A 27-year-old transgender man sits forward on the stretcher, one hand pressed to his lower abdomen. He says the pain began as a dull ache and now catches sharply when he moves; he has also noticed a little spotting. He has not had a period in months and is unsure whether his hormone medication matters. The pregnancy test is pending, and the next question is yours to ask.

— What’s your move? Read on.

Before you read
  • When should pregnancy enter the differential despite testosterone use or amenorrhea?
  • How do you make the evaluation affirming without missing an emergency?

When to Think of It

Use the patient’s stated name and pronouns, and ask what terms they prefer for body parts and care. Clarify relevant organs, surgeries, hormone use, and pregnancy possibility rather than inferring them from gender identity or appearance. Consider pregnancy in any patient with a uterus and ovaries who could have had sperm exposure—even with testosterone use, amenorrhea, or contraception.

Sick or Not Sick

The key fork is physiologic instability or a time-critical condition versus a stable patient suitable for a focused workup. In pelvic pain or bleeding, do not let gender identity or testosterone use rule out pregnancy; identify shock, peritonitis, or concerning ultrasound findings early.

The First Fifteen Minutes

  • Ask permission before sensitive questions or examination; explain why each question matters, offer a chaperone, and protect privacy.
  • For a patient with pregnancy potential and abdominal/pelvic pain or bleeding → obtain a urine or serum pregnancy test; pregnancy testing is based on organs and exposure, not gender identity.
  • For significant pain in a stable patient → acetaminophen 1,000 mg PO or IV; it provides analgesia without obscuring the need to investigate the cause. Do not exceed 4,000 mg/day in a healthy adult; use a lower limit with liver disease, heavy alcohol use, or other risk factors.
  • For instability or suspected internal bleeding → establish large-bore IV access, send type and crossmatch, and activate the hemorrhage/transfusion pathway as indicated; resuscitation and urgent specialty involvement take priority over a complete history.

Definitive Care & Disposition

Evaluate the presenting complaint using the relevant anatomy and risks: for pelvic pain, that may include pregnancy testing, pelvic ultrasound, and gynecology consultation. Do not require a genital examination unless it is clinically necessary, and obtain consent before proceeding. Continue or pause established hormone therapy only after considering the acute condition and, when useful, consulting the patient’s prescriber; the ED visit is not a reason to discontinue it reflexively. Disposition depends on the underlying diagnosis, stability, and ability to complete urgent follow-up.

How This One Kills

The dangerous error is excluding pregnancy because the patient uses testosterone or has no periods—delaying diagnosis of ectopic pregnancy until rupture and hemorrhagic shock.
The Differential — What Else Looks Like This
  • Testosterone-associated amenorrhea — does not establish infertility; mistaking it for pregnancy exclusion can miss ectopic pregnancy.
  • Gender dysphoria or anxiety — may affect how a patient describes symptoms, but does not explain away focal tenderness or abnormal vital signs; anchoring can delay diagnosis.
  • Urinary infection — urinary symptoms or pyuria may coexist with another cause of pelvic pain; treating a urine result alone can miss a surgical emergency.

The Second-Day Story

A patient may be reluctant to disclose anatomy, sexual exposure, or hormone use after prior disrespectful care, and testosterone may make menstrual history unhelpful. Ask permission, explain the clinical reason for each question, and use neutral, specific language; when pregnancy is possible, test rather than relying on reported bleeding patterns or presumed fertility.
Back to Our Patient
Back to our 27-year-old patient. Recognize that lower abdominal pain and spotting merit a pregnancy test despite testosterone use and months without periods; respectfully ask about relevant anatomy and sperm exposure. He is initially stable, so risk-stratify with serial vitals, pregnancy testing, and pelvic ultrasound rather than assuming a hormone-related cause. The test is positive, and ultrasound shows an adnexal mass with free fluid; gynecology is consulted urgently, and he is admitted for definitive management of a suspected ectopic pregnancy.
Patient Presentation to Attending
How you’d present this patient on the floor — tight, pertinent positives and negatives, no rambling
“This is a 27-year-old transgender man presenting with worsening lower abdominal pain and new spotting. The pain started as a dull ache and is now sharp with movement; he reports months of amenorrhea while taking testosterone. He is sexually active with a partner who produces sperm and has not had sterilization. He is currently hemodynamically stable, with focal lower abdominal tenderness but no generalized peritonitis. His pregnancy test is positive, and pelvic ultrasound shows an adnexal mass with free fluid. I’m concerned for ectopic pregnancy; I’ve involved gynecology urgently and am arranging admission and ongoing assessment for bleeding.”

Study Directive

Practice a 30-second, permission-based sexual and reproductive history using neutral language. Review which organs and surgeries change the differential for pelvic pain, pregnancy, and routine screening; then write a one-sentence explanation for when you would offer a pregnancy test.