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Hormone therapy for transgender adults poses potential CVD risks

Long-term cross-sex hormone therapy for transgender individuals is associated with potential cardiovascular risks, but also offers psychological benefits, according to a review published in Annals of Internal Medicine.

The investigators call for more research to determine the cardiovascular risk factors in gender-affirming care.

“Recent reports estimate that 0.6% of adults in the United States, or approximately 1.4 million persons, identify as transgender,” Carl G. Streed Jr., MD, from Brigham and Women’s Hospital, and colleagues wrote. “Despite gains in rights and media attention, the reality is that transgender persons experience health disparities, and a dearth of research and evidence-based guidelines remains regarding their specific health needs.”

Cross-sex hormone therapy (CSHT) is an essential part of transgender care; however, how it affects CV morbidity and mortality in transgender men and women is unknown, according to Streed and colleagues. To better understand this gap in information and improve primary and specialty care, they reviewed 13 studies that evaluated the effect of cross-sex hormone therapy on transgender individuals.

For all transgender individuals, CSHT improved psychological functioning. However, CSHT, particularly with testosterone, worsened CVD risk factors, including BP elevation, insulin resistance and lipid derangements, but did not increase CV morbidity or morality in transgender men. In addition, some CSHT formulations increased potential thromboembolic risk in transgender women. Compared with high-dose oral ethinyl estradiol formulations, lower-dose transdermal and oral bioidentical estrogen formulations are superior. It is crucial to reduce CV risk factors, such as increased BP, diabetes and tobacco use, for the prevention of CVD in transgender populations, especially older transgender women with higher CV risks, regardless of the age of initiation or duration of CSHT, according to the authors.

“Providers caring for transgender patients should understand that although CSHT is associated with potential risks, providing gender-affirming care has important psychosocial benefits,” Streed and colleagues concluded. “As such, use of CSHT requires continued, shared decision making between the patient and clinician to weigh the risks and benefits.”

“Future research ideally should be based on large prospective cohort studies that include cisgender men and women, transgender men and women receiving CSHT, and transgender men and women not receiving CSHT,” they added. “Such studies should be powered to evaluate differences among various CSHT regimens and should have sufficient follow-up to adequately assess cardiovascular outcomes.” – by Alaina Tedesco

Disclosure: Streed reports receiving funding support from an institutional National Research Service Award, the Ryoichi Sasakawa Fellowship Fund and the Brigham and Women’s Hospital Division of General Internal Medicine and Primary Care. Please see full study for complete list of all other authors’ relevant financial disclosures.