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Gosiker B, Moutchia J, Nguyen N, Getahun D, Goodman M. Changes in Blood Lipids Following Initiation of Gender Affirming Hormone Therapy: A Systematic Review and Meta-Analysis. J Clin Transl Endocrinol 2024; 36:100349. [PMID: 38737626 PMCID: PMC11087959 DOI: 10.1016/j.jcte.2024.100349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/08/2024] [Accepted: 04/29/2024] [Indexed: 05/14/2024] Open
Abstract
Aim The aim of this study was to conduct a systematic review and meta-analysis of changes in low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), total cholesterol, and triglycerides following initiation of feminizing or masculinizing gender affirming hormone therapy (GAHT). Methods A search of Ovid MEDLINE, Embase, Web of Science, SCOPUS, and CINAHL databases identified potentially relevant articles published from 1990 through 2024. Both observational and randomized trials of adults receiving feminizing or masculinizing GAHT with baseline and follow-up measures were included. Articles were reviewed for eligibility using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines. The risk of bias in each study was quantified using the NHLBI Study Quality Assessment Tool for Before-After (Pre-Post) Studies with No Control Group. Random effects models were used to compute the before-and-after meta-differences in mean values for each parameter along with the I2 statistic to assess heterogeneity of results. Results Thirty-five studies met the criteria for inclusion in the meta-analysis. Masculinizing GAHT was associated with significant changes in serum lipids from baseline up through the 60-month timepoint with meta-difference of means (95% CI) estimates of 26.2mg/dL (23.3,29.0) for LDL-C, 26.1mg/dL (22.8,29.4) for total cholesterol, 30.7mg/dL (6.9,54.6) for triglycerides and -9.4mg/dL (-12.1, -6.7) for HDL-C. Studies evaluating the effects of feminizing GAHT on balance demonstrated no notable changes in HDL-C or triglycerides while the results for LDL-C and total cholesterol were inconsistent. Heterogeneity of results ranged from minimal (I2 = 0%) to substantial (I2 = 90%). Conclusions While the results for transfeminine individuals on GAHT appear somewhat reassuring, transmasculine patients receiving testosterone may benefit from closer monitoring of lipid profiles.
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Affiliation(s)
- Bennett Gosiker
- Kaiser Permanente Bernard J. Tyson School of Medicine, United States
| | - Jude Moutchia
- Penn Medicine, University of Pennsylvania, United States
| | - Nghiem Nguyen
- Kaiser Permanente Bernard J. Tyson School of Medicine, United States
| | - Darios Getahun
- Kaiser Permanente Southern California, Department of Research and Evaluation, Southern California Permanente Medical Group, United States
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, United States
| | - Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Emory University, United States
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2
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Dix C, Moloney M, Tran HA, McFadyen JD. Venous Thromboembolism and Estrogen-Containing Gender-Affirming Hormone Therapy. Thromb Haemost 2024; 124:387-398. [PMID: 37816389 DOI: 10.1055/a-2188-8898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
Gender-affirming therapy involves the use of hormones to develop the physical characteristics of the identified gender and suppressing endogenous sex hormone production. Venous thromboembolism (VTE) is a known risk of exogenous estrogen therapy, and while evidence of VTE risk among transgender women using modern gender-affirming hormone therapy (GAHT) is still emerging, it is thought to affect up to 5% of transgender women. Historically, GAHT was associated with a high risk of VTE; however, modern preparations are less thrombogenic mainly due to significantly lower doses used as well as different preparations. This review presents the available literature regarding the following four topics: (1) risk of VTE among transgender women receiving estradiol GAHT, (2) how the route of administration of estradiol affects the VTE risk, (3) perioperative management of GAHT, (4) VTE risk among adolescents on GAHT. There is a need for large, longitudinal studies of transgender women using GAHT to further characterize VTE risk and how this is affected by factors such as patient age, duration of GAHT use, tobacco use, body mass index, and comorbidities. Future studies in these areas could inform the development of clinical guidelines to improve the care of transgender people.
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Affiliation(s)
- Caroline Dix
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Australia
| | - Mollie Moloney
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
| | - Huyen A Tran
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Australia
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
| | - James D McFadyen
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Australia
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
- Atherothrombosis and Vascular Biology Program, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
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3
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Tienforti D, Pastori D, Barbonetti A. Effects of gender affirming hormone therapy with testosterone on coagulation and hematological parameters in transgender people assigned female at birth: A systematic review and meta-analysis. Thromb Res 2024; 236:170-178. [PMID: 38457996 DOI: 10.1016/j.thromres.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/28/2024] [Accepted: 02/28/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Hormone replacement therapy is associated with an increased thromboembolic risk. The effects of testosterone (T) on coagulation markers in people assigned female at birth (AFAB) under gender affirming hormone therapy (GAHT) are not well described. METHODS Systematic review and meta-analysis on English-language articles retrieved from PubMed, Scopus and Cochrane Library up to April 2023 investigating T therapy in AFAB people. Coagulation parameters included international normalized ratio (INR), fibrinogen, activated partial thromboplastin clotting time (aPTT), plasminogen activator inhibitor-1 (PAI-1); hematological variables included hemoglobin (Hb) and hematocrit (HCT). We also reported the rate of thromboembolic events. Data were combined as mean differences (MD) with a 95 % confidence interval (CI) of pre- vs post-follow-up values, using random-effects models. RESULTS We included 7 studies (6 prospective and 1 retrospective) providing information on 312 subjects (mean age: 23 to 30 years) who underwent GAHT with variable T preparation. T therapy was associated with a significant increase in INR values [MD: 0.02, 95 % confidence interval (CI): 0.01-0.03; p = 0.0001], with negligible heterogeneity (I2 = 4 %). T therapy was associated with increased Hb (MD: 1.48 g/dL, 95%CI: 1.17 to 1.78; I2 = 9 %) and HCT (4.39 %, 95%CI: 3.52 to 5.26; I2 = 23 %) values. No effect on fibrinogen, aPTT and PAI-1 was found. None of the study reported thromboembolic events during the follow-up. CONCLUSION Therapy with T increased blood viscosity in AFAB men. A slight increase in INR values was also found, but the clinical relevance and mechanism(s) of this finding needs to be clarified.
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Affiliation(s)
- Daniele Tienforti
- Andrology Unit, Department of Clinical Medicine, Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy.
| | - Daniele Pastori
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Arcangelo Barbonetti
- Andrology Unit, Department of Clinical Medicine, Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
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Li R. Preoperative hypocoagulative state is an independent risk factor for wound complications and infection in gender-affirming bottom surgeries. J Plast Reconstr Aesthet Surg 2024; 91:413-420. [PMID: 38479123 DOI: 10.1016/j.bjps.2024.02.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 02/06/2024] [Accepted: 02/22/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Bottom gender affirmation surgery (GAS) involves the risks of bleeding and associated complications. Effective preoperative blood management is paramount across surgical disciplines with international normalized ratio (INR)≤1.5 advised prior to certain surgeries. This study aimed to examine the proportion of patients who were hypocoagulative before they underwent bottom GAS and assess the influence of hypocoagulability on their 30-day post-operative outcomes. METHOD A retrospective study on female-to-male (FtM) and male-to-female (MtF) bottom GAS was performed based on American college of surgeons national surgical quality improvement program (ACS-NSQIP) database from 2005 to 2021. Patients with hypocoagulation were identified when PTT> 60 s, PT > 30 s, and/or INR> 2. Multivariable logistic regression was used to compare the 30-day perioperative outcomes between patients with hypocoagulation and controls. RESULTS In this study, 380 patients (182 FtM, 198 MtF) with hypocoagulation and 1176 controls (886 FtM, 310 MtF) were included. Mortality and organ system complications were infrequent in both groups. Patients with hypocoagulation had higher wound complication rates (13.68% vs. 2.64%, aOR 2.858, p < 0.01), especially wound dehiscence (10.00% vs. 0.60%, aOR 4.424, p < 0.01) and organ space infection rates (2.11% vs. 0.26%, aOR 12.77, p < 0.01). Additionally, patients with hypocoagulation had higher sepsis (0.79% vs. 0.09%, aOR 15.508, p = 0.04) and readmission rates (4.74% vs. 2.47%, aOR 1.919, p = 0.03), but lower rates of discharge not to home (7.92% vs. 25.38%, aOR 0.324, p < 0.01). CONCLUSION Preoperative hypocoagulative state is observed in approximately a quarter of the patients undergoing bottom GAS and is an independent risk factor for increased risks of 30-day wound complications and infections. Therefore, meticulous monitoring of preoperative hemostasis and implementing hemostasis control before surgery may be necessary. Thus, it may be advisable to discontinue oral anticoagulants before the surgery.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC 20052, USA.
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van Zijverden LM, Wiepjes CM, van Diemen JJK, Thijs A, den Heijer M. Cardiovascular disease in transgender people: a systematic review and meta-analysis. Eur J Endocrinol 2024; 190:S13-S24. [PMID: 38302717 DOI: 10.1093/ejendo/lvad170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 02/03/2024]
Abstract
OBJECTIVE Hormone therapy in transgender people might be associated with an increased risk of cardiovascular disease (CVD). We aimed to investigate whether the risk of CVD is increased in transgender people compared with people of the same birth sex. DESIGN AND METHODS PubMed, Cochrane, Embase, and Google Scholar were searched until July 2022. Studies evaluating cardiovascular events in transgender women or men were included. Primary outcomes were stroke, myocardial infarction (MI), and venous thromboembolism (VTE). The risk for transgender women versus cisgender men and for transgender men versus cisgender women was analysed through random-effects meta-analysis. RESULTS Twenty-two studies involving 19 893 transgender women, 14 840 transgender men, 371 547 cisgender men, and 434 700 cisgender women were included. The meta-analysis included 10 studies (79% of transgender women and 76% of transgender men). In transgender women, incidence of stroke was 1.8%, which is 1.3 (95% confidence interval [CI], 1.0-1.8) times higher than in cisgender men. Incidence of MI was 1.2%, with a pooled relative risk of 1.0 (95% CI, 0.8-1.2). Venous thromboembolism incidence was 1.6%, which is 2.2 (95% CI, 1.1-4.5) times higher. Stroke occurred in 0.8% of transgender men, which is 1.3 (95% CI, 1.0-1.6) times higher compared with cisgender women. Incidence of MI was 0.6%, with a pooled relative risk of 1.7 (95% CI, 0.8-3.6). For VTE, this was 0.7%, being 1.4 (95% CI, 1.0-2.0) times higher. CONCLUSIONS Transgender people have a 40% higher risk of CVD compared with cisgender people of the same birth sex. This emphasizes the importance of cardiovascular risk management. Future studies should assess the potential influence of socio-economic and lifestyle factors.
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Affiliation(s)
- Lieve Mees van Zijverden
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam,De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
| | - Chantal Maria Wiepjes
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam,De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
| | - Jeske Joanna Katarina van Diemen
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
| | - Abel Thijs
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
| | - Martin den Heijer
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam,De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
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Iwamoto SJ, Rothman MS, T’Sjoen G, Defreyne J. Approach to the Patient: Hormonal Therapy in Transgender Adults With Complex Medical Histories. J Clin Endocrinol Metab 2024; 109:592-602. [PMID: 37683089 PMCID: PMC10795931 DOI: 10.1210/clinem/dgad536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 09/02/2023] [Accepted: 09/06/2023] [Indexed: 09/10/2023]
Abstract
While endocrinologists continue to initiate gender-affirming hormone therapy (GAHT) in healthy transgender and gender diverse (TGD) patients, they may also encounter more TGD patients in their clinics with complex medical histories that influence the patient-provider shared decision-making process for initiating or continuing GAHT. The purpose of this Approach to the Patient article is to describe management considerations in 2 adults with thromboembolic disease and 2 adults with low bone mineral density in the setting of feminizing and masculinizing GAHT.
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Affiliation(s)
- Sean J Iwamoto
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO 80045, USA
- Endocrinology Service, Medicine Service, Rocky Mountain Regional Veterans Affairs Medical Center, Eastern Colorado Health Care System, Aurora, CO 80045, USA
- UCHealth Integrated Transgender Program, University of Colorado Hospital, Aurora, CO 80045, USA
| | - Micol S Rothman
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO 80045, USA
- UCHealth Integrated Transgender Program, University of Colorado Hospital, Aurora, CO 80045, USA
| | - Guy T’Sjoen
- Department of Endocrinology and Center for Sexology, Ghent University Hospital, 9000 Ghent, Belgium
| | - Justine Defreyne
- Department of Endocrinology and Center for Sexology, Ghent University Hospital, 9000 Ghent, Belgium
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Cortez S, Moog D, Lewis C, Williams K, Herrick C, Fields M, Gray T, Guo Z, Nicol G, Baranski T. Effectiveness and Safety of Different Estradiol Regimens in Transgender Women (TREAT Study): Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e53092. [PMID: 38133914 PMCID: PMC10770781 DOI: 10.2196/53092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/02/2023] [Accepted: 11/03/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Current guidelines for gender-affirming hormone therapy (GAHT) for transgender women are mostly based on clinical experience from experts in the field and treatments used on postmenopausal women. While care is currently provided with the best available evidence, there is a critical gap in knowledge about the safest and most effective estradiol routes of administration for GAHT in transgender women; this statement is supported by the World Professional Association for Transgender Health on their Standards of Care for the Health of Transgender and Gender Diverse People, version 8. Furthermore, the reported rates of cardiometabolic adverse events in transgender women highlight the importance of investigating changes in lipoproteins, glucose, and insulin sensitivity, among other markers while receiving GAHT. OBJECTIVE This study aims to evaluate the degree of testosterone suppression achieved at 1, 6, and 12 months in treatment-naive transgender women when randomized to GAHT with estradiol and spironolactone as antiandrogens. As a secondary aim, this study will assess the treatment effect on metabolic and coagulation factors from baseline to 6 and 12 months after initiating GAHT. METHODS This is a prospective pilot, open-label, randomized clinical trial conducted at an adult transgender clinic in a tertiary medical center. The 3 treatment arms include once-daily sublingual 17-β estradiol, twice-daily sublingual 17-β estradiol, and transdermal 17-β estradiol. All participants received spironolactone as an antiandrogen. Transgender women aged 18 to 45 years who are being evaluated for the initiation of GAHT with 17-β estradiol and did not have a history of coagulopathy, cigarette smoking, liver disease, dyslipidemia requiring treatment, or use of gonadotropin-releasing hormone agonist were eligible to enroll. The main outcome is the total testosterone suppression at 1 and 6 months after the initiation of GAHT, and the secondary outcome is to assess treatment effect in a lipid panel; homeostatic model assessment for insulin resistance; coagulation factors II, IX, and XI; Von Willebrand factor; activated protein C resistance; protein C; and protein S at baseline, 6 months, and 12 months after therapy is initiated. RESULTS This study was funded in March 2022, and enrollment concluded in August 2022. It was concluded in July 2023, and currently, the results are being analyzed for publication. CONCLUSIONS The Transgender Estradiol Affirming Therapy (TREAT) study offers a rigorous and reproducible approach to answer important questions regarding GAHT in transgender women, specifically, the most effective 17-β estradiol regimen to suppress testosterone levels to 50 ng/dL, as currently recommended. TRIAL REGISTRATION ClinicalTrials.gov NCT05010707; https://clinicaltrials.gov/study/NCT05010707. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/53092.
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Affiliation(s)
- Samuel Cortez
- Division of Pediatric Endrocinology, Department of Pediatrics, Washington University School of Medicine, St Louis, MO, United States
| | - Dominic Moog
- Washington University School of Medicine, St Louis, MO, United States
| | - Christopher Lewis
- Division of Pediatric Endrocinology, Department of Pediatrics, Washington University School of Medicine, St Louis, MO, United States
| | - Kelley Williams
- Division of Endocrinology, Diabetes, and Lipid Metabolism, Department of Medicine, Washington University School of Medicine, St Louis, MO, United States
| | - Cynthia Herrick
- Division of Endocrinology, Diabetes, and Lipid Metabolism, Department of Medicine, Washington University School of Medicine, St Louis, MO, United States
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO, United States
| | - Melanie Fields
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine, St Louis, MO, United States
- Department of Neurology, Washington University School of Medicine, St Louis, MO, United States
| | - Teddi Gray
- Department of Psychiatry, Washington University School of Medicine, St Louis, MO, United States
| | - Zhaohua Guo
- Department of Psychiatry, Washington University School of Medicine, St Louis, MO, United States
| | - Ginger Nicol
- Department of Psychiatry, Washington University School of Medicine, St Louis, MO, United States
| | - Thomas Baranski
- Division of Endocrinology, Diabetes, and Lipid Metabolism, Department of Medicine, Washington University School of Medicine, St Louis, MO, United States
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8
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Garland K, Mullins E, Bercovitz RS, Rodriguez V, Connors J, Sokkary N. Hemostatic considerations for gender affirming care. Thromb Res 2023; 230:126-132. [PMID: 37717369 DOI: 10.1016/j.thromres.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/24/2023] [Accepted: 09/08/2023] [Indexed: 09/19/2023]
Abstract
Gender dysphoria or gender incongruence is defined as "persons that are not satisfied with their designated gender" [1]. The awareness and evidence-based treatment options available to this population have grown immensely over the last two decades. Protocols now include an Endocrine Society Clinical Practice Guideline [1] as well as the World Professional Association of Transgender Health Standards of Care (WPATH SOC) [2]. Hematologic manifestations, most notably thrombosis, are one of the most recognized adverse reactions to the hormones used for gender-affirming care. Therefore, hematologists are frequently consulted prior to initiation of hormonal therapy to help guide safe treatment. This review will focus on the scientific evidence related to hemostatic considerations for various gender-affirming therapies and serve as a resource to assist in medical decision-making among providers and patients.
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Affiliation(s)
- Kathleen Garland
- Children's Minnesota, Minneapolis, MN 55404, United States of America.
| | - Eric Mullins
- Cincinnati Children's Hospital Medical Center and University of Cincinnati-College of Medicine, Cincinnati, OH 45229, United States of America
| | - Rachel S Bercovitz
- Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States of America
| | - Vilmarie Rodriguez
- Nationwide Children's Hospital, The Ohio State University, Columbus, OH 43205, United States of America
| | - Jean Connors
- Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA 02115, United States of America
| | - Nancy Sokkary
- Children's Healthcare of Atlanta, Atlanta, GA 30308, United States of America
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Bouck EG, Grinsztejn E, Mcnamara M, Stavrou EX, Wolberg AS. Thromboembolic risk with gender-affirming hormone therapy: potential role of global coagulation and fibrinolysis assays. Res Pract Thromb Haemost 2023; 7:102197. [PMID: 37822706 PMCID: PMC10562871 DOI: 10.1016/j.rpth.2023.102197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/14/2023] [Accepted: 07/18/2023] [Indexed: 10/13/2023] Open
Abstract
Gender-affirming hormonal therapies are a critical component of the care of transgender individuals. Transgender people are commonly prescribed estrogen or testosterone to promote male-to-female or female-to-male transitions and to preserve gender-specific characteristics long-term. However, some exogenous hormones, especially certain estrogen preparations, are an established risk factor of thrombosis. As the number of individuals seeking gender-based care is rising, there is an urgent need to identify and characterize the mechanisms underlying hormone-associated thrombosis and incorporate this information into clinical algorithms for diagnosis and management. Herein, we discuss historical evidence on the incidence of thrombosis and changes in plasma composition in transgender and cisgender cohorts. We present 3 case studies to demonstrate knowledge gaps in thrombosis risk stratification and prediction tools. We also present data from in vitro coagulation and fibrinolysis assays and discuss how information from these kinds of assays may be used to help guide the clinical management of transgender individuals.
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Affiliation(s)
- Emma G. Bouck
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Eduarda Grinsztejn
- Department of Medicine, Hematology and Oncology Division, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Megan Mcnamara
- Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Evi X. Stavrou
- Medicine Service, Section of Hematology-Oncology, Louise Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA
- Department of Medicine, Hematology and Oncology Division, CWRU School of Medicine, Cleveland, OH, USA
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
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10
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Pribish AM, Iwamoto SJ. Cardiovascular disease and feminizing gender-affirming hormone therapy: Implications for the provision of safe and lifesaving care. CURRENT OPINION IN PHYSIOLOGY 2023; 33:100650. [PMID: 36968433 PMCID: PMC10035588 DOI: 10.1016/j.cophys.2023.100650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Sex recorded at birth, gender identity, and feminizing gender-affirming hormone therapy (fGAHT) likely contribute to cardiovascular disease (CVD) risk in transgender women. Understanding the interplay of these factors is necessary for the provision of safe, affirming, and lifesaving care. Among transgender women taking fGAHT, data show increases in CVD mortality and rates of myocardial infarction, stroke, and venous thromboembolism compared to reference populations, depending on study design and comparators. However, most studies are observational with a paucity of contextualizing information (e.g., dosing, route of administration, gonadectomy status), which makes it difficult to parse adverse fGAHT effects from confounders and interaction with known CVD risk factors (e.g., obesity, smoking, psychosocial and gender minority stressors). Increased CVD risk in transgender women points toward a need for greater attention to CVD management in this population including cardiology referral when indicated and additional research on the mechanisms and mediators of CVD risk.
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Affiliation(s)
- Abby M. Pribish
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, 12631 East 17 Avenue, B130, Aurora, CO, 80045, USA
| | - Sean J. Iwamoto
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Anschutz Medical Campus, 12801 East 17 Avenue, Mail Stop: 8106, Aurora, CO, 80045, USA
- Endocrinology Service, Medicine Service, Rocky Mountain Regional Veterans Affairs Medical Center, Eastern Colorado Health Care System, 1700 North Wheeling Street, Aurora, CO, 80045, USA
- UCHealth Integrated Transgender Program, 1635 Aurora Court, Anschutz Outpatient Pavilion, 6 Floor (Diabetes and Endocrinology Clinic), Aurora, CO, 80045, USA
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11
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Arrington-Sanders R, Connell NT, Coon D, Dowshen N, Goldman AL, Goldstein Z, Grimstad F, Javier NM, Kim E, Murphy M, Poteat T, Radix A, Schwartz A, St Amand C, Streed CG, Tangpricha V, Toribio M, Goldstein RH. Assessing and Addressing the Risk of Venous Thromboembolism Across the Spectrum of Gender Affirming Care: A Review. Endocr Pract 2023; 29:272-278. [PMID: 36539066 PMCID: PMC10081942 DOI: 10.1016/j.eprac.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/01/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Accumulating evidence demonstrates that gender affirming hormone therapy (GAHT) improves mental health outcomes in transgender persons. Data specific to the risks associated with GAHT for transgender persons continue to emerge, allowing for improvements in understanding, predicting, and mitigating adverse outcomes while informing discussion about desired effects. Of particular concern is the risk of venous thromboembolism (VTE) in the context of both longitudinal GAHT and the perioperative setting. Combining what is known about the risk of VTE in cisgender individuals on hormone therapy (HT) with the evidence for transgender persons receiving HT allows for an informed approach to assess underlying risk and improve care in the transgender community. OBSERVATIONS Hormone formulation, dosing, route, and duration of therapy can impact thromboembolic risk, with transdermal estrogen formulations having the lowest risk. There are no existing risk scores for VTE that consider HT as a possible risk factor. Risk assessment for recurrent VTE and bleeding tendencies using current scores may be helpful when assessing individual risk. Gender affirming surgeries present unique perioperative concerns, and certain procedures include a high likelihood that patients will be on exogenous estrogens at the time of surgery, potentially increasing thromboembolic risk. CONCLUSIONS AND RELEVANCE Withholding GAHT due to potential adverse events may cause negative impacts for individual patients. Providers should be knowledgeable about the management of HT in transgender individuals of all ages, as well as in the perioperative setting, to avoid periods in which transgender individuals are off GAHT. Treatment decisions for both anticoagulation and HT should be individualized and tailored to patients' overall goals and desired outcomes, given that the physical and mental health benefits of gender affirming care may outweigh the risk of VTE.
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Affiliation(s)
- Renata Arrington-Sanders
- Division of Adolescent and Young Adult Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nathan T Connell
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Devin Coon
- Division of Plastic Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Departments of Plastic Surgery and Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nadia Dowshen
- Craig-Dalsimer Division of Adolescent Medicine, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Anna L Goldman
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Zil Goldstein
- Callen-Lorde Community Health Center, New York, NY; City University of New York Graduate School of Public Health & Health Policy, New York, New York
| | - Frances Grimstad
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
| | - Noelle Marie Javier
- Associate Professor, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ellie Kim
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Martina Murphy
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Tonia Poteat
- Associate Professor of Social Medicine, Center for Health Equity Research, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Asa Radix
- Callen-Lorde Community Health Center, New York, New York
| | - Aviva Schwartz
- North American Thrombosis Forum, Brookline, Massachusetts
| | - Colt St Amand
- Department of Psychology, University of Houston, Houston, Texas; Department of Family Medicine, Mayo Clinic, Rochester, Minnesota
| | - Carl G Streed
- Assistant Professor of Medicine, Section of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine Center for Transgender Medicine and Surgery, Boston Medical Center, Boston, Massachusetts
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA and the Atlanta VA Medical Center, Decatur, Georgia
| | - Mabel Toribio
- Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Robert H Goldstein
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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Yu JL, Lane M, Roach GD, Morrison SD. Perioperative venous thromboembolism risk considerations in the gender diverse patient - Should we consider more than just estrogen? Thromb Res 2023; 222:40-42. [PMID: 36565678 DOI: 10.1016/j.thromres.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/04/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Jenny L Yu
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA, United States of America.
| | - Megan Lane
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Gavin D Roach
- Division of Pediatric Hematology-Oncology, Seattle Children's Hospital and University of Washington, Seattle, WA, United States of America
| | - Shane D Morrison
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA, United States of America
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13
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Johnson N, Chabbert-Buffet N. Hormonothérapies de transition chez les personnes transgenres. Med Sci (Paris) 2022; 38:905-912. [DOI: 10.1051/medsci/2022151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Aujourd’hui encore, la prise en charge médicale des personnes transgenres pâtit d’une insuffisance d’offre de soins et de formation des soignants. La mise en œuvre d’une hormonothérapie est souvent souhaitée par les personnes transgenres et il est nécessaire qu’un médecin sache l’instaurer et la suivre tout au long de la transition. Nous abordons dans cette revue le traitement hormonal féminisant (THF) chez les femmes transgenres adultes, et le traitement hormonal masculinisant (THM) chez les hommes transgenres adultes.
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14
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Bunderen CCV, Leentjens J, Middeldorp S. Transgender Medicine and Risk of Venous Thromboembolism. Hamostaseologie 2022; 42:301-307. [PMID: 36323277 DOI: 10.1055/a-1891-8158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
Gender dysphoria refers to psychological distress that results from an incongruence between gender identity and sex assigned at birth. Administration of sex hormones is most often used as a first step to develop and maintain physical characteristics consistent with gender identity. Gender-affirming hormone treatment is considered beneficial for the quality of life and reduction of depression. However, estrogen and androgen-lowering hormone therapies used in transwomen are in particular associated with increased risk of venous thromboembolism. In this review, introduced by a clinical case, we provide an overview of the currently available medical therapies in transgender medicine, and put the associated increased risk of venous thromboembolism into perspective.
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Affiliation(s)
- C C Van Bunderen
- Division of Endocrinology, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Leentjens
- Division of Vascular Medicine, Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - S Middeldorp
- Division of Vascular Medicine, Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, The Netherlands
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Abstract
Objectives As of 2016, 1.4 million people in the United States were identified as transgender. Transgender people face health disparities and may be at high risk for cardiovascular disease (CVD). The objective of this study was to examine the odds of CVD for those who report a transgender identity compared with cisgender. Methods We used logistic regression to examine whether transgender identity was associated with CVD after accounting for factors commonly associated with CVD. Data were obtained from the Behavioral Risk Factor Surveillance Survey for the years 2015 through 2019. Results Of the participants, 93.1% reported no CVD and 6.9% reported CVD. For participants with female sex recorded at birth, those identifying as transgender had 2.66 times higher odds of CVD (95% confidence interval [CI]: 1.60-4.41) than those identifying as cisgender. For participants with male sex recorded at birth, the odds of CVD were not statistically significantly different for transgender identity compared with cisgender identity; however, those who were gender nonconforming had 2.21 times higher odds of CVD (95% CI: 1.04-4.70) compared with those with cisgender identity. Additional significant predictors of CVD were age, race, body mass index, alcohol consumption, exercise, and smoking status. Conclusion Participants who were female sex recorded at birth had statistically significant increased odds of CVD for those reporting transgender identity compared with cisgender identity. However, transgender identity did not change the odds of CVD compared with cisgender identity for participants who were male sex recorded at birth.
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Affiliation(s)
- Isabelle Howerton
- Public Health Program, Brown School, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Jenine K. Harris
- Public Health Program, Brown School, Washington University in St. Louis, St. Louis, Missouri, USA
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Abstract
Transgender and gender diverse (TGD) individuals may undergo a wide range of care during gender transition including mental health counseling, gender-affirming hormonal therapy, and various surgeries. Hormone therapy effectively converts the hormonal milieu into that of the affirmed gender and produces measurable alterations in serum markers for coronary artery disease and other hematologic conditions (eg, erythrocytosis, venous thrombosis). Although illegal in the United States, some transgender women may receive silicone injections for breast and soft tissue augmentation, which can lead to devastating local complications, as well as silicone migration, pulmonary embolism, systemic reactions, and death. Smoking rates are higher among transgender and sexual minority populations, placing them at elevated risk of smoking-related diseases, including lung cancer. Some opportunistic infections may be more common in the TGD populations, attributable to higher rates of coexisting infection with human immunodeficiency virus. Radiologists should be aware that these patients may develop cancer of their natal organs (eg, breast, prostate), especially as some of these tissues are not completely removed during gender-affirming surgery, which may manifest with thoracic involvement by secondary neoplasia. As more TGD patients seek medical care, thoracic radiologists can reasonably expect to interpret imaging performed in this population and should be aware of possible disease processes and potential complications of hormonal and surgical therapies.
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Scheres LJJ, Hylckama Vlieg A, Cannegieter SC. Sex‐specific aspects of venous thromboembolism: What is new and what is next? Res Pract Thromb Haemost 2022; 6:e12722. [PMID: 35619638 PMCID: PMC9127145 DOI: 10.1002/rth2.12722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 04/01/2022] [Accepted: 04/19/2022] [Indexed: 11/08/2022] Open
Abstract
Men seem to have a higher intrinsic risk of venous thromboembolism (VTE) than women, regardless of age. To date, this difference has not been explained. By integrating state‐of‐the‐art research presented at the International Society on Thrombosis and Haemostasis Congress of 2021 with the available literature, we address potential explanations for this intriguing risk difference between men and women. We discuss the role of exogenous and endogenous sex hormones as the most important known sex‐specific determinants of VTE risk. In addition, we highlight clues on the role of sex hormones and VTE risk from clinical scenarios such as pregnancy and the polycystic ovary syndrome. Furthermore, we address new potential sex‐specific risk factors and unanswered research questions, which could provide more insight in the intrinsic risk difference between men and women, such as body height and differences in body fat distribution, leading to dysregulation of metabolism and inflammation.
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Affiliation(s)
- Luuk J. J. Scheres
- Department of Clinical Epidemiology Leiden University Medical Center Leiden The Netherlands
- Department of Internal Medicine & Radboud Institute of Health Sciences (RIHS) Radboud University Medical Center Nijmegen The Netherlands
| | - Astrid Hylckama Vlieg
- Department of Clinical Epidemiology Leiden University Medical Center Leiden The Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical Epidemiology Leiden University Medical Center Leiden The Netherlands
- Department of Internal Medicine Section of Thrombosis and Haemostasis Leiden University Medical Center Leiden The Netherlands
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18
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Schutte MH, Kleemann R, Nota NM, Wiepjes CM, Snabel JM, T’Sjoen G, Thijs A, den Heijer M. The effect of transdermal gender-affirming hormone therapy on markers of inflammation and hemostasis. PLoS One 2022; 17:e0261312. [PMID: 35290388 PMCID: PMC8923509 DOI: 10.1371/journal.pone.0261312] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/30/2021] [Indexed: 11/23/2022] Open
Abstract
Background Cardiovascular risk is increased in transgender persons using gender-affirming hormone therapy. To gain insight into the mechanism by which sex hormones affect cardiovascular risk in transgender persons, we investigated the effect of hormone therapy on markers of inflammation and hemostasis. Methods In this exploratory study, 48 trans women using estradiol patches plus cyproterone acetate (CPA) and 47 trans men using testosterone gel were included. They were between 18 and 50 years old and did not have a history of cardiovascular events. Measurements were performed before and after 3 and 12 months of hormone therapy. Results After 12 months, in trans women, systemic and endothelial inflammatory markers decreased (hs-CRP -66%, (95% CI -76; -53), VCAM-1–12%, (95% CI -16; -8)), while platelet activation markers increased (PF-4 +17%, (95% CI 4; 32), β-thromboglobulin +13%, (95% CI 2; 24)). The coagulation marker fibrinogen increased transiently, after 3 months (+15%, (95% CI 1; 32)). In trans men, hs-CRP increased (+71%, (95% CI 19; 145)); platelet activation and coagulation markers were not altered. In both trans women and trans men, leptin and adiponectin changed towards reference values of the experienced gender. Conclusions Platelet activation and coagulation marker concentrations increased in trans women using transdermal estradiol plus CPA, but not in trans men using testosterone. Also, concentrations of inflammatory markers decreased in trans women, while hs-CRP increased in trans men. Our results indicate that hormone therapy may affect hemostasis in transgender persons, which could be an underlying mechanism explaining the increased cardiovascular risk in this population.
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Affiliation(s)
- Moya H. Schutte
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Robert Kleemann
- Department Metabolic Health Research, The Netherlands Organisation for Applied Scientific Research (TNO), Leiden, The Netherlands
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Nienke M. Nota
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Chantal M. Wiepjes
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jessica M. Snabel
- Department Metabolic Health Research, The Netherlands Organisation for Applied Scientific Research (TNO), Leiden, The Netherlands
| | - Guy T’Sjoen
- Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
| | - Abel Thijs
- Department of Internal Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Martin den Heijer
- Department of Endocrinology and Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- * E-mail:
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Cocchetti C, Romani A, Collet S, Greenman Y, Schreiner T, Wiepjes C, den Heijer M, T’Sjoen G, Fisher AD. The ENIGI (European Network for the Investigation of Gender Incongruence) Study: Overview of Acquired Endocrine Knowledge and Future Perspectives. J Clin Med 2022; 11:jcm11071784. [PMID: 35407392 PMCID: PMC8999511 DOI: 10.3390/jcm11071784] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 02/06/2023] Open
Abstract
Literature on the efficacy and safety of gender-affirming hormonal treatment (GAHT) in transgender people is limited. For this reason, in 2010 the European Network for the Investigation of Gender Incongruence (ENIGI) study was born. The aim of this review is to summarize evidence emerging from this prospective multicentric study and to identify future perspectives. GAHT was effective in inducing desired body changes in both trans AMAB and AFAB people (assigned male and female at birth, respectively). Evidence from the ENIGI study confirmed the overall safety of GAHT in the short/mid-term. In trans AMAB people, an increase in prolactin levels was demonstrated, whereas the most common side effects in trans AFAB people were acne development, erythrocytosis, and unfavorable changes in lipid profile. The main future perspectives should include the evaluation of the efficacy and safety of non-standardized hormonal treatment in non-binary trans people. Furthermore, long-term safety data on mortality rates, oncological risk, and cardiovascular, cerebrovascular and thromboembolic events are lacking. With this aim, we decided to extend the observation of the ENIGI study to 10 years in order to study all these aspects in depth and to answer these questions.
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Affiliation(s)
- Carlotta Cocchetti
- Andrology, Women’s Endocrinology and Gender Incongruence Unit, Florence University Hospital, Viale Pieraccini 6, 50100 Florence, Italy; (C.C.); (A.R.)
| | - Alessia Romani
- Andrology, Women’s Endocrinology and Gender Incongruence Unit, Florence University Hospital, Viale Pieraccini 6, 50100 Florence, Italy; (C.C.); (A.R.)
| | - Sarah Collet
- Department of Endocrinology, Center for Sexology and Gender, Ghent University Hospital, 9000 Ghent, Belgium; (S.C.); (G.T.)
| | - Yona Greenman
- Institute of Endocrinology and Metabolism, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv 6997801, Israel;
| | - Thomas Schreiner
- Department of Endocrinology, Oslo University Hospital, 0130 Oslo, Norway;
| | - Chantal Wiepjes
- Department of Endocrinology, Amsterdam University Medical Center, VUmc, 1018 WT Amsterdam, The Netherlands; (C.W.); (M.d.H.)
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, VUmc, 1018 WT Amsterdam, The Netherlands
| | - Martin den Heijer
- Department of Endocrinology, Amsterdam University Medical Center, VUmc, 1018 WT Amsterdam, The Netherlands; (C.W.); (M.d.H.)
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, VUmc, 1018 WT Amsterdam, The Netherlands
| | - Guy T’Sjoen
- Department of Endocrinology, Center for Sexology and Gender, Ghent University Hospital, 9000 Ghent, Belgium; (S.C.); (G.T.)
| | - Alessandra Daphne Fisher
- Andrology, Women’s Endocrinology and Gender Incongruence Unit, Florence University Hospital, Viale Pieraccini 6, 50100 Florence, Italy; (C.C.); (A.R.)
- Correspondence:
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20
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Kerrebrouck M, Vantilborgh A, Collet S, T’Sjoen G. Thrombophilia and hormonal therapy in transgender persons: A literature review and case series. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 23:377-391. [PMID: 36324880 PMCID: PMC9621226 DOI: 10.1080/26895269.2022.2025551] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Background: Venous thromboembolism (VTE) is a rare side effect of hormonal therapy in transgender persons. Prothrombotic genetic variants can increase this risk. For this reason, previous VTE and/or genetic thrombophilia may be considered by some as contraindications to hormonal treatment. Aim: To formulate directions for clinical practice about the indications for thrombophilia screening and when to consider combination therapy of therapeutic anticoagulation and hormonal treatment as a safe alternative to withholding hormonal treatment. Methods: We conducted a literature search and describe a case series. All adult patients with gender dysphoria and a known prothrombotic genetic variant or history of VTE were invited by letter to participate in this study. Results: In our center, thrombophilia screening before start of hormonal treatment was restricted to those with a personal or family history of VTE. Sixteen individuals with a history of VTE and/or an underlying prothrombogenic condition were described. The time of follow up varied from 4 months to 20 years. Seven trans women had a positive thrombophilia screening (2 Factor V Leiden (FVL), 1 FVL + anticardiolipin antibodies, 1 FVL + high Factor VIII coagulant activity, 1 protein C deficiency, 1 prothrombin mutation, 1 positive lupus anticoagulant). Three trans women experienced an unprovoked VTE after start of hormonal therapy of which one lead to a positive thrombophilia screening. One VTE event in a trans woman was assumed to be provoked by surgery. Five trans men were identified with a prothrombogenic mutation (3 FVL, 1 protein C deficiency, 1 prothrombin mutation). One trans man, with a negative thrombophilia screen, experienced multiple provoked VTE events before start of hormonal therapy. Conclusion: Based on our literature review and case series we offer guidance when confronted with patients with previous VTE and/or genetic thrombophilia requesting hormonal interventions.
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Affiliation(s)
| | - Anna Vantilborgh
- Department of Hematology, Ghent University Hospital, Ghent, Belgium
| | - Sarah Collet
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Guy T’Sjoen
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
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21
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Aranda G, Halperin I, Gomez-Gil E, Hanzu FA, Seguí N, Guillamon A, Mora M. Cardiovascular Risk Associated With Gender Affirming Hormone Therapy in Transgender Population. Front Endocrinol (Lausanne) 2021; 12:718200. [PMID: 34659112 PMCID: PMC8515285 DOI: 10.3389/fendo.2021.718200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/02/2021] [Indexed: 11/13/2022] Open
Abstract
Transgender men and women represent about 0.6 -1.1%% of the general population. Gender affirming hormone therapy (GAHT) helps ameliorate gender dysphoria and promote well-being. However, these treatments' cardiovascular (CV) effects are difficult to evaluate due to the limited number of extensive longitudinal studies focused on CV outcomes in this population. Furthermore, these studies are mainly observational and difficult to interpret due to a variety of hormone regimens and observation periods, together with possible bias by confounding factors (comorbidities, estrogen types, smoking, alcohol abuse, HIV infection). In addition, the introduction of GAHT at increasingly earlier ages, even before the full development of the secondary sexual characteristics, could lead to long-term changes in CV risk compared to current data. This review examines the impact of GAHT in the transgender population on CV outcomes and surrogate markers of CV health. Furthermore, we review available data on changes in DNA methylation or RNA transcription induced by GAHT that may translate into changes in metabolic parameters that could increase CV risk.
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Affiliation(s)
- Gloria Aranda
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi I Sunyer- Hospital Clinic, Barcelona, Spain
| | - Irene Halperin
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi I Sunyer- Hospital Clinic, Barcelona, Spain
- Endocrinology Department, Hospital Clinic, Barcelona, Spain
| | | | - Felicia A. Hanzu
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi I Sunyer- Hospital Clinic, Barcelona, Spain
- Endocrinology Department, Hospital Clinic, Barcelona, Spain
| | - Núria Seguí
- Endocrinology Department, Hospital Clinic, Barcelona, Spain
| | - Antonio Guillamon
- Departamento de Psicobiologia, Universidad Nacional de Educación a Distancia (UNED), Madrid, Spain
| | - Mireia Mora
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi I Sunyer- Hospital Clinic, Barcelona, Spain
- Endocrinology Department, Hospital Clinic, Barcelona, Spain
- *Correspondence: Mireia Mora,
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