Testosterone didn't create the pain—it was already there
A small but striking Australian study has quietly challenged a long-standing clinical assumption: that testosterone therapy worsens pelvic pain in young people assigned female at birth. Among 102 transgender and gender-diverse adolescents, those using hormone therapy reported lower rates of pelvic pain than those who were not — a finding that inverts earlier adult research conducted without comparison groups. The result does not yet constitute proof, but it opens a more careful question about what medicine has too quickly assumed, and what transgender youth have long been asked to endure without adequate inquiry.
- Pelvic pain is so prevalent among transgender adolescents that nearly 78% of those surveyed reported it — and more than half had missed school or work because of it.
- Prior studies warned that testosterone could worsen pelvic pain, but those studies never included a control group of transgender youth not on hormones, leaving the claim scientifically unanchored.
- The new data inverts the assumption: 90% of non-hormone users reported pain, compared to 69% of those on testosterone — and among hormone users with pain, over 80% said it predated their treatment.
- One unsettling outlier emerged: testosterone users were far more likely to experience pain during orgasm, a pattern researchers cannot yet explain.
- Scientists urge restraint — the study is small, cross-sectional, and drawn from a single clinic, meaning longitudinal research must now follow to separate hormone effects from the simple relief of menstrual suppression.
A survey of 102 transgender and gender-diverse adolescents in Australia has challenged a widely held medical assumption — that testosterone therapy increases pelvic pain in people assigned female at birth. The study, published in the International Journal of Transgender Health, found the opposite: youth actively using testosterone reported lower rates of pelvic pain than peers who were not on hormones.
Pelvic pain is common in this population and carries a serious practical toll. Nearly 78% of all participants reported lower abdominal discomfort in the six months before the survey. More than half had missed school or work because of it, and almost 70% had withdrawn from extracurricular activities. Earlier research on adult transgender men had suggested hormone therapy might worsen symptoms by altering pelvic floor muscles or uterine activity — with some studies citing rates as high as 70% — but those studies lacked a comparison group, making it impossible to isolate testosterone's role.
Pediatric gynecologist Dehlia Moussaoui at the Royal Children's Hospital Melbourne designed the study to address that gap. Participants completed an online survey about pain location, intensity, timing, and management. About 60% were using testosterone, mostly via long-acting injection. When divided by hormone use, the difference was clear: 90% of non-users reported pain, versus 69% of those on testosterone. Among hormone users who did have pain, more than 80% said it had begun before they started treatment, and fewer than 17% said it emerged afterward.
One unexpected finding complicated the picture: testosterone users were far more likely to experience pain during orgasm — nearly 59%, compared to 24% of non-users. The cause remains unknown. For pain management, over-the-counter medications and heat were the most commonly used and effective approaches.
Researchers are careful to frame the findings as preliminary. The study captures a single moment in time, draws from one clinic, and cannot prove that testosterone directly reduces pain risk. Longitudinal research tracking the same adolescents over years — and separating menstrual-cycle pain from other sources — will be necessary before firmer conclusions can be drawn.
A survey of 102 transgender and gender-diverse adolescents in Australia has upended a long-held assumption in medical practice: that testosterone therapy causes pelvic pain in young people assigned female at birth. The finding, published in the International Journal of Transgender Health, suggests the opposite—that youth taking gender-affirming testosterone actually report lower rates of lower abdominal discomfort than their peers who are not on hormones.
Pelvic pain is a broad category of discomfort located in the abdomen below the navel, and it can originate from reproductive organs, the bowel, the urinary tract, or the muscles supporting the pelvic floor. In people assigned female at birth, it often manifests as dysmenorrhea—the cramping and pain associated with menstruation—though it can also occur independently of the menstrual cycle. The symptom is common enough that it drives young people to miss school and withdraw from social life. Transgender men and masculine-identified individuals frequently seek medical help managing it, and earlier research on adult cohorts had suggested that introducing testosterone into the body might worsen the problem by altering pelvic floor muscle structure or changing uterine lining activity. Some older studies reported that up to 70 percent of transgender men experienced lower abdominal pain after starting hormone therapy. But those studies lacked a crucial element: a control group of transgender individuals not taking testosterone. Without that comparison, researchers could not determine whether testosterone itself was truly responsible for the pain.
Dehlia Moussaoui, a pediatric gynecologist at the Royal Children's Hospital Melbourne, designed an exploratory study to fill that gap. Her team created an online survey and distributed it to patients at the hospital's Gender Service, inviting transgender and gender-diverse individuals assigned female at birth who were 12 or older. The survey asked whether participants had experienced lower abdominal pain in the previous six months, provided an anatomical diagram to ensure clarity, and collected information about testosterone formulations, duration of hormone use, and pain management strategies. Participants rated their pain intensity on a scale of zero to ten.
One hundred and two adolescents and young adults completed the survey, with an average age just over 18. About 60 percent were actively using testosterone therapy, most in the form of long-acting injections. Across the entire group, pelvic pain was strikingly common: nearly 78 percent reported experiencing lower abdominal discomfort in the six months before the survey. The practical toll was severe. More than half had missed school or work because of cramping, and almost 70 percent said the pain kept them from extracurricular activities.
When the researchers divided the youth by hormone use, a clear pattern emerged. Among those not taking testosterone, 90 percent reported pelvic pain. Among those actively taking the hormone, about 69 percent did. The difference challenged the prevailing narrative. Among testosterone users who currently had pelvic pain, over 80 percent said the pain existed before they started hormone therapy. Less than 17 percent reported that pain first appeared after beginning treatment. For those with pre-existing pain, testosterone's effect was mixed: about 38 percent saw no change, roughly 21 percent experienced improvement, and another 24 percent reported worsening.
Participants described their pain in varied ways—cramping most frequently, followed by aching and sharp sensations, usually located just above the pubic bone. Sexual activity emerged as a common trigger, particularly masturbation and penetrative sex. One notable difference between the groups stood out: adolescents on testosterone were much more likely to experience pain during orgasm. Nearly 59 percent of the testosterone group reported this, compared to only 24 percent of those not on hormones. The reason remains unclear.
When managing pain, most adolescents turned first to over-the-counter medications like acetaminophen and ibuprofen, with 50 to 60 percent finding them effective. Heat applied to the abdomen proved popular and successful—nearly 65 percent used it, and almost 70 percent of those found relief. Physical exercise helped only a small fraction. Medications prescribed to suppress menstruation showed a complicated relationship with pain rates, though researchers noted that youth with severe cramps are more likely to seek such medications in the first place, making causation difficult to establish.
The researchers emphasize caution. The study is cross-sectional, capturing a single moment rather than tracking change over time. It cannot prove that testosterone directly reduces pain risk. The sample size of 102 is small, and recruitment bias is a real concern—adolescents suffering chronic pain may have been more motivated to complete a survey about pain than those feeling well. Because the participants came from a single clinic in Australia, their experiences may not reflect those of transgender youth in other health systems. Future research will need to follow the same adolescents over years, measuring pain before and long after hormone initiation. Researchers will also need to separate pain driven by the menstrual cycle—which testosterone naturally suppresses—from pain caused by other factors. That distinction may be key to understanding what the current data actually reveals.
Notable Quotes
The findings challenge the assumption held by some medical professionals that gender-affirming testosterone treatment is a primary driver of lower abdominal pain in this population— Study findings, International Journal of Transgender Health
The Hearth Conversation Another angle on the story
Why does this finding matter so much? Doctors have been warning about testosterone and pelvic pain for years.
Because those warnings were based on studies without a comparison group. You can't know if testosterone causes pain if you're only looking at people taking testosterone. This study finally asked: what about people not taking it?
And the answer was surprising.
Very. Ninety percent of youth not on testosterone reported pelvic pain. That's higher than the 69 percent on hormones. It suggests the pain isn't coming from the testosterone itself.
But some people on testosterone did report pain getting worse.
True. About a quarter said that. But 80 percent of those with pain on testosterone had it before they started. The hormone didn't create the pain—it was already there.
So what's actually causing it?
That's the honest answer: we don't know yet. It could be related to anatomy, to other hormonal factors, to sexual activity, to stress. The study is preliminary. It's a snapshot, not a full picture.
What about the orgasm finding? That seemed specific.
It did. Nearly 60 percent of testosterone users reported pain with orgasm, versus 24 percent without hormones. Why? Nobody knows. That's the kind of thing that needs deeper investigation.