Pelvic pain in transmasculine adolescents receiving testosterone therapy

Transgender and gender diverse individuals embodying endometriosis: a systematic review

Background

Transgender and gender diverse (TGD) people embody social and health inequalities that disproportionately affect this community more than the cisgender population. Endometriosis is a chronic condition of the reproductive tract that affects 5-10% of cisgender women. A recent systematic review with meta-analysis uncovered a pooled prevalence of 25.14% among TGD individuals undergoing gender-affirming surgeries.

Objective

This study aims to investigate the causes of the gap in prevalence of endometriosis between the TGD community and the cisgender population.

Methods

A systematic review with a fit-for-framework analysis was conducted. Results were analysed according to the adjusted developmental framework for embodiment with an intersectional approach. Sources were categorised in multi-levels relating to the framework mechanisms of expression, shaping, interaction, and incorporation.

Results

Four hundred twenty-three (423) studies published between 2001 and 2024 in English and Spanish were identified on the PubMed, Web of Science, Sociological abstracts, and PsycInfo databases. Thirty-two (32) peer-reviewed sources were selected.

Discussion

The higher prevalence of endometriosis among TGD people compared to the cisgender population reflects a complex phenomenon whereby individual biomedical characteristics, and psychological and environmental factors interplay on multiple levels throughout one's lifespan. The prevalence gap is striking in a context where TGD people experience great barriers and delays to access healthcare, and endometriosis is typically understood as a "women's disease." TGD people express lifestyle and environmental factors correlated with endometriosis more often than cisgender women, such as history of trauma, low self-image, obesity. Endometriosis interacts with one's quality of life, and especially with gendered expectations related to menstruations, family planning and sexuality. This interference can result in biographical disruption and gender self-perception changes in both cisgender and TGD people. Exogenous testosterone use as gender-affirming therapy results in amenorrhea in 80% of cases. However, endometrium and follicular activities are still reported upon testosterone use suggesting endometriosis may be active. It is hypothesised that testosterone use could lead to a hyper-estrogenic state that would stimulate endometriosis proliferation.

Menstrual management in transgender and gender diverse individuals: psychiatric and psychosocial considerations

Transgender and gender-diverse (TGD) menstruators are individuals assigned female at birth (AFAB)*, who retain the capacity to menstruate and have a gender identity that differs from their natal sex. Reports indicate up to 1.6 million individuals in the US identify as TGD. Until recently, the mainstream menstrual discourse has failed to capture the experience of transmenstruators. However, a better understanding of the menstrual experiences of TGD-AFAB will allow for more individualized patient-centered care. In this review, we provide the relevant data necessary to inform the psychiatric management of menstruation in TGD-AFAB individuals, including experiences of menstruation, preferences for menstrual management, and the impact on mental health. Our review indicates that menstrual care in TGD patients must be tailored to the individual; clinicians should remain open-minded to the unique experience of transmenstruators; gender-affirming menstrual care is necessary to reduce psychological burden. It should not be assumed that TGD-AFAB menstruators are utilizing appropriate contraceptive methods and should receive contraceptive and fertility preservation counseling. We highlight the importance of having these conversations early in the reproductive arch, even before puberty onset. Keeping in mind the gender minority stress model, in the upcoming sections, we discuss the limited body of literature on mood disorders in TGD-AFAB individuals who menstruate, undergo menstrual suppression, or continue to ovulate. The psychological impact of hormonal therapies is also reviewed.

Transgender and gender diverse people with endometriosis: A perspective on affirming gynaecological care

Transgender and gender diverse people presumed female at birth experience gynaecological conditions, such as chronic pelvic pain at elevated rates, estimated to impact between 51% and 72% of this population, compared to rates of up to 26.6% in cisgender women. The negative impact of these conditions is likely amplified due to limited access to safe and affirming healthcare. Despite this high prevalence rate, there is limited research investigating the prevalence, presentation or management options for trans and gender diverse people with endometriosis. Cisgender women with endometriosis report barriers to accessing care, with lengthy times to diagnosis and limited treatment options available. However, barriers for trans and gender diverse individuals are enhanced by physician bias and lack of education in gender-affirming care. This is reflected in stories of discrimination and denial of basic healthcare. A healthcare environment built on the presumption that gynaecological patients are women, others trans and gender diverse patients, which can result in avoidance of needed medical care. A lack of knowledge of gender-affirming care alongside healthcare provider bias highlights a need for gender-affirming care and bias reduction training in undergraduate healthcare provider curricula. Research to date assessing current curriculum in Australia and Aotearoa (New Zealand) shows limited inclusion of lesbian, gay, bisexual, trans, queer, intersex, asexual and other related identities content as a whole with gender-affirming care being among the least-frequently addressed topics. This review will detail barriers to accessing gender-affirming healthcare specific to gynaecology, interweaving the experiences of a non-binary individual seeking access to gender-affirming endometriosis care.

Transgender health and the impact of aging and menopause

Gender affirming hormone therapy (GAHT) is used by many transgender people to reduce gender incongruence and improve psychological functioning. As GAHT shares many similarities with menopausal hormone therapy, clinicians supporting people through menopause are ideally placed to manage GAHT. This narrative review provides an overview of transgender health and discusses long-term effects of GAHT to consider when managing transgender individuals across the lifespan. Menopause is less relevant for transgender individuals who take GAHT (often given lifelong) to achieve sex steroid concentrations generally in the range of the affirmed gender. For people using feminizing hormone therapy, there is an elevated risk of venous thromboembolism, myocardial infarction, stroke and osteoporosis relative to cisgender individuals. For trans people using masculinizing hormone therapy, there is an increased risk of polycythemia, probable higher risk of myocardial infarction and pelvic pain which is poorly understood. Proactive mitigation of cardiovascular risk factors is important for all transgender people and optimization of bone health is important for those using feminizing hormones. With a lack of research to guide GAHT in older age, a shared decision-making approach is recommended for the provision of GAHT to achieve individual goals whilst minimizing potential adverse effects.