What is the first‑line imaging modality for a 24‑year‑old transgender man presenting with abdominal or pelvic cramping to evaluate for ovarian cysts?

First-Line Imaging for Ovarian Cyst Evaluation in Transgender Men

Combined transabdominal and transvaginal ultrasound is the first-line imaging modality for evaluating suspected ovarian cysts in a 24-year-old transgender man with pelvic cramping. 1

Recommended Imaging Approach

Perform both transabdominal and transvaginal ultrasound together as the standard initial evaluation. 1 This combined approach provides:

• Transabdominal component offers a larger field of view to visualize adnexa positioned high in the pelvis, assess free pelvic fluid, and evaluate overall pelvic architecture 2, 1
• Transvaginal component provides superior spatial and contrast resolution for detailed evaluation of ovarian structures, with high-frequency probe proximity minimizing interference from bowel gas and adipose tissue 2, 3
• Color Doppler assessment should be performed simultaneously as a standard component, with spectral Doppler added when indicated 2, 1

Diagnostic Performance

The combined ultrasound approach demonstrates excellent diagnostic capabilities for common ovarian pathology:

• Overall sensitivity of 78.4% for ovarian torsion, endometriotic cysts, hemorrhagic cysts, tubo-ovarian abscess, and dermoid cysts 1
• Abnormal or absent ovarian venous flow on Doppler has 100% sensitivity and 97% specificity for ovarian torsion 1, 4
• Simple ovarian cysts are readily identified and characterized 2, 5

When Transvaginal Ultrasound May Not Be Feasible

If transvaginal ultrasound cannot be performed, transabdominal-only ultrasound is acceptable in specific circumstances 1:

• Patient discomfort or inability to tolerate transvaginal approach
• Post-treatment vaginal stenosis or fibrosis (relevant consideration in some transgender men on testosterone)
• Large fibroids or surgical changes limiting transvaginal visualization

However, recognize that transabdominal-only approach sacrifices the superior resolution needed to detect subtle ovarian and tubal pathology 1.

Critical Pitfalls to Avoid

• Never order transvaginal ultrasound alone as this may miss high-lying adnexal pathology and free fluid critical to diagnosis 1
• Do not skip Doppler evaluation, which is essential for assessing vascular abnormalities and distinguishing between different pathologies 1, 3
• Avoid ordering transabdominal ultrasound alone unless transvaginal is truly contraindicated, as you will sacrifice diagnostic accuracy 1

Next Steps if Ultrasound is Nondiagnostic

If the combined ultrasound examination is nondiagnostic or equivocal, proceed to CT abdomen and pelvis with IV contrast. 1 CT demonstrated 89% sensitivity versus 70% for ultrasound in adults with abdominopelvic pain when the differential diagnosis was broad 1. CT is particularly useful when:

• Clinical presentation is nonspecific with broad differential diagnosis including non-gynecologic etiologies 2
• There is concern for complications such as ovarian torsion with equivocal ultrasound findings 2, 4
• MRI pelvis may be considered as a problem-solving examination if both ultrasound and CT are inconclusive, offering 80-85% sensitivity for ovarian torsion and 96% sensitivity for tubo-ovarian malignancy 2, 4

Special Considerations for Transgender Men

While the evidence does not specifically address transgender men, the same anatomical structures require evaluation regardless of gender identity. Testosterone therapy does not eliminate ovarian pathology risk, and standard gynecologic imaging protocols apply 5.