Histologic Findings in Gynecologic Tissue From Transmasculine Individuals Undergoing Gender-Affirming Surgery

Abstract

Context.— Gender-affirming surgery is part of a multidisciplinary approach in gender transitioning. Deeper histologic examination may strengthen care for transmasculine individuals and increase the understanding of the influence of hormonal therapy in specific organs. Objective.— To evaluate and catalogue histologic findings of tissue obtained from gender-affirming gynecologic surgery and cervical cytology specimens. Design.— This is an institutional review board–approved retrospective study that included transmasculine individuals who underwent gender-affirming gynecologic surgery from January 2015 to June 2020. All surgical gynecologic pathology and cervical cytology slides were reviewed by 2 pathologists. Results.— Fifty-five patients were included, which represented 40 uteri, 35 bilateral ovaries, 15 vaginectomy specimens, and 24 cervical cytology results. The median age was 27 years (range, 18–56) and 94% (50 of 53) of patients were receiving testosterone for at least 1 year. Seventy-five percent (30 of 40) of endometria were inactive, while 25% (10 of 40) showed evidence of cycling. Transitional cell metaplasia was the most common finding in the cervix (17 of 40) and vagina (15 of 15), reflecting a high percentage (4 of 24) of unsatisfactory or ASC-US (atypical squamous cells of undetermined significance) cervical cytologies. Prostatic-type glands were identified in 20% (8 of 40) of cervices and 67% (10 of 15) of vaginectomy specimens. Multiple bilateral cystic follicles and evidence of follicular maturation were present in 57% (20 of 35) of cases. Four cases showed paratubal epididymis-like mesonephric remnant hypertrophy. Conclusions.— A comprehensive evaluation of tissue from gender-affirming surgery increases knowledge of the changes following androgen therapy in transmasculine individuals and may contribute to optimal patient care by raising awareness of normal histologic variations in this population.

Cervicovaginal cytology, HPV testing and vaginal flora in transmasculine persons receiving testosterone

“…The diagnosis of HSIL in transmasculine persons receiving testosterone can be challenging due to a high percentage of atrophic changes, showing hyperchromatic crowded groups of cells with increased nuclear to cytoplasmic ratio. These findings are not commonly seen in young individuals and can represent a diagnostic pitfall for HSIL not only in cytology, but also in histologic specimens 6 . Due to frequent atrophic changes and unsatisfactory Pap tests, HPV testing can aid in the screening of transmasculine individuals.…”

“…In addition to barriers in screening, morphologic changes in the genital tract following testosterone may affect screening results 6–9 . Testosterone is one of the strategies that transmasculine individuals can elect to align physical traits to their gender identity.…”

“…2 In addition to barriers in screening, morphologic changes in the genital tract following testosterone may affect screening results. [6][7][8][9] Testosterone is one of the strategies that transmasculine individuals can elect to align physical traits to their gender identity. A few reports have shown that cytopathologic findings in cervicovaginal cytology specimens (Pap tests) from transmasculine individuals receiving testosterone are more likely to be unsatisfactory and show atrophic changes.…”

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

“…Atrophic squamous cells can appear as small cells with hyperchromatic nuclei which might mimic dysplasia. Transitional cell metaplasia is usually characterised by elongated nuclei and longitudinal grooves 17,19–21 …”

“…Transitional cell metaplasia is usually characterised by elongated nuclei and longitudinal grooves. 17,[19][20][21] Despite the overall paucity of literature that exists on cervical Pap tests and histopathology for FTMT individuals, few studies have documented the effects of testosterone therapy, which induces cervical epithelial atrophy that could mimic high-grade cervical dysplasia. 17,19,22 The aim of this study was to investigate whether the availability of the clinical information would have an impact on the Pap test diagnostic outcome as compared to the cisgender population.…”