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