Rapid systematic literature review of endometriosis in transgender, gender diverse and non-binary individuals: Barriers, treatment, and lived experiences

Abstract

Introduction

It is anticipated that endometriosis, a chronic inflammatory condition affecting around 10% of people assigned female at birth (AFAB), is significantly underreported within transgender, gender diverse, and non-binary (TGDN) people due to specific barriers this population experiences in gaining access to supportive, gender-affirming healthcare. This rapid systematic literature review (RSLR) aims to explore existing research on the management, treatment, and lived experiences of endometriosis and associated pelvic pain among TGDN individuals AFAB, to ultimately inform enhanced future healthcare.

Methods

Conducted in accordance with World Health Organization guidelines, multiple databases were searched with a search strategy developed using Boolean operators. Studies were assessed against predetermined inclusion/exclusion criteria, with included studies published in English, with no date/geographical limitations applied and relevant to the research question. Drawing upon Braun and Clarke, collected data were analyzed using a thematic analysis approach.

Results

Twelve studies were identified, with findings highlighting significant healthcare barriers for TGDN people AFAB with endometriosis, including delayed diagnosis, limited provider knowledge, and gender dysphoria linked to gynecological care. Studies highlighted a lack of awareness among healthcare providers, contributing to inadequate support.

Conclusions

This RSLR provides timely insights into current treatment approaches, barriers to care, and potential strategies to improve gender-affirming and holistic healthcare for TGDN people AFAB experiencing endometriosis and related pelvic pain. Addressing systemic barriers through further research and future interventions may inform improved diagnosis, treatment, and access to care, creating a more supportive and gender-affirming healthcare environment for this underserved population.

Introduction

Endometriosis, a chronic inflammatory condition, is recognized for its debilitating impacts on daily life, including reproductive and sexual health (Fourquet et al., 2010; Huang et al., 2023). This condition is characterized by the presence of endometrial tissue outside the uterus, resulting in pain, inflammation, potential infertility, and organ damage (Agarwal et al., 2019). Endometriosis is typically diagnosed through clinical presentation, imagery, and laparoscopic confirmation and may be investigated during routine pelvic examinations and general health management. Common symptoms include dysmenorrhea (severely painful menstruation), dyspareunia (painful intercourse), and infertility (Huang et al., 2023). Prevalence data suggest endometriosis affects approximately 10% of individuals assigned female at birth (AFAB; Vallée et al., 2023), inclusive of transgender, gender diverse, and non-binary (TGDN) people. However, endometriosis and other pelvic pain is often underreported within these populations due to stigma and systemic barriers regarding accessing gender affirming healthcare for physical and mental health concerns (Eder & Roomaney, 2025; Phillips et al., 2024; Swan et al., 2023). Despite the substantial health burden of endometriosis (Huang et al., 2023), the current medical framework primarily targets cisgender women, often leaving TGDN individuals AFAB with grossly unmet healthcare needs which may lead to heightened gender dysphoria (Ellis et al., 2025).

Transgender, gender diverse, and non-binary people face additional challenges in accessing timely and appropriate support and management for endometriosis (Eder & Roomaney, 2024). Barriers include systemic discrimination, lack of provider knowledge regarding TGDN health and bodily matters, and healthcare services that fail to provide inclusivity toward gender diversity (Franks et al., 2023; Giacomozzi et al., 2024; Windt et al., 2024). Gynecological care is often structured around the assumption that only cisgender women AFAB experience gynecological conditions such as endometriosis, resulting in TGDN individuals feeling excluded or uncomfortable accessing treatment and support (Giaco­mozzi et al., 2024). Gender dysphoria can also be exacerbated by pelvic-related symptoms and lack of access to gender-affirming healthcare (Ellis et al., 2025). Existing gynecological treatment approaches such as hormonal therapies or surgical interventions may not suitably nor specifically meet the needs of TGDN individuals, leading to gaps in effective and affirming healthcare. Conse­quently, there is evidence to suggest many TGDN people experience significant delays in diagnosis and treatment and/or continue to self-manage symptoms and avoid medical intervention (Ellis et al., 2025; Giacomozzi et al., 2024), contributing to adverse and potentially preventable health outcomes.

This rapid systematic literature review (RSLR) aims to explore the existing body of literature investigating the management, treatment, and lived experiences of endometriosis and associated pelvic pain among TGDN individuals AFAB (Eder & Roomaney, 2024; Giacomozzi et al., 2024). It is anticipated that endometriosis in TGDN populations often goes undiagnosed or inadequately treated, exacerbating both physical issues and emotional distress (Moussaoui et al., 2024). While the WPATH Standards of Care, Version 8 acknowledges the importance of gender-affirming care and recognizes reproductive health concerns such as endometriosis within TGDN populations, significant gaps remain in clinical guidance and research addressing their specific healthcare needs (Coleman et al., 2022). Through an RSLR, this paper seeks to illuminate healthcare challenges and explore potential treatment options for TGDN individuals AFAB with endometriosis, thereby working toward developing evidence-based recommendations to enhance clinical practice and healthcare services for this underserved key priority group.

Methods

A RSLR was conducted to evaluate and analyze existing literature surrounding endometriosis and associated pelvic pain experiences among TGDN individuals’ AFAB. This review aimed to explore evidence regarding existing treatment modalities and ascertain barriers to accessing appropriate healthcare and support. The review began with a clearly defined research question developed through a PICO approach, a commonly used approach in evidence-based healthcare research which seeks to define the Population, Intervention, Comparison, and Outcomes relevant to the research aim (McGill, n.d.). Inclusion and exclusion criteria were systematically developed and refined through a critical appraisal process to determine study eligibility. A search was conducted on December 12, 2024, across four databases (Web of Science, PubMed, Scopus, and ProQuest) and results were presented following PRISMA’s three-stage process, which can be seen in Figure 1 (Page et al., 2021). All article titles and abstracts were screened, and suitable articles underwent a critical appraisal following The Joanna Briggs Institute (JBI) Critical Appraisal Tool (Joanna, 2020).

Figure 1.

Prisma flowchart.

The authors of this article comprise of an interdisciplinary research team with expertise in menstrual cycle physiology, sexual health, gender studies, healthcare, and clinical/health psychology. As researchers and professionals engaged in trans health, rights and advocacy, as well as menstrual cycle-related research, we acknowledge the systemic barriers that TGDN people experience in accessing competent, gender-affirming healthcare. Our research team includes individuals with diverse lived experiences related to gender, including non-binary and cisgender experiences, and professional/clinical backgrounds working with diverse individuals within sexual and reproductive health. This informs our critical approach to examining the gaps in care and treatment for TGDN individuals with endometriosis and pelvic pain. We recognize the urgent need for improved healthcare practices and seek to contribute to the growing body of literature advocating for better, evidence-based, and more inclusive, equitable, and affirming medical care.

Review question

The following research question was developed to drive this RSLR: “What does existing literature reveal about the management, treatment, and lived experiences of endometriosis and associated pelvic pain among transgender, gender diverse, and non-binary people?”.

Inclusion/exclusion criteria

No specific date or geographical limits were placed on the search, allowing for a broad and inclusive exploration of available literature. However, it should be noted that as an emerging topic of research, most studies investigating endometriosis in TGDN populations have been published within the past five years. The following inclusion criteria were applied: (1) peer-reviewed studies reporting on empirical data that investigates TGDN individuals experiencing endometriosis and/or chronic pelvic pain which is atypical of expected menstrual discomfort; (2) studies published in English; and (3) studies with full text available. The following exclusion criteria were implemented: (1) studies that do not provide full text access; (2) research focusing solely on cisgender individuals without evidence of TGDN-specific experiences: and (3) studies that do not adequately describe or report the management or treatment of chronic pelvic pain and/or endometriosis, therefore failing to meet the specific requirements of the target population. There were no geographical or date limitations applied.

Search strategy

A preliminary database search was conducted across a range of electronic databases including Web of Science, PubMed, Scopus, and ProQuest, and the search string was refined accordingly. Following this, inclusion and exclusion criteria were developed to filter through data and ensure that the literature was peer-reviewed, had full text options available online, were published in English, and focused on TGDN individuals AFAB with chronic and/or clinically significant pelvic pain and/or endometriosis

The search string was developed with input from members of the research team who have expertise in relevant areas, including TGDN health, endometriosis, sexual health, sociology and psychology, and importantly, with people part of the TGDN community. It was intentionally designed to be broad in scope to ensure comprehensive capture of pertinent literature across diverse disciplines and sources. To avoid inadvertently excluding pertinent studies, no restrictions were placed on the presence of an official medical diagnosis of endometriosis or duration of pelvic pain. The search strategy was designed to capture a wide spectrum of experiences including early or undiagnosed presentations, in addition to diagnosed cases, whilst ensuring relevance to the research objectives. The PICO approach adopted in the study can be seen in Table 1. The primary objective for the search was to collate evidence by identifying existing themes and begin to explore the complexities for TGDN individuals AFAB when gaining access to gender-affirming endometriosis care and identify gaps in existing research to inform future research.

Table 1.

PICO protocol.

Population	Transgender and gender diverse individuals who are assigned female at birth.
Intervention	Management and treatment of endometriosis in TGDN individuals.
Condition	Endometriosis and associated menstrual pelvic pain which is deemed chronic or beyond the level of expected menstrual pain.
Outcome	Drawing from the systematic literature review, the project will formulate evidence-based recommendations for clinicians and allied health professionals.

The search terms were selected in conjunction with the research team. The search terms used for the review were: (“endometriosis” OR “pelvic pain” OR “menstrual pain” OR “dysmenorrhea”) AND (transg* OR “gender diverse” OR “genderqueer” OR “gender nonbinary” OR “transgender” OR “nonbinary”) AND (“treatment” OR “intervention” OR “experience” OR “healthcare”). These terms were combined to develop a Boolean search string; truncation and wildcards were also used to capture variations in terminology. The search string was then put into a systematic review tool developed by Bond University (Clark et al., 2018), “Polyglot,” and the relevant search strings were applied to the four databases. The results from this preliminary search can be viewed in Figure 2.

Figure 2.

Search string summary.

Screening

All articles were screened using PRISMA’s three-stage process, which can be seen in Figure 1 (Page et al., 2021). The first stage focused on identifying and removing duplicate articles. The second stage involved screening titles and abstracts, while the final stage consisted of a full-text review (Page et al., 2021). During the initial screening, all results were imported into the Systematic Review Accelerator’s deduplication tool (Clark et al., 2018). Following the screening process, results were imported into RAYANN with duplicates removed (Ouzzani et al., 2016). RAYANN is a web-based tool for systematic review screening that facilitates collaboration. The use of RAYANN streamlined the screening process to enhance efficiency and collaboration among researchers by allowing multiple reviewers to work simultaneously, apply blind screening, and resolve conflicts efficiently (Ouzzani et al., 2016). Research has shown that RAYANN’s collaborative functionalities assist the inclusion process and minimize bias through the blind review capability, making it a valuable tool for RSLR (Ouzzani et al., 2016). Three independent reviewers (MD, BL, DB) screened titles and abstracts, applying the established inclusion and exclusion criteria. Full text screening was conducted to identify potentially eligible studies, applying a Joanna Briggs Institution screening approach to determine article eligibility (Joanna Briggs Institute, 2020).

Data synthesis and analysis

A narrative synthesis approach was applied for data analysis to systematically summarize and interpret the findings from the included studies. This method was chosen to provide a structured and transparent means of integrating diverse types of evidence, particularly as a meta-analysis was not feasible due to the quantity and heterogenous nature of the data across included studies.

Key characteristics of the studies, including study design, geographical location, and key findings, were extracted and synthesized in a comprehensive table (Table 2). This table facilitated the identification of patterns, similarities, and discrepancies across the studies, drawing out key data relevant to the research objectives. Eligible articles were then synthesized using Braun and Clarke (2023) thematic analysis, which emphasizes a reflexive process of identifying, analyzing, and reporting patterns within the data. One member of the research team (MD) initially coded the data and two other authors (BL, DB) subsequently reviewed coded data. Codes were then discussed and refined collaboratively through a reflexive thematic analysis process following Braun and Clarke (2023) guidelines. While this review drew on Braun and Clare’s (2023) reflective thematic analysis framework to guide the synthesis of findings, it is important to acknowledge that the principles were applied with a degree of flexibility. As such, thematic analysis was used primarily as a tool for organizing and interpreting patterns across studies, rather than for producing a fully elaborated reflexive thematic analysis due to constraints of available data. Therefore, Braun and Clarke (2023) principles served as a general framework, guiding the analysis. The findings were reported developing the following five themes: (1) Navigating Diagnostic Delays in Cisnormative Systems; (2) Systemic barriers and treatment accessibility; (3) Clinical gaps in provider knowledge; (4) Uncertainty in the role of testosterone use in symptom treatment and exacerbation; and (5) Healthcare experiences and discrimination. This allowed for gaps and limitations to be identified and guide recommendations for future research.

Table 2.

Characteristics of results (N = 12).

Citation	Country of Origin and language	Methods Participants and Quality Appraisal	Aim of study	Key Findings
Eder and Roomaney (2024) Transgender and non-binary people’s perception of their healthcare in relation to endometriosis, International Journal of Transgender Health, 25:4, 911-925, DOIhttps://doi.org/10.1080/26895269.2023.2286268	South Africa- Participants global (English)	Qualitative 198 participants 8/10	The study explores the experiences of transgender and nonbinary individuals with endometriosis in healthcare settings, focusing on medical gaslighting, misgendering, and discrimination. Participants reported frequent symptom dismissal, delayed diagnoses, and a lack of understanding from healthcare providers. Misgendering and non-affirming behaviors compounded feelings of invalidation, leading many to avoid or delay care.	Participants frequently experienced healthcare providers dismissing their pain and symptoms, leading to delayed diagnoses and inadequate care for endometriosis. This often presented as dismissing symptoms (which is also an issue amongst cisgender individuals). Cisnormative diagnostic framework meant that medical professionals often overlooked symptoms in TGD patients and not being screened in routine assessments leading to delayed diagnosis.
Ellis, K., Armor, W., & Wood, R. (2024). "I never see anyone like myself represented in discussions about endometriosis": Priorities of LGBTQIA+ endometriosis patients in New Zealand. Culture, Health & Sexuality. https://doi.org/10.1080/13691058.2024.2394650	New Zealand (English)	Qualitative 28 participants 8/10	This study investigates the experiences of LGBTQIA+ individuals with endometriosis in New Zealand, highlighting diagnostic delays, medical assumptions, and the impact of cis- and heteronormativity on care. Participants reported that medical encounters often focused on penetration and pregnancy, overlooking diverse identities and relationships. Endometriosis exacerbated gender dysphoria for some, influenced access to gender-affirming treatments, and contributed to feelings of dismissal and loss of bodily autonomy.	Participants reported that medical encounters often centered on issues related to reproductive health as opposed to menstruation. The healthcare systems failure to acknowledge and proactively recognize that gender diverse individual also suffered from atypical menstrual pain and discomfort created additional barriers to support and intervention. As a result, some participants reported feeling further alienated and reluctant to seek support from medical professionals.
Shim, J. Y., Laufer, M. R., & Grimstad, F. W. (2020). Dysmenorrhea and Endometriosis in Transgender Adolescents. Journal of pediatric and adolescent gynecology, 33(5), 524–528. https://doi.org/10.1016/j.jpag.2020.06.001	Boston, USA (English)	A retrospective review 35 transmasculine adolescents 7/10	This study investigated the impact of dysmenorrhea and endometriosis among TGD adolescents. However, endometriosis was an important secondary focus, as it was identified during the evaluation of dysmenorrhea. The findings on endometriosis were significant but incidental in the sense that only a subset (7 out of 35 participants) underwent laparoscopic evaluation, and all were confirmed to have endometriosis.	Among 35 transmasculine adolescents with a mean age of 14.9 years, 82.9% (29 individuals) were diagnosed with dysmenorrhea after initiating social transition. The study highlighted the diagnostic challenges faced by transgender adolescents, emphasizing the need for healthcare providers to consider endometriosis in this population. Participants reported that dysmenorrhea and endometriosis significantly affected their daily activities and overall quality of life.
Eder, C., & Roomaney, R. (2024). Transgender and non-binary people’s experience of endometriosis. Journal of Health Psychology, 0(0). https://doi.org/10.1177/13591053241266249	South Africa- Participants global (English)	Qualitative phenomenological study 11 Participants 8/10	This study explored the experiences of 11 transgender and non-binary individuals with endometriosis. There was a very small sample number so this must be noted when analyzing the results. The study used phenomenological methods, they conducted multiple interviews to understand participants’ challenges, healthcare interactions, and the impact of endometriosis on their lives	The study found that transgender and non-binary individuals with endometriosis often faced delayed diagnoses, misgendering, and discrimination from healthcare providers. Many participants described a sense of "unhomeliness," feeling disconnected from their bodies and healthcare environments due to these challenges. The lack of inclusive healthcare practices exacerbated these feelings. Participants also reported emotional distress stemming from a lack of recognition and understanding of their unique needs. The study highlights the importance of gender-affirming care and calls for more research into the experiences of gender diverse people with endometriosis to improve healthcare outcomes and reduce feelings of exclusion.
Grimstad, F. W., Boskey, E. R., Clark, R. S., & Ferrando, C. A. (2023). Prevalence of pelvic pain in transgender individuals on testosterone. The journal of sexual medicine, 20(12), 1459–1465. https://doi.org/10.1093/jsxmed/qdad135	USA (English)	Observational 280 participants 9/11	The study investigated the prevalence of endometriosis-related pain among transgender men and non-binary individuals assigned female at birth undergoing testosterone therapy.	A significant proportion of transgender men and non-binary individuals on testosterone reported experiencing pelvic pain. The study explored whether this pain could be related to endometriosis, though definitive conclusions were not reached. Findings are based on self-reported data, which may be influenced by recall bias and variability in pain perception. Some participants developed pelvic pain after starting testosterone therapy, raising questions about hormonal influences.
Moussaoui, D., Elder, C. V., O’Connell, M. A., Mclean, A., Grover, S. R., & Pang, K. C. (2022). Pelvic pain in transmasculine adolescents receiving testosterone therapy. International Journal of Transgender Health, 25(1), 10–18. https://doi.org/10.1080/26895269.2022.2147118	Melbourne, Australia (English)	A retrospective cohort study 158 trans adolescents 9/11	This study investigates pelvic pain in trans adolescents on testosterone. The research aimed to examine the prevalence and characteristics of pelvic pain in this group as well as any potential association with testosterone use.	Among 158 trans adolescents receiving testosterone therapy, 23.4% reported experiencing pelvic pain, often described as cramps or like period pain. This pain typically began around 1.6 months after starting testosterone. Those who received additional menstrual suppression were more likely to report pelvic pain. However, the study did not explore underlying causes like endometriosis or other gynecological conditions. As a retrospective cohort study, its findings are limited by potential recall bias, and the lack of longitudinal data prevents the establishment of causality.
Moussaoui, D., Hoq, M., Elder, C. V., Grover, S. R., O’Connell, M. A., & Pang, K. C. (2024). Is there an association between pelvic pain and gender-affirming testosterone therapy in trans masculine adolescents? An exploratory cross-sectional study. International Journal of Transgender Health, 1–11. https://doi.org/10.1080/26895269.2024.2392685	Global (English)	Exploratory cross-sectional study 79 participants 6/8	This exploratory study examined pelvic pain in trans adolescents assigned female at birth, focusing on the relationship between testosterone use and pelvic pain. It found a lower prevalence of pain in testosterone users compared to non-users. Treatment options included paracetamol, heat therapy, NSAIDs, pelvic floor physiotherapy, and Buscopan. The study included 79 participants and involved an exploratory study seeking to investigate pain prevalence and causative factors.	The study found that 77.5% of participants reported pelvic pain in the past six months, with a lower prevalence in those using testosterone (69.4%) compared to non-users (90%). Treatment options tried included paracetamol (81%), heat therapy (64.6%), NSAIDs (60.8%), pelvic floor physiotherapy (5.1%), and Buscopan (2.5%). Among treatments, heat therapy and NSAIDs were the most effective, while Buscopan had a 100% effectiveness rate for those who tried it. The study suggests testosterone may reduce pelvic pain by inhibiting menstruation, offering anti-inflammatory effects, and alleviating gender dysphoria.
Zwickl, S., Burchill, L., Wong, A. F. Q., Leemaqz, S. Y., Cook, T., Angus, L. M., Eshin, K., Elder, C. V., Grover, S. R., Zajac, J. D., & Cheung, A. S. (2023). Pelvic Pain in Transgender People Using Testosterone Therapy. LGBT health, 10(3), 179–190. https://doi.org/10.1089/lgbt.2022.0187	Australia (English)	Exploratory cross-sectional study 486 participants 7/8	The focus of this study is the implications of testosterone use for gender affirmation therefore endometriosis is secondary to this. The research aimed to identify factors associated with the onset of pelvic pain following the initiation of testosterone therapy.	Out of 486 participants, 351 (72.2%) reported experiencing pelvic pain after starting testosterone therapy. This pain was most commonly described as cramping (72.6%) and aching (58.1%), primarily located in the suprapubic (hypogastric) region (87.2%) The lack of association with endometriosis suggests that while endometriosis can cause pelvic pain, it may not be a primary factor in this context.
Tordoff, D. M., Lunn, M. R., Flentje, A., Atashroo, D., Chen, B., Dastur, Z., Lubensky, M. E., Capriotti, M., & Obedin-Maliver, J. (2024). Chronic pelvic pain among transgender men and gender diverse adults assigned female at birth. Andrology, 10.1111/andr.13703. Advance online publication. https://doi.org/10.1111/andr.13703	USA (English)	Cross sectional longitudinal study 2,579 Participants 7/8	The study aimed to explore the prevalence, correlates, and impact of Chronic Pelvic Pain (CPP) in this population. It included 2,579 participants and investigated factors such as testosterone therapy and the presence of other health conditions. The study’s focus was to better understand how CPP affects transgender and gender diverse individuals and to examine potential associations with testosterone use and other health factors, with an emphasis on the unique experiences of this group.	The study by Tordoff et al. (2025) found that 18% of transgender men and gender diverse individuals assigned female at birth reported chronic pelvic pain (CPP). Common associated conditions included irritable bowel syndrome, polycystic ovary syndrome, uterine fibroids, and mental health issues like PTSD and depression. Testosterone use was linked to a 21% lower prevalence of CPP. In longitudinal analysis, 19% of participants developed new-onset CPP after starting testosterone therapy, while 56% had prior pain.
Schwartz, B. I., Bear, B., Short, V. L., & Kazak, A. E. (2023). Outcomes of menstrual management use in transgender and gender diverse adolescents. Obstetrics & Gynecology, 141(4), 748–755. https://doi.org/10.1097/AOG.0000000000005123	USA (English)	Retrospective chart review 101 participants 6/8	This retrospective chart review of 101 TGD individuals assessed the access and type of menstrual management those patients received.	This study found that combining oral contraceptives and norethindrone acetate effectively achieved amenorrhea and improved overall mood with minimal side effects. 90% of participants used this combination. Participants reported improved mood and reduced gender dysphoria related to menstruation. Some participants did experience ‘breakthrough bleeding’ though this was not a major factor of discontinuation of treatment or management.
Scatoni, A., Roberts, Z., Boskey, E. R., Staffa, S., Roden, R. C., Redwood, E., & Grimstad, F. (2024). Danazol’s use for menstrual suppression in transgender individuals: A retrospective multi-site cohort study. Women’s Health, 20, 1–9. https://doi.org/10.1177/17455057241265081	USA (English)	Retrospective Cohort Study 45 participants 7/11	This study analyzed the use of danazol for menstrual suppression, particularly among transgender patients. Among 46 patients, 84.9% of transgender individuals achieved amenorrhea within three months at a median dose of 400 mg daily. Danazol improved or resolved endometriosis-related symptoms in 100% of transgender patients and 50% of non-transgender patients. It was also effective in alleviating dysmenorrhea and pelvic pain, with transgender patients experiencing greater relief compared to non-transgender counterparts	The research found that most participants experienced successful menstrual suppression with danazol and continued its use at follow-up. Additionally, nearly all individuals with gender dysphoria reported improvement with danazol use. The findings suggest that danazol not only induces amenorrhea but also provides desired androgenic effects, thereby improving gender dysphoria, pelvic pain, and dysmenorrhea.
Grimstad, F. W., Boskey, E., & Grey, M. (2020). New-Onset Abdominopelvic Pain After Initiation of Testosterone Therapy Among Trans-Masculine Persons: A Community-Based Exploratory Survey. LGBT health, 7(5), 248–253. https://doi.org/10.1089/lgbt.2019.0258	USA (English)	Quantitative Cross Sectional Study 127 Participants 6/8	This study conducted a community-based survey to explore new-onset abdominopelvic pain among trans-masculine individuals initiating testosterone therapy. The study included 127 participants and aimed to characterize the nature and onset of this pain, providing preliminary insights into its prevalence and potential causes.	Study found that 69.4% of participants experienced new-onset abdominopelvic pain after starting testosterone therapy. The pain was commonly intermittent, cramping, and localized to the suprapubic region. Pain onset occurred on average one year after starting testosterone. Participants who retained a uterus and ovaries were more likely to experience suprapubic pain. Among those seeking treatment, hysterectomy was reported as an effective solution for resolving the pain in all 28 participants who underwent the procedure.

Quality appraisal

The quality of the studies was assessed using The Joanna Briggs Institute (JBI) Critical Appraisal Tool (Joanna Briggs Institute, 2020). This tool provides a comprehensive evaluation of the methodological quality and reliability of RSLRs (Joanna Briggs Institute, 2020), allowing for an explicit consideration of the risk of bias in the included studies while also permitting all eligible and relevant studies to be included in the final review and synthesis. To ensure the process was rigorous, the quality appraisal was undertaken by three independent reviewers (MD, BL, DB) in a blind review, where any discrepancies were discussed, reviewed, and agreed upon through consensus. The agreed quality appraisal review scores are outlined in the results section (see Table 2).

Results

Table 2 provides a summary of the characteristics of the data. This RSLR analyzed 12 studies (Eder & Roomaney, 2024, 2025; Ellis et al., 2025; Grimstad et al., 2020, 2023; Moussaoui et al., 2024, 2024; Scatoni et al., 2024; Schwartz et al., 2023; Shim et al., 2020; Tordoff et al., 2025; Zwickl et al., 2023) exploring endometriosis in TGDN individuals, including access to support, treatment and healthcare. The included studies examined various aspects of diagnosis, treatment accessibility, provider knowledge, testosterone use, and the impact of healthcare experiences on the wellbeing of TGDN individuals with endometriosis. The included studies examined various aspects of diagnosis, treatment accessibility, provider knowledge, testosterone use and implications, and the impact of healthcare experiences on the wellbeing of TGDN individuals with endometriosis. The studies in this review were published between 2020 and 2024, highlighting this as an emerging topic within healthcare research. Specifically, the studies were distributed with one study published in 2020, two in 2022, four in 2023, and five studies published in 2024. This suggests a significant increase in research in recent years, highlighting that endometriosis in TGDN individuals AFAB is a growing area of interest. The studies were conducted across multiple regions, including the USA, New Zealand, Australia, and South Africa, with global samples. All studies originated from English-speaking countries, with all studies published in English. The geographic diversity of these studies provides valuable insights into the healthcare barriers faced by TGDN individuals AFAB with endometriosis across the world.

Methodologically, five studies were qualitative in design, exploring the lived experiences and healthcare perceptions of transgender and non-binary individuals with endometriosis (Eder & Roomaney, 2024, 2025; Ellis et al., 2025; Grimstad et al., 2020; Shim et al., 2020). Four studies utilized cross-sectional designs, including community surveys and exploratory analysis of pelvic pain prevalence related to testosterone use (Grimstad et al., 2020; Moussaoui et al., 2024; Tordoff et al., 2025; Zwickl et al., 2023). Three retrospective cohort or chart review studies examined menstrual management strategies and their outcomes among TGDN populations (Moussaoui et al., 2024; Scatoni et al., 2024; Schwartz et al., 2023). These diverse methodologies provided a comprehensive perspective on both the subjective and clinical dimensions of endometriosis and pelvic pain in TGDN individuals (see Table 2).

Regarding quality assessment, the majority of the studies were of high-quality, most scored 70% or higher on the JBI quality appraisal, indicating strong methodological rigor. Notably, Grimstad et al. (2020) achieved a high score of 9/10, while five other studies; Zwickl et al. (2023), Moussaoui et al. (2024), Eder and Roomaney (2024, 2025) and Ellis et al. (2025) received scores of 8/10. Additional high-quality studies included Moussaoui et al. (2024) and Grimstad et al. (2023), scoring 9/11 and Schwartz et al. (2023) with 6/8. A small number of studies scored modestly, but still above average, such as Shim et al. (2020) and Tordoff et al. (2025) both scoring 7/10 and Scatoni et al. (2024), scoring 7/11. Across these studies, consistent themes were identified highlighting the significant barriers TGDN individuals AFAB face when accessing healthcare and treatment for endometriosis. Overall, the evidence identified the challenges TGDN individuals face within predominantly cisnormative systems, emphasizing the critical need for inclusive, affirming, approaches to diagnosis and treatment to enhance health outcomes and address disparities in this population.

Navigating diagnostic delays in cisnormative systems

Delays in diagnosis were common across multiple studies, largely due to cisnormative diagnostic frameworks and a lack of provider recognition and awareness regarding endometriosis in TGDN individuals (Eder & Roomaney, 2024, 2025; Ellis et al., 2025; Shim et al., 2020; Vallée et al., 2023). Eder and Roomaney (2025) reported that transgender individuals often faced significant diagnostic delays, with a median delay of 12 years, thus exacerbating distress and physical pain. Similarly, Ellis et al. (2025) highlighted how medical practitioners frequently overlooked atypical presentations of menstrual related pain in TGDN individuals AFAB, leading to a lack of timely diagnosis and intervention. Another key factor is the barriers to accessing routine gynecological screening and testing among TGDN individuals AFAB, which contributed to a delay or lack of adequate diagnosis amongst this population group (Vallée et al., 2023). These diagnostic delays were further compounded by systemic barriers to treatment accessibility, including a lack of provider knowledge and gender-affirming care.

Systemic barriers and treatment accessibility

Access to suitable treatment was affected by systemic barriers, including a lack of provider knowledge and awareness. Eder and Roomaney (2025) found that participants often encountered “medical gaslighting” (i.e. the downplaying of symptoms by health professionals; see (Fetters, 2018; (Sebring, 2021) leading to insufficient support physically, emotionally and mentally. Reproductive healthcare assumptions amongst providers significantly hindered access to treatment and pain management (Grimstad et al., 2023). Eder and Roomaney (2024) highlighted the negative impact that medical gaslighting can have on TGDN individuals sharing the lived experience of a participant in their study, stating:

I generally don’t bring it [gender identity] up to medical professionals because there is just a list of other things I need addressed. I feel like having that experience with the first gynecologist who was just gaslighting me every second, that I didn’t want to give doctors another reason to dismiss my pain (p 915).

Furthermore, Moussaoui et al. (2024) noted that pain management/treatment was often self-managed due to inadequate access to gender-affirming healthcare. The authors suggest that this may in part be related to insufficient knowledge or training among clinicians (Moussaoui et al., 2024).

Clinical gaps in provider knowledge

Lack of provider knowledge about endometriosis among TGDN individuals AFAB appears to contribute to underdiagnosis and inadequate care in this population. Shim et al. (2020) highlighted that diagnostic evaluations were underutilized in TGDN patients, with insufficient investigation when compared to cisgendered counterparts. Eder and Roomaney (2024) identified a pattern of healthcare professionals dismissing pelvic pain and symptoms amongst TGDN people AFAB, leading to unnecessary, avoidable and prolonged suffering, thus further widening the gap of access to adequate healthcare. Limited provider knowledge not only delays the diagnosis and treatment of endometriosis in TGDN individuals AFAB but also adds complexity to its management, especially when gender-affirming care, such as testosterone therapy, is involved.

Uncertainty in the role of testosterone use in symptom treatment and exacerbation

The impact that testosterone therapy has on endometriosis remains unclear, with mixed findings across the studies included in this review. Some individuals experienced symptom relief with testosterone administration (Vallée et al., 2023), while others developed new onset pelvic pain (Grimstad et al., 2020; Moussaoui et al., 2024). Grimstad et al. (2023) observed high prevalence of pelvic pain among transgender individuals AFAB on testosterone, although definitive conclusions regarding the link to endometriosis were not possible. Moussaoui et al. (2024) found that 23.4% of TGDN adolescents AFAB on testosterone reported pelvic pain, often emerging after the onset of treatment initiation. The purpose of this review was not explicitly focusing on the potential efficacy of testosterone as an endometriosis treatment; however, these studies have been explored in this review because participants fell within the inclusion criteria for this RSLR. The conflicting findings about the role of testosterone in either exacerbating or mitigating pelvic pain highlight the need for further research investigating the implications of testosterone on the onset, development and management of endometriosis. The ambiguities surrounding the effect of testosterone treatment on endometriosis in TGDN individuals is further intensified by broader challenges in healthcare access where the quality of care and healthcare experience is largely influenced by systemic and interpersonal barriers.

Healthcare experiences and discrimination

The reviewed studies consistently highlighted negative healthcare experiences among TGDN individuals’ AFAB with endometriosis. Practitioners who failed to provide an affirming model of healthcare discouraged individuals from seeking adequate medical care (Eder & Roomaney, 2025). Ellis et al. (2025) reported that participants frequently felt isolated within the healthcare system, largely due to healthcare providers’ focus on the specific needs of TGDN individuals AFAB and using cisgendered language when discussing gynecological issues. The psychosocial impact of endometriosis on TGDN individuals AFAB was evident, with Eder and Roomaney (2025) highlighting that many individuals struggled with an increase in gender dysphoria exacerbated by menstrual symptoms.

The included studies varied in methodology, sample size, and geographic focus, and collectively provide insights into the systemic barriers faced by TGDN individuals AFAB seeking gynecological healthcare. Findings highlight significant barriers to appropriate endometriosis healthcare, including delays in diagnosis, a lack of provider knowledge, and gender dysphoria exacerbated by gynecological care. Several studies reported significant delays in diagnosis due to a lack of awareness among healthcare providers about endometriosis among TGDN individuals (Eder & Roomaney, 2024, Ellis et al., 2025; Eder & Roomaney, 2024, 2025; Shim et al., 2020; Vallée et al., 2023). The review demonstrates the need for more research in this area to enable evidence based, inclusive and affirming healthcare approaches to improve outcomes for TGDN individuals’ AFAB with endometriosis.

Discussion

Endometriosis is a chronic, often debilitating condition (with significant functional impairment) that can affect any individual with a uterus, including TGDN individuals AFAB (Eder & Roomaney, 2025). While existing research predominantly explored the relationship between testosterone use and the implications for endometriosis or related symptoms, with currently unclear results, there remains a significant gap in understanding the broader healthcare experiences and barriers faced by TGDN people AFAB with this condition. Research into how endometriosis is experienced and managed by this group remains sparse, yet studies such as those by Eder and Roomaney (2025), Ellis et al. (2025), and Vallée et al. (2023) provide valuable insights into the unique challenges encountered.

Eder and Roomaney (2025) examined healthcare interactions for TGDN individuals AFAB with endometriosis, revealing that many participants experienced substantial barriers to care, including medical gaslighting, misgendering, and discriminatory practices. These factors contributed to delayed diagnoses, with participants in this study reporting an alarming median delay of up to 12 years (Eder & Roomaney, 2025). The lack of awareness and education among healthcare providers about TGDN concerns and associated bodily matters was highlighted as a critical factor further complicating timely and effective treatment. Similarly, Ellis et al. (2025) emphasized that the cisnormative approach typically adopted by healthcare practitioners, which focuses on menstruation and pregnancy, leads to inadequate care for individuals with diverse gender experiences. Similar to the findings in this review, research has consistently shown that TGDN individuals AFAB face persistent challenges and barriers in accessing reproductive and gynecological healthcare, including screening and treatment services (Agénor et al., 2021). Participants in the present study also described how endometriosis exacerbated gender dysphoria and created additional difficulties in accessing gender-affirming care, further complicating their overall healthcare experiences (Ellis et al., 2025). A critical gap in the literature remains regarding a broad, systematic analysis of the barriers and experiences faced by TGDN people in accessing healthcare for conditions such as endometriosis. While existing studies provide important insights regarding specific aspects of healthcare access, such as diagnostic delays and the challenges of navigating cisnormative medical frameworks, they do not fully address the broader spectrum of barriers these individuals face. There is an urgent need for comprehensive research that explores the intersecting factors, such as healthcare provider biases, institutional barriers, and the lack of gender-affirming care within medical systems, that hinder access to appropriate diagnosis and treatment for TGDN people AFAB with endometriosis. This gap highlights the importance of conducting further research that examines the experiences of TGDN individuals across a wide range of healthcare settings, ultimately aiming to create a more inclusive and supportive framework for care. Understanding these barriers more thoroughly will also be essential to improving healthcare outcomes for this population and ensuring that gender-affirming healthcare is appropriately integrated into the care of individuals with endometriosis.

Research by Shim et al. (2020) and Vallée et al. (2023) further demonstrates the lack of targeted research and diagnostic evaluations for TGDN individuals AFAB with endometriosis and other pelvic pain. Shim et al. (2020) found dysmenorrhea, often attributed to endometriosis, was under-recognized in transmasculine adolescents’ post-transition, which may delay diagnosis and treatment. Vallée et al. (2023) corroborated this by identifying the significant gaps in knowledge about endometriosis in TGDN people AFAB, noting the condition remains under-researched and highlighting the absence of standardized diagnostic approaches, which further impede optimal care.

Additionally, studies examining pelvic pain among TGDN individuals AFAB on testosterone therapy, such as those by Grimstad et al. (2023), Moussaoui et al. (2024), and Zwickl et al. (2023), suggest the need for further and timely investigation into the causes of pelvic pain and endometriosis. One key question emerging from this research is whether testosterone therapy itself contributes to pelvic pain or if individuals with preexisting pain are more likely to seek testosterone as part of their gender-affirming care. These studies note that a significant proportion of TGDN individuals AFAB on testosterone therapy report pelvic pain, yet there is little focus on exploring potential underlying causes such as endometriosis. Grimstad et al. (2023) highlight that, despite testosterone’s role in inducing amenorrhea and atrophic changes in the reproductive organs, many TGDN people continue to experience persistent cyclical pelvic discomfort, suggesting that understanding the pathogenesis of endometriosis in TGDN individuals AFAB is complex. Additionally, it has been proposed that atrophic changes to the uterine and vaginal tissues due to testosterone therapy could lead to increased sensitivity or discomfort, although the associated mechanisms remain poorly understood (Vallée et al., 2023). Moussaoui et al. (2024) suggest the use of testosterone therapy may mask typical gynecological symptoms; thus, delaying potential diagnosis and treatment for endometriosis. This delay is further exacerbated as screening and treatment for endometriosis among TGDN patients AFAB is typically overlooked in routine treatment and healthcare screening amongst practitioners. Furthermore, Zwickl et al. (2023) discussed the effect of gender dysphoria related to gynecological care and examinations, and broadly the lack of education surrounding gender-affirming care in this sector. As a result, many TGDN individuals may avoid or delay seeking care due to fear of discrimination, lack of knowledge, and medical gaslighting.

Limitations

While this review highlights important insights into the healthcare experiences of TGDN individuals AFAB with endometriosis and/or chronic pelvic pain, several limitations must be considered. First, the limited number of studies (12 in total) included in the review restricts the generalizability and consistency of the findings. The sample sizes of some of the studies were relatively small, and most focused on specific geographic regions, particularly English-speaking countries, which may not fully represent the global diversity of TGDN populations. However, it is important to note that the number and scope of studies were appropriate for a scoping review, and the sample was sufficient to draw meaningful conclusions in this emerging area of research. Furthermore, the limited number of studies highlights a significant gap in the evidence base and further supports the need for further research into endometriosis among TGDN individuals. By systematically collating and synthesizing the available literature, this review provides a foundation for future work and offers initial insights to guide future research working toward more inclusive and affirming models of care.

Additionally, while this review draws attention to the barriers to timely diagnosis and treatment, much of the research to date has concentrated on the relationship between testosterone therapy and endometriosis symptoms, leaving a significant gap in understanding the broader healthcare challenges faced by TGDN individuals with this condition. This focus on medical treatment often overlooks other key aspects of healthcare access, such as the emotional and psychological support needs of TGDN individuals, healthcare provider biases, and the intersectionality between gender experiences, healthcare access, and other comorbidities.

Considering these findings, it is evident that a more inclusive, comprehensive approach to investigating and understanding the healthcare experiences of TGDN individuals AFAB with endo­metriosis is essential. Addressing the barriers to timely diagnosis and treatment, including overcoming healthcare provider biases, and improving best-practice awareness, will be crucial in enhancing care for this population.

Conclusions and future recommendations

This RSLR aimed to examine existing research on the management, treatment, and lived experiences of endometriosis and associated pelvic pain among TGDN individuals AFAB, ultimately to inform enhanced future healthcare. Findings from the review stress the importance for healthcare providers to receive comprehensive education and training on TGDN health, particularly in relation to gynecological conditions such as endometriosis, to reduce medical gaslighting, inadvertent discrimination, and symptom dismissal (Eder & Roomaney, 2025). Medical training programs and continuing professional development should incorporate gender-affirming care principles to enhance provider competency and confidence in ensuring that healthcare professionals are equipped with evidence-based knowledge to support TGDN individuals sensitively and effectively (Ellis et al., 2025; Franks et al., 2023; Windt et al., 2024). The development of standardized, evidence-based training programs for practitioners is crucial and should focus on improving diagnostic accuracy, reducing implicit biases, and fostering culturally competent care (Kaladharan et al., 2021; Kaltsas et al., 2024; Mullens et al., 2017; Vallée et al., 2023). It is recommended that there is advisory from the TGDN community, scholars, and medical practitioners to lead discussions in developing a ‘best practice’ approach to healthcare. Additionally, gender inclusive clinical guidelines must be established to support multidisciplinary collaboration between healthcare professionals, gynecologists, endocrinologists, and gender-affirming care specialists, ensuring that TGDN individuals receive comprehensive and affirming healthcare (Shim et al., 2020). It is the responsibility of healthcare and support providers (e.g. bilingual cultural health workers, peer-led services; (Mullens, et al., 2020; Ortiz, et al., 2020) to take reasonable actions in removing foreseeable barriers to access and treatment. Improving access to gender-affirming gynecological and reproductive healthcare services is essential in minimizing the currently observed delays in endometriosis diagnosis and treatment amongst TGDN people AFAB (Grimstad et al., 2023) and is consistent with recommendations arising for TGDN people in related health contexts, including promoting person-centered care (Piñón-O’Connor et al., 2023; Windt et al., 2024).

Healthcare environments should adopt practices to reduce gender dysphoria during gynecological care, including offering self-administered or peer-led testing and alternative diagnostic methods, and recognize the additional challenges that individuals face, to work toward empathetic healthcare (Kaltas et al., 2024; (Mullens et al., 2019; Zwickl et al., 2023). Expanding research on the prevalence, progression, and treatment outcomes of endometriosis among TGDN individuals AFAB is necessary to develop specific and inclusive care strategies, including investigations into the impact of testosterone therapy on pelvic pain and endometriosis symptoms (Moussaoui et al., 2024). By addressing these gaps and barriers, and implementing structured, evidence-based practitioner training programs, healthcare systems can work toward providing equitable, evidence-based, and gender-affirming care for TGDN individuals AFAB with endometriosis, improving their health outcomes and quality of life. It is evident that meaningful progress can only be made through continued research, open dialogue, and a commitment to listening to the lived experiences of TGDN individuals AFAB.

Funding Statement

This study was funded by the Queensland Government Sexual Health Research Fund 2024 grant scheme.

Disclosure statement

No potential conflict of interest was reported by the author(s).