Chapter 20: Case Studies in Transgender and Gender Diverse Primary Care

INTRODUCTION

This chapter comprises clinical case scenarios based on common clinical presentations encountered in primary care. These cases can be used by individuals for self-study or by groups of learners to foster discussion. The goal of these cases is to highlight key aspects of primary care provision for transgender and gender diverse (TGD) individuals and to offer possible ways to approach the scenarios.

CASE STUDY 1: MANDY

Mandy is a 60-year-old transgender woman who presents for her annual physical. She has been seeing you as her primary care provider for years. She began oral estradiol therapy 15 years ago and switched to transdermal patches 10 years ago. She underwent vaginoplasty and breast augmentation surgery 5 and 7 years ago, respectively. She has a 30-pack-year history of smoking but quit before having the surgeries; she states that she has just started social tobacco smoking when out with friends (approximately 10 cigarettes per week). She drinks alcohol socially. There is no family history of breast cancer or lung cancer. Her father died of prostate cancer at age 55. Mandy has not had a mammogram since she had her breast augmentation surgery, as she is worried about her breast implants “popping” when she gets the mammogram. She is up to date on colon cancer screening with colonoscopy.

Discussion Questions

1. Is Mandy due for breast cancer screening? If so, what modality should be used if she has breast implants?

   It is recommended that transgender women on feminizing hormones start breast cancer screening at age 50 or earlier if they have a family history of breast cancer¹ (see Chapter 18, “Screening for Cancer and Cardiovascular Disease”). A study of 2260 transgender women in the Netherlands found higher rates of breast cancer in this population compared with cisgender men but lower rates compared with cisgender women.¹ Individuals with either silicone or saline breast implants still need mammography for breast cancer screening. Although many women worry about breast implants “popping” during a mammogram due to the compression used, this event happens very rarely. Individuals should notify the mammographer that they have implants so that the appropriate views are obtained.

2. If she had injected silicone into her breasts (also known colloquially as “pumping”), would that change which breast cancer screening modality is appropriate?

   Mammograms are less accurate for breast cancer screening in the presence of injected silicone or other free particulates as they obscure breast tissue. Contrast-enhanced magnetic resonance imaging of the breast is the imaging modality of choice in this situation.⁴

3. Is Mandy eligible for any additional health screenings because of her history of smoking? How would you counsel her on the risks of restarting smoking socially at this time?

   1. Mandy meets the United States Preventive Services Task Force (USPSTF) criteria for lung cancer screening: she is an adult between the ages of 55 and 80 years old with ...