Are Genitourinary Syndrome (GSM) symptoms common in trans males undergoing testosterone therapy?

Genitourinary Syndrome Symptoms in Trans Males on Testosterone Therapy

Yes, Genitourinary Syndrome (GSM) symptoms are common in transgender men undergoing testosterone therapy, with over 60% experiencing vulvovaginal pain during sexual activity and 72% reporting some form of pelvic pain after starting testosterone. 1, 2

Prevalence and Presentation of GSM Symptoms

Testosterone therapy in transgender men causes several changes that can lead to GSM symptoms:

• Vaginal/genital pain: 64.6% of trans men report genital pain or discomfort during sexual activity 1

  • Most commonly in the vagina or frontal genital opening (52.2%)
  • Around the clitoris (29.1%)
  • Labia (24.5%)

• Pelvic pain: 72.2% of trans men report experiencing pelvic pain following testosterone initiation 2

  • Most commonly described as suprapubic and "cramping" in nature
  • Can persist despite months or years of testosterone therapy

Mechanism of GSM in Trans Men

The development of GSM symptoms in transgender men on testosterone therapy occurs through several pathways:

• Decreased estrogen levels: Testosterone therapy leads to decreased estrogen in the vaginal tissues 1
• Atrophic vaginal tissue: Results in decreased vaginal lubrication and potential discomfort during sexual activity 1
• Androgen sensitivity of pelvic floor muscles: May contribute to pelvic floor dysfunction 2

Risk Factors and Associated Conditions

Several factors are associated with higher likelihood of GSM symptoms:

• Persistent menstruation: Strongly associated with pelvic pain after testosterone therapy 2
• History of post-traumatic stress disorder: Increases odds of pelvic pain 2
• Pain with orgasm: Associated with higher likelihood of pelvic pain 2
• Testosterone delivery method: Gel formulations are associated with higher rates of persistent vaginal bleeding/spotting compared to injections 3
• Lower serum testosterone levels: Associated with persistent vaginal bleeding/spotting 3

Management Approaches

For transgender men experiencing GSM symptoms, consider:

1. Optimize testosterone therapy:

   • Ensure serum testosterone levels are in the physiologic male range (300-1,000 ng/dL) 4
   • Consider switching from gel to injectable testosterone if vaginal bleeding/spotting persists 3

2. Add progestogen therapy:

   • If vaginal bleeding persists after 3 months of testosterone therapy, adding a progestogen can decrease bleeding intensity 3

3. Consider non-estrogen therapies that may help with GSM symptoms:

   • Polycarbophil-based vaginal moisturizers
   • Hyaluronic acid preparations
   • Topical DHEA or testosterone (though evidence is limited in this population) 5

Clinical Monitoring and Follow-up

• Monitor for persistent vaginal bleeding or spotting

  • Most transgender men experience cessation of bleeding within 3 months of starting testosterone 3
  • By 12 months, only 4.7% report bleeding and 6.9% report spotting 3
  • No participants reported vaginal bleeding or spotting after 18 months of testosterone therapy 3

• Assess for sexual function changes

  • Testosterone therapy is associated with increased interest in sexual activity and improved ability to orgasm 1
  • However, this may be accompanied by increased vaginal pain during sexual activity 1

Important Considerations

• Patient education: Inform patients that GSM symptoms are common and may require specific management beyond testosterone therapy
• Screening: Regular assessment for GSM symptoms should be part of routine care for transgender men on testosterone
• Multidisciplinary approach: Consider referral to specialists in sexual medicine, pelvic floor physical therapy, or gynecology when symptoms persist despite optimization of hormone therapy

Pitfalls to Avoid

• Assuming all genital discomfort is psychological: The physiological effects of testosterone on vaginal tissues are real and require medical management
• Overlooking the impact on quality of life: GSM symptoms can significantly impact sexual function and satisfaction
• Focusing only on testosterone levels: Even with optimal testosterone levels, some patients may require additional interventions for GSM symptoms
• Neglecting to discuss sensitive topics: Providers should proactively ask about GSM symptoms as patients may hesitate to report them due to discomfort or fear of stigma