Cervical Cancer Screening for Transmasculine or Gender Non-Conforming Individuals

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

What is the cervix?

The cervix is 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 exam. Cervical cancer develops when cells in the cervix 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. Very few people who have HPV will develop cervical cancer; so having HPV doesn't mean that you will get cancer.

Even though HPV is considered an STI, intercourse or penetration is not necessary to pass it on - it can be passed on through skin-to-skin contact as well. 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 strains (types) of HPV. Of these, 12 are "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. During a Pap test, cells from the cervix are collected, which is located at the top of the vagina. The provider puts 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. You should talk with your insurance provider about coverage. 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?

You could experience physical or emotional discomfort related to screening. 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 21 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 talk to your healthcare provider about this.
• 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?

There are many organizations that make recommendations regarding cervical cancer screening and they may vary. It is important to talk to your provider about what type of screening is right for you and when you should have the tests done. To help understand what screening may look like for you, these are the recommendations from The American College of Obstetricians and Gynecologists (ACOG):

• All individuals with a cervix should have a Pap test starting at age 21 and have this test done every 3 years.
• From ages 30 to 65, all individuals with a cervix 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 done every 3 years.
• 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 two negative, consecutive co-tests.
  • Or three negative, consecutive pap tests in the last 3 to 5 years.
• Individuals 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.
• Individuals who have had the HPV vaccine should still follow the screening recommendations for their age group.
• While ACOG does not recommend a cervical cancer screening every year, individuals should still see their provider for a yearly checkup.

Individuals who are at high risk for cervical cancer may need to be screened more often. Individuals at high risk could be those with HIV infection, organ transplant, or in-utero exposure to the drug DES. 

You should talk to your healthcare provider for specific recommendations for you.

What can I expect after the procedure?

• You may have some bleeding after screening, 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 to 3 weeks.

Talking to your Healthcare Provider

• Let your provider 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 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 talk with your provider who can give the necessary 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 look under a 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/