Pelvic pain has slipped into the clinical conversation about gender-affirming hormone therapy without anyone ever measuring how much it really weighs. A team at the University Hospital of Zurich (Switzerland), with collaborating centres in Innsbruck, Bern, Thun and Winterthur, now publishes in eClinicalMedicine the first systematic review and meta-analysis on the subject: eleven studies, 4,176 transmasculine people —2,891 of them on testosterone— and a result that unsettles the most repeated assumption of all, the one that says testosterone protects against this pain.
One in three or four, on testosterone
The pooled prevalence of pelvic pain among those receiving testosterone was 39% (95% CI: 23-55). That is higher than the 5-25% that the literature estimates for chronic pelvic pain in cisgender women, although the authors themselves warn that a direct comparison is limited: the populations, the definitions of pain and the way it is measured all differ.
The team searched MEDLINE, Embase, Scopus and CENTRAL for studies published between January 2013 and June 2026 and assessed their quality with the Joanna Briggs Institute checklists. Three studies were of high quality, eight of moderate quality and none of low quality. The protocol was registered in PROSPERO (CRD420261278643) and the work received no funding.
The course of the pain: persistence outweighs relief
- Among those who already had pain before starting testosterone, 72% (95% CI: 62-81) still had it afterwards; only 26% (18-34) improved or stopped having it.
- Some 31% (95% CI: 5-65) of those who started out without pain reported new-onset pelvic pain after beginning treatment.
- In surgical cohorts —people who had undergone affirming hysterectomy— prevalence rose to 50%, against 28% in non-surgical populations.
- Prevalence was almost identical between those taking testosterone and those who were not: 39% versus 41%, with overlapping confidence intervals.
What lies behind that 39% (and what does not)
The two largest community studies, recruiting from online trans health cohorts, gave markedly lower figures —7% and 16%— which suggests that in the general transmasculine population the burden is real but smaller than in clinical samples. In surgical cohorts, by contrast, pelvic pain may itself have been the reason for surgery: this is what is known as indication confounding, and it would explain why the methodologically strongest studies (with prevalences of 90%, 81% and 69%) are precisely those that recruited operated people.
The key figure for not drawing conclusions beyond the data is the last one: if those taking testosterone and those not taking it show virtually the same numbers, there is no evidence that the hormone increases pelvic pain. Nor is there evidence that it resolves it. The authors insist that without randomised trials —and with most of the included work using a cross-sectional design— cause and effect cannot be claimed, and that people who receive hormone therapy and those who do not differ systematically in dysphoria severity, menstrual status, access to care or underlying gynaecological conditions.
Why it matters
For many transmasculine people, pelvic pain and pain during sex belong to an intimate sphere that is rarely raised in the consulting room, and the expectation that “testosterone will fix it” can leave untreated those who are still in pain months later. The clinical message of the meta-analysis is straightforward: pain should be asked about proactively, assessed before and after starting hormone therapy, and treated without giving up affirming care in order to do so. The authors call for prospective studies using standardised pain instruments and for research into the hormonal, tissue-level and psychosocial mechanisms involved.
The work does not address the biological basis of gender identity: it measures a symptom and its trajectory in people going through a medical transition. But it supplies a clinical piece that was missing and that bears directly on the quality of life of those who undergo it.
Source: Prevalence and clinical course of pelvic pain among transmasculine individuals on gender-affirming testosterone: a systematic review and meta-analysis. Weidlinger S, Niggli A, van Trotsenburg M, et al. eClinicalMedicine 2026;100:104233. DOI: 10.1016/j.eclinm.2026.104233.
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