Increased vaginal cuff dehiscence among gender diverse people on testosterone

A majority of gender diverse people undergoing gender-affirming hysterectomy have a history of gender-affirming testosterone use, so it is important for surgeons to understand the impact of preoperative testosterone on postoperative complications of hysterectomy.

To compare the rates of vaginal cuff dehiscence among gender diverse people on testosterone and cisgender women and to identify factors associated with vaginal cuff dehiscence.

This is a retrospective cohort study of adults who underwent total hysterectomy from June 1, 2014, to December 31, 2019, for benign indications within an integrated healthcare delivery system. Gender diverse people on testosterone had at least 6 months of preoperative testosterone use, and all patients were followed for at least 6 months. The primary outcome was based on International Classification of Diseases, Ninth/Tenth Revision, Clinical Modification diagnosis codes for vaginal cuff dehiscence. Kruskal-Wallis, chi-squared, or Fisher exact tests were performed to compare gender diverse people on testosterone and cisgender women. Multivariable logistic regression was conducted to estimate adjusted odds ratio for vaginal cuff dehiscence.

Of the 21,200 patients included, 154 (0.7%) were gender diverse people on testosterone and 21,046 (99.3%) were cisgender women. The gender diverse cohort was younger than the cisgender cohort (median age 27 vs 46 years, P<.001) and had fewer comorbidities (respectively, 18.2% vs 27.0% with a Charlson Comorbidity Index ≥1, P=.014; 2.6% vs 6.8% with diabetes mellitus, P=.039; and 11.0% vs 27.1% with hypertension, P<.001). A greater proportion of patients had vaginal cuff dehiscence in the gender diverse than cisgender cohort (5.8% vs 2.4%, P=.014). Being in the gender diverse cohort was associated with a 2.18 times higher adjusted odds of vaginal cuff dehiscence (95% confidence interval [CI], 1.08-4.41, P=.030). Age at hysterectomy (adjusted odds ratio=0.95 [95% CI, 0.90-0.998], P=.043), hypertension (adjusted odds ratio=1.38 [95% CI, 1.13-1.68], P=.002), and operative time (adjusted odds ratio=1.01 [95% CI, 1.003-1.02], P=.003) were significant, independent predictors of vaginal cuff dehiscence.

Despite having fewer comorbidities, gender diverse people on testosterone had more than twice the risk of vaginal cuff dehiscence relative to cisgender women. Surgeons should be aware of the increased risk of vaginal cuff dehiscence among gender diverse people on testosterone and maintain a high index of suspicion when triaging postoperative complaints. Further investigation is needed to better understand the pathogenesis of vaginal cuff dehiscence among gender diverse people on testosterone and to optimize the safety of hysterectomy within this population.