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.