Endometrial hyperplasia is a condition in which the lining of the uterus grows thicker than it should be. In some cases, the thickened endometrium can develop abnormal cells, which might become cancerous and lead to uterine cancer. Obviously, cancer is a bad thing and we want to avoid it. There are a few reasons that endometrial hyperplasia a concern for FTMs: excess androgen exposure (ie: testosterone) appears to lead to Polycystic Ovarian Syndrome-like ovaries in FTMs. It has been found that women with PCOS have a higher rate of endometrial hyperplasia than women without PCOS. Generalizing this to trans men, we can speculate that PCOS-like ovaries in FTMs on testosterone might also lead to PCOS-like endometrial hyperplasia in FTMs. Additionally, FTMs that are on testosterone develop amenorrhea (no periods), and while this is generally due to the uterine lining becoming thin and atrophic, there is a small possibility of the lining building up and becoming thicker instead. There was an article published in the 1980’s about a small sample of FTMs who had hysterectomies. The authors reported that the number of the samples that had hyperplasia was higher than normal. This led to concerns about FTMs having undiagnosed hyperplasia, although to my knowledge there has not been any similar follow-up study to confirm or refute this. Finally, trans men may avoid medical care, thus ignoring signs of endometrial hyperplasia (such as vaginal bleeding or spotting while on testosterone) which could lead them to potentially develop undetected/untreated uterine cancer.
So how do we screen for this uncommon but important condition in trans men? The answer is…wait, there’s no answer. At least, not an evidence-based, universally accepted recommendation for screening. Different providers have different recommendations. Some recommend a pelvic ultrasound every 2 years before hysterectomy. Some recommend a pelvic ultrasound about 18 months after initiation of testosterone. Some recommend no screening unless a patient develops vaginal bleeding. Some recommend an annual “progesterone challenge” in which the patient is given 10 days of progesterone to try to induce vaginal bleeding, with the idea that any built-up endometrium will be sloughed off.
The progesterone challenge is my least favorite of the screening ideas. Not only does it seem like an emotionally difficult practice for the patient, but it seems unnecessary. I don’t know how many cases of endometrial hyperplasia are caught this way, but my guess is not many–it seems like a low yield type of screening. Plus, I don’t entirely get what it is looking for. If the patient doesn’t bleed, does that imply that the patient doesn’t have any endometrium to shed? Because that would be a good thing. Or does it imply that the endometrium is not shedding and is building up? Because that would be a bad thing. If the patient does bleed, does that mean that the patient is safe because their endometrium has sloughed? Or does it mean that the patient should be evaluated more because they have built up an endometrial lining and they really should have an atrophic lining? And given all these possible outcomes, what are the next steps after the progesterone?
So…what do I recommend? At this point, I’m leaning towards a) the pelvic ultrasound at 18 months post-initiation of testosterone or b) no screening unless symptomatic. As a relatively new and still-nervous provider, I would feel reassured if all of my FTM patients on testosterone had normal uterine ultrasounds. However, I understand that getting a pelvic ultrasound is not fun, particularly if a patient is uncomfortable with the internal (vaginal) approach, and can also be expensive or hard to access. So it seems reasonable to me to present the evidence–or lack thereof–to patients and let them decide. None of my patients have opted for a voluntary pelvic ultrasound yet. None have opted for a voluntary progesterone challenge, either. But at least they have the information.
*I’ve put “Do literature search about uterine hyperplasia in FTMs” on my To Do List, just in case I have missed any new or groundbreaking research. As soon as I have some free time (ha) I’ll get to it. And if I find anything new, I’ll let you know.