Cross-Sex Hormone Therapy Associated With Medical Risks and Psychosocial Benefits in Transgender Patients Interview with:

Carl G Streed Jr. M.D. Pronouns: he, him, his, himself Fellow, Division General Internal Medicine & Primary Care Brigham & Women’s Hospital

Dr. Streed

Carl G Streed Jr. M.D.
Pronouns: he, him, his, himself
Fellow, Division General Internal Medicine & Primary Care
Brigham & Women’s Hospital What is the background for this study? What are the main findings?

Response: Recent reports estimate that 0.6% of adults in the United States, or approximately 1.4 million persons, identify as transgender. 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. The lack of research to characterize cardiovascular disease (CVD) and CVD risk factors in transgender populations receiving cross-sex hormone therapy (CSHT) limits appropriate primary and specialty care. As with hormone therapy in cisgender persons (that is, those whose sex assigned at birth aligns with their gender identity), existing research in transgender populations suggests that CVD risk factors are altered by CSHT.

Despite current limitations, the available literature suggests several key issues to consider when prescribing hormone therapy to transgender and cisgender adults:

  • Although data are conflicting regarding the risks and benefits of testosterone replacement in cisgender men, newer studies suggest an increased CVD risk associated with testosterone replacement in older cisgender men.
  • Systemic estrogen–progestin combination hormone replacement is not recommended for cisgender women because of an increased risk for MI and stroke, and estrogen-only hormone replacement requires a discussion of risk based on the age of the patient.
  • Cross-sex hormone therapy, particularly with testosterone, has been associated with potential worsening of cardiovascular risk factors (such as blood pressure elevation, insulin resistance, and lipid derangements), although these changes have not been associated with increases in observed cardiovascular morbidity or mortality in transgender men receiving CSHT. (A caveat, however, is that most studies have included mostly younger men.)
  • Cross-sex hormone therapy for transgender women has potential thromboembolic risk, and lower-dose transdermal and oral bioidentical estrogen formulations are preferred to high-dose oral ethinyl estradiol formulations.
  • Clinicians must closely follow older transgender women if they have higher cardiovascular risk, regardless of the use, age of initiation, or duration of CSHT.
  • Reducing cardiovascular risk factors (such as hypertension, diabetes, and tobacco use) remains critical in preventing CVD in transgender populations. What should clinicians and patients take away from your report?

Response: Cross-sex hormone therapy is associated with potential risks, but its psychosocial benefits cannot be denied. Use of CSHT requires continued, shared decision making between patient and clinician. What recommendations do you have for future research as a result of this study?

Response: To evaluate difference among various CSHT regimens, 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. Is there anything else you would like to add?

Response: Clinicians of all specialties ought receive training in providing care for transgender patients. Caring for transgender patients needs to be part of undergraduate and graduate medical education as well as continuing medical education. Additionally, research that addresses issues faced by transgender individuals and communities need to directly involve transgender individuals in its design and analysis; research needs to be a collaboration. Thank you for your contribution to the community.


Streed CG, Harfouch O, Marvel F, Blumenthal RS, Martin SS, Mukherjee M. Cardiovascular Disease Among Transgender Adults Receiving Hormone Therapy: A Narrative Review. Ann Intern Med. [Epub ahead of print 25 July 2017] doi: 10.7326/M17-0577

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.




Last Updated on July 27, 2017 by Marie Benz MD FAAD