Introduction

The World Professional Association for Transgender Health (WPATH) considers hysterectomy with or without salpingectomy and/or oophorectomy a medically necessary gender-affirming surgery for trans men interested in the procedure. The reasons for surgery are diverse: a sense of organs feeling incongruent with one’s gender identify, to promote further masculinization, to assist with changing legal documents, avoiding gynecology visits and prevention of gynecologic problems, or for specific gynecologic issues such as pelvic pain, cramping, bleeding, tumors, cysts, or endometriosis.

The psychological benefits of gender-affirming surgery are well-documented. Cases of regret are rare. In cases of female-to-male gender-affirming surgery, sexual function appears to improve. Over half of all transgender men surveyed desire hysterectomy in the future, with approximately 21% having had the procedure already.

Mistrust and mistreatment between the transgender community and the health-care system are well-established. Approximately half of transgender persons can recall having to educate their providers regarding care, with 19% surveyed being refused care altogether. Given the experience of discrimination and the lack of appropriate providers, many have avoided the health-care system. By understanding the experiences of transgender patients in the health-care system, providers can better understand their reasons for requesting gender-affirming surgery. In this chapter, we will review various perioperative considerations for surgeons performing hysterectomy in the transgender man ( Table 14.1 ).

Preoperative Considerations

As with cisgender patients, preoperative counseling is critical in the transitioning patient. A thorough preoperative assessment should include a discussion about the mode and extent of surgery, coordination with other health-care providers, review of postoperative care and expectations, and assessment of the patient’s support system.

Perioperative Management

There are currently no specific guidelines on the perioperative care of transgender men undergoing hysterectomy; however, planning is necessary, and there are some nuances in this patient population that should be considered before proceeding to the operating room. Preoperative testing including laboratory studies, cardiac evaluation, and pulmonary function tests should be performed according to standard American Society of Anesthesiologists (ASA) guidelines, taking into account the patient’s comorbid medical conditions.

Testosterone therapy is associated with an increased risk of hyperlipidemia, hypertension, and polycythemia, and it is best to have these health conditions optimized prior to surgery, either through titration of testosterone dosing or independent treatment. These conditions, however, are common even in the general population, and are not a contraindication to “elective” hysterectomy in general, and should not be considered as such for trans men. Most trans men on testosterone therapy have some degree of polycythemia. There is no evidence that secondary polycythemia is an independent risk factor for venous thromboembolism (VTE), so standard prophylaxis with sequential compression devices is reasonable. If the patient is also obese or has other risk factors (prior VTE, malignancy, etc.), adding pharmacologic prophylaxis is indicated. Smoking or obstructive sleep apnea are important ventilatory issues as laparoscopic hysterectomy is performed in the Trendelenburg position. The effect of testosterone on weight isn’t completely understood, but may cause fat redistribution from a subcutaneous location to a visceral one, which is relevant to patient positioning and feasibility of performing the procedure. Some studies show increased insulin resistance and fasting blood glucose associated with testosterone use, so if not already done, screening for diabetes mellitus should be performed, so that the postoperative period may include glycemic control if appropriate. No studies have demonstrated an increased risk of cardiovascular events such as myocardial infarction, VTE, or stroke among transgender men on hormone therapy; therefore, cardiac testing should follow standard risk assessment. Standard antibiotic prophylaxis should be administered according to Surgical Care Improvement Project (SCIP) guidelines.

It is important to create a safe and welcoming medical environment for transgender patients, a population already at risk for avoiding care due to discrimination or disrespect. Guidelines can be found at the UCSF Center of Excellence website that include recommendations for cultural humility, gender-neutral bathrooms, staff training, and so on. This is especially true for men who are being seen by a gynecologic surgeon who almost exclusively treats cisgender women. Providing advance notice to front-line staff that a transgender patient is on the schedule can avoid awkward misunderstandings at clinic visits and in the operating room. Preparing as many people as possible is wise, especially if the electronic medical record (EMR) does not capture the patient’s identity well due to its own limitations or for insurance reasons.

Most minimally invasive hysterectomies are now outpatient procedures, and the ability to discharge a posthysterectomy patient on the same day as surgery is especially important for transgender patients, as it reduces the chance of an insensitive encounter or an inadvertent admission to a gynecology floor occupied by women. Scheduling earlier in the day is associated with greater success for same-day discharge, so making these surgeries first-start cases is helpful. Implementation of Enhanced Recovery After Surgery (ERAS) pathways such as pre-emptive analgesia, prevention of postoperative nausea/vomiting, in operating room (OR) catheter removal, early resumption of normal diet, and so on are similarly important. Surgeons should be mindful of loved ones who accompany the patient on surgery day and ask the patient in private if they are aware of the procedure specifics and if he would like the surgeon to provide them with an update after surgery.

Liberal introduction of activity is generally warranted after gynecologic laparoscopy, but opening of the vaginal cuff (dehiscence) occurs more commonly after laparoscopic hysterectomy compared with other modalities, and isn’t necessarily associated with penetrative vaginal intercourse, so avoiding strenuous activity for several weeks following hysterectomy is warranted. If a patient doesn’t use the vagina for sex and hasn’t experienced bleeding following surgery, a speculum exam can be safely deferred at the postoperative visit. Vaginal PAP tests are needed in future visits only if a patient has had a history of severe cervix dysplasia within the last two decades. There is no recommended ovarian cancer screening for those who retain ovaries, but future providers should keep in mind that ovarian pathology is possible if oophorectomy is not performed at the time of hysterectomy, and constitutional symptoms suggesting pelvic disease should be evaluated in a standard fashion. Although rare, primary peritoneal cancer can still occur in patients after the ovaries are removed; thus trans men with symptoms should be assessed.