Providing informed, inclusive care to transgender patients includes offering screening for endometrial cancer in men who retain a uterus and ovaries. Researchers are still learning about the possible changes in health — including cancer risk — that could be associated with medical and surgical transition. However, some evidence suggests the need for continued screening for certain conditions such as endometrial cancer in some populations of trans men.
Navigating A Theoretical Risk
Many transgender men use exogenous testosterone as part of their medical transition, which can end menstrual periods and ovulation — both desirable results for many of these patients. After testosterone is administered, it undergoes aromatization to create estrogen; theoretically, this could result in higher amounts of unopposed estrogen, which in turn could raise the risk of endometrial cancer in these transmasculine patients, notes research published by UCSF Transgender Care.
However, there are only two reported cases of endometrial cancer in transgender men receiving testosterone therapy. In one case, reported in Epidemiologic Reviews, the patient was diagnosed seven years after the start of treatment. In the other, published in the Journal of the Endocrine Society, a transgender man was diagnosed with uterine cancer a few years after beginning weekly testosterone injections and anastrozole, a drug used to decrease the amount of estrogen produced by the body. In contrast, a larger, more recent study of 49 patients published in the Journal of Urology found no evidence of malignant or pre-malignant changes in the endometrium of trans men with a uterus in response to long-term testosterone therapy.
Observational studies have found an association between endometrial cancer and high testosterone levels in postmenopausal cisgender women. Meanwhile, some research has found an increased risk of endometrial cancer in women with polycystic ovarian syndrome. A study published in Reproductive Biomedicine Online found that around 80 percent of trans male study participants showed evidence of polycystic ovaries (greater than 12 antral follicles per ovary) after being on hormone therapy for at least six months.
Evaluating Transgender Men for Endometrial Cancer
A literature review published in Epidemiologic Reviews points out the possibility that endometrial cancer could be missed in transmasculine patients if they lack early signs of the disease, such as abnormal bleeding. OB/GYNs should offer their trans patients comprehensive cancer screening options to catch gynecological cancers as soon as possible. While providing endometrial cancer screening to transmasculine patients, physicians should consider the following.
- Choose the right tool. When investigating for endometrial cancer, ultrasound is the top choice of screening tool. A pelvic ultrasound can assess the endometrium and thickening of the endometrium can indicate the presence of endometrial cancer. This makes ultrasound a natural first step in evaluating for endometrial cancer before progressing to a biopsy.
- Be sensitive to dysphoria. Transvaginal ultrasound can be particularly traumatic to some transmasculine patients and have the potential to trigger gender dysphoria. Talk to your patients first about the need for ultrasound and its role in evaluating for endometrial hyperplasia or cancer. Explain what they should expect and offer support and reassurance throughout the exam.
Although transvaginal ultrasound can be uncomfortable for some transgender patients, it is key for detecting endometrial cancer in men — allowing OB/GYNs to provide informed, inclusive care to every patient in their practice.
