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

Abstract

BackgroundThe transgender population faces unique psychosocial and physical obstacles to cervical cancer screening. Additionally, most individuals undergo masculinizing testosterone hormone therapy, and the physiologic changes can cause cytomorphologic alterations that may mimic lesions. Although the literature on cervicovaginal cytology is growing in this patient population, it is still limited.MethodsThe pathology information system was queried for all Papanicolaou (Pap) tests from transgender men from January 2013 to February 2023. The original diagnostic categories were catalogued. Cases were reviewed to evaluate the cytomorphologic alterations. Clinical data were also sought, including whether the sample was self‐collected. Two comparison groups were established: one was a postpartum atrophic group and the other was an all‐comer group.ResultsA total of 51 cases from 43 individuals were identified, with a mean age of 31 years. Approximately a third of cases (18 of 51; 35%) were self‐collected. The abnormal rate was low, with 5.9% of cases rendered atypical squamous cells of undetermined significance on original review and no lesions identified. The Pap unsatisfactory rate according to original reports was 3.9%. This increased to 13.7% when the cases were rereviewed, which was significantly higher than the all‐comer comparison group. The unsatisfactory rate did not correlate with self‐collection. Atrophy was a prevalent cytomorphologic alteration, with the vast majority of cases (92%) showing at least mild atrophy. Small blue cells and transitional cell metaplasia were seen in many cases (53% and 43%, respectively).ConclusionsThere are clinical and morphologic considerations that are distinct to the transgender patient population. Laboratory personnel and diagnosticians need to be aware of these in order to optimize patient care.

Challenging lesions in cervical cytology: The elusive HSIL

“…These are not typically concerning for HSIL but may cause concern for a glandular lesion, in particular endometrial adenocarcinoma with high N:C ratios arranged in a streaming configuration with ovoid to spindled nuclei with fine, evenly distributed chromatin, inconspicuous-to-small nucleoli, nuclear membrane irregularities (wrinkling), small perinuclear halos, and longitudinal grooves (Figure 6A,B). 25 Transitional cell metaplasia has been traditionally thought of as an infrequent but not uncommon finding detected on Pap tests from postmenopausal women. Indeed, many consider transitional cell metaplasia to be a variant of atrophy.…”

“…Transitional cell metaplasia has been noted in cytology samples at frequencies up to 88.2% in this patient population. [25][26][27][28] Its main importance is in its potential to resemble high-grade dysplasia given its increased N:C ratio, nuclear contour irregularities, and tendency to present in sheets or groups which at times may appear crowded. 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.…”

Prevalence of Cervical Cancer Precursor Lesions in Transgender Men: a Systematic Review

“…Thus, 73 studies were read, and 62 of these studies were excluded for different reasons. An abstract was considered potentially eligible, but it was not included in the analysis because it was not possible to obtain the full text [11]. No additional studies were found in the references of the other studies.…”