Cardiovascular Risks of Hormone Therapy in Transgender Individuals

MedicalResearch.com Interview with:

Michael Goodman, MD, MPH Professor of Epidemiology Director, MD/MPH program Emory University School of Public Health Atlanta, GA  30322

Dr. Goodman

Michael Goodman, MD, MPH
Professor of Epidemiology
Director, MD/MPH program
Emory University School of Public Health
Atlanta, GA  30322

MedicalResearch.com: What is the background for this study? What are the main findings? 

Response: There is a concern that hormone therapy may be associated with higher risk of certain cardiovascular problems such as heart attacks, stroke and formation of blood clots (“venous thromboembolism”).

To study this concern we examined data on 4,960 transgender and gender non-conforming people enrolled in Kaiser Permanente health systems in Georgia, Northern California, and Southern California. They were matched to 48,686 cisgender men and 48,775 cisgender women.  Below are the main findings

  • Rates of venous thromboembolism in all transwomen were approximately twice as high as the rates among cisgender men or cisgender women. The data for stroke and myocardial infarction demonstrated little difference between transwomen and cisgender men, but 80% to 90% higher rates among transwomen compared to cisgender women.
  • When the analyses focused specifically on transwomen who started therapy with female hormone estrogen at Kaiser Permanente, the incidence of both venous thromboembolism and stroke was more clearly elevated relative to either reference group.  There was evidence that incidence of both of these conditions among transwomen was particularly increased two to six years after estrogen initiation. By contrast, the association between estrogen therapy and myocardial infarction was less evident due to relatively few observed events.
  • Transmen did not appear to have significantly higher rates of venous thromboembolism, ischemic stroke, or myocardial infarction than their non-transgender counterparts, but this group was rather young and included a relatively small proportion of participants who initiated their hormone therapy during the study.

MedicalResearch.com: What should readers take away from your report?

Response: It is important to be aware of these findings, but the risks should be weighed against the benefits of hormone therapy.     

MedicalResearch.com: What recommendations do you have for future research as a result of this work? 

Response: The body of transgender health research is growing, but high quality data are still lacking with respect to many critical gaps in knowledge.  Closing these knowledge gaps will require larger, more in-depth, studies performed independently by different institutions and in a variety of settings.  The important next steps are to compare different types of hormone therapy, and especially estrogen.  Critical unanswered research questions include relative risks and benefits of:

  • Different estrogen formulations
  • Doses
  • Route of administration
  • Combinations with other drugs

Answers to these research questions will guide hormone therapy choices in the future.  

MedicalResearch.com: Is there anything else you would like to add?

Response: Our study design, its implementation and interpretation of results relied on extensive input from the Stakeholder Advisory Group, which included representatives of the transgender community at each site as well as health care providers with clinical expertise in this area. 

Citation:

Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons: A Cohort Study

Darios Getahun, MD, PhD, MPH; Rebecca Nash, MPH; W. Dana Flanders, MD, MPH, DSc; Tisha C. Baird, MD; Tracy A. Becerra-Culqui, PhD; Lee Cromwell, MS; Enid Hunkeler, MA; Timothy L. Lash, PhD; Andrea Millman, MA; Virginia P. Quinn, PhD; Brandi Robinson, MPH; Douglas Roblin, PhD; Michael J. Silverberg, PhD; Joshua Safer, MD; Jennifer Slovis, MD; Vin Tangpricha, MD, PhD; Michael Goodman, MD, MPH 

 Ann Intern Med. 2018.
DOI:10.7326/M17-2785
2018 American College of Physicians 

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