When I first came out to my mom as trans a few years ago, she didn’t have to say she already knew. Instead, she reminded me of when I begged her for a hysterectomy in sixth grade. As I sobbed about hating my period and wanting it gone forever, she asked 11-year-old me a question I didn’t know could be asked: Do you think maybe you don’t want to be a girl?

I don’t remember my answer, just that I ignored that feeling for another decade. Now, I have great news for that version of me: As of three and a half months ago, I got the hysterectomy I’ve always wanted. But going through the process itself, especially as a trans man, wasn’t what I expected it to be.

I’m processing my healing the best way I know how: by writing a love letter to anyone who’s had a hysterectomy, especially my trans siblings, because my God, this shit is hard. The most loving thing I can think to do is tell people everything I wish I had known before surgery. Your surgeon should explain everything to you thoroughly; mine certainly did (and even fielded late-night panic-questions.) Even so, there’s some things you can’t know until you go through them.

Some of the information here applies to anyone who gets a hysterectomy. Some might apply only to trans masculine people who are on testosterone. Some might apply only to people with underlying chronic illnesses, as I have endometriosis and Crohn’s disease, both of which affected my surgical healing process. None of the following is medical advice since I’m not a medical professional, just a trans man who’s been through the process.

1. Hysterectomies are very customizable to your medical and gender-affirmation needs.

I knew going into this that there were multiple types of hysterectomies. What I didn’t realize was just how many options I had, all of which I could customize to best fit what I wanted out of surgery. Since this surgery was for medical reasons and gender affirming reasons, I had a lot to consider: Should I keep my cervix? What about my ovaries? What type of surgical technique would be best to achieve what I want?

I didn’t want to have to get pap smears, so I chose to remove my cervix. I did want my body to still produce its own hormones in case I lose access to testosterone, so I kept my ovaries. I wanted any potential spots of endometriosis to be removed, so I had a robotic-assisted laparoscopy.

I was originally planning to get my ovaries removed, but the night before I was scheduled for surgery, I worried about the consequences of not having ovaries if I had to stop T, the big one being loss of bone density. I worried that I wouldn’t be able to change my surgical plan since the specifics had already been approved by insurance. I sent my surgeon a panicked message at midnight, less than 12 hours before I was due in the OR:

I know this is extremely last minute, but am I allowed to last-second change my mind and keep one or both ovaries? Would we still be able to remove any endometriosis that we find if I keep them?

She messaged me back at 6am: Not a problem, Max. You have up until you are sleeping under anesthesia to change your mind. Endometriosis we will always address and remove it.

I met with her in person pre-surgery and talked through the reasoning behind keeping the ovaries, and we mutually agreed to leave them in. She crossed “oophorectomy” off the list of procedures for the day and told me we can always go back for them later.

WHAT YOU CAN DO: Talk to your surgeon about what you’re looking to get out of surgery so you can both come to an agreement on what’s right for you. I’m no health insurance expert, but I’d imagine I was able to make my last-minute choice because I was opting out of a procedure that was already approved, not asking them to add a procedure that wasn’t approved yet. So if you’re not sure yet if you want to remove your ovaries or cervix, it may be worth telling insurance you do want that so you have more choice flexibility later.

2. If you’re on testosterone, the consequences of removing your ovaries are different from someone not on testosterone.

The most common thing you’ll find online when looking up information about removing ovaries is that removing them results in immediate menopause. The major reason behind keeping my ovaries was wanting a backup source of hormones in my body, but a small part of it was that I feared the emotional consequences of menopause. What would happen to me when my body switched from running on a combination of estrogen and testosterone to just testosterone? As it turns out, that’s a total misunderstanding of the situation… and I’ve already been in menopause for years.

The medical definition of menopause is “a point in time when a person has gone 12 consecutive months without a menstrual period.” By that definition, I’ve actually been in menopause for a decade, since I haven’t had a period since I was 18 thanks to IUDs. If you’re on testosterone and haven’t had a period in a year, congrats, you have already induced menopause.

My idea that I was switching my body from running on a combination of hormones to solely testosterone was also a misconception. If you’re trans, you may already know that trans women on HRT sometimes take testosterone blockers in addition to estrogen. However, it’s rare for trans men on HRT to be prescribed estrogen blockers, unless they have a specific condition that makes testosterone more likely to aromatize back into estrogen. Why? Because while estrogen-only HRT can lower testosterone levels, it’s not always enough on its own; meanwhile, testosterone consistently lowers estrogen in trans men even without a blocking mechanism like aromatase inhibitors.

A 2018 study found that “with increased testosterone levels in transgender men, a significant decrease in estradiol levels was noted.” This happens because, as a member of my medical care team who prescribes HRT put it, “if testosterone and estrogen are in a race to bind to your body’s receptors, testosterone will win every time.” This is an extremely simplified version of a complicated process, but basically, my fear of what it would be like to “switch” to a testosterone-dominated hormonal system was silly. I’ve already been living testosterone-dominantly.

Ovaries are my body’s primary producer of estrogen, but they’re not the only ones. Estrogen is also produced in adipose tissue (fat) and the adrenal glands. While it’s still true that not having ovaries and not taking any additional hormone replacement therapy can have adverse health effects, my concern of having zero estrogen would not be true.

Every human body needs some level of both testosterone and estrogen to function. According to the aforementioned 2018 study, “even though the fall in estradiol levels was significant statistically, the actual levels remained within the normal male range, even with 6 years of follow-up.” To translate, you will still have some estrogen in your body if you’re on T just like a cis man would, and that’s healthy.

Even if you’re not on any form of hormone replacement therapy, removing your ovaries doesn’t necessarily mean you have to go on either estrogen or testosterone. I asked my surgeon if I removed my ovaries and lost access to T whether I would have to take estrogen. She said I would likely have to take medication for bone density, but no, I wouldn’t necessarily need to start E. And even if I did take E, it wouldn’t have to be forever; anyone who removes their ovaries and uses estrogen as their replacement hormone of choice typically only takes HRT until the age of natural menopause, around their early fifties.

WHAT YOU CAN DO: When considering ovary removal, do your best to consider the ways this will affect your personal hormone balance. You will likely experience greater changes to that balance if you’re not currently on HRT. No one can tell you whether removing your ovaries is right for you besides you and your doctor/surgeon, and even then, you have the final say.

3. You should mentally and physically prepare for some level of pain.

Pain is subjective, but surgery is surgery, so you are almost guaranteed to experience some pain while healing. My hysterectomy was laparoscopic, so I assumed that because I’ve had an exploratory laparoscopy to diagnose my endometriosis, that I knew what the pain would be like. I underestimated the pain by a longshot, and I think this mental unpreparedness made everything harder.

A 2016 study found that the overall pain level after total laparoscopic hysterectomies is most intense the day of surgery, then starts decreasing. The study also found that the majority of patients studied also experienced shoulder pain, peaking at an average of 24 hours post-surgery, and perineal pain, “which was more severe than abdominal pain in approximately 30% of patients.” If you’re wondering what perineal pain means, I can save you a Google: you might know that area as the taint.

Personally, I did not experience a significant amount of shoulder or perineal pain. The abdominal pain and incisional pain, however, were excruciating. I can’t sugarcoat this part: The level of pain I experienced was what I would consider traumatic. As a chronically ill person, I’m no stranger to pain, but I still have flashbacks to what it felt like to wake up from surgery when something hurts the surrounding surgical area. It was the worst pain I’ve ever experienced, and I’ve had a botched spinal tap before. But sure enough, similar to the findings of the study, the pain level went from agonizing to present-but-bearable within the first day or two post-surgery.

WHAT YOU CAN DO: My experience does not mean that you will have the same pain level I did. The best thing you can do is prepare to stay “ahead of” the pain by following a strict painkiller schedule, whatever you determine that to be with your surgeon. Mine was a combination of non-narcotic painkillers and small doses of opioid painkillers, but if you’re concerned about taking opioids, there are ways to work around that and still keep your pain under control. Your medical care team will tell you what to do and give you discharge papers to reference in case the post-anesthesia haze makes you forget. Set alarms in your phone to remind yourself. And as a bonus comfort, consider buying yourself a heating pad (I’m partial to the cordless kind that you can clip around you like a seatbelt.)

4. Some amount of bleeding after surgery is normal, even if it’s dysphoria-inducing.

The people in my life who have had hysterectomies all experienced some level of bleeding afterward. Most of them bled for the first few days after surgery. My case was different, so I thought something was wrong, but it turns out this is also within the realm of normal. According to Mayo Clinic, you may bleed for “several days to several weeks after a hysterectomy… [as] sutures dissolve and the tissues heal.” However, the bleeding “should be light,” not as heavy and dark as a full-on period. If you’re experiencing heavier bleeding, contact your surgeon as soon as possible.

I didn’t start bleeding until day 20 after surgery. It was brownish-red and more spotting than bleeding, but I was still caught off guard by it, especially nearly three weeks into healing. According to my surgeon, this was a sign of healing: the brownish color of the blood meant it was old, and it could now escape after previously being hindered by internal swelling. This didn’t make it any more pleasant of an experience. The first night I started bleeding, the sensation of blood escaping me kept me up all night. Add the dysphoria and mental weight of feeling like I’m getting a period again for the first time in a decade, and you can see why this was my second least-favorite side effect (second only to the post-surgical constipation).

WHAT YOU CAN DO: Make sure you have pads in the house while you’re healing. Post-surgical bleeding may cause you dysphoria. If buying period products makes you feel bad like it does for me, now’s the time to rely on a friend to pick up those pads for you. Rest assured that no, this is not a period, and once you’ve had your uterus removed, you will never menstruate again. If you’re bleeding heavily enough to soak through a pad, contact your surgeon and get medical attention ASAP.

5. You don’t have to give up all sex while you’re healing.

Cis-het society conditions us to think “sex” means “penis in vagina” and nothing else. So when you look up questions like “when can I have sex after a hysterectomy?,” a lot of the answers you’ll find are from cisgender straight women asking about that specific act. Exact limitations vary based on what type of hysterectomy you have, but I was advised to avoid all internal penetration for six weeks. As a trans man, penetration has never been much on the menu for me personally, so what about everything else? Do I have to tell my girlfriend not to touch me at all? My surgeon told me I could resume non-penetrative sexual activity “whenever I felt up for it,” which still wasn’t for a couple weeks anyway due to pain.

If you’re someone who really likes penetration, be warned that this surgery might change how that feels for you, especially if you have your cervix removed. In hysterectomies that remove the cervix, your surgeon will create a vaginal cuff at the end of the vagina — as one not-so-affirmingly-named source called Hyster Sisters phrases it, “kind of like the end of a sock” — and the resulting swelling can make sex uncomfortable. This can potentially be helped with pelvic floor physical therapy, or just giving yourself more time to heal.

WHAT YOU CAN DO: It might feel embarrassing, but if you want to know when you’re cleared for non-penetrative sex, you need to ask your surgeon that specifically. They may also have good recommendations for a pelvic floor therapist if you feel you need one. If you have a partner, make sure they’re looped in on what your medical limitations are for sex as you’re healing. And whenever you resume sexual activity, start slowly — your body is healing from trauma, which isn’t always sexy, but listening to your body is.

6. Post-surgery complicated feelings are normal.

When I was healing from top surgery, I wouldn’t call the experience easy, but the hardest part was the body horror of it all. Overall, the horrors were far outweighed by how happy I was for my body to look closer to how I wanted it to. Getting a hysterectomy was a much harder process for me, both physically and emotionally.

I kept a journal of my healing process, and I think the version of me more immediately dealing with the aftermath explains it better than the current version of me can:

Day 23: I’ve been wrestling with this for days, but I don’t regret surgery. I regret needing it. The outcome I really want is to have been born a cis man in the first place. Top surgery made me feel like being trans was hard but beautiful. This hysterectomy has made me feel like being trans (especially while chronically ill) is a lifelong sentence of physical pain and discomfort. I think both feelings can be true. 

In the face of this grueling recovery, I’ve been lazy about taking my shots — or more accurately, anxious and putting it off. T shots barely even hurt me, but it’s just one more thing that hurts. I can’t take any more things that hurt right now. I imagine waking up in a body that doesn’t need to change to be happy while I struggle to fall asleep through the pain in this one. Top surgery was a joy I shared publicly. This hysterectomy has been a nightmare I write in my notes app about.

Almost exactly eight weeks after surgery, it’s the day of the inauguration. My fear for every trans person’s ability to get affirming surgery in the future skyrockets. I watch as a handful of well-meaning cis friends share an infographic on how more people regret having kids than having gender-affirming surgery.

It’s affirming that that’s true, but deep down, some part of me also wishes we’d stop focusing on whether trans people regret their surgeries at all. We consistently have to advocate hard for our own care, and we don’t even get to stop there — we’re also expected to be the perfect patients, always uncomplicatedly happy about everything transition throws our way, or else we play into right-wing detransitioners’ narratives of regret and mutilation.

Now that I’m on the other side of the acute healing phase, I can firmly say that no, I DON’T regret my hysterectomy. I can focus on the relief I feel knowing my uterus and its multiple cysts are gone and any endometriosis we found was excised. No period and no pregnancy are prizes I would pay heavily for, and I have.

But when healing was hard, there were moments where I did regret surgery. I was worried I caused myself physical pain that would never end (it did) over something I could’ve just solved with IUDs forever (with the tenuous state of rights for everyone with a uterus in this country, I’m not sure that I could have.)

The feelings of regret were temporary, but the pain of them was so compounded by shame. I did not feel allowed to have complicated emotions about this surgery, because anything short of trans joy and inspiration is too easy for transphobes to mold to their rhetoric and too hard for cis allies to swallow. This surgery was not about joy. It was about necessity. It was about all the bad things that will never happen to me now that my uterus can’t keep trying to fuck me over.

WHAT YOU CAN DO: If you’re healing from surgery and you have complicated feelings about it, know you’re not alone. Surgery is allowed to suck, even when it’s a surgery that you really wanted. Your healing does not have to fit anyone’s narrative — yes, even the trans joy narrative. Being trans is complicated. Being any kind of person is complicated. You are allowed to feel however you feel. It’s your body, and in a perfect world, you’d never have to justify your feelings about it to anyone.

If you want to pursue a hysterectomy, you can do this. This one random trans guy writing this article believes in you.

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