Pelvic Pain Is Far More Common Than Assumed in Transmasculine People on Testosterone, First Meta-Analysis Finds

Pelvic pain affects roughly four in ten transmasculine individuals taking gender-affirming testosterone, and for most of those who had pain before starting the hormone, the symptoms do not go away. That is the central conclusion of the first systematic review and meta-analysis to quantitatively synthesise the prevalence and clinical course of pelvic pain in this population, published in eClinicalMedicine. The findings directly challenge a widespread assumption among both clinicians and patients: that shifting the hormonal milieu from oestrogen-dominant to androgen-dominant protects against pelvic pain.

The research team, led by Susanna Weidlinger and colleagues, searched MEDLINE, Embase, Scopus and the Cochrane Central Register of Controlled Trials for studies published from 2013 to June 2026, a cut-off chosen to coincide with the replacement of gender identity disorder with gender dysphoria in the DSM-5. From 3,548 records identified, 2,252 unique publications were screened and 212 went to full-text assessment. Eleven studies ultimately met the inclusion criteria, drawn from five countries, six of them from the United States. Together they enrolled 4,176 transmasculine individuals, of whom 2,891 were receiving testosterone therapy. Study designs ranged from a single prospective cohort to five retrospective cohorts, three cross-sectional surveys, one retrospective case series and one qualitative interview study, with sample sizes spanning just 14 participants to more than 2,500.

The pooled prevalence of pelvic pain among transmasculine people on testosterone was 39 percent, with a 95 percent confidence interval of 23 to 55 percent. That figure exceeds the estimated 5 to 25 percent prevalence of chronic pelvic pain in cisgender women worldwide, although the authors caution that direct comparison is limited by differences in populations, pain definitions and how symptoms were ascertained. Among those on testosterone who were not scheduled for gender-affirming surgery, the pooled prevalence was lower at 28 percent, while in surgical cohorts, where pelvic pain was often documented as an indication for hysterectomy, it climbed to 50 percent. Strikingly, prevalence among those not taking testosterone was 41 percent, statistically indistinguishable from the figure in testosterone users, offering no evidence of a clear protective or harmful association.

Perhaps the most clinically consequential results concern what happens to pain over time. Among individuals with preexisting pelvic pain, symptoms persisted after testosterone initiation in a pooled 72 percent of cases, while only 26 percent experienced improvement or remission. One study reported worsening in 24 percent of participants. Meanwhile, roughly 31 percent of previously asymptomatic individuals reported new-onset pelvic pain after starting testosterone, though this estimate carries an extremely wide confidence interval of 5 to 65 percent and rests on just three studies with very different designs. A retrospective clinical cohort reported new-onset pain in 71 percent of affected patients, a cross-sectional study of adolescents found 17 percent, and a prospective online cohort found 11 percent, a spread that reflects differences in recruitment, symptom documentation and ascertainment methods.

The statistical picture is dominated by heterogeneity. The I-squared statistic exceeded 99 percent for most prevalence estimates, meaning that nearly all of the observed variation between studies reflects real differences rather than chance. Study populations ranged from highly selected surgical cohorts to large community samples recruited through online transgender health networks, and pain was variously defined as chronic pelvic pain lasting three months or longer, cyclic and acyclic lower abdominal pain, or simply any pain documented in medical records as a reason for surgery. No study used a validated pain assessment tool, and only a minority applied established time-based criteria for chronicity. The authors therefore present their pooled estimates as descriptive summaries of the literature rather than precise population-level parameters.

Methodological quality, assessed with Joanna Briggs Institute checklists, ranged from moderate to high, with three studies rated high quality and eight moderate. A consistent weakness was the failure to address confounding, even where potential confounders were identified. The authors also flag a subtler problem: confounding by indication and possible reporting bias in surgical cohorts. Because insurance coverage for gender-affirming hysterectomy varies widely and often requires documented medical indications beyond gender dysphoria itself, clinicians and patients may have incentives to record pelvic pain to facilitate approval, potentially inflating prevalence in surgical subgroups. The contrast between 90 percent prevalence documented as a surgical indication in one cohort and 7 to 16 percent in community-based samples illustrates how much ascertainment context matters.

Why might pelvic pain be so common in this population despite testosterone’s suspected pain-protective properties? The authors sketch a multifactorial and still incompletely understood pathophysiology. First, testosterone induces vaginal epithelial atrophy, analogous to the genitourinary syndrome of menopause, which may increase susceptibility to dyspareunia, bacterial vaginosis and cystitis; one large study found that nearly two-thirds of transmasculine individuals experienced vulvovaginal pain during sexual activity, with current testosterone use independently associated with increased vaginal pain. Second, testosterone does not reliably suppress the ovaries: histological signs of recent ovulatory activity have been documented in roughly 30 to 40 percent of transmasculine individuals at oophorectomy, independent of serum testosterone levels, duration or preparation type, and endometrial activity persists in a substantial proportion. One cohort found that endometrial proliferation was significantly more frequent with transdermal gel and short-acting testosterone esters than with long-acting testosterone undecanoate, plausibly because fluctuating hormone levels allow intermittent recovery of follicular activity and local aromatisation of testosterone to estradiol.

Third, pelvic floor dysfunction appears highly prevalent, reported in 94 percent of transmasculine individuals on testosterone in one study. The levator ani, the principal pelvic floor muscle, is highly androgen-responsive, and whether masculinising doses induce hypertonicity contributing to pain has not been directly studied. Fourth, psychosocial factors loom large: gender dysphoria, minority stress and barriers to care, including discrimination and discomfort with pelvic examinations, may amplify pain perception and reduce help-seeking. Notably, one study of gender minority individuals found that stress, rather than gender identity or hormone therapy type, was the factor most strongly associated with chronic pain, underscoring the relevance of a biopsychosocial framework. Endometriosis also remains relevant even under testosterone: one surgical series found intraoperatively confirmed endometriosis in nearly 27 percent of patients undergoing gender-affirming hysterectomy, with higher rates among those reporting pelvic pain.

The clinical implications are concrete. The authors recommend that clinicians counsel patients before treatment that pelvic pain is common both before and during testosterone therapy and that the hormone does not reliably resolve preexisting symptoms. Preexisting gynaecologic conditions should be evaluated where feasible before testosterone initiation, since prior pain, dysmenorrhea, endometriosis and ovarian cysts are associated with persistent symptoms. Gynaecologic follow-up should continue despite amenorrhea, given the evidence of residual ovarian and endometrial activity, and clinicians should maintain a low threshold for investigating new or worsening pain. Care environments should actively address barriers through inclusive language, trauma-informed approaches and alternatives such as self-collected specimens.

The review also maps the road ahead for research. Future studies should employ validated, multidimensional pain instruments that distinguish pain subtypes and mechanisms, and the recently validated Transmasculine and Gender Diverse Pelvic Symptom Index offers the first gender-affirming instrument designed specifically for this purpose. Prospective cohorts with standardised assessment before testosterone, during therapy and after hysterectomy or oophorectomy are needed to characterise pain trajectories and identify modifiable risk factors. The limitations are real: nearly all analyses showed extreme heterogeneity, most studies were cross-sectional, confounder control was sparse, prior hysterectomy status was incompletely reported, and the evidence base is concentrated in the United States and Australia, with no studies from low- and middle-income countries and none at all on transfeminine individuals. Publication bias also cannot be excluded. Even so, as the first quantitative synthesis of its kind, the analysis establishes that pelvic pain is a substantial and previously underappreciated burden in an underserved population, and it replaces a comforting assumption with a more honest, and more clinically useful, picture of what testosterone can and cannot do.

Subject of Research: Prevalence and clinical course of pelvic pain in transmasculine individuals receiving gender-affirming testosterone therapy

Article Title: Prevalence and clinical course of pelvic pain among transmasculine individuals on gender-affirming testosterone: a systematic review and meta-analysis

Article References: Weidlinger, S., Niggli, A., van Trotsenburg, M., Feil, K., Weidlinger, C., Vidal, A., Gulz, M., Pape, J., Laue, J., Leeners, B., von Wolff, M., Karrer, T., & Camastral-Urech, K. (2026). Prevalence and clinical course of pelvic pain among transmasculine individuals on gender-affirming testosterone: a systematic review and meta-analysis. eClinicalMedicine, 100, Article 104233. https://doi.org/10.1016/j.eclinm.2026.104233

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Keywords: pelvic pain, transmasculine, testosterone, gender-affirming hormone therapy, systematic review, meta-analysis, chronic pain, endometriosis, pelvic floor dysfunction, transgender health, gynaecology, minority stress