Cancer Screening and Prevention for Transgender People

Cancer prevention saves lives. This applies to everyone, regardless of gender identity. Yet, for transgender and non-binary people, cancer screenings represent a landscape full of gaps, confusion, and barriers that too often lead to delayed diagnoses or, worse, completely skipping check-ups.

The problem is structural: national screening programs are designed around a binary model that associates certain exams with a legal sex assigned at birth. But a trans person’s body does not necessarily align with the expectations tied to their registered sex at birth. A trans woman has a prostate. A trans man may have a cervix. Hormone therapies alter tissues and risk profiles. And the healthcare system, in most cases, is ill-equipped to handle this complexity.

This article provides a practical guide based on available scientific evidence [1][2][3], aiming to clarify which oncological screenings are recommended for trans people, how hormone therapy influences risk, and how to overcome the barriers preventing access to adequate prevention. It does not replace medical advice: every case is individual and should be discussed with competent healthcare professionals.

The Problem: Screenings Based on Legal Sex

In Italy, the oncological screening programs of the National Health Service (SSN) are organized by the National Institute of Health and managed at the regional level [8]. The three main free screening programs are:

• Breast screening (mammogram): aimed at women aged 50 to 69 (in some regions 45-74)
• Cervical screening (Pap smear or HPV test): aimed at women aged 25 to 64
• Colorectal screening (fecal occult blood test): aimed at men and women aged 50 to 69

The invitation criterion is the sex registered at the registry office. This means that a trans woman (MtF) registered as male will not receive an invitation for a mammogram, even if she has developed breast tissue through estrogen therapy. Similarly, a trans man (FtM) who has legally updated his documents will not receive an invitation for a Pap smear, even if he still has a cervix.

The result is a gap in care. Trans people fall through the cracks of a system that does not account for them. Data from the Journal of Clinical Oncology (2022) confirm that transgender people have significantly lower cancer screening rates compared to the cisgender population [3]. Not because cancer affects them less, but because the system fails to intercept them.

Screenings for Trans Women (MtF)

Trans women have a specific oncological risk profile, determined by the combination of present organs, current hormone therapy, and individual medical history. Here are the recommended screenings.

Breast Screening

Estrogen therapy induces the development of breast tissue in trans women, generally starting from the first months of treatment [4]. With breast tissue comes the risk of breast cancer, albeit to a lesser extent than in cisgender women.

A study in the BMJ (2019) found that the risk of breast cancer in trans women on estrogen therapy is increased compared to cisgender males, but still remains lower than that of cisgender women [5]. Current recommendations are:

• After at least 5 years of estrogen therapy, trans women should follow the same mammography screening recommendations as cisgender women [1][2]
• A mammogram is recommended starting at age 50 (or 40 if there are familial risk factors)
• Screening should be continued every two years, just like for the general population
• Trans women with breast implants can still undergo a mammogram, provided they inform the technician about the implants

Prostate Screening

The prostate is not removed during a vaginoplasty. All trans women retain their prostate, regardless of the surgeries they have undergone [3]. Prostate cancer therefore remains a possibility, although long-term estrogen therapy appears to reduce the risk.

Key points:

• Screening for prostate cancer (PSA testing, digital rectal exam) follows standard age-based guidelines: discussion with a doctor starting at age 50 (or 45 if there is a family history) [1]
• Estrogen therapy lowers PSA levels, making this marker potentially less reliable [3]. A seemingly normal PSA value in a trans woman could hide an issue. It is crucial that the doctor interprets the PSA in the context of hormone therapy
• After a vaginoplasty, the prostate exam can be performed vaginally instead of rectally

Liver Monitoring

Estrogen therapy, particularly when taken orally, passes through the liver and can affect liver function over time [4]. Prolonged use of anti-androgens like cyproterone acetate also requires attention:

• Liver function tests (AST, ALT, GGT) at least once a year
• Periodic abdominal ultrasound in the presence of risk factors (alcohol consumption, fatty liver disease, previous hepatitis)

Bone Density

Bone health is an often overlooked aspect. Estrogen therapy protects bones, but periods of hypogonadism (low levels of all sex hormones, for example during a transition gap or after suspending therapy) can compromise bone mineral density [4]:

• Bone densitometry (DEXA scan) is recommended for trans women over 60, or earlier if risk factors are present (smoking, excessive thinness, family history of osteoporosis, prolonged periods without hormone therapy)

Screenings for Trans Men (FtM)

Trans men have oncological screening needs that depend directly on the organs still present and any surgical procedures they have undergone.

Cervical Screening (Pap test / HPV test)

This is probably the most important and most neglected screening for trans men. If the cervix is present—meaning a total hysterectomy has not been performed—cervical screening is necessary, regardless of testosterone therapy and gender identity [1][2][3].

The recommendations:

• HPV test or Pap smear at the same intervals recommended for cisgender women (every 3-5 years between ages 25 and 64, depending on regional protocols) [8]
• Testosterone therapy can cause vaginal atrophy, making the cervical swab more difficult and potentially painful. Applying local estradiol (cream or vaginal suppositories) for a few weeks before the exam can improve the situation without significantly interfering with testosterone therapy [2]
• Atrophy induced by testosterone can also generate atypical cytological results that do not indicate pathology but are related to hormonal changes. It is important that the pathologist is informed of the ongoing therapy

Breast / Chest Screening

The situation varies based on surgical history:

• Trans men without mastectomy: should follow the same recommendations for mammography screening as cisgender women (biennial mammogram starting at age 50, or earlier if there is a family history) [1]
• Trans men post-mastectomy: gender-affirming mastectomy removes most of the breast tissue, but not all of it. Residual tissue may remain, particularly in the underarm area and along the mammary line [3]. There are no standardized guidelines for post-mastectomy screening in trans men. The recommended approach is an annual clinical exam of the chest wall and a discussion with a doctor about the appropriateness of imaging (ultrasound or MRI) in the presence of high-risk factors (BRCA mutations, strong family history)

Uterine and Ovarian Screening

If the uterus and ovaries are still present:

• There are no population screening programs for ovarian or endometrial cancer. However, awareness of symptoms is crucial [6]
• Vaginal bleeding after testosterone-induced amenorrhea is a sign not to be ignored. After the menstrual cycle has stopped due to testosterone therapy, any subsequent bleeding should be evaluated with a pelvic ultrasound [3]
• A pelvic ultrasound (transabdominal, if the transvaginal one is too uncomfortable) can be useful for periodic monitoring if risk factors are present
• Some preliminary data suggest that long-term testosterone might promote endometrial atrophy, but research is still limited and monitoring remains recommended [5]

Liver Function and Polycythemia

Testosterone therapy has specific metabolic effects that require monitoring [4]:

• Complete blood count (CBC) at least every 6-12 months: testosterone stimulates the production of red blood cells. Too high a hematocrit (above 54%) increases the risk of thrombotic events and requires adjusting the therapy
• Liver function: annual tests, particularly in the first years of therapy or in the presence of additional risk factors
• Lipid profile: testosterone tends to increase LDL cholesterol and decrease HDL. Regular monitoring is essential for cardiovascular prevention

Screenings for Non-Binary People

For non-binary people, the guiding principle is simple in theory and complex in practice: screenings must be based on the organs present and the therapies being used, not on gender identity or legal sex [2][7].

In concrete terms:

• A non-binary AMAB (assigned male at birth) person taking low-dose estrogens should follow the recommendations for breast screening after 5 years of therapy, and maintain prostate screening
• A non-binary AFAB (assigned female at birth) person taking testosterone should continue cervical screening if they have a cervix, and monitor their chest wall if they have had a mastectomy
• Non-binary people not on hormone therapy follow standard recommendations for their sex assigned at birth

The WPATH SOC-8 emphasizes that personalized screenings are essential for people with non-binary identities and transition paths [2]. An open dialogue with a doctor is needed to define a tailored prevention plan.

The Effect of Hormone Therapy on Cancer Risk

One of the most frequently asked questions concerns the link between hormone therapy and cancer. The available data, despite the limitations of ongoing research, is overall reassuring [5].

Estrogen and Breast Cancer

A Dutch cohort study published in the BMJ in 2019, which analyzed data from over 2,200 trans women, found an increased risk of breast cancer compared to cisgender males, but significantly lower than that of cisgender women [5]. The risk appears to increase with the duration of estrogen therapy and becomes clinically relevant after about 5-10 years of exposure. This data forms the basis of the recommendation to start mammography screening after 5 years of therapy [1].

It is important to contextualize this: the absolute risk remains low. Estrogen therapy does not turn breast cancer into a certainty, but it creates the biological conditions (breast tissue exposed to hormonal stimulation) for it to occur. Prevention, not fear, is the appropriate response.

Testosterone and Endometrial Risk

Regarding testosterone in trans men, the data is less clear. Some researchers have hypothesized that the peripheral conversion of testosterone into estrogen (via the aromatase enzyme) could theoretically stimulate the endometrium and increase the risk of endometrial cancer [3]. However, large-scale clinical studies have not confirmed a significant increase in this risk [5].

The predominant effect of testosterone on the endometrium seems to be atrophy, not stimulation. Nevertheless, abnormal uterine bleeding during testosterone therapy always requires evaluation [2].

Testosterone and Other Cancers

There is no convincing evidence that testosterone increases the risk of ovarian cancer or other gynecological cancers [5]. Some observational studies have suggested a possible association, but the numbers are too small to draw definitive conclusions.

Overall Picture

A literature review published in the Journal of Clinical Oncology in 2022 concluded that the overall cancer risk in trans people on hormone therapy is not significantly different from that of the general population [3]. The key message is not “hormone therapy is risk-free,” but rather “oncological risks are manageable with prevention and monitoring, exactly as for the cisgender population.” The European Society for Medical Oncology has reiterated this principle in its recommendations for LGBTQ+ cancer care [7].

Barriers to Access

Knowing which screenings to do is necessary but not sufficient. For many trans people, practically accessing cancer prevention is an obstacle course.

Dysphoria During Exams

Some screenings require the exposure or manipulation of body parts that are a source of intense dysphoria. A Pap smear for a trans man can be a profoundly distressing experience, not because of the exam itself but because of what it implies: lying on a gynecological exam table, exposing genitals that do not align with one’s identity, and facing a medical setting designed for women [3][7].

A mammogram for a trans man who hasn’t had a mastectomy, a prostate exam for a trans woman, a transvaginal pelvic ultrasound: these are all potential dysphoria triggers that can lead to screening avoidance.

Strategies that can help:

• Communicating your needs to healthcare staff in advance
• Asking to be called by the correct name and pronouns during the exam
• Requesting, where possible, healthcare providers who are sensitized to or trained in trans health issues
• Discussing less invasive alternatives with a doctor (e.g., transabdominal instead of transvaginal ultrasound)
• Considering psychological support to manage anticipatory anxiety related to these exams

Misgendering in Healthcare

Being called by one’s legal name or the wrong pronouns in a waiting room, finding a gender on a medical report that does not match one’s identity, having to explain one’s medical history to every new provider: these are common experiences for trans people in the healthcare system [7]. These experiences are not mere annoyances: they are concrete barriers that lead many people to avoid medical check-ups, including cancer prevention.

NHS Invitation Letters

In Italy, invitation letters for oncological screenings are sent to homes using legal names and sex assigned at birth. A trans man who has not yet legally changed his documents may receive a letter addressed to his female name for a Pap smear. A trans woman who has updated her documents will not receive an invitation for a mammogram. In both cases, the system creates a problem where there shouldn’t be one [8].

Avoidance of Care

The result of these barriers is well-documented: trans people access cancer screenings less than the cisgender population [3]. Not due to personal negligence, but due to a system that makes access unnecessarily difficult. Every missed screening is a lost opportunity for early diagnosis.

The Situation in Italy

The Italian healthcare system presents specific critical issues in the management of oncological screenings for trans people.

Screenings Linked to the Legal Registry

Regional screening programs send out invitations based on the sex registered at the registry office [8]. This creates two problematic scenarios:

• Before legal gender recognition: the person receives invitations consistent with their sex assigned at birth. A trans man receives an invitation for a mammogram and a Pap smear (potentially useful, but under the wrong name). A trans woman does not receive an invitation for a mammogram (a screening she might need)
• After legal gender recognition: the situation reverses. The trans man no longer receives the invitation for a Pap smear (which he might still need if he has a cervix). The trans woman starts receiving an invitation for a mammogram (appropriate if on estrogen therapy for at least 5 years)

In neither case does the system work flawlessly. Changing legal documents solves some problems and creates others.

Systemic Gaps

To date, there is no national Italian protocol defining cancer screening for trans people [8]. The AIRC has started raising awareness on the topic [6], but operational recommendations at the SSN level are still absent. The responsibility falls entirely on the individual and their primary care doctor, who must know the full medical history and proactively order the appropriate screenings.

Some centers specializing in trans health (such as SAIFIP in Rome or CIDIGEM in Turin) integrate cancer screening recommendations into long-term follow-up care. But most trans people are not followed by specialized centers and rely on general practitioners, who may not have the specific expertise to handle this complexity.

What Can Be Done Practically

• Inform your primary care doctor of your hormonal and surgical history, and explicitly ask which screenings are indicated
• Actively request screenings not covered by the regional program for your legal sex (for example, a trans woman can request a mammogram through her primary care doctor even if she doesn’t receive the automatic invitation)
• Keep clear documentation of your medical history (start of hormone therapy, surgeries performed, present organs) to share with any new healthcare provider

Practical Recommendations: Summary Table

The following table summarizes the recommended screenings based on individual circumstances. It is an orientation tool, not a substitute for medical advice.

Trans Women (MtF)

Screening	When	Notes
Mammogram	After 5+ years of estrogen therapy, starting at age 50 (or 40 with family history), every 2 years	Risk is lower than cisgender women, but present
Prostate (PSA + exam)	Starting at age 50 (or 45 with family history), following standard guidelines	PSA is lowered by estrogens: interpret with caution
Colorectal screening	Starting at age 50, every 2 years	Same as the general population
Liver function	Annually	Particularly important with oral therapy
Bone densitometry	Starting at age 60 or earlier with risk factors	Pay attention to periods without hormonal coverage

Trans Men (FtM)

Screening	When	Notes
Pap smear / HPV test	Ages 25 to 64, every 3-5 years	Only if the cervix is still present
Mammogram or chest ultrasound	Starting at age 50 (or 40 with family history), every 2 years	If no mastectomy was performed. Post-mastectomy: annual clinical exam
Pelvic ultrasound	Periodically, according to medical advice	If uterus and ovaries are present. Watch out for abnormal bleeding
Colorectal screening	Starting at age 50, every 2 years	Same as the general population
Complete Blood Count	Every 6-12 months	Hematocrit monitoring for polycythemia risk
Liver function	Annually	Monitoring linked to testosterone therapy

Non-Binary People

Situation	Recommended Screenings
AMAB, on estrogen therapy	Same as for trans women
AMAB, no hormone therapy	Prostate and colorectal screening per guidelines for sex assigned at birth
AFAB, on testosterone therapy	Same as for trans men
AFAB, no hormone therapy	Cervical, breast, and colorectal screening per guidelines for sex assigned at birth

Conclusion

Cancer does not discriminate based on gender identity. But the prevention system does, often unintentionally, when it fails to see trans people for who they are: individuals with specific bodies, unique medical histories, and the right to the same quality of prevention as anyone else.

Oncological prevention for trans people does not require a different kind of medicine. It requires more attentive medicine: one that looks at the organs present, not the legal sex; that considers hormone therapy within the overall risk profile; and that knows how to welcome patients without generating unnecessary dysphoria.

The scientific data is clear: hormone therapy does not turn trans people into high-risk subjects for cancer [3][5]. The risk exists, as it does for everyone, and it must be managed with the tools of modern prevention: regular screenings, awareness of one’s own risk factors, and dialogue with competent professionals.

If there is one takeaway message from this article, it is this: do not skip screenings out of fear, dysphoria, or bureaucratic difficulties. Talking to your doctor, even when it is uncomfortable, is an act of self-care. Early diagnosis saves lives. Being trans does not change this reality—if anything, it makes it even more important to remember.