Cervical Cancer Screening for Transmasculine or Gender Non-Conforming Individuals

Anyone with a cervix, including transmasculine and gender non-conforming individuals, may need cervical cancer screening. It can be uncomfortable for many people to think about having screening, but it is important. Cervical cancer can be cured when found early or prevented when pre-cancers are found.

What is the cervix?

The cervix is the name for the lowest part of the uterus. The cervix connects the uterus with the vagina. The cervix can be examined by your healthcare provider during a routine pelvic examination. Cervical cancer develops when cells in the cervix begin to grow out of control.

What causes cervical cancer?

Almost all cervical cancers are caused by a virus called HPV (human papillomavirus). HPV is a sexually transmitted infection (STI) that is very common. While HPV is referred to as an STI, intercourse or penetration is not necessary to pass it on - it can be passed on through skin-to-skin contact as well. However, very few people who have HPV will develop cervical cancer; so simply having HPV doesn't mean that you will get cancer.

Things that increase the risk of having an HPV infection include having multiple sexual partners (or partners who have multiple partners), other sexually transmitted infections (STIs), HIV infection, and smoking. There are more than 200 types or “strains” of HPV. Of these, 12 are considered "high-risk" strains, which can cause cervical cancer – or other types of cancer (anal, head & neck, penile, vaginal, and vulvar cancers).

What screening tests are available?

HPV and Pap testing are used to screen for cervical cancer. The Pap test involves collecting cells from the cervix, which is located at the top of the vagina. To perform the test, the provider inserts a tool called a speculum into the vaginal opening. This is used to hold the vaginal walls open. Then a small brush or mini spatula tool is used to collect cells from the cervix. Providers may also use the cells collected to test for high-risk types of HPV.

There is a vaccine available to prevent the types of HPV that most commonly cause cervical cancer. The HPV vaccine is recommended for all individuals aged 12-26. It is approved for use up to age 45, though insurance companies usually don't cover the HPV vaccine for individuals over the age of 26. Talk to your healthcare provider about your risk factors and if vaccination is right for you. Even if you already have a type of HPV, you can still be vaccinated. The vaccine can protect you from other types (strains) of HPV.

How can I make screening more comfortable for me?

A number of things can make you feel uncomfortable with screening. These can include physical discomfort with the test and emotional discomfort with the entire process, from visiting a gynecology office to having the test. Taking testosterone can make the lining of your vagina tender and irritated. This can add to your discomfort with the exam.

If you are concerned about physical discomfort, talk to your provider. They may be able to use a smaller size speculum. Using a water-based lubricant on the speculum can make the exam more comfortable. In some cases, you may be able to insert the speculum or do the swab yourself. Some people find it helpful to use a mirror to watch the exam while it is being done. Your position during the exam can help make the exam more comfortable. Slide your buttocks down, just past the end of the table. Do your best to relax, this helps relax your pelvic muscles.

Who should have screening?

Anyone with a cervix, including transmasculine and gender-nonconforming individuals, over the age of 25 who have a cervix should be screened for cervical cancer.

If you have had a hysterectomy, you may still need cervical cancer screening.

• If your cervix is intact or partially intact, you will need regular Pap tests.
• If you have had a complete hysterectomy, including the removal of your cervix and you have no history of cervical cancer or precancer, you will likely NOT need regular Pap tests. You should discuss this with your healthcare provider.
• If you have had a complete hysterectomy and you have a history of cervical cancer or precancer, you may need regular Pap tests of the remaining tissue.

When should I get screened?

The American Cancer Society recommends the following guidelines for cervical cancer screening:

• All individuals should begin cervical cancer screening at age 25.
• Individuals between the ages of 25 and 65 should have:
  • Primary HPV testing every 5 years. This test is not yet available at many centers/practices.
  • If this test is not available, you should be screened with co-testing, which is a combination of an HPV and Pap test. This should be done every 5 years.
  • If HPV testing is not available, then a Pap test alone should be performed every three years
• Thus over the age of 65 who have had regular cervical screenings that were normal should not be screened for cervical cancer.
• Individuals who have been diagnosed with cervical pre-cancer should continue to be screened until they meet one of the following criteria over the previous 10 years:
  • Two negative, consecutive HPV tests.
  • Or 2 negative, consecutive co-tests.
  • Or 3 negative, consecutive pap tests in the last 3-5 years.
• Those who have had their uterus and cervix removed in a hysterectomy and have no history of cervical cancer or pre-cancer should not be screened.
• If you have had the HPV vaccine you should still follow the screening recommendations for your age group.
• While the ACS does not recommend cervical cancer screening every year, you should still see their provider for an annual checkup.

Those who are at high risk for cervical cancer may need to be screened more often. High-risk individuals include those with HIV infection, organ transplant, or in-utero exposure to the drug DES. They should talk with their doctor or nurse for specific recommendations.

What can I expect after the procedure?

• You may have some bleeding after the procedure, which is normal.
• In some cases, the sample may not be enough to run the test and you may need another sample taken.
• Your provider will call you or message you with the results in 1-3 weeks.

Talking to your Healthcare Provider

• Let your providers know your preferred name and pronouns, any history of hormone use, and surgeries you have had.
• Let your provider know what words you prefer to use to describe your body parts.
• In some cases, your insurance company may deny coverage of this essential screening if the gender in your medical record is different from your sex assigned at birth. This is due to outdated gender-specific flagging algorithms. If this happens, please discuss it with your provider who can provide the appropriate clinical information about your anatomy and the need for screening.
• Be sure your provider knows if you are taking testosterone and if you have stopped menstruating as these things can impact the way your cervical cells appear under the microscope.

Resources for More Information

UCSF Center of Excellence for Transgender Health - https://prevention.ucsf.edu/transhealth

The World Professional Association for Transgender Health - https://www.wpath.org/