Background: Since pelvic gender-affirming surgery (GAS) is no longer required for legal gender change, we expect a growing number of transgender men and gender nonbinary people who refrain from pelvic surgery. Little is known about the effects of long-term testosterone use on the reproductive organs. Polycystic ovaries and endometrial changes have been described in previous histology-based studies. Furthermore, cervical cancer screening (CCS) is still recommended in sexually active individuals with a cervix. Transgender men face several barriers to participate in classic CCS initiatives, which involve a pelvic examination. Different methods for CCS pose a promising alternative.
Methods: The ELANTES (Effecten van Langdurig Testosteron) study was a combined cross-sectional and retrospective study in adult transgender men or gender nonbinary people without previous GAS who started testosterone at least five years ago. A pelvic magnetic resonance imaging (MRI) was performed to map the anatomical changes in the reproductive organs. If pelvic MRI was already performed in the past, consent was obtained to assess the results. Additionally, human papillomavirus (HPV) detection in self-collected urine and vaginal samples as an alternative to the classic CCS was explored. Participants were invited to perform a Colli-Pee® urine sample and/or an Evalyn® vaginal brush. Quantitative polymerase chain reaction (qPCR) was used to detect HPV DNA. They also completed a short questionnaire.
Results: A total of 22 transgender men were included in the study. Nineteen of them participated in CCS. Mean age was 31.0 years. Mean duration of testosterone therapy was 70.0 months. Mean ovarian volume was 5.2 mL and mean follicle count was 12.7. Depending on the criteria used, 18.2-59.1% of participants fulfilled criteria for polycystic ovarian morphology (PCOM) diagnosis. Mean endometrial thickness (ET) was 3.3 mm. A thin ET (1-4 mm) was seen in 81.8% of participants. The remaining 18.2% had an ET of 5-7 mm. Intermediate-risk HPV prevalence was 11.7% for the Colli-Pee® samples and 17.6% for the Evalyn® brushes. No high-risk HPV was detected. The use of these self- collection devices was well-received and favoured over classic CCS by the participants.
Conclusion: No clinically relevant alterations in the reproductive organs were observed on MRI imaging in this small cohort of adult transgender men using long-term testosterone, who did not undergo pelvic GAS. Self-collected urine samples and vaginal brushes showed low prevalence for intermediate-risk HPV. No high-risk type HPV was detected. Self-sampling provides a unique opportunity to reach a population that is otherwise difficult to reach for CCS.