Prostate Cancer in Transgender Patients: Screening & Treatment Guide

Do transgender women have a prostate?

Yes – transgender women (assigned male at birth) are born with a prostate gland. The prostate is not removed during gender-affirming surgery (vaginoplasty). Only the testicles and scrotal tissue are typically removed; the prostate remains in place.

Therefore, transgender women remain at risk for prostate cancer, BPH, and prostatitis. The prostate does not regress completely with estrogen therapy, although it may shrink.

Prostate cancer risk in transgender women

Prostate cancer risk in transgender women is likely lower than in cisgender men due to androgen deprivation from gender-affirming hormone therapy (estrogen + anti-androgens). However, cases have been reported, and the risk is not zero.

• Estrogen therapy suppresses testosterone production (similar to medical castration)
• Anti-androgens (spironolactone, cyproterone acetate) block androgen receptors
• This creates a state similar to androgen deprivation therapy (ADT) for prostate cancer
• Long-term estrogen use may reduce prostate cancer risk, but data are limited

Reported cases:

• Case reports exist of prostate cancer in transgender women, including metastatic disease
• Most cases occurred in older transgender women who started hormones later in life
• Cancer can still develop despite low testosterone levels (castration-resistant)

Effect of gender-affirming hormone therapy on prostate cancer

Gender-affirming hormone therapy (estrogen + anti-androgens) has complex effects on the prostate:

• Testosterone suppression: Estrogen reduces LH and FSH, lowering testicular testosterone production. Most transgender women achieve castrate levels (<50 ng/dL).
• Prostate atrophy: Prolonged estrogen exposure causes prostatic involution (shrinkage).
• PSA suppression: PSA levels are significantly lower (often <0.5 ng/mL) due to reduced androgen stimulation.
• Cancer risk reduction: Likely reduces risk, but does not eliminate it (castration-resistant prostate cancer can still occur).

Screening recommendations

There are no formal guidelines specifically for prostate cancer screening in transgender women. The following approach is recommended based on expert opinion:

• Baseline PSA: Obtain at age 45-50 (or earlier if high-risk family history)
• Screening frequency: Every 2-5 years depending on PSA level (similar to cisgender men)
• High-risk patients: Family history of prostate, breast, ovarian, or pancreatic cancer – start at age 40
• Shared decision-making: Discuss benefits and harms with patient

Special considerations:

• PSA thresholds should be lower (see below)
• Digital rectal exam (DRE) may be difficult or declined by the patient – consider alternative (MRI)
• If patient has had vaginoplasty, the prostate is palpable through the neovagina (anterior wall)

PSA interpretation – lower normal ranges

Due to estrogen-induced androgen suppression, PSA levels in transgender women are much lower than in cisgender men.

• Typical PSA range: <0.5 ng/mL (often <0.1 ng/mL)
• Abnormal threshold: Any PSA >1.0 ng/mL is concerning and warrants evaluation
• PSA velocity: A rising PSA (even from 0.1 to 0.5 ng/mL) should be investigated
• No established age-specific ranges – use clinical judgment

Example:

• A transgender woman with baseline PSA 0.2 ng/mL who rises to 0.8 ng/mL in 1 year – this is a significant increase and requires evaluation (MRI, possibly biopsy).

Diagnosis and treatment considerations

Diagnosis:

• MRI of the prostate is feasible (transgender women can have MRI without issues)
• Prostate biopsy can be performed via transperineal or transrectal approach
• Biopsy may be more challenging due to altered anatomy (vaginoplasty) – transperineal is often preferred

Treatment:

• Surgery (radical prostatectomy): Technically possible; may be more complex due to prior pelvic surgery
• Radiation therapy: Standard external beam or brachytherapy; consider dose to neovagina
• Hormone therapy: Most transgender women are already on estrogen (which is anti-androgenic). Additional ADT (LHRH agonists) may be used.
• Chemotherapy: Same as for cisgender men

Special considerations:

• Gender-affirming hormone therapy is NOT contraindicated in prostate cancer
• Estrogen may be continued (it has anti-androgenic effects)
• Discuss fertility preservation (sperm banking) before treatment if relevant

Transgender men (female-to-male) – minimal risk

Transgender men (assigned female at birth) are not born with a prostate gland. They have Skene's glands (paraurethral glands), which are homologous to the prostate but are not the same organ.

• Prostate cancer risk: Extremely low (case reports exist of adenocarcinoma arising from Skene's glands)
• Testosterone therapy: Does not create a prostate gland
• Screening: Not recommended unless patient has a known prostate (e.g., intersex condition)

Interactive FAQ – Prostate cancer in transgender patients

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Disclaimer: This information is for educational purposes and intended for clinicians. Prostate cancer screening in transgender patients should be individualised. Consult a urologist at Vivekananda Hospital for personalised care.