For a 37‑year‑old transgender man on testosterone who retains a cervix, had a normal cervical cancer screen six years ago, is HPV‑vaccinated, quit smoking three years ago, has a BMI of 27, and normal hemoglobin A1c and lipid panel one year ago, which screening is indicated now?

Cervical Cancer Screening for a 37-Year-Old Transgender Man

The correct answer is (b) HPV testing with cytology—this patient is due for cervical cancer screening now.

Rationale for Screening at This Visit

This 37-year-old transgender man retains a cervix and requires routine cervical cancer screening according to the same guidelines that apply to cisgender women. 1, 2 His last screening was 6 years ago at age 31, which exceeds the recommended 3- to 5-year interval for individuals in this age group. 1

Age-Appropriate Screening Strategy (Ages 30-65)

For individuals aged 30-65 years with a cervix, three screening options are acceptable:

• Cotesting (HPV + cytology) every 5 years is the preferred strategy according to NCCN and ACOG guidelines. 1, 2
• Cytology alone every 3 years is acceptable but less preferred. 1, 2
• Primary HPV testing alone every 5 years is the preferred strategy per the 2020 ACS guideline, though cotesting remains acceptable during the transition period. 1

Since this patient's last screening was 6 years ago, he has exceeded even the longest recommended interval (5 years for cotesting or primary HPV testing), making screening overdue regardless of which guideline framework is applied. 1

Why Testosterone Therapy Does Not Alter Screening Recommendations

Transgender men on testosterone therapy follow identical cervical cancer screening guidelines as cisgender women. 1, 2 The 2020 ACS guideline explicitly states that recommendations apply to "all asymptomatic individuals with a cervix, regardless of their sexual history or HPV vaccination status...including transgender men who retain their cervix." 1

• Testosterone induces atrophic changes in cervical cytology, including transitional cell metaplasia and small parabasal cells, but these are benign morphologic findings that do not increase cancer risk or alter screening intervals. 3
• HPV vaccination status does not eliminate the need for screening, as current vaccines cover only approximately 70% of oncogenic HPV types (primarily 16 and 18). 1, 2, 4

Why Other Options Are Incorrect

Option (a): Mammography

• Mammography screening begins at age 40-50 years in average-risk individuals. 2
• This 37-year-old patient with BMI 27 and no family history has no indication for mammography at this time.

Option (c): No Further Screening

• This is incorrect because the patient is overdue for cervical cancer screening. 1
• Discontinuing screening is only appropriate after age 65 years when three criteria are met: (1) adequate prior screening (three consecutive negative cytology tests or two consecutive negative cotests within the past 10 years), (2) most recent test within 5 years, and (3) no history of CIN 2/3 or cervical cancer. 1, 2, 4
• This patient does not meet age or documentation criteria for screening cessation.

Option (d): Repeat HbA1c and Lipid Panel

• With normal HbA1c and lipid panel one year ago, BMI 27, and no diabetes risk factors, repeat metabolic screening is not indicated at this visit. 2
• The most pressing preventive health need is overdue cervical cancer screening.

Practical Implementation

Order cotesting (HPV + cytology) at this visit. 1, 2 This approach:

• Provides the highest sensitivity for detecting CIN 2/3 and cervical cancer. 1, 5
• Allows for 5-year screening intervals if both tests are negative, reducing future screening burden. 1
• Permits risk-stratified management if results are abnormal, following 2019 ASCCP risk-based guidelines. 1

Common Pitfalls to Avoid

• Do not assume testosterone therapy exempts transgender men from cervical cancer screening—they face the same HPV-related cancer risk as cisgender women and require identical screening. 1, 2
• Do not defer screening based on HPV vaccination history—vaccination does not eliminate the need for routine screening because vaccines do not cover all oncogenic HPV types. 1, 2, 4
• Do not misinterpret atrophic cytologic changes from testosterone as abnormal—transitional cell metaplasia and small parabasal cells are expected benign findings in this population and should not trigger unnecessary colposcopy. 3
• Do not screen annually—annual screening provides no additional benefit at any age and increases harms through false-positives and overtreatment. 1, 2, 4