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Dysmenorrhea and Endometriosis in Transgender Adolescents

  • Jessica Y. Shim
    Correspondence
    Address correspondence to: Jessica Y. Shim, MD, Division of Gynecology, Department of Surgery, Boston Children's Hospital, 333 Longwood Ave, LO-545, Boston, MA 02115; Phone: (617) 355-5785
    Affiliations
    Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts

    Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
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  • Marc R. Laufer
    Affiliations
    Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts

    Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts

    Center for Infertility and Reproductive Surgery, Brigham & Women's Hospital, Boston, Massachusetts

    Boston Center for Endometriosis, Boston, Massachusetts
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  • Frances W. Grimstad
    Affiliations
    Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts

    Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
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      Abstract

      Study Objective

      To study the presentation of dysmenorrhea and endometriosis in transmasculine adolescents and review their treatment outcomes.

      Design

      A retrospective review.

      Setting

      Boston Children's Hospital.

      Participants

      Transmasculine persons younger than 26 years old who were diagnosed with dysmenorrhea and treated between January 1, 2000 and March 1, 2020.

      Interventions

      Not applicable.

      Main Outcome Measures

      An electronic medical record review of the clinical characteristics, transition-related care, and treatment outcomes.

      Results

      Dysmenorrhea was diagnosed in 35 transmasculine persons. Mean age was 14.9 years ± 1.9 years. Twenty-nine (82.9%) were diagnosed after social transition. Twenty-three of 35 (65.7%) were first treated with combined oral contraceptives, but 14/23 (61%) discontinued or transitioned to alternative therapy. Twelve patients with dysmenorrhea alone initiated testosterone treatment, and 4/12 (33.3%) experienced persistent symptoms. Seven of 35 patients with dysmenorrhea (20.0%) were laparoscopically evaluated for endometriosis, and it was confirmed in all seven. Six had stage I disease, and one had stage II. Three of the 7 (42.9%) were diagnosed after social transition, with one diagnosed 20 months after initiating testosterone treatment. Their endometriosis was treated with combined oral contraceptives, danazol, or progestins; four experienced suboptimal response during treatment with these therapies alone. Two of those with suboptimal response subsequently resolved their dysmenorrhea when using testosterone. Five patients with endometriosis initiated testosterone treatment, and of the 5 (40%) experienced persistent symptomatology with combined testosterone and progestin therapies.

      Conclusion

      To our knowledge, this is the first study to characterize endometriosis in transmasculine persons. Evaluation for endometriosis was underutilized in transmasculine persons with dysmenorrhea, despite those who underwent laparoscopic evaluation and had disease confirmation. Although testosterone treatment can resolve symptoms in some, others might require additional suppression. Endometriosis should be considered in transmasculine persons with symptoms even when they are using testosterone.

      Key Words

      Introduction

      The transmasculine gender spectrum includes transgender men and non-binary gender persons whose sex was assigned female at birth. Cisgender female persons are those whose gender identity is congruent with the sex they were assigned at birth. Within obstetrics and gynecology, much of the research on the transmasculine population has been dedicated to fertility preservation, hysterectomies, and the reproductive changes associated with gender-affirming hormone therapy. Although many transmasculine persons seek gynecologic care for these aforementioned needs, less is known about their care for other gynecologic issues.
      Genital bleeding might be a concern of transmasculine persons because it can affect gender dysphoria.
      • Hembree W.C.
      • Cohen-Kettenis P.T.
      • Gooren L.
      • et al.
      Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society Clinical Practice Guideline.
      ,
      • Chrisler J.C.
      • Gorman J.A.
      • Manion J.
      • et al.
      Queer periods: attitudes toward and experiences with menstruation in the masculine of centre and transgender community.
      Gender dysphoria includes distress or discomfort that might be anatomical and/or physiological, including distress or discomfort associated with the reproductive organs and their function.
      • Knudson G.
      • De Cuypere G.
      • Bockting W.
      Recommendations for revision of the DSM diagnoses of gender identity disorders: consensus statement of the World Professional Association for Transgender Health.
      ,
      American Psychiatric Association
      Gender dysphoria.
      Most transmasculine persons are aware of menstrual suppression and are more desirous to stop or delay menstruation than their cisgender peers.
      • Chrisler J.C.
      • Gorman J.A.
      • Manion J.
      • et al.
      Queer periods: attitudes toward and experiences with menstruation in the masculine of centre and transgender community.
      Transgender men might have negative attitudes toward menstruation, which leads them to desire menstrual suppression, but menstruating can be additionally bothersome because of the associated qualities such as dysmenorrhea. Additionally, dysmenorrhea or premenstrual syndrome might be the presenting symptom(s) of gender dysphoria among adolescents.
      Committee on Health Care for Underserved Women: Committee Opinion No. 512: Health Care for Transgender Individuals.
      Pelvic pain without pathology has been documented among transmasculine persons in small studies, however, dysmenorrhea or secondary etiologies of dysmenorrhea among transmasculine persons is not presently described in the literature.
      • Obedin-Maliver J.
      • Light A.
      • Haan de G.
      • et al.
      Feasibility of vaginal hysterectomy for female-to-male transgender men.
      ,
      • Grimstad F.W.
      • Boskey E.
      • Grey M.
      New onset abdominopelvic pain after initiation of testosterone therapy among trans-masculine persons: a community-based exploratory survey.
      Adolescents frequently suffer from menstrual discomfort, and endometriosis affects at least two-thirds of adolescents who have not improved with conventional medical therapy for dysmenorrhea.
      • Janssen E.B.
      • Rijkers A.C.
      • Hoppenbrouwers K.
      • et al.
      Prevalence of endometriosis diagnosed by laparoscopy in adolescents with dysmenorrhea or chronic pelvic pain: a systematic review.
      Because endometriosis can be debilitating to adolescents’ quality of life, and a delay in diagnosis can lead to disease progression, gynecologists should be prepared to diagnose this condition in all populations including transmasculine individuals.
      • Gallagher J.S.
      • DiVasta A.D.
      • Vitonis A.F.
      • et al.
      The impact of endometriosis on quality of life in adolescents.
      Particularly as transgender reproductive medicine expands and transgender persons have interests in accessing fertility services, the diagnosis of endometriosis might affect the use and/or outcomes of fertility preservation in this population.
      • Insogna I.G.
      • Ginsburg E.
      Expanding our understanding of fertility preservation outcomes in transgender men.
      ,
      • Ethics Committee of the American Society for Reproductive Medicine
      Access to fertility services by transgender persons: an Ethics Committee opinion.
      The purpose of this retrospective study was to investigate how dysmenorrhea is managed in transmasculine adolescents at our institution. Secondary goals included describing the presentation of endometriosis in transgender men and their treatment outcomes, as well as analyzing the effects of testosterone treatment initiation on dysmenorrhea in transmasculine adolescents.

      Materials and Methods

      This project was approved by the Boston Children's Hospital institutional review board. A retrospective review was performed of all transmasculine persons younger than 26 years old who were treated at Boston Children's Hospital, between January 1, 2000, and March 1, 2020. Electronic medical records were reviewed; patients were included in the study if they had visit diagnostic codes of gender dysphoria (F64.0, F64.1, F64.2, F64.8, F64.9) and dysmenorrhea (N94.4, N94.5, N94.6). Patients were excluded from the study if there was no clinical documentation of male pronouns, of transgender or non-binary gender identity, or if they were sex-assigned male at birth.
      Demographic characteristics were obtained including age and ethnicity. Gynecologic history was also extrapolated including menstrual history, gynecologic complaints, hormonal/nonhormonal medications prescribed, surgeries performed, and gynecologic and non-gynecologic comorbidities. Transition-related care was also reviewed and data on timing of social transition (defined as patient self-disclosure of publicly identifying along the transmasculine spectrum), initiation of gender-affirming hormone therapy, and any gender-affirming surgical history were also obtained. Electronic medical record notes were reviewed to assess for documentation of a change in dysmenorrhea with therapies used.

      Results

      Thirty-five transmasculine adolescents had a visit diagnosis of dysmenorrhea. The mean age at the time of diagnosis of dysmenorrhea was 14.9 years ± 1.9 years. The average age of menarche was 11.9 years ± 1.1 years. Twenty-nine transmasculine adolescents (82.9%) were given a diagnosis of dysmenorrhea after social transition to the male gender. Other gynecologic comorbidities were rare; three had a diagnosis with polycystic ovarian syndrome, one had pelvic floor dysfunction, and one patient had a Müllerian anomaly of uterine didelphys with a longitudinal vaginal septum. Other complaints during menstruation included depressive or suicidal thoughts with bleeding; five of 35 (14.2%) expressed these symptoms in conjunction with their dysmenorrhea.
      Twenty-three transmasculine adolescents were first treated with combined oral contraceptives, 17/23 (74%) of whom began treatment after social transition. More than half (14/23, or 61%) discontinued or transitioned to an alternative therapy; eleven of the 14 who discontinued or transitioned to an alternative therapy had started the oral contraceptives after social transition. Eleven transitioned to norethindrone acetate, one patient switched to a levonorgestrel intrauterine device (IUD), one started danazol therapy, and one discontinued hormonal therapy entirely and elected for scheduled nonsteroidal anti-inflammatory medications with menses. The most common reason for switching from combined oral contraceptive therapy was persistent bleeding or pain (10/14, or 71.4%), whereas 3/14 patients (21.4%) cited breast tenderness, and one reported side effects that were not otherwise specified. Twelve patients with dysmenorrhea alone initiated testosterone treatment, and 4/12 (33.3%) experienced persistent symptoms, therefore requiring continued progestin therapy with testosterone.
      Only seven of the 35 transgender men with dysmenorrhea (20.0%) were laparoscopically evaluated for endometriosis, and it was confirmed in all seven. The mean age at diagnosis was 15.7 years ± 0.88 years. Three of seven (42.9%) were diagnosed after social transition, with one diagnosed after initiation of testosterone treatment. Six had stage I disease, and 1 had stage II disease at the time of laparoscopy. Their endometriosis was treated with combined oral contraceptives (n = 1), danazol (n = 2), or progestin therapy (n = 4). One patient treated with danazol and three treated with progestins (norethindrone acetate, levonorgestrel intrauterine device) experienced suboptimal response; the patient treated with danazol and one patient treated with norethindrone acetate resolved their endometriosis-associated symptoms with subsequent testosterone therapy.
      Five patients with endometriosis started testosterone treatment. Two patients had been receiving testosterone treatment for more than one year and experienced persistent bleeding and pain symptoms with trialing norethindrone acetate and then a levonorgestrel intrauterine device in conjunction with testosterone treatment. One patient with endometriosis underwent gender-affirming hysterectomy with bilateral salpingo-oophorectomy.

      Discussion

      To our knowledge, this is the first study to describe the presentation of endometriosis in the transgender population. We identified seven transmasculine adolescents with different gender-affirming treatment histories, in whom endometriosis was laparoscopically confirmed. Although three patients achieved resolution of endometriosis-associated symptoms with conventional endometriosis therapies, two experienced improvement after starting testosterone therapy, and two experienced persistent symptoms despite testosterone use and therefore required continuation of progestin therapies in conjunction.
      In our study, most of the patients with endometriosis received their diagnosis before their social transition, compared with the group diagnosed with dysmenorrhea alone. Insufficient data were available on determining if the onset of symptoms in the adolescents diagnosed with endometriosis was different from those diagnosed with dysmenorrhea only. The identification of endometriosis before social transition might suggest that the adolescents were significantly impaired from the disease, prompting evaluation. This is consistent with previous studies suggesting that adolescents affected by endometriosis have significantly worse reports of quality of life compared with their unaffected peers.
      • Gallagher J.S.
      • DiVasta A.D.
      • Vitonis A.F.
      • et al.
      The impact of endometriosis on quality of life in adolescents.
      ,
      • Marinho M.C.P.
      • Magalhaes T.F.
      • Fernandes L.F.C.
      • et al.
      Quality of life in women with endometriosis: an integrative review.
      The identification of dysmenorrhea after social transition might be in part from the significant stigma, discrimination, and effect on mental health. Before the time of transition, transgender adolescents might feel disempowered in accessing health care for conditions before alleviation of their gender dysphoria.
      • Chodzen G.
      • Hildago M.A.
      • Chen D.
      • et al.
      Minority stress factors associated with depression and anxiety among transgender and gender-nonconforming youth.
      • Reisner S.L.
      • Aktz-Wise S.L.
      • Gordon A.R.
      • et al.
      Social epidemiology of depression and anxiety by gender identity.
      • Johns M.M.
      • Lowry R.
      • Andrzejewski J.
      • et al.
      Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students – 19 states and large urban school districts, 2017.
      Patients identified in this study received a range of hormonal treatments for their endometriosis, which could be influenced by numerous factors including their gender identity, effects/side effects (including those perceived by patients and clinicians), and clinicians' comfort.
      • Krempasky C.
      • Harris M.
      • Abern L.
      • et al.
      Contraception across the transmasculine spectrum.
      Combined oral contraceptives are a commonly prescribed and first-line option for the management of dysmenorrhea in adolescents and young adults.
      Dysmenorrhea and endometriosis in the adolescent
      ACOG Committee Opinion No. 760. American College of Obstetricians and Gynecologists.
      More than half of the transmasculine adolescents in our study transitioned away from combined oral contraceptive use for the management of their dysmenorrhea. Although the most cited reason for discontinuation was for persistent bleeding and pain, one-fifth experienced chest/breast tenderness, which could exacerbate a transmasculine persons’ gender dysphoria and/or make use of chest binders painful.
      • Krempasky C.
      • Harris M.
      • Abern L.
      • et al.
      Contraception across the transmasculine spectrum.
      Although not assessed in our study, some transmasculine patients might want to avoid combined oral contraceptives because of alternative reasons, including dysphoria triggered by the act of repeatedly taking a medication generally associated with cisgender women, or the perceived feminizing effects of estrogen and progesterone.
      • Krempasky C.
      • Harris M.
      • Abern L.
      • et al.
      Contraception across the transmasculine spectrum.
      Patients have additionally reported concerns of hormonal contraceptives counteracting the masculinizing effects of testosterone.
      • Gomez A.
      • Walters P.C.
      • Dao L.T.
      “Testosterone in a way is birth control”: contraceptive attitudes and experiences among transmasculine and genderqueer young adults.
      However, estradiol levels of patients receiving combined oral contraceptives have been reported to be within the same range of levels in persons receiving testosterone gender-affirming hormone therapy.
      • Mishell D.R.
      • Thorneycroft I.H.
      • Nakamura R.M.
      • et al.
      Serum estradiol in women ingesting combination oral contraceptive steroids.
      Thorough counseling with an evidence-based discussion on the physiological effects of hormones might help support patients in identifying a medication that alleviates their symptoms and is aligned with their goals.
      One specific hormonal treatment used in the endometriosis population of particular interest for transmasculine care was danazol, a synthetic steroid and a derivative of 17 α-ethinyltestosterone.
      • Barbieri R.L.
      Endometriosis 1990 – current treatment approaches.
      Danazol is theorized to ameliorate endometriosis symptoms by creating a hyperandrogenic, progestenic state, impairing ovulation and inducing atrophy of the endometrium. Danazol has been reported to be an effective treatment for endometriosis-associated pelvic pain, however, it is not conventionally used in the cisgender population because of its androgenic side effects.
      • Selak V.
      • Faruqhar C.
      • Prentice A.
      • et al.
      Danazol for pelvic pain associated with endometriosis.
      The infrequent use of danazol in the setting of endometriosis might affect clinician comfort in prescribing it for the treatment of dysmenorrhea and endometriosis in transmasculine populations. In our study, only 2 patients received danazol and both prescriptions were by the same gynecologist (M.R.L.). Patients receiving danazol might experience dose-dependent side effects, such as acne, hirsutism, and weight gain, with additional potentially irreversible effects such as deepening of the voice.
      • Boothroyd C.V.
      • Lepre F.
      Permanent voice change resulting from danazol therapy.
      Although it is an effective treatment for endometriosis, the side effect profile of danazol has contributed to worse reported quality of life scores among cisgender women, and therefore further research is warranted to determine if danazol is a more accepted treatment method among transgender men.
      • Rock J.A.
      • Truglia J.A.
      • Caplan R.J.
      Zoladex (goserelin acetate implant) in the treatment of endometriosis: a randomized comparison with danazol. The Zoladex Endometriosis Study Group.
      ,
      • Burry K.A.
      Nafarelin in the management of endometriosis: quality of life assessment.
      Seventeen of 35 patients (48.6%) identified in our study proceeded with testosterone for gender-affirming treatment. The patients received subcutaneous testosterone cypionate and were within cisgender male range dosing. This percentage might be secondary to the time frame and age range of which the electronic medical records were abstracted (mean age of starting testosterone 16.4 years ± 1.5 years). Although testosterone is not a conventional therapy for endometriosis, one may expect its efficacy for endometriosis-associated symptoms to be similar to that of danazol. Studies have shown cessation of menses within 6 months of testosterone initiation in up to 85% of transgender patients.
      • Meyer W.
      • Webb A.
      • Stuart C.
      • et al.
      Physical and hormonal evaluation of transsexual patients: a longitudinal study.
      • Nakamura A.
      • Watanabe M.
      • Sugimoto M.
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      • Deutsch M.B.
      • Bhakri V.
      • Kubicek K.
      Effects of cross-sex hormone treatment on transgender women and men.
      • Ahmad S.
      • Leinung M.
      The response of the menstrual cycle to initiation of hormonal therapy in transgender men.
      In our study, 6/17 patients (35.3%) = with dysmenorrhea or endometriosis had persistent bleeding and pain while receiving testosterone. Two experienced persistent endometriosis-associated pain and bleeding despite concomitant testosterone therapy and levonorgestrel intrauterine device use. The persistence of symptoms can be explained by the incomplete ovulatory suppression by testosterone or intrauterine device use; although luteinizing hormone and follicle-stimulating hormone levels might change in the presence of a hyperandrogenic state, incomplete suppression can lead to breakthrough ovulation.
      • Krempasky C.
      • Harris M.
      • Abern L.
      • et al.
      Contraception across the transmasculine spectrum.
      ,
      • Spinder T.
      • Spijkstra J.J.
      • van den Tweel J.G.
      • et al.
      The effects of long term testosterone administration on pulsatile luteinizing hormone secretion and on ovarian histology in eugonadal female to male transsexual subjects.
      ,
      • Taub R.L.
      • Adriane E.S.
      • Neal-Perry G.
      • et al.
      The effect of testosterone on ovulatory function in transmasculine individuals.
      Atrophic bleeding from endometrial lining instability can also ensue. Furthermore, endometrial activity has been reported in the uterine pathology of transmasculine persons receiving testosterone, despite amenorrhea.
      • Grimstad F.W.
      • Fowler K.G.
      • New E.P.
      • et al.
      Uterine pathology in transmasculine persons on testosterone: a retrospective multicenter case series.
      Transmasculine persons affected by dysmenorrhea or endometriosis must, therefore, be counseled that testosterone might not completely mitigate their symptoms, and other hormonal therapies might need to be used in conjunction with purposes including bleeding, pain, or contraception.
      Only one of the patients with endometriosis underwent total laparoscopic hysterectomy and bilateral salpingo-oophorectomy at age 18 years. His procedure was not performed within our institution therefore we were unable to view records regarding the procedure such as final pathology. His endometriosis-associated symptoms resolved with combined oral contraceptives before the initiation of testosterone treatment. Although gynecologic surgery is one component of gender-affirming care and regarded as medically necessary for those who desire it, not all transmasculine persons desire hysterectomy.
      Committee on Health Care for Underserved Women: Committee Opinion No. 512: Health Care for Transgender Individuals.
      ,
      • Reilly Z.P.
      • Fruhauf T.F.
      • Martin S.J.
      Barriers to evidence-based transgender care: knowledge gaps in gender-affirming hysterectomy and oophorectomy.
      When counseling on hysterectomy with or without oophorectomy, transmasculine persons should be counseled similarly to cisgender women on the potential advantages and disadvantages of definitive surgery including the effect on fertility and endometriosis-related symptoms. Conservative surgical treatment of endometriosis (eg, laparoscopic excision and/or ablation) is the first-line surgical option for persons affected by endometriosis, but hysterectomy is a gender-affirming, viable option for treatment of endometriosis.
      • Practice Committee of the American Society for Reproductive Medicine
      Treatment of pelvic pain associated with endometriosis: a committee opinion.
      Hysterectomy does not guarantee freedom from pain and reoperation.
      • Shakiba K.
      • Bena J.F.
      • McGill K.M.
      • et al.
      Surgical treatment of endometriosis: a 7-year follow-up on the requirement for further surgery.
      ,
      • Soliman A.M.
      • Du E.X.
      • Yang H.
      • et al.
      Retreatment rates among endometriosis patients undergoing hysterectomy or laparoscopy.
      Additionally, young transmasculine patients should be counseled as their cisgender female counterparts about hysterectomy without oophorectomy, because not all transmasculine patients desire oophorectomy.
      • Grimstad F.W.
      • Boskey E.
      Empowering transmasculine youth by enhancing reproductive health counseling in the primary care setting.
      Limitations of our study include the possibility of confounding. We did not have further menstrual information on the patients with dysmenorrhea and endometriosis (eg, pain scores, the onset of symptoms), and some risk factors might have been under-reported (eg, familial history of endometriosis). Study outcomes were ascertained using electronic data and visit diagnoses, and coding for dysmenorrhea might be underused by clinicians who do not provide gynecologic-specific care. This study design might not have captured further charts to provide a larger data set. Adolescents with endometriosis might present with chronic pelvic pain including acyclic pelvic pain. Thus, patients with cyclic and acyclic pelvic pain might not carry a diagnosis of dysmenorrhea and therefore were missed in our study.
      • Laufer M.R.
      • Goitein L.
      • Bush M.
      • et al.
      Prevalence of endometriosis in adolescent girls with chronic pelvic pain not responding to conventional therapy.
      In our study, only 7/35 (20%) ultimately underwent laparoscopic evaluation for endometriosis. Although the prevalence of laparoscopy for dysmenorrhea in the general adolescent population is difficult to ascertain, endometriosis has been identified in up to 47% of adolescents who underwent laparoscopy for pelvic pain.
      • Goldstein D.P.
      • De Cholnoky C.
      • Emans S.J.
      Adolescent endometriosis.
      Laparoscopy was likely underutilized, and endometriosis might therefore be under-reported. The underutilization of laparoscopy is likely contributed by the factors that similarly contribute to delayed diagnosis of endometriosis in the cisgender population, including the normalization of symptoms and the intermittent hormonal suppression of symptoms.
      • Ballard K.
      • Lowton K.
      • Wright J.
      What’s the delay? A qualitative study of women’s experiences of reaching a diagnosis of endometriosis.
      In addition, there has been a general lack of knowledge of menstrual disorders that might affect transmasculine persons, which could contribute to health disparities.
      Additionally, as greater numbers of transmasculine youth are having access to puberty-blocking medication this might influence the presentation and progression of dysmenorrhea and endometriosis in these patients.
      • Lopez C.M.
      • Solomon D.
      • Boulware S.D.
      • et al.
      Trends in the use of puberty blockers among transgender children in the United States.
      Puberty-blocking therapies are generally gonadotropin-releasing hormone agonists, which are also medications that are effective when empirically used for endometriosis.
      • Ling F.W.
      Randomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected endometriosis. Pelvic Pain Study Group.
      Use of puberty-blocking therapies early in puberty might successfully prevent the emergence of endometriosis-related symptoms. None of our patients used puberty-blocking agents. Further studies will need to be done to assess for the development of endometriosis-related symptoms in persons who underwent puberty-blocking therapy and progressed directly to testosterone treatment to better understand how this might influence presentation and symptomatology during testosterone treatment.
      Strengths of this study include the access to electronic data and follow-up within a large tertiary care referral center; the Gender Multispecialty Service at Boston Children's Hospital was the first major program in the United States to focus on gender-diverse and transgender adolescents and provides ongoing medical and affirmative care.
      In conclusion, we identified transmasculine adolescents affected by dysmenorrhea and endometriosis, and the medical treatment options for their symptoms varied widely. Because there are no data to support one treatment over another, the treatment choice used by each patient depended on the treatment efficacy, patient preferences, medication side effects, contraceptive needs, and gender dysphoria. Our study also showed individual variation in the susceptibility to menstrual and pain suppression by androgens, danazol and testosterone. Clinicians should strongly consider laparoscopic evaluation for endometriosis in transmasculine patients with persistent and significant dysmenorrhea despite treatment with hormonal agents (eg, estrogen/progestin, progestin-only, and androgen therapies) and no other identified etiologies. Further research is warranted regarding endometriosis and other gynecologic conditions in transgender men to improve the quality of care that this unique community receives.

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