Chronic pelvic pain in transgender people is widespread and poorly understood, major review finds

Chronic pelvic pain, defined as non-cyclical pain persisting for at least three months in the pelvis or lower abdomen, is one of the most disabling pain conditions medicine knows, drawing contributors from gynaecological, urological, gastrointestinal, vascular, neuromuscular and neurological systems, all tangled up with central sensitisation and psychosocial factors. Yet almost everything clinicians know about it comes from studies of cisgender people. A new scoping review published in eClinicalMedicine has now mapped, for the first time in a systematic way, the global literature on chronic pelvic and related genital pain in transgender and gender-diverse people, and the picture it paints is one of a substantial, under-recognised burden of suffering colliding with a strikingly thin evidence base.

The review, led by Ragav Chona and Gianni R. Lorello and conducted according to Joanna Briggs Institute methodology with pre-registration on the Open Science Framework, searched ten bibliographic databases from inception through 30 July 2025, combining controlled vocabulary for pelvic pain and transgender health with free-text keywords covering gender-affirming hormone therapy, vaginoplasty and dilation-related pain. From 6,534 records, the team screened 3,823 unique titles and abstracts and ultimately included 24 reports representing 23 unique cohorts and 5,527 transgender and gender-diverse participants. Inter-reviewer agreement at screening was nearly perfect, with a Cohen’s kappa of 0.99, and the reviewers also performed an exploratory risk-of-bias appraisal using design-specific checklists, the Cochrane RoB 2 tool and ROBINS-I.

What the synthesis found is a field dominated by observational and descriptive work. Of the 24 reports, ten were cross-sectional or psychometric studies, four were retrospective cohorts or audits, two were prospective cohorts, four were qualitative, three were case reports, and just one was a randomised trial. Thirteen reports came from North America, five from Europe, two each from Brazil and Australia, and two used international samples; no report was based in Africa or Asia. Fourteen reports focused on transmasculine people or other participants assigned female at birth, seven on transfeminine people, and three on mixed groups. Critically, only one report applied a formal duration-defined chronic pelvic pain criterion of at least three months, meaning most prevalence figures in the literature describe broader pelvic and genital symptom burden rather than chronic pelvic pain itself.

That single duration-defined study, drawing on more than 2,500 trans men and gender-diverse adults assigned female at birth in the PRIDE Study, estimated a chronic pelvic pain prevalence of 17.7 percent. Around it, heterogeneous symptom estimates ranged from 9.6 percent vulvar pain to 72.2 percent pelvic pain after starting testosterone, with dyspareunia reported in 61.5 percent of one transmasculine sample, pelvic pain in 36.0 percent of transmasculine participants on testosterone for at least a year, and 50.7 percent preoperative pelvic pain among transgender men undergoing hysterectomy. The reviewers are emphatic that these figures cannot be pooled or read as a prevalence range, because the samples, definitions and measures differ so wildly, but together they signal a real and recurrent clinical problem in selected populations.

The most scientifically intriguing thread concerns testosterone. Several studies described new-onset cramping or suprapubic pain after testosterone initiation, sometimes with dysorgasmia or breakthrough bleeding despite amenorrhoea, while the one duration-defined study found current testosterone use associated with lower chronic pelvic pain prevalence than non-use. The review argues these findings should not be read as either a protective or a causative effect. Supporting biological context comes from histological work outside the included studies: high-dose testosterone exposure has been linked to loss of vaginal epithelial layers, glycogen depletion and reduced oestrogen-receptor expression, while uterine and endometrial case series show heterogeneous responses, with some specimens showing active or proliferative endometrium despite amenorrhoea. The plausible interpretation is mechanistic heterogeneity: testosterone may suppress cyclic uterine, ovarian or peritoneal activity and ease pain in some people, while in others incomplete ovarian suppression, residual endometrial activity or hypoestrogenic tissue effects may drive dryness, irritation, dyspareunia and pelvic floor guarding.

A second major context is gender-affirming surgery. Postoperative pelvic and genital pain, dyspareunia and dilation-related difficulties are common early after urogenital surgery and, in the available follow-up, often improve during the first postoperative year, but longer-term cohorts have documented dyspareunia, lower abdominal pain and pelvic floor distress more than a decade after surgery. Reported pain generators include introital and neovaginal stenosis, scarring and granulation tissue, neuroma and nerve irritation, urethral complications, and rare structural pathology such as a pubic aneurysmal bone cyst that caused chronic groin pain and resolved after resection. The reviewers frame these trajectories within the established persistent postsurgical pain literature, involving peripheral injury, central sensitisation and psychosocial context, and argue that doing so supports routine outcome measurement and early identification of complications without pathologising gender-affirming surgery itself.

Across both transmasculine and transfeminine participants, pelvic floor neuromuscular impairments emerged as a recurring and potentially modifiable contributor, with hypertonicity, myofascial trigger points and coordination deficits described alongside dilation pain, orgasm-associated cramping and mixed urinary or bowel symptoms. One cross-sectional study of transgender men on testosterone found pelvic floor dysfunction in 94.1 percent of participants. Yet the treatment evidence is sobering: the only randomised trial, comparing routine postoperative pelvic floor physiotherapy with standard care after vaginoplasty, found no differences at 12 weeks in ease or pain with dilation, pelvic floor symptoms, vaginal length or subjective improvement. That argues against routine physiotherapy for every surgical patient, the reviewers note, but does not establish that targeted rehabilitation is ineffective for people with examination-confirmed hypertonicity, myofascial pain or function-limiting dilation pain, which case reports suggest can respond to manual release, down-training, biofeedback and graded dilator retraining.

The review also identifies psychosocial and trauma-related factors as a fourth interacting domain. Adverse childhood experiences, sexual trauma and minority stress, the chronic stigma-related stressors associated with marginalised group status, were associated with higher pain burden and multisite pain, and qualitative studies describe dysphoria, layered isolation, non-affirming healthcare experiences and delayed help-seeking among transgender and non-binary people with endometriosis, including diagnostic delays approaching ten years. The authors are careful to stress that these factors must not be used to psychologise symptoms or dismiss peripheral pain generators; rather, trauma-informed, gender-affirming communication can support trust, consent for examination and engagement with rehabilitation, while clinicians maintain diagnostic breadth across gynaecological, urological, gastrointestinal, musculoskeletal, neuropathic and psychosocial domains.

To translate the evidence into practice, the team proposes a six-step, evidence-informed diagnostic framework: confirm the pain phenotype and chronicity with a body map and validated scales; establish anatomy and exposure context, including hormone formulation, surgical history and bleeding patterns, without inferring anatomy from gender identity; screen for overlapping contributors; perform a consent-based, tailored examination; select targeted tests guided by symptoms rather than a routine panel; and triage and coordinate multidisciplinary care. The framework is explicitly pragmatic rather than validated, but it embodies the review’s central clinical message: pelvic pain during masculinising hormone therapy or after gender-affirming surgery should prompt structured evaluation, not be assumed to be a routine effect of testosterone or surgery, and no single contributor, hormonal, surgical, anatomical or psychosocial, should be blamed alone.

The limitations the authors acknowledge are as instructive as the findings. Chronicity definitions varied or were absent in 19 of 24 reports, no validated transgender-specific chronic pelvic pain measure exists, key variables such as hormone dosing, serum levels and surgical technique were inconsistently captured, and convenience sampling may over-represent those with higher symptom burden. Race and ethnicity were rarely analysed, though descriptive data hinted at higher pain prevalence among several non-White identity groups. The research agenda that follows is clear: prospective longitudinal cohorts beginning at or before hormone initiation, validated and inclusive patient-reported outcome measures, adequately powered trials of hormonal, rehabilitative, surgical and multidisciplinary strategies, and community-engaged, intersectional data collection. For now, the review’s verdict stands: chronic pelvic pain in transgender and gender-diverse people is real, common in the settings studied, and demanding of the same rigorous, biopsychosocial, equity-focused attention that has transformed care for everyone else.

Subject of Research: Chronic pelvic and genital pain in transgender and gender-diverse people

Article Title: Chronic pelvic and related genital pain in transgender and gender-diverse people: a scoping review

Article References: Chona, R., Sabbah, S. G., Englesakis, M., Di Renna, T., Drodge, O., Rosenbloom, B. N., Leonardi, M., & Lorello, G. R. (2026). Chronic pelvic and related genital pain in transgender and gender-diverse people: a scoping review. eClinicalMedicine, 101, Article 104252. https://doi.org/10.1016/j.eclinm.2026.104252

Image Credits: AI Generated

DOI: 10.1016/j.eclinm.2026.104252

Keywords: chronic pelvic pain, transgender health, gender-affirming hormone therapy, testosterone, vaginoplasty, pelvic floor dysfunction, scoping review, minority stress, central sensitisation, dyspareunia, gender-affirming surgery, pain medicine