Postoperative Vaginal Bleeding Concerns after Gender-Affirming Hysterectomy in Transgender Adolescents and Young Adults on Testosterone

Study Objective

This study aimed to characterize the incidence and management of postoperative vaginal bleeding concerns experienced by transgender adolescents and young adults (AYA) on testosterone hormone therapy after gender-affirming hysterectomy (GAH).

Methods

This was a retrospective cohort of transgender AYA, 18 years and older, using testosterone therapy who underwent a GAH between July 2020 and September 2021 at a tertiary care children's hospital. The incidence of patient-reported postoperative vaginal bleeding concerns and management of bleeding are described.

Results

Patient ages ranged between 18 and 33 years. Among 25 patients who met the inclusion criteria, 13 (52.0%) reported vaginal bleeding concerns. No modifiable patient or operative characteristics reached statistical significance in association with postoperative bleeding concerns. Among patients with bleeding concerns, 10 (76.9%) experienced such concerns during the first 2 weeks after surgery, and 6 (46.2%) had resolution of bleeding without intervention. Among 11 patients who underwent an exam for evaluation of bleeding, findings included granulation tissue (n = 5, 45.5%), vaginal atrophy (n = 4, 36.4%), bleeding vessel (n = 1, 9.1%), mucosal separation (n = 1, 9.1%), or no cause of bleeding identified (n = 4, 36.4%).

Conclusions

Over half of transgender AYA on testosterone therapy in this cohort reported postoperative vaginal bleeding concerns that were most often secondary to atrophy and granulation tissue, suggesting possible susceptibility to vaginal tissue trauma at the time of GAH and granulation-susceptible healing in patients on testosterone. As vaginal bleeding could worsen gender dysphoria, these findings support the need for patient counseling on postoperative bleeding expectations and identification of interventions to reduce vaginal bleeding after GAH.

Introduction

Transgender and gender nonbinary (TGNB) adolescents and young adults (AYA) assigned female sex at birth may seek a variety of methods to achieve phenotypic alignment with their gender identity, including the use of gender-affirming hormonal therapy and surgery.¹ Some TGNB AYA born with a uterus do not wish to carry a pregnancy in the future and might seek hysterectomy for gender-affirming as well as non-gender-related reasons.^1,2 These reasons could include gynecologic pathology and symptoms such as failure of medical approaches to menstrual suppression, breakthrough bleeding on testosterone, and pelvic pain.^3,4

As genital bleeding can worsen dysphoria,^5,6 a common goal of gender affirmation is the cessation of menses. For those on testosterone therapy, many may experience rapid induction of amenorrhea, whereas others may take additional medications in addition to testosterone should breakthrough bleeding occur.^6,7 Testosterone hormone therapy causes cessation of menses secondary to partial or complete ovulation suppression and endometrial atrophy.^8,9 Limited data demonstrate that exogenous testosterone use also creates an estrogen-deficient and hyperandrogenic vaginal environment that is susceptible to tissue atrophy.8., 9., 10. Of patients who undergo gender-affirming hysterectomy (GAH), most have been on long-term testosterone before surgery, and goals are likely to include complete cessation of genital bleeding.^7,11 As such, postoperative genital bleeding could impact TGNB patients differently from cisgender patients. It is unknown if long-term testosterone use impacts postoperative vaginal bleeding patterns following GAH.

Although there are no differences in significant postoperative complications between GAH and other benign hysterectomies,¹² no studies to date have characterized the patient recovery experience after GAH, including postoperative vaginal bleeding. There is currently no known literature that identifies risk factors for abnormal or prolonged vaginal bleeding experienced after a GAH, which could be affected by androgenic effects on the vaginal epithelium. Similarly, patient dysphoria related to genital bleeding and how it impacts patients’ quality of postoperative recovery and seeking of medical care in the postoperative period have not been previously described in the literature. This study aimed to help address this gap. Our goal was to characterize the incidence of vaginal bleeding concerns experienced by a cohort of TGNB AYA on testosterone therapy after GAH. Secondary aims included identifying patient and operative characteristics associated with postoperative vaginal bleeding concerns. Our hypothesis is that most of our patients would report concerns regarding postoperative vaginal bleeding.