Prostate cancer in trans women: what you need to know.
Updated: Apr 22
Disclaimer: This does not constitute medical advice, consult your medical practitioner if you have concerns. Useful links are provided below.
Two of the leading Urology journals recently released information regarding prostate cancer that all transitioned women should know: notably that prostate cancer is still a possibility. In them, they looked at the effects of HRT and lower surgery on the development and progress of prostatic cancer and challenge some of the underlying assumptions made by clinicians and trans women alike. Currently in the UK, advice, and information about prostate cancer is directed almost entirely at cisgender men, and can be upsetting and distressing for trans women to access. Transgender women and those who have had lower surgery are less likely to want to read about something which seems to only be directed at men and may think that, because they have had lower surgery, that prostate disease is something that won't affect them. Here, I'll briefly discuss prostate cancer, and although other prostate conditions do exist, I won't be covering them. I'll try and give a little context and detail, and use language, terminology, and descriptions that are more comfortable and accessible to trans women.
The prostate sits underneath the bladder and surrounds the urethra, and is responsible for producing ejaculate. For trans women, this is the clear fluid that lubricates a neovagina and is homologous to the Skenes gland in cisgender women. The prostate, therefore, is not removed during genital reconstructive surgery for many reasons: vaginal lubrication, the risk of urological complications (urinary incontinence) due to nerve damage, and maintaining sexual function. [Image: Prostate cancer UK]
The risks of getting prostate cancer are obviously the same in cisgender men and trans women who do not have hormones or surgery as they are bio-identical. Prostate cancer is the leading cause of cancer in cismen: with 52,300 new cases each year: thats 1 in 6 cismen during their lifetime. The incidence of prostate cancer in transgender women, however, is variable, depending on the specific hormonal regimen, and the age at which they start HRT. There are both alpha and beta oestrogen receptors, and testosterone receptors in the prostate, all of which may affect the development or inhibition of prostate cancer. It is thought that trans women on oestrogen only regimes without testosterone blockers are at higher risk, from animal studies.
What this translates to for trans women on testosterone blockers, or post genital reconstruction is an approximate 5 times decrease in prostate cancer. That's still a significant number of trans women at risk from prostate cancer during their lifetime, being about 1 in 30 trans women in a lifetime. It is thought that prostate cancer may start in trans women in their early 30's yet remain small and undetected and develop more slowly than in cismen due to differences in hormonal levels. All of the prostate cancers in trans women in this group were "adenocarcinomas" - these cells secrete mucous, digestive juices or other liquids. Such cancers are "metastatic", meaning they can spread in the body.
Assessment of, and signs and symptoms of prostate cancer in trans women are particularly problematic, both because of varying hormonal regimens, a lack of evidence and controls, and some difficulty accurately detecting prostate cancer even in cisgender men. "Symptoms of prostate problems can include:
* needing to urinate more often, especially at night – for example if you often need to go again two hours after urinating
*difficulty starting to urinate
*straining or taking a long time to finish urinating
*a weak flow when you urinate
*a feeling that your bladder has not emptied properly
*needing to rush to the toilet – you may occasionally leak before you get there
*dribbling urine." - Prostate cancer UK . Assessment of an enlarged prostate through digital examination (feeling inside you) should be transvaginally for trans women with a vagina as digital rectal examination "will not necessarily allow palpation of the prostate". A digital examination (examination with a finger) remains only 50% sensitive to accurate detection. Similarly, blood tests for a raised PSA (prostate specific antigen - a protein produced in excess by cancer cells, but also healthy prostate cells) is not a very sensitive test. This guide talks about the pros and cons of the PSA test although is entirely dedicated to cisgender men. A prostate MRI (magnetic resonance imaging) scan is recommended internationally for suspected prostate cancer. Similarly, biopsies, if required, can be done transvaginally rather than rectally or through the perineum. It is recommended that trans women seek the same treatment options and healthcare screening as cisgender men: that means having a discussion with your doctor about getting a PSA test if you're over 50, symptomatic, or have a high risk of developing prostate cancer (for example a family history).
Treatment options for confirmed tumors are best dealt with by discussion with your doctor, however, there are specific considerations for trans women with a vagina, as radiotherapy may cause vaginal damage, and discussing this with your doctors is particularly important. For those considering genital reconstructive surgery, a discussion between a GRS surgeon and the doctor treating prostatic cancer should occur, as any surgery down there complicates potential GRS so it's important to speak up about any future intentions.
Useful links and references:
Cancer Research: https://www.cancerresearchuk.org/about-cancer/prostate-cancer Prostate Cancer Incidence under Androgen Deprivation: Nationwide Cohort Study in Trans Women Receiving Hormone Treatment: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7379905/ Prostate cancer in transgender women: What does a urologist need to know? https://bjui-journals.onlinelibrary.wiley.com/doi/epdf/10.1111/bju.15521
Embryologic and hormonal contributors to prostate cancer in transgender women
Info about the PSA test (made for cis men):
About adenocarcinomas: https://my.clevelandclinic.org/health/diseases/21652-adenocarcinoma-cancers