Indications and contraindications
Transgender men (F/M) with a well-documented diagnosis of gender dysphoria who wish to undergo an irreversible procedure to remove the uterus and adnexa (hysterectomy with salpingo-oophorectomy). Indications are typically established by a psychiatrist or sexologist who conducts assessments, orders diagnostic tests, and prepares documentation confirming gender dysphoria. Patients should meet all criteria set out in the WPATH Standards of Care (SOC) to be considered surgical candidates. In addition, other medical considerations must be taken into account. Long-term exposure to testosterone may also constitute an additional indication for hysterectomy. Based on medical literature and oncologic experience, we inform F/M patients that prolonged testosterone therapy may increase the risk of malignant changes in the upper female reproductive tract. Some evidence also suggests that testosterone exposure can increase the risk of abnormal uterine bleeding in certain individuals, which may likewise be an indication for hysterectomy.
The Standards of Care for transsexual, transgender, and gender-nonconforming people (SOC), published by the World Professional Association for Transgender Health (WPATH), are professional guidelines that set recommendations for gender-affirming surgery (GAS) in transgender patients. The SOC are specific in certain recommendations, such as advising at least one year of hormone therapy before gonadectomy, to allow a period of reversible changes in appearance before an irreversible operation.
Indications for hysterectomy / removal of the uterus and ovaries in F/M patients
- A document with PESEL confirming gender data or a final civil court judgment
- For non-Polish citizens: two letters from mental-health professionals experienced in transgender care
- Persistent, well-documented gender dysphoria for at least 2 years
- Capacity to make a fully informed decision and provide consent
- Age 18+
- Any significant medical or mental health conditions are well treated and controlled
- Twelve months of continuous hormone therapy aimed at inducing gender characteristics (unless hormones are not clinically indicated for the individual)
The SOC do not prescribe a fixed order in which transition-related surgeries must occur. The number and sequence of procedures may vary depending on each patient’s unique needs and on how they choose to coordinate their treatment plan with the care team. Many patients opt to undergo gonadectomy—removal of the internal reproductive organs—as the second procedure in their sequence.
Fertility
Hysterectomy is a surgery in which the gonads—ovaries—are permanently removed, eliminating the possibility of having genetically related children in the future. As part of due diligence before surgery, we usually advise trans men (and AFAB non-binary people) to consider fertility-preservation options. In line with transparency and medical ethics, we inform every patient about the possibility of retaining the uterus and using advanced assisted-reproduction technologies to experience parenthood later. A patient may choose oocyte retrieval with cryopreservation before or during surgery. Preserved oocytes can then be used for in vitro fertilization or transferred to a partner’s uterus or a gestational surrogate. Patients should be aware that a break from testosterone therapy is typically required during preparation for and performance of these procedures.
If a patient decides, for example, to become pregnant, testosterone therapy cannot be continued throughout pregnancy. Finally, cost considerations should be discussed: assisted-reproduction technologies can be expensive and are typically not covered by insurers.
Preoperative assessment of the patient
Preoperative assessment for hysterectomy/oophorectomy includes a discussion of the patient’s future plans for Genital Reconstruction Surgery (GRS). The scope of surgery is reviewed during the preoperative consultation. There are several variants of hysterectomy. Removal of the uterus can be performed at the same time as chest reconstruction, vaginectomy with perineal closure, or both. If a trans man (or AFAB non-binary person) wishes to pursue phalloplasty, they may choose to have the vagina removed during one of the staged procedures. Some surgeons, however, prefer performing the vaginectomy at the time of phalloplasty, because vaginal mucosa is often used for urethral lengthening during creation of the neophallus.
Preparation for surgery
Removal of the uterus with the ovaries and/or the vagina is a complex operation and requires preparation according to medical guidance. Certain factors affect wound healing and cosmetic outcomes. Candidates who smoke and/or have excess weight are advised to stop smoking and reach a healthy BMI before surgery. Conditions that impair healing (e.g., diabetes) should be appropriately treated and medically controlled prior to the procedure.
In the perioperative period, hormone therapy may be paused at least 2 weeks before surgery. Supraphysiologic testosterone levels can increase serum estrogen via aromatization, which may potentially raise thromboembolic risk. However, the overall incidence of thromboembolic events in transgender patients is low. The decision to hold hormone therapy is individualized—based on patient preferences and the surgical team’s judgment in consultation with an endocrinologist. Perioperative VTE prophylaxis includes heparin-based agents, mechanical measures (sequential compression devices, compression stockings), and early mobilization/physiotherapy. Antibiotic prophylaxis is recommended, covering Gram-negative, Gram-positive, and anaerobic organisms.
Surgical technique: total hysterectomy with bilateral salpingo-oophorectomy.
Total hysterectomy involves complete removal of the uterus and cervix and, in transgender patients, is typically performed together with removal of the fallopian tubes and ovaries. The operation can be performed via an open approach or laparoscopically, depending on indications and patient preference.
Published data show that, unfortunately, many patients present to centers without experience in transgender care, where removal of reproductive organs is performed as it would be in post-menopausal women—for example, without removing the cervix. This significantly complicates subsequent reconstructive treatment and creates a real risk of cervical cancer.
1. Metoda laparoskopowa
For patients without contraindications to laparoscopy, a total laparoscopic hysterectomy (TLH) is recommended. Advantages include an excellent cosmetic outcome by avoiding a long lower-abdominal scar. Laparoscopy may reduce postoperative pain and, when performed in centers experienced in team-based care of trans men, preserves structures often essential for later reconstruction—such as the inferior epigastric vessels and rectus muscles.
Vaginal hysterectomy, although minimally invasive, can be challenging in trans men because the pelvis may resemble that of a nulliparous woman, and the vaginal canal can show marked atrophy due to testosterone. In some patients, a vaginal hysterectomy may be effectively equivalent to an open procedure.
The operation is performed under general endotracheal anesthesia, with the patient in the dorsal lithotomy position. After skin and vaginal antisepsis, a Foley catheter is placed in the bladder. A uterine manipulator is inserted vaginally and secured to the cervix with a stitch through the device’s ring. Pneumoperitoneum is then created by insufflating gas into the abdominal cavity via a needle. The pneumoperitoneum provides visualization of the pelvic organs. In many TLH techniques a periumbilical port and three trocars are used; the number and location of ports are adjusted to uterine size and any coexisting intra-abdominal pathology.
The goals include lysis of any intra-abdominal adhesions, followed by removal of the adnexa (fallopian tubes and ovaries), when indicated. Uterine supporting ligaments are divided; the broad ligaments are opened to identify the ureters; the bladder is dissected off the uterus (and anterior vaginal wall), and the rectum is mobilized posteriorly as needed. Once adequate mobilization is achieved, the uterine vessels are sealed and transected. The uterus and cervix are then separated from the vaginal cuff. Monopolar cautery or a harmonic scalpel may be used for colpotomy and specimen detachment. The uterus is removed transvaginally; alternatively, an extraction sleeve/specimen bag can be used. If the uterus is too large to pass vaginally—which may occur less often in trans men and AFAB non-binary patients—a mini-laparotomy can be performed. The uterosacral ligaments may be incorporated during closure of the vaginal cuff. All instruments and ports are removed and the incisions are closed.
Total laparoscopic hysterectomy with bilateral salpingo-oophorectomy (and, when required, a small-incision open approach) has a low complication rate. Compared with cisgender counterparts, trans men and AFAB non-binary patients often have smaller, lighter uteri, are younger, and have lower parity; these factors can contribute to reduced blood loss and shorter hospital stays. Reported complications are generally minor, such as urinary tract infection, allergic reactions, and transient leg hypesthesia.
Although TLH in transgender patients yields outcomes similar to those in cisgender women, there are specific challenges in FTM patients that must be considered. The combination of mucosal atrophy with a narrow, nulliparous-type vagina and long-term testosterone exposure often results in marked vaginal atrophy, making transvaginal laparoscopic access very difficult. Another technique for removing the uterus and adnexa through a narrow vaginal canal is to use uterine morcellation prior to extraction; however, this grinds the organ intra-abdominally and prevents thorough histopathologic assessment. Given reported cases of malignancy following such management, this method should be used only after careful preoperative imaging and evaluation. The best approach for a patient’s long-term health is to ensure a complete postoperative histopathological examination of the removed organ.
2. Metoda otwarta. Histerektomia z krótkim cięciem.
Striving for the best cosmetic outcome—the main argument in favor of laparoscopy—is not always optimal for a patient’s future care, and open procedures remain a good solution to several limitations of laparoscopy. Not infrequently, laparoscopy ends in conversion to an open procedure with a transverse incision; moreover, we are aware of cases in which, to facilitate laparoscopy, the organs were not fully removed.
An open operation allows a complete hysterectomy (with or without vaginectomy) through a relatively short incision, while safely removing the entire organ, maintaining good control over adjacent structures—ureters, bladder, rectum—and, crucially, enabling a full histopathological assessment. In our experience, patients are mobilized fully the next day and can return home independently. The open incision in our practice is placed low and is typically used later for penile reconstruction, so after completing the full transition there is no visible trace of the hysterectomy—only a discreet semicircular incision within the corona of the neophallus.
Open surgery is particularly important for people who plan further genital reconstruction. During this operation, preparatory steps are performed to enable subsequent stages of care. Elevating the bladder creates a favorable vesicourethral angle, which facilitates urination through the neophallus. Patients typically do not report voiding difficulties, urinary frequency, or urgency—which can be caused by bladder descent after laparoscopy. Open surgery also allows full control when removing the vagina from the pelvic floor, providing better protection of the bladder and rectum.
The choice of method is made by the patient after discussing these issues with the surgeon performing the hysterectomy.
Cancer risk
An important issue to discuss with trans men (and AFAB non-binary people) before hysterectomy is the need for regular cervical cancer screening. According to the American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines, there is no need to continue screening after hysterectomy unless there is a history of high-risk cervical dysplasia, HPV infection, or cervical intraepithelial neoplasia. If a patient has previously had CIN II or CIN III, the guidelines require continuing routine screening for at least 20 years from the time of diagnosis. Patients diagnosed with cervical cancer during preparation for hysterectomy should be referred to a gynecologic oncologist for appropriate evaluation and oncologic treatment.
Total hysterectomy with bilateral oophorectomy in adolescents
WPATH has published guidelines for medical and surgical care in adolescents. They group interventions into three categories: fully reversible, partially reversible, and irreversible. Fully reversible interventions delay the physical changes of puberty. Partially reversible interventions include hormone therapy. Irreversible interventions refer to certain surgical procedures. WPATH recommends that adolescents do not undergo surgery until they reach the age of majority for medical consent and have lived continuously for 12 months in a gender role consistent with their gender identity.
Our understanding of the challenges faced by young trans patients leads us to support their decisions regarding surgical care—most often removal of breast glands (“top surgery”). Provided there is a specialist-confirmed diagnosis of gender dysphoria sourceused“transsexualism”source used “transsexualism”sourceused“transsexualism”, at least 6 months of hormone therapy, the young person understands the treatment process and consents, and parental consent is obtained, we can proceed with such care. In the case of hysterectomy, we wait until the patient’s legal status has been settled.
Timeless Chirurgia Plastyczna
- ul. Gen. Abrahama 18/322
03-982 Warszawa - pon-pt: 9:00-19:00
- tel. (+48) 508 713 484
- klinika@timeless.com.pl