Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for evaluation for gender-affirming hysterectomy and bilateral salpingo-oophorectomy. Patient reports persistent gender dysphoria related to reproductive anatomy. Patient has been on stable testosterone hormone replacement therapy for [Number] years with no contraindications. Patient reports no history of pelvic inflammatory disease, endometriosis, or abnormal uterine bleeding. Patient understands the permanent nature of the procedure and the requirement for lifelong hormone monitoring.
Clinical Examination Findings
General: Patient is alert and oriented, in no acute distress. Abdomen: Soft, non-tender, non-distended, bowel sounds present. Pelvic/Bimanual Exam: Uterus is [size/position], mobile, non-tender. Adnexa: No masses or tenderness palpated. External genitalia: Consistent with long-term testosterone therapy; no signs of atrophy or inflammation.
Treatment Protocol
Plan: Proceed with total laparoscopic hysterectomy and bilateral salpingo-oophorectomy. Pre-operative clearance obtained. Patient counseled on risks including hemorrhage, infection, injury to bladder/ureters, and surgical menopause. Patient advised to continue testosterone therapy as directed by endocrinology. Post-operative follow-up scheduled for 2 weeks.