Clinical history of female‐to‐male transgender patients is needed to avoid misinterpretation of cervical Papanicolaou tests

Abstract

Objective: Cervical cancer screening is as important in female-to-male transgender (FTMT) patients as it is in cisgender female patients. The aim of this study was to examine the impact of clinical information regarding gender identity and testosterone therapy on the cytological interpretations.Methods: A list of FTMT patients and cisgender female patients who had received a cervical Papanicolaou (Pap) test for cancer screening was obtained. The cytological diagnoses, rendered at the time of collection, were recorded. A retrospective slide review with knowledge of the pertinent clinical information, including testosterone therapy status, was performed. The data sets were statistically compared.Results: Of 122 cervical Pap tests in 111 FTMT individuals, 23 (19%) had surgical follow-ups; 73 (60%) had HPV testing, of which 12 (16%) were positive for high-risk strains; and 79 (65%) were known to be receiving testosterone. On the "original" review, 12 (9.8%) tests were diagnosed as unsatisfactory. Seventy-one (58%) Pap tests were initially diagnosed as negative for intraepithelial lesion or malignancy (NILM) without atrophy and 32 (26%) with atrophy. Seven (5.7%) of the tests were initially diagnosed as abnormal. On the "retrospective" review, the rate of unsatisfactory tests remained the same, and atrophy was observed in 76 (62%) tests. The number of abnormal tests was reduced to 4 (3.3%) after the retrospective review. Almost all comparative studies returned a P-value of ≤0.05. Conclusion:Our findings indicate that clinical information regarding whether a subject is transgender and/or is receiving testosterone therapy is crucial to avoiding Pap test overcalls.

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.…”

“…In the current study, rereview showed that if strict cellular criteria as established by the Bethesda System were followed, almost 14% of cases would have been considered unsatisfactory for evaluation. The unsatisfactory rate has ranged from 0% up to 23.4%, with variation in whether the rate differed from overall institutional or matched cohorts 21‐26 . In a large study by Peitzmeier et al., the investigators recorded the results of Pap tests from their large transgender population and found the inadequacy rate to be 10.8% (44 of 415) 8 .…”

“…In review of the literature, the abnormal cervicovaginal Pap test rate for the transgender population has varied from 5.6% up to 29.2%. [21][22][23][24][25][26] There are likely several factors contributing to this variation in abnormal rate. As reviewed in the preceding paragraphs, there are a number of alterations that may cause challenges with cytomorphologic interpretation, including the presence of atrophy and inflammatory changes.…”

Challenging lesions in cervical cytology: The elusive HSIL

“…Clinical context can also be quite helpful in alerting the diagnostician to the possibility of this entity. 29 It should be noted, however, that lesions may certainly occur in both postmenopausal women as well as transgender patients and so this finding does not rule out the possibility of a concurrent lesion.…”

“…Features that help in distinguishing transitional cell metaplasia from HSIL include the streaming quality of the cellular groups, the lack of hyperchromasia, and the lack of mitotic activity. Clinical context can also be quite helpful in alerting the diagnostician to the possibility of this entity 29 . It should be noted, however, that lesions may certainly occur in both postmenopausal women as well as transgender patients and so this finding does not rule out the possibility of a concurrent lesion.…”