What is the appropriate treatment for genital pain in a female-to-male (FtM) individual?

Genital Pain in Female-to-Male Transgender Individuals

The approach to genital pain in a female-to-male transgender person requires first determining whether the pain is related to testosterone therapy, gender-affirming practices like chest binding or genital tucking, infectious causes, or underlying dermatologic conditions, with treatment directed at the specific etiology identified.

Initial Diagnostic Approach

Determine the Anatomical Source and Context

• Assess whether pain is vaginal/vulvar, clitoral, or related to gender-affirming practices, as testosterone use is associated with vaginal atrophy that causes pain during sexual activity in over 60% of transgender men 1
• Evaluate for infectious etiologies including sexually transmitted infections (gonorrhea, chlamydia) if the patient is sexually active, particularly if there is urethral involvement or dysuria 2
• Screen for dermatologic conditions such as lichen sclerosus, which can cause genital pain, scarring, and dyspareunia in individuals with vulvar anatomy 2

Key History Elements

• Duration and timing of testosterone therapy, as cross-sex hormone administration changes pain patterns, with some individuals developing new pain after starting hormones while others experience improvement 3
• Sexual activity patterns and associated pain, noting that vaginal pain during sexual activity is the most common complaint (52.2% report vaginal/frontal genital opening pain), followed by clitoral pain (29.1%) 1
• Use of gender-affirming practices including chest binding or genital tucking, which can cause pain but should not be discouraged; instead, discuss harm reduction strategies 2

Treatment Algorithm Based on Etiology

For Testosterone-Related Vaginal Atrophy and Sexual Pain

Vaginal estrogen therapy (pills, rings, or creams) is the first-line treatment for vaginal dryness and painful intercourse caused by testosterone-induced atrophy, as it has been shown effective in postmenopausal women and breast cancer survivors 2

• Vaginal DHEA (prasterone) can be considered as an alternative, with evidence showing improvements in sexual desire, arousal, pain, and overall sexual function in cancer survivors 2
• Vaginal moisturizers and lubricants (gels, oils, topical vitamin D or E) can help alleviate vaginal dryness and sexual pain, though data are limited 2
• Topical lidocaine applied to the vulvar vestibule before vaginal penetration may improve dyspareunia 2
• Pelvic floor physical therapy may improve sexual pain, arousal, lubrication, orgasm, and satisfaction, with evidence from gynecologic cancer survivors showing significant improvement in sexual function 2

For Infectious Causes (If Sexually Active)

If urethritis or sexually transmitted infection is suspected, obtain urethral swab or first-void urine for gonorrhea and chlamydia testing, and initiate empiric treatment with ceftriaxone 250 mg IM once plus doxycycline 100 mg orally twice daily for 10 days 2, 4

• Consider epididymitis if there is unilateral testicular pain (relevant post-phalloplasty or metoidioplasty), though this is rare in individuals assigned female at birth 2
• Test for syphilis and HIV as part of the evaluation for sexually transmitted infections 2, 4

For Dermatologic Conditions

If lichen sclerosus is suspected (white plaques, scarring, architectural changes), perform a biopsy to confirm diagnosis and initiate treatment with ultra-potent topical corticosteroids 2

• Monitor for complications including introital narrowing, clitoral hood adhesions with pseudocyst formation, and vulvodynia (neuropathic pain that persists despite resolution of skin lesions) 2
• Refer to gynecology or dermatology if there is treatment failure, significant scarring, or concern for malignancy (4-5% risk of squamous cell carcinoma with chronic lichen sclerosus) 2

For Neuropathic/Persistent Pain (Vulvodynia)

Recognize that vulvodynia may develop after any inflammatory condition and does not respond to topical corticosteroids, requiring neuropathic pain management 2

• Consider integrative therapies including yoga, meditation, and cognitive behavioral therapy, which have shown effectiveness in improving sexual functioning 2
• Avoid focusing solely on vaginal penetration in assessment and treatment, as this narrow approach fails to address the broader experience of pain and sexual function 5, 6

Critical Considerations

Testosterone Effects on Pain

• Testosterone use has complex effects: it increases interest in sexual activity and ability to orgasm, but also increases vaginal pain during sexual activity 1
• Some individuals experience pain improvement with testosterone (particularly those with pre-existing pain), while others develop new pain after starting hormones 3
• Gender affirmation through testosterone may improve overall sexual function despite physiological changes that could theoretically worsen pain 1

Common Pitfalls to Avoid

• Do not dismiss pain as purely psychological or solely attribute it to testosterone without evaluating for treatable causes like infection or dermatologic conditions 5, 6
• Avoid discouraging gender-affirming practices like binding or tucking; instead, provide harm reduction counseling 2
• Do not overlook the multifactorial nature of genital pain, which includes physiological, psychological, and social components requiring comprehensive assessment 5, 6
• Recognize that pain assessment must include a broad perspective on both pain mechanisms and sexual function beyond penetrative activity 5

Adjunctive Management

• Analgesics (ibuprofen 400 mg every 4-6 hours) can be used for acute pain relief 7
• Address psychosexual concerns, as chronic genital pain significantly impacts quality of life and sexual functioning, with problems often persisting after successful treatment of the underlying condition 2
• Consider referral to a sexual health specialist for comprehensive management when pain persists despite initial interventions 2