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Hi everyone, my name is Valentina Rodriguez-Triana, and I am one of the assistant clinical professors here at the UCLA Department of OB/GYN. Today we're going to be talking a little bit about some gender affirmation surgery options for a female to male transgender patient. If you are following us on Twitter, you can feel free to send me some questions at the end of this talk using the hashtag #UCLAMDChat, and you can also leave some comments on Facebook. So here are some topics that I want to go through for today. I wanted to give everyone a little bit of a background in terms of the national trends for the gender affirmation surgery in the United States. From there, I thought it would be helpful to maybe goes through some basic anatomy of the pelvis because that leads us right into what kind of surgery options are available for patients. Once we talk about those surgical options, I wanted to give everyone a little bit of a sense of what the recovery would be like for the different surgery options available and definitely talk about life after surgery because that would be the whole point of doing it in the first place. And at the very end, I wanted to go through a little bit of what some fertility options are available to patients after they decide to proceed with some gender affirmation surgeries. By way of some background, the WPATH, which is our guiding organization that gives us a lot of the guidelines into gender affirmation surgery, says that this kind of surgery is both effective and medically necessary in the United States. We've looked at some trends as to how many people are choosing to go forward with surgery, and from the National Transgender Discrimination Survey that was done in 2011, we know that about 21% of trans men have decided to go through with a hysterectomy, and another 58% of trans men would want at least a hysterectomy, leaving another 21% of men who do not want a hysterectomy or have not had it done. And I think that what that shows us is the vast majority of trans men have either had a hysterectomy or at least would be interested in having a hysterectomy. Generally throughout the country, we've seen that in the past few years, there is an increase in the number of patients who are desiring to move forward with the gender affirmation surgery, and not only that, but there is also an increase in the number of insurance companies that are going to be paying for this procedure. This is a little bit of anatomy, and I think it's always really good to go back to this because it helps give people a sense of what they would like--organs they would like to remove and which organs they would like to keep. Some of this seems intuitive, but because the pubic anatomy is hidden I think it's worth at least going bit by bit through each of the organs. The first is the vagina, which can or cannot be used in penetrative vaginal intercourse. We're not going to be talking about vaginectomies and vaginoplasties today; that will be addressed in later webinars. Next is the cervix, and the cervix, really, we treat as its own separate organ. That's the organ that gets sampled during pap smears. That's what we screen for cervical cancer. And for some people, it can or cannot play a role in sexual intercourse. There's also the uterus, and within the uterus we know that this would house any pregnancies, also the area that sheds the lining every month when people menstruate. The fallopian tubes, that, really their sole purpose is for conception and for fertility, for helping people achieve pregnancy, and finally, the ovary. Two major functions of the ovary: first function, to produce the hormones estrogen and progesterone, and second function, to carry the eggs that people can later use if they'd like to start a family and achieve fertility. So keeping that in mind of all the different parts of the pelvic system, we like to get and go through what are the options for people who are seeking gender affirmation surgery and really there are a few different options on the table. The first and the most obvious is to have a hysterectomy, which is essentially the complete removal of the uterus. Within that we have a subcategory of a partial hysterectomy, meaning keeping the cervix in place, or total hysterectomy, meaning removing the uterus and the cervix together, and really that's a little bit contingent upon if someone has any sexual pleasure from keeping the cervix in place, if it's something important to them or if they're okay with removing it. There's also an oophorectomy, which is just removing both the ovaries on either side. There is a salpingectomy, which is what we call removal of the fallopian tubes. This is really more for people who would like to contrast that to use contraception more than anything else and prevent pregnancies, and then within that we have removing one or all of the above. So people can decide to remove just the ovaries, people can decide to remove just the uterus, or people can decide to remove the uterus, the tubes, the ovaries, and the cervix altogether. When we talk about removing all of these organs, the question that follows is how, in fact, do we go about removing them, and fortunately, these type of procedures lend themselves to a lot of minimally invasive options. There are three options that we mostly talk about when offering these surgeries. The first is performing a vaginal hysterectomy, and this is really to move the uterus and the cervix together. It's incisionless surgery because there are no incisions on the patient's abdomen, and all the organs are removed from below. At the very top of the vagina there are sutures that close it shut. There's also a laparoscopic hysterectomy, and we do the laparoscopy, we essentially insert a little camera into the patient's belly button and 5 or 3 small little ports that are about 5 millimeters in size in the rest of the abdomen, and from there, we're able to detach the uterus. We can also detach the ovaries, the fallopian tubes, and remove everything via the vagina. The other option is to do a robotic surgery, which, this is kind of a little example of what it would look like, but essentially, the surgeon is in a separate console from where the robot is doing the surgery, and then finally, as an option, we have an open surgery, and that's kind of a low bikini incision. For most of these kinds of surgeries, minimally invasive options are available, and I think, really, what kind of surgery a patient has available to them depends a little bit on what exactly they would like removed, how big their uterus is or the ovaries are, and what the surgeon's preference and skillset is. Here are some preoperative considerations. If you're thinking about having any of these kinds of surgeries, a lot of these apply, really, to anybody who is going to be having a surgery. It's really important that patients are evaluated by a gynecologist, and preferably the one who would be doing the surgery, so people can meet face to face with their surgeon and go through a lot of the different pros and cons, risks and benefits. We like patients to be 18 or older. Informed consent is really necessary, and having that conversation with your gynecologist may be sure that your questions are answered and that you feel like you have a good understanding of the kind of surgery that you'd like. We do like to see medical clearance. Really, what that means for any patient undergoing surgery is that you've been evaluated by a primary care doctor who's listened to your heart, your lungs, and said that you are fit to have a surgery and that there are no other issues that need to be addressed beforehand. We do like to see two letters of support to mental health or behavioral health letters of support, and this is per again our guiding organization, which is the WPATH. It's also recommended that patients should have lived at least 12 months in the gender that they identify, just because it helps a lot with the acclimation to have undergone the hormone therapy first and then the surgical therapy afterwards. And then a lot of questions come up about preoperative exams, pap smears, and ultrasounds, and a little bit of this is going to be contingent upon your gynecologist's preference and what your previous medical history was, in terms of pap smears as well as what kind of symptoms patients have. So, most gynecologists will want to do a pelvic exam in the office to assess the size of the uterus and make sure that there are no large masses. I think that's really important for patients to know before they make that appointment, just that they're prepared for that, in terms of pap smears. Our pap smears required for these kinds of procedures, it kind of depends-- it depends a little bit upon what your previous pap smear history was, what your sexual history has been, and whether or not you're going to be keeping or removing the cervix, and then the final is a transvaginal ultrasound necessary for this, also kind of depends on whether or not you're having symptoms that would be concerning, like heavy bleeding symptoms, pelvic pressure symptoms, things like that. Not all ultrasounds of the pelvis need to be done transvaginally or inside the vagina. A lot of them can be done on the abdomen or even outside the labia. So if these are things that are worrisome to you, first you should address them with your gynecologist and make sure that you feel comfortable having whatever exams done, and second, just make sure to see if there are alternatives to having invasive procedures before these kinds of surgeries. Some other surgical considerations, and really these apply to anybody who is to be undergoing these kinds of procedures, there's always a risk of bleeding, pain, and infection. We tell people that for all kinds of surgeries, the risk of damage to other organs, specifically for this kind of surgery, we like to talk to patients about the risk of damage to the bladder and damage to the ureters, and those are the tubes that connect the kidneys to the bladder, and they course right under the uterus. So we like to let people know that while that risk is very very low of damaging them, it's not zero. The procedure itself is relatively short, it takes usually about two hours or so, and it's done under general anesthesia, meaning that patients are completely asleep. It's an outpatient procedure. So, typically patients would show up in the morning, have their surgery, and then within a few hours after surgery, they would go home, and something that I think is important, just to keep in mind, is that these procedures are generally not reversible. So, once the uterus has been removed, we cannot reattach it, and the same thing with the ovaries. So, what's the recovery like for a procedure like this? The good news is that it's relatively quick, whether it's done vaginally, laparoscopically, or robotically. Patients tend to recover each day a little bit more and feel a little bit better each day. After going home the same day, pain control is usually pretty straightforward, a good regimen of ibuprofen, a good regimen of Tylenol, and every now and then some narcotic, really gets people through. We like to see people by the morning, or by the next morning, walking, going to the bathroom on their own, trying to eat a regular diet. So, people generally start to get back into their normal activities within a few days. In terms of wound care, I have here just a little example, again, of what--where the incisions might be if you're having this done laparoscopically and how small they would be. Wound care is not really a big issue for a patient, generally because the incisions are so small, and they're closed after, with sutures that dissolve underneath the skin, and so, apart from keeping the area clean and dry, most people don't have to do too much to take care of their wound. There are some activity restrictions that we should just keep in mind. The incisions on the outside of the abdomen are small, but the one inside at the very top of the vagina can be a couple centimeters in length, and that's the one that we want to make sure that we're keeping safe from opening up. So because of that, we tell patients no heavy lifting and no--nothing inside the vagina for at least about 6 weeks to let that area heal entirely. Post-op follow-up is really recommended, and usually surgeons like to see their patients 2 weeks and then maybe 6-8 weeks after surgery, just to make sure that patients are feeling comfortable, that everything seems to be working okay, In terms of their intestines and their bladder, and also just to go through a lot of the details of the surgery, so that patients feel like they have a good understanding of what happened. So why get this done in the first place? What would be the benefit of going through procedures like this? And I'll kind of compartmentalize this again, in terms of the different areas of the different pelvic anatomy. So if there's no uterus, the benefit is that there is going to be no bleeding, either irregular bleeding from being on the hormone therapy or just regular menstrual bleeding, and for a lot of patients, that can really improve their quality of life. If there's no ovaries, Then there's no higher production of estrogen and progesterone, and because of that, patients who are on testosterone can usually come down on their testosterone dose because they're not competing with that estrogen. I put here as an aside, if there's no tubes patients don't need contraception, and that's true. If there's no fallopian tubes, people don't need to contracept. However, safe sex is always still a requirement, and if there's no cervix, then there's no need for pap smears, as long as patients have had regular pap smears and no dysplasia prior to getting the cervix removed. So if patients remove the uterus, the tubes, the ovaries, and the cervix together, generally the maintenance and the life afterwards becomes pretty straightforward and less tedious. So if we talk about removing these organs, I think it really begs the issue of, what about patients who want to start a family or who want to grow a family? What options are available to them, so they can still grow a family while also undergoing a procedure that feels right to them? There are a couple of options. If patients decide that they want to have their ovaries removed, then prior to removing the ovaries, if that patient knows that they would really like to parent their own biologic children, we can do egg freezing or a site freezing, and essentially, that involves just being able to save the eggs, freeze them to then use them at a later time. If patients are already on testosterone, that's fine, we can still do the egg freezing. It's a matter of stopping the testosterone, getting the eggs, and starting it again Along that same token, there's embryo freezing, so if the embryo is really already the uniting of the sperm and the egg together, and if patients already know that they'd like to do that, they can freeze an embryo instead and then have the ovaries removed for a later date. Along that same line, there's always the option later on, if patients don't want to freeze anything in advance, of using a donor egg and donor sperm if they'd like to start a family or continue to grow a family, and then finally, for patients who know that they don't want to carry a pregnancy and who may or may not want to use their own eggs, there's always the option of a gestational carrier. So, having a gender affirmation surgery should not conflict with a patient's desire to grow their family or to continue to build it. Something that I think is important is just that a lot of insurances will not cover these kinds of procedures, so these are things that we should do our homework about before undergoing anything irreversible. So this is our organization, the Gender Health Program, and if you have any questions about any of the things that I talked about today, I really encourage you to go onto our website and take a look. This was just a little sneak peek at so many of the options that we have available to patients as part of their gender affirmation process. In this Gender Health Program, we also have a very multidisciplinary team of primary care doctors, endocrinologists, urologists, plastic surgeons, gynecologists, reproductive endocrinologists, so there are a world of resources available to people who really want one umbrella organization to help them navigate all the different procedures and medications that they can be on to help them as part of their process. And if you're looking for a couple of more resources, I mentioned WPATH a couple of times in the talk, and they're, like I said, the guiding organization that helps us come up with guidelines to help patients figure out what's right for them. You can go to their website. They also have a standard of care document, which I think is really helpful if you're thinking about starting a hormone therapy or undergoing a procedure, and then finally, our website has a lot more information, also, about the different gynecologic procedures available, also has a lot of information on contraception, family planning, growing a family, so not just gender affirmation surgeries, but life in general, and making sure that your fertility goals are kept in mind. And if you have any questions, I will take them now at that #UCLAMDChat, and I think we are getting some now. So the first question that we're getting is to talk a little bit about sex after the gender affirmation surgeries and what that's like. So, the vagina can or cannot be used for penetrative intercourse, and for people who decide that they do use their vagina for penetrative intercourse, but still would like to undergo a procedure, we generally don't think that it changes sexual function after. The only caveat is that people really need to make sure that area heals well before undergoing any type of procedure, before undergoing any intercourse, but generally it shouldn't affect sexual function afterwards. If anything, sometimes it can probably improve it. There are questions about insurance and insurance coverage for these kinds of procedures. Increasingly, and I think that the last study that I showed does demonstrate this too, more insurance companies are covering this because it is considered a medically necessary procedure for female-to-male trans patients. So I think also Medical and Medicare are trying to pay for it also, so I would just check with them, but it's encouraging to see that more insurance companies are starting to cover these procedures as well. Thank you so much for joining me today. Please feel free to refer to our website for any other questions you have.