Prevalence of Cervical Cancer Precursor Lesions in Transgender Men: a Systematic Review

Prevalence of Cervical Cancer Precursor Lesions in Transgender Men: a Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Prevalence of Cervical Cancer Precursor Lesions in Transgender Men: a Systematic Review Nicole Bauermann Maffessoni, Luiza Michel Graciano, Ana Carolina Silva Pinheiro, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3437228/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose To assess the prevalence of cervical cancer precursor lesions in transgender men who have undergone screening by Pap smear, with the intent of contributing with data for the formulation of public policies to widen access to this population. Methods observational studies were selected, with no language or year restrictions, which presented Pap smear results in transgender men. Reviews, case reports and qualitative studies were excluded. The PRISMA guidelines were followed. The risk of bias was assessed using the “NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies”. Results Eleven studies met the inclusion criteria. The prevalence of precursor lesions in transgender men was 0.8%, which is in line with the rates expected by the BETHESDA system for women. However, there was a very high rate of unsatisfactory results in this population (10%), compared to what was expected by the BETHESDA system (1%). Conclusion There is no difference between the prevalence of cervical cancer precursor lesions among transgender men and the expected population prevalence. The number of unsatisfactory tests is high, probably due to the use of testosterone by this population, which makes difficult to collect the material. Studies on transgender men are limited and heterogeneous, and mostly American, limiting the quality of evidence. We suggest that cervical cancer screening policies include, in the exams, information about transgender status and the use of testosterone so that we can reflect on the real health situation of trans men in the context of prevention. Transgender Men Cervical cancer Cervical screening Papanicolaou test Screening Figures Figure 1 INTRODUCTION Transgender men are people born with female reproductive structure but who identify themselves as male individuals. The majority don't have the reassignment surgery and still have female reproductive organs, being exposed to the same risks as women to gynecological cancer, especially cervical cancer [ 1 ]. Therefore, transgender men should follow the same prevention and screening guidelines as women. Nevertheless, adherence to cervical cancer screening in the transgender population is lower than the women's adherence [ 2 , 3 ]. Among the factors reported to that are: dysphoria [ 3 , 4 ], discrimination [ 3 – 6 ], clinics and gynecological offices focused on the female public, low understanding about the health of the transgender population by professionals [ 4 ] and negative experiences at the health service [ 7 ]. It is known that 95–99% of cervical cancer is directly related to Human Papillomavirus (HPV) infection and it is strongly preventable through precancerous lesions diagnosis by screening tests [ 8 ]. However, there is little information about the prevalence of cervical lesions on transgender men. The lack of studies on this population makes it difficult to understand the specific health needs of transgender men, which is crucial for full health access. The aim of this systematic review is to assess the prevalence of precursor lesions of cervical cancer in transgender men who underwent screening by cervical-vaginal smear or Pap smear, to contribute with data to formulate public policies for widen the access to health services to this population. METHODS This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) guidelines [ 9 ]. Inclusion and exclusion criteria Observational studies such as cohort, cross-sectional or case-control, which present Pap test results in a sample of transgender men, were included in this review without language or year restriction. Reviews, case reports and qualitative studies were excluded. Search strategy A wide research strategy was conducted in PubMed and BVS databases to identify all available relevant records. Other studies found in references of studies that were not identified by searching the databases were searched manually for additional records. The search strategy is presented in Table 1 . Table 1 Search strategy Concepts Search terms MeSh 1. Population : Transgender men with cervix “Transgender men” OR “transgender man” OR “female-to-male” OR “trans men” OR “FTM” OR “transmasculine” OR “trans masculine” OR “transgender” Transgender, transgender persons 2. Outcome : Cervical cancer screening through Pap smear “Cervical cancer” OR “Pap test” OR “Pap smear” OR “HPV” Uterine cervical cancer, Uterine cervical neoplasms, screening, diagnostic procedure, cell screening, screening test Concepts 1 e 2 were combined with boolean operators AND: “1” AND “2”. Data extraction and analysis Two authors independently reviewed the titles and abstracts of the studies found by the search strategy to determine if they seemed relevant to the review. Potentially relevant records were examined independently in their entirety and decisions based on eligibility criteria were made regarding inclusion. Disagreements were resolved by arbitration of the other authors. The data from the studies were extracted manually by all the authors and included: author, year of publication, country, design, sample size, number of Pap smears performed, average age of the participants and the results of the tests (Table 2 ). Risk of bias The risk of bias was evaluated using the measurement instrument “ NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies” [ 10 ], which contains 14 items that assess the methodological quality and risk of bias of cohort and cross-sectional studies. For each question, a point is assigned when the article contemplates the item in its entirety, and higher scores represent a lower risk of bias. The results of the application of this tool to each of the studies are summarized in Table 3 . RESULTS Study inclusion The search in the databases resulted in 336 potentially eligible studies until June 29, 2023. After the duplicates were removed, there were 245 unique records. Of these, 172 were excluded based on the analysis of the title and abstract, mainly because they focused on inappropriate population or outcome. Thus, 73 studies were read, and 62 of these studies were excluded for different reasons. An abstract was considered potentially eligible, but it was not included in the analysis because it was not possible to obtain the full text [ 11 ]. No additional studies were found in the references of the other studies. The results of the research and the selection process were presented in the PRISMA flow diagram (Preferred Reporting items for Systematic Reviews and Meta-Analysis) (Fig. 1 ). Characteristics of the studies Eleven articles met the inclusion criteria in the review (total sample = 759 participants; average = 69 participants per study). Most studies (91%, n = 10) were carried out in the United States, except for a study in the United Kingdom. About 73% (n = 8) of the studies were published in the last five years (2019 or later) and all of them were published in the last decade (2014 or later). The average age of the study participants ranged from 22 years [ 4 ] to 42.5 years old [ 12 ]. The studies showed a sample number that covered between 5 [ 6 ] and 233 [ 1 ] participants, and the number of Pap smears performed ranged between 5 [ 6 ] and 415 [ 1 ]. The data extracted from the studies are summarized in Table 2 . Table 2 Description of studies included in the analysis. Author (year) Country of origin Study design Sample Mean age Pap smears performed Exam results Davis et al., (2021) [ 13 ] USA Retrospective cohort 89 31.3 89 Negative = 84 Positive = 5 Plummer et al., (2021) [ 2 ] USA Retrospective cohort 71 26 77 Negative = 53 Positive = 6 Unsatisfactory = 18 Hsu Lin et al., (2022) [ 7 ] USA Retrospective cohort 61 28 65 Negative = 48 Positive = 7 Unsatisfactory = 10 Williams et al.,(2020) [ 12 ] USA Retrospective cohort 14 42,5 17 Negative = 14 Positive = 2 Unsatisfactory = 1 Moatamed et al., (2022) [ 14 ] USA Retrospective cohort 111 28 122 Negative = 106 Positive = 4 Unsatisfactory = 12 Peitzmeier et al., (2014) [ 1 ] USA Retrospective cohort 233 31 415 Negative = 345 Positive = 25 Unsatisfactory = 45 Stewart et al., (2020) [ 3 ] USA Cross-sectional 55 31 55 Negative = 50 Positive = 5 Goldstein et al., (2020) [ 15 ] USA Cross-sectional 53 32 57 Negative = 52 Positive = 1 Unsatisfactory = 4 Woodland et al., (2018) [ 6 ] USA Cross-sectional 5 33 5 Negative = 5 Positive = 0 Adkins et al., (2018) [ 16 ] USA Retrospective cohort 11 Not specified 24 Negative = 14 Positive = 7 Unsatisfactory = 3 Berner et al., (2021) [ 4 ] United Kingdom Cross-sectional 35 22 35 Negative = 29 Positive = 6 Risk of bias of included studies The total risk of bias score of the studies ranged from 4 to 11 (on a scale ranging from 0 to 14, mean score = 9.18; standard deviation (SD) = 2.28). The most frequently contemplated items were the blinding of the evaluators, the description of the research question and the population, and the consistency of the exposure measures. The least frequently contemplated items were the justification of the sample size, exposure done more than once, and the consistency of the result measures (Table 3 ). Table 3 Quality Assessment: NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies [ 10 ] Question number Author 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Total (n)% Davis et al., (2021) [ 13 ] Y N Y N N Y Y Y Y N Y Y Y Y 10 Plummer et al., (2020) [ 2 ] Y Y Y Y N Y Y Y Y N N Y N Y 10 Hsu Lin et al., (2022) [ 7 ] Y Y Y Y N Y Y Y Y N Y Y N Y 11 Williams et al., (2020) [ 12 ] Y Y Y Y N Y Y Y Y N N Y Y Y 11 Moatamed et al., (2022) [ 14 ] Y Y Y Y N Y Y Y Y N N Y Y Y 11 Peitzmeier et al., (2014) [ 1 ] Y Y Y Y N Y Y Y Y N Y Y N Y 11 Stewart et al., (2020) [ 3 ] Y Y Y Y N N N N Y N N Y Y Y 8 Goldstein et al., (2020) [ 15 ] Y Y Y N N N N Y Y N N Y Y Y 8 Woodland et al., (2018) [ 6 ] N Y N N N N N N Y N N Y Y N 4 Adkins et al., (2018) [ 16 ] Y Y Y Y N Y Y Y Y N Y Y Y N 11 Berner et al., (2021) [ 4 ] Y Y N Y N N N N N N Y Y N Y 6 Y : Yes; N : No Laboratory findings In the 11 studies found, 738 participants underwent the pap smear test, resulting in 961 tests performed. Of these, 68 abnormal results (7%) were reported. In addition, 93 (10%) results were considered unsatisfactory for evaluation (Table 4 ). Seven studies [ 1 , 2 , 7 , 12 , 14 – 16 ] pointed to the presence of unsatisfactory results for evaluation, requiring the repetition of the exam in these individuals. The main reasons described for the unsatisfactory results were inadequate or scarce cellularity [ 1 , 2 , 7 , 14 ], inflammatory cells [ 1 , 2 , 7 ], blood and the use of lubricant in the test [ 1 ], many of these related to the use of testosterone. Types of cellular changes Eight articles [ 1 , 2 , 7 , 12 – 16 ] specified the cellular changes found in the exams. The most reported were atypical squamous cells of undetermined significance, low-grade intraepithelial lesion, high-grade intraepithelial lesion, atypical squamous cells (cannot exclude high-grade squamous intraepithelial lesion) and atypical glandular cells of undetermined significance. In these eight studies, 866 tests were analyzed in total, and the prevalence of cervical cancer precursor lesions was 0.8%. The prevalence of each type of abnormality can be seen in Table 4 . Data on the expected prevalence of lesions from the 3rd edition of the Bethesda System for Cervical Cytology Report were used for comparison [ 17 ]. Other cellular abnormalities frequently described in the studies were: atrophy [ 2 , 7 , 12 , 14 , 16 ], hypoplasia [ 1 , 2 , 14 ], metaplasia [ 2 , 12 , 14 ], inflammatory cells [ 1 , 2 , 16 ] and increase in basal and parabasal cells [ 2 , 7 , 14 , 16 ]. Table 4 Prevalence of abnormal cytological results Abnormal cytological results Records (n) Prevalence (%) Expected prevalence (%)* ASC-US 23 2,65 4–5 ASC-H 3 0,34 < 10 of ASC AGC 1 0,11 0,1 − 0,2 LSIL 21 2,42 2,5 HSIL 4 0,46 0,5 Total = 866 exams + ASC-US : atypical squamous cells of undetermined significance; ASC-H : atypical squamous cells (cannot exclude HSIL); AGC : atypical glandular cells; LSIL : low-grade squamous intraepithelial lesion; HSIL : high-grade squamous intraepithelial lesion. * According to the Bethesda System for Cervical Cytology Reporting [ 17 ] +Total of tests of the eight studies that specify the types of cytological changes. HPV-DNA detection by hybrid capture The hybrid capture HPV-DNA test was used in seven studies [ 2 , 7 , 12 – 16 ] and it was reported as a good alternative after an unsatisfactory pap smear, as it has high sensitivity for the detection of HSIL [ 18 ]. The results of the HPV-DNA test after the Pap smear test are presented in Table 5 . Table 5 HPV-DNA + Pap smear results Author HPV-DNA testing + Pap smear HPV negative results HPV positive results Unsatisfactory results Davis et al., (2021) [ 13 ] 50 46 (45 NILM; 1 HSIL) 4 (2 NILM; 2 LSIL) 0 Plummer et al., (2020) [ 2 ] 27 22 (NILM) 5 (4 NILM; 1 ASC-US) 0 Hsu Lin et al., (2022) [ 7 ] 32 23 (22 NILM; 1 ASC-US) 6 (2 NILM; 2 ASC-US; 2 HSIL) 3 Williams et al., (2020) [ 12 ] 5 4 (3 NILM; 1 ASC-US) 1 (NILM) 0 Moatamed et al., (2022) [ 14 ] 73 55 (51 NILM; 3 ASC-US; 1 LSIL) 10 (8 NILM; 1 ASC-US; 1 ASC-H) 8 Goldstein et al., (2020) [ 15 ] 28 23 (NILM) 5 (4 NILM; 1 LSIL) 0 Adkins et al., (2018) [ 16 ] 12 8 (NILM) 4 (1 NILM; 1 ASC-US; 1 ASC-H; 1 HSIL) 0 NILM : negative for intraepithelial lesion or malignancy; ASC-US : Atypical squamous cells of undetermined significance; ASC-H : atypical squamous cells (cannot exclude HSIL); LSIL : low-grade squamous intraepithelial lesion; HSIL : high-grade squamous intraepithelial lesion. Hormone therapy with testosterone The use of hormone therapy with testosterone (HTT) was reported in ten of the studies analyzed [ 1 – 4 , 7 , 12 – 16 ]. In four of the studies [ 2 , 7 , 12 , 16 ], all participants were on HTT. According to six studies [ 1 , 2 , 7 , 12 , 14 , 16 ], the use of testosterone has a direct relationship with the number of unsatisfactory results for evaluation. One study [ 6 ] did not present participants under the use of hormone therapy and there was no presence of unsatisfactory results. While in studies in which 100% of the participants were under HTT [ 2 , 7 , 12 , 16 ], the rate of unsatisfactory results ranged from 7–27%. According to the BETHESDA system, the rate of unsatisfactory results should be up to 1% [ 17 ]. The number of participants who used testosterone in each study is shown in Table 6 . Table 6 Use of hormone therapy with testosterone in the studies Author Sample On HTT Unsatisfactory results Davis et al. [ 13 ] 89 73 (82%) 0 (0%) Plummer et al. [ 2 ] 71 71 (100%) 18 (25%) Hsu Lin et al. [ 7 ] 61 61 (100%) 10 (16%) Williams et al. [ 12 ] 14 14 (100%) 1 (7%) Moatamed et al. [ 14 ] 111 81 (73%) 12 (10%) Peitzmeier et al. [ 1 ] 233 211 (91%) 45 (19%) Stewart et al. [ 3 ] 55 3 (5%) 0 (0%) Goldstein et al. [ 15 ] 53 50 (95%) 4 (7.5%) Woodland et al. [ 6 ] 5 0 (0%) 0 (0%) Adkins et al. [ 16 ] 11 11 (100%) 3 (27%) Berner et al. [ 4 ] 35 25 (72%) 0 (0%) Exam’s adherence Six studies [ 2 , 3 , 4 , 7 , 13 , 15 ] reported that transgender men are not performing the cervical cancer screening test at the appropriate frequency. The main reasons for lower adherence to the examination were: physical discomfort and anxiety for pelvic examination [ 1 , 2 , 4 , 7 , 13 , 14 ], emotional distress [ 1 – 4 , 7 , 13 ], gender dysphoria [ 3 , 4 , 13 ], discrimination [ 2 – 4 , 6 ] and absence of health insurance [ 6 , 15 ]. In addition to the low adherence to the examination, transgender men showed a low rate of follow-up after an unsatisfactory or abnormal result [ 1 , 2 , 4 , 7 ], decreasing the effectiveness of screening. DISCUSSION This is the first systematic review that assesses the prevalence of precursor lesions of cervical cancer in FTM (female-to-male) patients. We analyzed 11 studies and 961 Pap smears. The precancerous lesions’ prevalence, including HSIL and ASC-H, was approximately 0,8%, which is in the expected rate for women’ screening according to the Bethesda system [ 17 ]. Equally, the rates of cytological abnormalities found are within expected, besides ASC-H, which is slightly increased. However, we observed that the number of unsatisfactory tests in this population is 10 times higher than the United States of America’s rate. This data is concerning, because the follow-up rate to redo the Pap smear is very low, resulting in inefficient screening. Most of the FTM people go through hormonal transition with testosterone, which can make the examination and interpretation of the Pap smear more difficult, because there is cervical atrophy. The frequent findings found in this studied sample were atrophy, metaplasia, hypoplasia, blood, and inflammatory cells [ 1 , 2 , 7 , 12 , 14 , 16 ]. Because of that, the usage of intravaginal estrogen cream 7 days prior to the screening exam is recommended to help ease the patient’s pain and discomfort, in addition to increasing the exam’s effectiveness. However, considering that there are FTM patients that attributes a negative image for their genitals, the estrogenization could also happen orally, as an alternative [ 19 ]. Because most of the studies are from the USA, they followed their country's guideline of performing Pap smears and HPV-DNA tests by hybrid capture [ 15 ]. Analyzing the collected data, HPV positive testes were more present in those cases that had a negative cytology for cellular lesions, followed by ASC-US and HSIL. The FTM population’s low adherence to cervical cancer screening may be justified by several reasons such as physical discomfort and anxiety for the pelvic examination, exam’s discomfort, emotional distress, gender dysphoria and discrimination. It is important to look for alternatives that ensures this population a better health access. That could include turning the gynecological spaces more welcoming and neutral gender or encouraging health professionals to specialize their treatment. Accordingly, information that identifies the transgender condition and the usage of testosterone are extremely relevant to the screening and correct diagnosis since they translate the hormonal level of that individual [ 17 ]. Pap smears are cheap and easy to perform. Besides that, it is a very good screening method to reduce the incidence of cervical cancer. However, the evidence existing around Pap smears in FTM patients is extremely limited because we were unable to find databases that correctly identify this population. The big databases which provide cancer statistics do not specify gender related issues. Therefore, there is no specific data of the transgender population, which makes it difficult to individualize public health policies for this vulnerable group. In the studies analyzed in this review, we also verified low quality and heterogenous data. Within the most compromised items in the analysis, we observed the fragility of the sample calculation, because there is no way to infer that to a populational representation. Besides the scarce literature that exists, most of it is from the United States of America, which limits the evidence to the American population, not reflecting other countries’ situation about cervical cancer screening and the way the health system works in different countries. CONCLUSION There is low to moderate evidence that supports that the prevalence of precancerous lesions in the FTM population is similar to the number expected in cis women population. All the studies analyzed are from developed countries, therefore, there is no prevalence data from underdeveloped nations. Attention must be paid for the number of unsatisfactory results, because it was above what is expected, which can be justified by the testosterone use of the FTM population. The studies in the transgender male population are scarce, heterogenous and mostly from the USA, which limits the extrapolation of the data. We suggest as a public health policy the inclusion of information about being a transgender person and the use of testosterone in the exam sheet information. Declarations Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests: The authors have no relevant financial or non-financial interests to disclose. Author contributions: N.B. Maffessoni and L.M. Graciano conceived the review. N.B. Maffessoni developed the search strategy. N.B. Maffessoni and L.M. Graciano conducted the searches and the screening independently. N.B. Maffessoni, L.M. Graciano, A.C.Pinheiro conducted the data extraction and analysis. N.B. Maffessoni, L.M. Graciano and A.C. Pinheiro written the first manuscript draft. A.V. Roehe and C.G. Bica supervised the study and critically revised the final version. All authors provided critical input for important intellectual content, reviewed, and approved the final version of the manuscript. Data availability: The data that support the findings of this study are available via the URL/DOI cited in reference section, or with the corresponding author under reasonable request. Ethics approval: Not applicable. Acknowledgements We thank Bianca Gomes Panis, from Universidade Federal de Ciências da Saúde de Porto Alegre (RS, Brasil), for collaborating in this review. References Peitzmeier SM, Reisner SL, Harigopal P, Potter J (2014) Female-to-Male Patients Have High Prevalence of Unsatisfactory Paps Compared to Non-Transgender Females: Implications for Cervical Cancer Screening. J Gen Intern Med 29(5):778-84. https://doi.org/10.1007/s11606-013-2753-1 Plummer RM, Kelting S, Madan R, O’Neil M, Dennis K, Fan F (2021) Cervical Papanicolaou tests in the female-to-male transgender population: should the adequacy criteria be revised in this population? An Institutional Experience. J Am Soc Cytopathol. 10(3):255-260. https://doi.org/10.1016/j.jasc.2021.01.004 Stewart T, Lee YA, Damiano EA (2020) Do Transgender and Gender Diverse Individuals Receive Adequate Gynecologic Care? An Analysis of a Rural Academic Center. Transgend Health 5(1):50-58. https://doi.org/10.1089/trgh.2019.0037 Berner AM, Connolly DJ, Pinnell I et al (2021) Attitudes of transgender men and non-binary people to cervical screening: a cross-sectional mixed-methods study in the UK. Br J Gen Pract 71(709):e614-e625. https://doi.org/10.3399/bjgp.2020.0905 Jaffee KD, Shires DA, Stroumsa D (2016) Discrimination and delayed health care among transgender women and men: implications for improving medical education and health care delivery. Med Care. 54(11):1010-1016. https://doi.org/10.1097/mlr.0000000000000583 Woodland MB, Callanan L, Schnatz PF, Jiang X (2018) Gynecologic Screening for Men in an OBGYN Resident Community Outreach Clinic: The Transgender Care Experience. J Low Genit Tract Dis. 22(4):333-335. https://doi.org/10.1097/lgt.0000000000000429 Lin LH, Zhou F, Elishaev E, Khader S, Hernandez A, Marcus A, Adler E (2022) ervicovaginal cytology, HPV testing and vaginal flora in transmasculine persons receiving testosterone. Diagn Cytopathol. 50(11):518-524. https://doi.org/10.1002/dc.25030 World Health Organization (2022) Cervical cancer. WHO website. https://www.who.int/news-room/fact-sheets/detail/cervical-cancer. Accessed 30 July 2023 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372:n71. https://doi.org/10.1136/bmj.n71 NHLBI (2013) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. National Heart, Lung and Blood Institute. https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools . Accessed 21 July 2023 Torous VF (2023) Cervicovaginal Papanicolaou tests in transgender men: Cytomorphologic alterations, interpretation considerations, and clinical implications. Cancer Cytopathol. https://doi.org/10.1002/cncy.22731 Williams MPA, Kukkar V, Stemmer MN, Khurana KK (2020) Cytomorphologic Findings of Cervical Pap Smears From Female-to-Male Transgender Patients on Testosterone Therapy. Cancer Cytopathol. 128(7):491-498. https://doi.org/10.1002/cncy.22259 Davis K, Kwon R, Graham A, White M, Maleki Z, Rodriguez E (2021) Comparison of Cervical Cancer Screen Results on Female-to-Male Transgender Patients With Female Patients. Am J Clin Pathol. 157(4):540-545. https://doi.org/10.1093/ajcp/aqab158 Moatamed NA, Barco AD, Yang SE, Ying Y, Zhang S, Rodriguez EF (2022) Clinical history of female-to-male transgender patients is needed to avoid misinterpretation of cervical Papanicolaou tests. Cytopathology. 34(2):120-129. https://doi.org/10.1111/cyt.13199 Goldstein Z, Martinson T, Ramachandran S, Lindner R, Safer JD (2020) Improved Rates of Cervical Cancer Screening Among Transmasculine Patients Through Self-Collected Swabs for High-Risk Human Papillomavirus DNA Testing. Transgend Health. 5(1):10-17. https://doi.org/10.1089/trgh.2019.0019 Adkins BD, Barlow AB, Jack A, Schultenover SJ, Desouki MM, Coogan AC, Weiss VL (2018) Characteristic findings of cervical Papanicolaou tests from transgender patients on androgen therapy: Challenges in detecting dysplasia. Cytopathology. 29(3):281-287. https://doi.org/10.1111/cyt.12525 Nayar R, Wilbur DC (2015) The Bethesda System for Reporting Cervical Cytology. Springer, United States of America Chen F, Lin LH, Hindi I et al. (2023) HPV co-testing of unsatisfactory papanicolaou tests: implications for follow-up intervals. Am J Clin Pathol 160(2):137-143. https://doi.org/10.1093/ajcp/aqad026 Weyers S, Garland SM, Cruickshank M, Kyrgiou M, Arbyn M (2021) Cervical cancer prevention in transgender men: a review. BJOG 128(5):822-826. https://doi.org/10.1111/1471-0528.16503 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3437228","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":240827290,"identity":"89172297-1803-46d0-b4dd-768fb4099638","order_by":0,"name":"Nicole Bauermann Maffessoni","email":"data:image/png;base64,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","orcid":"","institution":"Universidade Federal de Ciências da Saúde de Porto Alegre","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Nicole","middleName":"Bauermann","lastName":"Maffessoni","suffix":""},{"id":240827291,"identity":"823409db-128f-4858-bc21-e8f0a9c245ec","order_by":1,"name":"Luiza Michel Graciano","email":"","orcid":"","institution":"Universidade Federal de Ciências da Saúde de Porto Alegre","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Luiza","middleName":"Michel","lastName":"Graciano","suffix":""},{"id":240827292,"identity":"366fa32c-2e2c-4522-95e4-6a7c8fc79a98","order_by":2,"name":"Ana Carolina Silva Pinheiro","email":"","orcid":"","institution":"Universidade Federal de Ciências da Saúde de Porto Alegre","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ana","middleName":"Carolina Silva","lastName":"Pinheiro","suffix":""},{"id":240827293,"identity":"e5ae6c61-8872-4cc3-be9f-1120e6ba955f","order_by":3,"name":"Adriana Vial Roehe","email":"","orcid":"","institution":"Universidade Federal de Ciências da Saúde de Porto Alegre","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Adriana","middleName":"Vial","lastName":"Roehe","suffix":""},{"id":240827295,"identity":"04cb5a8c-53b1-49ae-b347-92334572d096","order_by":4,"name":"Claudia Giuliano Bica","email":"","orcid":"","institution":"Universidade Federal de Ciências da Saúde de Porto Alegre","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Claudia","middleName":"Giuliano","lastName":"Bica","suffix":""}],"badges":[],"createdAt":"2023-10-12 11:44:31","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false,"coiExplicitlySet":false},"doi":"10.21203/rs.3.rs-3437228/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3437228/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":44939895,"identity":"13e19ab5-0137-4bba-b93c-17bbe37f206f","added_by":"auto","created_at":"2023-10-19 17:41:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":351884,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA Flow Diagram\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3437228/v1/8ad0b2627384b8154ee9bfda.png"},{"id":64479542,"identity":"00d21271-ebfc-4fa7-9207-c446feec77df","added_by":"auto","created_at":"2024-09-13 16:10:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1140446,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3437228/v1/04195153-c10d-4e35-bed8-d8198206dc57.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePrevalence of Cervical Cancer Precursor Lesions in Transgender Men: a Systematic Review\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eTransgender men are people born with female reproductive structure but who identify themselves as male individuals. The majority don't have the reassignment surgery and still have female reproductive organs, being exposed to the same risks as women to gynecological cancer, especially cervical cancer [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Therefore, transgender men should follow the same prevention and screening guidelines as women. Nevertheless, adherence to cervical cancer screening in the transgender population is lower than the women's adherence [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Among the factors reported to that are: dysphoria [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], discrimination [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], clinics and gynecological offices focused on the female public, low understanding about the health of the transgender population by professionals [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and negative experiences at the health service [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is known that 95\u0026ndash;99% of cervical cancer is directly related to Human Papillomavirus (HPV) infection and it is strongly preventable through precancerous lesions diagnosis by screening tests [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, there is little information about the prevalence of cervical lesions on transgender men. The lack of studies on this population makes it difficult to understand the specific health needs of transgender men, which is crucial for full health access.\u003c/p\u003e \u003cp\u003eThe aim of this systematic review is to assess the prevalence of precursor lesions of cervical cancer in transgender men who underwent screening by cervical-vaginal smear or Pap smear, to contribute with data to formulate public policies for widen the access to health services to this population.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) guidelines [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003eObservational studies such as cohort, cross-sectional or case-control, which present Pap test results in a sample of transgender men, were included in this review without language or year restriction. Reviews, case reports and qualitative studies were excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSearch strategy\u003c/h2\u003e \u003cp\u003eA wide research strategy was conducted in PubMed and BVS databases to identify all available relevant records. Other studies found in references of studies that were not identified by searching the databases were searched manually for additional records. The search strategy is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSearch strategy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eConcepts\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSearch terms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMeSh\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePopulation\u003c/b\u003e: Transgender men with cervix\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Transgender men\u0026rdquo; OR \u0026ldquo;transgender man\u0026rdquo; OR \u0026ldquo;female-to-male\u0026rdquo; OR \u0026ldquo;trans men\u0026rdquo; OR \u0026ldquo;FTM\u0026rdquo; OR \u0026ldquo;transmasculine\u0026rdquo; OR \u0026ldquo;trans masculine\u0026rdquo; OR \u0026ldquo;transgender\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTransgender, transgender persons\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eOutcome\u003c/b\u003e: Cervical cancer screening through Pap smear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Cervical cancer\u0026rdquo; OR \u0026ldquo;Pap test\u0026rdquo; OR \u0026ldquo;Pap smear\u0026rdquo; OR \u0026ldquo;HPV\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUterine cervical cancer, Uterine cervical neoplasms, screening, diagnostic procedure, cell screening, screening test\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eConcepts 1 e 2 were combined with \u003cem\u003eboolean\u003c/em\u003e operators AND: \u0026ldquo;1\u0026rdquo; AND \u0026ldquo;2\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData extraction and analysis\u003c/h2\u003e \u003cp\u003eTwo authors independently reviewed the titles and abstracts of the studies found by the search strategy to determine if they seemed relevant to the review. Potentially relevant records were examined independently in their entirety and decisions based on eligibility criteria were made regarding inclusion. Disagreements were resolved by arbitration of the other authors. The data from the studies were extracted manually by all the authors and included: author, year of publication, country, design, sample size, number of Pap smears performed, average age of the participants and the results of the tests (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eRisk of bias\u003c/h2\u003e \u003cp\u003eThe risk of bias was evaluated using the measurement instrument \u0026ldquo;\u003cem\u003eNIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies\u0026rdquo;\u003c/em\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], which contains 14 items that assess the methodological quality and risk of bias of cohort and cross-sectional studies. For each question, a point is assigned when the article contemplates the item in its entirety, and higher scores represent a lower risk of bias. The results of the application of this tool to each of the studies are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStudy inclusion\u003c/h2\u003e \u003cp\u003eThe search in the databases resulted in 336 potentially eligible studies until June 29, 2023. After the duplicates were removed, there were 245 unique records. Of these, 172 were excluded based on the analysis of the title and abstract, mainly because they focused on inappropriate population or outcome. Thus, 73 studies were read, and 62 of these studies were excluded for different reasons. An abstract was considered potentially eligible, but it was not included in the analysis because it was not possible to obtain the full text [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. No additional studies were found in the references of the other studies. The results of the research and the selection process were presented in the PRISMA flow diagram (Preferred Reporting items for Systematic Reviews and Meta-Analysis) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of the studies\u003c/h2\u003e \u003cp\u003eEleven articles met the inclusion criteria in the review (total sample\u0026thinsp;=\u0026thinsp;759 participants; average\u0026thinsp;=\u0026thinsp;69 participants per study). Most studies (91%, n\u0026thinsp;=\u0026thinsp;10) were carried out in the United States, except for a study in the United Kingdom. About 73% (n\u0026thinsp;=\u0026thinsp;8) of the studies were published in the last five years (2019 or later) and all of them were published in the last decade (2014 or later). The average age of the study participants ranged from 22 years [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] to 42.5 years old [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The studies showed a sample number that covered between 5 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and 233 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] participants, and the number of Pap smears performed ranged between 5 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and 415 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The data extracted from the studies are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescription of studies included in the analysis.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor (year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCountry of origin\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy design\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean age\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePap smears performed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eExam results\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDavis et al., (2021) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative\u0026thinsp;=\u0026thinsp;84\u003c/p\u003e \u003cp\u003ePositive\u0026thinsp;=\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlummer et al.,\u003c/p\u003e \u003cp\u003e(2021) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative\u0026thinsp;=\u0026thinsp;53\u003c/p\u003e \u003cp\u003ePositive\u0026thinsp;=\u0026thinsp;6 Unsatisfactory\u0026thinsp;=\u0026thinsp;18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHsu Lin et al., (2022) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative\u0026thinsp;=\u0026thinsp;48\u003c/p\u003e \u003cp\u003ePositive\u0026thinsp;=\u0026thinsp;7 Unsatisfactory\u0026thinsp;=\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWilliams et al.,(2020) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative\u0026thinsp;=\u0026thinsp;14\u003c/p\u003e \u003cp\u003ePositive\u0026thinsp;=\u0026thinsp;2 Unsatisfactory\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoatamed et al., (2022) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative\u0026thinsp;=\u0026thinsp;106\u003c/p\u003e \u003cp\u003ePositive\u0026thinsp;=\u0026thinsp;4 Unsatisfactory\u0026thinsp;=\u0026thinsp;12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeitzmeier et al., (2014) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e233\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e415\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative\u0026thinsp;=\u0026thinsp;345\u003c/p\u003e \u003cp\u003ePositive\u0026thinsp;=\u0026thinsp;25\u003c/p\u003e \u003cp\u003eUnsatisfactory\u0026thinsp;=\u0026thinsp;45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStewart et al., (2020) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e \u003cp\u003ePositive\u0026thinsp;=\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGoldstein et al., (2020) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative\u0026thinsp;=\u0026thinsp;52\u003c/p\u003e \u003cp\u003ePositive\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003cp\u003eUnsatisfactory\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWoodland et al., (2018) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative\u0026thinsp;=\u0026thinsp;5\u003c/p\u003e \u003cp\u003ePositive\u0026thinsp;=\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdkins et al., (2018) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative\u0026thinsp;=\u0026thinsp;14\u003c/p\u003e \u003cp\u003ePositive\u0026thinsp;=\u0026thinsp;7 Unsatisfactory\u0026thinsp;=\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBerner et al., (2021) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative\u0026thinsp;=\u0026thinsp;29\u003c/p\u003e \u003cp\u003ePositive\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eRisk of bias of included studies\u003c/h2\u003e \u003cp\u003eThe total risk of bias score of the studies ranged from 4 to 11 (on a scale ranging from 0 to 14, mean score\u0026thinsp;=\u0026thinsp;9.18; standard deviation (SD)\u0026thinsp;=\u0026thinsp;2.28). The most frequently contemplated items were the blinding of the evaluators, the description of the research question and the population, and the consistency of the exposure measures. The least frequently contemplated items were the justification of the sample size, exposure done more than once, and the consistency of the result measures (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuality Assessment: \u003cem\u003eNIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies\u003c/em\u003e [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"16\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"16\" nameend=\"c16\" namest=\"c1\"\u003e \u003cp\u003eQuestion number\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c14\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c15\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c16\"\u003e \u003cp\u003eTotal (n)%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDavis et al., (2021) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlummer et al., (2020) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHsu Lin et al., (2022) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWilliams et al., (2020) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoatamed et al., (2022) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeitzmeier et al., (2014) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStewart et al., (2020) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGoldstein et al., (2020) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWoodland et al., (2018) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdkins et al., (2018) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBerner et al., (2021) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"16\"\u003e\u003cb\u003eY\u003c/b\u003e: Yes; \u003cb\u003eN\u003c/b\u003e: No\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLaboratory findings\u003c/h2\u003e \u003cp\u003eIn the 11 studies found, 738 participants underwent the pap smear test, resulting in 961 tests performed. Of these, 68 abnormal results (7%) were reported. In addition, 93 (10%) results were considered unsatisfactory for evaluation (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Seven studies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] pointed to the presence of unsatisfactory results for evaluation, requiring the repetition of the exam in these individuals. The main reasons described for the unsatisfactory results were inadequate or scarce cellularity [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], inflammatory cells [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], blood and the use of lubricant in the test [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], many of these related to the use of testosterone.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTypes of cellular changes\u003c/h2\u003e \u003cp\u003eEight articles [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13 CR14 CR15\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] specified the cellular changes found in the exams. The most reported were atypical squamous cells of undetermined significance, low-grade intraepithelial lesion, high-grade intraepithelial lesion, atypical squamous cells (cannot exclude high-grade squamous intraepithelial lesion) and atypical glandular cells of undetermined significance. In these eight studies, 866 tests were analyzed in total, and the prevalence of cervical cancer precursor lesions was 0.8%. The prevalence of each type of abnormality can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Data on the expected prevalence of lesions from the 3rd edition of the Bethesda System for Cervical Cytology Report were used for comparison [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOther cellular abnormalities frequently described in the studies were: atrophy [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], hypoplasia [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], metaplasia [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], inflammatory cells [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and increase in basal and parabasal cells [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrevalence of abnormal cytological results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbnormal cytological results\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecords (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrevalence (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExpected prevalence (%)*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASC-US\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASC-H\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0,34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10 of ASC\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAGC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0,11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,1\u0026thinsp;\u0026minus;\u0026thinsp;0,2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLSIL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2,5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHSIL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0,46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal =\u0026nbsp; 866 exams\u003c/b\u003e\u003csup\u003e\u003cb\u003e+\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eASC-US\u003c/b\u003e: atypical squamous cells of undetermined significance; \u003cb\u003eASC-H\u003c/b\u003e: atypical squamous cells (cannot exclude HSIL); \u003cb\u003eAGC\u003c/b\u003e: atypical glandular cells; \u003cb\u003eLSIL\u003c/b\u003e: low-grade squamous intraepithelial lesion; \u003cb\u003eHSIL\u003c/b\u003e: high-grade squamous intraepithelial lesion.\u003c/p\u003e \u003cp\u003e \u003cb\u003e*\u003c/b\u003eAccording to the Bethesda System for Cervical Cytology Reporting [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e+Total of tests of the eight studies that specify the types of cytological changes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eHPV-DNA detection by hybrid capture\u003c/h2\u003e \u003cp\u003eThe hybrid capture HPV-DNA test was used in seven studies [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13 CR14 CR15\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and it was reported as a good alternative after an unsatisfactory pap smear, as it has high sensitivity for the detection of HSIL [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The results of the HPV-DNA test after the Pap smear test are presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHPV-DNA\u0026thinsp;+\u0026thinsp;Pap smear results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHPV-DNA testing\u0026thinsp;+\u0026thinsp;Pap smear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHPV negative results\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHPV positive results\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnsatisfactory results\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDavis et al., (2021) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (45 NILM; 1 HSIL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (2 NILM; 2 LSIL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlummer et al., (2020) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (NILM)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (4 NILM; 1 ASC-US)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHsu Lin et al., (2022) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (22 NILM; 1 ASC-US)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (2 NILM; 2 ASC-US; 2 HSIL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWilliams et al., (2020) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (3 NILM; 1 ASC-US)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (NILM)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoatamed et al., (2022) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (51 NILM; 3 ASC-US; 1 LSIL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (8 NILM; 1 ASC-US; 1 ASC-H)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGoldstein et al., (2020) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (NILM)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (4 NILM; 1 LSIL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdkins et al., (2018) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (NILM)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (1 NILM; 1 ASC-US; 1 ASC-H; 1 HSIL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eNILM\u003c/b\u003e: negative for intraepithelial lesion or malignancy; \u003cb\u003eASC-US\u003c/b\u003e: Atypical squamous cells of undetermined significance; \u003cb\u003eASC-H\u003c/b\u003e: atypical squamous cells (cannot exclude HSIL); \u003cb\u003eLSIL\u003c/b\u003e: low-grade squamous intraepithelial lesion; \u003cb\u003eHSIL\u003c/b\u003e: high-grade squamous intraepithelial lesion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eHormone therapy with testosterone\u003c/h2\u003e \u003cp\u003eThe use of hormone therapy with testosterone (HTT) was reported in ten of the studies analyzed [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13 CR14 CR15\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In four of the studies [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], all participants were on HTT. According to six studies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], the use of testosterone has a direct relationship with the number of unsatisfactory results for evaluation.\u003c/p\u003e \u003cp\u003eOne study [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] did not present participants under the use of hormone therapy and there was no presence of unsatisfactory results. While in studies in which 100% of the participants were under HTT [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], the rate of unsatisfactory results ranged from 7\u0026ndash;27%. According to the BETHESDA system, the rate of unsatisfactory results should be up to 1% [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The number of participants who used testosterone in each study is shown in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUse of hormone therapy with testosterone in the studies\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOn HTT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnsatisfactory results\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDavis et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlummer et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHsu Lin et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (16%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWilliams et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoatamed et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81 (73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (10%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeitzmeier et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e233\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e211 (91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45 (19%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStewart et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGoldstein et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (7.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWoodland et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdkins et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (27%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBerner et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (72%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eExam\u0026rsquo;s adherence\u003c/h2\u003e \u003cp\u003eSix studies [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] reported that transgender men are not performing the cervical cancer screening test at the appropriate frequency. The main reasons for lower adherence to the examination were: physical discomfort and anxiety for pelvic examination [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], emotional distress [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], gender dysphoria [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], discrimination [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and absence of health insurance [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition to the low adherence to the examination, transgender men showed a low rate of follow-up after an unsatisfactory or abnormal result [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], decreasing the effectiveness of screening.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis is the first systematic review that assesses the prevalence of precursor lesions of cervical cancer in FTM (female-to-male) patients. We analyzed 11 studies and 961 Pap smears. The precancerous lesions\u0026rsquo; prevalence, including HSIL and ASC-H, was approximately 0,8%, which is in the expected rate for women\u0026rsquo; screening according to the Bethesda system [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Equally, the rates of cytological abnormalities found are within expected, besides ASC-H, which is slightly increased.\u003c/p\u003e \u003cp\u003eHowever, we observed that the number of unsatisfactory tests in this population is 10 times higher than the United States of America\u0026rsquo;s rate. This data is concerning, because the follow-up rate to redo the Pap smear is very low, resulting in inefficient screening.\u003c/p\u003e \u003cp\u003eMost of the FTM people go through hormonal transition with testosterone, which can make the examination and interpretation of the Pap smear more difficult, because there is cervical atrophy. The frequent findings found in this studied sample were atrophy, metaplasia, hypoplasia, blood, and inflammatory cells [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Because of that, the usage of intravaginal estrogen cream 7 days prior to the screening exam is recommended to help ease the patient\u0026rsquo;s pain and discomfort, in addition to increasing the exam\u0026rsquo;s effectiveness. However, considering that there are FTM patients that attributes a negative image for their genitals, the estrogenization could also happen orally, as an alternative [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBecause most of the studies are from the USA, they followed their country's guideline of performing Pap smears and HPV-DNA tests by hybrid capture [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Analyzing the collected data, HPV positive testes were more present in those cases that had a negative cytology for cellular lesions, followed by ASC-US and HSIL.\u003c/p\u003e \u003cp\u003eThe FTM population\u0026rsquo;s low adherence to cervical cancer screening may be justified by several reasons such as physical discomfort and anxiety for the pelvic examination, exam\u0026rsquo;s discomfort, emotional distress, gender dysphoria and discrimination. It is important to look for alternatives that ensures this population a better health access. That could include turning the gynecological spaces more welcoming and neutral gender or encouraging health professionals to specialize their treatment. Accordingly, information that identifies the transgender condition and the usage of testosterone are extremely relevant to the screening and correct diagnosis since they translate the hormonal level of that individual [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePap smears are cheap and easy to perform. Besides that, it is a very good screening method to reduce the incidence of cervical cancer. However, the evidence existing around Pap smears in FTM patients is extremely limited because we were unable to find databases that correctly identify this population. The big databases which provide cancer statistics do not specify gender related issues. Therefore, there is no specific data of the transgender population, which makes it difficult to individualize public health policies for this vulnerable group.\u003c/p\u003e \u003cp\u003e In the studies analyzed in this review, we also verified low quality and heterogenous data. Within the most compromised items in the analysis, we observed the fragility of the sample calculation, because there is no way to infer that to a populational representation.\u003c/p\u003e \u003cp\u003eBesides the scarce literature that exists, most of it is from the United States of America, which limits the evidence to the American population, not reflecting other countries\u0026rsquo; situation about cervical cancer screening and the way the health system works in different countries.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThere is low to moderate evidence that supports that the prevalence of precancerous lesions in the FTM population is similar to the number expected in cis women population. All the studies analyzed are from developed countries, therefore, there is no prevalence data from underdeveloped nations. Attention must be paid for the number of unsatisfactory results, because it was above what is expected, which can be justified by the testosterone use of the FTM population. The studies in the transgender male population are scarce, heterogenous and mostly from the USA, which limits the extrapolation of the data. We suggest as a public health policy the inclusion of information about being a transgender person and the use of testosterone in the exam sheet information.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u0026nbsp;\u003c/strong\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e N.B. Maffessoni and L.M. Graciano conceived the review. N.B. Maffessoni developed the search strategy. N.B. Maffessoni and L.M. Graciano conducted the searches and the screening independently. N.B. Maffessoni, L.M. Graciano, A.C.Pinheiro conducted the data extraction and analysis. N.B. Maffessoni, L.M. Graciano and A.C. Pinheiro written the first manuscript draft. \u0026nbsp; A.V. Roehe and C.G. Bica supervised the study and critically revised the final version. All authors provided critical input for important intellectual content, reviewed, and approved the final version of the manuscript.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e The data that support the findings of this study are available via the URL/DOI cited in reference section, or with the corresponding author under reasonable request.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e We thank Bianca Gomes Panis, from Universidade Federal de Ci\u0026ecirc;ncias da Sa\u0026uacute;de de Porto Alegre (RS, Brasil), for collaborating in this review.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePeitzmeier SM, Reisner SL, Harigopal P, Potter J (2014) Female-to-Male Patients Have High Prevalence of Unsatisfactory Paps Compared to Non-Transgender Females: Implications for Cervical Cancer Screening. J Gen Intern Med 29(5):778-84. https://doi.org/10.1007/s11606-013-2753-1\u003c/li\u003e\n\u003cli\u003ePlummer RM, Kelting S, Madan R, O\u0026rsquo;Neil M, Dennis K, Fan F (2021) Cervical Papanicolaou tests in the female-to-male transgender population: should the adequacy criteria be revised in this population? An Institutional Experience. J Am Soc Cytopathol. 10(3):255-260. https://doi.org/10.1016/j.jasc.2021.01.004\u003c/li\u003e\n\u003cli\u003eStewart T, Lee YA, Damiano EA (2020) Do Transgender and Gender Diverse Individuals Receive Adequate Gynecologic Care? An Analysis of a Rural Academic Center. Transgend Health 5(1):50-58. https://doi.org/10.1089/trgh.2019.0037\u003c/li\u003e\n\u003cli\u003eBerner AM, Connolly DJ, Pinnell I et al (2021) Attitudes of transgender men and non-binary people to cervical screening: a cross-sectional mixed-methods study in the UK. Br J Gen Pract 71(709):e614-e625. https://doi.org/10.3399/bjgp.2020.0905 \u003c/li\u003e\n\u003cli\u003eJaffee KD, Shires DA, Stroumsa D (2016) Discrimination and delayed health care among transgender women and men: implications for improving medical education and health care delivery. Med Care. 54(11):1010-1016. https://doi.org/10.1097/mlr.0000000000000583 \u003c/li\u003e\n\u003cli\u003eWoodland MB, Callanan L, Schnatz PF, Jiang X (2018) Gynecologic Screening for Men in an OBGYN Resident Community Outreach Clinic: The Transgender Care Experience. J Low Genit Tract Dis. 22(4):333-335. https://doi.org/10.1097/lgt.0000000000000429 \u003c/li\u003e\n\u003cli\u003eLin LH, Zhou F, Elishaev E, Khader S, Hernandez A, Marcus A, Adler E (2022) ervicovaginal cytology, HPV testing and vaginal flora in transmasculine persons receiving testosterone. Diagn Cytopathol. 50(11):518-524. https://doi.org/10.1002/dc.25030\u003c/li\u003e\n\u003cli\u003eWorld Health Organization (2022) Cervical cancer. WHO website. https://www.who.int/news-room/fact-sheets/detail/cervical-cancer. Accessed 30 July 2023\u003c/li\u003e\n\u003cli\u003ePage MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372:n71. https://doi.org/10.1136/bmj.n71 \u003c/li\u003e\n\u003cli\u003eNHLBI (2013) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. National Heart, Lung and Blood Institute. https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools . Accessed 21 July 2023\u003c/li\u003e\n\u003cli\u003eTorous VF (2023) Cervicovaginal Papanicolaou tests in transgender men: Cytomorphologic alterations, interpretation considerations, and clinical implications. Cancer Cytopathol. https://doi.org/10.1002/cncy.22731 \u003c/li\u003e\n\u003cli\u003eWilliams MPA, Kukkar V, Stemmer MN, Khurana KK (2020) Cytomorphologic Findings of Cervical Pap Smears From Female-to-Male Transgender Patients on Testosterone Therapy. Cancer Cytopathol. 128(7):491-498. https://doi.org/10.1002/cncy.22259 \u003c/li\u003e\n\u003cli\u003eDavis K, Kwon R, Graham A, White M, Maleki Z, Rodriguez E (2021) Comparison of Cervical Cancer Screen Results on Female-to-Male Transgender Patients With Female Patients. Am J Clin Pathol. 157(4):540-545. https://doi.org/10.1093/ajcp/aqab158\u003c/li\u003e\n\u003cli\u003eMoatamed NA, Barco AD, Yang SE, Ying Y, Zhang S, Rodriguez EF (2022) Clinical history of female-to-male transgender patients is needed to avoid misinterpretation of cervical Papanicolaou tests. Cytopathology. 34(2):120-129. https://doi.org/10.1111/cyt.13199\u003c/li\u003e\n\u003cli\u003eGoldstein Z, Martinson T, Ramachandran S, Lindner R, Safer JD (2020) Improved Rates of Cervical Cancer Screening Among Transmasculine Patients Through Self-Collected Swabs for High-Risk Human Papillomavirus DNA Testing. Transgend Health. 5(1):10-17. https://doi.org/10.1089/trgh.2019.0019\u003c/li\u003e\n\u003cli\u003eAdkins BD, Barlow AB, Jack A, Schultenover SJ, Desouki MM, Coogan AC, Weiss VL (2018) Characteristic findings of cervical Papanicolaou tests from transgender patients on androgen therapy: Challenges in detecting dysplasia. Cytopathology. 29(3):281-287. https://doi.org/10.1111/cyt.12525\u003c/li\u003e\n\u003cli\u003eNayar R, Wilbur DC (2015) The Bethesda System for Reporting Cervical Cytology. Springer, United States of America \u003c/li\u003e\n\u003cli\u003eChen F, Lin LH, Hindi I et al. (2023) HPV co-testing of unsatisfactory papanicolaou tests: implications for follow-up intervals. Am J Clin Pathol 160(2):137-143. https://doi.org/10.1093/ajcp/aqad026\u003c/li\u003e\n\u003cli\u003eWeyers S, Garland SM, Cruickshank M, Kyrgiou M, Arbyn M (2021) Cervical cancer prevention in transgender men: a review. BJOG 128(5):822-826. https://doi.org/10.1111/1471-0528.16503\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Transgender Men, Cervical cancer, Cervical screening, Papanicolaou test, Screening","lastPublishedDoi":"10.21203/rs.3.rs-3437228/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3437228/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo assess the prevalence of cervical cancer precursor lesions in transgender men who have undergone screening by Pap smear, with the intent of contributing with data for the formulation of public policies to widen access to this population.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eobservational studies were selected, with no language or year restrictions, which presented Pap smear results in transgender men. Reviews, case reports and qualitative studies were excluded. The PRISMA guidelines were followed. The risk of bias was assessed using the \u003cem\u003e\u0026ldquo;NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eEleven studies met the inclusion criteria. The prevalence of precursor lesions in transgender men was 0.8%, which is in line with the rates expected by the BETHESDA system for women. However, there was a very high rate of unsatisfactory results in this population (10%), compared to what was expected by the BETHESDA system (1%).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThere is no difference between the prevalence of cervical cancer precursor lesions among transgender men and the expected population prevalence. The number of unsatisfactory tests is high, probably due to the use of testosterone by this population, which makes difficult to collect the material. Studies on transgender men are limited and heterogeneous, and mostly American, limiting the quality of evidence. We suggest that cervical cancer screening policies include, in the exams, information about transgender status and the use of testosterone so that we can reflect on the real health situation of trans men in the context of prevention.\u003c/p\u003e","manuscriptTitle":"Prevalence of Cervical Cancer Precursor Lesions in Transgender Men: a Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-10-19 17:41:28","doi":"10.21203/rs.3.rs-3437228/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"019fd36d-5870-40dd-9761-23697d2d97a5","owner":[],"postedDate":"October 19th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-13T16:02:37+00:00","versionOfRecord":[],"versionCreatedAt":"2023-10-19 17:41:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3437228","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3437228","identity":"rs-3437228","version":["v1"]},"buildId":"GqpaHPwrfC8PjnIFayRh5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}