As OB/GYNs educate their patients on regular screenings for breast cancer and reproductive cancers, they must not neglect a key segment of their patient base: transgender individuals. According to a 2016 report by the Williams Institute, about 0.6 percent of adults in the United States identify as transgender. As that number increases, gynecologists should expect to encounter trans patients in their practice.
Trans gynecology patients can include transmasculine people (an umbrella term for those who were assigned female at birth but identify as male), transfeminine people (an umbrella term for those who were assigned male at birth but identify as female) and nonbinary people (those who identify as neither exclusively male or female, or identify as a combination of both). Individual patients might use more specific terminology such as trans woman, agender or genderqueer.
Overall, transgender people are vastly underrepresented in medical research. However, some studies do suggest that transmasculine patients may be at an increased risk for certain cancers and at a decreased risk for others. Understanding these risks can help guide your approach to routine screenings.
Here's how clinicians can honor the unique needs of gender-diverse patients while screening them for breast cancer and gynecologic concerns.
Breast Cancer Risk in Transgender Patients
The risk of breast cancer can vary among transgender people, according to a 2019 large cohort study published in the British Medical Journal. This study found an increased risk of breast cancer in trans women compared with cisgender men, and a lower risk of breast cancer in trans men compared with cisgender women. In trans women, the risk of breast cancer increased 46-fold during a median 18 years of hormone treatment. For trans women, hormone treatment is a long-term, often lifelong regimen that usually includes antiandrogens and estrogens.
The study's authors concluded that breast cancer screening guidelines for cisgender women can also apply to transgender people who use gender-affirming hormone treatment and have or retain breast tissue. Clinicians should discuss the risks of breast cancer with trans female and trans male patients as rigorously as they would with cisgender female patients.
Endometrial and Ovarian Cancer in Trans Men
Although research on the risk of endometrial cancer in transgender men is sparse, a study in Reproductive Medicine Online suggests that nearly half of trans men who use gender-affirming testosterone but still have a uterus experience endometrial atrophy. This atrophy is similar in nature to that found in postmenopausal women, according to the University of California at San Francisco (UCSF) Transgender Care center.
For this reason, as well as a "lack of cultural competency" among OB/GYN providers who treat trans men, the UCSF Transgender Care center advises against routine screening for endometrial cancer in amenorrheic transmasculine patients who use testosterone and retain a uterus. Patients who experience unexplained vaginal bleeding, however, should contact their physician for further examination.
Despite some case reports of ovarian cancer among transgender men, there is currently no evidence to support an increased risk of this disease in trans men who use testosterone. Gynecologists should follow the same ovarian cancer counseling and screening recommendations for transgender men and transmasculine patients that they would for cisgender women.
Ultrasound for Transmasculine and Nonbinary Patients
The use of transvaginal ultrasound can aid in the diagnosis of unexplained vaginal bleeding, endometrial cancer and ovarian cancer. However, a transvaginal exam can be traumatic for transmasculine and nonbinary patients who experience gender dysphoria. If you believe an examination is warranted, it is important to talk to your patient beforehand about the possible benefits of an exam and explain what to expect to assuage any anxiety.
For transmasculine patients who decline to undergo transvaginal examination — or who undergo vaginectomy but retain one or more ovaries — transrectal or transabdominal ultrasound can be an acceptable option for pelvic imaging, according to the UCSF Transgender Care center. Patients with severe dysphoria may find that relaxation techniques and antianxiety medication ease distress during exams.
Honest and open communication is key when discussing the risks of reproductive or breast cancer with trans patients. Let your patient lead the discussion regarding pronouns, anatomical terminology and comfortable screening options for their body. From screening to treatment, ensure they understand each step and ultimately feel comfortable and respected in your care.
