Cardiovascular Disease During Gender Transition

The cohort study by Getahun and colleagues (2018, Annals of Internal Medicine) found an increased risk of venous thromboembolism and ischemic stroke among trans women taking estrogen.

Findings from Getahun 2018

The cohort study by Getahun and colleagues (2018, Annals of Internal Medicine) found an increased risk of venous thromboembolism and ischemic stroke among trans women taking estrogen. The same study found no clearly increased cardiovascular risk among trans men taking testosterone, but the follow-up period was relatively short.

Dutch Cohort Data

The Amsterdam cohort study (Wiepjes et al. 2018) has followed a large group of transgender people since 1972 and provides long-term data on cardiovascular and metabolic outcomes. The results support periodic cardiovascular risk assessment during long-term hormone treatment.

Recommendations

International guidelines recommend actively monitoring risk factors (blood pressure, lipids, glucose, smoking, and weight) and, when risk is elevated, adjusting the route of estrogen administration — for example, switching from oral to transdermal estrogen.

Amsterdam Research on Heart Attacks and Stroke

A 2019 study published in the journal Circulation compared more than 2,500 transgender women and more than 1,300 transgender men from the Amsterdam gender clinic with the general population. Trans women had strokes and thrombosis more often than both men and women, and heart attacks more often than women. Trans men had heart attacks more often than women. The figures on stroke and heart attacks among estrogen users are available on genderrisico.nl.

Mortality

The same research group published mortality figures in 2021 covering a period of nearly fifty years. Mortality among trans women was approximately twice as high as among men in the general population, while mortality among trans men was higher than among women. Cardiovascular disease was one of the leading causes of death, alongside lung cancer, HIV-related disease, and suicide. The difference compared with the general population had not narrowed over the decades.

How Hormones Affect Risk

Estrogen increases the blood's tendency to clot, especially in tablet form and at higher doses; see thrombosis risk with estrogen. Testosterone increases the number of red blood cells, making the blood thicker, and worsens the lipid profile. Smoking, excess weight, and high blood pressure add to these risks. The studies cannot determine what proportion of the risk is caused by hormones and what proportion is due to lifestyle and stress. Because treatment is lifelong, ongoing monitoring by a general practitioner or internist remains necessary. See estrogen, testosterone, and side effects of hormones.