{"paper_id":"66f32401-8ac1-45fe-8f29-e2de19fb5f9a","body_text":"C A Ferrando Endometriosis in \ntransmasculine patients\nC7–C10\n3:2\nCOMMENTARY\nEndometriosis in transmasculine individuals\nCecile A Ferrando\nCenter for Urogynecology & Pelvic Reconstructive Surgery, Women’s Health Institute, Center for LGBT Care, Cleveland Clinic, Cleveland, Ohio, USA\nCorrespondence should be addressed to C A Ferrando: ferranc2@ccf.org\nThis paper forms part of a special series on Endometriosis. The guest editors for this section were Dr Mathew Leonardi (McMaster University, Canada) \nand Dr Warren (Lauren) Foster (McMaster University, Canada).\nLay summary\nTransmasculine people are assigned female at birth but identify as male. These patients often are prescribed testosterone \ntherapy as part of their transition. This treatment can affect ovulation and stop menstrual periods. Endometriosis is \na common condition that causes pelvic pain in some people born with female pelvic organs. Not a lot is known about \ntransmasculine people and how often endometriosis affects them. Testosterone should help treat if not reduce the \nincidence of endometriosis. This commentary looks at the current literature in order to help clarify existing knowledge \ngaps. Transmasculine patients who present for hysterectomy as a surgery to help them affirm themselves in their self-\nidentified gender sometimes report pelvic pain symptoms as well. There are many reasons why patients report pain \nbefore surgery, and this can be related to endometriosis, even though this diagnosis is less expected in this group. \nProviders caring for transmasculine patients should be aware of this.\nReproduction and Fertility (2022) 3 C7–C10\nTransmasculine individuals are assigned female at birth \nbut some identify as male or choose to take on a masculine \ngender expression. Some patients choose to transition \nto their self-identified gender, and a proportion of these \npatients are prescribed long-term regimens of testosterone \ntherapy. Testosterone therapy is known to cause cessation \nof ovulation and menses, and many of these patients report \namenorrhea within months of starting testosterone. Very \nlittle data exist looking at the effects of short- and long-\nterm testosterone use on ovarian and uterine function \n(MEDLINE Search 2000-2021). As clinicians treating this \npatient population, we have previously made assumptions \nabout the low incidence of endometriosis in these patients; \nhowever, up until recently, very few publications have \nexisted specifically looking at pelvic pain and endometriosis \nin transmasculine individuals and we do not know the \nprevalence of this condition in this patient population. \nThis lack of knowledge can be attributed to the barriers \nmany trans patients face when accessing care and their \nresultant underrepresentation in medicine. Therefore, the \naim of this commentary is to review the literature on pelvic \npain and endometriosis in transmasculine patients seeking \nhysterectomy.\nHysterectomy is a common gender-affirming surgery \nthat some transmasculine patients undergo. Some \ntransmasculine patients also present for management \nof pelvic pain and describe endometriosis symptoms. \nSometimes, patients seek hysterectomy for a combination \nof their pain and their desire to transition to their self-\nidentified gender. For some surgeons, it is hard to decipher \nthe true indication for hysterectomy, but among those \nwho routinely care for this patient population, it is widely \naccepted that hysterectomy is a reasonable choice for most \npatients, as the removal of the pelvic organs helps patients \nfeel more aligned with their self-identified masculine \ngender, which reduces their gender dysphoria. In order \nto undergo hysterectomy as gender affirmation surgery, \nproviders are encouraged to follow the World Professional \n-21-0096ID: XX-XXXX; \n3 2\nThis work is licensed under a Creative Commons \nAttribution 4.0 International License.\nhttps://raf.bioscientifica.com © 2022 The authors\n Published by Bioscientifica Ltdhttps://doi.org/10.1530/RAF-21-0096\n Downloaded from Bioscientifica.com at 06/11/2026 02:31:53AM\nvia Open Access. This work is licensed under a Creative Commons Attribution\n4.0 International License.\nhttp://creativecommons.org/licenses/by/4.0/\n\n\nC A Ferrando Endometriosis in \ntransmasculine patients\nC83:2\nAssociation for Transgender Health (WPATH) Standards of \nCare (WPATH 2021), which outline suggested preoperative \nrequirements for patients and the providers caring for \nthem.\nAs we know, endometriosis is most commonly diagnosed \nby visual inspection and identification of the disease. \nSpecific to the transmasculine population, few studies have \nlooked at and commented on the intraoperative findings of \npatients undergoing hysterectomy for gender affirmation, \neven in the setting of reported pelvic pain. In a study \nlooking at adolescent patients, 35 transmasculine patients \nwith mean age of 15 years presented with dysmenorrhea, \nand of those who were placed on testosterone therapy for \ngender affirmation, one in three had persistent pelvic pain \nsymptoms (Shim et al. 2020). Of the patients in the cohort, \nseven were evaluated laparoscopically and all patients \nwere found to have endometriosis. Our group at Cleveland \nClinic recently published a retrospective analysis of 67 \ntransmasculine individuals who underwent hysterectomy \nfor gender affirmation (Ferrando et al. 2021). In this cohort, \nwe found that only 60% of the patients were amenorrheic \non testosterone and 50% reported pelvic pain at the time of \nthe consultation. There was heterogeneity in the way that \npatients presented with gynecologic complaints in this \ncohort. All patients, however, desired hysterectomy to also \ntreat their gender dysphoria. At the time of laparoscopy, the \nintraoperative incidence of endometriosis was 27%, and it \nwas pathology-confirmed in 77.8% of cases. Endometriosis \nwas found in 32% of patients who reported pelvic pain at \nthe preoperative consultation and in 22% of patients who \ndid not complain of pain. In addition, type of preoperative \npelvic pain (constant vs cyclic) was not associated with \nendometriosis findings.\nVery few pelvic organ pathology studies exist, looking \nat hysterectomy specimens in transgender men undergoing \nhysterectomy, and the reports that have been published \nshow mixed findings. For example, Grimstad et  al. (2019) \ndescribed the characteristics of uterine pathology in \n94 transgender men on testosterone who underwent \nhysterectomy for gender affirmation. Interestingly, the \nmajority of the pathology reports from these patients \ndemonstrated active endometrium. Conversely, Khalifa \net  al. (2019) looked at a similar patient population and \nreported that the majority of the specimens they evaluated \nhad endometrial changes consistent with inactive \nendometrium. With these mixed findings, it is hard to \ndefinitively conclude what effects testosterone may have \non the endometrium. But given that there is a report of \nthe presence of active endometrium in some patients, we \ncan consider that some patients do not have complete \ncessation of ovarian function and/or endometrial activity \non testosterone, which means that in those patients \npredisposed to have endometriosis, even on testosterone \ntherapy, they may have active disease.\nThe above finding could be attributed to aromatization \nof exogenous testosterone to estradiol in the peripheral \ntissues. There are no studies specifically looking at \nestradiol level trends in trans individuals using long-\nterm testosterone. But it is very plausible that high \nlevels of androgens may be converted to estrogen in this \nclinical scenario, leading to a hyper-estrogenic state in \nthese patients. Endometriosis is considered an estrogen-\ndependent disease. And while the aforementioned \nhypothesis does not explain the mechanism by which \nendometriosis may occur in a higher proportion of trans \nindividuals compared to their cisgender counterparts, \nit may explain why they may be symptomatic of their \ndisease, even if they are amenorrheic.\nAs many as 1 in 10 women suffer from endometriosis. \nHowever, the prevalence of incidentally diagnosed disease \nis even higher. For instance, 17% of women undergoing \nlaparoscopic ovarian drilling were found to have \nendometriosis at the time of their laparoscopic procedure \n(Hager et  al. 2019), and in a large cohort of 465 women \nundergoing tubal sterilization, the reported incidence of \nan incidentally found endometriosis during these cases \nwas nearly 12% (Tissot et al. 2017). In the study our group \nperformed, we had paradoxical findings compared to what \nwe see in our cisgender female population. We found \nthat the incidence of incidental endometriosis was much \nhigher than expected, but the incidence of endometriosis \nin patients who presented with complaints of pelvic pain \npreoperatively was much lower than what is commonly \nfound in the cisgender women.\nEndometriosis is present in up to 87% of patients who \npresent for management of chronic pelvic pain (Falcone &  \nFlyckt 2018). In our study, only one in three patients who \npresented with preoperative pelvic pain were found to \nhave endometriosis at the time of their hysterectomy. \nIn that paper, we describe the differences that exist \nbetween the transmasculine and cisgender female \npopulations as it relates to perception of pain, which is a \npersonal experience. In our paper, we write: ‘Transgender \nmen carry the burden of feeling dysphoric about the \nThis work is licensed under a Creative Commons \nAttribution 4.0 International License.\nhttps://doi.org/10.1530/RAF-21-0096\nhttps://raf.bioscientifica.com © 2022 The authors\n Published by Bioscientifica Ltd Downloaded from Bioscientifica.com at 06/11/2026 02:31:53AM\nvia Open Access. This work is licensed under a Creative Commons Attribution\n4.0 International License.\nhttp://creativecommons.org/licenses/by/4.0/\n\n\nC A Ferrando Endometriosis in \ntransmasculine patients\nC93:2\nmismatch between their biologic sex and their gender \nidentity, which may manifest as pain or an amplification \nof the pain that is experienced with normal ovulation or \nmenses. These patients may also be susceptible to high \ntone pelvic floor disorders although data on the incidence \nof this condition in transgender patients are sparse. \nNevertheless, this type of pain should also be considered \nwhen counseling patients. Providers performing gender \naffirmation surgeries should be aware of these points and \nour recommendation is not to minimize or overlook the \nkind of pain that is felt by this patient population. While it \nmay not always be endometriosis, persistent pain in these \npatients remains a potential indication for hysterectomy, \nand providers should give this consideration when \nevaluating this patient population’ ( Ferrando et al. 2021). \nThis finding highlights the complexity that exists in \ncaring for this patient population. These patients may \nhave less intraoperative findings in the setting of self-\nreported pain. Conversely, these patients tend to have a \nhigher incidence of incidental findings of endometriosis, \nand so surgeons seeing these patients should consider \nthis and be prepared to manage a complex pelvic case if \nnecessary.\nThe majority of the studies that currently exist are \nlimited by their retrospective nature and the reliance on \nthe electronic medical record to obtain data. Because of \nthese methods, we are not able to draw conclusions about \npain characterization in this patient population. For \ninstance, it is not clear if all patients presenting with pain \nhave ‘endometriosis’-specific type pain, or whether it is a \ncombination of this type of pain with other pain syndromes. \nAgain, the contribution of the gender dysphoria felt by \npatients presenting for surgical interventions also makes \nit hard to interpret with confidence some of the results \npresented in these studies. Some patients may confuse \nwhat some cis women may describe as ‘normal’ menstrual \ndiscomfort with actual pelvic pain, as the discomfort felt \nabout their bodies may amplify their symptoms. Future \nresearch should focus on better defining pain symptoms, \ncollecting pre- and postoperative pain scores, and also \ncreating comparative cohorts with cisgender populations \nseeking the same interventions for pain. This would allow \nus to better characterize pain symptoms in each group, \nto evaluate if pain is resolved in the same way and also \nto determine if endometriosis is similar between patient \ngroups.\nIn summary, endometriosis exists in transmasculine \nindividuals. Those seeking hysterectomy may present with \nreports of pain symptoms and some may only seek the \nprocedure for gender affirmation. Either way, hysterectomy \nis a medically indicated procedure in individuals assigned \nfemale at birth seeking alignment with their self-identified \nmasculine gender. In those with pain symptoms, providers \nshould be aware that traditional management options may \nnot always be appropriate for patients given their desire \nto virilize. Further, many patients feel favorable about \nhaving a hysterectomy for gender affirmation. Perhaps the \nnewest piece of data we have now is that more patients \nthan expected have incidental findings of endometriosis. \nSurgeons performing these procedures for this patient \npopulation should be aware of this and should be prepared \nin some cases to perform a more complicated hysterectomy.\nDeclaration of interest\nThe author declares receiving authorship royalties from UpToDate, Inc.\nFunding\nThis work did not receive any specific grant from any funding agency in the \npublic, commercial or not-for-profit sector.\nReferences\nFalcone T & Flyckt R 2018 Clinical management of endometriosis. \nObstetrics and Gynecology 131 557–571. (https://doi.org/10.1097 /\nAOG.0000000000002469)\nFerrando CA, Chapman G & Pollard R 2021 Preoperative pain \nsymptoms and the incidence of endometriosis in transgender men \nundergoing hysterectomy for gender affirmation. Journal of Minimally \nInvasive Gynecology 28 1579–1584. (https://doi.org/10.1016/j.\njmig.2021.01.018)\nGrimstad FW, Fowler KG, New EP , Ferrando CA, Pollard RR, \nChapman G, Gomez-Lobo V & Gray M 2019 Uterine pathology in \ntransmasculine persons on testosterone: a retrospective multicenter \ncase series. American Journal of Obstetrics and Gynecology 220 257.\ne1–257.e7. (https://doi.org/10.1016/j.ajog.2018.12.021)\nHager M, Wenzl R, Riesenhuber S, Marschalek J, Kuessel L, \nMayrhofer D, Ristl R, Kurz C & Ott J 2019 The prevalence \nof incidental endometriosis in women undergoing laparoscopic \novarian drilling for clomiphene-resistant polycystic ovary syndrome: \na retrospective cohort study and meta-analysis. Journal of Clinical \nMedicine 8 1210–1222. (https://doi.org/10.3390/jcm8081210)\nKhalifa MA, T oyama A, Klein ME & Santiago V 2019 Histologic \nfeatures of hysterectomy specimens from female male transgender \nindividuals. International Journal of Gynecological Pathology 38 520–527. \n(https://doi.org/10.1097 /PGP .0000000000000548)\nThis work is licensed under a Creative Commons \nAttribution 4.0 International License.\nhttps://doi.org/10.1530/RAF-21-0096\nhttps://raf.bioscientifica.com © 2022 The authors\n Published by Bioscientifica Ltd Downloaded from Bioscientifica.com at 06/11/2026 02:31:53AM\nvia Open Access. This work is licensed under a Creative Commons Attribution\n4.0 International License.\nhttp://creativecommons.org/licenses/by/4.0/\n\n\nC A Ferrando Endometriosis in \ntransmasculine patients\nC103:2\nShim JY, Laufer MR & Grimstad FW 2020 Dysmenorrhea and \nendometriosis in transgender adolescents. Journal of Pediatric \nand Adolescent Gynecology 33 524–528. (https://doi.org/10.1016/j.\njpag.2020.06.001)\nTissot M, Lecointre L, Faller E, Afors K, Akladios C & Audebert A \n2017 Clinical presentation of endometriosis identified at interval \nlaparoscopic tubal sterilization: prospective series of 465 cases. Journal \nof Gynecology Obstetrics and Human Reproduction 46 647–650. (https://\ndoi.org/10.1016/j.jogoh.2017.05.003)\nWPATH 2021. World Professional Association for transgender health \nSOC v7. (available at: https ://ww w.wpa th.or g/pub licat ions/ soc). Last \naccessed 27 October 2021.\nReceived in final form 6 April 2022\nAccepted 20 April 2022\nAccepted Manuscript published online 20 April 2022\nThis work is licensed under a Creative Commons \nAttribution 4.0 International License.\nhttps://doi.org/10.1530/RAF-21-0096\nhttps://raf.bioscientifica.com © 2022 The authors\n Published by Bioscientifica Ltd Downloaded from Bioscientifica.com at 06/11/2026 02:31:53AM\nvia Open Access. This work is licensed under a Creative Commons Attribution\n4.0 International License.\nhttp://creativecommons.org/licenses/by/4.0/","source_license":"CC0","license_restricted":false}