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