Can chronic testosterone use cause body aches in individuals?

Chronic Testosterone Use and Body Aches

Chronic testosterone use can cause body aches, particularly pelvic and musculoskeletal pain, though the relationship is complex and varies by patient population.

Evidence for Testosterone-Associated Pain

In Transgender Populations

The most robust evidence demonstrates that testosterone therapy frequently causes new-onset abdominopelvic pain in trans-masculine individuals:

• 72.2% of trans-masculine persons on testosterone reported experiencing pelvic pain following initiation of therapy, with pain typically described as cramping and localized to the suprapubic region 1
• The median interval from testosterone initiation to pain onset was 1 year (range: 1 month to 20 years), indicating both early and delayed presentations 2
• Pain was most commonly intermittent (79.5%), cramping in nature (75.6%), and suprapubic in location (78.7%) 2
• Those with intact uterus and ovaries were 9.50 times more likely to experience suprapubic pain compared to other abdominopelvic regions 2

Predictive Factors for Pain Development

Specific clinical factors increase the likelihood of testosterone-associated pain:

• Persistent menstruation after testosterone initiation is strongly associated with higher odds of pelvic pain 1
• Current or previous history of post-traumatic stress disorder increases pain risk 1
• Experiences of pain with orgasm are associated with higher odds of pelvic pain 1
• Notably, no association was found with genital dryness, intrauterine device use, previous pregnancy, penetrative sexual activities, endometriosis, vulvodynia, vaginismus, depression, anxiety, or obesity 1

Pain Resolution

All 28 respondents who achieved pain resolution identified hysterectomy as the effective treatment, suggesting a reproductive organ etiology for testosterone-associated pelvic pain 2

Contrasting Evidence: Testosterone as Analgesic

Paradoxically, testosterone can also improve certain pain conditions:

• In female-to-male transsexuals, 61.5% reported pain, but in those with pre-existing pain before testosterone, 6 of 11 subjects experienced improvement after testosterone administration 3
• Testosterone therapy has been proposed as a treatment for central sensitization in chronic pain conditions like fibromyalgia, with low testosterone levels linked to inflamed nociceptive nervous systems 4
• Testosterone may play a beneficial, protective role against inflammation and pain through modulation of lipid metabolism and inflammatory mediators 5

Musculoskeletal Pain

Male-to-female transsexuals receiving estrogens and anti-androgens (testosterone suppression) reported increased musculoskeletal pain:

• 29.8% of male-to-female transsexuals under hormone treatment reported painful conditions, with 11 subjects developing pain only after beginning hormone treatment 3
• Pain consisted mainly of headaches, breast pain, and musculoskeletal pain 3

Clinical Approach to Testosterone-Associated Body Aches

Initial Assessment

When evaluating body aches in patients on chronic testosterone therapy, prioritize:

• Location specificity: Suprapubic/pelvic pain suggests reproductive organ involvement, particularly if uterus and ovaries are intact 2, 1
• Timing: Document interval from testosterone initiation to pain onset (median 1 year but highly variable) 2
• Pain characteristics: Assess for cramping quality and intermittent pattern typical of testosterone-associated pain 2
• Menstrual status: Persistent menstruation is a key risk factor for pain development 1
• Psychiatric comorbidities: Screen for PTSD, which increases pain risk 1
• Sexual function: Inquire about pain with orgasm as a predictor 1

Management Algorithm

For pelvic/suprapubic pain in trans-masculine patients with intact reproductive organs:

1. Consider hysterectomy as definitive treatment if pain is severe and refractory, as this was universally effective in achieving pain resolution 2
2. Address persistent menstruation through menstrual suppression strategies 1
3. Evaluate for pelvic floor muscle dysfunction given the androgen sensitivity of pelvic floor musculature 1

For musculoskeletal pain:

• Recognize that this may represent a direct effect of testosterone on pain pathways 3
• Consider that pain improvement may occur over time as hormonal equilibrium is established 3

Critical Pitfall to Avoid

Do not discontinue testosterone without thorough evaluation, as this may worsen gender dysphoria and overall quality of life 6. The Mayo Clinic emphasizes that gender-affirming hormone therapy should not be stopped reflexively in response to pain complaints 6.

Additional Considerations

Testosterone therapy carries other risks that may indirectly contribute to body aches:

• Sleep apnea exacerbation may occur, particularly in patients with identifiable risk factors, which can worsen overall pain perception 7, 8
• Erythrocytosis occurs in 3-18% with transdermal formulations and up to 44% with injections, potentially causing systemic symptoms 8