Should Trans Men have a Hysterectomy?

Dr. Richard J. Curtis, The London Gender Clinic

There is little written on this topic and no research.

Having a hysterectomy/oöphorectomy involves an operation with attendant risks. Although it is a frequently performed procedure, it should not be underestimated in terms of the potential adverse consequences, and it has a significant effect on the workings of the body.

Cervical Cancer

Any trans man who has had sexual intercourse with a man (regardless of condom use) is at risk of developing cervical cancer. It is caused by a wart virus transmitted at the time of intercourse. The risks of transmission increase with the number of partners and frequency of contact. In future, this will not be so much of an issue due to the vaccine currently being given to young girls. The only commonly available means of detecting the early stages of cervical cancer is by having a smear.

Cervical cancer is common and it kills. Any trans man who is at risk must have regular smears in accordance with the national screening program. It is not particularly pleasant. No woman likes having it done. You may find it embarrassing regardless of your gender presentation, and it can be uncomfortable. Unfortunately, many trans men decline to undertake this procedure.

I say this: JUST GET OVER IT, go and get tested. There is no mileage in putting your masculine gender ideal above your health; that’s just putting your head in the sand. It is far better to be a living trans man than a dead one. There is no can’t, it is a question of won’t. You cannot escape the fact that you have a vulnerable cervix. Accept it and pay attention to it.

A smear test is not difficult to organise. The national screening program operates for those aged 25+ years. It is accessed most easily via your GP, and in many practices, the practice nurse performs the procedure. It is not easy to obtain elsewhere on the NHS but private services provide a feasible alternative. Results will be sent to your GP.

Therefore, relative indication No. 1 for having a hysterectomy is an at-risk trans man who fails to undertake cervical screening.

Contraception

Contraception is required for those who have sex with men. Do not believe that the absence of menstruation means pregnancy could not occur. It can!

Due to the masculinisation process, it is unfeasible to take the usual oestrogen-based contraceptives like the pill. Progesterone based contraceptives are viable but unfortunately their commonest side effect tends to involve bleeding.

Barrier methods such as caps and condoms are straightforward but less reliable, somewhat intrusive in ‘the moment’ and require pre-planning. Condoms are mandatory anyway when having intercourse to reduce the risks of sexually transmitted infections. With careful use, they can be an effective means, but user-error renders them less reliable than hormone or coil methods. Very few condoms ’split‘. If they do, it is usually due to bad technique; in reality, ‘condom split’ generally means ‘forgot’, ‘a bit the worse for wear’ or ‘didn’t bother’, to use one. Intrauterine devices (coils) are also a possibility. Fitted for 5 years, they reduce the intrusion factor and are very reliable as a means of contraception.

In the event of unprotected intercourse you can take the morning after pill, but it is likely to cause bleeding. The alternative is having a coil fitted, and the worst-case scenario, is an abortion – an incredibly stressful procedure with, for some people, ongoing psychological consequences.

Relative indication No. 2 for a hysterectomy is a trans man who, for whatever reason, fails to attend to contraception requirements, therefore risking sexually transmitted disease and pregnancy.

Risk of Pelvic Cancer

The most difficult debate centres around the risk of developing ovarian or uterine cancer.

Uterine Cancer usually occurs in women 55-70 years old. It is not uncommon. Risk factors for it are obesity, no children, diabetes, pelvic irradiation, late menopause, family history of ovarian, breast or colon cancer, tamoxifen use, ovarian pathology, unopposed oestrogen, age.

Symptoms: Post – menopausal bleeding, inter-menstrual bleeding;

Diagnosis: Biopsy, occasionally found on cervical smear;

Survival: 5 years survival if caught early = 72%; if caught late = 56%.

Ovarian Cancer occurs in 1:2500 women over 55 years old and is therefore uncommon. Risk Factors for it are age, family history, no children, infertility.

Symptoms: Vague: vaginal bleeding, abdominal pain and bloating, constipation, uterine prolapse, frequency of urination;

Diagnosis: Laparotomy, (opening the abdomen);

Survival: 80% present late in which case 5-year survival is only 15%.

Diagnosis of both of these problems is possible but it is often at a late stage, especially with respect to ovarian cancer. As with smears and contraception, some trans men will ignore advice or warning signs.

Does taking testosterone mask the usual symptoms? No one knows whether testosterone reduces the chances of diagnosis or whether it might cause a more aggressive form of disease – or less aggressive either. Cases in trans men have been documented at a younger age, less than 50 years old.

Unfortunately, there are no screening tests for either form of cancer.

AN ULTRASOUND SCAN DOES NOT TELL YOU WHETHER OR NOT YOU HAVE CANCER, SO THE FACT THAT NOTHING SHOWS UP ON YOUR SCAN IS NOT A GUARANTEE THAT YOU DON’T.

It may reveal ovarian cysts or thickening of the uterine lining but their presence or absence does not guarantee the presence or absence of cancer. Common advice from medical quarters recommends having a pelvic ultrasound every 3 years. This is not a bad idea as if there are cysts or thickening, it can be looked into but the individual should not assume that cancer has been ruled out.

Again, however, it is psychologically uncomfortable for trans men to undergo gynaecological procedures. My advice remains the same; get it sorted. Running a sensor over the abdomen is not the end of the world. Neither is a trans-vaginal scan and it’s less uncomfortable than a smear. The absolute risks of having either ovarian or uterine cancer are very low in a person who is not taking testosterone. No one knows the absolute risk in a trans man, Unfortunately, the physiology is not favourable owing to way in which testosterone is metabolised.

Testosterone in the bloodstream is an active compound of itself.

However, it is converted in two ways:

  • into dihydrotestosterone (DHT), a much more potent androgen in skin, genitals, liver;
  • into oestrogen in fat.

The conversion to oestrogen is the problem. Taking testosterone eliminates the menstrual cycle by inhibiting the actions of oestrogen leading to a subsequent reduction in progesterone, thus the natural production of both these hormones diminishes. However, testosterone is converted to oestrogen but the reduction in progesterone means that the uterus is exposed to unopposed oestrogen.

Unopposed oestrogen increases the risk of uterine thickening in such a way that cancer is more likely to occur. In typical female physiology this does not occur (because oestrogen is ’opposed‘) but in trans men the exposure to unopposed oestrogen is prolonged. It can therefore be seen that an unlucky trans man with a predisposition for developing cancer could unwittingly be increasing his risk by taking testosterone. This risk will be cumulative, the longer the oestrogen is unopposed, the higher the risk. Therefore, younger trans men should be mindful of this.

As a separate point, enzyme pathways can become saturated. The greater the administered amount of testosterone, the more likely the conversion to oestrogen once the dihydrotestosterone pathway is saturated.

Polycystic ovary syndrome is common in women. This is a syndrome of unknown cause characterised by cyst formation in the ovaries, a slightly increased testosterone level and increased luteinising hormone (LH, a hormone in the brain). It results in irregular periods, acne, infertility, obesity and virilisation. However, it also leads to a threefold increased risk of uterine cancer and possibly ovarian cancer as well.

The above considerations as well as any family history of pelvic cancer lead to relative indications for a hysterectomy Nos. 3 and 4.

Breakthrough Bleeding

Relative indication No. 5 is the risk of breakthrough bleeding (BTB). Bleeding is most likely to occur during changes in dosage or the method of testosterone administration. As time goes on, it could occur owing to the build up of the endometrial lining as occurs in a normal menstrual cycle, or because something changes in the physiology of an individual, e.g. age, other illnesses, other drugs, compromised liver or kidney function.

BTB is not life threatening itself although it can be a sign of more serious issues and should never be ignored. It is however, somewhat unwelcome.

Reducing Testosterone Post Oöphorectomy

Finally, but very importantly, relative indication No. 6, is that an oöphorectomised individual does not need as much testosterone. NB. If you are still taking &slsqo;pre-op’ doses, this is not in your best interest and you should seek advice. This should include measuring relevant hormone parameters in addition to testosterone levels to determine an individualised, appropriate testosterone dose which will keep you in good health. Note, there are no standardised pre-op and post-op doses. Everyone is different. It is impossible to tell if replacement is adequate without the appropriate tests.

Being able to lower the dose of testosterone post oöphorectomy is very valuable in reducing the risk of side effects. The primary reason the dose is higher pre-op is so that menstruation is suppressed. To some degree, this has arisen historically since Sustanon was the most widely available formulation and leads typically to testosterone levels above the norm so people tend to assume that this is desirable. In reality, menstruation will generally stop in time with testosterone levels in the normal range but patience is required.

Many trans men think that more drug is better. More won’t necessarily masculinise more if you are not pre-disposed to responding, but it could lead to more side effects. The reason trans men do not end up fully like genetic men is due to the action of other hormones at puberty like growth hormone, thyroxine and insulin. More testosterone cannot substitute for the absence of the interaction with these substances.

Conclusion

There is no right or wrong as to whether a hysterectomy/oöphorectomy should occur after several years on testosterone or not.

My opinion based on what I have read, what I see in patients and on my personal experience is that having the operation should be given serious consideration. Each individual will know how they feel about each of the six reasons why it may be beneficial but must also be mindful of the downsides of undergoing the procedure.

From a personal perspective I know I did not want to undergo smears, have to worry about contraception, breakthrough bleeding, was happy to reduce my risks of cancer in organs that were of no use to me and am extremely glad to have not needed to take testosterone in high dosage because my body does not tolerate it.

Notes

  1. ‘indication’, when used in medicine, means ‘reason why a particular treatment or procedure should be undertaken’. ’Absolute indication’ means that the evidence of need for medical intervention is compelling; in this case, ‘relative indication’ means the evidence is less than compelling, but still persuasive.
  2. ‘Unopposed oestrogen’ describes oestrogen that has no accompanying progesterone to limit its impact (see Ovarian cancer)
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