By Katherine Rivlin, MD, MSc
Associate Professor, Department of Obstetrics and Gynecology, University of Chicago
A retrospective chart review of individuals undergoing gender-affirming hysterectomy, vaginectomy, or both found no difference in 30-day perioperative outcomes between those who received a preoperative internal pelvic examination and those who did not. These findings indicate that omitting such potentially triggering exams may be safe.
Murphy EC, Kim Y, Weinstein MM. Omission of pelvic examination before gender-affirming hysterectomy and vaginectomy. Obstet Gynecol 2023; May 4. doi: 10.1097/AOG.0000000000005189. [Online ahead of print].
Transmasculine and gender non-binary individuals face bias and discrimination from healthcare professionals, as well as a lack of knowledge regarding best practices. As a result, many underuse or entirely avoid seeking healthcare, which worsens healthcare inequities.1,2 Seeking care from OB/GYNs can be especially challenging, as such environments often are particularly gendered.3 Clinicians must create safe and affirming spaces to foster a more inclusive environment. This includes building knowledge on best practices, training all staff (from the front desk to the clinical team), using inclusive signage and healthcare forms, and building a flexible and inclusive electronic medical record.2 This also includes critically evaluating traditional practices within the field of OB/GYN to better understand how such practices may hinder the care of gender-expansive individuals.
Transmasculine and gender non-binary individuals often interface with OB/GYNs when seeking gender-affirming surgery. Hysterectomy with or without salpingo-oopherectomy and vaginectomy are medically necessary for individuals with gender dysphoria who desire the procedure.2 A traditional component of the preoperative evaluation is an office-based pelvic examination to evaluate anatomy, anticipate challenges, and determine the surgical route of approach. However, pelvic exams can trigger gender dysphoria. Fear of such an exam may prompt patients to avoid care.4 With little evidence to guide best practices, surgeons have adopted a wide range of approaches to preoperative evaluation. Some conduct in-person exams on all patients; others offer a transabdominal ultrasound as an alternative. Still others avoid any preoperative examination and defer a pelvic exam until the patient is under anesthesia in the operating room for their surgery. In this circumstance, all preoperative appointments can occur either in person or through telehealth.
This study provides novel insights into the safety of foregoing a preoperative in-clinic internal pelvic exam in advance of gender-affirming hysterectomy and vaginectomy by comparing surgical outcomes between those who do and those who do not have a preoperative pelvic exam prior to surgery. The study team conducted a retrospective chart review in a tertiary care academic medical center of individuals undergoing gender-affirming hysterectomy with or without vaginectomy, or vaginectomy alone between April 2018 and March 2022. No chart was excluded.
From the medical record, the team abstracted patient demographics, a history of vaginal penetrative intercourse, and the use of testosterone therapy. They reviewed clinical notes from the primary surgeon in the year preceding surgery for encounter type (in-person or telehealth) and the use of preoperative ultrasound and internal pelvic exam. Surgical outcomes included the length of surgery, estimated blood loss, and 30-day postoperative outcomes. They also reviewed records of emergency room visits, readmissions, and surgical site and urinary tract infections. They divided the cohort into two groups: examined and exam-omitted, based on report of an internal pelvic exam during an in-person visit within one year prior to gender-affirming surgery. No power calculation was performed.
During the study period, 62 patients underwent gender-affirming hysterectomy and/or vaginectomy. All surgeries included an exam under anesthesia at the start of the case. All hysterectomies occurred by laparoscopy. Of 62 patients, 32% (n = 20) underwent hysterectomy, 29% (n = 18) underwent both hysterectomy and vaginectomy, and 39% (n = 24) underwent vaginectomy alone. Included patients were mostly white (n = 53, 86%) with a mean age of 22 years and a mean body mass index of 29. On average, included patients had used testosterone therapy for six years. Only two patients were parous. Of the 38 patients undergoing hysterectomy, 19 had had preoperative cervical cancer screening and three had a prior history of cervical dysplasia, all low-grade. The examined group included 29 individuals (47%) and the exam-omitted group included 33 individuals (53%). Of the exam-omitted group, 61% (n = 20) had a preoperative telemedicine visit and 9% (n = 3) had preoperative ultrasound. No findings from the preoperative ultrasound, in-office preoperative pelvic exam, or exam under anesthesia changed the surgical route of approach.
The team found no significant differences in patient characteristics nor in perioperative complications, such as estimated blood loss, visit to the emergency room, or hospitalization, between the examined and exam-omitted groups, nor any difference in major intraoperative complications, such as ureteral, bladder, bowel, or vessel injury. All pathology results were benign.
COMMENTARY
In-office internal pelvic exam in advance of gender-affirming hysterectomy and vaginectomy did not affect surgical outcomes in this study. Although this study is retrospective, with a small sample size, and likely underpowered to detect differences in surgical complication rates, it does provide a necessary foundation for surgeons to critically review the necessity of an in-person preoperative pelvic examination in this patient population.
The use of telemedicine for preoperative evaluation similarly resulted in low complication rates. Therefore, telemedicine may present an acceptable alternative to in-person evaluation, even preoperatively. Telemedicine is particularly patient-centered, since it allows patients to obtain care from the comfort of home, with a lower risk of interacting with non-affirming staff or spaces. This may reduce fear and improve autonomy, which could improve healthcare use in this vulnerable patient population.5
Avoiding a potentially triggering and dysphoric exam often is the most patient-centered approach to providing care for individuals with gender dysphoria. However, clinicians should adapt the findings of this study to each individual circumstance. Individual patients could present with specific complaints or concerns that necessitate an in-person exam. Others may require or feel more comfortable with a preoperative cervical cancer screening. Pelvic exams are not necessarily dysphoric for every patient. Self-collected human papillomavirus specimens can provide a patient-centered alternative for those patients for whom a pelvic exam is triggering; although, to date, there is no patient-collected human papillomavirus test approved by the U.S. Food and Drug Administration.6 Clinicians should discuss the risks and benefits of an in-person preoperative pelvic exam with each patient and use shared decision-making to determine the best course of action. This study provides the best evidence to date for such a discussion.
REFERENCES
- James SE, Herman JL, Rankin S, et al. The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality; 2016.
- Moseson H, Zazanis N, Goldberg E, et al. The imperative for transgender and gender nonbinary inclusion: Beyond women’s health. Obstet Gynecol 2020;135:1059-1068.
- [No authors listed]. ACOG Committee Opinion No. 823, Health Care for Transgender and Gender Diverse Individuals: Correction. Obstet Gynecol 2022;139:345.
- Peitzmeier SM, Khullar K, Reisner SL, Potter J. Pap test use is lower among female-to-male patients than non-transgender women. Am J Prev Med 2014;47:808-812.
- Hamnvik OPR, Agarwal S, AhnAllen CG, et al. Telemedicine and inequities in health care access: The example of transgender health. Transgender Health 2022;7:113-116.
- Reisner SL, Deutsch MB, Peitzmeier SM, et al. Test performance and acceptability of self- versus provider-collected swabs for high-risk HPV DNA testing in female-to-male trans masculine patients. PLoS One 2018;13:e0190172.
