Is a Pap smear recommended for a transgender male with a cervix and no history of hysterectomy?

Cervical Cancer Screening in Transgender Men

Yes, transgender men who retain their cervix absolutely require cervical cancer screening following the same guidelines as cisgender women, regardless of gender identity, sexual history, or testosterone use. 1

Clear Guideline Consensus

Both the CDC and American Cancer Society explicitly state that all persons with a cervix should receive cervical cancer screening, regardless of sexual orientation or gender identity, including transgender men who retain their cervix. 1

Recommended Screening Protocol

Age to Begin and End Screening

• Start screening at age 25 years 1
• Continue through age 65 years (assuming adequate negative prior screening) 1

Preferred Screening Strategy (Ages 25-65)

• Primary HPV testing every 5 years is preferred 1
• Acceptable alternatives if primary HPV testing unavailable: 1
  • Co-testing (HPV + cytology) every 5 years
  • Cytology (Pap smear) alone every 3 years

Criteria to Stop Screening at Age 65

• Two consecutive negative HPV tests, OR 1
• Two consecutive negative co-tests, OR 1
• Three consecutive negative cytology tests within the past 10 years, with the most recent test within the recommended interval 1

Critical Clinical Considerations

Testosterone Use Does Not Eliminate Risk

The cervix remains at full risk for HPV infection and cervical dysplasia/cancer even with testosterone therapy. 2, 3 Research demonstrates that transgender men on testosterone have similar rates of abnormal Pap tests and HPV infection compared to cisgender women (relative risk 0.625 for abnormal Pap, 95% CI 0.25-1.59). 3

Common Barriers to Address

• Transgender men are significantly less likely to be up-to-date on cervical cancer screening compared to cisgender women 4, 5
• Approximately 50% of transgender men have not had screening within the past 3 years 5
• Many healthcare providers incorrectly believe transgender men are at lower risk or don't need screening, particularly if they don't engage in penile-vaginal intercourse 6

Improving Screening Uptake

• HPV self-sampling may be preferred by transgender men (57% preference in one study) and could improve screening rates 5
• Transgender men who have experienced discrimination are more likely to prefer self-sampling (OR 3.29,95% CI 1.38-7.84) 5
• Liquid-based cytology can be performed at any time during the menstrual cycle (if applicable), while conventional cytology should ideally be scheduled 10-20 days after menses 1

Exception: After Total Hysterectomy

Screening is NOT needed if: 1

• Total hysterectomy with cervix removal was performed
• No history of CIN 2, CIN 3, or adenocarcinoma in situ within the past 25 years
• No history of cervical cancer

Screening IS still needed if: 1

• Supracervical/subtotal hysterectomy with cervix retained (follow standard screening guidelines) 2
• History of CIN 2+ or adenocarcinoma in situ within past 25 years (continue screening for ≥25 years from diagnosis, even past age 65) 1

Key Pitfalls to Avoid

• Do not assume transgender men don't need screening based on gender identity, testosterone use, or sexual practices 1, 6
• Do not assume hysterectomy means no cervix - verify through operative notes whether cervix was removed 2
• Do not screen more frequently than recommended intervals unless indicated by abnormal results 1
• Do not use Pap tests as STI screening - they are specifically for cervical cancer screening 1