What is the best cervical cancer screening recommendation for a 36-year-old transgender male (Female-To-Male, FTM) with a history of Human Papillomavirus (HPV) vaccination, previous normal cervical cancer screening 6 years ago, and a 10-pack-year history of tobacco use?

Cervical Cancer Screening Recommendation

This 36-year-old transgender male patient requires HPV testing with cytology (cotesting) now, as the last cervical cancer screening was 6 years ago and current guidelines recommend screening every 3-5 years for individuals aged 25-65 years with a cervix, regardless of gender identity or HPV vaccination status. 1

Rationale for Screening Decision

Screening Applies to All Individuals with a Cervix

• Transgender men who have not undergone hysterectomy with cervix removal require the same cervical cancer screening as cisgender women, as current guidelines explicitly state recommendations apply to "all individuals with a cervix" regardless of gender identity. 1
• The patient's testosterone therapy does not eliminate cervical cancer risk and does not modify screening recommendations. 1

Screening Interval Has Been Exceeded

• The patient's last screening was 6 years ago (at age 30), which exceeds all recommended screening intervals. 1
• For individuals aged 25-65 years, the American Cancer Society 2020 guidelines recommend primary HPV testing every 5 years (preferred), or cotesting every 5 years, or cytology alone every 3 years. 1
• The USPSTF 2019 guidelines similarly recommend screening every 3 years with cytology alone, every 5 years with primary HPV testing, or every 5 years with cotesting for ages 30-65. 1

HPV Vaccination Does Not Eliminate Screening Need

• HPV-vaccinated individuals must follow the same age-specific screening recommendations as unvaccinated individuals because vaccines do not cover all oncogenic HPV types. 1, 2
• The American Cancer Society explicitly states that screening recommendations do not differ based on vaccination status. 1

Tobacco History Increases Risk

• The patient's 10-pack-year smoking history (though quit 3 years ago) represents an additional risk factor for cervical cancer, further supporting the need for screening. 1

Recommended Screening Strategy

Optimal Test Selection

• Cotesting (HPV testing combined with cytology) every 5 years is the most appropriate option for this 36-year-old patient, as it provides comparable benefits to cytology alone with a longer screening interval. 1
• Primary HPV testing alone every 5 years is the preferred strategy per 2020 ACS guidelines if available. 1
• Cytology alone every 3 years remains acceptable where primary HPV testing is not available. 1

Future Screening Schedule

• After this screening, if results are negative, the patient should continue screening every 3-5 years (depending on method used) until age 65. 1
• Screening can be discontinued after age 65 only if the patient has adequate negative prior screening (3 consecutive negative cytology tests OR 2 consecutive negative HPV tests OR 2 consecutive negative cotests within the past 10 years, with the most recent within 3-5 years). 1, 3

Why Other Options Are Incorrect

Mammography Not Indicated

• Mammography screening typically begins at age 40-50 for average-risk individuals, and this 36-year-old patient does not meet age criteria. 1
• Testosterone therapy in transgender men may affect breast tissue, but standard screening guidelines still apply based on age and risk factors.

A1c and Lipid Panel Not Due

• The patient had normal A1c and lipid panel 1 year ago. 1
• With BMI 27 (overweight but not obese), normal prior results, and no other diabetes risk factors mentioned, repeat testing is not urgently needed at this visit.

"No Further Screening" Is Incorrect

• The 6-year gap since last cervical cancer screening clearly exceeds all recommended intervals. 1
• Cervical cancer screening remains the highest priority preventive service for this patient based on the time elapsed since last screening.

Common Pitfalls to Avoid

• Never assume transgender male patients have had hysterectomy—always verify surgical history, as many transgender men retain their cervix. 1
• Do not discontinue cervical cancer screening based solely on testosterone therapy or gender identity—screening applies to all individuals with a cervix. 1
• HPV vaccination does not eliminate the need for screening—this is a critical misconception that can lead to missed cancers. 1, 2
• Ensure the patient understands that despite male gender identity, cervical cancer screening remains medically necessary and potentially life-saving. 1