INTRODUCTION
Pelvic pain in transgender and gender diverse (herein referred to as trans) people presumed female at birth, who are using testosterone as gender-affirming hormone therapy (GAHT) is poorly understood.1 Understanding adverse effects of testosterone therapy is important given that trans people comprise an estimated 0.5 – 4.5% of the adult population,2-4 and there is an increasing demand for gender-affirming healthcare globally.5-7
Testosterone GAHT which may be given at standard doses or low doses for people who desire ‘partial masculinisation’, is very effective at inducing physical changes including significant genital and reproductive system effects, an increase in body and facial hair, deepening of the voice, increase in muscle mass, and a decrease in fat mass.8 Menstrual cessation, one of the most desired aspects of testosterone GAHT, typically occurs within the first six months of therapy, as well as clitoral enlargement, vulvovaginal atrophy and increase in libido.9, 10 Endometrial changes can be varied regardless of menstrual cessation with either proliferative (in 40%) or atrophic endometrium (in 50%).11 No significant histopathological changes appear to occur in the ovaries.12
Pelvic pain in people presumed female is extremely common in the general population with 17 – 81% reporting dysmenorrhoea, 8 – 22% reporting dyspareunia and 2 – 24% reporting noncyclical pain.13 Chronic pelvic pain persisting beyond six months, affects 1 in 7.14 Causes are multifactorial and rarely reflect a single pathological process.15There is a considerable economic burden on people experiencing chronic pelvic pain and on healthcare systems worldwide.16Diagnosis and management can be challenging and requires an individualised approach.17
As clinicians (gynaecologists, endocrinologists, physiotherapists), we have seen increasing numbers of trans individuals on testosterone seeking assistance to relieve symptoms of pelvic pain. However, at the time of conception of this study, no studies had been published on the topic of pelvic pain in trans individuals using testosterone GAHT. From our clinical perspective, we hypothesised that pelvic pain in trans people using testosterone is predominantly lower abdominal, and similar to menopause, that atrophic vaginitis and vaginal intercourse would contribute to pelvic pain.18 Further, we hypothesised that pre-existing endometriosis, vulvodynia, or vaginismus would be risk factors. Given the limited research on the prevalence and/or the characteristics of pelvic pain experienced by individuals using testosterone GAHT this was an exploratory study aiming to identify the prevalence of pelvic pain in trans people using testosterone GAHT and to explore potential factors associated with experiencing pelvic pain after commencing testosterone GAHT.