Prevalence and clinical course of pelvic pain among transmasculine individuals on gender-affirming testosterone: a systematic review and meta-analysis
Abstract
Summary Background Pelvic pain is increasingly recognised among transmasculine individuals receiving gender-affirming testosterone therapy, yet no systematic synthesis of prevalence or clinical course exists. Methods We conducted the first systematic review and meta-analysis of pelvic pain in transgender individuals. We searched MEDLINE, Embase, Scopus, and CENTRAL from January 2013 to June 2026. Studies reporting prevalence or clinical course of pelvic pain in transmasculine individuals with or without testosterone therapy were included. Methodological quality was assessed using Joanna Briggs Institute checklists. Pooled prevalence estimates were calculated using random-effects models. PROSPERO registration: CRD420261278643. Findings Eleven studies encompassing 4176 transmasculine individuals were included, of whom 2891 received testosterone therapy. Among those receiving testosterone, the pooled prevalence of pelvic pain was 39% (95% CI 23–55%), significantly higher than in cisgender women (5–25%). Prevalence was higher in surgical cohorts (50%, 95% CI 12–88%) than in non-surgical populations (28%, 95% CI 13–46%). New-onset pelvic pain was reported in 31% (95% CI 5–65%) of previously asymptomatic individuals after testosterone initiation. Critically, among individuals with preexisting pain, 72% (95% CI 62–81%) reported persistence, while only 26% (95% CI 18–34%) reported improvement or remission after testosterone initiation. Interpretation Pelvic pain is common among transmasculine individuals and frequently persists despite testosterone therapy. These findings challenge the widespread assumption that androgenic hormonal transition is protective against pelvic pain and highlight the urgent need for proactive assessment and gender-affirming management in this population. Prospective studies with standardised pain assessment and investigation of hormonal, tissue-level, and psychosocial mechanisms are needed to develop evidence-based interventions. Funding No funding was received.