In the realm of gender-affirming care, hormone therapy plays a vital role. However, its impact on cardiovascular health, including risks associated with heart attacks, strokes, and blood clots, is a topic of much discussion and debate. Understanding these risks and benefits is crucial for individuals seeking hormone therapy for gender transition, particularly those with pre-existing health conditions.

The Role of Hormones in Cardiovascular Health

Hormones such as estrogen, testosterone, and progesterone are not only central to gender identity but also play significant roles in cardiovascular health:

• Estrogen is generally considered protective against heart disease in cisgender women before menopause.
• Testosterone levels have been linked with cardiovascular risks, yet the evidence is not conclusive. Some studies suggest that low testosterone levels might increase the risk of heart disease in men.
• Progesterone, often used in combination with estrogen, may impact blood clot risks, but bioidentical progesterone is considered safer than synthetic progestins.

Hormone Therapy in Gender-Affirming Care

For transgender and gender-diverse individuals, hormone therapy can be critical for aligning physical characteristics with gender identity, helping with mental and emotional wellbeing.

Understanding the Risks

• Heart Attacks and Strokes: Hormone therapy may slightly modify the risk of cardiovascular events, but the current evidence suggests that the risk increase is minimal and should be weighed against the significant benefits of hormone therapy for gender incongruence.
• Blood Clots: Estrogen, when taken orally, can increase the risk of thromboembolic events. The risk is lower with transdermal (through the skin) applications and with bioidentical formulations.

Positive Perspective on Hormone Use

• Natural Hormone Production: Individuals with heart disease or a history of blood clots are not typically required to suppress their natural hormones. This perspective extends to gender-affirming hormone therapy. Choosing a hormone profile that aligns with a person’s gender identity can be safely managed even in the presence of these conditions.
• Managing Risks: Just as in the general population, individuals undergoing hormone therapy should manage cardiovascular risk factors such as smoking, high blood pressure, and cholesterol.

Special Considerations for Antiandrogens

• Spironolactone and Heart Disease: In individuals with heart disease, especially those on multiple medications, spironolactone is not always the optimal choice for an antiandrogen. Its potential for drug interactions and effects on electrolyte balance (like increasing potassium levels) and blood pressure necessitates careful consideration and monitoring in this group.

Recommendations from WPATH and the Endocrine Society

Both the World Professional Association for Transgender Health (WPATH) and the Endocrine Society provide guidelines for gender-affirming hormone therapy:

• Individualised Care: They recommend individualised treatment plans and careful monitoring for those with pre-existing cardiovascular conditions.
• Informed Decision-Making: The guidelines emphasise informed consent, where people are informed about the potential risks and benefits of having or not having hormone therapy, and make their own decisions.
• Regular Monitoring: For all people, and for those at higher risk of cardiovascular events, regular monitoring and any adjustment of hormone therapy is important to maintain normal levels of hormones.

Conclusion

In conclusion, while there are some risks associated with hormone therapy in the context of cardiovascular health, these risks are generally low and should be balanced against the considerable benefits of hormone therapy in gender-affirming care. Managing cardiovascular risks through lifestyle changes and regular medical monitoring, as recommended by WPATH and the Endocrine Society, can further mitigate these risks. The decision to undergo hormone therapy should be made on an individual basis, taking into account the person’s overall health, risk factors, and the importance of hormone therapy in their gender transition journey.

FAQs

Can I commence gender affirming hormone treatment if I have coronary heart disease or heart failure?

Having coronary heart disease or heart failure is not a contraindication to gender affirming hormone treatment. However, it is important to understand that heart attacks, strokes, and blood clots do not have a singular cause, but are complex outcomes of multiple interacting factors. These can include high blood pressure, high cholesterol, smoking, diabetes, being overweight, and inactivity. Hence, your overall risk can be decreased by addressing any of these risk factors that are relevant to you.

Furthermore, your risk can be decreased by making sure that your coronary heart disease or heart failure are optimally treated. We therefore recommend that you continue to attend your doctor and cardiologist so that your treatment for your coronary heart disease or heart failure can be monitored and optimised.

I have a family history of cardiovascular disease. Can I commence gender affirming hormone treatment?

Having a family history of cardiovascular disease is not a contraindication to gender affirming hormone treatment. However, it is important that you understand the risks so that you can make an informed decision.

It is important to understand that heart disease, strokes, and blood clots do not have a singular cause, but are complex outcomes of multiple interacting factors. These can include high blood pressure, high cholesterol, smoking, diabetes, being overweight, and inactivity. Hence, your overall risk can be decreased by addressing any of these risk factors that are relevant to you. For this reason, we recommend that you have annual health checks to monitor your blood pressure, cholesterol, smoking status, and diabetes.

Can testosterone cause blood clots?

There is some evidence that gender affirming hormone treatment can increase the risk of blood clots, however, it is important to understand that blood clots do not have a singular cause, but are complex outcomes of multiple interacting risk factors, such as smoking, high cholesterol, and inactivity. Therefore, the overall risk of blood clots can be decreased by addressing these risk factors.