Cervicovaginal cytology, HPV testing and vaginal flora in transmasculine persons receiving testosterone

Abstract

Background Testosterone is one of the strategies that transmasculine persons can elect in order to align physical traits to their gender identity. Previous studies have shown morphologic changes in the genital tract associated with testosterone. Here, we aim to evaluate cervicovaginal cytology specimens (Pap tests) and high‐risk HPV (HR‐HPV) testing from transmasculine individuals receiving testosterone. Methods This is a retrospective cohort of 61 transmasculine individuals receiving testosterone from 2013 to 2021. Cytologic diagnoses from 65 Pap tests were correlated with HPV status and histologic follow‐up and compared with the institutional data and a cohort of cisgender women with atrophic changes. Results The median age was 28 years and median time of testosterone use was 3 years. Transmasculine persons showed significantly higher rates of HSIL (2%) and unsatisfactory (16%) when compared with the institutional data and atrophic cohort of cisgender women. After reviewing slides of 46 cases, additional findings were noted: atrophy was present in 87%, glycogenated cells were seen in 30%, and Lactobacilli were substantially decreased in 89%. Among 32 available HPV tests, 19% were positive for HR‐HPV and 81% were negative. On histologic follow‐up, all HR‐HPV‐positive cases with abnormal cytology showed HSIL, while none of the HPV‐negative cases revealed HSIL. Conclusion Our study cohort demonstrated a high percentage of abnormal Pap tests in transmasculine persons receiving testosterone. Testosterone seems to induce changes in squamous cells and shifts in vaginal flora. HR‐HPV testing can be a useful adjunct in the workup of abnormal Pap tests from transmasculine individuals.

Cervicovaginal Papanicolaou tests in transgender men: Cytomorphologic alterations, interpretation considerations, and clinical implications

“…The literature on cervicovaginal cytology specimens from transgender patients is limited but growing. Although the literature to date on Pap tests from transgender patients has been divided on the rate of abnormal interpretations relative to cisgender cohorts, [21][22][23][24][25][26] in the current study there was no significant difference in the abnormal rate within the transgender group and either the postpartum atrophic comparison group or the all-comer comparison group on the basis of original diagnosis. Fewer than 6% of cases received an atypical diagnosis (which was fewer than 4% after rereview and was actually significantly lower relative to the postpartum group) and no lesions were identified, either prospectively, retrospectively, or on follow-up.…”

“…37 In a subsequent cytologic evaluation of cervicovaginal Pap tests from this patient population, Lin et al noted lactobacilli to be substantially decreased in 89% of their cases, which correlated with both atrophy and the length of time receiving testosterone therapy. 24 In the current study, two thirds of cases (67%) did not show appreciable lactobacilli on cytologic review. In a mechanism similar to that seen in postmenopausal women, testosterone therapy decreases estrogen, which affects the availability of glycogen and thereby makes the vaginal environment less favorable for lactobacilli.…”

“…has been found to involve anywhere between 62% and 93% of patient samples. [21][22][23][24][25] In the current study, the vast majority of cases (92%)…”

“…The high-risk human papillomavirus (HR-HPV) positivity rate did not differ significantly between the transgender and postpartum groups (12.8% vs. 19.1%; p = .5) as well as the transgender and allcomer groups (12.8% vs. 8.1%; p = .9). The findings of this study relative to those of prior cytomorphologic studies [21][22][23][24][25][26] are summarized in Table 2.…”

“…Adkins et al 21 Williams et al 22 Plummer et al 23 Lin et al 24 Davis et al 26 Moatamed et al Abbreviations: AGC, atypical glandular cells; ASCH, atypical squamous cells cannot rule out high-grade lesion; ASCUS, atypical squamous cells of undetermined significance; Higher, higher with statistical significance; HPV, human papillomavirus; HSIL, high-grade squamous intraepithelial lesion; LSIL, low-grade squamous intraepithelial lesion; N/A, not available; NILM, negative for intraepithelial lesion or malignancy; NS, not significant; Unsat, unsatisfactory.…”