What is the best course of action for a female-to-male (FTM) transgender patient with left lower pelvic pain, history of a 5.5cm cyst on the right ovary, and previous hysterectomy with the left ovary remaining?

Management of Left Lower Pelvic Pain in FTM Transgender Patient with Retained Left Ovary

Obtain transvaginal ultrasound (or transabdominal/transrectal if preferred by patient) as the first-line imaging to evaluate the remaining left ovary for cyst characteristics, size, and any concerning features. 1, 2

Initial Diagnostic Approach

Imaging Strategy

• Transvaginal ultrasound with color or power Doppler is the preferred initial imaging modality to characterize any ovarian pathology and assess vascularity of solid components 2, 3
• For this patient population, offer transabdominal or transrectal ultrasound as alternatives if transvaginal approach causes significant dysphoria or distress 1
• Use trauma-informed consent practices: explicitly ask permission, allow the patient to guide the examination, and offer chaperone with patient's preferred gender 1

Critical History Elements Specific to TGD Patients

• Document organ inventory (remaining left ovary, any other reproductive structures) to guide appropriate medical workup 1
• Assess for dysmenorrhea if patient still menstruates, as this can severely exacerbate gender dysphoria and chronic pain syndromes 1
• Screen for trauma history, as TGD persons experience sexual assault at higher rates and this predisposes to chronic pelvic pain conditions 1
• Evaluate pain amplifiers including functional status, medical comorbidities, and psychosocial factors 1

Management Algorithm Based on Ultrasound Findings

If Simple Cyst 5-10 cm Detected

• Follow-up ultrasound in 8-12 weeks to confirm if functional or reassess for wall abnormalities 2, 3
• Simple cysts have extremely low malignancy risk (<1%) regardless of size 2, 3
• If patient is on testosterone therapy, timing of follow-up ultrasound may need adjustment as traditional "proliferative phase" recommendations may not apply 2

If Complex Cyst or Concerning Features

• Immediate gynecologic referral for cysts with solid components, papillary projections, or septations with other concerning features 3, 4
• Consider surgical intervention for persistent symptomatic cysts despite conservative management 3

If Acute Complications Suspected

• Evaluate for ovarian torsion, which can occur despite normal Doppler flow on ultrasound 5
• Significant pain with risk factors may require exploratory laparotomy even with reassuring imaging 5
• The risk of acute complications (torsion, rupture) in benign-appearing lesions is approximately 0.2-0.4% 2

Special Considerations for Residual Ovary Syndrome

• Residual ovary syndrome (ROS) occurs in at least 5% of patients following hysterectomy with ovarian conservation 6
• ROS presents as pelvic pain, pelvic mass, or dyspareunia and can develop acutely (within weeks) or years after surgery 6
• Given this patient's history of 5.5cm cyst on the contralateral (now removed) ovary, there is heightened risk for cyst development in the remaining ovary 6

Multidisciplinary Referral Strategy

• Refer to gynecologic specialist experienced in TGD care for consideration of hormone treatment adjustments, laparoscopic evaluation for endometriosis if dysmenorrhea present, or surgical management 1
• Consider trauma specialist referral if history reveals sexual assault or significant psychological distress contributing to pain syndrome 1
• Avoid recommendations against gender-affirming practices (like chest binding if applicable); instead discuss safer methods while addressing medical concerns 1

Critical Pitfalls to Avoid

• Do not perform fine-needle aspiration of ovarian masses due to risk of spreading malignant cells if cancer present 3, 4
• Do not assume absence of reproductive organs based on gender presentation—always verify organ inventory 1
• Do not delay sensitive examinations if medically urgent, but establish trust and use trauma-informed approach when possible 1
• Do not overlook nongynecologic causes: left lower quadrant pain can arise from gastrointestinal (diverticulitis), urologic, or musculoskeletal etiologies 1, 7, 8
• If clinical picture suggests diverticulitis or other non-gynecologic pathology, CT abdomen/pelvis with IV contrast is the most accurate initial test (98% diagnostic accuracy for diverticulitis) 1