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.
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).
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.
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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