Trans People on Hormone Therapy Don’t Mind Potential Cardiovascular Side Effects

Trans adults using gender-affirming hormone therapy said they were content that it helped their overall well-being and, indirectly, felt it benefited their cardiovascular health, researchers reported.

Based on interviews with 21 transgender and nonbinary people, most had already spoken with their clinicians about cardiovascular monitoring while on hormone therapy, and most said that cardiovascular health was ultimately not a primary factor in the decision to use gender-affirming hormone therapy.

Instead of worrying about the potential cardiovascular risks, they said they believed that their improved well-being from using gender-affirming hormone therapy indirectly improved cardiovascular health, according to Sofia Ahmed, MD, of University of Calgary and Alberta Health Services in Edmonton, and colleagues reporting in Circulation: Cardiovascular Quality and Outcomes.

To illustrate the point, the investigators quoted two participants, among others, who were both transgender men age 28 to 37 years old:

• “I think [starting testosterone] led to a lot more paying attention to my body. It led to a lot more awareness around diet and diabetes risks. I also stopped drinking as much as I used to … I would say that my health is much better now. I think about it a lot more. I pay attention to it a lot more. I enjoy being healthy more.”
• “The hormone therapy has improved my mental health and improved my physical health and made it more doable for me to be active on a regular basis, which is probably improving heart health, but where does it come from? I don’t know.”

Interview subjects also suggested that better knowledge and attitude from healthcare providers would facilitate the transition process.

“Given the positive associations between care aligned with patient priorities, self-rated health, and health outcomes, these findings should be considered as part of shared decision-making and person-centered care,” Ahmed and colleagues wrote.

Trans people are considered an underserved population with disproportionately high rates of cardiovascular disease. Concerns about additional harm from gender-affirming hormone therapy have not come to fruition, as data on the relationship between and cardiovascular outcomes are inconclusive — save a consistent but small increased risk in venous thromboembolism associated with estrogen-based hormone therapy, the investigators noted.

“Of note, these studies have been largely limited to either self-report of cardiovascular disease or administrative data, which does not account for unmeasured factors such as smoking or psychosocial factors including gender minority stress,” Ahmed’s group highlighted. “To date, there have not been any large-scale prospective studies evaluating the relationship between gender-affirming hormone therapy and cardiovascular outcomes, or perceived cardiovascular health.”

In an accompanying editorial, Carl Streed, Jr., MD, MPH, of Boston University and Boston Medical Center, and Asa Radix, MD, PhD, MPH, of Columbia University and Callen-Lorde Community Health Center in New York City, said that clinicians “may be overly concerned about the potential negative impact” of gender-affirming hormone therapy.

The effects of other cardiovascular risk factors — tobacco or alcohol use, say — should not be ignored, the duo stressed.

“Rather than focusing on potential, yet mostly unproven, negative associations between [gender-affirming hormone therapy] and cardiovascular health, clinicians should incorporate these additional perspectives of gender-affirming care into their practice as part of shared decision-making and person-centered care. Centering patient perspectives and goals requires us to acknowledge their broader impact on health, including mental and social well-being,” Streed and Radix wrote.

For their qualitative study, Ahmed and colleagues conducted semistructured interviews in 2023 with transgender and nonbinary people who had been using gender-affirming hormone therapy for at least 3 months.

They recruited across Alberta, British Columbia, and Manitoba, and found 21 eligible volunteers (median age 27 years, 62% assigned female at birth, 80% white).

Major limitations of the study include the lack of representation of trans and nonbinary people who chose not to use hormone therapy, and those who initiated and then discontinued their hormone therapy due to adverse events.

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