Preoperative Pain Symptoms and the Incidence of Endometriosis in Transgender Men Undergoing Hysterectomy for Gender Affirmation

Abstract

Study objective: To describe the incidence of pelvic pain in transgender men undergoing hysterectomy for gender affirmation and to describe the incidence of endometriosis found at the time of surgery.

Design: Retrospective chart review of transgender men presenting for gender-affirming hysterectomy between 2010 and 2019. Patients were identified by Current Procedural Terminology codes and documented male gender in the medical record, which was queried for perioperative data.

Setting: All patients underwent minimally invasive hysterectomy under general anesthesia by 2 surgeons at 2 institutions.

Patients: Patients were individuals assigned female at birth identifying as male who met the criteria for gender-affirming hysterectomy.

Interventions: Hysterectomy performed using preferred techniques by the surgeons in this study.

Measurements and main results: Sixty-seven (N = 67) patients underwent hysterectomy: 98.5% (66) total laparoscopic with salpingo-oophorectomy and 1.5% (1) total laparoscopic with ovarian preservation. Mean age and body mass index were 29(±8) years and 28.6(±6.7) kg/m², respectively. Of the patients, 89.5% (60) were on testosterone for a median of 36 (12-300) months: 59.7% (40) were amenorrheic, 43.2% (29) had dysmenorrhea, 17.9% (12) reported heavy menses, and 14.9% had irregular menses. Furthermore, 50.7% (34) complained of pelvic pain (35.3% constant, 64.7% cyclic). Intraoperative endometriosis was diagnosed in 26.9% (18) of the patients: in 32.3% of the patients who reported pelvic pain and in 21.9% of the patients without pain. There were no differences between patients with endometriosis compared with those without endometriosis except for those with endometriosis were more likely to report irregular bleeding (27.8% vs 8.3%, p = .04) and were also more likely to complain of heavy menses (66.7% vs 35.4%, p = .03).

Conclusion: Of the transgender men who presented for hysterectomy, 50% reported pelvic pain, but only 1 in 3 with pain had findings of endometriosis. Patients found to have endometriosis were more likely to report irregular bleeding and/or heavy menses.

Keywords: Gender dysphoria; Genital affirmation surgery; Pelvic pain.