Trans men are often given conflicting evidence and information about hysterectomies. The simple fact is, there isn’t very much data on the long term health implications of testosterone, and how hysterectomies might address that.
Hysterectomies are available on the NHS for trans people, and most gender identity clinics recommend you at least consider getting one after 5 years on testosterone (although the current medical evidence for this recommendation is weak). This would usually be a total hysterectomy with salpingo-oopherectomy (so removing the womb, ovaries and fallopian tubes). Hysterectomies can either be done as a stand-alone surgery, or as part of a metoidioplasty or phalloplasty procedure. However, decisions about hysterectomies will depend on your own circumstances and, as always, you don’t have to have any treatment you don’t want.
Here are some things to think about:
The evidence on association between testosterone usage and cancer risk is poor. There is no conclusive evidence either way. Feldman (2007, Haworth Press) reviewed the available evidence and concluded that testosterone may cause changes in the cervix, which can look like pre-cancerous cells (but it is unclear how likely these cells are to develop into cancer) and that some small, not very reliable studies suggest that there might be a link to ovarian cancer. There is also the possibility of a link to endometrial cancer, although that is largely based on assuming trans men have similarities to women with polycystic ovary syndrome. Wesp (2016) suggests there is not a strong justification for recommending hysterectomy on the grounds of either ovarian or endometrial cancer.
The risk of cervical cancer can be reduced by having smear tests at regular intervals. If you do not want to have smear tests, a hysterectomy may be an option to consider. Endometrial and ovarian cancers are not routinely screened for, and aren’t detected by smear tests. However, they are relatively rare in people under 40.
Unless you have already had eggs or embryos frozen there is no currently existing, licensed process in the UK which would allow you to have your own biological children after a total hysterectomy and oopherectomy (you can of course still foster, adopt or use donors). While there are sometimes discussions in the news about creating sperm from other cells, cloning, or similar techniques, these processes are not currently anywhere near being licensed in humans in the UK and it would probably be unwise to base your future family plans on the availability of such techniques.
For some people, knowing that they are definitely and permanently infertile may be exactly what they want (though there are other long-term contraceptive options available to trans men, such as progesterone only pills, and depo provera). However, if you think you may want your own biological children some day, you may want to delay a hysterectomy, or look into freezing options first.
For some trans men and non-binary people, knowing that they have internal organs associated with being female is a part of their dysphoria, and removing these organs is an important part of their transition. For other trans men, this is not a concern.
Once you have had a total hysterectomy, you will no longer produce female hormones. However, there is little evidence about the impact of hysterectomy on trans masculine people’s hormones. Some people find that they need to take less testosterone after hysterectomy. Others may find it makes no difference. You should therefore keep a closer eye on your testosterone levels after hysterectomy, and talk to your GP, endocrinologist or GIC specialist if it looks like they need adjusting.
Pain, cramps, bleeding
Some trans people find that they experience abdominal pain, cramps and/or bleeding after taking testosterone for several years. Other trans people may have pre-existing problems such as polycystic ovary syndrome and endometriosis. A hysterectomy may resolve these symptoms. However, there are often other, less intrusive options that might also address these symptoms if you do not want surgery.
If you intend on having a metoidioplasty or phalloplasty later, it is usually considered best not to have a hysterectomy which leaves a long horizontal scar, as it may affect the later surgeries. A keyhole hysterectomy avoids this problem, and is also generally quicker to recover from. If this isn’t possible, it is sometimes suggested a vertical scar may be better than a horizontal one.
The implications of surgery
A hysterectomy is a significant operation and, like all operations, carries some risks. Your surgeon will go through exactly what these are, but they will include the possibility of serious complications. Most serious complications are extremely rare, especially if you are younger and otherwise in good health. However, you should always think carefully before going ahead with surgery. Some people also report hysterectomy has an impact upon sexual sensation. There is limited data on this in trans masculine people (and surgeons sometimes assume we don’t have certain types of sexual intercourse, meaning they may not raise the issue). If this is a concern for you, talk to your surgeon.
Hysterectomy can take a while to recover from. Laparoscopic (keyhole) hysterectomy is usually a quicker recovery than abdominal surgery. Your hospital will be able to give you more information, but in general you should plan for 1-5 nights in hospital, 4-8 weeks off work (longer if your job involves heavy lifting) and up to 8 weeks of being unable to drive.
Arrangements for surgery
Trans men should not be put on a general female ward if they do not want to be, unless there is no other safe option. This can cause problems, as clearly gynaecology wards will usually be female. The usual arrangements are either that they are placed in a male ward (frequently the urology ward), or in a side room. Non-binary people may have more difficulty, as hospitals may have only male and female wards. Whatever arrangements are made should be discussed with you, and decisions should focus on what you want, not what is easiest for staff.
You will often need to have a pre-operative assessment at the gynaecology unit. Some men find it awkward to be sat in a gynaecology waiting room full of women. It may be helpful to ask for an assessment at the very beginning or end of the day (when there will be fewer patients around) or to arrange for a female relative or friend to come with you. Different units have different policies on whether they need to examine you. Some may be happy to just do an external ultrasound (like the ones pregnant people have), which only require you to expose your belly. Some might prefer to do a more intimate examination. If you aren’t comfortable with that, ask whether it can be avoided.
In the UK, you can receive gender recognition without having had any surgery at all. However, in some other countries, trans men may need to have a hysterectomy before their new gender can be recognised. For trans men with dual nationality or non-UK documentation, this may be a factor. The European Court of Human Rights ruled in April 2017 that it is a breach of human rights to require trans people to be sterilised.