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 ).
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.
World professional association for transgender health criteria
Several criteria for genital surgery exist, but most surgeons follow those put forth by the WPATH. Patients are candidates for surgery if they meet the following criteria: well-documented gender dysphoria, capacity to give informed consent, age of majority in the patient’s country, well-controlled medical and/or mental health concerns, and 12 months of hormonal therapy when able ( Table 14.2 ). They also recommend preoperative evaluation and letters of support for the surgery by two separate mental health professionals trained in transgender care. This so-called requirement has been contended by some as of late, as many see a second letter as unnecessary and overly burdensome for patients. This recommendation may change in the future. WPATH also recommends starting hormonal therapy prior to genital surgery to “introduce a period of reversible estrogen or testosterone suppression, before the patient undergoes an irreversible surgical intervention.” They also affirm that living in their self-identified gender role will allow the transgender man to experience a number of various life events and establish a support system. Surgeons may find themselves using these guidelines a as a framework only and adapting them based on their working relationship with the patient, as well as the extent of the surgery being considered.
Genital surgery can include hysterectomy, salpingectomy, oophorectomy, metoidioplasty, vaginectomy, scrotoplasty, and implantation of prostheses. The role of hysterectomy, with concomitant salpingectomy, and/or oophorectomy, will be reviewed in this chapter. These procedures can be performed through an open, laparoscopic/robotic, or vaginal approach, with minimally invasive strategies being preferable. A total hysterectomy (as opposed to subtotal or supracervical) with salpingectomy is superior, to avoid additional future procedures, as well as complications related to leaving the fallopian tubes in situ. Bilateral oophorectomy is performed in the majority of cases where fertility preservation isn’t desired. Additional concomitant reconstructive surgery (metoidioplasty, phalloplasty) may be considered for those patients seeking complete genital surgery.
Elective appendectomy can be safely performed during gynecologic surgery. The procedure is easy to perform, low-risk, may simplify the differential for acute exacerbations of chronic pain, and has the potential to avoid future imaging and surgical procedures. The benefit is greatest for patients less than 35 years of age, making this procedure relevant for many trans men having hysterectomies in early adulthood. This vulnerable population may want to avoid needing future emergent care from unfamiliar providers with varying levels of cultural sensitivity.
Preoperative testing for the transgender male should include age-appropriate and risk-appropriate screening. Transgender patients are at increased risk for misuse of drugs and alcohol, avoidance of the health-care system due to discrimination and/or lack of insurance, and attempts at self-harm and suicide. Transgender patients report HIV infection at four times the national average. Surgeons should individualize sexually transmitted infection screening according to the risk profile of the particular patient considering hysterectomy.
Patients should be counseled regarding cervix cancer screening, and PAP testing should generally be performed according to the most recent American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines. Female-to-male patients have a higher rate of inadequate PAP smears as well as longer time to follow-up, thought secondary to both provider and patient discomfort during pelvic examination, as well as the atrophic and cellular changes that can occur with testosterone therapy. Recommendations for making pelvic exams in trans men more comfortable are outlined in the University of California San Francisco’s (UCSF) Center of Excellence for Transgender Health website. Although there are no data to support this approach, some have deferred speculum exams for cervix dysplasia screening after evaluating history of sexual practices and potential symptoms of cervix cancer, since the only condition that would change the planned procedure from simple hysterectomy would be an invasive carcinoma greater than stage 1A2. Routine screening for ovarian cancer or endometrial cancer in the asymptomatic patient is not recommended. While there is a theoretical concern for the conversion of exogenous testosterone to estrogen, there is currently no strong evidence that trans men are at increased risk for endometrial cancer compared with the general population.
Plans for future fertility should always be considered during discussions of genital gender-affirming surgery. There has historically been an unwillingness to offer reproductive services to transgender persons, due to concern for offspring, the patient, or outright discrimination. American Congress of Obstetricians and Gynecologists (ACOG) has addressed the latter issue, firmly opposing any discrimination of transgender persons based on the principle of justice. Similarly, the American Society for Reproductive Medicine released a statement indicating that “denial of access to fertility services is not justified.” Review of available studies do not show evidence for psychological injury to the offspring of transgender persons, with the American Academy of Pediatrics pointing out lack of evidence to support such claims.
A discussion of fertility plans with a trans man considering hysterectomy (and his partner, if applicable) is similar to preoperative counseling with a cisgender woman who is considering surgical removal of her reproductive organs for benign or malignant reasons. For more in-depth discussions or procedures such as preoperative oocyte or embryo cryopreservation, transgender men should be referred to reproductive endocrinologists, preferably with experience treating trans patients. Patients should be informed that fertility treatment involves temporary cessation of exogenous testosterone in order to achieve ovulation induction. Data are scant regarding ovarian function recovery after testosterone therapy, but extrapolating from case reports and from patients with polycystic ovarian syndrome, it seems that recovery of the functional gonadal tissues is possible. Discussing fertility with the prepubertal patient requires a particularly careful approach, given that young patients may feel unprepared to make decisions regarding their future fertility. These conversations should be held with the patient’s clinician, a mental health professional, and the patient’s parents or supportive persons when possible. Many patients will choose to delay puberty with GnRH analogs. While spontaneous ovulation should theoretically occur following cessation of these suppressive medications, there are few data to support the response and timing of return to ovulation. The Endocrine Society suggests deferring genital gender-affirming surgery until an individual is at least 18 years of age.
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.