What is the best course of action for a 26-year-old female-to-male (FTM) patient with intermittent left suprapubic area pain, history of heavy irregular periods now stopped due to hormone replacement therapy (HRT), previous right ovarian cyst, and hysterectomy with preservation of the left ovary?

Immediate Pelvic Ultrasound with Doppler to Evaluate the Retained Left Ovary

This 26-year-old FTM patient on testosterone HRT with intermittent left suprapubic pain and a retained left ovary requires transvaginal/transabdominal pelvic ultrasound with Doppler as the initial imaging study to evaluate for ovarian pathology, pelvic congestion syndrome, or other adnexal causes of pain. 1, 2

Diagnostic Approach

Initial Imaging Strategy

• Pelvic ultrasound (transvaginal and transabdominal) with Doppler is the first-line imaging modality for evaluating reproductive-age patients with subacute/chronic pelvic pain of suspected gynecologic origin 1, 3
• The ultrasound should specifically assess:
  • The retained left ovary for cysts (simple, hemorrhagic, or complex), masses, or torsion 1, 3
  • Pelvic veins for engorgement (≥8 mm diameter), low-velocity flow, and retrograde flow patterns suggestive of pelvic congestion syndrome 2
  • Presence of free fluid or other peritoneal findings 4

Key Differential Diagnoses to Consider

Ovarian pathology (most likely given history):

• Hemorrhagic or functional ovarian cysts on the retained left ovary are common causes of intermittent pelvic pain in reproductive-age individuals 3, 5
• Ovarian torsion, though less common, must be excluded as it requires urgent surgical intervention 3, 5
• The patient's history of right ovarian cyst increases likelihood of recurrent ovarian cyst formation 1

Pelvic congestion syndrome:

• Testosterone therapy in FTM patients does not eliminate estrogen entirely, and residual ovarian function can contribute to pelvic venous congestion 2
• Ultrasound with Doppler can identify engorged periuterine and periovarian veins (≥8 mm) with characteristic low-velocity and retrograde flow 2
• This condition is associated with chronic/intermittent pelvic pain that worsens with standing and improves with lying down 2

Post-surgical complications:

• Adhesions from prior hysterectomy can cause chronic pelvic pain, though these are typically not well-visualized on ultrasound 1
• Ovarian remnant syndrome is unlikely given recent surgery with intentional ovarian preservation 1

Advanced Imaging if Ultrasound is Inconclusive

• MRI pelvis without and with IV contrast is the next appropriate step if ultrasound findings are equivocal or require further characterization 1

• MRI is superior for:

  • Detecting endometriosis (which can persist or develop even on testosterone) 1
  • Characterizing complex adnexal masses 1
  • Evaluating pelvic congestion syndrome with MR venography 2

• CT abdomen/pelvis with IV contrast is less ideal due to radiation exposure in a young patient but may be considered if the differential broadens to include gastrointestinal or urologic causes 1

Management Considerations Based on Findings

If Functional/Hemorrhagic Ovarian Cyst Identified:

• Conservative management with observation is appropriate for most functional cysts, as they typically resolve spontaneously 3, 5
• Pain management with NSAIDs 3
• Follow-up ultrasound in 6-8 weeks to confirm resolution 3

If Pelvic Congestion Syndrome Confirmed:

• Medical management options are limited in FTM patients already on testosterone HRT 2
• Ovarian vein embolization (with or without internal iliac vein embolization) is safe and effective for refractory pelvic congestion syndrome 2
• Completion oophorectomy (removal of the retained left ovary) may be considered for intractable pain, particularly since this patient has already undergone hysterectomy and is on HRT 6

If Ovarian Torsion Suspected:

• Immediate surgical consultation for diagnostic laparoscopy and detorsion or oophorectomy 3, 5
• Ultrasound findings include enlarged ovary with peripheral follicles, absent or reversed diastolic flow on Doppler, and free fluid 3

If No Ovarian Pathology Identified:

• Consider non-gynecologic causes: urologic (interstitial cystitis, urolithiasis) or gastrointestinal (irritable bowel syndrome, inflammatory bowel disease) 1, 7
• Musculoskeletal causes including osteitis pubis or pelvic floor dysfunction should be evaluated clinically 7

Critical Clinical Pitfalls

• Do not assume testosterone HRT eliminates all ovarian function or risk of ovarian pathology - the retained ovary can still develop cysts, undergo torsion, or contribute to hormonal symptoms 8
• Pelvic congestion syndrome is often overlooked in patients with prior pelvic surgery but remains a significant cause of chronic pelvic pain 2, 6
• Ovarian torsion can occur even with a single remaining ovary and requires high clinical suspicion with acute-onset or severe pain 3, 5
• The patient's history of menorrhagia and ovarian cysts suggests possible underlying polycystic ovarian morphology, which may persist despite testosterone therapy 2

Hormone Therapy Considerations

• If the retained ovary is removed, ensure adequate estrogen replacement in addition to testosterone to prevent premature osteoporosis, cardiovascular disease, and cognitive decline associated with surgical primary ovarian insufficiency in young patients 8
• Transdermal estradiol is preferred over oral formulations for hormone replacement after bilateral oophorectomy 8