In May, 2020, we published a blog on what we know about how hormones in gender affirming care impacts cardiovascular risk. One of the difficulties that we face in providing gender affirming care is the lack of high-quality studies about the health impacts of gender affirming care in transgender, gender diverse, and/or nonbinary people. We often must apply data learned in studies on cisgender people to us. This is one of the reasons we believe in informed consent: we will be honest about what we know and do not know so that you can make decisions about your medical care with as much information as possible.
Our conclusions from a review of the available data about the impact of testosterone on Cardiovascular Disease Risk in transmasculine people taking testosterone for gender affirmation in May, 2020 were:
- Taking testosterone can increase your total body weight, which is a risk factor for CVD.
- BUT testosterone can also cause an overall decrease in total body fat, which is a protective factor against CVD
- Gained weight may be lean muscle mass, which can be protective against heart disease.
Testosterone often changes some lipid labs:
- It can cause higher homocysteine and triglyceride levels and lower HDL levels – all three of these can increase CVD risk
- However, total cholesterol and LDL cholesterol usually don’t increase on testosterone
- This means that overall lipid profile changes may not affect CVD risk much
What does this mean for heart disease events?
- Heart Attack Probability: No change in risk of having a heart attack (myocardial infarction).
- Stroke Probability: No change in risk of having a stroke
- Blood clot Probability: No change in risk of having a blood clot
In July of 2021, the American Heart Association published a statement discussing cardiovascular disease risk in transgender and genderdiverse populations, how to assess it, and implications for continued research and providing care1. Their conclusions were that, based on the evidence we do have, transmasculine people as a group do appear to experience higher rates of heart attack compared to cisgender men and cisgender women. However, there was no clear evidence that taking testosterone was the cause for this increased risk Instead, the authors point to emerging research that this increase in heart disease risk is a result of minority stress.
Minority Stress Theory describes, essentially, the impact of micro and macro aggressions and other experiences of marginalized populations on the body.
The theory envisions a holistic view of body systems: minority stressors cause stress levels to rise and stay risen, which cause negative chemical and physical changes in the body over time.
A figure from the American Heart Association statement illustrates how these stressors can impact cardiovascular health. Pictured below is The intersectional transgender multilevel minority stress model. (CVD indicates cardiovascular disease; HDL, high-density lipoprotein; LDL, low-density lipoprotein; and SGM, sexual and gender minority.)
The authors highlight the impact of “Resilience Factors”
Factors such as exercise, gender euphoria, social support, affirmation, and queer joy can improve your heart health.
There isn’t a lot of direct evidence to support that resilience factors can improve heart health in gender diverse populations, but there is a lot of indirect evidence, and many of us can draw a clear line between our body’s health and the presence or absence of marginalizing stress in our lives. We’re on board with proclaiming that gender euphoria and queer joy are good for your heart!
A review of the literature
With this publication in mind, we set out to read studies published in the last year and a half about cardiovascular risk in people taking gender affirming testosterone. Much of what we learned in our last review has additional evidence behind it now, but there is still not enough evidence to know definitively if taking testosterone is beneficial or harmful to heart-health.
The increasing body of evidence includes:
- For adolescents starting T into young adulthood, body weight and cholesterol levels are not significantly different compared to their cis peers. However, transmen are more likely to be heavier at the start of hormone therapy.2
- Lipid profiles tend to worsen in the first two years after starting T (increased total cholesterol, triglycerides, and LDL cholesterol, and lower HDL cholesterol.)3,4 Longer term studies appear to indicate that total cholesterol levels do not change, and there is no increase to total cardiovascular risk.10
- There is insufficient data to know if blood pressure levels are negatively affected by starting T.5
- In adults starting T, body weight increases, but fat mass decreases (increased muscle) – this is protective to heart health.6
- Three small studies indicated that inflammatory markers and measurements of early indicators of atherosclerosis increased on T. However these studies were both short in duration and had few participants, and other studies show protective effects of testosterone on blood vessels. It is not understood why this is, and no conclusions about overall cardiovascular risk were made.7,8,9,10
- There appears to be no increased risk of stroke or blood clots for transmasculine individuals from testosterone. Rates of diabetes appear to be higher compared to cisgender women, but not compared to cisgender men.10
- Overall, there appears to be no increased risk of cardiovascular or cerebrovascular disease in transmasculine people from testosterone.10
Back to The American Heart Association and Minority Stress
We know that stress can impact us on a daily basis. Over time, daily and systemic stressors in the lives of marginalized populations can lead to higher overall disease rates, including cardiovascular disease. All of the studies we’ve cited so far conclude that more research is necessary to fully understand cardiovascular disease risk in transgender, gender diverse, and nonbinary people. The American Heart Association goes further in recognizing that gender-affirming treatment improves modifiable disease risk behaviors: when we experience gender euphoria and are affirmed, we tend to smoke and drink less, we tend to exercise more, we get better sleep, and we may get better overall care.
An important factor in addressing overall risk is screening for HIV and preventing HIV infection through safer sex practices and PrEP. Individuals infected with HIV have a significantly increased risk for a variety of cardiovascular complications. In the United States, CVD has become a key contributor to mortality among individuals living with HIV.11 The impact of living with HIV on cardiovascular disease may be even higher in transgender, gender diverse, and nonbinary populations.
Putting it All Together
- Gender affirming testosterone does not appear to significantly raise your cardiovascular risk
- Especially in marginalized populations, daily and systemic stress can raise your risk of heart disease
- We can’t control some of this stress
- Gender affirmation – including hormone therapy – can reduce the burden of these stressors
- So can other heart healthy behaviors: exercise, limiting alcohol and tobacco, getting sufficient sleep, experiencing joy, good nutrition
- HIV can significantly increase cardiovascular risk. Prevention, detection of, and early treatment for HIV are important to your heart health.
- Safer sex practices and PrEP are great tools for protecting your heart!
If you are a QueerDoc patient, your provider will discuss the risks and benefits of hormones, your individual cardiovascular risk factors, and things you can do to protect your cardiovascular system. We encourage all patients and providers to have these discussions regularly.
- Streed, Carl G Jr et al. “Assessing and Addressing Cardiovascular Health in People Who Are Transgender and Gender Diverse: A Scientific Statement From the American Heart Association.” Circulation, CIR0000000000001003. 8 Jul. 2021, doi:10.1161/CIR.0000000000001003
- Klaver, Maartje et al. “Hormonal Treatment and Cardiovascular Risk Profile in Transgender Adolescents.” Pediatrics vol. 145,3 (2020): e20190741. doi:10.1542/peds.2019-0741
- Cocchetti, Carlotta et al. “Does Gender-Affirming Hormonal Treatment Affect 30-Year Cardiovascular Risk in Transgender Persons? A Two-Year Prospective European Study (ENIGI).” The journal of sexual medicine vol. 18,4 (2021): 821-829. doi:10.1016/j.jsxm.2021.01.185
- Schönauer, Luca Maria et al. “Hormone therapy in female-to-male transgender patients: searching for a lifelong balance.” Hormones (Athens, Greece) vol. 20,1 (2021): 151-159. doi:10.1007/s42000-020-00238-2
- Connelly, Paul J et al. “Transgender adults, gender-affirming hormone therapy and blood pressure: a systematic review.” Journal of hypertension vol. 39,2 (2021): 223-230. doi:10.1097/HJH.0000000000002632
- Spanos C, Bretherton I, Zajac JD, Cheung AS. Effects of gender-affirming hormone therapy on insulin resistance and body composition in transgender individuals: A systematic review. World J Diabetes. 2020 Mar 15;11(3):66-77. doi: 10.4239/wjd.v11.i3.66. PMID: 32180895; PMCID: PMC7061235.
- Gulanski, Barbara I et al. “Compromised endothelial function in transgender men taking testosterone.” Clinical endocrinology vol. 92,2 (2020): 138-144. doi:10.1111/cen.14132
- Testosterone administration increases leukocyte-endothelium interactions and inflammation in transgender men
Iannantuoni, Francesca et al.
Fertility and Sterility, Volume 115, Issue 2, 483 – 489
- The heart of the matter: balancing potential cardiovascular risks with known benefits of gender-affirming testosterone
Stroumsa, Daphna et al.
Fertility and Sterility, Volume 115, Issue 2, 334 – 335
- Connelly PJ, Marie Freel E, Perry C, Ewan J, Touyz RM, Currie G, Delles C. Gender-Affirming Hormone Therapy, Vascular Health and Cardiovascular Disease in Transgender Adults. Hypertension. 2019 Dec;74(6):1266-1274. doi: 10.1161/HYPERTENSIONAHA.119.13080. Epub 2019 Oct 28. Erratum in: Hypertension. 2020 Apr;75(4):e10. PMID: 31656099; PMCID: PMC6887638.