Routine Screening for Transgender and Gender Diverse Adults Taking Gender-Affirming Hormone Therapy: a Narrative Review

ABSTRACT

Despite the growing number of adult transgender and gender diverse (TGD) patients seeking health services, there are many unknowns regarding how routine screening recommendations should be applied to TGD persons receiving gender-affirming hormone therapy (GAHT). Patients taking GAHT may have disease risks that differ from what is expected based on their sex assigned at birth or affirmed gender identity. We discuss two patient cases, one transgender man and one transgender woman who present for routine medical care, to review several conditions that may be impacted by the hormones utilized in masculinizing and feminizing GAHT and for which screening recommendations are available for TGD adults: cardiovascular risk factors, osteoporosis, breast cancer, cervical cancer, and prostate cancer. We reviewed the TGD-specific screening recommendations from several major medical organizations and programs and found them to be largely based upon expert opinion due to a lack of evidence. The goal of this narrative review is to assist healthcare professionals in counseling and screening their TGD patients when and where appropriate. Not all TGD adults have the ability or need to receive routine medical care from a specialized TGD health clinic; therefore, it is essential for all healthcare professionals involved in routine and gender-affirming care to have knowledge about these conditions and screenings.

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References

  1. 1.

    Flores AR, Herman JL, Gates GJ, Brown TNT. How many adults identify as transgender in the United States? 2016. https://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Transgender-in-the-United-States.pdf. Accessed 6/17/2020.

  2. 2.

    James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality, Washington, DC, 2016, Washington, DC. 2016. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf. Accessed 6/17/2020.

  3. 3.

    Shires DA, Stroumsa D, Jaffee KD, Woodford MR. Primary Care Clinicians' Willingness to Care for Transgender Patients. Ann Fam Med. 2018;16(6):555-8. doi:https://doi.org/10.1370/afm.2298

    Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism. 2012;13:165-232.

    Article  Google Scholar 

  5. 5.

    World Health Organization, Cardiovascular Diseases https://www.who.int/health-topics/cardiovascular-diseases/#tab=tab_1. Accessed 6/17/2020.

  6. 6.

    Maraka S, Singh Ospina N, Rodriguez-Gutierrez R, et al. Sex Steroids and Cardiovascular Outcomes in Transgender Individuals: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab. 2017;102(11):3914–23. https://doi.org/10.1210/jc.2017-01643

  7. 7.

    Streed CG, Jr., Harfouch O, Marvel F, Blumenthal RS, Martin SS, Mukherjee M. Cardiovascular Disease Among Transgender Adults Receiving Hormone Therapy: A Narrative Review. Ann Intern Med. 2017;167(4):256–67. https://doi.org/10.7326/m17-0577

  8. 8.

    Caceres BA, Jackman KB, Edmondson D, Bockting WO. Assessing gender identity differences in cardiovascular disease in US adults: an analysis of data from the 2014-2017 BRFSS. J Behav Med. 2020;43(2):329–38. doi:https://doi.org/10.1007/s10865-019-00102-8

    Article  PubMed  Google Scholar 

  9. 9.

    Alzahrani T, Nguyen T, Ryan A, et al. Cardiovascular Disease Risk Factors and Myocardial Infarction in the Transgender Population. Circ Cardiovasc Qual Outcomes. 2019;12(4):e005597. https://doi.org/10.1161/CIRCOUTCOMES.119.005597

  10. 10.

    Getahun D, Nash R, Flanders WD, et al. Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons: A Cohort Study. Ann Intern Med. 2018;169(4):205-13. https://doi.org/10.7326/M17-2785

  11. 11.

    Nota NM, Wiepjes CM, de Blok CJM, Gooren LJG, Kreukels BPC, den Heijer M. Occurrence of Acute Cardiovascular Events in Transgender Individuals Receiving Hormone Therapy. Circulation. 2019;139(11):1461–2. https://doi.org/10.1161/CIRCULATIONAHA.118.038584

  12. 12.

    Irwig MS. Cardiovascular health in transgender people. Rev Endocr Metab Disord. 2018;19(3):243–51. https://doi.org/10.1007/s11154-018-9454-3

    Article  PubMed  Google Scholar 

  13. 13.

    Irwig MS. Testosterone therapy for transgender men. Lancet Diabetes Endocrinol. 2017;5(4):301–11. https://doi.org/10.1016/S2213-8587(16)00036-X

  14. 14.

    Tangpricha V, den Heijer M. Oestrogen and anti-androgen therapy for transgender women. Lancet Diabetes Endocrinol. 2017;5(4):291–300. https://doi.org/10.1016/S2213-8587(16)30319-9

  15. 15.

    van Velzen DM, Paldino A, Klaver M, et al. Cardiometabolic Effects of Testosterone in Transmen and Estrogen Plus Cyproterone Acetate in Transwomen. J Clin Endocrinol Metab. 2019;104(6):1937–47. https://doi.org/10.1210/jc.2018-02138

  16. 16.

    Elamin MB, Garcia MZ, Murad MH, Erwin PJ, Montori VM. Effect of sex steroid use on cardiovascular risk in transsexual individuals: a systematic review and meta-analyses. Clin Endocrinol (Oxf). 2010;72(1):1–10. https://doi.org/10.1111/j.1365-2265.2009.03632.x

  17. 17.

    Klaver M, Dekker M, de Mutsert R, Twisk JWR, den Heijer M. Cross-sex hormone therapy in transgender persons affects total body weight, body fat and lean body mass: a meta-analysis. Andrologia. 2017;49(5). https://doi.org/10.1111/and.12660

  18. 18.

    Wierckx K, Elaut E, Declercq E, et al. Prevalence of cardiovascular disease and cancer during cross-sex hormone therapy in a large cohort of trans persons: a case-control study. Eur J Endocrinol. 2013;169(4):471–8. https://doi.org/10.1530/eje-13-0493

  19. 19.

    Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017;102(11):3869–903. https://doi.org/10.1210/jc.2017-01658

  20. 20.

    UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco, Guidelines for the Primary and Gender-Affiring Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016. https://transcare.ucsf.edu/guidelines. Accessed 6/17/2020.

  21. 21.

    Lewiecki EM, Ortendahl JD, Vanderpuye-Orgle J, et al. Healthcare Policy Changes in Osteoporosis Can Improve Outcomes and Reduce Costs in the United States. JBMR Plus. 2019;3(9):e10192. https://doi.org/10.1002/jbm4.10192

  22. 22.

    Cauley JA. Estrogen and bone health in men and women. Steroids. 2015;99(Pt A):11–5. https://doi.org/10.1016/j.steroids.2014.12.010

  23. 23.

    Rothman MS, Iwamoto SJ. Bone Health in the Transgender Population. Clin Rev Bone Miner Metab. 2019;17(2):77–85. https://doi.org/10.1007/s12018-019-09261-3

  24. 24.

    Van Caenegem E, Taes Y, Wierckx K, et al. Low bone mass is prevalent in male-to-female transsexual persons before the start of cross-sex hormonal therapy and gonadectomy. Bone. 2013;54(1):92-7. https://doi.org/10.1016/j.bone.2013.01.039

  25. 25.

    Fighera TM, da Silva E, Lindenau JD, Spritzer PM. Impact of cross-sex hormone therapy on bone mineral density and body composition in transwomen. Clin Endocrinol (Oxf). 2018;88(6):856–62. https://doi.org/10.1111/cen.13607

  26. 26.

    Wiepjes CM, de Jongh RT, de Blok CJ, et al. Bone Safety During the First Ten Years of Gender-Affirming Hormonal Treatment in Transwomen and Transmen. J Bone Miner Res. 2019;34(3):447–54. https://doi.org/10.1002/jbmr.3612

  27. 27.

    Singh-Ospina N, Maraka S, Rodriguez-Gutierrez R, et al. Effect of Sex Steroids on the Bone Health of Transgender Individuals: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab. 2017;102(11):3904-13. https://doi.org/10.1210/jc.2017-01642

  28. 28.

    Wiepjes CM, de Blok CJ, Staphorsius AS, et al. Fracture Risk in Trans Women and Trans Men Using Long-Term Gender-Affirming Hormonal Treatment: A Nationwide Cohort Study. J Bone Miner Res. 2020;35(1):64–70. https://doi.org/10.1002/jbmr.3862

  29. 29.

    Panagiotakopoulos L. Transgender medicine - puberty suppression. Rev Endocr Metab Disord. 2018;19(3):221–5. https://doi.org/10.1007/s11154-018-9457-0

  30. 30.

    Rosen HN, Hamnvik OR, Jaisamrarn U, et al. Bone Densitometry in Transgender and Gender Non-Conforming (TGNC) Individuals: 2019 ISCD Official Position. J Clin Densitom. 2019;22(4):544–53. https://doi.org/10.1016/j.jocd.2019.07.004

    Article  PubMed  Google Scholar 

  31. 31.

    Joint R, Chen ZE, Cameron S. Breast and reproductive cancers in the transgender population: a systematic review. BJOG. 2018;125(12):1505–12. https://doi.org/10.1111/1471-0528.15258

    CAS  Article  PubMed  Google Scholar 

  32. 32.

    Gooren LJ, van Trotsenburg MA, Giltay EJ, van Diest PJ. Breast cancer development in transsexual subjects receiving cross-sex hormone treatment. J Sex Med. 2013;10(12):3129–34. https://doi.org/10.1111/jsm.12319

    Article  PubMed  Google Scholar 

  33. 33.

    de Blok CJM, Wiepjes CM, Nota NM, et al. Breast cancer risk in transgender people receiving hormone treatment: nationwide cohort study in the Netherlands. BMJ. 2019;365:l1652. https://doi.org/10.1136/bmj.l1652

    Article  PubMed  PubMed Central  Google Scholar 

  34. 34.

    Brown GR, Jones KT. Incidence of breast cancer in a cohort of 5,135 transgender veterans. Breast Cancer Res Treat. 2015;149(1):191–8. https://doi.org/10.1007/s10549-014-3213-2

    Article  PubMed  Google Scholar 

  35. 35.

    Slagter MH, Gooren LJ, Scorilas A, Petraki CD, Diamandis EP. Effects of long-term androgen administration on breast tissue of female-to-male transsexuals. J Histochem Cytochem. 2006;54(8):905–10. https://doi.org/10.1369/jhc.6A6928.2006

    CAS  Article  PubMed  Google Scholar 

  36. 36.

    Monstrey SJ, Ceulemans P, Hoebeke P. Sex Reassignment Surgery in the Female-to-Male Transsexual. Semin Plast Surg. 2011;25(3):229–44. https://doi.org/10.1055/s-0031-1281493

    Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Committee on Health Care for Underserved W. Committee Opinion no. 512: health care for transgender individuals. Obstet Gynecol. 2011;118(6):1454–8. https://doi.org/10.1097/AOG.0b013e31823ed1c1

  38. 38.

    Phillips J, Fein-Zachary VJ, Mehta TS, Littlehale N, Venkataraman S, Slanetz PJ. Breast imaging in the transgender patient. AJR Am J Roentgenol. 2014;202(5):1149–56. https://doi.org/10.2214/AJR.13.10810

    Article  PubMed  Google Scholar 

  39. 39.

    Chlebowski RT, Anderson GL, Aragaki AK, et al. Association of Menopausal Hormone Therapy With Breast Cancer Incidence and Mortality During Long-term Follow-up of the Women's Health Initiative Randomized Clinical Trials. JAMA. 2020;324(4):369–80. https://doi.org/10.1001/jama.2020.9482

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    Eismann J, Heng YJ, Fleischmann-Rose K, et al. Interdisciplinary Management of Transgender Individuals at Risk for Breast Cancer: Case Reports and Review of the Literature. Clin Breast Cancer. 2018. https://doi.org/10.1016/j.clbc.2018.11.007

  41. 41.

    Pivo S, Montes J, Schwartz S, et al. Breast Cancer Risk Assessment and Screening in Transgender Patients. Clin Breast Cancer. 2017;17(5):e225–e7. https://doi.org/10.1016/j.clbc.2016.08.003

    Article  PubMed  Google Scholar 

  42. 42.

    Miglioretti DL, Rutter CM, Geller BM, et al. Effect of breast augmentation on the accuracy of mammography and cancer characteristics. JAMA. 2004;291(4):442–50. https://doi.org/10.1001/jama.291.4.442

    CAS  Article  PubMed  Google Scholar 

  43. 43.

    Evans A, Trimboli RM, Athanasiou A, et al. Breast ultrasound: recommendations for information to women and referring physicians by the European Society of Breast Imaging. Insights Imaging. 2018;9(4):449–61. https://doi.org/10.1007/s13244-018-0636-z

    Article  PubMed  PubMed Central  Google Scholar 

  44. 44.

    Committee on Practice B-G. Practice Bulletin No. 168: Cervical Cancer Screening and Prevention. Obstet Gynecol. 2016;128(4):e111-30. https://doi.org/10.1097/AOG.0000000000001708

  45. 45.

    Walboomers JM, Jacobs MV, Manos MM, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol. 1999;189(1):12–9. https://doi.org/10.1002/(SICI)1096-9896(199909)189:1<12::AID-PATH431>3.0.CO;2-F

    CAS  Article  PubMed  Google Scholar 

  46. 46.

    Huh WK, Ault KA, Chelmow D, et al. Use of primary high-risk human papillomavirus testing for cervical cancer screening: interim clinical guidance. Gynecol Oncol. 2015;136(2):178–82. https://doi.org/10.1016/j.ygyno.2014.12.022

    Article  PubMed  Google Scholar 

  47. 47.

    Reisner SL, Deutsch MB, Peitzmeier SM, et al. Test performance and acceptability of self- versus provider-collected swabs for high-risk HPV DNA testing in female-to-male trans masculine patients. PLoS One. 2018;13(3):e0190172. https://doi.org/10.1371/journal.pone.0190172

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  48. 48.

    Potter J, Peitzmeier SM, Bernstein I, et al. Cervical Cancer Screening for Patients on the Female-to-Male Spectrum: a Narrative Review and Guide for Clinicians. J Gen Intern Med. 2015;30(12):1857–64. https://doi.org/10.1007/s11606-015-3462-8

    Article  PubMed  PubMed Central  Google Scholar 

  49. 49.

    Adkins BD, Barlow AB, Jack A, et al. Characteristic findings of cervical Papanicolaou tests from transgender patients on androgen therapy: Challenges in detecting dysplasia. Cytopathology. 2018;29(3):281–7. https://doi.org/10.1111/cyt.12525

    CAS  Article  PubMed  Google Scholar 

  50. 50.

    Surveillance, Epidemiology, and End Results Program (SEER), Cancer Stat Facts: Prostate Cancer. National Cancer Institute. Bethesda, MD. https://seer.cancer.gov/statfacts/html/prost.html. .

  51. 51.

    Kensler KH, Pernar CH, Mahal BA, et al. Racial/ethnic variation in PSA testing and prostate cancer incidence following the 2012 U.S.P.S.T.F. recommendation. J Natl Cancer Inst. 2020. https://doi.org/10.1093/jnci/djaa171

  52. 52.

    van Kesteren P, Meinhardt W, van der Valk P, Geldof A, Megens J, Gooren L. Effects of estrogens only on the prostates of aging men. J Urol. 1996;156(4):1349–53.

    Article  Google Scholar 

  53. 53.

    Ingham MD, Lee RJ, MacDermed D, Olumi AF. Prostate cancer in transgender women. Urol Oncol. 2018. https://doi.org/10.1016/j.urolonc.2018.09.011

  54. 54.

    Silverberg MJ, Nash R, Becerra-Culqui TA, et al. Cohort study of cancer risk among insured transgender people. Ann Epidemiol. 2017;27(8):499–501. https://doi.org/10.1016/j.annepidem.2017.07.007

    Article  PubMed  Google Scholar 

  55. 55.

    Mulhem E, Fulbright N, Duncan N. Prostate Cancer Screening. Am Fam Physician. 2015;92(8):683-8.

    PubMed  Google Scholar 

  56. 56.

    Trum HW, Hoebeke P, Gooren LJ. Sex reassignment of transsexual people from a gynecologist's and urologist's perspective. Acta Obstet Gynecol Scand. 2015;94(6):563–7. https://doi.org/10.1111/aogs.12618

    Article  PubMed  Google Scholar 

  57. 57.

    Weyers S, De Sutter P, Hoebeke S, et al. Gynaecological aspects of the treatment and follow-up of transsexual men and women. Facts Views Vis Obgyn. 2010;2(1):35–54.

    CAS  PubMed  PubMed Central  Google Scholar 

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ACKNOWLEDGEMENTS

SJI was supported by an Advanced Fellowship in Geriatrics from the Geriatric Research, Education, and Clinical Center, Rocky Mountain Regional VA Medical Center, VA Eastern Colorado Health Care System, Office of Academic Affiliations, U.S. Department of Veterans Affairs. SJI receives funding through a National Institutes of Health/University of Colorado Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) K12 grant (supported by NIH 5 K12 HD057022-13, PIs: Regensteiner JG and Santoro NF).

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Correspondence to Sean J. Iwamoto MD.

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MSR completed a one-time consulting project for AbbVie. SJI, FG and MSI declare that they do not have a conflict of interest.

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Prior Presentations: Presented as a mini-symposium at the U.S. Professional Association for Transgender Health 2019 Meeting in Washington, DC, on September 7, 2019.

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Iwamoto, S.J., Grimstad, F., Irwig, M.S. et al. Routine Screening for Transgender and Gender Diverse Adults Taking Gender-Affirming Hormone Therapy: a Narrative Review. J GEN INTERN MED (2021). https://doi.org/10.1007/s11606-021-06634-7

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KEY WORDS

  • transgender
  • screening
  • cardiovascular disease
  • osteoporosis
  • cancer