Hypertension and Gender Affirming Hormone Treatment

Hypertension and Gender Affirming Hormone Treatment

What is hypertension?

The measurement of blood pressure involves two numbers. The higher number is called the systolic pressure and reflects the force at which your heart is pumping blood around your body. The lower number is called the diastolic pressure and reflects the resistance to the blood flow in your blood vessels when the heart is relaxed.
For blood to flow effectively around the body, sufficient blood pressure must be maintained. Hence, having a blood pressure that is very low can result in health problems, such as fainting, confusion, headache, tiredness, and kidney injury. This is called hypotension. However, having a blood pressure that is very high can result in injury to the walls of the blood vessels, which can also result in health problems. This is called hypertension.
Hypertension itself usually has no symptoms, but it is associated with increased lifetime risks of various health problems. These include increased risks of cardiovascular disease, heart failure, stroke, aneurysms, kidney disease, peripheral vascular disease. Hence, management of blood pressure can be associated with significant health benefits. 

How is hypertension diagnosed?

The healthy range for blood pressure is considered to be between 90/60mmHg and 120/80mmHg. Hypertension is diagnosed if the blood pressure is greater than 140/90mmHg.

What causes hypertension?

Hypertension does not usually have a singular cause, but is the outcome of multiple interacting causal factors. These include smoking, excessive alcohol consumption, stimulant drugs including caffeine, stress, inactivity, being overweight, and consuming too much salt. The risk of hypertension is also increased by advancing age, having a family history of hypertension, and being a member of a socially disadvantaged group.

How is hypertension treated?

Hypertension can be treated with lifestyle changes and antihypertensive medication. Lifestyle changes aim to address the risk factors that may be relevant. They include stopping smoking, exercising regularly, maintaining a healthy weight, decreasing alcohol consumption, decreasing caffeine consumption, and decreasing salt consumption.

Antihypertensive medications include ACE inhibitors (enalapril, lisinopril), angiotensin receptor antagonists (candesartan, losartan), calcium channel blockers (amlodipine, diltiazem), diuretics (bendroflumethiazide, amiloride), beta blockers (bisoprolol, atenolol), and alpha blockers (doxazosin).

What is the evidence on hypertension in the transgender community?

Research suggests that transgender people suffer from cardiovascular health disparities compared to cisgender people. The causes of these health disparities are complex and socially mediated. Transgender people comprise a marginalised group who suffer various social harms, including prejudice, stigmatisation, exclusion, and rejection. These stressors have psychological, behavioural, and physiological effects, which in turn have detrimental consequences on cardiovascular health, including increased blood pressure (Streed et al., 2021).

Can hormones affect blood pressure?

Hormones can influence blood pressure, although their effects are varied. Testosterone tends to increase blood pressure, whereas oestrogen tends to decrease blood pressure. This partly explains why the average blood pressure of cisgender men is usually higher than the average blood pressure of cisgender women, although there may also be other factors that contribute to this difference.

In a recent study, testosterone treatment in transgender men was associated with a 2.6mmHg increase in average systolic pressure. By contrast, oestrogen treatment in transgender women was associated with a 4.0mmHg decrease in average systolic pressure. This suggests that gender affirming hormone treatment moved the blood pressures of transgender men and women into the respective ranges expected for men and women.

What are the implications for gender affirming hormone treatment?

Hypertension is not a contraindication to gender affirming hormone treatment. If you are receiving gender affirming hormone treatment and have hypertension, then the appropriate management is to treat your hypertension and to address any cardiovascular risk factors, not to change your gender affirming hormone treatment.

While hormones do influence blood pressure, gender affirming hormone treatment does not cause hypertension. Rather, it changes your physiological profile so that your blood pressure moves closer to the range expected for your gender.

Nonetheless, it is important to note that transgender people do have higher risks of hypertension and cardiovascular disease for other reasons unrelated to hormones, notably the above mentioned social disparities. Hence, having regular health checks to screen for hypertension may be recommended for this population.

References

  1. Banks, K., Kyinn, M., Leemaqz, S. Y., Sarkodie, E., Goldstein, D., Irwig, M. S. (2021). “Blood Pressure Effects of Gender-Affirming Hormone Therapy in Transgender and Gender-Diverse Adults”. Hypertension, 77 (6): 2066–2074.
  2. Streed, C. G. Jr, Beach, L. B., Caceres, B. A., Dowshen, N. L., Moreau, K. L., Mukherjee, M., Poteat, T., Radix, A., Reisner, S. L., and Singh, V. (2021). “Assessing and Addressing Cardiovascular Health in People Who Are Transgender and Gender Diverse: A Scientific Statement from the American Heart Association. Circulation”. 144 (6): e136–e148.