Hysterectomy

This page provides a brief summary of a gender affirming hysterectomy and offers guidance to help you support your trans patients if they undergo this surgical intervention.

Hysterectomies are typically sought by trans people who were presumed female at birth (PFAB), including men and non-binary people, to stop menstruation, remove any possibility of pregnancy, or for other health issues. Not all trans people want, seek or can have surgery, and being trans doesn’t necessitate surgery either. Find out more about that here.

Information for community members about hysterectomies is available here.

The Standards of Care - 7th Ed (SoC7) is published by the World Professional Association for Transgender Health (WPATH) and offers guidance to clinicians working with trans patients all over the world, including criteria and recommended referral pathways for those seeking particular medical and surgical interventions.

The SoC7 does not specify an order by which surgeries should occur, if sought at all, and are guidelines, not legislated requirements.

WPATH state that a hysterectomy is considered “a medically necessary component of gender affirming surgical therapy for those transgender men who choose to seek this procedure.”

There are several kinds of surgical options, and the procedure chosen will depend on the surgeon’s expertise and the physical capacity, and needs, of the patient.

Hysterectomy options include:

• Full hysterectomy - removes all parts of the uterus, cervix, fallopian tubes, and ovaries

• Partial hysterectomy - removes the uterus and fallopian tubes but not the cervix

• Oophorectomy - removes the ovaries only

The three surgical approaches to a hysterectomy are:

• Abdominal laparotomy, which involves an incision in the lower abdomen

• Transvaginal, which involves removing the uterus through the vagina or front hole

• Abdominal laparoscopy, which involves a small incision near the belly button

Before surgery

At appointments in the lead up to surgery, your patient might like to discuss their expectations and concerns, as well as their hopes and fears. It will be important to have an open conversation about what surgery can and cannot do. They may have been waiting many years for this particular surgery and feel that they have a lot riding on it. They may not be part of a supportive network or could be the centre of a thriving friendship circle. They might be clear about what they need from you, or really unsure. 

Your patient will also need to be referred to a mental health professional for support and assessment to confirm readiness for surgery.

Finding comprehensive, evidence-based information about gender affirming surgical processes can be a challenge, and so your patient might benefit from your additional research, including contacting a specific surgeon, if requested, or connecting with other health professionals to better understand and explain the process, possible complications, risk factors and outcomes. 

It’s also likely that a patient’s GP will be the first point of contact for any post-surgical care and complications, so having a sense of what might be happening, and being able to engage with additional clinician peer networks could prove advantageous. 

Surgery location

If your patient is contemplating surgery in Australia, it is prudent to encourage them to obtain private health insurance when and if they can afford it. This will help cover some of the costs such as the hospital stay. Their surgeon will be able to provide the applicable MBS Item Numbers that can be checked with the health insurer. 

If a patient is considering having surgery overseas, they will very likely appreciate a discussion about the benefits and risks of travelling overseas for surgery. This can be complex, especially if the surgery they’re seeking is not performed, or widely available, in Australia. 

For some patients, benefits can include cost saving, particularly if they’re not able to access private health insurance or Medicare in Australia, having greater choice of surgeons and being connected to a global community of trans people (we do a great job of offering comprehensive surgical reviews to the community).

Risks tend to arise from a lack of access to post-surgical care, including being able to effectively, and efficiently treat complications. Additional complications can arise if a patient is not being able to take the requisite time off work or study, and inadvertently damaging the surgical site. 

Around surgery

Around the point of surgery, the surgeon and their staff will typically be supporting the patient through any fears and complications.

Some surgeons require patients to decrease hormones, particularly estrogen, for a period of time in the lead up to, and immediately following, surgery. Your patient may want to discuss time-frames, expectations, and potential side effects from this. 

After surgery

As well as providing regular post-surgical care for your patient, you might find yourself supporting them through learning how their body now functions and feels.

Even if a surgical outcome is affirming for people, it can still be confronting. Discuss with your patient that it is normal to feel excited, but also very normal to feel overwhelmed, uncomfortable, to grieve, and to take time to become used to their body again. This isn’t an indication that they have made a mistake, or regret their decision, but a normal part of reconnecting with how their body appears and functions.

It can also be valuable to discuss how sensation may change, and what this might feel like. Having an honest conversation about how your patient will need to learn this for themselves over time can be helpful too. Refer to peer networks or a mental health professional, as needed.

Once post-surgical pain has settled, nerves and sensations might be altered. If the patient wants to have receptive frontal sex, this feeling can be different to how it felt prior to their surgery. Patients may experience increased dryness and benefit from a short course of topical estrogen cream. Some patients may need a dose or cycle adjustment to their testosterone regime, if applicable. Regular monitoring of trough testosterone levels will be helpful. 

Healing can take months, and how they feel may change throughout that period of healing, and afterwards.