Purpose of Review
The purpose of this review is to update readers on the multifactorial nature of pelvic pain with specific considerations for the female to male (FtM) transgender patient.
Secondary effects of testosterone therapy include both genital and musculoskeletal changes that may contribute to the development of pelvic pain. Hysterectomy is therapeutic for gender affirmation and underlying pain conditions. Postsurgical pain from further pelvic reconstruction may be the result of the reconstruction itself, surgical scarring, or prostheses.
Pelvic pain is a common condition with many contributing factors. For the FtM patient, pelvic pain may be present at any point in the transition process. Pain conditions may be pre-existing or occur as a result of medical or surgical treatment of gender dysphoria. Research is needed on sex hormone-specific influences on the development of pelvic pain and mitigation strategies for treatment-specific development of pelvic pain in the transgender population.
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Sorge RE, Totsch SK. Sex differences in pain. J Neurosci Res. 2017;95(6):1271–81.
Girard-Tremblay L, Auclair V, Daigle K, Leonard G, Whittingstall K, Goffaux P. Sex differences in the neural representation of pain unpleasantness. J Pain. 2014;15(8):867–77.
• Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. Int J Transgend. 2012;13(4):165–232 Comprehensive guidelines to provide evidence-based care in transgender health.
•• Obedin-Maliver J, Light A, de Haan G, Jackson RA. Feasibility of Vaginal Hysterectomy for Female-to-Male Transgender Men. Obstet Gynecol. 2017;129(3):457–63 This retrospective cohort study identified pelvic pain as the most common indication for hysterectomy for FtM.
Iacovides S, Avidon I, Baker FC. What we know about primary dysmenorrhea today: a critical review. Hum Reprod Update. 2015;21(6):762–78.
Janssen EB, Rijkers AC, Hoppenbrouwers K, Meuleman C, D'Hooghe TM. Prevalence of endometriosis diagnosed by laparoscopy in adolescents with dysmenorrhea or chronic pelvic pain: a systematic review. Hum Reprod Update. 2013;19(5):570–82.
ACOG Committee Opinion No. 760: dysmenorrhea and endometriosis in the adolescent. Obstet Gynecol. 2018;132(6):e249–e58.
Latthe P, Latthe M, Say L, Gulmezoglu M, Khan KS. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health. 2006;6:177.
Proctor M, Farquhar C. Diagnosis and management of dysmenorrhoea. BMJ. 2006;332(7550):1134–8.
Sultan C, Gaspari L, Paris F. Adolescent dysmenorrhea. Endocr Dev. 2012;22:171–80.
• Deutsch MB, Bhakri V, Kubicek K. Effects of cross-sex hormone treatment on transgender women and men. Obstet Gynecol. 2015;125(3):605–10 In this study, induction of amenorrhea occurred in 84% of patients 6 months after starting hormonal therapy.
Ferrero S, Gillott DJ, Venturini PL, Remorgida V. Use of aromatase inhibitors to treat endometriosis-related pain symptoms: a systematic review. Reprod Biol Endocrinol. 2011;9:89.
Unger CA. Hormone therapy for transgender patients. Transl Androl Urol. 2016;5(6):877–84.
•• Deutsch MB. Guidelines for the primary and gender-affirming care of transgender and gender non-binary people. San Francisco: Center of Excellence for Transgender Health, Department of Family & Community Medicine, University of California, San Francisco. 2016; These guidelines have a specific chapter about the approach to pelvic pain in transgender men.
Bofill Rodriguez M, Lethaby A, Grigore M, Brown J, Hickey M, Farquhar C. Endometrial resection and ablation techniques for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019;1:CD001501.
Thomassee MS, Curlin H, Yunker A, Anderson TL. Predicting pelvic pain after endometrial ablation: which preoperative patient characteristics are associated? J Minim Invasive Gynecol. 2013;20(5):642–7.
Wortman M, Cholkeri A, McCausland AM, McCausland VM. Late-onset endometrial ablation failure--etiology, treatment, and prevention. J Minim Invasive Gynecol. 2015;22(3):323–31.
Rachlin K, Hansbury G, Pardo ST. Hysterectomy and oophorectomy experiences of female-to-male transgender individuals. International Journal of Transgenderism. 2010;12(3):155–66.
Dennerstein L, Dudley EC, Hopper JL, Guthrie JR, Burger HG. A prospective population-based study of menopausal symptoms. Obstet Gynecol. 2000;96(3):351–8.
Freeman EW, Sammel MD, Lin H, Gracia CR, Pien GW, Nelson DB, et al. Symptoms associated with menopausal transition and reproductive hormones in midlife women. Obstet Gynecol. 2007;110(2 Pt 1):230–40.
• Chan KJ, Jolly D, Liang JJ, Weinand JD, Safer JD. Estrogen levels do not rise with testosterone treatment for transgender men. Endocr Pract. 2018;24(4):329–33 This article shows that transgender men on testosterone therapy have suppression of estrogen equivalent to levels in cisgender men.
Miller N, Bedard YC, Cooter NB, Shaul DL. Histological changes in the genital tract in transsexual women following androgen therapy. Histopathology. 1986;10(7):661–9.
Baldassarre M, Giannone FA, Foschini MP, Battaglia C, Busacchi P, Venturoli S, et al. Effects of long-term high dose testosterone administration on vaginal epithelium structure and estrogen receptor-alpha and -beta expression of young women. Int J Impot Res. 2013;25(5):172–7.
Rahn DD, Good MM, Roshanravan SM, Shi H, Schaffer JI, Singh RJ, et al. Effects of preoperative local estrogen in postmenopausal women with prolapse: a randomized trial. J Clin Endocrinol Metab. 2014;99(10):3728–36.
• Winston MCpherson G, Long T, Salipante SJ, Rongitsch JA, Hoffman NG, Stephens K, et al. The vaginal microbiome of transgender men. Clin Chem. 2019;65(1):199–207 Vaginal flora of transgender men lack lactobacilli and may be associated with clinical symptoms.
Perrone AM, Cerpolini S, Maria Salfi NC, Ceccarelli C, De Giorgi LB, Formelli G, et al. Effect of long-term testosterone administration on the endometrium of female-to-male (FtM) transsexuals. J Sex Med. 2009;6(11):3193–200.
Futterweit W, Deligdisch L. Histopathological effects of exogenously administered testosterone in 19 female to male transsexuals. J Clin Endocrinol Metab. 1986;62(1):16–21.
Loverro G, Resta L, Dellino M, Edoardo DN, Cascarano MA, Loverro M, et al. Uterine and ovarian changes during testosterone administration in young female-to-male transsexuals. Taiwan J Obstet Gynecol. 2016;55(5):686–91.
Baba T, Endo T, Honnma H, Kitajima Y, Hayashi T, Ikeda H, et al. Association between polycystic ovary syndrome and female-to-male transsexuality. Hum Reprod. 2007;22(4):1011–6.
Grimstad FW, Fowler KG, New EP, Ferrando CA, Pollard RR, Chapman G, et al. Uterine pathology in transmasculine persons on testosterone: a retrospective multicenter case series. Am J Obstet Gynecol. 2019;220(3):257.e1–7.
Cloke B, Christian M. The role of androgens and the androgen receptor in cycling endometrium. Mol Cell Endocrinol. 2012;358(2):166–75.
Reiter RC, Gambone JC. Nongynecologic somatic pathology in women with chronic pelvic pain and negative laparoscopy. J Reprod Med. 1991;36(4):253–9.
Tu FF, As-Sanie S, Steege JF. Prevalence of pelvic musculoskeletal disorders in a female chronic pelvic pain clinic. J Reprod Med. 2006;51(3):185–9.
•• Lamvu G, Carrillo J, Witzeman K, Alappattu M. Musculoskeletal Considerations in Female Patients with Chronic Pelvic Pain. Semin Reprod Med. 2018;36(2):107–15 This paper describes different musculoskeletal conditions leading to pelvic pain and has a detailed description on how to perform a complete musculoskeletal pelvic examination.
Gebhart GF, Bielefeldt K. Physiology of visceral pain. Compr Physiol. 2016;6(4):1609–33.
Cervero F. Visceral pain-central sensitisation. Gut. 2000;47 Suppl 4:iv56–7 discussion iv8.
Cervero F. Visceral versus somatic pain: similarities and differences. Dig Dis. 2009;27(Suppl 1):3–10.
Gyang A, Hartman M, Lamvu G. Musculoskeletal causes of chronic pelvic pain: what a gynecologist should know. Obstet Gynecol. 2013;121(3):645–50.
Kind S, Otis JD. The interaction between chronic pain and PTSD. Curr Pain Headache Rep. 2019;23(12):91.
•• Raja S, Hasnain M, Hoersch M, Gove-Yin S, Rajagopalan C. Trauma informed care in medicine: current knowledge and future research directions. Fam Community Health. 2015;38(3):216–26 This paper reviews the applicability and impact of the trauma-informed care pyramid in the clinical setting.
Langenderfer-Magruder L, Whitfield DL, Walls NE, Kattari SK, Ramos D. Experiences of intimate partner violence and subsequent police reporting among lesbian, gay, bisexual, transgender, and queer adults in Colorado: comparing rates of cisgender and transgender victimization. J Interpers Violence. 2016;31(5):855–71.
National Coalition of Anti-Violence Programs. Lesbian, gay, bisexual, transgender, queer, and HIV-affected intimate partner violence. 2013.
Calton JM, Cattaneo LB, Gebhard KT. Barriers to help seeking for lesbian, gay, bisexual, transgender, and queer survivors of intimate partner violence. Trauma Violence Abuse. 2016;17(5):585–600.
Cheatle MD. Biopsychosocial approach to assessing and managing patients with chronic pain. Med Clin North Am. 2016;100(1):43–53.
Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007;133(4):581–624.
•• U.S. Department of Health and Human Services. Pain management best practices Inter-Agency Task force report: updates, gaps, inconsistencies, and recommendations. Retrieved from US Department of Health and Human Services website: https://www.hhs.gov/ash/advisory-committees/pain/reports/index html. Accessed Dec. 2019. These national guidelines provide specific recommendations on how to approach chronic pain.
Carrillo JL, Lamvu G. The Force is With You: Mind Tricks for Chronic Pelvic Pain. PWJ. 2019;7(4):36–43.
James A, Thompson J, Neumann P, Briffa K. Change in pain knowledge occurring after a neuroscience education seminar for women with chronic pelvic pain. Australian & New Zealand Continence Journal. 2016;22(4).
Choi BC, Pak AW. Multidisciplinarity, interdisciplinarity and transdisciplinarity in health research, services, education and policy: 1. Definitions, objectives, and evidence of effectiveness. Clin Invest Med. 2006;29(6):351–64.
Gatchel RJ, McGeary DD, McGeary CA, Lippe B. Interdisciplinary chronic pain management: past, present, and future. Am Psychol. 2014;69(2):119–30.
Nancarrow SA, Booth A, Ariss S, Smith T, Enderby P, Roots A. Ten principles of good interdisciplinary team work. Hum Resour Health. 2013;11:19.
•• Defreyne J, Elaut E, Kreukels B, Fisher AD, Castellini G, Staphorsius A, et al. Sexual desire changes in transgender individuals upon initiation of hormone treatment: results from the Longitudinal European Network for the Investigation of Gender Incongruence. J Sex Med. 2020; This survey noted persistent menstrual bleeding in transgender men is associated with decreased sexual desire.
• Zoorob D, Higgins M, Swan K, Cummings J, Dominguez S, Carey E. Barriers to Pelvic Floor Physical Therapy Regarding Treatment of High-Tone Pelvic Floor Dysfunction. Female Pelvic Med Reconstr Surg. 2017;23(6):444–8 There are many barriers to performing pelvic floor physical therapy in cisgender women.
Smith YL, Van Goozen SH, Kuiper AJ, Cohen-Kettenis PT. Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals. Psychol Med. 2005;35(1):89–99.
Worldwide, AAGL Advancing Minimally Invasive Gynecology. AAGL position statement: route of hysterectomy to treat benign uterine disease. J Minim Invasive Gynecol. 2011;18(1):1–3.
Committee Opinion No ACOG. 444: choosing the route of hysterectomy for benign disease. Obstet Gynecol. 2009;114(5):1156–8.
Bretschneider CE, Sheyn D, Pollard R, Ferrando CA. Complication rates and outcomes after hysterectomy in transgender men. Obstet Gynecol. 2018;132(5):1265–73.
O'Hanlan KA, Dibble SL, Young-Spint M. Total laparoscopic hysterectomy for female-to-male transsexuals. Obstet Gynecol. 2007;110(5):1096–101.
Bogliolo S, Cassani C, Babilonti L, Musacchi V, Nappi RE, Spinillo A. Robotic single site hysterectomy with bilateral salpingo-oophorectomy in female to male transsexualism. J Sex Med. 2014;11(1):313.
Groenman F, Nikkels C, Huirne J, van Trotsenburg M, Trum H. Robot-assisted laparoscopic colpectomy in female-to-male transgender patients; technique and outcomes of a prospective cohort study. Surg Endosc. 2017;31(8):3363–9.
Wierckx K, Van Caenegem E, Elaut E, Dedecker D, Van de Peer F, Toye K, et al. Quality of life and sexual health after sex reassignment surgery in transsexual men. J Sex Med. 2011;8(12):3379–88.
Boskey ER, Cone RA, Whaley KJ, Moench TR. Origins of vaginal acidity: high D/L lactate ratio is consistent with bacteria being the primary source. Hum Reprod. 2001;16(9):1809–13.
Soper DE. Bacterial vaginosis and surgical site infections. Am J Obstet Gynecol. 2020;222(3):219–23.
McElligott KA, Havrilesky LJ, Myers ER. Preoperative screening strategies for bacterial vaginosis prior to elective hysterectomy: a cost comparison study. Am J Obstet Gynecol. 2011;205(5):500.e1–7.
Nikkels C, van Trotsenburg M, Huirne J, Bouman MB, de Leeuw R, van Mello N, et al. Vaginal Colpectomy in transgender men: a retrospective cohort study on surgical procedure and outcomes. J Sex Med. 2019;16(6):924–33.
Gooren LJ. Management of female-to-male transgender persons: medical and surgical management, life expectancy. Curr Opin Endocrinol Diabetes Obes. 2014;21(3):233–8.
Gomes da Costa A, Valentim-Lourenco A, Santos-Ribeiro S, Carvalho Afonso M, Henriques A, Ribeirinho AL, et al. Laparoscopic vaginal-assisted hysterectomy with complete Vaginectomy for female-to-male genital reassignment surgery. J Minim Invasive Gynecol. 2016;23(3):404–9.
Monstrey SJ, Ceulemans P, Hoebeke P. Sex reassignment surgery in the female-to-male transsexual. Semin Plast Surg. 2011;25(3):229–44.
Nikolavsky D, Yamaguchi Y, Levine JP, Zhao LC. Urologic Sequelae following Phalloplasty in transgendered patients. Urol Clin North Am. 2017;44(1):113–25.
Pigot GLS, Sigurjonsson H, Ronkes B, Al-Tamimi M, van der Sluis WB. Surgical experience and outcomes of implantation of the ZSI 100 FtM malleable penile implant in transgender men after Phalloplasty. J Sex Med. 2020;17(1):152–8.
Neuville P, Morel-Journel N, Cabelguenne D, Ruffion A, Paparel P, Terrier JE. First outcomes of the ZSI 475 FtM, a specific prosthesis designed for phalloplasty. J Sex Med. 2019;16(2):316–22.
Neuville P, Morel-Journel N, Maucourt-Boulch D, Ruffion A, Paparel P, Terrier JE. Surgical outcomes of erectile implants after phalloplasty: retrospective analysis of 95 procedures. J Sex Med. 2016;13(11):1758–64.
Hage JJ, Bloem JJ, Bouman FG. Obtaining rigidity in the neophallus of female-to-male transsexuals: a review of the literature. Ann Plast Surg. 1993;30(4):327–33.
Falcone M, Garaffa G, Gillo A, Dente D, Christopher AN, Ralph DJ. Outcomes of inflatable penile prosthesis insertion in 247 patients completing female to male gender reassignment surgery. BJU Int. 2018;121(1):139–44.
Falcone M, Garaffa G, Raheem A, Christopher NA, Ralph DJ. Total phallic reconstruction using the radial artery based forearm free flap after traumatic penile amputation. J Sex Med. 2016;13(7):1119–24.
Conflict of Interest
Dr. Moulder reports personal fees from Hologic, outside the submitted work.
Dr. Carrillo reports personal fees from Abbvie, outside the submitted work.
Dr. Carey reports personal fees from Teleflex, personal fees from Med IQ, personal fees from MT ACOG, personal fees and other from Medical Expert in Surgery Litigation, outside the submitted work.
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Moulder, J.K., Carrillo, J. & Carey, E.T. Pelvic Pain in the Transgender Man. Curr Obstet Gynecol Rep (2020). https://doi.org/10.1007/s13669-020-00293-x
- Pelvic pain
- Transgender man
- Gender affirmation
- Myofascial pain