Omission of Preoperative Internal Pelvic Exam May Not Affect Safety of Gender-affirming Hysterectomy

When transmasculine individuals undergo gender-affirming pelvic surgery, a preoperative internal pelvic examination is traditionally performed to guide the hysterectomy route and anticipate any challenges. However, many transmasculine individuals wish to avoid pelvic examinations because they elicit gender dysphoria. With greater use of telemedicine, pelvic examinations before gender-affirming surgery are often deferred to the operating room.

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Researchers at Massachusetts General Hospital have published evidence of the safety of omitting a preoperative internal pelvic examination before gender-affirming hysterectomy and vaginectomy. Youngwu Kim, MD, a urogynecologist in the Division of Female Pelvic Medicine and Reconstructive Surgery in the Department of Obstetrics and Gynecology, Milena M. Weinstein, MD, co-director of the Center for Pelvic Floor Disorders in the Department, and a resident doctor Ellen Murphy report the data in Obstetrics & Gynecology.

Methods

The team retrospectively studied all 62 patients, average age of 33, who underwent gender-affirming pelvic surgery performed at Mass General between April 2018 and March 2022. Twenty patients had hysterectomy alone, 18 had both hysterectomy and vaginectomy, and 24 had vaginectomy alone. All hysterectomies were performed laparoscopically.

The "examined" group (n=29, 47%) was defined as patients with an internal pelvic examination performed during an in-person visit within one year before surgery. The other 33 patients were designated the "exam-omitted" group.

Patient Characteristics

The mean patient age was 33, most were white (86%), the mean body mass index was 29 kg/m^2, and the average time on testosterone therapy was six years. Two patients were parous.

Preoperative Care

Of the 38 patients who underwent hysterectomy, 19 had preoperative cervical cancer screening and three had a history of cervical dysplasia, all low-grade.

The only statistically significant difference between the examined and exam-omitted groups was the type of preoperative visit: 32% of patients in the examined group vs. 68% in the exam-omitted group had preoperative telemedicine visits (P<0.001).

Of the 33 patients in the exam-omitted group, three had a pelvic ultrasonogram before surgery as an alternative to internal examination. No findings changed the surgical approach or examination under anesthesia.

Complications

No intraoperative complication (ureteral, bladder, bowel, or vessel injury) was reported in the examined or exam-omitted group.

The groups did not differ significantly in perioperative outcomes:

• Estimated blood loss—113 mL in the examined group vs. 135 mL in the exam-omitted group
• Operative time—141 vs. 130 minutes
• Emergency Department visit within 30 days—17% vs. 9%
• Surgical site infection within 30 days—7% vs. 9%
• Urinary tract infection within 30 days—14% vs. 3%
• Readmission within 30 days—14% vs. 6%

Suggestions for Surgeons

Surgeons are encouraged to rethink the necessity of an internal pelvic examination before gender-affirming hysterectomy and vaginectomy. In addition, a preoperative telemedicine visit seems to be a safe alternative to in-person visits and may further improve access to gender-affirming surgical care.

As a caveat, because of the small sample size, the study may be underpowered to detect differences in complication rates between the two groups.

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Learn more about the Division of Female Pelvic Medicine and Reconstructive Surgery

Refer a patient to the Mass General Department of Obstetrics and Gynecology