Hysterectomy

Who it’s for

Anyone who wants it, in principle. Most gender clinics and surgeons ask for one or two letters of support and a period on testosterone, though testosterone is not a medical requirement. The common reasons are dysphoria around the uterus and periods, breakthrough bleeding on testosterone, pelvic pain, and planning for genital surgery, which usually needs the uterus gone first.

There is a fertility decision inside this one. A hysterectomy ends the possibility of carrying a pregnancy, and if the ovaries go too it ends the possibility of using your own eggs. If any of that might matter to you, fertility preservation is a conversation to have before, not after.

Nicotine, weight and general health are assessed as for any abdominal surgery. See eligibility.

Before you book

Decide whether the ovaries stay or go, and write down why. It's the one part of this operation you can't undo and can't add later without a second surgery, and it deserves more than a yes or no at the pre-op visit.

How it’s done

Almost all hysterectomies for trans men are laparoscopic. Under general anaesthetic the surgeon makes three or four small cuts on the abdomen, one usually in the navel, and inflates the abdomen with gas to make room. A camera goes in one port and instruments in the others. The uterus is detached from its ligaments and blood supply, with the tubes and, if planned, the ovaries.

The uterus then comes out through the vagina, which is closed at the top with stitches. Robotic-assisted surgery is the same operation with the surgeon at a console. A vaginal hysterectomy, done entirely from below with no abdominal cuts, is possible for some people but less common in this group because a testosterone-narrowed vagina makes it harder. An open abdominal incision is now rare and reserved for a large uterus or complications.

Whether the cervix is removed with the uterus is worth confirming. It almost always is, and should be, because leaving it means continued cervical screening and a small remaining cancer risk.

Before your pre-op appointment

Write down your answer to the ovary question and your answer to the fertility question, even if the answer is "I don't know yet". Both get asked, and "I don't know yet" is a fine answer as long as it's a considered one rather than a surprised one.

Hysterectomy recovery

The first few days are the gas. Laparoscopic surgery leaves gas in the abdomen that works its way out over two or three days. It causes a bloated, crampy feeling, and a distinctive ache in the shoulders that nobody warns you about. Walking helps more than lying down. The cuts themselves are small and heal quickly.

After that it is fatigue and the internal healing you cannot see. Desk work in two to three weeks for most people, physical work in four to six. The top of the vagina, where the uterus was detached, takes about six weeks to heal fully, and until then nothing goes inside and no heavy lifting. Some light bleeding or discharge in the first weeks is normal; heavy bleeding or fever is a call.

In the first three days

Walk around the house every hour you're awake, even if it's just to the kitchen and back. The shoulder pain is trapped gas, and moving is the only thing that shifts it faster.

Hysterectomy scars

Three or four small scars on the abdomen, each one to two centimetres. One is usually hidden in the navel and the others sit low on the belly or to the sides. They are red for a few months and fade to faint marks that most people stop noticing within a year. If you plan to have phalloplasty later, the surgeons will sometimes coordinate port placement so nothing sits where a future incision needs to go.

Risks and complications

The standard risks of abdominal surgery. Bleeding, infection, a reaction to the anaesthetic, and injury to nearby structures, the bladder, the ureters (the tubes from kidney to bladder) and the bowel, which is uncommon but the reason surgeons are careful. Blood clots are a small risk after any pelvic surgery and the reason you are told to walk early.

Specific to hysterectomy, the top of the vagina can occasionally open before it has healed, usually because something went in too early, and it needs re-stitching. If the ovaries are removed you go into surgical menopause instantly, which testosterone largely covers for trans men but which is worth understanding. See oophorectomy.

Long term, there is a small increase in the chance of pelvic floor weakness, as after any hysterectomy. There is also a debate about bone health, which comes down to staying on testosterone.

Hysterectomy results

Nothing visible changes and that is the result. No periods, no cervical screening, no uterine cancer risk, and for many people a specific dysphoria that simply stops. Testosterone dosing sometimes needs a small adjustment afterwards, particularly if the ovaries went too.

What it does not do is change anything externally. If genital surgery is the plan, the hysterectomy is the first step, not the destination.

Alternatives to hysterectomy

For periods alone, testosterone stops them for most people within a year, and for the rest a progestin or an IUD usually works. For cancer risk alone, screening continues to work. So the alternative to hysterectomy for someone not planning genital surgery is to keep the uterus and manage it, which plenty of trans men do.

Once genital surgery is on the table the alternatives narrow, because nearly every surgeon wants the uterus gone first. The related decision is the ovaries.

Combining hysterectomy with other surgery

Hysterectomy is the surgery most often combined with others. It is regularly done under the same anaesthetic as top surgery, with the gynaecologist and the chest surgeon working in sequence. That saves a recovery and sometimes a facility fee. It is also often done in the same operation as vaginectomy, or as stage one of a metoidioplasty or phalloplasty plan.

The usual advice is to have it at least three to six months before genital surgery if not combined, so the pelvis has fully healed. See surgery order.

Hysterectomy cost

Hysterectomy is the bottom surgery most likely to be covered. It is a standard gynaecological operation with a well-worn insurance pathway, and in public systems it is often the least contested step. Self-pay, the number depends heavily on whether it is in a hospital or a surgical centre and whether an overnight stay is included.

Ask whether the quote covers the surgeon, anaesthetist and facility together, and whether removing the ovaries or tubes changes it. Usually it does not.

Choosing a hysterectomy surgeon

A hysterectomy is a gynaecologist's operation, and the surgeon does not need to specialise in trans care to do it well. What they do need is experience of laparoscopic hysterectomy on a testosterone-affected pelvis, which is drier and narrower than they may be used to. They also need an attitude that does not make the consultation harder than it should be.

The questions I would ask are how many laparoscopic hysterectomies they do a year, and whether they have operated on trans men before. Then whether they remove the cervix routinely, and how they coordinate with the surgeon doing your genital surgery if you have one lined up. A gynaecologist who already works alongside a gender surgeon is worth a longer journey.

At the consultation

Ask "have you operated on trans men before, and do you work with any gender surgeons?" A gynaecologist who says yes to both will make the whole sequence simpler than one who's good but starting from scratch with you.

Frequently asked questions

Do I have to have a hysterectomy before bottom surgery?

For metoidioplasty with urethral lengthening and for phalloplasty, nearly all surgeons require it, usually with a vaginectomy. For simple release metoidioplasty, no. See combining.

Will my ovaries be removed?

Only if you choose. It is a separate decision with its own trade-offs, and many people keep them. See oophorectomy.

Does it affect testosterone?

Sometimes a small dose adjustment is needed afterwards, particularly if the ovaries are removed. Your prescriber will check levels a few months on.

What about the scars?

Three or four small abdominal scars, one usually hidden in the navel. They fade to faint marks within a year. See scars.