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Gender-Affirming Hysterectomy ± Bilateral Salpingo-Oophorectomy (HBSO)

Gender-affirming hysterectomy is a medically necessary masculinizing procedure for transmasculine and gender-diverse individuals with gender dysphoria, as recognised by ACOG, WPATH, and the Endocrine Society.[1][2] It is the second most desired masculinizing surgery after chest reconstruction, with 79% of transmasculine individuals reporting having undergone or wanting hysterectomy.[1] It may be performed as a standalone procedure for dysphoria alleviation, or as a prerequisite / first stage before vaginectomy and phalloplasty with urethral lengthening.[3][4]

This is the dedicated atlas page. For the cohort-level framework, see Masculinizing Gender-Affirming Surgery. For downstream stages, see vaginectomy and phalloplasty pages within that section.

Indications​

  • Primary: alleviation of gender dysphoria related to the presence of a uterus and/or menstruation.[1][3]
  • Secondary: prerequisite for phalloplasty with urethral lengthening (UL typically requires prior hysterectomy + vaginectomy); elimination of breakthrough bleeding on testosterone; theoretical cancer-risk reduction (no endometrial-cancer cases reported in transmasculine individuals on testosterone).[2][5]
  • Standalone: may be performed independently of other genital surgeries, or combined with BSO, vaginectomy, and/or metoidioplasty / phalloplasty.[1][6]

Eligibility Criteria (Endocrine Society 2017)​

[2]
  1. Persistent, well-documented gender dysphoria.
  2. Legal age of majority (≥ 18 yr).
  3. ≥ 12 mo continuous gender-affirming hormone therapy (unless medically contraindicated).
  4. ≥ 12 mo successful continuous full-time living in the affirmed gender role.
  5. Well-controlled medical or mental-health conditions.
  6. Demonstrable knowledge of all practical aspects of surgery.

Many insurance carriers require one or two mental-health letters before authorisation.[1]

Preoperative Considerations​

Fertility counselling​

Essential before surgery. Hysterectomy (especially with BSO) produces permanent infertility. In practice few transmasculine individuals carry a pregnancy or use their oocytes after gender-affirming treatment, but oocyte cryopreservation should be discussed.[1][3]

  • Vaginal atrophy — testosterone causes mucosal thinning and introital narrowing (post-menopausal-like changes).
  • Nulliparity — most patients are young and nulliparous → small uterus without descent.
  • Increased perineal-laceration risk — testosterone users have 3.3× higher risk of intraoperative vaginal lacerations requiring repair (RR 3.3, 95% CI 1.03–10.5) per Pando 2024.[7]
  • Genital examination may worsen dysphoria — EUA before initiating the procedure may be appropriate.[1]
  • Preoperative vaginal estrogen considered to improve tissue quality; postoperative vaginal estrogen was required more frequently in testosterone-using patients (8.0% vs 1.7%, p = 0.01).[7]

Surgical Approaches​

A minimally invasive approach is recommended.[8][9]

ApproachFrequencyKey considerations
Total laparoscopic hysterectomy~57% (most common)Preferred; avoids vaginal manipulation that may worsen dysphoria; good visualisation[1][2]
Robotic-assisted laparoscopicIncreasingSimilar outcomes to conventional laparoscopic; higher cost; ergonomic advantages[10]
Laparoscopic-assisted vaginal (LAVH)~20%Combines laparoscopic + vaginal components[1]
VaginalLess commonNo abdominal scarring; technically difficult — vaginal atrophy, narrow introitus, absent uterine descent[4]
Abdominal (open)~15%Reserved for complex cases; higher complication rates[1]
2-port laparoscopic (Marfori novel)NovelMinimises port-site scarring; good outcomes described[11]

Intraoperative technical considerations[12][8]​

  • Two-layer vaginal-cuff closure recommended to reduce cuff complications; preferable for patients whose pelvic organs cause dysphoria.
  • Adequate margin on the infundibulopelvic ligament at oophorectomy to minimise the risk of ovarian remnant syndrome → otherwise persistent menstruation, particularly distressing in this population.
  • Concurrent procedures: often combined with BSO; may be staged with vaginectomy and genital reconstruction.[6]

The Oophorectomy Decision​

Shared decision-making. No definitive evidence-based recommendation exists.[1][13]

Arguments for oophorectomy:

  • Eliminates endogenous estrogen production and ovarian-pathology risk.
  • Removes a source of dysphoria for many patients.
  • Rare ovarian-cancer cases reported in transmasculine individuals on testosterone.[2]
  • Prevents ovarian-remnant syndrome and persistent menstruation.

Arguments for ovarian preservation:

  • Preserves fertility potential (oocyte retrieval remains possible).
  • In cisgender women, premenopausal oophorectomy is associated with increased cardiovascular events and all-cause mortality — not demonstrated in transmasculine individuals on testosterone.[13]
  • Testosterone has anabolic effects on cortical bone and, in adequate doses, prevents bone demineralisation.[1]
  • Some patients may lose access to testosterone in the future (cost, access barriers); endogenous estrogen serves as a safety net.[1]

Insufficient long-term outcomes data to make definitive oophorectomy recommendations in this population.[13]

Uterine Pathology on Testosterone​

Despite amenorrhea in most testosterone-treated patients, histopathology reveals persistent endometrial activity:[14][15]

  • Active (proliferative) endometrium in 40–69% of specimens.
  • Atrophic endometrium in ~50%.
  • Endometrial polyps in ~11%.
  • No endometrial-cancer cases reported.
  • 1 case of complex hyperplasia without atypia in 94 patients (Grimstad 2019).[14]
  • Uterus typically small with endometrial atrophy on gross exam.[2]

Clinical significance of persistent endometrial activity despite clinical amenorrhea remains uncertain.[14][15]

Outcomes and Safety​

Complication rates comparable to hysterectomy for benign indications in cisgender women.

Bretschneider 2018 NSQIP analysis (n = 40,742 hysterectomies; 526 gender-affirming):[9]

  • Transgender male status not independently associated with postoperative complications — adjusted OR 1.11 (95% CI 0.56–2.10).
  • Composite complication rate ~3.4% vs 3.3% controls.
  • Minimally invasive approaches significantly lower complication rates vs open: laparoscopic adjusted OR 0.09; vaginal adjusted OR 0.04.
  • Gender-affirming patients were younger, healthier, with lower BMI and shorter hospital stays vs controls.

Pando 2024 (n with testosterone use vs no-testosterone controls):[7]

  • Postoperative vaginal bleeding more frequent in testosterone users (RR 1.74, 95% CI 1.1–2.7) — did not translate to increased ED visits.

Psychological Outcomes​

Almazan 2021 (n = 27,715 transgender adults):[16] undergoing ≥ 1 gender-affirming surgeries associated with:

  • Lower past-month psychological distress (aOR 0.58).
  • Lower past-year smoking (aOR 0.65).
  • Lower past-year suicidal ideation (aOR 0.56).

Bakir 2025 qualitative study — transmasculine individuals report less distress and more happiness after hysterectomy, describing it as "escaping the gender prison".[17]

Epidemiology and Disparities​

  • Approximately 0.3% of all hysterectomies in the US are performed for transmasculine individuals.[12][9]
  • GAS utilisation increased > 5-fold from 2012 to 2019 (0.9 to 5.0 per 100,000 inpatient records).[18]
  • Mean age at gender-affirming hysterectomy ~31 yr.[19]
  • Among transmasculine patients, uterus removal is the most desired and unmet surgical need (61.4%), followed by oophorectomy (59.8%).[20]
  • Significant insurance disparities: Medicaid OR 0.27 and Medicare OR 0.15 for undergoing GAS vs private insurance.[18]

Relationship to Other Masculinizing Genital Surgeries​

Hysterectomy is often a prerequisite or concurrent procedure for subsequent genital reconstruction:[4][6]

  • Phalloplasty with urethral lengthening — hysterectomy and vaginectomy typically required to allow urethral elongation and prevent a persistent vaginal cavity.[4]
  • Metoidioplasty — may be performed with or without prior hysterectomy and vaginectomy.[1][4]
  • Staging: HBSO commonly performed as a first stage, with genital reconstruction following after recovery.[6]

Evidence Limitations​

  • The Bretschneider 2018 NSQIP analysis is the largest comparative outcomes study (n = 526 gender-affirming) and shows safety parity with cisgender hysterectomy.[9]
  • No randomised trials of approach or oophorectomy decision in this population.
  • Long-term cardiovascular and bone outcomes of premenopausal oophorectomy in testosterone-treated transmasculine individuals are not well characterised — cisgender data may not apply.[13]
  • Endometrial activity vs cancer risk — persistent proliferative endometrium in 40–69% on testosterone, but no cancer cases reported; clinical significance unclear.[14][15]
  • Validated PROMs specific to gender-affirming hysterectomy outcomes are lacking.

References​

1. Committee on Gynecologic Practice and Committee on Health Care for Underserved Women. Health care for transgender and gender diverse individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021;137(3):e75–e88. doi:10.1097/AOG.0000000000004294

2. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017;102(11):3869–3903. doi:10.1210/jc.2017-01658

3. Carbonnel M, Karpel L, Cordier B, Pirtea P, Ayoubi JM. The uterus in transgender men. Fertil Steril. 2021;116(4):931–935. doi:10.1016/j.fertnstert.2021.07.005

4. Jackson Q, Yedlinsky NT, Gray M. Lifelong care of patients after gender-affirming surgery. Am Fam Physician. 2024;109(6):560–565.

5. Berli JU, Knudson G, Fraser L, et al. What surgeons need to know about gender confirmation surgery when providing care for transgender individuals: a review. JAMA Surg. 2017;152(4):394–400. doi:10.1001/jamasurg.2016.5549

6. Gomes da Costa A, Valentim-Lourenço A, Santos-Ribeiro S, et al. Laparoscopic vaginal-assisted hysterectomy with complete vaginectomy for female-to-male genital reassignment surgery. J Minim Invasive Gynecol. 2016;23(3):404–409. doi:10.1016/j.jmig.2015.12.014

7. Pando C, Gerlach LR, Challa SA, Pan AY, Francis J. Operative complications, vaginal bleeding, and practice considerations for patients on testosterone undergoing gender-affirming hysterectomy. J Minim Invasive Gynecol. 2024;31(10):836–842. doi:10.1016/j.jmig.2024.05.026

8. Simko S, Popa O, Stuparich M. Gender-affirming care for the minimally invasive gynecologic surgeon. Curr Opin Obstet Gynecol. 2024;36(4):301–312. doi:10.1097/GCO.0000000000000956

9. Bretschneider CE, Sheyn D, Pollard R, Ferrando CA. Complication rates and outcomes after hysterectomy in transgender men. Obstet Gynecol. 2018;132(5):1265–1273. doi:10.1097/AOG.0000000000002936

10. Robot-assisted surgery for noncancerous gynecologic conditions: ACOG Committee Opinion, Number 810. Obstet Gynecol. 2020;136(3):e22–e30. doi:10.1097/AOG.0000000000004048

11. Marfori CQ, Wu CZ, Katler Q, et al. Hysterectomy for the transgendered male: review of perioperative considerations and surgical techniques with description of a novel 2-port laparoscopic approach. J Minim Invasive Gynecol. 2018;25(7):1149–1156. doi:10.1016/j.jmig.2017.09.008

12. Lee Cruz AS, Cruz J, Behbehani S, et al. Hysterectomy and oophorectomy for transgender patients: preoperative and intraoperative considerations. J Minim Invasive Gynecol. 2024;31(4):265–266. doi:10.1016/j.jmig.2023.12.009

13. Reilly ZP, Fruhauf TF, Martin SJ. Barriers to evidence-based transgender care: knowledge gaps in gender-affirming hysterectomy and oophorectomy. Obstet Gynecol. 2019;134(4):714–717. doi:10.1097/AOG.0000000000003472

14. Grimstad FW, Fowler KG, New EP, et al. Uterine pathology in transmasculine persons on testosterone: a retrospective multicenter case series. Am J Obstet Gynecol. 2019;220(3):257.e1–257.e7. doi:10.1016/j.ajog.2018.12.021

15. Hawkins M, Deutsch MB, Obedin-Maliver J, et al. Endometrial findings among transgender and gender nonbinary people using testosterone at the time of gender-affirming hysterectomy. Fertil Steril. 2021;115(5):1312–1317. doi:10.1016/j.fertnstert.2020.11.008

16. Almazan AN, Keuroghlian AS. Association between gender-affirming surgeries and mental health outcomes. JAMA Surg. 2021;156(7):611–618. doi:10.1001/jamasurg.2021.0952

17. Bakir S, Öztürk R, Eminov A, et al. "Escaping the gender prison" — transgender men's experience before and after hysterectomy: a qualitative study. J Homosex. 2025;72(8):1466–1485. doi:10.1080/00918369.2024.2379969

18. Chu J, Nagpal M, Dobberfuhl AD. Utilization and cost of gender-affirming surgery in the United States from 2012 to 2019. Ann Surg. 2025;281(5):814–822. doi:10.1097/SLA.0000000000006296

19. Wright JD, Chen L, Suzuki Y, Matsuo K, Hershman DL. National estimates of gender-affirming surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. doi:10.1001/jamanetworkopen.2023.30348

20. Pletta DR, Quint M, Radix AE, et al. Gender-affirming surgical history, satisfaction, and unmet needs among transgender adults. JAMA Netw Open. 2025;8(9):e2532494. doi:10.1001/jamanetworkopen.2025.32494