Endometrial findings among transgender and gender nonbinary people using testosterone at the time of gender-affirming hysterectomy

Objective: To describe clinical characteristics and associated endometrial findings of transgender and gender nonbinary people using gender-affirming testosterone. Design: Retrospective case series. Setting: Academic medical center and public safety net hospital. Patient(s): Eighty-one patients using gender-affirming testosterone therapy undergoing hysterectomy for the indication of gender affirmation from 2000 to 2018. Intervention(s): None. Main Outcome Measure(s): Preoperative clinical characteristics and endometrium surgical pathology diagnoses. Result(s): Median age was 31 years (interquartile range [IQR] 27–40), and median body mass index 27 kg/m² (IQR 24–30). Six patients (7%) were parous and 60 (74%) had amenorrhea. Thirty-three patients (40%) had proliferative and 40 (50%) atrophic endometrium. Endometrial polyps were found in nine patients (11%) of the sample. Endometrial findings were similar in the subgroup of 60 patients with preoperative amenorrhea. There were no cases of endometrial hyperplasia or malignancy. In bivariate analysis, those with proliferative endometrium were found to be, on average, 5.6 years younger than those with atrophic endometrium. There were no clinical factors associated with having proliferative versus atrophic endometrium in multivariable models. Conclusion(s): People using gender-affirming testosterone may have either proliferative or atrophic endometrium, including people who present with amenorrhea. Further study is needed to develop evidence-based guidelines for appropriate screening for endometrial hyperplasia or cancer in this population.