Cervical gonorrhea in a transgender man post hysterectomy

Introduction

Cisgender men who have sex with cisgender men (MSM) have increased rates of sexually transmitted infections (STIs) and are targeted by the Centers for Disease Control and Prevention (CDC) for more frequent screening. ¹ Limited information is available about STI and HIV risk among transgender persons in general, with even less information related to transgender men.^2,3 Transgender men who have sex with cisgender men have been noted to be at elevated STI and HIV risk similar to cisgender MSM.^1,3,4 A recent presentation of symptomatic gonorrhea in a transgender man highlights several important diagnostic, care, and screening issues.

Case report

A 40-year-old transgender man presented to the Hawaii Department of Health Sexually Transmitted Disease Clinic with a one-day history of green vaginal discharge. He reported a monogamous relationship with a cisgender male partner for over five years. He disclosed sex with a cisgender casual male partner fourteen months earlier. Soon thereafter, he was diagnosed and treated for gonorrhea by his gynecologist and was negative on retest three months post-treatment.

For the past 14 months, he reported mutual monogamy with his steady partner. Sexual repertoire included receptive vaginal and anal intercourse, performing and receiving anilingus, and performing and receiving oral sex. All sexual contacts were without condoms. His last intercourse was two days prior to symptom onset.

Pertinent history included a cesarean delivery, hysterectomy with bilateral salpingo-oophorectomy, and previously noted gonorrhea. He was on testosterone therapy and reported his last Pap smear was prior to his hysterectomy.

Pelvic examination revealed a copious amount of greenish purulent vaginal discharge. Vaginal saline wet-mount preparation showed large numbers of white blood cells (WBCs); 10% potassium hydroxide vaginal wet-mount preparation was negative. Gram-stained swab of the vaginal discharge revealed too-numerous-to-count WBCs with Gram-negative intracellular diplococci (GNID). Limited speculum examination was done due to patient discomfort, copious discharge, and history of total hysterectomy.

Vaginal swabbed specimens were examined for Neisseria gonorrhoeae and Chlamydia trachomatis by nucleic acid amplification tests (NAATs) and plated on Martin-Lewis media. A rectal specimen was tested by NAAT for N. gonorrhoeae and C. trachomatis, and an oropharyngeal specimen was tested for N. gonorrhoeae by NAAT.

Our case-patient was diagnosed as having presumptive gonorrhea based on Gram stain findings and treated with 250 mg ceftriaxone intramuscularly and 1 gm oral azithromycin. His vaginal culture was positive for N. gonorrhoeae. Vaginal and rectal NAATs were positive for N. gonorrhoeae and negative for C. trachomatis; oropharyngeal NAAT was negative for N. gonorrhoeae. He had a nonreactive syphilis serology and negative HIV test. He was advised to notify his partner to seek evaluation, testing, and presumptive treatment; abstain from intercourse for seven days after he and his partner had received treatment and his symptoms resolved; and retest in three months. ¹

Our case-patient returned to clinic three weeks post-treatment and reported resolution of symptoms within two days after treatment. More complete speculum examination was possible. Vaginal examination was unremarkable. The cervix was visualized and Gram-stained endocervical swabbed specimen showed 10–20 WBCs per oil immersion field with no GNID. Endocervical and rectal NAATs were negative for N. gonorrhoeae.

The patient provided written informed consent allowing release of medical records from his obstetrician/gynecologist. She was the same physician who delivered the patient’s child via cesarean section and performed his hysterectomy for gender affirmation purposes. Total hysterectomy was not possible due to uterine adhesions to the bladder wall attributed to scarring from a complicated cesarean delivery. Subtotal hysterectomy and bilateral salpingo-oophorectomy were performed. The patient was lost to follow-up for approximately nine years when he presented for a routine evaluation that included a Pap smear (of which patient was apparently unaware), endocervical N. gonorrhoeae and C. trachomatis NAAT, and syphilis serology. The only abnormal test result reported was the aforementioned positive N. gonorrhoeae NAAT. The patient provided written informed consent for his information to be published.

Discussion

Our patient’s gonorrhea presentation with copious vaginal discharge was unexpected as N. gonorrhoeae is noted to only infect columnar or transitional epithelial cells, ⁵ and he reported a total hysterectomy and denied dysuria. Our client had not been screened for cervical cancer or STIs for several years post hysterectomy and was apparently unaware that he still had a cervix. The Institute of Medicine highlighted the stigma, burdens, and health disparities experienced by transgender persons in their 2011 report to the National Institutes of Health. ⁶ A recently published literature review documented a multitude of obstacles for transgender adults related to healthcare services including discrimination by providers, gender nonaffirming attitudes, and restricted healthcare benefits. ⁷ The Fenway Institute ⁸ and the University of California at San Francisco ⁹ have developed recommendations for healthcare providers serving transgender clients. Recommendations were made to our client for continued cervical cancer screening and at least annual screening for HIV and STIs, including N. gonorrhoeae and C. trachomatis testing at all relevant exposed sites. ¹⁰ Pre-exposure HIV prophylaxis was also discussed.