Are Transgender Men And Women Who Take Hormones At Risk For Heart Disease
The impact of hormone therapy on the heart health of transgender men and women has been the subject of several studies published within the last year. But medical experts and researchers aren’t ready to sound the alarm just yet.
“We have to recognize that hormones can be lifesaving therapy for trans people,” said Dr. Richard Greene, an associate professor at New York University School of Medicine. “The answer is figuring out how to give them safely and how to modify some of these cardiovascular risk factors in the best way possible.”
One study found that transgender women who take hormones were more than twice as likely to have a stroke and deep vein clots compared to cisgender men and women or people who identify as the sex they were assigned at birth. In addition, both trans women and trans men had a higher risk of heart attack than cisgender women.
Still, the findings aren’t enough reason for doctors to stop prescribing hormones primarily estrogen to transgender women and testosterone to transgender men. Greene said he found some of the science behind the more recent research “problematic.”
Many of the studies don’t ask how long a person has identified as transgender or consider the kinds of hormones being used. Some older types of estrogen are associated with higher risk for stroke, he said. In addition, most studies did not ask whether the individuals taking hormones considered themselves non-binary, or not identifying as either man or woman.
Male To Female Transition Hormone Therapy Or Feminine Transitioning Hormone Therapy:
Hormone therapy for feminine transitioning individuals increases the levels of estrogen, while lower the levels of testosterone in to a typical female range, thus resulting in internal and also visible changes to the body. Estrogen is the main feminizing hormone that is responsible for the development of secondary sex characteristics in the body. Progesterone is a third hormone that is directly linked to the reproductive cycle in a female and is not produced in a male.
What Are The Emotional And Intellectual Effects Of Estrogen
People are very different so their emotional and intellectual changes vary widely. People taking estrogen have reported:
- Feeling more emotional and more in touch with their feelings
- Crying more easily
- Depression or sadness
- Thinking differently, having different ways of looking at things
- Feeling more like myself when taking a hormone that aligns with gender identity feeling more comfortable in ones body
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Informed Consent Hrt In Atlanta
Druid Hills Primary Care and Erin Everett, NP-C, AAHIVS, are one of the few practices in Atlanta to offer Informed Consent HRT for transgender patients.
Informed Consent is a legal document that is used to outline a patients understanding and agreement to receive a hormone replacement therapy. To learn more about the Informed Consent HRT process, please visit my blog article on the subject.
Hormone Therapy For Adults
The aim of hormone therapy is to make you more comfortable with yourself, both in terms of physical appearance and how you feel. The hormones usually need to be taken for the rest of your life, even if you have gender surgery.
It’s important to remember that hormone therapy is only one of the treatments for gender dysphoria. Others include voice therapy and psychological support. The decision to have hormone therapy will be taken after a discussion between you and your clinic team.
In general, people wanting masculinisation usually take testosterone and people after feminisation usually take oestrogen.
Both usually have the additional effect of suppressing the release of “unwanted” hormones from the testes or ovaries.
Whatever hormone therapy is used, it can take several months for hormone therapy to be effective, which can be frustrating.
It’s also important to remember what it cannot change, such as your height or how wide or narrow your shoulders are.
The effectiveness of hormone therapy is also limited by factors unique to the individual that cannot be overcome simply by adjusting the dose.
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Effects Of Estrogen Treatment
Testosterone blockers are a necessary part of estrogen treatment for transfeminine people because testosterone acts more strongly in the body than estrogen does. Therefore, in order for transfeminine people to experience the effects of estrogen treatment, they must block their testosterone. The most common medication used to block testosterone is spironolactone or “spiro.” Some also have their testicles removed so that they can take a lower dose of estrogen and not need a testosterone blocker.
The purpose of estrogen treatment for transfeminine people is to cause physical changes that make the body more feminine. The combination of a testosterone blocker with estrogen can lead to the following types of desired changes in the body:
- breast growth
- softening and smoothing of the skin
- reduced acne
- slowed or stopped scalp balding
All of these are changes that can reduce gender dysphoria and improve quality of life. There are also some changes that occur that are less obvious. Some of these, like a reduction in testosterone, fewer penile erections, and a decline in blood pressure are generally considered to be positive changes. Others, like decreased sex drive and changes in cholesterol and other cardiovascular factors, may be less desirable.
Indications For Bmd Screening
- All patients over 65 years old.
- Patients 50-64 years old at higher risk for osteoporosis .
- Consider before 50 years in:
- Certain high-risk conditions such as hyperparathyroidism or malabsorption syndrome.
- Patients who have undergone orchiectomy and have been on low-dose or no hormones for any significant length of time .
- Patients who have been on anti-androgens or a GnRH analogue for a significant length of time without co-administration of exogenous estrogen.
Keep in mind:
- There are no studies to guide the interpretation of BMD results and fracture risk in trans people, and whether to use sex assigned at birth or affirmed gender. One option is be to interpret results in comparison to both cis men and cis women.
- Frequency of BMD screening will depend on the results of the initial scan.
Breast/Chest health
- 1 Feldman J, Safer J. Hormone Therapy in Adults: Suggested Revisions to the Sixth Version of the Standards of Care. International Journal of Transgenderism 2009 11:146.
Keep in mind:
In Ontario, transfeminine patients who have changed their OHIP sex marker to ââ¬Åfemaleââ¬ï¿½ can be screened as part of the organized Ontario Breast Screening Program.
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Long Term Hormonal Treatment For Transgender People
Hormone Therapy In Children And Young People
Some young people with lasting signs of gender dysphoria who meet strict criteria may be referred to a hormone specialist to see if they can take hormone blockers as they reach puberty. This is in addition to psychological support.
GIDS needs to apply to the Court for permission to start puberty blockers for children and young people under the age of 16. This is because a recent court ruling states that it’s doubtful children and young people under the age of 16 are able to give informed consent for this treatment.
The Court will be asked to consider in each case whether hormone treatment is in the best interests of the young person.
Different arrangements apply for young people aged 16 and 17, as the law presumes they are able to give informed consent. In these cases, an application to the court will only be necessary if there is any doubt about the young person’s capacity to give consent or disagreement about the best interests of the young person.
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What Are The Steps Before I Can Be Prescribed Hormones To Transition To My Affirmed Gender
It usually takes two separate visits to the UI LGBTQ Clinic before you will be prescribed hormones.
During the first appointment, you will meet with one of the doctors and she will review your personal and family health history and perform an exam. You will also meet with the pharmacist who will review the medications commonly used. She will review the risks of the medications and common side effects as well as a timeline of expected changes. You will have baseline blood work done during this visit. If you recently had blood work done, please bring these results with you for the doctor to review.
We generally require people to have at least one evaluation from a mental health professional such as a therapist, counselor, or psychiatrist. The evaluation should focus on your gender history and ability to understand the risks and benefits of treatment used to transition to another gender. After the evaluation, the mental health professional will provide you with the necessary letter that you will share with the doctor. If you need help finding a therapist who has experience working with transgender and gender non-conforming people, we can help identify a mental health provider for you. While it is not required that you have ongoing appointments with the therapist, the doctor or therapist may recommend this.
Emotional Effects Of Hormone Therapy On Transgender People
The emotional effects of masculine and feminine transitioning hormone therapy are similar. Changes in hormone levels can affect your moods and feelings both, positively as well as negatively. However, during hormone therapy in transgender people, it gets difficult to tell which mood variations are because of chemical change and which are because of other factors. For example, happiness could result from bringing the body more in line with the mind.
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How Do I Prepare For Feminizing Hormone Therapy
There are many steps to help you prepare, including:
- Patient education to explain how treatment works and what to expect. This includes reviewing risks and benefits.
- Medical history to check for estrogen-dependent conditions, like certain breast cancers and endometriosis.
- Physical exam to ensure you are healthy enough to start feminizing hormone therapy.
- Lab tests, including a blood panel, urinalysis and liver function test.
- Mental health evaluation to make a gender dysphoria diagnosis. It also confirms your understanding of therapy and ability to agree to it.
How To Get Access To Estrogen Hormone Therapy
If a person decides to transition, it is essential to receive estrogen hormone therapy from healthcare professionals.
Buying and taking hormones from other sources carries many risks, such as poor quality of drugs, improper doses, and possible harm.
In order to start the process, a person must discuss their options with a healthcare professional.
Transcaresite has a directory of trans-friendly medical professionals. If an individuals healthcare insurance covers the cost of transitioning, it is important to check that the healthcare professional a person chooses is in their insurance network.
The World Professional Association for Transgender Health recommends healthcare professionals and individuals undergo several steps before starting estrogen hormone therapy.
These include:
The GLMA is the national LGBTQI+ medical association that also has provider listings for trans-affirming care.
- psychiatric, including any mental health conditions
- social, such as social support and legal history
- family, such as a history of psychiatric illnesses, suicides, and substance use
- developmental, such as education level and any history of trauma
- any instances of substance use
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Balancing The Risks And Benefits
Transgender women and transfeminine people are people whose assigned sex at birth is male, yet they exist as women. Transgender people represent a group that includes not just transgender women but also non-binary people who have a more feminine gender identity than the one that is expected for their recorded sex at birth. The term “transfeminine” is an umbrella term that encompasses both transgender women and feminine people of non-binary identity. Many transgender people experience what is known as gender dysphoriathis is discomfort caused by people’s bodies not matching their sense of identity.
This photo contains content that some people may find graphic or disturbing.
Not every transgender person deals with their gender dysphoria in the same way. However, for many people, hormone therapy can help them feel more like themselves. For transmasculine people, this involves testosterone treatment. For transfeminine people, this usually involves a combination of testosterone blockers and estrogen treatment.
What Are The Risks Of Hormone Treatment
Ideally, medical treatment should be based on scientific evidence, but there is little research about the use of cross-sex hormones. Guidance is therefore provided, which may be used flexibly, taking account of your particular needs and keeping the risk to your health as low as possible.
Hormone treatment for trans people at reasonable dosages is remarkably safe. The hormone products that you will be prescribed are very like the natural hormones produced by the body. Most people taking hormones do not experience any major problems.
However, all medication has potential side effects, and some people may have serious adverse reactions to it. You need to be aware of the possible risks, however remote, before deciding to start treatment.
The most serious risks when taking oestrogens are:
Thrombosis Pulmonary embolism Altered liver function.
The most serious risk when taking testosterone is:
Polycythaemia .The risk of developing complications from hormone treatment is relatively small and is less common if your general health is good.Thrombosis in trans women is more likely to occur within the first year of treatment, particularly if you are taking a hormone called ethinylestradiol.There are far fewer risks of thrombosis with oestradiol, which is the product most widely prescribed for trans women now.
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Creating Your Hormone Therapy Plan
Well need to look at several factors, including:
- Your goals how much you hope to change
- Your age and medical history
A blood test happens first. This will give us a baseline to compare against after you start hormones.
Analyzing your blood also helps us see if taking hormones could cause side effects. And well continue to monitor your blood levels during therapy to make sure youre OK.
We usually get lab results back in a couple of days. If we dont see any issues, usually then your transgender hormone therapy can start.
Surgery For Trans Men
Common chest procedures for trans men include:
- removal of both breasts and associated chest reconstruction
- nipple repositioning
Breast implants for trans women are not routinely available on the NHS.
Gender surgery for trans men includes:
- construction of a penis
- construction of a scrotum and testicular implants
- a penile implant
Removal of the womb and the ovaries and fallopian tubes may also be considered.
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Transgender Hormone Therapy Is Safe When Monitored For Certain Risks
One of the most often cited reasons by medical providers for hesitation in providing hormone therapy to transgender individuals is the fear of harm. The review demonstrates that hormone therapy is relatively safe, at least as far as the modest literature out there can determine. Providers should be reassured that the harms that do exist are relatively rare and can often be avoided with conventional monitoring.
The take-home points from the review are:
1. The current literature suggests that transgender hormone therapy is safe for most situations and reasonable to monitor.
2. The current literature is quite thin, with a need for large, more carefully done studies to address concerns regarding more subtle harms.
The findings align with the hormone approach found in both the World Professional Association for Transgender Health Standards of Care and The Endocrine Society Guidelines. The primary difference between this review and the two guidelines is the failure to detect increased cancer risk despite the concerns raised in the guidelines.
Use of hormone therapy in trans* adults is considered safe when carefully monitored for certain risks, such as venous thromboembolism in trans women women with use of estrogen therapy, according to a literature review published in the February 24 issue of the Journal of Clinical and Translational Endocrinology. The findings may help reduce the barriers for transgender individuals to receive medical care.
References
What You Need To Know
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Transgender people using hormone treatment need lifelong medical support and care. Hormonal treatment for gender dysphoria resembles hormone replacement therapy for people with hypogonadism.
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Hormone treatment in transgender people is accepted to be safe and increases overall wellbeing in most people. The most common side effects are venous thrombosis in trans women due to oestrogens and polycythaemia caused by androgens in trans men.
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Some trans women will not have had their prostate removed and some trans men keep their ovaries. Be aware of the risk of cancer in these sites and think about the added risk of hormone supplementation.
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Who Is Feminizing Hormone Therapy For
Feminizing hormone therapy is an option for transwomen people who were assigned male at birth but identify as women. This therapy is a common treatment for gender dysphoria .
Nonbinary or intersex people may also choose to undergo feminizing hormone therapy. Nonbinary people have gender identities that dont fit inside traditional male or female categories. Intersex people are born with reproductive or sexual characteristics that dont fit traditional perceptions of male and female bodies. They may have conditions affecting their gonads, external genitals or chromosome patterns.
Stated simply, feminizing hormone therapy is for anyone who feels that theres a mismatch between their external appearance and their authentic sense of gender and self.