Pelvic pain in transmasculine adolescents receiving testosterone therapy

Background: Pelvic pain is a common complaint among individuals assigned female at birth. However, few studies have explored pelvic pain among transmasculine patients on gender-affirming testosterone treatment, and most of these were performed in adult populations. Aims: The aim of our study was to investigate the prevalence, risk factors, nature and treatment of pelvic pain among trans adolescents on testosterone. Methods: A retrospective cohort study was performed on all trans adolescents started on gender-affirming testosterone treatment at our institution between 2007 and 2020. Results: Among 158 trans adolescents who were started on testosterone therapy and followed-up for at least six months, 37 (23.4%) reported pelvic pain, with a median interval between testosterone initiation and reported onset of pain of 1.6 months (range 0.3-6.4). The prevalence of pelvic pain was higher in patients who were receiving menstrual suppression (n = 36, 26.3%) compared to those who were not (n = 1, 4.8%), giving a risk difference of 21.5% (95% CI 9.8% to 33.2%, p = 0.028). The most common descriptive terms were "cramps" (n = 17, 45.9%) and "similar to previous period pain" (n = 8, 21.6%). A range of different pharmacological strategies were employed, including paracetamol, NSAIDs, danazol, norethisterone, medroxyprogesterone, etonogestrel implant, intra-uterine device, goserelin and pelvic floor physiotherapy, with variable outcomes. Conclusion: In conclusion, we report here - in what is to our knowledge the first time - the prevalence rate of pelvic pain in trans adolescents on gender-affirming testosterone treatment, and observe that a quarter of them described pelvic pain. Limitations of our study include its retrospective nature, which is likely to be associated with under-reporting of pelvic pain, and the limited documentation of the nature and likely causes of this pain within the medical records. Prospective longitudinal studies to better understand the nature, etiology and optimal management of testosterone-associated pelvic pain are therefore warranted.

Approach to the Patient: Pharmacological Management of Trans and Gender-Diverse Adolescents

Internationally, increasing numbers of children and adolescents with gender dysphoria are presenting for care. In response, gender-affirming therapeutic interventions that seek to align bodily characteristics with an individual's gender identity are more commonly being used. Depending on a young person's circumstances and goals, hormonal interventions may aim to achieve full pubertal suppression, modulation of endogenous pubertal sex hormone effects, and/or development of secondary sex characteristics congruent with their affirmed gender. This is a relatively novel therapeutic area and, although short-term outcomes are encouraging, longer term data from prospective longitudinal adolescent cohorts are still lacking, which may create clinical and ethical decision-making challenges. Here, we review current treatment options, reported outcomes, and clinical challenges in the pharmacological management of trans and gender-diverse adolescents.

Selective Estrogen Receptor Modulators: A Potential Option For Non-Binary Gender-Affirming Hormonal Care?

Gender dysphoria describes the distress associated with having a gender identity that differs from one's birth-assigned sex. To relieve this distress, transgender, and gender diverse (henceforth, trans) individuals commonly undergo medical transition involving hormonal treatments. Current hormonal treatment guidelines cater almost exclusively for those who wish to transition from male to female or vice versa. In contrast, there is a dearth of hormonal options for those trans individuals who identify as non-binary and seek an androgynous appearance that is neither overtly male nor female. Though prolonged puberty suppression with gonadotrophin releasing hormone agonists (GnRHa) could in theory be gender-affirming by preventing the development of unwanted secondary sex characteristics, this treatment option would be limited to pre- or peri-pubertal adolescents and likely have harmful effects. Here, we discuss the theoretical use of Selective Estrogen Receptor Modulators (SERMs) for non-binary people assigned male at birth (AMAB) who are seeking an androgynous appearance through partial feminization without breast growth. Given their unique range of pharmacodynamic effects, SERMs may represent a potential gender-affirming treatment for this population, but there is a lack of knowledge regarding their use and potentially adverse effects in this context.

OR15-01 Blockers and Bones: Loss of Absolute Bone Mineral Density Is Common in Trans- and Gender- Diverse Adolescents Treated with GnRHa

Background: The expected pubertal accrual of bone mineral density (BMD) may be disrupted in trans and gender diverse (TGD) adolescents who undergo pubertal suppression with Gonadotropin Releasing Hormone agonists (GnRHa)1. The extent of this effect remains unclear and is confounded by varying methods used to assess BMD1.

While BMD Z-scores in GnRHa-treated TGD adolescents may be expected to decline relative to pubertal peers, this measure provides no information on actual changes in BMD. Annualised, percent change in BMD (%BMD velocity, %BMDV) provides a standardised measure of accrual or loss, but has not been reported in this context.

Aims: (1) To evaluate bone accrual or loss using %BMDV in a cohort of GnRHa-treated TGD adolescents; (2) to explore associations between baseline characteristics (BMD Z score, Vitamin D status and Tanner Stage) and %BMDV.

Methods. Retrospective 10yr audit at tertiary pediatric gender service. Bone densitometry data were collected at baseline and 12-24monthly during GnRHa. Areal BMD values and Z-scores for lumbar spine (LS) and total hip (TH) were obtained. %BMDV between baseline and final scan was calculated for LS and TH. Population data for %BMDV before and during puberty were derived from the BMD in Childhood Study2. Results are reported as mean (±SD) or mean difference (MD; 95% confidence interval).

Results. Data from 28 patients (20 transfemale; 8 transmale) who commenced GnRHa at 13.3 (±2.0) yrs and were observed over 23.2 (±11.5) mo were included. Mean (±SD) %aBMDV during GnRHa therapy was -0.66 (±4.54) %/yr for TH and +1.91 (±4.23) %/yr for LS, both substantially lower than %aBMDV in pre-pubertal population controls (~+3-4%/year). 53% of GnRHa-treated youth exhibited negative %aBMDV, indicating bone loss, at TH and/or LS. %aBMDV was lower in (i) Vitamin D deficient youth, with MD at TH (-6.07; -9.00, -3.13); and LS (-4.93; -9.56, -0.30) relative to Vitamin D sufficient peers and (ii) youth who were Tanner stage 4+ at baseline, with MD at TH (-4.1; -7.7, -0.44) and LS (-3.6; -7.2, 0.01) relative to Tanner stage 2-3 peers. Height-adjusted Z scores declined from baseline with GnRHa treatment in >95% of patients and were not predictive of %aBMDV.

Conclusion. GnRHa-treated TGD adolescents in this cohort exhibited lower BMD accrual rates than pre-pubertal population controls. Over half of our cohort lost BMD, which is a significant concern in adolescence. Vitamin D deficiency and more advanced pubertal stage at GnRHa initiation were associated with greater bone loss during treatment. These data highlight the need to monitor and optimise bone health in GnRHa-treated TGD young people. We recommend routine annual densitometry and %BMDV evaluation regardless of baseline Z-scores as well as routine screening and treatment of vitamin D deficiency while on GnRHa.

References.

1.

Chew D., et al., Pediatrics, 2018. 141: p.e20173742.

2.

Zemel B.S., et al., JCEM, 2011. 96 p.3160-9.