At one of the follow-ups after the diagnosis of my post-hysterectomy vesico vaginal fistula (VVF) I asked my gynecologist if he thought the effects of testosterone on vaginal tissue could have played a role in my complication. He thought for a moment, then replied that he didn’t think so.
I was certainly not the first trans man that my surgeon had performed a hysterectomy for, but I don’t know just how much recent experience he has with trans men. There’s also very little data out there about the effects of testosterone on vaginal tissue. (Trans men are a very understudied population.) However, I have come across references that state the following:
- Testosterone makes vaginal tissues weaker, thinner, drier, more brittle.
- Testosterone changes the pH of vaginal tissue to be more alkaline.
If vaginal tissues in a trans man are weaker and thinner, wouldn’t that call for a surgeon performing hysterectomy to be more cautious with the pressure used in suturing?
Isn’t is plausible that my androgenized vaginal tissues were weaker and thinner and thus more susceptible to the pressure of that slipped stitch that went through the vaginal wall and into my bladder?
When I was asked to facilitate the Hysto Stories discussion group at the 2009 Gender Odyssey Conference in Seattle, I knew this would be an opportunity for me to share my story about VVF and also consult with some of the leading minds in FTM surgery to get their thoughts about my theory of increased risk.
Dr. Toby Meltzer’s presentation, FTM: GRS, was particularly eye opening. He stated:
- Atypical bacteria is found in the androgenized vagina.
- Androgenized vaginal tissues are not preferred for urethroplasty because they are weakened.
While not referencing hysterectomy and VVF specifically, this information seems like supporting evidence for my theory.
I attended Dr. Burt Webb’s presentation on hysterectomy the next day. Dr. Webb is the OB/GYN who works with Dr. Meltzer in Scottsdale, AZ. Dr. Webb performs vaginectomy (colopocleisis) and hysterectomy for FTM patients. I asked Dr. Webb if he thought testosterone had negative effects on vaginal tissues that could weaken them and put trans men at higher risk of complications. He didn’t think so. I cited Dr. Meltzer’s comments from the day before and he seemed surprised, then said he didn’t know. (Which I think is a fine answer. It’s better than bull.) Hoping I wasn’t dominating the Q&A, I went on to briefly tell him about my VVF. It then seemed obvious that Dr. Webb didn’t have much clinical experience with VVF. I don’t mean that disrespectfully, it’s just that he said a few things that are not true:
- VVF’s often heal spontaneously.
FALSE: The chances of spontaneous healing of VVF with conservative treatment (catheterization) is less than 5%. With no treatment, that drops to less than 1%. - VVF’s aren’t caused by a stitch.
FALSE: Biopsies performed on excised fistula tracts have shown them to be caused by sutures. The presentation of my VVF indicated quite clearly that it was the result of a single misplaced stitch—not a scalpel nick.
Like my own gynecologist, I can’t expect Dr. Webb to be an expert on VVF if he hasn’t seen them in his own practice. They just aren’t that common.
But wouldn’t you know it… Shortly after leaving Dr. Webb’s presentation, I got an email on my Blackberry from another trans man who recently suffered a post-hysto VVF, had two repair surgeries, and is still experiencing related pain and discomfort. Similar stories have been trickling into my inbox since I first published information about my own VVF. I think it’s quite possible that trans men are at higher risk of VVF due to the androgenization of vaginal tissues, and I’ll keep looking for more facts that might support this. I don’t need to be right about this—in fact, I’d prefer to be wrong—but if the theory holds true, trans men and gynecologists need to be aware of this heightened risk.
UPDATE, 09/21/09: Dr. Kate O’Hanlan is a Gynecologic Oncologist based at Sequoia Hospital in Redwood City, CA. Dr. O’Hanlan has significant experience with trans men, and is the lead author of a 2007 study that I have referenced here before, Total Laparoscopic Hysterectomy for Female-to-Male Transsexuals (PDF.) In Dr. O’Hanlan’s pre-op info handout for trans men (PDF), it states:
At your physical exam, Dr. O’Hanlan may have prescribed low-dose Estradiol suppository tablets… these tablets help maintain mucosal tissues and will play an important role in your internal healing… Once we are sure the internal scar line is cleanly healed, you will no longer need the tablets. In any case, the hormone dose is local and so low that it will not interfere with your testosterone treatment.
This is the first time I’ve come across a recommendation for Estriadol pre-hysterectomy to “maintain” vaginal tissues and help with healing. This isn’t clear cut support for my theory of androgenized vaginal tissue and higher hysto risk factors for trans men, but I’d love to get Dr. O’Hanlan’s thoughts about it.
Hat tip to Nico for sending me this reference! Thank you for contributing!!
UPDATE #2, 10/18/09: Estrogen suppository tablets are also prescribed to trans men who experience bleeding with penetration, restoring integrity to weakened, androgenized vaginal tissues.
Gender Outlaw 
This is a fascinating subject for more research. I am really glad you are posting about this. I am 1 day post hysto, and well, as a frequent reader here, i have been thinking of your story. I will ask my dr if she’s noticed anything, she does a lot of hystos on FTMs. Again, thank you.
Hey Nico, rest up my friend! I found I was a little too drugged out post-hysto to sit at the computer for more than a few minutes. I would LOVE for you to ask your doctor about T and it’s effects on vaginal tissues! Please let me know what you find out. And I’ll say it again: rest up!!
thanks for the advice. anyways, it will prolly be a few weeks or so, when i can ask her at my post-op checkup.
The whole VVF problem is a frightening one, and just not someting that people really think about. It’s awesome that you’re bringing awareness to this subject.
Thankfully Jack, VVF is still quite uncommon. But it is scary. And as my urologist put it, 1% is the same as 100% if it happens to you.
I think the solution is simply information. If I had talked to my surgeon about the risks of VVF, and that I might be a higher risk patient, I don’t think I would have suffered from an iatrogenic VVF.
I have a consult in Oct..I will ask my doc what she thinks..I gotta admit after hearing the perils of VVF I’m not very excited.
oh I have to mention..my social worker thinks it’s terrible that transmen talk online and get eachother all worked up..she says FTMs shouldn’t be doing this because it’s a female thing to gossip and it’s more likely with MTFs..
I have no desire to deal with her once this is over.
Be sure to read my last comment to Jack. VVFs aren’t that common. It’s a risk to be aware of, and if trans men are at higher risk, then simply having this knowledge in the hands of the surgeon and patient will reduce the risk considerably.
As for your social worker… yeah, time to move on! Sharing information is not the same thing as gossip. It’s about education and making informed decisions, not getting “worked up.” Ridiculous.
I don’t see how talking online about our common issues is any less masculine than, say, guys who get online to chat about Star Wars or lacrosse or all the millions of other trivial things that guys get online to chat about. In fact, the main difference is that this is bigger and more important and affects more portions of our lives than most of those other entertainment-centered things. So why shouldn’t we talk about it online? It’s even a running joke on 4chan that “there are no girls on the Internet.”
And furthermore, being able to talk about things and get them off your chest is HEALTHY, whether you’re a guy or a girl. Your social worker doesn’t seem to be very educated in… well, social workings.
Either way I will for sure tell her about my concerns over VVF. I would also like to ask if your surgeon took any special precautions ie: smaller instruments, smaller incision (cervix) to lessen the risk of fissures, nicks or anything else that may hinder a GRS later on?
Yes, my SW is a douche. Thanks for the support *ladies*!!
I don’t think my surgeon changed his methods in any way for my surgery. And this is exactly what I’m getting at: I don’t think trans men are routine hysto patients. There are gynecologists out there who are taking special measures though, like Dr. O’Hanlan.
Just had Hysto consult. She said there is no need to stop testosterone use before or after surgery and that it was worse to stop and start. Only difference is the ovaries have shrunken which makes removal easier. Not unlike menopausal women or women on androgen therapy.
No serious risk factors being trans. Able to make abdominal scar under 2 inches and vertical if laparoscopic route fails.
What do you think? Sound legit?
There’s debate out there about whether or not testosterone hinders the healing process. Neither of my surgeons felt particularly strongly about this and simply recommended abstaining for 2 weeks pre-op, then resuming normally post-op. Seemed reasonable to me.
“Only difference”… that’s not entirely true. Yes, ovaries are shrunken. There’s also the chance of vaginal atrophy, making a vaginal procedure more difficult (or inadvisable) for some guys. (If your consult was about a total lap procedure that might explain why vaginal atrophy wasn’t mentioned.)
“No serious risk factors being trans”… I hope not, that’s what I’m trying to find out. I do think that we’re different from female patients seeking a hysto, and I question a surgeon’s expertise with trans health if they assert that there’s no difference. Menopausal women or women on androgen therapy aren’t taking the kinds of T dosages that trans men are on, so this comparison can only go so far.
The question with hormones was clotting. Which is picked up during the pre-op bloodwork. Also your endo should be routinely checking this while on T anyways.
I should mention I’ve been on T 4 months @ .5cc. It is lap w. vaginal removal.
If the atrophy is severe you would have an indication anytime you had an “encounter” with your vagina. You would probably be getting vaginitis more frequently.
And menopausal women can be treated with testosterone for the reversal of vaginal atrophy granted yes, in a lower dose.
You need to remember you actually are female. The gyno is looking for a healthy vagina and even though we’re trans our vaginas will either look normal or not regardless of what we’re on.
I feel the need to defend my surgeon..sorry.
PS. I meet Brassard in Nov. I’ll let you know if he’s a hard ass.
From personal experience, at a dose of 2oomg IM biweekly for almost 4 years. My ovaries did not shrink. I had PCOS before transition and they remained large and painful. They were larger than a biowoman without PCOS. Also- my uterus did not shrink either. My doc assumed that it had. In fact when he opened me up he was surprised and saw that it was the size of an 8 week pregnancy without any fibroids. Not all FTM’s will have ‘shrinking’ organs. I should have been in chemical menopause but I wasn’t. T labs were all normal on annual visits so I know the dose isn’t the problem.
I’m a little confused why you would ask me if your surgeon is legit, then feel the need to “defend” against my response.
Clotting is one testosterone related concern. It’s effects on healing are another (and widely debated.)
Not all trans guys have “encounters” with their vaginas, nor do they suffer symptoms of things like vaginitis, yet many do find out through a hysto consult that they’ve had some testosterone related atrophy and are not candidates for lap-assisted hysto.
It’s not as simple as a healthy looking vag or not. My whole point is that I think testosterone makes it more complex than that.
You use “you” a lot in your comment. Is that a global “you” or are the comments directed at me specifically? I need to remember that I’m actually female? I don’t understand the context of this advice and I’m inclined to disregard it.
I’m not making this personal. I like to argue. I apologize if I came across as agressive. There is no question that T does things to the body as a whole. My point is whether it has atrophied the vagina or not this is something that the surgeon should pick up regardless. The “female” point I was making is that whether you (me, him, her,us..) are trans or not we all still have vaginas and if the health of said organ is in question the surgeon should recognize this through exam, ultrasounds, tests…whether it be from T use or otherwise.
I understand you are upset about VVF and dedicate a lot of your time to trans issues and education and I thank you for that I have learnt a lot. Like I said I like to argue..it’s my flaw by nature. I’m not trying to offend. We’ll agree to disagree on this one.
It’s actually pretty hard to get me to take things personally, so no worries there. Absolutely, a surgeon should be able to ascertain if atrophy is present, and evaluate the health of vaginal tissues. My point is that I question a gynecologist’s expertise with trans health if they dismiss the possibility that trans men need specialized care (due to testosterone use and it’s effect on vaginal tissues.) I’m not clear on what aspect of this you disagree with.
I guess what I’m trying to say is that I hope all doctors involved are confident in their ability to assess all potential risks for all medications one may be on.
Just because a doctor does not anounce that he/she is looking for specific T related side affects and perhaps thay may not be aware there could be some does not mean they will overlook the fact that our bodies have/are changing. It’s a learning curve for the medical comminuty. And long term studies..there aren’t any. Who knows..the H1N1 vaccine may cause vaginal tissue to atrophy..?
I don’t need “specialized” care, nor do I want it. That’s where I disagree.
Hi guys. I just went to gyno Dr.Tregoning this past week. He would be doing a full laparoscopic prodedure. I asked him what he thought about being on T during surgery. He said not to stop it. I also asked about vaginal estradiol suppositories. He didn’t think it would be necessary since the hysto wasn’t being done through the vagina.