Hysterectomy

Introduction

Hysterectomy with and without salpingectomy/oophorectomy is considered by WPATH to be a medically necessary component of gender affirming surgical therapy for those transgender men who choose to seek this procedure.[1] It is unknown how many transgender men desire and obtain hysterectomy for the purposes of gender affirmation or in the context of gender dysphoria. In the National Transgender Discrimination Survey, 21% of trans men surveyed had undergone hysterectomy.[2] 58% desired a hysterectomy at some time in the future, and 21% had no desire for a hysterectomy, It is unclear what differentiated individuals who had already undergone hysterectomy from those who desired the procedure in the future, though access to care and financial considerations are likely contributors. Also unclear is how reproductive desires may play into decisions about hysterectomy and or oophorectomy. Furthermore, it is unclear from this study what proportion of these hysterectomies were due to a medically pathologic condition rather than gender dysphoria, since hysterectomy is one of the most common non-obstetrical surgical procedures.

A study of 134 transgender men reported a diversity of indications for hysterectomy, though most procedures were performed for gender affirmation. In that study, 58% underwent hysterectomy because organs were incongruent with current gender identity, 47% for further physical masculinization, 43% to facilitate a change in legal documents, and 37% to avoid future gynecological appointments. However, this same study also noted that for many this procedure was seen as "preventive" in 59%, was performed because of pre-existing medical problems in 26%, specifically for "tumors, cysts, fibroids or endometriosis" in 22% or to stop extreme bleeding and cramping in 22%.[3] Since widespread explicit insurance coverage for hysterectomy for purposes of gender affirmation is both recent and evolving, it is possible that some of the decisions to perform hysterectomy in the setting of pathologic conditions may have been hastened by coexisting gender dysphoria.

Surgical approaches

Best practice for the surgical approach to hysterectomy in transgender men has not been studied. Hysterectomy may be performed abdominally, laparoscopically, or vaginally. Based on existing evidence, the American Congress of Obstetricians and Gynecologists has stated that for patients in whom the approach is appropriate, a vaginal approach has the fewest complications and blood loss, quickest recovery, and is the most cost-effective.[4] For transgender men, vaginal hysterectomy has the added benefit of leaving no abdominal scars. Initial data [5,6] support the notion that vaginal hysterectomy is appropriate for transgender men. Many other studies have noted that laparoscopic hysterectomy, the second least invasive form of hysterectomy, is also possible and can successfully be accomplished without additional complications.[7-11]

Hysterectomy has been successfully combined with other gender affirming surgeries performed on the same day in the same operating suite including vaginectomy, mastectomy, and genital reconstruction including metoidioplasty and phalloplasty.[10,12] Hysterectomy itself does not largely differ, however some modifications in concurrent surgeries and extent of dissection may differ depending on the goals of the transgender patient. For example if a transgender man undergoing hysterectomy has no plans for penetrative vaginal intercourse in the future, the vaginal cuff closure could be much more exterior, such that less of a vaginal orifice remains. Similarly, vaginectomy (removal of vaginal mucosal tissue) and colpocleisis (closure of the vaginal canal) could be performed if no vaginal orifice is desired, as long as there is no desire for future genital reconstructive surgery that would make use of the vaginal mucosa (for urethral lengthening etc). Finally, consideration of whether to retain or remove the ovaries and fallopian tubes at the time of surgery is also a personal decision and will be based on considerations of patient desire, future fertility, plans for exogenous (steroid) hormone administration, and other pathology that may be aided or exacerbated by ovarian removal (e.g., endometriosis).

While the WPATH Standards of Care require two mental health assessments prior to hysterectomy, this has been challenged academically [13] and in practice [7] given that non-transgender women may undergo a hysterectomy for equally or less compelling complaints without similar restrictions.

References

1. World Professional Association for Transgender Health (WPATH). Standards of care for the health of transsexual, transgender, and gender nonconforming people, 7th Version. WPATH; 2012 [cited 2016 Mar 10].
2. Grant JM, Mottet LA, Tanis J, Harrison J, Herman J, Keisling M. Injustice at every turn: a report of the National Transgender Discrimination Survey. National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011 [cited 2016 Mar 17].
3. Rachlin K, Hansbury G, Pardo ST. Hysterectomy and oophorectomy experiences of female-to-male transgender individuals. Int J Transgenderism. 2010 Oct 12;12(3):155-66.
4. Obedin-Maliver J, Light A, DeHaan G, Steinauer J, Jackson R. Vaginal hysterectomy as a viable option for female-to-male transgender men: Obstet Gynecol. 2014 May;123:126S - 127S.
5. Kaiser C, Stoll I, Ataseven B, Morath S, Schaff J, Eiermann W. [Vaginal hysterectomy and bilateral adnexectomy for female to male transsexuals in an interdisciplinary concept] Vaginale Hysterektomie und beidseitige Adnexektomie in interdisziplinärem Konzept bei Frau zu Mann - Transsexualismus. Handchir - Mikrochir - Plast Chir. 2011 Aug;43(04):240-5.
6. O'Hanlan KA, Dibble SL, Young-Spint M. Total laparoscopic hysterectomy for female-to-male transsexuals. Obstet Gynecol. 2007 Nov;110(5):1096-101.
7. Bartos P, Struppl D, Popelka P. [Role of total laparoscopic hysterectomy in genital reconstruction in transsexuals]. Ceska Gynekol Ceska Lek Spolecnost J Ev Purkyne. 2001 May;66(3):193-5.
8. Chapin DS. Laparoscopically assisted vaginal hysterectomy in female-to-male transsexuals. Plast Reconstr Surg. 1993 Apr;91(5):962.
9. Ergeneli MH, Duran EH, Ozcan G, Erdogan M. Vaginectomy and laparoscopically assisted vaginal hysterectomy as adjunctive surgery for female-to-male transsexual reassignment: preliminary report. Eur J Obstet Gynecol Reprod Biol. 1999 Nov;87(1):35-7.
10. Perrone AM, Scifo MC, Martelli V, Casadio P, Morselli PG, Pelusi G, et al. Hysterectomy and bilateral salpingoovariectomy in a transsexual subject without visible scarring. Diagn Ther Endosc. 2010;2010.
11. Ott J, van Trotsenburg M, Kaufmann U, Schrögendorfer K, Haslik W, Huber JC, et al. Combined hysterectomy/salpingo-oophorectomy and mastectomy is a safe and valuable procedure for female-to-male transsexuals. J Sex Med. 2010 Jun;7(6):2130-8.
12. Weiss E, Green J. Transgender patients care. Am J Obstet Gynecol. 2014 Aug;211(2):185-6.