Prostate and testicular cancer considerations in transgender women

Prostate cancer

Documented cases of prostate cancer in trans women with a variety of hormone use and surgical histories have been reported.[1-3] Most cases of prostate cancer in trans women have been in individuals who started hormones after age 50; such cases may actually represent occult neoplasms, which existed prior to initiation of hormone therapy.[4] In a cohort of 320 transgender women in Belgium who had undergone vaginoplasty, PSAs along with transvaginal ultrasound and digital vaginal examination of the prostate revealed lower PSA and prostate volume than what would be expected in a non-transgender men of corresponding age.[5] Some anti-androgens, such as 5-alpha reductase inhibitors have also been documented to decrease the PSA result.[6] Removal of gonads in addition to estrogen exposure likely reduces risk for prostate cancer and benign prostatic hypertrophy.[4,5]

Regardless, primary care providers should remain aware of the possibility of prostate cancer in transgender women, even those who have undergone gonadectomy. The decision to perform screening for prostate cancer in transgender women should be made based on guidelines for non-transgender men. If a prostate exam is indicated, both rectal and neovaginal approaches may be considered. Transgender women who have undergone vaginoplasty have a prostate anterior to the vaginal wall, and a digital neovaginal exam examination may be more effective.[5] It should be noted that when PSA testing is performed in transgender women with low testosterone levels, it may be appropriate to reduce the upper limit of normal to 1.0 ng/ml.[4]

Testicular cancer

There has been one case of testicular cancer reported in the literature.[7] It is likely that risk decreases with androgen suppression. Routine testicular cancer screening is not recommended in non-transgender men, and there is no evidence to perform screening in transgender women. Transgender women adherent to therapeutic doses of estrogen plus an androgen blocker, and with persistent testosterone elevations, should be evaluated for testicular tumors by physical exam, as well as human chorionic gonadotropin (hCG), alpha-fetoprotein (AFP) and lactic dehydrogenase (LDH) levels, and possibly a scrotal ultrasound.

References

1. Miksad RA, Bubley G, Church P, Sanda M, Rofsky N, Kaplan I, et al. Prostate cancer in a transgender woman 41 years after initiation of feminization. JAMA. 2006 Nov 15;296(19):2316-7.
2. Turo R, Jallad S, Prescott S, Cross WR. Metastatic prostate cancer in transsexual diagnosed after three decades of estrogen therapy. Can Urol Assoc J J Assoc Urol Can. 2013 Aug;7(7-8):E544-6.
3. Dorff TB, Shazer RL, Nepomuceno EM, Tucker SJ. Successful treatment of metastatic androgen-independent prostate carcinoma in a transsexual patient. Clin Genitourin Cancer. 2007 Jun;5(5):344-6.
4. Trum HW, Hoebeke P, Gooren LJ. Sex reassignment of transsexual people from a gynecologist's and urologist's perspective. Acta Obstet Gynecol Scand. 2015 Jun;94(6):563-7.
5. Weyers S, De Sutter P, Hoebeke S, Monstrey G, 'T Sjoen G, Verstraelen H, et al. Gynaecological aspects of the treatment and follow-up of transsexual men and women. Facts Views Vis ObGyn. 2010;2(1):35-54.
6. Marks LS, Andriole GL, Fitzpatrick JM, Schulman CC, Roehrborn CG. The interpretation of serum prostate specific antigen in men receiving 5alpha-reductase inhibitors: a review and clinical recommendations. J Urol. 2006 Sep;176(3):868-74.
7. Wolf-Gould CS, Wolf-Gould CH. A transgender woman with testicular cancer: a new twist on an old problem. LGBT Health. 2015 Dec 24.