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A Technical Guide to Gender-Affirming Hysterectomy

Medically reviewed by Nicole M on October 3, 2024.

Gender-affirming hysterectomy is a surgical procedure that involves the removal of the uterus. Transgender, non-binary and gender expansive patients with a uterus may benefit from this procedure to alleviate the gender dysphoria or discomfort associated with the presence of their natal reproductive organs. In some cases, this procedure may help toaddress issues with pelvic pain, abnormal uterine bleeding, or precancerous cervical conditions [1]. Since Dr. Ley (she/her/they) does not perform this procedure, we recommend that patients undergo a hysterectomy with a gynecological surgeon at least 8-12 weeks prior to their bottom surgery procedure. At this time, the GCC does not offer hysterectomies. This article provides information on important preoperative considerations, surgical options and the recovery process.

What is a hysterectomy?

A hysterectomy generally involves the surgical removal of the uterus and the cervix (total hysterectomy) but the cervix can also be preserved (partial hysterectomy). If the cervix is removed, the upper part of the vaginal canal is sutured closed to form a vaginal cuff and provide support to surrounding structures. Additionally, patients can also opt to have other reproductive organs removed such as the fallopian tubes (salpingectomy) or ovaries (oophorectomy) as part of gender-affirming surgical care for transgender and non-binary individuals. That said, a full or partial oophorectomy is not obligatory.

Given that hysterectomies, salpingectomies and oophorectomies affect a patient’s fertility, we strongly encourage all of our patients to look into fertility preservation options prior to surgery.

Navigating the procedure: A step-by-step guide to undergo surgery

Gender-affirming hysterectomy is a surgical procedure that requires careful planning and preparation. The process typically involves the following steps:

• Support Letter: Generally speaking, to get insurance to cover your gender-affirming surgery,  you will need to present a support letter from one or two licensed mental health professionals. At this time, the GCC does not offer hysterectomies. Please check with your OBGYN and your insurance provider to see what their specific requirements are for candidacy and coverage.
• Pre-Operative Evaluation: To get a surgery date, individuals will often need to undergo a comprehensive medical assessment, which includes physical examinations, diagnostic or laboratory tests, and discussions with healthcare providers to ensure that you are physically and emotionally ready for the surgery. Since the GCC does not offer hysterectomies at this time, please consult with your OBGYN about their requirements for undergoing this procedure.

• Physical exam: While this may be uncomfortable for some, a physical examination will be performed to assess for other pelvic or cervical conditions, which can include a Pap smear as part of the examination.
• Diagnostic and laboratory tests: An ultrasound may be performed to evaluate the uterus and ovaries to determine any abnormalities, especially if the patient has any abnormal bleeding or other symptoms that need to be assessed.  Routine laboratory testing can also be done as part of this process or as part of a pre-operative clearance for surgery.

What procedures can accompany a hysterectomy?

Many patients who are interested in a metoidioplasty or phalloplasty are also interested in getting their uteruses removed. Generally speaking, we recommend that patients undergo a hysterectomy 8-12 weeks prior to another bottom surgery procedure since we do not offer this procedure at this time.

Your surgical options explained: How is a hysterectomy performed?

Hysterectomies are usually performed in a hospital setting under general anesthesia. Different surgical approaches can be used to perform the procedure based on an individual’s specific needs. Minimally invasive techniques through a vaginal or laparoscopic approach are most commonly performed due to faster recovery times and less visible scarring [2]. Regardless of the technique used, any organs that are removed from your body will be sent for pathology testing to screen for any abnormalities. For specific questions on the cost of your hysterectomy, please consult with your OBGYN as we do not offer this procedure at this time.

Below are the techniques that can be used for this procedure:

• Vaginal hysterectomy: This approach involves removing the uterus through an incision made in the vaginal canal. Patients are positioned to lie on their back with their legs separated and placed on stirrups. Similar to a Pap smear, a speculum is inserted in the vaginal canal in order to perform the procedure. No incisions are made on the abdomen unless a camera (laparoscope) is used for more visualization.
• Laparoscopic hysterectomy: A small incision (10-12mm) is made near the umbilicus (the naval or belly button) along with two to three smaller incisions (5mm) in different areas of the lower abdomen that serve as ports where a small camera (laparoscope) and surgical instruments can be inserted to perform the procedure. Carbon dioxide gas is used to slightly inflate the abdomen to allow for better visualization of the abdominal cavity and create some space to maneuver the camera and instruments inside the abdomen. The uterus is surgically removed from its surrounding structures and pulled out of the body through the incision near the umbilicus or through the vaginal canal. Then, the instruments and camera are removed and the abdomen deflated before the incisions are closed. Robotic systems can also be used to assist during the procedure for better precision (robotic-assisted laparoscopic hysterectomy).
• Abdominal (or open) hysterectomy: This approach is not as commonly performed unless there are any indications (i.e., larger uterus, other pelvic conditions, etc) in which a minimally invasive approach is not feasible. The procedure usually leaves a more noticeable scar in the lower abdomen (10-20 cm) in order to remove the uterus.

Surgical recovery: Post-operative care

Following any surgical procedure, patients will receive specialized aftercare instructions to manage pain and inflammation, monitor for complications, and support their healing. The following are general aftercare guidelines for hysterectomy patients. That said, your surgeon may have specific recommendations that should be taken into consideration [3].

• Same-day discharge: Patients can typically expect to go home the same day after surgery if they have good pain control and can urinate after removing the urinary catheter.

• Recovery times: Patients can expect to be in recovery for 2-4 weeks. During this time, they should avoid heavy lifting (>10 lbs) or straining. Patients will be advised to observe pelvic rest or avoid inserting anything in the vaginal canal for 6-8 weeks post-op to minimize infection or delayed healing.

• Post-op vaginal bleeding: Within the first week after surgery, patients can expect to have vaginal spotting or discharge that can appear red, pink, brown, or yellow as stitches dissolve internally. An occasional blood clot or more bleeding may occur when standing up or after urinating but heavy bleeding that completely soaks a large pad within an hour should warrant a call to your surgeon.
• Shoulder pain: Aside from the pain or discomfort expected from having surgery, some patients may experience shoulder pain from the gas used to inflate the abdomen during a laparoscopic procedure. The increased pressure in the abdomen can stretch or irritate the diaphragm and transmit a sensation of pain through nerves near the shoulder area. This usually resolves in a few days and can be managed with post-op pain medications.

Pre-Surgical Considerations for Transgender and Non-binary Individuals 

As transgender individuals navigate gender-affirming hysterectomy, there are several unique considerations to address:

• Fertility Preservation: Individuals who may wish to have biological children in the future should explore options to preserve fertility before undergoing sterilization procedures. While patients can opt to keep their ovaries when undergoing a hysterectomy to maintain the potential of having biological children, it is crucial to discuss how this affects chances of fertility in the future. Additionally, we highly encourage patients to consult with reproductive specialists to consider other fertility preservation options, such as freezing ovaries, eggs, or embryos. You can learn more about fertility preservation here.
• Hormone Therapy: If patients opt to remove their ovaries, hormone replacement therapy (i.e. estrogen, testosterone, or both) may be necessary to minimize cardiovascular risks and adverse effects on bone density [4]. Patients taking testosterone may need to adjust their dose following an oophorectomy and should consult with an endocrinologist or their healthcare provider after surgery.
• Support and Resources: Aside from the physical assistance required to recover from surgery, patients should have access to a comprehensive network of support, including mental health professionals, support groups, and community resources, to help with any emotional or psychological aspects of the recovery process.

Benefits for Physical and Mental Well-being

A gender-affirming hysterectomy can bring many physical and emotional or psychological benefits to patients. These include:

• Improved physical and emotional well-being: The procedure can alleviate physical symptoms like pelvic pain or abnormal bleeding that may also cause emotional distress as these can trigger feelings of gender incongruence. Not to mention, for many patients, a hysterectomy can allow for the removal or prevention of uterine cancer and/or the alleviation of physical pain.
• Reduced gender dysphoria: This procedure may also help diminish feelings of discomfort around the presence of reproductive organs that do not align with a patient’s gender.
• Enhanced quality of life: By aligning their physical body with their gender identity, transgender individuals can experience an increased sense of confidence, self-esteem, and overall life satisfaction, empowering them to live more authentically.

References

1. Cao, Connie D. MD; Amero, Molly A. MD; Marcinkowski, Katrina A. MD; Rosenblum, Norman G. MD, PhD; Chan, Joanna S. Y. MD; Richard, Scott D. MD. Clinical Characteristics and Histologic Features of Hysterectomy Specimens From Transmasculine Individuals. Obstetrics & Gynecology 138(1):p 51-57, July 2021. | DOI: 10.1097/AOG.0000000000004421 
2. Louie, M., Moulder, J.K. Hysterectomy for the Transgender Man. Curr Obstet Gynecol Rep 6, 126–132 (2017). https://doi.org/10.1007/s13669-017-0211-5
3. Patient education: Care after gynecologic surgery (Beyond the Basics) – UpToDate
4. SOC8 Homepage – WPATH World Professional Association for Transgender Health