A Mammogram Was Never On My Bucket List As A Transgender Woman

My last doctor’s appointment ended with incredible anxiety and a shift in my research from breast development to breast health.

Photo by National Cancer Institute on Unsplash

At my last check-up with my medical provider, my doctor suggested it may be time for me to begin biennial breast cancer screenings. She said I was eligible for my first mammogram. I am a transgender woman over 60 and have been taking estradiol for three and a half years.

In addition to generating a great deal of anxiety, it prompted me to do some research on the risks of developing breast cancer. I can’t speak for other transgender women, but I spent more time researching breast development on Gender Affirming Hormone Therapy than I did investigating the increased risk of breast cancer. I was also more concerned about the development of breast tissue generating unwanted attention from co-workers, family, and friends than I was about breast cancer.

Most women begin cancer screenings at 40 years of age. But most women began breast development when they were eleven or twelve. I did not begin significant breast development until four years ago. Is that enough time for me to be at risk for breast cancer development?

The guidelines for breast cancer screening for cisgender women are confusing enough and often change depending on personal and family history. The guidelines for transgender women can be even more confusing.

One of the most highly regarded recommendations for trans women comes from the American College of Radiology (ACR). They recommend the following.

If less than 5 years of hormone use and average risk, no testing.

If less than 5 years of hormone use, 25 to 30 years or older and higher-than-average risk, annual digital breast tomosynthesis (DBT, also called a 3D mammogram) or mammogram “may be appropriate”

If 5 or more years of hormone use, 40 years or older, and average risk, annual DBT or mammogram “may be appropriate”

I have been taking spironolactone, a testosterone blocker for over ten years, on and off. However, I have not been taking estradiol in any form for more than 4 years.

The National Library of Medicine included an article on the National Institute of Health website on the screening of cancer in the transgender community, by Sterling and Garcia. The authors examine the current guidelines, best practices, and a proposed care model. I was primarily interested in the recommendations for breast cancer screening as a transgender woman taking gender-affirming hormone therapy (GATH).

However, the article went far beyond merely listing recommendations for breast cancer screening guidelines for the transfeminine and transgender woman populations. The authors note even when transmasculine and transgender men undergo breast reduction without radical mastectomy, they remain at higher risk for breast cancer than cisgender men.

Similarly, transmasculine men remain at risk for uterine, ovarian, and uterine cancers unless and until they undergo gender-affirming bottom surgeries. transgender women and transfeminine populations remain at risk for prostate cancer.

As a transgender woman, the mention of prostate cancer risk caught my attention. I have not been asked to undergo normal prostate screening or have my PSA level checked since beginning GAHT. I wondered if there was a reduced risk while taking estradiol and spironolactone, but I have not pushed my provider for an exam. I will address this on my next visit.

The article also mentioned the importance of screenings for cervical screening for transmasculine men. The article also pointed out that individuals who are HIV+ can be at increased risk for anal cancer.

The authors pointed out that though a Netherlands study found “transfeminine patients have a 46-fold increased risk of breast cancer compared to cisgender men… the rate of breast cancer in transfeminine individuals was still lower than cisgender females (incidence ratio of 0.3).”

Due to the increased risk over that of cis-gender men, the authors proposed a screening protocol that mirrored those recommended by the American College of Radiology. Transfeminine patients’ mammograms are recommended every two years in patients over 50 and who have 5–10 years of GAHT treatments. All screening should be based on shared decision-making between the individual and their medical provider.

These cautionary factors illustrate the transgender community needs to be vigilant in getting screened for all forms of cancer. However, maybe the most important and encouraging statement for those taking gender-affirming hormone therapy is “there have been no well-designed studies published showing that long-term use of GAHT or suppression of a patient’s natal puberty increases cancer risk.”

That is news we can all live with!

Sterling, J., & Garcia, M. M. (2020). Cancer screening in the transgender population: A review of current guidelines, best practices, and a proposed care model. Translational Andrology and Urology, 9(6), 2771–2785. https://doi.org/10.21037/tau-20-954