Gynecologic function and dysfunction in transmasculine and gender-diverse individuals using testosterone therapy: a systematic review.

Abstract

To systematically review the current literature on gynecologic function and dysfunction in transmasculine and gender-diverse individuals in the context of testosterone therapy, with a focus on menstrual suppression, contraceptive needs, pelvic pain, vulvovaginal changes, and sexual health. PubMed, Embase, and Web of Science databases were searched through September 2025 using search terms related to transmasculine individuals, assigned female at birth, reproductive organs, and testosterone and gender-affirming hormone therapy. No restrictions on publication year were applied. Studies were included if they reported on the impact of exogenous testosterone on gynecologic or sexual (dys)function and contraceptive use and choices, in transmasculine and gender-diverse individuals. Only original human research studies were eligible. Studies focusing on fertility, reproductive outcomes, malignancy, histology, animal models, or individuals with differences of sex development were excluded. All included studies were critically appraised using Joanna Briggs Institute quality assessment tools, and findings were synthesized narratively. Fifty-seven studies were included. Testosterone was generally effective in achieving menstrual suppression, although breakthrough bleeding and ovulatory activity occurred in a substantial proportion of individuals. Contraceptive needs were frequently unmet, partly due to misinformation and provider-related barriers. Pelvic pain was commonly reported, with varied etiologies. While testosterone often increased sexual desire, dyspareunia and genital discomfort were frequently described. Vaginal microbiome alterations and epithelial changes were observed, although their clinical implications remain unclear. Testosterone-based gender-affirming hormone therapy has diverse effects on gynecologic function in transmasculine and gender-diverse individuals, including both physiologically expected as well as underexplored effects. Clinicians should adopt an individualized and affirming approach to care, while further research is needed to understand long-term outcomes, improve assessment tools, and close gaps in inclusive gynecologic healthcare.