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What Transgender Men and Transmasculine People Need to Know About Gynecologic Cancers

Screening is usually based on your anatomy—not your gender—but there are a few caveats to keep in mind.

Knowing when to be screened for certain cancers can be confusing. Recommendations are frequently updated and it can be a challenge to keep up with the most recent guidelines. That's especially the case for transgender, gender nonconforming and nonbinary individuals who are often left out of the research and guidelines that help patients plan their preventive care.

"We already know that trans and nonbinary people face disproportionate discrimination and stigma in seeking health care and in accessing insurance," says Halley Crissman, MD, MPH, an adjunct clinical assistant professor of obstetrics and gynecology at Michigan Medicine specializing in transgender health and gender-affirming care and director of gender-affirming care at Planned Parenthood of Michigan.

"When you think about reproductive and gynecologic care,” Dr. Crissman adds, “there are additional hurdles: the dysphoria of trying to seek care in a space that may be labeled as ‘women's health,’ the lack of provider knowledge, the intimate nature of much of the exam and discussion, as well as barriers related to the sex on one's insurance information."

For all of these reasons, transgender, gender nonconforming and nonbinary people assigned female at birth may be less likely to receive timely, appropriate and life-saving cancer screenings.

You may also be wondering if you even need these screenings if you've had gender-affirming surgery or have been on gender-affirming hormone therapy (GAHT) for some time. Without an informed healthcare provider (HCP) who is familiar with your specific healthcare needs and health history, it can be hard to know which exams you should actually get, as well as when and where to get them.

Fortunately, there is evidence-based guidance out there and a path toward getting the care you need.

Cervical cancer screening for transmasculine people
Cervical cancer is cancer that occurs in the cervix, the body part that connects the vagina to the uterus. It is almost always caused by the human papillomavirus (HPV).

While it used to be the leading cause of death for people assigned female at birth in the United States, the number of deaths from cervical cancer has dropped dramatically over the last few decades. This is a result of regular screening with Pap tests, which check for any cervical cell changes that could point to precancer, as well as increasing adoption of the HPV vaccine. Transgender men, however, are less likely to be up-to-date on their Pap tests, even though they are at risk of cervical cancer.

"What we recommend is that anyone with a cervix—regardless of gender—gets cervical cancer screening according to the national guidelines," says Crissman. These range by age, as follows:

  • You should begin getting Pap tests at age 21.
  • Between the ages of 21 and 29, if your Pap test results are normal, screening is recommended every three years. If results are abnormal, you may need to be screened more frequently.
  • Between the ages of 30 and 65, screening guidelines depend on which tests you're getting. If you're only getting a Pap test and your results are normal, you can wait three years until your next test. If you're only getting an HPV test or you're getting a Pap test and HPV test together (called "co-testing”) and your results are normal, you can wait five years until your next test. If results are abnormal, you may need to test more frequently.

Meanwhile, anyone between the ages of 9 and 26, regardless of gender, is advised to get the HPV vaccine. This is the first step toward prevention of cervical cancer. In certain circumstances, a healthcare provider (HCP) may recommend that people up to age 45 receive the vaccine.

While masculinizing hormone therapy (which involves taking a form of testosterone) doesn't seem to impact your risk of cervical cancer, it can make it harder to get a sufficient sample when screening.

"Basically, there aren't as many cervical cells typically obtained on a Pap smear of a transmasculine person on testosterone compared to a cisgender woman," explains Crissman. If that happens, it's recommended that you go back for another screening in two to four months.

In some cases, gender-affirming surgery might impact your cervical cancer screening recommendations. If you've had a total hysterectomy, which includes removal of the uterus and cervix, your HCP may determine that you don't need to have any more Pap tests, unless you also have a history of high-grade precancerous lesions.

Ovarian cancer screening for transmasculine people
While there's no screening recommendation for ovarian cancer for people at average risk—regardless of your gender—it's important to know the common risk factors and symptoms.

Risk factors for ovarian cancer include the following:

  • Being middle-aged or older (most cases of the disease occur after age 40, with half of all cases occurring in those 63 or older)
  • Having a family history of certain cancers
  • Being considered overweight or obese
  • Having a genetic mutation on the BRCA1 or BRCA2 genes
  • Having had children later in life or never having had a full-term pregnancy

If you're at a particularly high risk of ovarian cancer, you might be referred to a genetic counselor to see if surgery is appropriate to reduce your risk, such as a bilateral oophorectomy, which removes your ovaries. 

Symptoms of ovarian cancer include persistent bloating, bleeding or abnormal discharge, urinary or bowel changes, pelvic pain and difficulty eating or feeling full quickly.

Having a trusted and culturally competent HCP you can talk to about your risk factors and any new symptoms is key to helping you stay informed. Your HCP can also help ease any dysphoria (the distress you might experience when you feel your gender identity doesn’t align with your physical or physiological characteristics), which may arise from monitoring certain body parts.

Endometrial cancer screening for transmasculine people
As with ovarian cancer, screening for endometrial cancer (also known as uterine cancer) is not recommended for people at average risk of the disease, regardless of your gender. Again, it comes down to knowing the risk factors and symptoms.

The classic symptom of endometrial cancer is unexplained vaginal bleeding, particularly in post-menopausal cisgender women. For that reason, it's important for any transmasculine person taking testosterone to discuss abnormal bleeding with their HCP, especially if they've stopped menstruating while using testosterone. (Bear in mind, however, that a lack of bleeding does not mean no risk, so it’s important to stay in contact with your HCP on ways to reduce your risk of endometrial cancer.)

There are a number of more common reasons you might have unexplained bleeding, such as a polyp or an infection. But your HCP should consider endometrial cancer if you have certain risk factors, such as if you're older, you have a family history of certain cancers or if you're considered overweight.

"It's important to know that being overweight for a person of any gender is a risk factor for endometrial cancer. The reason is because fat tissue makes estrogen, and estrogen is what drives risk of endometrial cancer," says Crissman.

Finding affirming care and asking for accommodations
It can be difficult to find evidence-based, affirming care as a transgender person, but it is possible with a little planning. Here’s how:

Research your options. Online resources like OutCare and GLMA can help you find a provider in your area who understands LGBTQIA+ needs. Crissman also suggests word-of-mouth recommendations, checking with your local LGBTQIA+ organizations and trying Planned Parenthood. At the very least, you want to make sure that the medical office has a nondiscrimination policy and prioritizes creating a safe, affirming space for LGBTQIA+ patients.

Consider any insurance hurdles. If you're seeking gynecologic care and your health insurance has your gender listed as male, call the provider’s office ahead of time to find out if certain prior authorization or modification codes are needed to ensure that your visit is covered.

Know that you are entitled to safe, affirming care. Pelvic exams and gynecologic cancer screenings may trigger discomfort, trauma or gender dysphoria. Your HCP should be sensitive to this and make sure that you are comfortable at every step of the process. This can include telling you what's happening throughout the exam, allowing you to self-insert the speculum and making sure you know you can stop the pelvic exam at any point.

You can also ask for accommodations that may make you more comfortable, like anti-anxiety medication, stress-reduction strategies, a support person or even sedation. "And there should be a chaperone in the room for all sensitive exams," says Crissman.

If you cannot do a pelvic exam during this visit, that's also okay. Your provider should be able to address your other health needs, like STI screening or contraceptive counseling, and recommend a time for you to come back when you feel more comfortable. If they're not willing to work around your comfort level, they probably aren't the right provider for you. The key is to find someone with whom you can develop a level of comfort and trust so that, together, you can develop a plan for the care you need.

Medically reviewed in June 2021.

Sources:

Peitzmeier SM, Khullar K, Reisner SL, Potter J. Pap test use is lower among female-to-male patients than non-transgender women. Am J Prev Med. 2014;47(6):808-812.
Centers for Disease Control and Prevention. Cervical Cancer: What Should I Know About Screening? Page last reviewed: January 12, 2021.
UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco. Screening for cervical cancer in transgender men. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016.
National Cancer Institute. Next Steps after an Abnormal Cervical Cancer Screening Test: Understanding HPV and Pap Test Results. Updated: January 13, 2021.
UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco. Ovarian and endometrial cancer considerations in transgender men. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016.
American Cancer Society. Ovarian Cancer Risk Factors. Last Revised: January 26, 2021.
American Cancer Society. Signs and Symptoms of Ovarian Cancer. Last Revised: April 11, 2018.
Centers for Disease Control and Prevention. Cervical Cancer: What Are the Symptoms of Ovarian Cancer? Page last reviewed: March 8, 2021.
Grimstad FW, Fowler KG, New EP, et al. Uterine pathology in transmasculine persons on testosterone: a retrospective multicenter case series. Am J Obstet Gynecol. 2019;220(3):257.e1-257.e7.
Centers for Disease Control and Prevention. Uterine Cancer: What Are the Risk Factors? Page last reviewed: August 9, 2019.
Sterling J, Garcia MM. Cancer screening in the transgender population: a review of current guidelines, best practices, and a proposed care model. Transl Androl Urol. 2020;9(6):2771-2785.

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