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Feasibility of Vaginal Hysterectomy for Female-to-Male Transgender Men

Obedin-Maliver, Juno MD, MPH; Light, Alexis MD, MPH; de Haan, Gene MD; Jackson, Rebecca A. MD

doi: 10.1097/AOG.0000000000001866
Contents: Original Research
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OBJECTIVE: To describe the hysterectomy data among a cohort of transgender men and nontransgender (ie, cisgender) women with a particular goal to evaluate the feasibility of vaginal hysterectomy among transgender men.

METHODS: This cohort study includes all hysterectomies performed for benign indications on transgender men and cisgender women at a single academic county hospital from 2000 to 2012. Hysterectomy cases and patient gender were identified by billing records and confirmed by review of medical records. Primary study outcome was the hysterectomy route among transgender men compared with cisgender women. We also examined risk factors and operative outcomes. Student two-sided t tests, χ2 analysis, and descriptive statistics are presented; sensitivity analyses using regression techniques were performed.

RESULTS: Hysterectomies for benign gynecologic procedures were performed in 883 people: 33 on transgender men and 850 on cisgender women. Transgender men were younger, had fewer pregnancies and deliveries, and smaller uteri. The leading indication for hysterectomy differed significantly: pain (85%) was most common among transgender men (compared with 22% in cisgender women; P<.001), whereas leiomyomas (64%) was most common for cisgender women (compared with 21% in transgender men; P<.001). Vaginal hysterectomies were performed in 24% transgender men and 42% of cisgender women. Estimated blood loss was less among transgender men (P=.002), but when uterine size and route of hysterectomy were considered, the difference between gender groups was no longer significant. There was no difference in patients experiencing complications between the groups.

CONCLUSION: Transgender men and cisgender women have different preoperative characteristics and surgical indications. Vaginal hysterectomies have been successfully completed among transgender men. Because vaginal hysterectomy is a viable procedure for this population, it should be considered in surgical planning for transgender men.

For transgender men who are undergoing hysterectomy, the vaginal route is a viable option.

Departments of Obstetrics, Gynecology, and Reproductive Sciences and Epidemiology and Biostatistics, University of California, San Francisco, and the Department of General Internal Medicine, San Francisco Department of Veterans Affairs, San Francisco, California; the Department of Obstetrics and Gynecology, Washington Hospital Center, Washington, DC; and the Department of Obstetrics and Gynecology, Oregon Health Sciences University, Portland, Oregon.

Corresponding author: Juno Obedin-Maliver, MD, MPH, Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th Street, c/o WHCRC 6th Floor, San Francisco, CA 94158; email: ObedinMaliverJ@obgyn.ucsf.edu.

Original research was supported by a University of California San Francisco Clinical and Translational Sciences Institute Resident Research Grant.

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented at the Annual Clinical Meeting of the American College of Obstetricians and Gynecologists, April 26–30, 2014, Chicago, Illinois.

Each author has indicated that he or she has met the journal's requirements for authorship.

There are scarce data to guide the gynecologic care of transgender men.1,2 The terms “transgender men” and “FTM” describe individuals who identify as men but were assigned female sex at birth. Transgender individuals likely represent 0.3–0.5% of the U.S. population.3,4 Although not all transgender men use surgical treatments (eg, hysterectomy, vaginectomy, mastectomy, phalloplasty2,5) as part of the gender affirmation process, many do with associated improvements in quality of life.5–9 Twenty-one percent of transgender men undergo hysterectomy, and an additional 58% desire it but experience limited health care access, care avoidance secondary to discrimination, and lack of insurance coverage.10 However, little is known about hysterectomy outcomes among transgender men.2,5–7

Hysterectomies are the most common hospital-based nonobstetric procedure performed in the United States.11,12 As a result of decreased morbidity and cost, vaginal hysterectomy is the route of choice in cisgender women (those whose identify as women and were assigned female sex at birth).13,14 However, sources considering transgender men either negate or ignore the possibility of a vaginal hysterectomy citing nulliparity, limited descensus, and poor tissue quality secondary to testosterone use5,15–17 or describe questionably applicable practices for nonsubspecialty-trained gynecologists.18

We present a cohort study of all benign nonobstetric hysterectomies performed by nonsubspecialty-trained gynecologists over a 12-year period to describe patient characteristics and routes of hysterectomy by gender and evaluate if vaginal hysterectomies are feasible among transgender men. The primary outcome was route of hysterectomy. Secondary outcomes included conversion frequencies, complications, estimated blood loss, and operative time.

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MATERIALS AND METHODS

Hysterectomies performed at San Francisco General Hospital, a county safety net hospital, between 2000 and 2012 were identified using a billing database. We included all hysterectomies performed for nonobstetric, benign gynecologic indications with complete operative and pathologic reports during the study period. Patient gender was identified by examining preoperative visits, operative reports, anesthesia records, discharge summaries, and billing records for indicators of gender, including self-identified gender or gender transition before the operative date. Markers of male gender included: male pronouns, testosterone use for the purposes of gender affirmation, stated affirmed male gender identity, clinician documentation of transgender or male status, or concurrent diagnosis of the temporally appropriate diagnosis of gender identity disorder by then current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria.

Age, height, weight, gender identity at surgery, testosterone use, and length of use before surgery were collected from perioperative clinic and hospital records. Uterine size was determined by clinical history and physical as well as preoperative bimanual examination, noted as uterine height (weeks equivalent to centimeter measurement). Surgical indications were those as noted by the surgeon in preoperative history and physical and operative reports. Multiple surgical indications could be reported and were noted. Initial route of hysterectomy was that which was initiated after operating room examination under anesthesia. Conversion was defined as initiating one route of hysterectomy and changing route after initiation of the procedure. Conversion rates were delineated with respect from moving to either laparoscopic hysterectomy or vaginal hysterectomy to abdominal hysterectomy. To standardize nomenclature regarding laparoscopic assistance to perform the hysterectomy, we coded laparoscopic-assisted vaginal hysterectomy and total laparoscopic hysterectomy procedures separately; total laparoscopic hysterectomy was noted if the uterine vessels were ligated laparoscopically. Because few procedures were actually total laparoscopic hysterectomy, we combined total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy to create a laparoscopic hysterectomy category. Robotic-assisted laparoscopic procedures were not performed at this hospital during the study period.

Anesthesia time was recorded from anesthesia records and included entire time under anesthesia as operative time (from incision to closure), which was inconsistently recorded in anesthetic records.

Operative time greater than 4 hours was reported at the time of surgery by the surgical team and is noted separately. Intraoperative complications were derived from operative reports and postoperative reports about intraoperative occurrences that were designated as complications by the surgeons. These included anesthetic complications; nerve, vascular, bladder, ureteral, or bowel injury; unplanned removal of an organ; receiving a blood product transfusion; or death. Postoperative complications were categorized as acute (occurring after the procedure but before discharge) or delayed (occurring at any point after discharge for the remainder of the follow-up period). Acute complications were identified by review of all available clinical documentation (eg, progress notes, imaging, discharge summaries) from the time of surgery until discharge. Acute complications included new diagnosis of a nerve, bowel, bladder, or ureteral injury; bowel obstruction; clinically significant fever; infection (including chest, pelvic, genitourinary, wound); urinary retention; wound separation or dehiscence; hematoma; thromboembolism; transfusion; unplanned admission to the intensive care unit; or mortality. For delayed complications, all hospital-related data (eg, clinic charts, visit histories, medication administration) were reviewed from the time of the procedure until February 1, 2014. Delayed postoperative complications included all of the acute postoperative complications discovered after initial discharge as well as unplanned readmission or an unplanned emergency department visit without readmission. Both the University of California San Francisco Human Research Protection Program Committee on Human Research and San Francisco General Hospital Research Protocol Application approvals were obtained. Funding for this research was supported by a University of California San Francisco Clinical and Translational Sciences Institute Grant.

Baseline characteristics of patients were analyzed according to gender (Table 1). Comparative statistics were performed using two-sided t tests for continuous outcomes and χ2 tests for categorical outcomes with a Fisher exact test used for small sample comparisons when appropriate. For bivariate analysis by gender of nonnormal variables (eg, anesthesia time, estimated blood loss, and uterine weight), the Wilcoxon rank-sum test was used (Table 2). For all analyses, two-sided tests were performed and P<.05 was considered statistically significant. Where descriptive statistics were estimated, frequency data and proportions were used to represent outcomes.

Table 1.

Table 1.

Table 2.

Table 2.

Hysterectomy route was ultimately divided into abdominal hysterectomy, laparoscopic hysterectomy, or vaginal hysterectomy. Descriptive statistics were used to denote proportions of patients undergoing each type of hysterectomy and χ2 compared differences in route by gender (Table 2). Because of the possibility that some of the between-gender differences observed in our chosen outcomes could be explained by other variables, we conducted additional regression analyses to investigate the sensitivity of our findings to adjustment for selected factors with plausible confounding roles. We used multinomial logistic regression for both initial and final operative route outcomes, penalized logistic regression for the binary concurrent adnexal surgery and bilateral salpingo-oophorectomy outcomes, and linear regression for log-transformed mean estimated blood loss of different surgical routes.19 Variables considered included baseline characteristics that differed between gender groups, namely, age, gravidity, history of cesarean delivery, uterine size as measured in the operating room, preoperative pain, amenorrhea, and bulky leiomyomas as an indication for hysterectomy. These analyses were necessarily limited by the small sample of transgender men and did not allow for simultaneous adjustment for multiple predictors. Therefore, we focused on comparison of unadjusted results with those obtained while adjusting for the variables with the most plausible confounding roles and those that had the biggest impact on estimates. Conversion rates were calculated from minimally invasive procedure (laparoscopic hysterectomy or vaginal hysterectomy) to abdominal procedures (abdominal hysterectomy) initiated after the start of the case. All data were collected using RedCap 6.0. All analyses were performed using Stata 13.

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RESULTS

From 2000 to 2012, there were 883 hysterectomies performed for benign nonobstetric indications, 96.3% (n=850) in cisgender women and 3.7% (n=33) in transgender men. Review of billing data identified 31 individuals who had undergone hysterectomy and had male gender markers in the record system. Among those, seven were excluded from this analysis: three for accidental assignation of male gender in billing codes, three did not in fact have hysterectomies, and one had a known preoperative malignant gynecologic condition. Nine additional transgender men (9/33) were identified by hand review of entire medical records for each hysterectomy.

Baseline demographics and preoperative indications are presented in Table 1. Overall, transgender men were younger and had fewer pregnancies and deliveries. Uterine size was smaller with a mean of 7 cm in bimanual height in transgender men compared with 13 cm for cisgender women (P<.001). Two of the transgender men had delivered a baby (one by cesarean delivery and one by vaginal delivery.) Testosterone was used by almost all of the transgender men (91% [n=30]) with a wide range of length of use from 2 months to 14 years. Preoperative indications varied greatly between the two groups: most transgender men (85% [n=28]) had pain as a preoperative indication, whereas fewer cisgender women had this as a complaint (22% [n=186]; P<.001). Conversely, the most common preoperative diagnoses in cisgender women were leiomyomas (64% [n=543]) and bleeding (63% [n=537]), which were less prevalent among transgender men (21% [n=7] leiomyomas [P<.001] and 48% [n=16] bleeding [P=.09]).

To further explain pain as a preoperative indication among the 214 people who had pain as an indication for surgery, we performed secondary analyses evaluating for the presence of a correlation between pain and any of the following surgical–pathologic findings: adenomyosis, endometriosis, benign masses, cysts, leiomyomas, infection, or inflammation in any part of the histology (cervix, endometrium, myometrium, serosa, tubes, or ovaries). We found no consistent pathologic etiology to explain the preponderance of pain as an indication for surgery among the transgender men. However, we did find that in cisgender women who had pain (186/850 [22%]) as an indication for hysterectomy when compared with transgender men with the same indication (28/33 [85%]), cisgender women were more commonly found to have myometrial adenomyosis (38.2% of cisgender women compared with 7.1% of transgender men, P=.001) or leiomyomas (77.4% of cisgender women compared with 17.9% of transgender men, P<.001) on their pathology reports.

Routes of hysterectomy and concurrent adnexal surgeries are described in Table 2. For transgender men, the largest combined proportion of cases were completed either by laparoscopic hysterectomy (14/33 [42%]) or vaginal hysterectomy (8/33 [24%])—collectively less invasive methods. In contrast for cisgender women, the majority underwent abdominal hysterectomy (469/850 [55%]), a more invasive method. We considered various covariates for inclusion in a multinomial logistic regression model for assessing outcome of surgical route by gender. The only covariate that was consistently significant and clinically reasonable given a small sample size was uterine size. Models evaluating initial and final operative outcomes adjusted for uterine size attenuated the effect size, but the association remained significant at the 5% level. This suggests that uterine size may be an important predictor in the association between gender and operative route. Results from regression adjustment by uterine size for adnexal surgery or bilateral salpingo-oophorectomy outcomes were not different from unadjusted findings.

Estimated blood loss by surgical route considering gender was similarly evaluated and adjusted by uterine size using a linear regression model (Table 2). For this outcome the direction of association remained the same in the adjusted model; however, the magnitude and statistical significance of the association was not significant (P=.55; data not shown). This again suggests that uterine size may have been an important factor explaining some of the observed association between blood loss and gender. By comparison, the unadjusted association between blood loss and gender was significant in bivariate analysis (Table 3).

Table 3.

Table 3.

The mean and range of uterine size of vaginal hysterectomies were 5.9 cm (5–6 cm) for transgender men and 8.7 cm (4–18 cm) for cisgender women. None of the transgender men who had a vaginal hysterectomy were parous. For transgender men, there were two intraoperative conversions from laparoscopic hysterectomy to abdominal hysterectomy and none from vaginal hysterectomy to abdominal hysterectomy (8.3% conversion rate). For cisgender women, the conversion rate was 5.9% from laparoscopic hysterectomy or vaginal hysterectomy to abdominal hysterectomy (P=.65).

Further evaluation of intraoperative and postoperative features are found in Table 3. There was a wide range of anesthesia times, estimated blood loss, and uterine weight. Many procedures in both groups were greater than 4 hours long, but this did not differ significantly between groups. All (n=33) transgender men had adnexal surgery, and 97% (n=32) had a bilateral salpingo-oophorectomy. By comparison in the cisgender women group, 39% (n=327) had adnexal surgery and 27% (n=233) had a bilateral salpingo-oophorectomy.

There was no observable difference between the two gender groups with respect to the number of individuals experiencing one or more intraoperative, acute postoperative, or delayed postoperative complications, but the small sample size of transgender men may have obscured any true differences (Table 3). Transgender men had an average of 3.5 years of follow-up (range 0–14 years). Overall cumulative incidence of any complication was 12% (n=4) for this group. There were no intraoperative complications. For cisgender women there was an average of 4.7 years of follow-up (range 0–11 years), and overall cumulative incidence of any complication was 18% (n=150) among the cisgender women. Details regarding the proportion of specific complications experienced during the perioperative course can be found in Appendix 1, available online at http://links.lww.com/AOG/A919.

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DISCUSSION

Concerns that low parity and testosterone use in transgender men preclude vaginal hysterectomy are not supported by this study. These findings generalize the work of Kaiser et al who used vaginal hysterectomy in 97% of their transgender male patients undergoing gender-affirming procedures with a combined plastic surgery and pelvic reconstructive team. Our findings are novel in that diverse nonsubspecialty-trained gynecologists performed the hysterectomies and without performing concurrent gender affirmation procedures. Our findings were in contrast to previous publications,15,20 which suggest that vaginal hysterectomy cannot be offered to these patients because of nulliparity, “no uterine descent,” and “small, noncompliant, and atrophic vaginal walls” secondary to testosterone use.

Despite small numbers of transgender men, limiting population-level generalizations, there were no intraoperative adverse events and few postoperative ones suggesting no gross safety threats to pursuing vaginal hysterectomy. Furthermore, because transgender men tended to have smaller uteri, they are likely reasonable vaginal hysterectomy candidates. The implications of our findings are consistent with national guidelines to offer vaginal hysterectomy, when appropriate, to limit complications and morbidity while maximizing cost-effectiveness.11,13,14 Because transgender individuals are more likely to live in poverty, be under- or unemployed, and pay for medical care out-of-pocket,10,21 it is all the more urgent to approach these surgeries using minimally invasive procedures. An additional benefit of vaginal hysterectomy in transgender men is the absence of abdominal scars, which may make living in their affirmed gender easier by eliminating explanations of incisional patterns.15 Finally, a unique benefit for transgender men is minimized disruption of abdominal wall structures that may later be used for gender-affirming procedures. Therefore, our results indicate that vaginal hysterectomy is possible and gynecologists should consider it as a feasible option in transgender men. Furthermore, surgical route for hysterectomy among transgender men should be based on typical surgical decision-making criteria.11,15

Our findings, however, must be contextualized. Because cisgender women in this cohort more frequently underwent vaginal hysterectomy than expected in national data, this may suggest relative comfort with vaginal surgery among this practice group.22 Therefore, although vaginal hysterectomy is possible among transgender men, and guidelines encouraging vaginal hysterectomy should be followed regardless of gender, we recognize vaginal surgery comfort and practice in this institution may preclude replication for any prospective patient.

Notably, abdominal hysterectomy use was still high in both groups, which we attribute to uterine size; the mean uterine size of those having an abdominal hysterectomy was 15.2 cm (standard deviation 5.3) and lack of laparoscopic morcellation devices at this hospital. This is reflected in our regression analyses, that uterine size significantly confounded the association between gender and operative route. Therefore, differences between operative routes and outcomes by gender may stem from the uterine size, and this should be considered in surgical planning for transgender patients.

Overall, transgender men and cisgender women undergoing hysterectomy were different in terms of baseline characteristics and indications for surgery, suggesting consideration of these groups as separate populations in future studies. One significant difference between genders was that pain was the leading surgical indication among transgender men. Because pain did not correlate with pathology among transgender men, we surmise that: 1) pelvic pain etiology among transgender men was not revealed in pathologic analysis and might reflect pelvic floor musculoskeletal changes or metabolic effects such as inflammation,23,24 2) reporting pain facilitated hysterectomy where there was actual or presumed insurance noncoverage for gender-affirming hysterectomy absent an anatomic indication, or 3) both. Increasing insurance coverage for gender-affirming procedures under the Affordable Care Act and other policies may one day affect surgical indications for transgender men.

Study strengths lie in comprehensive determination of gender, comprehensive medical chart review, and that our patients were those presenting to a nonsubspecialty gynecology practice in an urban county hospital. Limitations include that gender identity is not routinely assessed nor collected from patients directly. Given frequent nondisclosure and poor capture of transgender identity in health care, our case series likely represents an undercount of transgender men.25–28 In addition, we were unable to assess changes in baseline symptomatology given follow-up based on complication-associated representation. Finally, the academic practice presented may differ from general practice.

We demonstrate that nonsubspecialty-trained gynecologists can perform vaginal hysterectomies for transgender men. Making this procedure accessible to transgender men has added benefit for this community. Prospective investigations are needed to understand gynecologic gender differences and comparative safety and acceptability data on route of hysterectomy for transgender men. Investigation is warranted into the motivations for hysterectomy, etiologies of pelvic pain, and postoperative satisfaction.

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