Characterizing ovarian histopathology in transgender and gender-diverse patients on testosterone: Informing shared decision-making in gender-affirming care

Background: Gender-affirming hysterectomies (GAH) are increasingly performed among transgender and gender-diverse (TGD) individuals, many of whom utilize testosterone. The World Professional Association for Transgender Health (WPATH) guidelines regarding oophorectomy at the time of hysterectomy defer to shared decision-making, as limited data exists on the effects of exogenous testosterone on an individual's ovaries. This study aims to describe the characteristics of the ovarian histopathology exemplified in this cohort and contribute to the growing gender-affirming care database that guides shared decision making between providers and patients that best align with a patient's mental and physical health goals. Methods: This observational study reviewed all hysterectomies performed in TGD individuals at a single academic institution in Wisconsin between January 1st, 2016 and December 31st, 2023 for primary or secondary indication of gender dysphoria. This study was submitted to the institutional review board (IRB) at the academic institution at which it was performed and was deemed exempt. Individuals were excluded if age <18, indication included malignancy, surgery was completed by an ObGyn subspecialist, or they had not used exogenous testosterone prior to surgery. Ovarian pathology reports and medical records for all subjects who underwent unilateral and bilateral oophorectomy at the time of their hysterectomy were reviewed, and patient demographics, indication for procedure, and preoperative testosterone use were abstracted. Results: During the study period, 144 hysterectomies were performed in self-identified TGD individuals. Of these, 95 (65.9%) underwent oophorectomy, either unilateral or bilateral, of which 89 (93.6%) of these hysterectomies plus oophorectomies had a primary or secondary indication of gender dysphoria/incongruence. One individual did not report prior use of exogenous testosterone and was excluded, leaving a study population size of 88 patients. Gender dysphoria/incongruence (84.1%) was the most common indication. Benign or unremarkable ovaries was the most common diagnosis in the 64 (72.8%) ovarian pathology reports. Simple/follicular cysts were seen in 20 (22.7%) of TGD individuals' ovarian specimens. No malignant ovarian pathology was identified in this cohort based on institutional procedural configuration, however, uncommon pathologies were also not identified presumably due to the sample size and age of the population studied. Conclusions: Ovarian pathology observed in this cohort of TGD individuals undergoing gender-affirming hysterectomy is consistent with previously reported findings, with benign ovarian changes being most common among TGD patients. However, rare outcomes and pathologies with long latency periods require substantially larger cohorts and longer follow-up to detect. As such, the absence of uncommon or malignant findings in this study should not be interpreted as evidence of low population risk. Rather, these results contribute incremental data to the limited body of evidence describing ovarian pathology in TGD individuals using testosterone.