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New survey data indicates that transgender and nonbinary adolescents who take testosterone report lower rates of lower abdominal pain compared to those who do not use the hormone. The findings challenge the assumption held by some medical professionals that gender-affirming testosterone treatment is a primary driver of lower abdominal pain in this population. The research was published in the *International Journal of Transgender Health*.
Pelvic pain refers to a broad spectrum of discomfort located in the abdomen beneath the navel. The symptom can originate from a variety of sources within the body. It may be caused by issues with the reproductive organs, the bowel, the urinary tract, or the muscles and nerves supporting the pelvic floor.
In individuals assigned female at birth, this discomfort frequently takes the form of dysmenorrhea. Dysmenorrhea is the medical term for pain and cramping associated with the onset of the menstrual cycle. Pain in this region can also be acyclic, meaning it occurs independently of a monthly period. Regardless of its exact origin, pelvic pain is a leading reason that young people assigned female at birth miss school and withdraw from social activities.
Transgender men and transgender masculine individuals commonly ask doctors for help managing pelvic pain. A few previous research projects focusing on adult cohorts suggested that using gender-affirming testosterone therapy might increase the risk of developing this specific type of pain. Medical professionals speculated that introducing testosterone into the body could alter the structure of the pelvic floor muscles or change the activity of the uterine lining in a way that causes discomfort.
Some earlier surveys found that up to 70 percent of transgender men experienced lower abdominal pain after starting hormone therapy. Many of these earlier adult studies, however, lacked a comparison group. They did not survey transgender individuals who were not taking testosterone. Without a control group, researchers could not determine if the hormone itself was truly linked to higher rates of pain. Very little data has been collected to confirm how pelvic pain affects transgender adolescents specifically.
A team of researchers led by Dehlia Moussaoui set up an exploratory study to address this gap in the scientific literature. Moussaoui is a pediatric gynecologist who was affiliated with the Royal Children’s Hospital Melbourne in Australia at the time of the research. Her team wanted to determine whether the proportion of transgender youth experiencing pelvic pain differed based on their testosterone use.
Moussaoui and her colleagues created an online survey and distributed it to patients who had sought care at the Royal Children’s Hospital Gender Service. They invited transgender and gender diverse individuals assigned female at birth who were 12 years of age or older. The survey asked participants to indicate whether they had experienced pain in the lower half of their abdomen over the previous six months.
The researchers provided a graphic diagram to help participants identify the correct anatomical area. The survey also collected information on the adolescents’ testosterone formulations, the length of time they had been taking hormones, and their methods for managing pain. Participants rated their pain intensity on a scale from zero to ten.
A total of 102 adolescents and young adults completed the survey. The average age of the respondents was just over 18 years old. About 60 percent of the participants reported that they were actively using some form of testosterone therapy. Most of these adolescents received long-acting testosterone injections.
Across the entire group, pelvic pain was highly common. Nearly 78 percent of all participants reported experiencing lower abdominal discomfort within the six months prior to the survey. The pain had heavy practical consequences for the respondents. Over half of the participants reported missing school or work because of their cramping, and almost 70 percent said the pain prevented them from joining extracurricular activities.
When the researchers separated the youth into two groups based on hormone use, a distinct pattern appeared in the data. Among the adolescents who were not taking testosterone, 90 percent reported experiencing pelvic pain. In the group actively taking the hormone, about 69 percent reported having pelvic pain.
The survey responses challenged the idea that testosterone routinely triggers entirely new pain symptoms. Among the individuals who used testosterone and currently experienced pelvic pain, over 80 percent stated that their pain was already present before they ever started hormone therapy. Less than 17 percent said their pain first occurred after they began taking testosterone.
For the adolescents with pre-existing pain, starting hormone therapy yielded mixed results. About 38 percent said their pain did not change after they began testosterone treatments. Roughly 21 percent of respondents reported that their pain improved, while another 24 percent said their pain worsened.
The adolescents described their pain in a variety of ways. Cramping was the most frequent description, followed by aching and sharp sensations. The pain was usually located in the suprapubic area, which is the zone just above the pubic bone.
The researchers asked the teenagers if specific activities reliably triggered their discomfort. Sexual activity was identified as a common trigger. Many participants reported that masturbation and penetrative sexual activity caused pain or cramping to flare up.
The data revealed a large difference between the two groups regarding one specific pain trigger. Adolescents taking testosterone were much more likely to experience pain when reaching orgasm. Nearly 59 percent of the testosterone group reported orgasm as a pain trigger. Among the group not taking hormones, only about 24 percent experienced pain with orgasm. The exact explanation for this discrepancy remains unknown.
Participants tried many different methods to relieve their discomfort. Over-the-counter pain medications like acetaminophen and non-steroidal anti-inflammatory drugs were the most popular choices. Between 50 and 60 percent of the adolescents who took these pills found them to be effective.
Non-pharmacological management strategies were also widely utilized. Applying heat to the abdomen was a popular and successful intervention. Nearly 65 percent of participants used heat therapy, and almost 70 percent of those users found it provided relief. Some participants tried physical exercise to manage their cramps, but only a small fraction found movement helpful.
Other medications presented a complicated statistical picture. In the survey, the use of medications prescribed for menstrual suppression was associated with a higher chance of experiencing pelvic pain. However, youth with severe period cramps are more likely to seek out menstrual suppression medications in the first place. After adjusting the data for hormone use, the difference in pain rates associated with these suppression medications was not statistically significant.
The researchers emphasize that their findings are preliminary and should be interpreted cautiously. The study relies on a cross-sectional survey design. This method provides a snapshot of a single moment in time. It cannot prove that giving a patient testosterone directly reduces their likelihood of experiencing pelvic pain.
The study design also carries a high risk of recruitment bias. Adolescents who currently suffer from chronic pain might be much more motivated to answer an email and complete a survey about pain than teenagers who feel fine. If adolescents without pain ignored the survey, the overall prevalence rates recorded by the research team would be artificially inflated.
The limited scope of the research presents another hurdle to generalizing the findings. The sample size of 102 participants is relatively small. Since the patients were recruited from a single pediatric gender clinic in Australia, their experiences might not perfectly reflect those of transgender youth receiving care in other health care systems.
Future investigations need to track the same group of transgender adolescents over several years, recording their pain levels both before and well after they initiate hormone treatments. This type of longitudinal study would provide a more accurate picture of how testosterone alters the body.
Researchers will also need to distinguish between pain caused by the menstrual cycle and pain that occurs without bleeding. Because testosterone frequently suppresses the menstrual cycle, it naturally reduces the occurrence of typical period cramps. This biological reality might be the main reason the study found lower overall pain rates in the hormone group. Medical providers will need more specific data to help their pediatric patients navigate abdominal pain during a gender transition.
The study, “Is there an association between pelvic pain and gender-affirming testosterone therapy in trans masculine adolescents? An exploratory cross-sectional study,” was authored by Dehlia Moussaoui, Monsurul Hoq, Charlotte V. Elder, Sonia R. Grover, Michele A. O’Connell, and Ken C. Pang.
