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.

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