Hysterectomy for the Management of Pelvic Pain in Transmasculine and Nonbinary Patients

INTRODUCTION: Hysterectomies are performed each year on cisgender patients for treatment of chronic pelvic pain (CPP), but little is known about the surgical treatment of transmasculine and nonbinary patients assigned female at birth (TMNB). Previous studies have shown pain is more often an indication for hysterectomy in the TMNB population and further analyses have shown there is not always a consistent pathologic etiology of this pain (Obedin-Maliver, Ferrando). In addition, it has been well documented that chronic pelvic pain is a complex disease that can be a manifestation of emotional and physical trauma. Given that many TMNB patients suffer with gender dysphoria, primary treatment of pelvic pain via hysterectomy in this population may be warranted. OBJECTIVE: The objective of this study is to evaluate the effectiveness of primary surgical management of chronic pelvic pain in TMNB patients. METHODS: A retrospective chart review was conducted from January 1, 2012, to April 1, 2023, using the Epic electronic medical record at a large urban academic center in [Redacted]. All patients >18 years of age who met ACOG criteria for the diagnosis of CPP and underwent hysterectomy were included. Those who had a diagnosis of cancer or pre-cancer were excluded. Demographic data was obtained, including sex-assigned at birth and gender identity, along with preoperative diagnoses, surgical interventions, pain scores, and surgical pathology. Chi-square, Fisher exact, and T-tests were run as appropriate. This study received IRB approval. RESULTS: A total of 458 patients met inclusion criteria, 37 of which were TMNB (8.1%) with the remaining 421 identifying as cisgender (91.9%). Despite meeting ACOG criteria, only 73% of TMNB patients and 48.9% of cisgender patients were formally diagnosed with CPP (p=0.005). Other common preoperative diagnoses were dysmenorrhea (29.7%, 22.1%, p=0.29), abnormal uterine bleeding (24.3%, 62.7% p<0.001), endometriosis/adenomyosis (10.8%, 55.8% p<0.001), and uterine fibroids (8.1%, 53.4% p<0.001) for TMNB and cis patients, respectively. A total of 122 (29%) cisgender patients underwent a total abdominal hysterectomy compared to one (2.7%) TMNB patient. The preferred surgical modality was laparoscopic-assisted vaginal hysterectomy (59.5%) for the TMNB cohort versus total laparoscopic hysterectomy (38.2%) for the cisgender cohort (p<0.001). On pathologic evaluation, benign pathology was most often seen in TMNB patients (56.8%, 3.6% p<0.001), whereas adenomyosis and/or endometriosis were more often noted in cisgender patients (10.8%, 66.3%; p<0.001) (Figure 1). CONCLUSIONS: Many TMNB patients experience CPP and are less likely to have pathology discovered at the time of hysterectomy. As such, hysterectomy should be offered as the primary treatment of CPP regardless of suspected preoperative etiology (Tables 1 and 2).