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Orchiectomy during transition

Orchiectomy is the surgical removal of the testes. In trans women, this procedure is performed to definitively stop their own testosterone production. It can be a standalone procedure or part of a vaginoplasty.

What the procedure is

Orchiectomy is the surgical removal of one or both testicles. In trans women it is performed bilaterally. The procedure ends testosterone production by the testes — an important endogenous source — and thus reduces the need for anti-androgenic medication such as cyproterone or spironolactone.

Indications in transition

Trans women often choose orchiectomy because:

• Anti-androgens used long-term can cause cardiovascular and liver strain;
• The procedure is relatively small compared to vaginoplasty;
• It improves hormonal stability — only estrogen needs to be supplemented;
• For those who do not want or cannot undergo vaginoplasty, it nevertheless brings about an important endocrine change.

Procedure

The procedure takes about 30-60 minutes and can be done under general or regional anaesthesia. Inframale or inguinal incisions. Recovery generally within one to two weeks, with restrictions on physical exertion. Complications are relatively limited: haematoma, infection, chronic pain in rare cases.

Hormonal consequences

Without testicles, the body no longer produces significant testosterone. Estrogen supplementation becomes lifelong necessary, not only for feminisation but also for bone health. Stopping estrogen after orchiectomy leads to rapid bone density loss, hot flashes and other hypogonadal symptoms.

Irreversibility

Complete and definitive. Sperm production ends; fertility is lost unless sperm has been frozen in advance. Those who detransition after orchiectomy can supplement testosterone externally but will never again have their own testicular function.

Relation to vaginoplasty

Vaginoplasty usually includes orchiectomy as part of the procedure. Orchiectomy without vaginoplasty is a separate choice: one then chooses the hormonal consequences without the complete genital reconstruction. For those who later still want vaginoplasty, prior orchiectomy is not a contraindication.

Fertility and informed consent

Prior to orchiectomy, sperm cryopreservation must be explicitly discussed and offered. Not all Dutch clinics do this consistently; cases where patients realise afterwards that sperm could have been preserved are documented. For minors of fertile age this conversation is particularly urgent.

Reimbursement

With diagnosed gender dysphoria, orchiectomy is reimbursed in the Netherlands via basic insurance. Conditions: practitioner's statement, possible waiting time and intake. With choice for orchiectomy without prior gender diagnosis (for example because of anti-androgenic side effects), reimbursement is less straightforward.

Consequences for hormone treatment

After orchiectomy, anti-androgenic medication (such as cyproterone acetate or spironolactone) is usually no longer needed. The estrogen dose can in many cases be reduced. Continued hormone substitution remains necessary to support bone health and general health.

Decision and consequences

The procedure is irreversible. Fertility is definitively lost; that is why sperm preservation is often discussed beforehand. The scrotum can remain intact and possibly be used later for a vaginoplasty.

Risks

General surgical risks apply: rebleeding, infection, complications of anaesthesia. The procedure is relatively small and the recovery period usually short. However, long-term consequences for bone density are important when hormone substitution lapses.