What Risks should I know about Feminizing Hormone Therapy for Transwomen?

admin April 10, 2024 Gender Affirmative Hormone Therapy (GAHT) No Comment

Although current Feminizing Hormone Therapy (FHT) regimens are generally effective with low risks of side effects and adverse events, it’s important to review the following information before beginning your gender affirmation:

  1. Venous Thromboembolism: Transgender women who take estrogen might have a small risk (range between 1% and 5%) of blood clots. They should avoid smoking, keep a healthy weight, and control high blood pressure to lower this risk. (Van Kesteren et al., 1997; Dittrich et al. 2005; Gooren et al., 2008; Canonico et al., 2008; Murad et al., 2010; Ott et al., 2010; Wierckx et al., 2012; Deutsch et al., 2015; Shatzel et al., 2017; Getahun et al., 2018).
  2. Dyslipidemia: A meta-analysis study looked at how hormones affect the blood fats of transgender women. They found that after using hormones for a while, there was no big change in the cholesterol levels (both LDL and HDL cholesterol), but triglyceride levels were higher after 2 years of treatment (Maraka et al., 2017). However, It’s not clear if the higher triglyceride levels seen in the study have a big impact on health or not.
  3. Diabetes: Transgender women might have a higher risk of type 2 diabetes mellitus (Wierckx et al., 2013) and an increase in markers of insulin resistance (Elbers et al., 2003), but more research is needed to confirm this.
  4. Hypertension: The effects of hormones on blood pressure (both systolic and diastolic) vary, but some studies suggest estrogen might increase blood pressure in some transgender women (Elbers et al., 2003; Wierckx et al., 2014; Quiro´s et al., 2015; Colizzi et al., 2015).
  5. Liver Health: Liver problems reported in transgender women might be due to factors like alcohol or viral hepatitis rather than hormone therapy, but it’s still a good idea to check liver enzymes regularly (Meyer et al., 1986; Asscheman et al., 1989; Van Kesteren et al., 1997; Hembree et al., 2017).
  6. Cardiovascular and other mortality: The hormone therapy used for transgender people are usually good and don’t cause many problems in the short term. But transgender women might have a higher chance of dying from heart problems, suicide, AIDS, and drug use compared to women who aren’t transgender (Asscheman et al., 2011; 3. Dhejne et al., 2011).
  7. Prostate Cancer Screening: Prostate cancer is rare in transgender women, but they should still be screened starting at age 50 because some cases have been reported (Thurston, 1994; Haarst, 1998; Dorff et al., 2007; Turo et al., 2013; Gooren & Morgentaler, 2014). 
  8. Breast Cancer: Transgender women may have a small risk of breast cancer, especially who develop breast tissue in response to gender-affirming hormone therapy, so regular screening is recommended, especially for those with additional risk factors like family history of breast cancer, BRCA2 mutation, Klinefelter syndrome etc. (Gooren et al., 2013; Maglione et al., 2014; Brown & Jones, 2015; Gooren et al., 2015; Gooren & Sjoen, 2018). 
  9. Bone Health and Osteoporosis: Estrogen has a role in bone metabolism, so transgender women should have bone density checks, especially if they have other risk factors like vitamin D deficiency, poor nutrition, and limited physical activity (Van Kesteren et al., 1998; Van Caenegem et al., 2013; Cauley, 2015; Van Caenegem et al., 2015; Singh et al., 2017; Tangpricha et al., 2017).
  10. Prolactin Levels: Estrogen treatment can affect prolactin levels in the blood, but the risk of developing a prolactinoma (a type of tumor) seems to be low. Still, it’s important to monitor prolactin levels regularly (Kovacs et al., 1994; Cunha et al., 2015; Fung et al. 2016; Nota et al., 2017; Defreyne  et al., 2017).
  11. Geriatric Transwoman (> 50 Years of Age): For older transgender women, taking estrogen and medroxyprogesterone, like in postmenopausal cisgender women, can raise the risk of health issues like stroke, breast cancer, and heart disease. Starting hormone therapy later in life, taking it for a long time, or using higher doses can increase the chances of stroke and blood clots. We don’t have enough data about the risks for transgender women over 50 years old, but we know it’s important to balance the benefits of feminizing effects with the risks of health problems. It might be necessary to lower the dose of estrogen or switch to a safer form to reduce risks (Manson et al., 2003; Chlebowski et al., 2003; Wassertheil et al., 2003; Patterson, 2004; Renoux et al., 2010).
  12. Cardiovascular Diseases: Taking feminizing hormone therapy (FHT) might increase the risk of cardiovascular disease (CVD) in transgender women (Streed et al., 2017). We don’t have a lot of information about how FHT affects CVD in transgender women, especially in those with pre-existing atherosclerosis (Goff et al., 2014). In transgender women, myocardial infarction rates were higher than in cisgender women but similar to cisgender men. This is especially higher in those who have other health issues like metabolic disease, smoke tobacco, or take certain types of estrogen pills (Getahun et al., 2018).
  13. Ischemic Stroke: Data about the effects of hormone therapy on stroke risk are limited. In postmenopausal cisgender women, hormone therapy can increase the risk of stroke. The risk depends on factors like when therapy is started and the type of estrogen used (Renoux et al., 2010; Boardman et al., 2015; Canonico et al., 2016). In transgender women, the risk of stroke goes up with hormone therapy, especially with oral estrogen (Maraka et al., 2017; Getahun et al., 2018). 
  14. HIV and Hormone Therapy: Transgender women are at a high risk of getting HIV. There’s worry about how HIV medicines and hormone therapy might interact. A recent study found that transgender women taking emtricitabine and tenofovir for HIV prevention might not have enough of these drugs in their bodies, compared to cisgender men  (Davidson et al., 2013; Radix et al., 2016). Because of this, transgender women with HIV who are also taking feminizing hormones might need a special HIV medicine plan that’s made just for them.
  15. Hormone Therapy during Surgeries: Before surgeries that don’t require long periods of bed rest, most people can keep taking estradiol. But for riskier surgeries or for those at high risk of blood clots, they may need to stop estrogen therapy for 2 to 6 weeks before the surgery. If stopping estrogen isn’t an option, they might switch to using estrogen patches instead of pills. After surgery, they’ll need treatment to prevent blood clots and should wait until they can move around well before starting estrogen again. For urgent surgeries, they’ll get special treatment to prevent blood clots (thrombosis prophylaxis with low-molecular-weight heparin). 10 Before surgery, they should also work on things like losing weight, quitting smoking, and avoiding drugs, to lower their risk of problems during and after surgery. Starting this process early in their gender transition is really important (Sieffert et al., 2015; Tangpricha et al., 2017).

Healthcare concept, idea of doctor caring about patient health. Female patient on a consultation with neurologist. Medical treatment and recovery. illustration

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