Gender Affirming Gynecologic Surgeries

Hysterectomy & Oophorectomy

Hysterectomies (the removal of the cervix and uterus) and oophorectomy (ovary removal) are additional surgical options that may be part of someone’s gender affirming process. Talk to your provider to see if you are a candidate for one or both of these services.

Wpath Standards Of Care

The providers follow the WPATH Standards of Care, which recommend two letters from qualified mental health care providers prior to the surgery.

WPATH Criteria for Hysterectomy/Oophorectomy

Persistent, well-documented gender dysphoria;
Capacity to make a fully informed decision and to consent for treatment;
Age of majority in a given country;
If significant medical or mental health concerns are present, they must be well controlled;
Twelve continuous months of hormone therapy as appropriate to the patient’s gender goals (unless hormones are not clinically indicated for the individual).

The aim of hormone therapy before gonad removal is to give the patient a period of estrogen or testosterone suppression that can be reversed before they have a surgery, which is not reversable.

What To Expect At Your First Appointment

At your first appointment, you will meet your gynecologic surgeon. With the surgeon you will:

discuss your ideas of what gender-affirming surgery means to you,
discuss options for retaining fertility,
complete a medical history, and
discuss insurance requirements (letters of support).

If you have been sexually active with a partner with a penis, they will need an up-to-date pap smear (this is not required for oophorectomy).

All patients will need a brief pelvic exam to confirm route of surgery. (The route of surgery is the entry point the surgeon uses: through your abdomen or vagina via laparoscopy.) You will not necessarily need a pap smear and/or pelvic exam on the day of initial consultation but may have one if there is time.

Who Is A Good Candidate For A Hysterectomy?

Almost all patients can undergo a hysterectomy. Conditions that could make this surgery difficult, however, include endometriosis or large fibroids. These conditions could also increase the risk of complications or require that we bring in another type of surgeon.

Obesity, particularly if you have a BMI greater than 40, can make hysterectomy surgery more challenging. We recommend that you work on weight management before your surgery; however, it is not an absolute requirement.

Risks and Side Effects

If you have scar tissue (adhesive disease) from previous procedures or severe endometriosis, this can increase the risk of injury to a patient’s abdominal and pelvic organs. While these injuries can be repaired, they can extend the recovery period and may even require additional surgical procedures.

There is also a risk of:

bleeding, which can require blood transfusion.
injury to the abdominal and pelvic organs, which can require an additional surgical procedure.
infection, which can require oral or IV antibiotics, as well as percutaneous drain placement.
change in surgical approaches to an abdominal approach, which requires the surgeon to make a larger abdominal incision.

Preparation For Surgery

Day Before Surgery

You will not need to do any preparation on the day before surgery. You will need to stop eating or drinking anything at midnight the day before surgery.

During Surgery

Laparoscopic Hysterectomy

To begin this procedure, the surgeon inserts an instrument (a uterine manipulator) into the uterus. There is a cup on the end of the instrument that we advance into the vagina to surround the cervix.

For patients who have never been sexually active through vaginal penetration, we typically need to make an incision along the perineum (the tissue between the vaginal opening and the anus) to advance the cup. This incision is similar to an episiotomy, which we repair at the end of the procedure.

We then insert a needle into your abdomen and inflate the abdomen with CO2. This creates more room for the surgeon to operate in. Following that, we insert three to four laparoscopic trocars into the abdomen. (Trocars are hollow tubes that instruments can pass through.) Through the trocars, we insert a camera and other operative instruments. We seal off and cut the blood supply to the ovaries if we are removing the ovaries.

If we are not removing your ovaries, we detach the uterus from the ovaries. We then seal and cut the blood supply to your uterus. We then incise the vagina in a circular fashion where it meets the cervix.
After this we remove the uterus, cervix, fallopian tubes, and ovaries through the vagina. Then the top of the vagina is closed.

Upper Vaginectomy With Hysterectomy

Patients planning on having a metoidioplasty or phalloplasty may also have an upper vaginectomy at the same time as a hysterectomy. This involves collapsing and sealing off the upper half of the vagina.

If you have had one or more vaginal deliveries, you may be a candidate for a vaginal hysterectomy, in which the entire surgery is completed through the vagina.

Recovery From Surgery

Leaving After Surgery

Many patients can go home the same day, but all patients have the option to stay until the morning after surgery. If you stay, you will be on a mixed gender recovery floor.

We will discharge you from the hospital with a mild narcotic, prescription-strength NSAIDs, and a stool softener. You can expect to need the mild narcotic for up to one week, and the NSAID for up to two weeks. You should use the stool softener as long as you are taking the narcotic.

Your incisions will be covered with skin glue or steri-strips. You will not need any stitches removed.

Recovery Time

Hysterectomy/Vaginectomy: Total healing time is six weeks, but you can resume most of your normal daily activities within two weeks. You cannot:

lift anything great than 10 pounds,
submerse yourself in water, use tampons, or
have vaginal penetration for six weeks.

Oophorectomy: The recovery time for oophorectomy is only two weeks.

Returning to Work

Patients who work at a desk or have some flexibility to their work schedule can often return to work within two weeks. If your job requires you to do a lot of lifting, bending, or stooping, you may want to take six weeks off.

While most patients are not in pain at two weeks after surgery, they may find themselves tired by early afternoon, which can make it difficult to return to full time work at two weeks.

Post-Op Care

You can shower the same day as surgery, but should not take a bath for six weeks. You must also let your pelvis rest for six weeks, which means no tampon use or vaginal intercourse. Patients can expect up to two weeks of light vaginal spotting, for which you can use a panty liner or light pad.