That’s because decades of hormone use is associated with an elevated risk of heart attacks and strokes as well as what’s known as venous thromboembolism, or clots in the deep veins of the leg, arm, or groin that can be life-threatening if they break loose and travel to the lungs, says the lead author of the paper, Angela Maas, MD, PhD, a professor of women’s cardiac health at Radboud University Medical Center in the Netherlands. “Because they have to use hormone therapy for the rest of their life, their risk seems to increase faster than in cisgender women over time,” Dr. Maas says.
What Is Feminizing Hormone Therapy?
Some transgender women may take estrogen, which can lead to physical changes that are caused by female sex hormones during puberty, including breast development. Transgender women who take estrogen before male puberty begins may be able to limit or avoid the development of male sex characteristics like a deeper voice and chest hair, according to the Mayo Clinic. For transgender women, taking estrogen can both curb production of the male sex hormone testosterone and boost the development of female sex characteristics. They may also take medication to block actions of testosterone in the body, which helps halt the development of male sex characteristics. The benefits of feminizing hormone therapy can include improved mental health, social functioning, and quality of life, according to the Mayo Clinic. Hormone therapy can also help improve sexual satisfaction and reduce the severity of what’s known as gender dysphoria, or psychological distress caused when your gender identity doesn’t match your sex assigned at birth. RELATED: Does Medicare Cover Transgender Surgery? But transgender women who take hormone therapy are also at elevated risk for several conditions that can increase the likelihood of events like heart attacks and strokes, according to the Mayo Clinic. These conditions include high blood pressure, type 2 diabetes, high triglycerides, and clots in deep veins or the lungs.
Heart Risks of Gender-Affirming Hormones
According to the new paper in the European Heart Journal, doctors stopped using one version of estrogen — oral ethinyloestradiol — because studies that emerged in the late 1990s showed this hormone was associated with up to a 20-fold increase in the risk of dangerous clots in the deep veins or lungs, called venous thromboembolisms (VTE). In recent years, the preferred form of estrogen for transgender women has been estradiol, a version of the female sex hormone estrogen that is also used by cisgender women to treat certain menopause symptoms. Transgender women who are over 40 are advised to use creams and other versions of estradiol applied to the skin to avoid the elevated risk of clots associated with oral forms of this hormone, the new paper notes. But transgender women on estrogen still have a greater risk for VTE than cisgender women or men. For example, compared with cisgender men, transgender women have an 80 percent higher risk of strokes and a 355 percent higher risk of VTE, the European Heart Journal paper notes. Even so, halting gender-affirming hormones isn’t necessarily an option for transgender women as they age, the paper points out. That’s because stopping treatment could lead to devastating psychological harms from gender dysphoria.
A Heart-Healthy Lifestyle Can Help
Part of the increased heart risks faced by transgender women has to do with the doses they take, which are typically larger than the amount prescribed for menopause symptoms, says Billy Caceres, RN, PhD, an assistant professor of LGBTQ+ Health at Columbia University School of Nursing in New York City. “Transgender women tend to take larger doses of hormones compared with cisgender women, which is what is hypothesized to drive the higher risk for cardiovascular disease observed in transgender women,” Dr. Caceres says. More research is still needed on the health effects of gender-affirming hormone therapy, particularly because much of what is known today is based on research of older forms of estrogen, Caceres adds. RELATED: Heart Attack Causes and Risk Factors Beyond this, transgender women also have some risk factors for cardiovascular disease that have nothing to do with hormones. In particular, transgender women are much more likely to smoke than cisgender women, Caceres notes. “Cardiovascular disease risk reduction in transgender women should take a holistic approach that incorporates smoking cessation, weight management, and stress reduction,” Caceres says. Transgender women on hormones should also be especially vigilant to get routine screenings for any signs of high blood pressure, elevated blood sugar, or increased levels of triglycerides — all of which can increase the risk of cardiovascular disease independent of any hormone use. Like cisgender women, transgender women should avoid smoking, limit alcohol, get plenty of exercise, and follow a heart-healthy diet, advises Maas. Transgender women, however, need to be even stricter with how closely they monitor any risk factors for heart disease and even more careful than cisgender women to eat well, exercise enough, and make other heart-healthy lifestyle choices, Mass says. RELATED: African Americans Who Smoke Are at Least Twice as Likely to Have Stroke, Study Finds
