What are the follow-up recommendations for a transgender male with a satisfactory Pap test result showing an atrophic pattern and no evidence of dysplasia or malignancy, who is undergoing testosterone (dihydrotestosterone) therapy?

From the Guidelines

For a transgender male on testosterone therapy with a satisfactory Pap test showing an atrophic pattern without dysplasia or malignancy, routine screening should continue every 3 years until age 65, assuming prior normal results. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of continued cervical cancer screening for individuals with a cervix, regardless of gender identity or hormone therapy status 1. The atrophic pattern noted in the Pap test result is an expected finding with testosterone therapy, as it causes thinning of the vaginal and cervical epithelium similar to what occurs in postmenopausal cisgender women. Despite this atrophic change, cervical cancer screening remains important because the risk of HPV infection and subsequent cervical abnormalities persists. Testosterone therapy does not eliminate this risk, and therefore, regular screening is crucial for early detection and prevention of cervical cancer.

Some key points to consider in the care of transgender men undergoing testosterone therapy include:

• The risk of erythrocytosis, which can be mitigated by smoking cessation, weight loss, and switching to a transdermal route of administration 1
• The potential impact on bone health, fertility, and pregnancy, which should be discussed with the patient as part of their overall care plan 1
• The importance of breast cancer and cervical cancer screenings, which are recommended for trans men on hormone therapy who are not electing gender-affirming surgery 1

In terms of screening options, providers should consider HPV co-testing or primary HPV testing as alternative screening options, which may be more comfortable for some patients. Additionally, using a smaller speculum and water-based lubricant can help minimize discomfort during Pap testing. Screening can be discontinued at age 65 if there is a history of adequate negative prior screening and no history of high-grade precancerous lesions. Overall, a comprehensive and individualized approach to care is essential for ensuring the best possible outcomes for transgender men undergoing testosterone therapy.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Prior to initiating testosterone gel, confirm the diagnosis of hypogonadism by ensuring that serum testosterone has been measured in the morning on at least two separate days and that these concentrations are below the normal range The FDA drug label does not answer the question.

From the Research

Follow-up Recommendations for Transgender Male with Satisfactory Pap Test Result

• The patient's satisfactory Pap test result showing an atrophic pattern and no evidence of dysplasia or malignancy indicates a low risk of cervical cancer or precancerous lesions 2, 3.
• However, it is essential to consider the patient's transgender status and testosterone therapy when interpreting the Pap test results, as these factors can affect the cytological findings 2, 3.
• The patient's age, length of time on testosterone, and history of trauma or PTSD symptoms should also be taken into account when assessing the risk of unsatisfactory Pap tests or abnormal results 4.
• Routine screening recommendations for transgender and gender-diverse adults taking gender-affirming hormone therapy are largely based on expert opinion due to a lack of evidence 5.
• Close surveillance and follow-up are still necessary for patients with negative cervical biopsies after Pap test interpretations of "atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion" 6.

Considerations for Future Pap Tests

• The patient's testosterone therapy and transgender status should be taken into account when interpreting future Pap test results 2, 3.
• The patient's age, length of time on testosterone, and history of trauma or PTSD symptoms should also be considered when assessing the risk of unsatisfactory Pap tests or abnormal results 4.
• Healthcare professionals should be familiar with the distinctive cytomorphological changes in Pap tests from patients on androgen therapy to evaluate them appropriately 3.

Importance of Clinical Information and Patient History

• Clinical information regarding the patient's gender identity and testosterone therapy status is crucial to avoiding misinterpretation of Pap test results 2.
• A thorough patient history, including age, length of time on testosterone, and history of trauma or PTSD symptoms, is essential for assessing the risk of unsatisfactory Pap tests or abnormal results 4.