跨性别男性的宫颈癌筛查

主要作者: Katherine T. Hsiao, MD, FACOG

概论

跨性别男性有患宫颈癌的风险。宫颈癌是全球第三大常见癌症[1];其中99%以上是由人乳头瘤病毒(hr-HPV)的几种高风险致癌菌株感染之一引起的。[2]通过骨盆检查获得子宫颈涂片检查可能对跨性别患者具有挑战性。宫颈癌的筛查不充分与跨性别者在医疗保健方面面临的文化敏感性障碍有关。[3]跨性别男性比非跨性别女性更不愿意接受宫颈癌筛查。[4]从未或很少接受宫颈癌筛查的人如果被慢性hr-HPV感染,发展为恶性肿瘤,发病率和死亡率的风险最高。[5]

据报告与非跨性别男性发生性关系的跨性别男性(trans MSM)在与伴侣口交,阴道和肛交期间不持续使用安全套,且患有hr-HPV感染和未检测到疾病进展的风险增加[6,7]。9至26岁之间的HPV疫苗接种可以显著降低宫颈癌,口腔癌和肛门癌的发病率[8-10]。非跨性别男性可以接受HPV疫苗接种,如果医疗机构提供这些服务,74%自我认定为同性恋或双性恋者的非跨性别男性愿意接种疫苗。[11,12]

筛查建议

宫颈癌筛查绝不应成为睾酮治疗的必要条件。跨性别男性的宫颈癌筛查,包括筛查间隔和开始和结束筛查的年龄,遵循美国癌症协会,美国阴道镜检查和宫颈病理学会(ASCCP),美国临床医学会,病理学家,美国预防服务工作组(USPSTF)和世界卫生组织认可的对非跨性别女性的建议(分级:X C S)。[13-15]与非跨性别女性一样,21岁以下的跨性别男性不应该进行子宫颈涂片检查,不管他们开始性生活的年龄有多长。[13]与非跨性别女性相比,跨性别男性的子宫颈涂片检查坏片的可能性要高10倍,这与进行睾酮治疗的时间长度正相关。[16]如果注意到阴道和/或宫颈组织的红斑,则在排除睾酮介导的萎缩性宫颈阴道炎之前,需要评估通常的炎症原因。炎症可能使宫颈组织的细胞学评估模糊并导致结果不理想。此外,这类检查申请还应表明任何睾酮的使用和是否闭经,以方便病理学家可以准确地解释细胞形态。

改善患者体验

促进更具支持性和敏感的环境包括使用文化敏感的语言,在脱衣之前与患者交谈,并仅要求患者从腰部向下更衣。痛苦的宫颈涂片检查经历可能导致患者逃避前来接受筛查和阴道镜检查。[17]一些轶事技术可以减轻患者的疼痛,比如儿科窥镜可以使子宫颈可见,并可以减少检查的不适;然而,重要的是避免使用过短的窥器以使其需要过大的外部压力来使宫颈可见。将臀部移动到检查台的末端并鼓励患者骨盆松弛也可以增加舒适度并改善子宫颈的可见性。如果检查者注意到紧张或焦虑,花时间进行口头放松练习可能会有所帮助。温水可以用于在插入之前润滑狭窄的窥器,以最小化患者的不适和不安而不损害涂片结果;在窥器的外部使用少量的水基润滑剂可以减少患者的不适,同时最大限度地降低样品不符合标准的风险。[18,19]应避免过量的润滑剂;关于过量润滑剂对涂片结果的影响的研究结果相互冲突。一些临床医生发现,通过首先将一根或两根手指放在阴道中并且在要求患者弯曲和放松他们的骨盆底肌肉的同时从后面施加压力来插入窥器会让患者感到更加舒适。指检(非双合诊检查)也可以帮助确定子宫颈的位置并最小化窥器检查期间的操作。对无症状的患者进行标准的双合诊检查可能不会增加临床价值,并可能增加患者的不适。[20]减少不适的其他方法可包括允许患者自己插入窥器或使用镜子观察这个过程,在检查前给予口服苯二氮䓬类药物,或在检查前一周使用阴道雌激素。

初步研究显示,与临床医生获得的样本相比,自行收集的HPV阴道样本同样有价值。这种方法对跨性别男性来说可能更容易接受。[21,22]未来HPV初步筛查对于跨性别男性也可以利用非阴道来源的标本;支持尿液HPV与宫颈HPV一致性的研究代表了一种潜在的非阴道分类方法。

参考文献

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