Pelvic pain in transmasculine adolescents receiving testosterone therapy

Figures & data

Table 1. Clinical characteristics of patient cohort.

	Total
Number of patients: n	158
Age at testosterone initiation: median (IQR) (years)	16.6 (1.4)
Past use of puberty blockers: n (%)	15 (9.5%)
Menstrual suppression: n (%)	137 (86.7%)
Menstrual suppression type: n (%)
Levonorgestrel IUD	10 (7.3%)
Oral combined contraceptive pill	2 (1.5%)
Etonogestrel	3 (2.2%)
Norethisterone	106 (77.4%)
Medroxyprogesterone acetate (injection)	13 (9.5%)
Medroxyprogesterone acetate (oral)	3 (2.2%)
Type of testosterone at initiation: n (%)
Topical	17 (10.8%)
3-weekly injection	63 (39.9%)
3-monthly injection	78 (49.4%)
Dose of testosterone at initiation: n (%)
Low dose	74 (46.8%)
High dose	84 (53.2%)
Serum testosterone value: median (IQR) (nmol/l)	8.9 (7.5)
Follow-up after T initiation: median (IQR) (months)	22.1 (15.4)

Low dose = topical testosterone formulation 12.5–25mg, testosterone enanthate or mixed testosterone esters 125 mg, testosterone undecanoate 500 mg.

High dose = topical testosterone formulation 32.5–50mg, testosterone enanthate or mixed testosterone esters 250 mg, testosterone undecanoate 1000 mg.

Table 2. Comparison of adolescents with and without pelvic pain.

	No pelvic pain	Pelvic pain	Difference in risk of pelvic pain	P value
Number of patients: n (%)	121 (76.6%)	37 (23.4%)
Age at testosterone initiation: median (IQR) (years)	16.8 (1.5)	16.3 (0.9)		0.08^d
Follow-up after T initiation: median (IQR) (months)	19.3 (15.4)	26.4 (11.6)		0.004^d
No past use of puberty blockers, n (%)	107 (74.8%)	36 (25.2%)	ref	0.196^b
Past use of puberty blockers, n (%)	14 (93.3%)	1 (6.7%)	−18.5% (95%CI: −33.0 to −4.0%)
No menstrual suppression, n (%)	20 (95.2%)	1 (4.8%)	ref	0.028^b
Menstrual suppression, n (%)	101 (73.7%)	36 (26.3%)	21.5% (95%CI: 9.8% to 33.2%)
Type of testosterone at initiation, n (%)				0.292^c
3-monthly injection	63 (80.8%)	15 (19.2%)	ref
3-weekly injection	47 (74.6%)	16 (25.4%)	6.2% (95% CI: −7.7% to 20%)
Topical	11 (64.7%)	6 (35.3%)	16.1% (95% CI: −8.3% to 40.4%)
Dose of testosterone at initiation, n (%)
Low dose	54 (73.0%)	20 (27.0%)	ref	0.315^c
High dose	67 (79.8%)	17 (20.2%)	−6.8% (95% CI: −20.1% to 6.5%)

Low dose = topical testosterone formulation 12.5-25mg, testosterone enanthate or mixed testosterone esters 125 mg, testosterone undecanoate 500 mg.

High dose = topical testosterone formulation 32.5-50mg, testosterone enanthate or mixed testosterone esters 250 mg, testosterone undecanoate 1000 mg.

^a Statistical test: Wilcoxon rank sum test.

^b Statistical test: Fisher exact test.

^c Statistical test: Chi-square test.

^d Difference in medians.

Table 3. Description and treatment of pelvic pain (n = 37 patients).

	Pelvic pain
Pelvic pain description, n (%)
Cramps	17 (45.9%)
Similar to period pain	8 (21.6%)
Sex-related pain	10 (27%)
Post orgasm/after sexual dreams	5 (13.5%)
During penetrative sex	3 (8.1%)
Arousal	2 (5.4%)
Early morning/or waking up at night	5 (13.5%)
Suspicion of pelvic floor spasms	5 (13.5%)
Associated with breakthrough bleeding	11 (29.7%)
Associated with nausea and/vomiting	4 (10.8%)
Pain radiating into lower limbs	2 (5.4%)
Treatment, n (%)
Paracetamol	9 (24.3%)
NSAID	9 (24.3%)
Codeine	2 (5.4%)
Danazol	4 (10.8%)
Progestogen (norethisterone, medroxyprogesterone)	10 (27%)
Levonorgestrel IUD	6 (16.2%)
GnRH agonist (zoladex, synarel)	3 (8.1%)
Amytriptilline	1 (2.7%)
Physiotherapy	1 (2.7%)
Heat pack	2 (5.4%)
Laparoscopy	1 (2.7%)

Table 4. Qualitative description of pelvic pain.

	Quote
Cramps	"Reminiscent of his previous period-related pain"
	"Period pain but without bleeding"
Sex-related pain	"In waves"
	"Sexual activity has become associated with deep sharp bilateral pelvic pain"
	"Triggers are arousal (not just secondary to penetration)"
	"New pelvic pain reported after orgasm"
	"Pain seems to occur after sexual dreams"
	"Attemps at penetrative vaginal sex with his partner have been associated with significant pain"
	"Unable to achieve penetration"
Temporal relationship with testosterone	"He describes some pelvic pain shortly after each injection"
	"Pain started within a few weeks of starting testosterone"
	"Since starting testosterone, pain appears to have become worse"

Figure 1. Outcome of pelvic pain with different treatment strategies. The number of patients who received different types of treatments for their pain is shown, and classified on the basis of whether improvement in pain was noted or not.