Omission of Pelvic Examination Before Gender-Affirming Hysterectomy and Vaginectomy

Gender-affirming pelvic surgery for transmasculine individuals may include hysterectomy with or without salpingo-oophorectomy and vaginectomy. The preoperative pelvic examination is traditionally performed to guide hysterectomy route and anticipate challenges for gender-affirming vaginectomy. However, pelvic examinations may elicit gender dysphoria and are avoided by many transmasculine individuals, creating barriers to surgical care.1,2 As an alternative, noninvasive imagining modalities such as transabdominal ultrasonography have been used for uterine assessment.3 Additionally, virtual care allows for increased access to surgery, where pelvic examination is deferred to the operating room.4 We hypothesized that it is safe to omit an in-office, preoperative, internal pelvic examination before gender-affirming hysterectomy and vaginectomy. The objective of our study was to compare surgical outcomes of patients with and without an in-office, preoperative, internal pelvic examination before gender-affirming hysterectomy and vaginectomy.

METHODS

We conducted a retrospective cohort study of patients at a tertiary care academic medical center who underwent gender-affirming hysterectomy, hysterectomy with vaginectomy, or vaginectomy alone (with prior hysterectomy) between April 2018 and March 2022. No patients were excluded during our study period. We abstracted patient demographics and characteristics, including history of vaginal intercourse and testosterone therapy, from electronic medical records. Race, a social construct mediated through interpersonal and structural racism contributing to health care professional and system bias, was collected as part of demographic data to understand its effect on discrepant surgical and postoperative outcomes. Additionally, clinical notes from the primary surgeon within 1 year of surgical date were reviewed for type of visit encounter (telemedicine vs in-person), use of preoperative ultrasonography, and internal pelvic examination. All hysterectomies were performed laparoscopically, with preceding examination under anesthesia, by nine attending surgeons assisted by fellow and resident surgeons. Intraoperative information was collected, including length of surgery, estimated blood loss, and 30-day postoperative outcomes, along with records of emergency department visits, readmissions, and surgical site and urinary tract infections. The cohort was divided into two groups (examined and examination-omitted) by report of an internal pelvic examination during an in-person visit within 1 year of the gender-affirming pelvic surgery. The two study groups were compared using χ2 or Student's t test analysis, with P-values determined using Stata 16.1. This study was approved by the IRB and was designated exempt from full review due to minimal risk to participants. A power analysis was not performed.

RESULTS

Sixty-two patients underwent gender-affirming surgeries, including hysterectomy alone (n=20, 32.3%), combined hysterectomy and vaginectomy (n=18, 29.0%), and vaginectomy alone (n=24, 38.7%). The mean age of the cohort was 32.7 years (SD 10.4). Most patients were White race (n=53, 85.5%), with a mean body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) of 29.1 (SD 6.7) and an average of 6.0 (SD 5.2) years on testosterone therapy; two patients were parous. Of the 38 patients who underwent hysterectomy, 19 (50.0%) had preoperative cervical cancer screening and three had a history of cervical dysplasia, all low-grade. Twenty-nine patients (46.8%) were in the examined group, and 33 (53.2%) were in the examination-omitted group. Twenty (60.6%) of the 33 patients in the examination-omitted group had preoperative telemedicine visits. Of the patients in the examination-omitted group, three (9.1%) had a pelvic ultrasonogram before surgery, which did not significantly differ from the examined group (n=6, 21.0%). There were no findings that changed surgical approach on preoperative ultrasonography nor examination under anesthesia. There were no significant differences in patient characteristics nor 30-day perioperative complications, such as blood loss, operative time, emergency department visits, and rehospitalization, between the examined and examination-omitted groups (Table 1). No major intraoperative complications were reported in either group, including ureteral, bladder, bowel, and vessel injury. All pathology results were benign.

T1Table 1.:

Gender-Affirming Pelvic Surgery With or Without In-Office, Preoperative, Internal Pelvic Examinations

DISCUSSION

Gender-affirming hysterectomy with or without concurrent vaginectomy or vaginectomy alone are overall safe surgeries with low complication rates in our study. An in-office, preoperative, internal pelvic examination did not significantly affect surgical complications for patients undergoing gender-affirming hysterectomy with or without vaginectomy, although our study is likely underpowered to detect differences. Patients who underwent preoperative evaluation through telemedicine without a pelvic examination also experienced low complication rates. Our results suggest that omission of an in-office, preoperative, internal pelvic examination may be a clinically acceptable practice before gender-affirming hysterectomy and vaginectomy.

Study limitations include a small, underpowered sample size; heterogenous authorship of cis-gendered women, which limits our perspective; and the inability to determine indications for preoperative examination when performed, due to the retrospective nature of our study design. However, because some transmasculine individuals report that internal pelvic examinations trigger symptoms of gender dysphoria, our results may encourage primary surgeons to rethink the necessity of an internal pelvic examination before gender-affirming hysterectomy and vaginectomy.5 Additionally, approximately one quarter of transgender individuals do not seek health care as a result of discrimination and health care mistreatment.6,7 Therefore, a preoperative telemedicine visit could allow for more patient autonomy, and our results indicate that this may be a safe alternative to in-person visits, which may further improve access to gender-affirming surgical care.

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