Symptomatic HPV-related neovaginal lesions in transgender women: case series and review of literature

Sexually transmitted infections and the vaginal microbiome after vaginoplasty

PURPOSE OF REVIEW

Transgender and gender-diverse individuals (TGD) are at risk for sexually transmitted infections. Gender affirmation surgery is a cornerstone of care for many TGD individuals. For genital gender affirmation, the surgical creation of a vagina may be performed through a number of techniques. Those who have undergone vaginoplasty have unique anatomical and biopsychosocial considerations, which we discuss.

RECENT FINDINGS

While sexually-transmitted infections including HPV, HSV, HIV, gonorrhea, and chlamydia, have been described in TGD individuals after vaginoplasty, the reports are very rare, and the provider should maintain an index of suspicion and maintain a broad differential for symptoms including neovaginal discharge. We discuss the association of the neovaginal microbiota composition with bacterial vaginosis, and how its modulation could potentially reduce bacterial vaginosis and sexually transmitted infection risk.

SUMMARY

We examine the literature regarding sexually-transmitted infections following vaginoplasty, and the neovaginal microbiome and its similarities and differences relative to the natal vaginal microbiome.

Understanding Sexual and Gender Minority Populations and Organ-Based Screening Recommendations for Human Papillomavirus-Related Cancers

OBJECTIVES

Sexual gender minority (SGM) populations are at risk for human papillomavirus (HPV)-related cancers of the anogenital tract and oropharynx and often face barriers to health care. The goals of this document are to clarify language to provide inclusive care for SGM populations and to provide recommendations for screening and prevention of HPV-related cancers in SGM populations.

MATERIALS AND METHODS

An expert committee convened by the American Society for Colposcopy and Cervical Pathology performed a narrative review of the literature through February 2023. A comprehensive MEDLINE database search was performed for relevant studies. The literature review was divided into categories by organ/topic and by SGM population. Given the variability in available data for several of the categories, recommendations were made based on national guidelines where appropriate or expert opinion where there were less data to support risk-based guidelines.

RESULTS

Definitions and terminology relevant to SGM populations are presented. The authors advocate the adoption of sexual orientation gender identity data collection and an organ-based screening approach, which is possible with knowledge of patient anatomy, sexual behaviors, and clinical history. This includes screening for cervical cancer per national recommendations, as well as screening for anal, vulvar, vaginal, penile, and oral cancers based on risk factors and shared clinical decision making. The authors recommend consideration of HPV vaccination in all SGM individuals up to age 45 years old who are at risk.

CONCLUSIONS

An organ-based screening approach is part of a global strategy to create an inclusive care environment and mitigate barriers to screening and prevention of HPV-mediated cancers in SGM populations.

Human Papillomavirus Positivity at 3 Anatomical Sites Among Transgender Women in Central Brazil

BACKGROUND

Transgender women (TGW) are susceptible to the acquisition of sexually transmitted infections (STIs), including human papillomavirus (HPV). Nonetheless, the exact data for this population are scarce. We estimated HPV positivity at the anal, genital, and oral sites among TGW and also identified the related characteristics and behaviors that could be risk factors for HPV infection in a sample of TGW in Brazil. Furthermore, we characterized the site-specific HPV genotypes among those who were positive for HPV at these 3 sites.

METHODS

A cross-sectional study was conducted on TGW in Goiânia City (Central-Midwest region), Brazil, between April 2018 and August 2019. Respondent-driven sampling was applied for recruitment. Next, self-collected anal, genital, and oral samples were examined for HPV DNA using polymerase chain reaction (SPF-10 primer). Human papillomavirus genotypes were identified in 12 TGW.

RESULTS

In the TGW included in the study, the anal, genital, and oral HPV positivity values were 77.2% (95% confidence interval [CI], 67.3%-84.6%), 33.5% (95% CI, 26.1%-48.9%), and 10.9% (95% CI, 5.8%-17.0%), respectively. In addition, the majority of 12 participants who tested for HPV had multiple genotypes. HPV-52 was the most prevalent genotype identified at the anal (66.6%) and genital (40.0%) sites, whereas HPV-62 and HPV-66 were the most common at the oral site (25.0%).

CONCLUSIONS

A high HPV positivity was observed among TGW. Therefore, additional epidemiological studies on HPV genotypes should generate health intervention information, including the prevention, diagnosis, and treatment of sexually transmitted infections.

Neovaginal Human Papillomavirus Prevalence in Transfeminine Individuals: A Systematic Review

OBJECTIVE

To assess the prevalence of high-risk human papillomavirus (hrHPV) and human papillomavirus (HPV)-associated abnormalities in the neovaginas of postvaginoplasty transfeminine patients to inform potential HPV-screening guidelines for this patient population.

DATA SOURCES

MEDLINE, ClinicalTrials.gov , the Cochrane Library, Scopus, and Google Scholar were searched through September 30, 2022.

METHODS OF STUDY SELECTION

The population included transfeminine individuals who had undergone vaginoplasty with an outcome of subsequent positive HPV diagnosis or HPV-related lesions. Randomized clinical trials, cohort studies, cross-sectional studies, and case reports available in English were included in the analysis. Identified articles were doubly screened, and accepted articles were doubly extracted.

TABULATION, INTEGRATION, AND RESULTS

Of 59 abstracts identified, 30 were screened for eligibility, of which 15 met the criteria for review. Included studies were assessed for vaginoplasty procedure type, time elapsed between vaginoplasty and HPV testing, HPV type, location and manner of sample collection, method of HPV diagnosis, and classification and location of HPV-associated neovaginal lesions. Studies were assigned a grade of evidence of very low, low, moderate, or high based on study design, precision, directness, and risk of bias. Prevalence of neovaginal hrHPV ranged from 8.3% to 20% in identified studies, and per-study prevalence of HPV-related neovaginal abnormalities ranged from 0% to 8.3% in patients.

CONCLUSION

The current body of research demonstrates that, after vaginoplasty, transfeminine individuals may develop neovaginal HPV infection with associated cytologic abnormalities or grossly apparent lesions. In some included studies, neovaginal HPV-associated lesions were highly advanced before they were identified. A small number of studies assessed neovaginal HPV prevalence in transfeminine individuals, with hrHPV prevalence ranging from 8.3% to 20%. However, broader conclusions about neovaginal HPV prevalence are limited by a lack of high-grade evidence in the existing literature. More rigorous prevalence research is needed to inform preventative care guidelines for transfeminine individuals at risk of developing HPV-related neovaginal complications.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022379977.

Principles and outcomes of gender-affirming vaginoplasty

Vaginoplasty is the most frequently performed gender-affirming genital surgery for gender-diverse people with genital gender incongruence. The procedure is performed to create an aesthetic and functional vulva and vaginal canal that enables receptive intercourse, erogenous clitoral sensation and a downward-directed urine stream. Penile inversion vaginoplasty (PIV) is a single surgical procedure involving anatomical component rearrangement of the penis and scrotum that enables many patients to meet these anatomical goals. Other options include minimal-depth, peritoneal and intestinal vaginoplasty. Patient quality of life has been shown to improve drastically after vaginoplasty, but complication rates have been documented to be as high as 70%. Fortunately, most complications do not alter long-term postoperative clinical outcomes and can be managed without surgical intervention in the acute perioperative phase. However, major complications, such as rectal injury, rectovaginal fistula, and urethral or introital stenosis can substantially affect the patient experience. Innovations in surgical approaches and techniques have demonstrated promising early results for reducing complications and augmenting vaginal depth, but long-term data are scarce.

Cytology and LGBT+ health: establishing inclusive cancer screening programs

There are substantial disparities in cancer screening for sexual minorities and gender non-conforming patients. In additional to patients having trauma due to negative experiences with the healthcare system, disparities may be heightened due to heteronormative and cisnormative design of screening programs and electronic medical record systems. Furthermore, there are morphologic challenges specific to certain specimen types from the LGBT + population, such as anal cytology samples, cervical cytology from transgender men taking testosterone, and neovaginal cytology samples. Men who have sex with men are at increased risk for anal cancer compared with the general population. While early detection of anal dysplasia decreases the risk of invasive carcinoma, screening programs are not widespread. Cervical cancer screening may be psychologically and physically challenging for transgender men and non-binary patients. The use of exogenous testosterone therapy causes atrophic changes in cervical cytology samples which mimic high-grade dysplasia. The rate of unsatisfactory samples are also increased in this population. Although HPV driven cancers have been reported in patients with neovaginas, there are currently no guidelines about appropriate screening for transgender women and intersex patients who have neovaginas. Cytopathologists can optimize the health of LGBT + patients in many ways including advocating for inclusive screening guidelines, validating self-collection for HPV and cytology samples, updating requisition forms to better capture the spectrum of gender expression, and recognizing the morphologic changes in cytology samples due to exogenous hormone use.

Reproductive Organ Pathology of Individuals Undergoing Gender-Affirming Surgery

As gender-affirming surgeries become more routine, it is increasingly important for pathologists to recognize the expected histologic changes seen in various tissues secondary to gender-affirming hormone therapy. For example, exogenous testosterone-related squamous atrophy or transitional cell metaplasia of the cervix may be confused for high-grade squamous intraepithelial lesion. In addition to distinguishing between benign and dysplastic/malignant features, pathologists should be mindful of the phrasing of their reports and aim to use objective, nongendered language.

Nonhormone-Related Histologic Findings in Postsurgical Pathology Specimens From Transgender Persons

OBJECTIVES

The objective of this review is to characterize the literature addressing postprocedural complications in persons undergoing gender-affirming surgeries.

METHODS

A literature search using the OVID MEDLINE and PubMed databases was performed to identify all studies describing histologic findings in surgical pathology specimens from transgender persons from 1946 to April 2021. The studies describing postsurgical complications were categorized based on anatomic site, type of complication, study design, publication region, and date.

RESULTS

Thirty-nine studies describing postsurgical complications in transgender women were identified. The most common sites of postprocedural pathology included the breasts and neovagina, with additional studies including buttocks and thighs, cutaneous sites, and the pulmonary system. Most of the literature comprised case reports, followed by case series and comparative studies. The search did not identify any studies of complications secondary to masculinizing surgeries.

CONCLUSIONS

This body of literature is small but growing. Most studies are case reports. There are significant gaps in the literature. The literature in this area is not yet mature enough to support a meta-analysis.

Anatomical and sexual health considerations among transfeminine individuals who have undergone vaginoplasty: A review

As acceptance of transgender and gender diverse individuals continues to increase, gender-affirming surgery, a cornerstone in the management of gender dysphoria, is becoming more readily available. HIV and sexually transmitted infections (STIs) disproportionately affect these populations, but there are limited epidemiologic and management data on STIs in people who have undergone gender-affirming genital surgery such as vaginoplasty. This review will provide clinicians with anatomical details about the various vaginoplasty procedures currently being performed, complications associated with these procedures, and an overview of the current literature describing HIV/STI epidemiology among transfeminine individuals who have undergone vaginoplasty.

Neovaginal and Anal High-Risk Human Papillomavirus DNA Among Thai Transgender Women in Gender Health Clinics

BACKGROUND

Although human papillomavirus (HPV)-related lesions in the neovagina of transgender women have been well documented, information on high-risk HPV (hrHPV) in the neovagina has been very limited. The objective of this study was to determine hrHPV DNA detection rate in the neovagina of transgender women.

METHODS

Neovaginal and anal swab were collected in liquid-based cytology fluid from transgender women visiting Gender Health Clinic and Tangerine Community Health Clinic in Bangkok, Thailand. Samples were processed for hrHPV DNA (reported as subtypes 16 and 18 or the pooled result of subtypes 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 66) by automated real-time polymerase chain reaction and for neovaginal cytology according to the Bethesda system. Demographic data and sexual history were obtained, and physical examination was conducted. HIV status was obtained from existing medical records.

RESULTS

Samples were collected from 57 transgender women (mean age, 30.4 years [interquartile range, 8 years]). From 35 of 57 valid neovaginal samples, 8 (20%) tested positive for hrHPV DNA. From 30 of 57 valid anal samples, 6 (19.4%) tested positive for hrHPV DNA. HIV status was known for 52 transgender women, 1 of which were HIV infected; neovaginal hrHPV was invalid in that patient.

CONCLUSIONS

One of 5 transgender women visiting sexual health clinics in Bangkok was found to have hrHPV DNA in neovaginal and anal compartments. Studies are needed to look at incidence and persistence of hrHPV infection to inform anogenital precancerous and cancerous screening programs for transgender women.

"When the pain is so acute or if I think that I'm going to die": Health care seeking behaviors and experiences of transgender and gender diverse people in an urban area

Introduction

Approximately 1.4 million transgender and gender diverse (TGD) adults in the United States have unique health and health care needs, including anatomy-driven cancer screening. This study explored the general healthcare experiences of TGD people in the Washington, DC area, and cancer screening experiences in particular.

Methods

Twenty-one TGD people were recruited through word of mouth and Lesbian Gay Bisexual Transgender Queer (LGBTQ)-specific community events. Participant interviews were conducted and recorded via WebEx (n = 20; one interview failed to record). Interviews were transcribed using Rev.com. Two coders conducted line-by-line coding for emergent themes in NVivo 12, developed a codebook by consensus, and refined the codebook throughout the coding process. Member checking was conducted to ensure credibility of findings.

Results

Three major themes served as parent nodes: health-care seeking behaviors, quality care, and TGD-specific health care experiences. Within these parent nodes there were 14 child nodes and 4 grand-child nodes. Subthemes for health care seeking behaviors included coverage and costs of care, convenience, trust/mistrust of provider, and provider recommendations for screening. Subthemes for quality of care included professionalism, clinical competence in transgender care, care coordination, provider communication, and patient self-advocacy. Overall, transgender men were less satisfied with care than transgender women.

Conclusions

Results suggest a need for improved provider communication skills, including clear explanations of procedures and recommendations for appropriate screenings to TGD patients. Results also suggest a need for improved clinical knowledge and cultural competency. Respondents also wanted better care coordination and insurance navigation. Overall, these findings can inform health care improvements for TGD people.

A Mayer-Rokitansky-Kuster-Hauser patient with leiomyoma and dysplasia of neovagina: a case report

Background

Most patients with congenital uterus and vaginal aplasia (i.e., Mayer–Rokitansky–Kuster–Hauser [MRKH] syndrome) have rudimentary pelvic uterine structures that contain smooth muscle. Although leiomyomas and dysplasia of vaginal mucosa are relatively common in the general population, they are rare in MRKH patients. Data on the vulnerability of neovaginas to HPV-associated dysplasia are limited.

Case presentation

A rare case of an MRKH patient with two gynaecological conditions detected during long-term gynaecological follow-up is presented. At the age of 21, the patient was treated for HPV-associated neovaginal dysplasia. At the age of 47, a pelvic leiomyoma was detected with transvaginal ultrasound and confirmed with magnetic resonance imaging.

Conclusion

A Pap smear or human papillomavirus testing is indicated in sexually active MRKH women. Uterine rudiments contain smooth muscle, which facilitates the development of oestrogen-dependent diseases, such as leiomyomas and adenomyosis. Although magnetic resonance imaging is recommended in cases of a pelvic mass, easily attainable and cost-efficient transvaginal ultrasound offers high diagnostic accuracy in patients with a surgically created neovagina and is suitable for the patients’ follow-up. Guidelines for the gynaecological follow-up of MRKH patients are warranted.

Condylomata acuminata of the neovagina in a transgender woman treated with trichloroacetic acid

Condylomata acuminata (genital warts) have been identified in transgender women after gender affirmation surgery. We describe a case of a 57-year-old transgender woman with biopsy-proven neovaginal condylomata acuminata following gender-affirmation vaginoplasty using the penile skin inversion technique. The patient was successfully treated with trichloroacetic acid. To our knowledge, this is the first case report demonstrating successful treatment of neovaginal condyloma with trichloroacetic acid. We provide a review of the relevant literature and highlight the evidence for the clinical utility of trichloroacetic acid in transgender women with condyloma of the neovagina.

Sigmoid Neovagina: A Case Presentation and Pathological Review of Intestinal Transfer

Intestinal vaginoplasty, first described in 1904, has more recently become a popular mechanism for gender-affirming surgery in the United States. We present the case of a transgender female patient with retained foreign bodies in her neovagina, which required endoscopic therapy, provide a brief review of the literature, and discuss the potential long-term complications that can arise from a neovagina after intestinal transfer. It is important that gastroenterologists have awareness and recognition of these issues, as surgical reconstruction using intestinal segments for transgender patients becomes more common.

Dermatologic Conditions in Transgender Populations

Transgender persons receiving gender-affirming hormone therapy and procedures may face specific skin conditions. Skin diseases in transgender patients often are underdiagnosed and underrecognized despite their important impact on quality of life and mental health. This article discusses pathophysiology, diagnosis, and treatment of common skin diseases in the transgender populations. For transmasculine patients, conditions include acne vulgaris and male pattern hair loss. For transfeminine patients, conditions include hirsutism, pseudofolliculitis barbae, and melasma. Postprocedural keloids and other cutaneous complications are discussed. Unique aspects of skin health in transgender persons should be considered in the context of multidisciplinary gender-affirming care.

Dermatologic Surgical Care for Transgender Individuals

BACKGROUND

Transgender individuals experience common and unique dermatologic concerns from severe acne associated with testosterone therapy in transmen to complications due to illicit silicone injections in transwomen. Currently, 2 survey studies and 4 reviews have addressed the dermatologic care of transgender individuals. However, none of them provide a focus on the dermatologic surgeon.

OBJECTIVE

To assess the dermatologic considerations in transgender individuals and the role of dermatologic surgeon in their care.

METHODS

The PubMed and MEDLINE databases were reviewed in June 2018 using keywords, such as transgender, procedures, hair removal, laser, and hormone therapy.

RESULTS

In total, 48 relevant publications addressing dermatologic care in transgender patients were reviewed. According to the literature, there are several critical dermatologic considerations in transgender patients, including hair growth and removal, acne vulgaris, facial procedures to masculinize and feminize the face, scar removal, and sexually transmitted infections.

CONCLUSION

As dermatologic surgeons have the privilege to improve the health care of transgender patients, they must understand the common and unique concerns of transgender individuals. Given the considerable spectrum of physical goals expressed by transmen and transwomen, individual patient preference must ultimately guide his/her/their dermatologic care.

Medical dermatologic conditions in transgender women

Many previous reviews and studies on transgender dermatology have highlighted the expected dermatologic manifestations of hormone affirmation therapy in transgender patients. Others have highlighted attitudes and practices of both transgender patients and medical professionals taking care of these patients. This review compiles data from other, lesser known aspects of transgender dermatology, including neovaginal concerns, neoplastic concerns (both neovaginal and cutaneous), autoimmune conditions, and the sequelae of injectable substances that have not been approved by the U.S. Food and Drug Administration. This review, like others, will be a stepping-stone and serve as an impetus for future research in transgender dermatology.

HPV-related squamous cell carcinoma in a neovagina after male-to-female gender confirmation surgery

Vaginoplasty by penile and scrotal skin inversion is a well-established technique for male-to-female gender confirmation surgery. In this setting, chronic inflammation and lacerations associated with history of human papillomavirus (HPV) infection may induce a high risk of malignant degeneration in the long term. A 78-year-old transgender woman was admitted with genital discomfort and neovaginal discharge. The patient’s history revealed male-to-female gender confirmation surgery with construction of a neovagina by penile and scrotal skin inversion at 33 years of age. Physical examination of the genitalia revealed presence of fecal material, suggestive of recto-neovaginal fistula. A biopsy specimen was positive for well-differentiated HPV-related squamous cell carcinoma. Magnetic resonance imaging (MRI) showed a bulky mass in the posterior wall of the neovagina that infiltrated the urethra, prostatic gland and the anterior rectal wall. Following a multidisciplinary evaluation, we performed a definitive sigmoid colostomy and administered chemotherapy. Long-term follow-up seems advisable in patients after vaginoplasty due to the possibility of delayed development of cancer. Following biopsy, we consider MRI as the modality of choice to identify possible infiltration of the adjacent structures. As data regarding these lesions are scarce and management is complex, a multidisciplinary approach is recommended.

Herpes neolabialis: herpes simplex virus type 1 infection of the neolabia in a transgender woman

A 24-year-old transgender woman consulted our outpatient clinic with a painful, itchy and red left labia. She underwent a penile inversion vaginoplasty 18 months before presentation. At physical examination of the left labia, erythema, edema and herpetic vesicles with ulceration were observed. A vesicle fluid swab was obtained and the presence of herpes simplex virus type 1 (HSV-1) was detected by PCR assay. Treatment consisted of oral valaciclovir (500 mg twice daily) for a total of five days.Topically-applied lidocaine cream (3%) was used for pain management. Treatment gave symptom relief in five days. At physical examination 14 days after symptom onset, there were no signs of active infection. To our knowledge, this is the first case report of HSV-1 infection of the neolabia in a transgender woman.