What are the differences in preventive care screening for transgender women compared to cisgender women?

Preventive Care Screening Differences for Transgender Women Compared to Cisgender Women

Transgender women require a hybrid screening approach that combines organ-based screening (for retained natal anatomy) with hormone-exposure-based screening (for feminizing hormone therapy effects), which differs fundamentally from the straightforward sex-based screening protocols used for cisgender women. 1

Breast Cancer Screening: The Key Difference

For Transgender Women on Feminizing Hormones ≥5 Years

Transgender women who have received 5 or more years of feminizing hormone therapy should undergo screening mammography starting at age 50 years (either annually per Fenway Health or biennially per UCSF guidelines). 1 This differs from cisgender women, who typically begin screening at age 40 years. 1

• The American College of Radiology recommends that transgender women aged 40+ with ≥5 years of hormone exposure may undergo screening mammography or digital breast tomosynthesis. 1
• The Endocrine Society takes a simpler approach, recommending transgender women follow the same screening schedule as cisgender women without specifying hormone duration requirements. 1

Critical distinction: Transgender women have substantially lower breast cancer risk than cisgender women (4.1 per 100,000 person-years vs. 155 per 100,000 person-years), but significantly higher risk than cisgender men (46.7-fold increased risk). 1

For Transgender Women Without Hormone Therapy or <5 Years

• No routine breast cancer screening is recommended for transgender women not receiving feminizing hormones or those with <5 years of exposure. 1
• This contrasts sharply with cisgender women, who receive screening based solely on age, not hormone exposure. 1

Higher-Risk Transgender Women

For transgender women aged 25-30+ with ≥5 years hormone use PLUS additional risk factors (personal history of breast cancer, chest irradiation at ages 10-30, BRCA mutations, or family history), screening mammography is usually appropriate. 1

Prostate Cancer Screening: Retained Natal Anatomy

Transgender women retain their prostate gland unless they undergo vaginoplasty with prostate removal, requiring prostate cancer screening based on natal anatomy despite feminizing hormone therapy. 2

• Standard prostate cancer screening guidelines for cisgender men should be applied, though feminizing hormones may reduce prostate size and PSA levels. 1
• This represents a fundamental difference from cisgender women, who obviously do not require prostate screening. 2

Cervical Cancer Screening: Not Applicable

• Transgender women do not have a cervix (unless they are intersex individuals with specific anatomical variations) and therefore do not require cervical cancer screening. 2
• This is identical to cisgender women who have undergone hysterectomy. 2

Cardiovascular Risk Screening: Elevated Risk Profile

Transgender women on estrogen therapy have significantly elevated cardiovascular risk compared to both cisgender women and cisgender men, requiring more aggressive cardiovascular screening. 1

Specific Elevated Risks

• Venous thromboembolism: Consistently increased risk compared to both cisgender men and women, even with modern estrogen formulations. 1
• Ischemic stroke: Elevated risk relative to cisgender women. 1
• Myocardial infarction: Increased risk compared to cisgender women. 1

Screening Implications

• More aggressive lipid screening and cardiovascular risk assessment should be performed compared to age-matched cisgender women. 3
• Pretreatment cardiovascular screening before initiating hormone therapy is essential. 3
• Regular monitoring of cardiovascular risk factors (hypertension, hyperlipidemia, diabetes) is necessary throughout hormone therapy. 3

Bone Density Screening: Complex Considerations

Transgender women on long-term estrogen therapy may have compromised bone structure, requiring individualized bone density assessment. 1

• Feminizing hormone therapy causes changes in body composition with increased fat mass and reduced muscle mass, potentially affecting bone health. 1
• Bone density screening should follow guidelines similar to cisgender women, with consideration for additional risk factors related to hormone therapy duration and dosing. 1

Colorectal Cancer Screening: Standard Approach

• Transgender women should follow the same colorectal cancer screening guidelines as cisgender women and men, based on age and risk factors. 2
• No evidence suggests hormone therapy significantly alters colorectal cancer risk. 2

Common Pitfalls to Avoid

• Do not assume transgender women need identical screening to cisgender women: The delayed breast cancer screening initiation (age 50 vs. 40) and hormone-duration requirements are critical differences. 1
• Do not forget natal anatomy screening: Prostate cancer screening remains necessary despite feminizing appearance and hormone levels. 2
• Do not underestimate cardiovascular risk: Transgender women have higher cardiovascular risk than cisgender women, requiring more vigilant screening. 1, 3
• Do not apply screening based solely on gender identity: Use an organ inventory approach that accounts for both natal anatomy and hormone-induced changes. 4

Algorithmic Approach to Screening Decisions

1. Document organ inventory regardless of gender presentation to determine which natal anatomy screenings apply. 4
2. Assess hormone therapy duration: If ≥5 years of feminizing hormones, initiate breast cancer screening at age 50. 1
3. Screen for cardiovascular risk factors more aggressively than for cisgender women due to estrogen-related thrombotic and cardiovascular risks. 1, 3
4. Apply natal male screening protocols for prostate cancer if prostate remains intact. 2
5. Use standard age-based screening for colorectal cancer and other non-sex-specific cancers. 2