Main Findings
Pelvic pain after initiation of testosterone therapy appears to be a common occurrence, reported by 72.2% of trans people responding to this online survey. Cramping pain in the suprapubic (hypogastric) regions were the most common descriptors. Factors associated with increased odds of reporting pain with testosterone were persistent menstruation (OR 4.46 (1.33, 14.97)), pain with orgasm (OR 32.72 (10.65, 100.52)), and current or previous diagnoses of PTSD (OR 2.50 (1.07, 5.85)). NSAIDs were most commonly used to relieve pain. Of the small number of participants (n=26) who had undergone hysterectomy, 72% reported reduction in pain.
Consistent with our hypothesis and the only other published study describing pelvic pain in trans people using testosterone GAHT, is the prevalence of approximately 70% and the description as cramping, most commonly in the hypogastrium or suprapubic region, followed by right and left iliac regions.1
Whilst our exploratory study cannot determine causation or mechanisms of pain, the increased likelihood of reporting pain in people with persistent menstruation and orgasm may possibly suggest increased pelvic floor muscle dysfunction.19 It is known that levator ani, the collective group of pelvic floor muscles consisting of the deeper layer of pubococcygeus, the iliococcygeus, and the puborectalis, as well as superficial perineal muscles such as the bulbospongiosus, are enriched with androgen receptors and exquisitely androgen-sensitive in male humans, and in male rodents.20 Androgen-receptor knock out mice, and men who have androgen deprivation therapy for prostate cancer have a marked reduction in the size of the levator ani muscle.21, 22 Androgens have been shown in female humans and rats to have anabolic effects on pelvic floor muscles.23-25 As such, it is plausible that with testosterone GAHT may affect the pelvic floor and perineal muscle, and therefore may contribute to the experience of pain.
Whilst pain from endometriosis has been described to worsen with orgasm and penetrative sexual activity,26 inconsistent with our hypothesis, our analysis did not show an association between having a diagnosis of endometriosis, diagnosis of vaginismus, vulvodynia or genital dryness and pelvic pain.
Participants who reported persistent menstruation had a significantly higher odds (OR 4.46) of reporting pain after starting testosterone. Individuals who do have persistent vaginal bleeding would generally be continuing to have typical rises and falls in estradiol and progesterone concentrations over the course of a menstrual cycle. Pelvic pain in people with persistent menstruation may arise from factors such as dysmenorrhoea from myometrial contractions, the release of inflammatory mediators that cause endometrial shedding, or pelvic floor muscle dysfunction. Menstruation with fluctuations in estradiol and testosterone levels have been demonstrated to affect pelvic floor muscle activity with significantly higher levels of muscle tone in the luteal phase relative to the follicular and ovulatory phases.27
Sexual dysfunction among trans people has been reported to be very common, likely compounded by increased sexual desire after commencing testosterone therapy.28 However there is little published research.29 Those who had pain with orgasm had a significantly elevated odds (OR 32.72) of reporting pelvic pain after starting testosterone GAHT. Pain with orgasm or dysorgasmia, is one of the least understood and poorly studied areas in sexual medicine, involving a complex interplay of psychological, neural, vascular, and endocrine factors. It has been hypothesised that dysorgasmia may be the result of bladder neck contractions, uterine neuro-inflammation, uterine contractions and/or pelvic floor musculature dystonia.30, 31 As such, treatment for sexual pain would be best tailored to the individual with a multidisciplinary approach involving gynaecology, physical therapy, pain management, sexual therapy, and mental health professionals who specialize in chronic pain.32 Further research is needed on aetiologies and evaluating multimodal approaches.
There is a known clear association between chronic pain and PTSD in people of all genders, explained by both genetic and environmental factors.33, 34 We observed that people who had a current or previous diagnosis of PTSD had a 150% higher odds (OR 2.50 (1.07, 5.85)) of reporting pelvic pain after starting testosterone GAHT. Research has previously shown that in cisgender women with chronic pelvic pain, that there is an increased prevalence of abuse experiences, high number of major life events and diagnosis of PTSD (but not depression).35, 36 It is not possible to disentangle whether experiencing severe pelvic pain causes PTSD or trauma-related factors that contributed to PTSD also impact upon pelvic pain. One study in 107 cisgender women suggests that temporally, PTSD appears to precede the diagnosis of chronic pelvic pain supporting a partial role for PTSD or its trauma-related trigger in the pathophysiology of chronic pelvic pain.37
Notably previous studies in people presumed to be female have suggested an independent association between chronic pelvic pain and anxiety, depression and mixed anxiety and depressive disorder.38 This was not observed in our analyses which potentially may be related to the high prevalence of depression and anxiety among trans people overall.39