Endometriosis and dysmenorrhea in transmasculine adolescents

The retrospective study in the Journal of Pediatric and Adolescent Gynecology found that of the 35 transmasculine individuals diagnosed with dysmenorrhea, only 20% (n = 7) were laparoscopically assessed for endometriosis, for which it was confirmed in all cases.

Six patients had stage I disease and one had stage II. Said principal investigator Jessica Shim, MD, a graduating fellow in pediatric and adolescent gynecology at Boston Children’s Hospital,

“Our office commonly encounters female adolescents with dysmenorrhea and pelvic pain, but occasionally we encounter transgender males with these symptoms. I was inspired to undertake the study after recognizing that there was a lack of evidence behind our counseling on the management of dysmenorrhea and endometriosis in transmasculine patients.”

The study comprised 35 transmasculine individuals younger than age 26 (mean age 14.9 years) who were diagnosed with dysmenorrhea and treated between Jan. 1, 2000, and March 1, 2020, at the hospital. In total, 29 patients (82.9%) were diagnosed after social transition.

Initial treatment consisted of combined oral contraceptives (OCs) for 23 patients (65.7%). But 61% of these patients (14 of 23) discontinued or transitioned to alternative therapy. The study also found that 12 patients with dysmenorrhea alone initiated testosterone, and 33.3% of them (4 of 12) experienced persistent symptoms.

Of the seven patients with confirmed endometriosis, three were diagnosed after social transition (42.9%) and one was diagnosed 20 months after initiating testosterone.

Endometriosis was treated with combined OCs, danazol or progestins. Four patients had a suboptimal response while on these therapies alone.

However, in two of those with suboptimal response, dysmenorrhea resolved after treatment with testosterone.

Two of the five patients with endometriosis began testosterone, but developed persistent symptomatology with combined testosterone and progestin therapies.

“The number of transmasculine adolescents who experienced persistent symptoms, despite taking testosterone, was surprising,” Dr. Shim told Contemporary OB/GYN.

Six of 17 patients with a diagnosis of dysmenorrhea continued to report bleeding and pelvic pain.

“Previous studies have demonstrated the majority of patients ceased menses after 6 months of testosterone, although they did not comment on pelvic pain,” Dr. Shim said. “Those findings highlight some of the pitfalls with testosterone therapy, including the incomplete ovulatory suppression and persistence of endometrial activity.”

Based on the findings of the current study, clinicians should strongly consider laparoscopic evaluation for endometriosis in transmasculine patients with persistent and significant dysmenorrhea, despite treatment with hormonal therapies including testosterone, according to Dr. Shim.

Because endometriosis can adversely impact a patient’s quality of life, including fertility, “it is crucial to identify and treat endometriosis in all persons, and not assume dysmenorrhea or endometriosis-associated symptoms are secondary to gender dysphoria,” Dr. Shim said.

In addition, further research is warranted on endometriosis and other gynecologic conditions that affect the transmasculine population.

“However, the presentation and preferred treatment methods for gynecologic conditions in transmasculine persons may differ from that in cisgender females, potentially resulting in underdiagnosis and insufficient treatment in this population,” Dr. Shim said.

See related story: “Endometriosis: Not for adults only” co-authored by Dr. Shim.

Dr. Shim reports no relevant financial disclosures.

Reference

1. Shim JY, Laufer MR, Grimstad W. Dysmenorrhea and endometriosis in transgender adolescents. J Pediatr Adolesc Gynecol. Published online June 11, 2020. doi:10.1016/j.jpag.2020.06.001