What are the next steps for an FTM (female-to-male) patient on testosterone therapy experiencing clitoral swelling and pain, who is also taking trazodone (antidepressant) and Abilify (aripiprazole, antipsychotic)?

Management of Clitoral Swelling and Pain in FTM Patient on Testosterone Therapy

This patient requires immediate clinical evaluation to differentiate between expected testosterone-induced clitoral growth versus pathological causes, with particular attention to ruling out priapism-like conditions and assessing for potential medication interactions with trazodone.

Immediate Assessment Priorities

Distinguish Normal from Pathological Changes

• Clitoral enlargement is an expected, irreversible effect of masculinizing testosterone therapy that typically develops within the first several months of treatment 1
• However, acute swelling with pain suggests a pathological process rather than normal virilization 1
• Examine for signs of clitoral priapism or prolonged engorgement, which can occur with testosterone therapy and requires urgent intervention if present for >4 hours 1

Evaluate Medication Interactions

• Trazodone has alpha2-adrenergic antagonist properties that can enhance genital blood flow and has been associated with priapism, though this is more commonly reported in cisgender males 1
• The combination of testosterone (which increases libido and clitoral sensitivity) with trazodone's vasodilatory effects may theoretically increase risk of prolonged clitoral engorgement 1
• Aripiprazole (Abilify) is not typically associated with genital swelling but should be documented 1

Physical Examination Approach

Use Trauma-Informed Technique

• Explicitly ask permission before performing genital examination and allow the patient to control the pace and extent of the exam 1
• Offer a chaperone of the patient's preferred gender 1
• Acknowledge that genital examination may trigger dysphoria or past trauma 1

Specific Examination Findings to Document

• Assess clitoral size, color, temperature, and degree of engorgement to differentiate normal testosterone-induced growth from acute pathology 1
• Evaluate for signs of infection (erythema, warmth, discharge) 1
• Check for vaginal atrophy or dryness, which is common with testosterone and can cause referred pain 2, 3
• Palpate for pelvic floor muscle tenderness, as pelvic floor dysfunction is increasingly recognized as a cause of pelvic pain in transgender men on testosterone 2

Differential Diagnosis and Management

If Prolonged Clitoral Engorgement/Priapism-Like Condition

• This requires urgent intervention if present for >4 hours to prevent tissue damage 1
• Consider temporarily discontinuing or reducing trazodone dose, as its alpha2-antagonist effects may be contributing 1
• Consult urology or experienced gender-affirming care provider urgently 1

If Pelvic Pain with Normal Clitoral Examination

• Pelvic pain is reported by 72% of transgender men after starting testosterone, most commonly described as cramping in the suprapubic region 2
• Persistent menstruation is strongly associated with pelvic pain in transgender men on testosterone 2
• Pain with orgasm is also associated with higher odds of pelvic pain after testosterone initiation 2
• Consider pelvic floor physical therapy referral, as androgen sensitivity of pelvic floor musculature may contribute to dysfunction 2

If Vaginal Atrophy Contributing to Symptoms

• Testosterone causes decreased vaginal estrogen and atrophic changes, leading to dryness and discomfort 3
• Over 60% of transgender men experience vulvovaginal pain during sexual activity 3
• Vaginal pain during sexual activity is specifically associated with current testosterone use 3
• Consider topical vaginal estrogen (does not interfere with masculinization) or vaginal moisturizers 3

Testosterone Therapy Adjustments

Assess Current Formulation and Monitoring

• Check hematocrit/hemoglobin immediately, as testosterone commonly causes erythrocytosis which can contribute to pelvic discomfort through increased blood viscosity 4, 5
• If hematocrit exceeds 54%, intervention is mandatory: reduce dose, temporarily discontinue, or perform therapeutic phlebotomy 4, 5
• Injectable testosterone has the highest erythrocytosis rate (43.8%) compared to transdermal gel (2.8-17.9%) 4, 5

Consider Formulation Switch

• If using injectable testosterone, switch to transdermal gel preparations which have significantly lower adverse effect rates and allow easier dose titration 4, 5
• Target mid-range testosterone levels (350-600 ng/dL) to minimize adverse effects while maintaining masculinization 5

Medication Review

Trazodone Considerations

• Trazodone is not recommended for erectile dysfunction and has limited efficacy data, with no significant benefit over placebo in controlled trials 1, 6
• If trazodone is being used for depression/sleep, consider whether the benefit outweighs potential contribution to genital symptoms 1, 6
• Discuss with prescribing psychiatrist about alternative antidepressants that do not have alpha2-antagonist effects if genital symptoms persist 1

Follow-Up Protocol

• Reassess at 1-2 months after any intervention to evaluate symptom resolution 4, 5
• If pain persists despite testosterone adjustment, systematic evaluation for pelvic floor dysfunction, persistent menstruation, and vaginal atrophy is warranted 2, 3
• Consider referral to gynecology specialist experienced in transgender care for persistent symptoms 1, 2

Critical Pitfalls to Avoid

• Do not dismiss genital pain as "normal" testosterone effects without thorough evaluation, as 72% of transgender men report pelvic pain requiring assessment 2
• Do not delay evaluation if priapism-like symptoms are present – tissue damage can occur rapidly 1
• Do not perform genital examination without explicit consent and trauma-informed approach, as this can cause psychological harm and erode trust 1
• Do not continue current testosterone regimen without checking hematocrit if any systemic symptoms are present 4, 5