When should mammography and DEXA bone density screening begin in a transgender woman on continuous estrogen hormone therapy, considering age, duration of therapy, and any additional breast cancer or osteoporosis risk factors?

Screening Recommendations for Transgender Women on HRT

Mammography Screening

For average-risk transgender women on continuous estrogen therapy, begin screening mammography at age 40 after completing 5 years of hormone therapy, or at age 50 if following more conservative guidelines. 1, 2

Age and Duration Thresholds

• The American College of Radiology states that screening mammography or digital breast tomosynthesis "may be appropriate" for transgender women aged 40 or older who have received at least 5 years of feminizing hormone therapy. 1, 3

• The Endocrine Society recommends transgender women follow the same screening schedule as cisgender women (typically starting at age 40), without specifying hormone duration requirements. 1, 2

• More conservative guidelines from Fenway Health recommend annual screening starting at age 50 with ≥5 years of hormone exposure, while UCSF recommends biennial screening at the same age threshold. 1, 2

Risk-Stratified Approach

• For higher-than-average-risk transgender women (personal history of breast cancer, chest irradiation between ages 10-30, genetic predisposition, or first-degree relative with genetic predisposition), screening mammography should begin at ages 25-30 regardless of hormone duration. 1, 3

• Breast cancer risk in transgender women on hormone therapy is 46.7-fold higher than cisgender men but remains substantially lower than cisgender women (4.1 vs. 155 per 100,000 person-years). 4

Clinical Considerations

• Digital breast tomosynthesis (3D mammography) may provide superior visualization in transgender women who develop dense breast tissue from estrogen therapy. 2

• Transgender women without hormone therapy or with less than 5 years of exposure generally do not require routine screening. 3

DEXA Bone Density Screening

Transgender women on long-term estrogen therapy should undergo DEXA screening following the same guidelines as cisgender women, typically starting at age 65 for average-risk individuals, or earlier if additional risk factors are present. 4

Screening Rationale

• Long-term estrogen therapy may compromise bone structure in transgender women, requiring individualized bone density assessment. 4

• Bone density screening should account for hormone therapy duration, dosing, and any periods of hormone interruption that could affect skeletal health. 4

Earlier Screening Indications

Consider DEXA screening before age 65 in transgender women with:

• History of orchiectomy (which eliminates endogenous testosterone production) 4
• Periods of inadequate hormone replacement 4
• Additional osteoporosis risk factors (smoking, low BMI, family history, glucocorticoid use) 4

Implementation Approach

• Use an organ inventory approach that accounts for both natal anatomy and hormone-induced changes rather than screening based solely on gender identity. 4, 3

• Ensure clinical staff are trained in transgender health terminology and trauma-informed care approaches to improve screening adherence. 3