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Hormone therapy increases risk for stroke, VTE in transgender women
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Transgender women who received hormone therapy had an increased incidence of venous thromboembolic events and stroke compared with men and women not receiving hormone therapy, according to a study published in Circulation.
Martin den Heijer, MD, PhD, professor of internal medicine at Vrije University in Amsterdam, and colleagues analyzed data from 2,517 transgender women (median age, 30 years) and 1,358 transgender men (median age, 23 years) who were receiving hormone therapy. The hormone therapies included in this study were testosterone for transgender men and estrogen with or without antiandrogens in transgender women.
Transgender women were followed up for a mean of 9.07 years, and transgender men were followed up for a mean of 8.1 years.
Compared with reference women and men, transgender women had a higher adjusted incidence of VTE (standardized incidence ratio [SIR] for women = 5.52; 95% CI, 4.36-6.9; SIR for men = 4.55; 95% CI, 3.59-5.69) and stroke (SIR for women = 2.42; 95% CI, 1.65-3.42; SIR for men = 1.8; 95% CI, 1.23-2.56). The risk for MI was higher in both transgender women (SIR = 2.64; 95% CI, 1.81-3.72) and transgender men (SIR = 3.69; 95% CI, 1.94-6.42) compared with reference women.
Because ethinylestradiol may be the cause for an increased CV risk in transgender women, researchers performed subanalyses that excluded transgender women who started hormone therapy before 2001. SIRs in this population were not lower compared with the ratios of patients in the total population.
“In light of our results, we urge both physicians and transgender individuals to be aware of this increased cardiovascular risk,” Nienke Nota, MD, researcher in the department of endocrinology at Amsterdam University Medical Center, said in a press release. “It may be helpful to reduce risk factors by stopping smoking, exercising, eating a healthy diet and losing weight, if needed, before starting therapy, and clinicians should continue to evaluate patients on an ongoing basis thereafter.” – by Darlene Dobkowski
Disclosures: The authors report no relevant financial disclosures.
Perspective
Back to TopMonica Mukherjee, MD, MPH, FACC, FASE
Despite much progress, there continues to be a paucity of data that characterizes the unique ASCVD risk factors in transgender populations receiving hormone therapy.
Current studies are limited by sample sizes and lack of prospective, longitudinal, long-term data.
In a recent study by den Heijer et al, a retrospective review was performed and transwomen and transmen were found to have higher rates of strokes, VTEs and MI compared with cisgender women and men.
Interestingly, the authors did not factor in the presence of traditional risk factors such as smoking, hypertension, hyperlipidemia, type 2 diabetes or family history when performing this analysis.
An important limitation to this study is the lack of an age- and ASCVD-matched control group.Hormonal therapy has been shown in cisgender women to increase risk for thromboembolic events and MI.
The present study continues to demonstrate that hormonal therapy in transwomen is similar and may have unique additional risk above and beyond traditional ASCVD risk although further prospective studies are needed.
Aggressive management of baseline ASCVD risk should be performed with stringent control of blood pressure, lipid levels, glycemic control and weight, in addition to cessation of smoking.
There are no data currently that demonstrate that antiplatelet therapies or anticoagulation is beneficial for primary prevention of ASCVD or thromboembolic events in transwomen receiving hormone replacement therapy who do not have other indications.
As mentioned above, prospective, longitudinal, long-term data is needed to follow these individuals for risk.
Studies are also needed that compare transwomen to age-matched cisgender groups with similar ASCVD risks at baseline prior to receiving hormone replacement therapy.
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