6%) were reported as most helpful. NSAIDs (46.4%) and paracetamol/acetaminophen (30.8%) were reported as the most helpful painkillers.

Among 26 people who underwent hysterectomy, 16 (61.5%) did so for pelvic pain and 12 (46.2%) did so due to gender dysphoria. Most (72%) reported less pelvic pain following hysterectomy, although 20% reported little to no change and two (8%) reported more pain.

“The increased likelihood of reporting pain in people with persistent menstruation and orgasm, as well as the known androgen sensitivity of the pelvic floor musculature, warrant further research on pelvic floor muscle dysfunction as a contributor,” Zwickl and colleagues wrote. “Until further evidence is available, a tailored multidisciplinary trauma-informed approach addressing the needs of the individual with pelvic pain should be provided, which may encompass pain management, sexual function, addressing persistent menstruation and mental health.”