Uterus
Nontumor
Female to male transgender histology

Editorial Board Member: Jennifer Bennett, M.D.
Editor-in-Chief: Debra Zynger, M.D.
Mahmoud A. Khalifa, M.D., Ph.D.

Topic Completed: 20 February 2020

Minor changes: 15 March 2020

Copyright: 2020, PathologyOutlines.com, Inc.

PubMed search: Female to male transgender [title]

Mahmoud A. Khalifa, M.D., Ph.D.
Page views in 2020 to date: 370
Cite this page: Khalifa MA. Female to male transgender histology. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/uterusfmtransgenderhistologic.html. Accessed August 7th, 2020.
Definition / general
  • Hysterectomy is part of the sex reassignment surgery in female to male transgender individuals
  • Surgery is typically performed following long periods of preoperative androgen administration
Essential features
ICD coding
  • ICD-10: Z87.890 - personal history of sex reassignment
  • ICD-10: N85.9 - noninflammatory disorder of uterus, unspecified
  • ICD-10: N83.0 - follicular cyst of ovary
Epidemiology
  • Any age, typically 20 - 45
Sites
  • Uterus, cervix, ovary
Pathophysiology
  • Long term androgenic medication administration
  • Androgen receptor (AR) is present in endometrial cells and, when activated, regulates genes involved in cytoskeletal organization and cell progression (Reprod Sci 2014;21:372)
  • Ectocervical transitional cell metaplasia has been described in postmenopausal uteri (Int J Gynecol Pathol 1997;16:89)
  • Abnormally high androgen levels have been known to suppress normal follicular development (Hormones (Athens) 2015;14:190)
Etiology
  • Histopathologic alterations seen in female to male transgender uteri are attributed to long term preoperative androgenic medication administration
Diagnosis
  • Diagnosis is typically evident based on the information received from gynecologist (e.g. gender dysphoria)
Case reports
Gross description
  • Typically unremarkable
Microscopic (histologic) description
Microscopic (histologic) images

Contributed by Mahmoud A. Khalifa, M.D., Ph.D.

Plump stromal cells and gland paucity

Ectocervical transitional cell metaplasia

High follicular density and cystic follicles

Negative stains
  • p16 in cervix
Sample pathology report
  • Uterus, fallopian tubes and ovaries, hysterectomy with bilateral salpingo-oophorectomy:
    • Inactive / atrophic endometrium with areas of decidua-like change and gland paucity
    • Myometrium with no significant histologic abnormality
    • Cervix with transitional cell metaplasia of ectocervix
    • Ovaries with cystic follicles and follicular density higher than expected for the patient's age
Differential diagnosis
  • High grade squamous intraepithelial lesion (HSIL)
    • Loss of polarity, cytologic atypia and mitotic figures
    • Immature cells with high N/C ratio, irregular nuclear contour and coarse chromatin
    • Superficial cells may show koilocytotic atypia and viral cytopathic changes
    • p16 shows strong and diffuse nuclear staining
Board review style question #1

    In a hysterectomy from a 27 year old individual with gender dysphoria, the cervical section exhibited the area depicted in the photomicrograph shown above. Which of the following is true?

  1. Lack of epithelial maturation is consistent with a high grade squamous intraepithelial lesion
  2. Occasional nuclear grooves and the presence of umbrella-like cells are interpreted as transitional cell metaplasia
  3. Occasional perinuclear halos consistent with human papillomavirus infection
  4. p16 immunohistochemistry will not be of value since it is not reliable in low grade squamous intraepithelial lesions
  5. Plump nuclei and prominent nucleoli suggest reactive inflammatory atypia and regeneration
Board review answer #1
B. Occasional nuclear grooves and the presence of umbrella-like cells are interpreted as transitional cell metaplasia

Reference: Female to male transgender histologic features

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Board review style question #2
    Which of the following is a known outcome of long term administration of androgen to a young individual with female phenotype?

  1. Serous carcinoma of the uterus
  2. Leiomyomata
  3. Atypical endometrial hyperplasia
  4. Endocervical polyp
  5. Cystic follicles of the ovary
Board review answer #2
E. Cystic follicles of the ovary

Reference: Female to male transgender histologic features

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