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Endocrine Societys eget review fandt kun lavkvalitetsbelæg for hormoners hjerterisici, med få undersøgte hændelser

Kønssteroider og kardiovaskulære udfald hos transkønnede personer: et systematisk review og metaanalyse

Systematiske & evidensgennemgangeKønshormoner
Authors
Spyridoula Maraka, Naykky Singh Ospina, Rene Rodriguez-Gutierrez, Caroline J. Davidge-Pitts, Todd B. Nippoldt, Larry J. Prokop, M. Hassan Murad
Journal
The Journal of Clinical Endocrinology & Metabolism
Year
2017
Source
https://doi.org/10.1210/jc.2017-01643

Summary

To prepare its 2017 guideline on hormone treatment for trans people, the Endocrine Society (a body of hormone doctors) paid Mayo Clinic reviewers to gather all studies on cross-sex hormones and heart health. They found 29 studies. Almost all simply observed patients, and many had no comparison group. Testosterone in trans men worsened cholesterol, raising 'bad' cholesterol and blood fats and lowering 'good' cholesterol. Estrogen in trans women raised blood fats. Heart attacks, strokes, blood clots and deaths were too rarely reported to measure risk, though they were more common in trans women. The reviewers judged the evidence low quality. The review mainly shows how little was known about heart safety when the guideline was written. Larger studies published since (for example Getahun 2018 and Nota 2019) are not included.

Key findings

  • Gennemgangen blev betalt af Endocrine Society til at støtte dens retningslinje fra 2017 om behandling af kønsdysfori (lidelse over ens køn) med hormoner.
  • Den inkluderede 29 studier med 3.231 transkvinder og 1.500 transmænd; kun 1 tildelte behandling tilfældigt, 17 sammenlignede blot folk før og efter, og kun 4 havde en sammenligningsgruppe.
  • Hos transmænd var testosteron efter 2 eller flere år forbundet med højere blodfedt (triglycerider, op med 21,4 mg/dL), højere ‘dårligt’ kolesterol (op med 17,8 mg/dL) og lavere ‘godt’ kolesterol (ned med op til 8,5 mg/dL).
  • Hos transkvinder var blodfedt højere efter 2 eller flere år (op med 31,9 mg/dL), uden tydelig ændring i kolesterol.
  • Blandt transkvinder rapporterede studierne 56 blodpropper hos 1.767 personer, 14 hjerteanfald hos 1.073, 8 slagtilfælde hos 859 og 139 dødsfald hos 1.486, heraf 23 hjerterelaterede dødsfald og 26 selvmord.
  • Blandt transmænd rapporterede studierne kun 1 blodprop hos 771, 1 hjerteanfald hos 478, ingen slagtilfælde hos 340 og 13 dødsfald hos 651.
  • Gennemgangerne vurderede den samlede evidens som af lav kvalitet, sandsynligvis påvirket af selektiv rapportering, med få data om de helbredshændelser, der betyder mest for patienterne.

Abstract

BACKGROUND: Transgender individuals receive cross-sex hormonal therapy to induce desired secondary sexual characteristics despite limited data regarding its effects on cardiovascular health. METHODS: A comprehensive search of several databases up to 7 April 2015 was conducted for studies evaluating the effect of sex steroid use on lipids, myocardial infarction, stroke, venous thromboembolism (VTE), and mortality in transgender individuals. Pairs of reviewers selected and appraised the studies. A random-effects model was used to pool weighted mean differences and 95% confidence intervals (CIs). RESULTS: We found 29 eligible studies with moderate risk of bias. In female-to-male (FTM) individuals, sex steroid therapy was associated with statistically significant increases in serum triglyceride (TG) levels at 3 to 6 months and at ≥24 months (21.4 mg/dL; 95% CI: 0.14 to 42.6) and in low-density lipoprotein cholesterol (LDL-C) levels at 12 months and ≥24 months (17.8 mg/dL; 95% CI: 3.5 to 32.1). High-density lipoprotein cholesterol (HDL-C) levels decreased significantly across all follow-up periods (highest at ≥24 months, -8.5 mg/dL; 95% CI: -13.0 to -3.9). In male-to-female (MTF) individuals, serum TG levels were significantly higher at ≥24 months (31.9 mg/dL; 95% CI: 3.9 to 59.9) without any changes in other parameters. Few myocardial infarction, stroke, VTE, and death events were reported (more frequently in MTF individuals). CONCLUSIONS: Low-quality evidence suggests that sex steroid therapy may increase LDL-C and TG levels and decrease HDL-C level in FTM individuals, whereas oral estrogens may increase TG levels in MTF individuals. Data about important patient outcomes remain sparse.

Conclusion

Low-quality evidence suggests that sex steroid therapy may increase LDL-C and TG levels and decrease HDL-C level in FTM individuals, whereas oral estrogens may increase TG levels in MTF individuals. Data about important patient outcomes remain sparse.