Clinical implications
Treatment of pelvic pain can be challenging in the general population.17 A multidisciplinary biopsychosocial approach which addresses contribution of various factors to the individual is needed.40 This may include medical therapies, pelvic floor physical therapy, addressing sexual function, hypersensitivity to pain and psychological factors such as PTSD.40 Respondents to this survey had reported various self-management strategies. Over the counter pain-relieving medications in the form of paracetamol, NSAIDs and heat were the most frequent strategies reported to manage pelvic pain. In a Cochrane review of management of dysmenorrhea, NSAIDs and heat were recommended as first line treatment to alleviate pain symptoms produced by the release of prostaglandins from the endometrial lining. It is recommended that these strategies are initiated 48 hours prior to onset of menses. Irregular bleeding and amenorrhea may explain the ineffectiveness of these strategies in this population; with limited warning of the onset of breakthrough bleeding episodes.41
Many trans people seek hysterectomy and/or oophorectomy as part of gender-affirmation, or due to pelvic pain or ongoing or abnormal bleeding. Of the individuals in this study who had a hysterectomy, pelvic pain was the most common indicator for surgery (64%), followed by gender dysphoria (48%). A total of 72% (N=18) reported relief of pelvic pain symptoms after hysterectomy. Whilst the overall number of respondents undergoing a hysterectomy and/or oophorectomy was too small for meaningful statistical analyses, surgery would indeed cure persistent menstruation which was much more likely in people reporting pain after commencing testosterone therapy. Moreover, cisgender women have also reported resolution or decrease in pelvic pain following hysterectomy.42 It must be noted that five individuals (20%) in this study reported no change in their pelvic pain and two (8%) reported an increase in pelvic pain following hysterectomy. Further research is warranted.
Whilst further studies need to evaluate the possibility of high pelvic floor muscle tone as a causative factor for pelvic pain in trans people after starting testosterone for gender affirmation, a recent systematic review of pelvic floor physical therapy to release myofascial trigger points found positive beneficial effects, particularly in people with chronic pelvic pain and dyspareunia.43 Given the lack of current treatments available to alleviate often debilitating pelvic pain in trans people on testosterone therapy, pelvic floor physical therapy may be a low-risk, treatment strategy to trial in addition to simple analgesics.40