Preoperative Assessment for Transmasculine Patients Undergoing Gender-Affirming Hysterectomy

This was a Cleveland Clinic IRB–approved (IRB No. 24-102) retrospective cohort study of transmasculine patients at a tertiary care center who underwent gender-affirming hysterectomy from 2017 to 2024. Patients were included if they were 18 years of age or older and if they underwent gender-affirming hysterectomy with or without concurrent masculinizing chest reconstruction. Patients with other gynecologic or secondary indications for hysterectomy were excluded. Patients were identified with the diagnostic code for gender dysphoria and the relevant procedure for all hysterectomy types. Patient characteristics were collected, as well as Pap test history, pelvic examination within 1 year of surgery, and pelvic ultrasonography conducted within 5 years of consultation. Race was included as a demographic variable in this study to examine the diversity of this cohort and to assess its representativeness of the broader, racially diverse population. Intraoperative and pathology data were also collected. All surgeries were performed by a single surgeon. Descriptive statistics were performed with JMP 17 software.

Fifty-seven patients underwent gender-affirming hysterectomy during the study period. Most had hysterectomy with or without adnexal surgery (n=48, 84.2%), and nine patients (15.8%) had concomitant chest reconstruction. The mean±SD age was 27.2±6.7 years, and most patients were White (n=48, 84.2%) with a mean±SD body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) of 28.2±6.6. Nearly all were on testosterone therapy (n=53, 93.0%), with a mean±SD duration of 53.2±38.3 months (Table 1 ). Patient Characteristics and Pelvic Ultrasound Findings BMI, body mass index; MRI, magnetic resonance imaging. Data are mean±SD or n (%). Among the 57 patients undergoing gender-affirming hysterectomy, 22 (38.6%) had a pelvic examination within 1 year of surgery, and 46 (80.7%) had an ultrasonogram within 5 years of surgery. Half of the ultrasonograms (n=24, 52.2%) were ordered specifically for the gender-affirming hysterectomy. Most ultrasonograms (n=33, 72.0%) yielded normal findings; physiologic ovarian cysts were the most common “abnormal” findings (n=7, 15.2%). One patient had a thickened endometrium, necessitating a preoperative endometrial biopsy. All 57 patients successfully underwent surgery through a conventional laparoscopic approach without conversion to another modality (Table 2 ). Two patients (3.5%) were identified as potential candidates for vaginal hysterectomy during examination under anesthesia; however, laparoscopic hysterectomy was performed because “possible vaginal hysterectomy” was not included in the consent. All specimens were removed through the vagina, and none required morcellation. The mean±SD specimen weight was 78.6±33.3 g. All pathology results were benign. Surgical Data IUD, intrauterine device; EIN, endometrial intraepithelial neoplasia. Data are mean±SD or n (%).

In this study, gender-affirming hysterectomy had a low complication rate. 9 – 11 This study found that preoperative pelvic ultrasound findings for gender-affirming hysterectomy did not alter the surgical approach for this small cohort of patients. Only one patient needed further workup, an endometrial biopsy for thickened endometrium, which was indicated independently of the ultrasound findings because of persistent uterine bleeding on testosterone therapy. No patients required intraoperative morcellation, and none of the postoperative pathology specimens showed large uterine specimens that warranted imaging for surgical planning. These results suggest that preoperative ultrasonography may not be necessary for patients desiring gender-affirming hysterectomy. In addition, pelvic examinations performed for non–preoperative evaluations (n=8, 14.0%) did not alter the surgical plan for a conventional laparoscopic procedure, although the numbers were very small in this study. This is consistent with previously published findings. 5 Given that nearly one in four transgender individuals avoids medical care because of mistreatment and discrimination, 12 , 13 efforts to reduce gender dysphoria, including pelvic examinations and pelvic ultrasonograms, are important. This study suggests that ultrasonography may not be necessary routinely preoperatively before gender-affirming hysterectomy. This decision could be left to patient and surgeon shared decision making based on individual risk stratification. For example, the patient with persistent abnormal uterine bleeding in the absence of exogenous testosterone therapy or an enlarged or leiomyomatous uterus should undergo the same evaluation recommended for cisgender women. 14 For patients receiving exogenous testosterone therapy experiencing persistent breakthrough bleeding, endometrial sampling should be considered because testosterone therapy does not always lead to an atrophic endometrium, a common misconception. 15 , 16 Laparoscopic techniques are common for gender-affirming hysterectomy, but vaginal hysterectomy is feasible in about 25% of cases. 11 , 17 – 19 Surgeons should consider adding possible vaginal hysterectomy to preoperative planning and consent. If oophorectomy is challenging vaginally, alternatives include completing the procedure laparoscopically or using the vaginal natural orifice transluminal endoscopic surgery (V-NOTES) approach, a safe option for transgender patients. 19 Study limitations include a small, unpowered sample size, a single surgeon's experience, and a predominantly White patient population. The retrospective nature of our study limited access to indications for pelvic ultrasonography ordered by other clinicians. Although definitive conclusions cannot be made as a result of these limitations, these findings provide us with an important start to further investigate preoperative planning for this patient population and an opportunity to increase access to gender-affirming hysterectomy.