Management of Ovarian Cysts in Individuals on Gender-Affirming Testosterone Therapy
Ovarian cysts in individuals on gender-affirming testosterone therapy should be managed according to standard ovarian cyst protocols with continued testosterone therapy, as research shows benign histopathology in all specimens from transmasculine individuals on testosterone. 1
Understanding Ovarian Cysts in the Context of Testosterone Therapy
Masculinizing hormone therapy (testosterone) is used to help transgender men and non-binary individuals assigned female at birth develop more masculine characteristics. Testosterone therapy induces several physical changes including:
- Thicker vocal cords producing deeper voice pitch
- Body and facial hair growth
- Menstrual suppression
- Increased libido
- Clitoral growth
- Increased muscle mass and reduced fat mass 2
Impact of Testosterone on Ovarian Tissue
Research specifically examining ovarian histopathology in transmasculine persons on testosterone therapy has shown:
- 49.4% of specimens had follicular/simple cysts
- 5.9% were polycystic
- 38.8% had normal pathology
- All specimens showed benign histopathology 1
Importantly, there was no association between the duration of testosterone therapy or body mass index and the presence of cysts in the ovaries.
Management Algorithm for Ovarian Cysts
Step 1: Evaluation and Classification
- Determine cyst type using ultrasound (simple, hemorrhagic, dermoid, endometrioma, or complex)
- Measure cyst size
- Assess for symptoms (pain, pressure)
Step 2: Management Based on Cyst Type and Size
Simple Cysts
- Premenopausal-equivalent individuals on testosterone:
- ≤3 cm: No follow-up required
3 cm but <10 cm: Follow-up ultrasound in 8-12 weeks
- If persistent or enlarging: Consider referral to ultrasound specialist or MRI 2
Hemorrhagic Cysts
- Premenopausal-equivalent individuals on testosterone:
- ≤5 cm: No further management required
5 cm but <10 cm: Follow-up in 8-12 weeks
- If persistent or enlarging: Referral for additional expertise 2
Dermoid Cysts and Endometriomas
- <10 cm: Optional initial follow-up at 8-12 weeks
- Consider annual ultrasound surveillance if not surgically removed 2
Complex or Concerning Cysts
- Follow O-RADS US risk stratification system for risk assessment
- Higher risk features warrant gynecology referral or MRI evaluation 2
Special Considerations
Continuation of Testosterone Therapy
- Testosterone therapy should generally be continued during management of ovarian cysts 2
- There is no evidence suggesting testosterone therapy increases risk of malignant transformation of ovarian cysts 1
Surgical Considerations
- For individuals requiring surgery for ovarian cysts but wishing to retain their ovaries:
- Counsel that ovarian retention while on testosterone appears safe based on histopathology findings 1
- Discuss options for cystectomy rather than oophorectomy when appropriate
Laboratory Interpretation
- Laboratory values should be interpreted in the context of gender-affirming hormone therapy
- For those on testosterone therapy for more than 1 year, many laboratory values should be interpreted based on their affirmed gender 2
Common Pitfalls to Avoid
Discontinuing testosterone unnecessarily: Research shows benign histopathology in ovaries of transmasculine persons on testosterone, supporting continuation of therapy 1
Assuming all ovarian cysts require surgical intervention: Many cysts can be managed conservatively with monitoring
Failing to consider the psychological impact: Discussions about reproductive organs may cause dysphoria in some individuals, so approach conversations with sensitivity
Not recognizing normal variations: Follicular/simple cysts are common (49.4%) in individuals on testosterone therapy and generally benign 1
By following standard ovarian cyst management protocols while continuing testosterone therapy, healthcare providers can effectively manage ovarian cysts in transmasculine individuals while supporting their gender-affirming care.