Mujeres trans con hormonas: 4,5 veces más coágulos y más ictus que hombres; hombres trans, más infartos que mujeres

Aparición de eventos cardiovasculares agudos en personas transgénero que reciben terapia hormonal

Estudios de cohorte y registros Hormonas cruzadas

Authors: Nienke M. Nota, Chantal M. Wiepjes, Christel J.M. de Blok, Louis J.G. Gooren, Baudewijntje P.C. Kreukels, Martin den Heijer
Journal: Circulation
Year: 2019
Source: https://doi.org/10.1161/CIRCULATIONAHA.118.038584

Summary

This short report used records from the Amsterdam gender clinic, which treats most trans people in the Netherlands. It counted strokes, heart attacks and blood clots in nearly 3,900 people on cross-sex hormones over about 8 to 9 years, and compared them with expected rates in the general population. Trans women had about 4.5 to 5.5 times the expected rate of blood clots and about twice the expected rate of stroke, and more heart attacks than women (but not men). Trans men had more heart attacks than women but about the same as men. Blood-clot risk was lower, though still raised, in trans women who started after 2001, when an older estrogen was dropped. The long follow-up makes this useful, but the comparison is with outside population figures, smoking was not accounted for, and the trans men's results rest on few events.

Key findings

El estudio incluyó a 2.517 mujeres trans y 1.358 hombres trans tratados en la clínica de género de Ámsterdam, seguidos unos 9 y 8 años de media.
Las mujeres trans tuvieron 73 coágulos de sangre en las venas: 5,5 veces la tasa esperada en las mujeres y 4,5 veces la de los hombres.
Las mujeres trans tuvieron 29 ictus (2,4 veces la tasa de las mujeres, 1,8 veces la de los hombres) y 30 infartos (2,6 veces la tasa de las mujeres; no superior a la de los hombres).
Los hombres trans tuvieron 11 infartos: 3,7 veces la tasa esperada en las mujeres e igual que la esperada en los hombres.
Los hombres trans tuvieron solo 6 ictus y 2 coágulos de sangre, sin diferencia clara con los hombres ni con las mujeres.
Dejar fuera a las mujeres trans que empezaron antes de 2001 (cuando se sustituyó un estrógeno más antiguo, el etinilestradiol) redujo la tasa de coágulos a unas 3,9 veces la de las mujeres y 3,4 veces la de los hombres; los otros riesgos no bajaron.
El 43–46 % de las personas del estudio fumaba, y esto no pudo tenerse en cuenta.

Conclusion

Considering the limitations, the authors conclude that the incidences of strokes and VTEs are higher in transwomen receiving hormone therapy than in both reference women and men, and that transwomen and transmen receiving hormone therapy are at higher risk of myocardial infarction than reference women. They urge physicians and transgender individuals to be aware of this increased cardiovascular risk and to reduce risk factors such as smoking.

Methodological limitations

Very short report: It was published as a two-page letter with few details, so how events were defined, who was left out and how results were checked are only briefly described.
Outside comparison only: Rates were compared with figures from separate Dutch and Norwegian population studies that found cases in different ways, not with a matched group of similar people.
Other risk factors ignored: The authors could not account for smoking (43–46% smoked) or life stresses, and weight, diabetes and other risk factors were not accounted for either.
Events may have been missed: Events were found by searching clinic files for doctors' letters. Events treated elsewhere and not reported back may have been missed, so true rates are probably higher.
Older drugs: Much of the follow-up involved older drugs (ethinylestradiol and high-dose cyproterone). Leaving out early starters lowered blood-clot risk, so the headline figure overstates risk on today's drugs, though risk was still raised.
Few events in trans men: Results rest on 6 strokes, 11 heart attacks and 2 blood clots, so the figures are very uncertain.
Some people left out: People who stopped hormones for long periods or switched between male and female hormones (such as some detransitioners) were excluded, as were 52 people with a past event.
Uneven follow-up: The typical person was followed for only about 4 to 6 years, much less than the average, so much of the data comes from a minority treated for a long time.
One clinic: Everyone was treated at one specialist centre, so results may not apply outside the Netherlands.

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Summary

Key findings

Conclusion