The hysterosalpingo-oophorectomy is a type of surgery where the uterus, fallopian tubes and ovaries are excised from the patient. In general, the indication for this type of surgery or for a partial surgery may vary from the treatment of gynecologic neoplasia, fibromas, to endometriosis, to uterine prolapse. Hysterectomy alone is a common surgery and the most common surgery in the gynecologic field after the cesarean section, with over 600,000 surgeries performed every year in the USA alone.
Based on the clinical presentation, it might be sufficient to remove only some, or part of the organs and the surgeries are known as:
- Hysterectomy, which involves the removal of the whole uterus
- Salpingo-oophorectomy, which is the removal of an ovary and its fallopian tube on one side
- Partial Hysterectomy, known also as subtotal hysterectomy or supracervical hysterectomy which is the removal of the uterus leaving the cervix intact in place.
All of these surgeries cause irreversible infertility.
In this blog post we will talk about one specific case: hysterosalpingo-oophorectomy, the removal of both ovaries, fallopian tubes and the whole uterus in the specific case of the FtM transgender patient in the context of sex reassignment surgery (SRS).
Why having the hysterosalpingo-oophorectomy in FtM SRS?
The main and obvious reason for which transgender males chose this surgery is to remove the sexual organs of the gender assigned at birth and not congruent with their gender identity, which is a cause of dysphoria, meaning a negative mental state which can result in depression, anxiety, and other psychiatric conditions. In this specific case it is known as gender dysphoria.
Moreover, hormone replacement therapy (HRT) with testosterone causes modifications in the tissues and it may lead to developing symptoms similar to PCOS (polycystic ovary syndrome) and endometrial hyperplasia with risk of developing tumors of the endometrium and of the ovaries. Being the FtM transgender population limited in numbers with most patient opting early for this type of surgery there are no definitive long-term studies on the effects that HRT can have on the uterus and ovaries. Hence, the previous is just a supposition based on the data currently available.
Another reason to undergo this surgery is that once you remove the female reproductive organs, there is no more estrogen production by the ovaries, which allows for a lower dose of testosterone to be taken for transitioning.
Fourth reason to choose the bilateral hysterosalpingo-oophorectomy in the FtM transitioning is that once they undergo this surgery, the patient does not have to worry anymore about having regular gynecological examinations nor about performing pap smear tests. These are often crucial factors in the decision to undergo this surgery since the transgender man generally feels uncomfortable or embarrassment due to having to undergo such examinations and getting rid of this duty often relieves the patient and eliminates a source of bad feelings. Furthermore, the removal of the female reproductive organs ends any chronic or possible future gynecologic issue, from menstruations, to abdominal cramps, to bleeding and pain.
It’s good to reiterate though that this surgery leads to the definitive, irreversible inability to bear children and should be chosen only by the transgender men who do not wish to maintain their fertility. Cryopreservation of the oocytes is an option to consider for those who do not want to completely lose the ability to procreate and should be discussed with the treating physicians.
Types of hysterectomy and salpingo-oophorectomy: the different options
There are several different surgical approaches for the hysterectomy. The choice depends upon several factors: the anatomical characteristics of the patient, the surgeon’s knowledge and experience, whether or not other surgical procedures are performed at the same time such as the vaginectomy, metoidioplasty or phalloplasty, and from the specific reason the patient is undergoing this surgery.
- Total abdominal (laparotomic) hysterosalpingo-oophorectomy
- Total laparoscopic hysterosalpingo-oophorectomy
- Total Vaginal hysterosalpingo-oophorectomy
- Laparoscopically assisted vaginal hysterosalpingo-oophorectomy
- Total robotic hysterosalpingo-oophorectomy
1. Total abdominal (laparotomic) hysterosalpingo-oophorectomy
The laparotomic technique, also known as TAH, is the most traditional and invasive technique available, but sometimes it is a necessary choice and it is advisable over other surgical techniques, such as in the case of large and widespread tumors that need to be excised. It requires a long incision between 12 and 30 cm long (5-12 inches) that can be made horizontally or vertically based on variables about the surgery and the patient. The laparotomic approach might also be required when difficulties emerge during a laparoscopic surgery. The surgery lasts about 1-3 hours and it is highly invasive, requiring an inpatient stay at the hospital of about 5 days and 6 to 8 weeks before full recovery and going back to all regular life activities without restrictions. The scar will be visible, but surgeons usually try to perform an horizontal incision right over the pubic line (Pfannenstiel incision); although visible and long, this way it should be easily concealable in public being covered by clothes or even by swimming suits.
2. Total laparoscopic hysterosalpingo-oophorectomy
The laparoscopic approach, known also as TLH, is usually the preferred and first choice for the FtM transgender patients.
The surgery requires general anesthesia. An incision long about 1 cm is made at the belly button, to minimize the aesthetic damage and make the scar almost invisible; through that incision the fiber optic is inserted, allowing for the visualization of the abdominal organs. To have a better visual, the abdomen is inflated with carbon dioxide (CO2). Three more incisions, about 0,5cm long, are then made: one suprapubic, on the median line of the abdomen which will be covered by pubic hair, and two suprailiac incisions, one on each side, right above the iliac crests and often made asymmetrically to make it less likely for a lay person to recognize them as obvious surgical scars. These incisions are where the surgical instruments are inserted and from them all anatomical structures, dissected first, will be extracted.
By using this surgical technique, blood loss is halved when compared to the laparotomic approach. Surgery lasts 1-3 hours and requires an in-hospital stay of 1-2 days. Post-op recovery is faster too with this technique, averaging 2-4 weeks before being able to go back to everyday activities.
3. Total Vaginal hysterosalpingo-oophorectomy
The total vaginal hysterosalpingo-oophorectomy, known also as TVH, involves the extraction of the reproductive organs through an incision made in the vagina. The whole surgery is carried out through the vaginal incision, thus leaving no obvious scar and having a better aesthetic result than the previous two techniques. The absence of abdominal incisions though, makes it harder to access the abdominal cavity for the surgeon, who might not be able to carry out the surgery in the presence of abdominal adhesions, or who might not be able to visualize and examine the tissues in the presence of endometriosis; this approach also increases the risk of inadvertent internal injuries and makes it harder to extract the ovaries, with higher chances of post-op complications. Being a surgery completely carried out through the vagina, it is easier to perform in the presence of vaginal laxity, which is common among multiparous women (those who had multiple pregnancies), but it is rarely the case of FtM transgender men who in almost all cases are nulliparous.
This surgery lasts about 1-3 hours with an in-hospital stay of about 1-5 days. Post-op recovery is about 6-8 weeks before being able to get back to everyday activities without restrictions.
4. Laparoscopically assisted vaginal hysterosalpingo-oophorectomy
The laparoscopically assisted vaginal hysterosalpingo-oophorectomy, known also as LAVH, combines two of the above surgical approaches which are TVH and TLH. The fiber optic and the surgical instruments are inserted through small abdominal incisions, as in TLH, but the uterus and the other organs are removed through an incision made in the vagina as in TVH.
Surgery lasts about 1-3 hours and requires an in-hospital stay of about 1-2 days. Post-op recovery is about 4 weeks long before being able to get back to everyday activities without any restriction.
5. Total robotic hysterosalpingo-oophorectomy
This procedure is similar to TLH, with the difference of being carried out with a surgical robot. It is a minimally invasive technique and the surgeon remotely controls the robot, instead of directly moving the instruments. This allows for greater precision of movements and a more precise execution of the surgery, which would not be possible with just human hands and arms. Surgery lasts a bit longer than with traditional methods, about 2-4 hours in total and has an higher cost; it requires 5 incisions instead of 3 or 4, and the incisions will be 8-12mm long instead of 5mm. As of today there is no clear evidence of the superiority of this technique when compared to TLH, reason for which medical associations such as the American College of Obstetricians and Gynecologists (ACOG) don’t advise this procedure, preferring TLH instead.
After surgery the patient might feel a little disoriented, this is a common and temporary side effect of anesthesia. Before surgery a urinary catheter will be inserted as well as one or more venous catheters for the IV administration of fluids and medications. Venous thrombosis prevention systems will be used too, such as compression stockings or an intermittent pneumatic compression device. Early mobilization is encouraged, so the patient will be helped to get up from bed and move around early with caution for a faster recovery.
Pain is subjective but will be controlled with medications; it will be caused by the surgical incisions, but it is possible to feel pain or discomfort at the level of the shoulder or diaphragm due to the distention caused by the CO2 when inflating the abdomen. Third and last cause of discomfort will be the bowels, with possible cramps when it will get back to its normal activity, about 24-36 hours post-op.
Risks and complications of the hysterosalpingo-oophorectomy
As any other surgery this procedure carries some variable risks based on the characteristics of the patient and the technique used by the surgeon. Among these, there are the risk of bleeding, infection, risks related to the administration of anesthesia and deep vein thrombosis. Among the possible complications there are the development of irritable bowel syndrome (IBS), incontinence, accidental damage to the intestine or urethra, formation of abdominal adhesions, chronic pain and prolapse.
Criteria for hysterosalpingo-oophorectomy in the female to male transition
The Standards of Care 7th edition of the World Professional Association for Transgender Health (WPATH) set the following criteria for accessing this type of surgery:
- Persistent and well documented diagnosis of gender dysphoria
- In full possession of one’s faculties. Able to make a fully informed decision and to give consent for treatment.
- Age of majority in a given country.
- The absence of absolute medical contraindications (medical conditions which would make it too risky to perform the surgery).
- 12 continuous months of hormone replacement therapy with testosterone, unless not clinically indicated for the patient
These criteria do not apply to patients having these surgical interventions for reasons other than gender dysphoria.
The reason for which hormone replacement therapy is set as a criterion is to allow the patient to experience testosterone and the suppression of estrogen in a reversible way, before committing to invasive and irreversible surgery.
- World Professional Association for Transgender Health – Standards of Care 7th ED
- Transgender Medicine: A Multidisciplinary Approach.
Leonid Poretsky, Wylie C. Hembree. Springer, 2019
- Principles of Transgender Medicine and Surgery, second edition.
Randi Ettner, Stan Monstrey, Eli Coleman. Routledge, 2016.
- Management of Gender Dysphoria
Carlo Trombetta, Giovanni Liguori, Michele Bertolotto. Springer, 2015
- Complication Rates and Outcomes After Hysterectomy in Transgender Men.
Bretschneider CE, Sheyn D, Pollard R, Ferrando CA – Obstetrics & Gynecology Journal, Nov 2018
- Total Laparoscopic Hysterectomy for Female-to-Male Transsexuals
O’Hanlan KA, Dibble SL, Young-Spint M – Obstetrics & Gynecology Journal, Nov 2007