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Eigen review Endocrine Society: slechts laagwaardig bewijs over hartrisico’s van hormonen; weinig gebeurtenissen

Geslachtssteroïden en cardiovasculaire uitkomsten bij transgenders: een systematische review en meta-analyse

Systematische & evidence reviewsCross-sekse hormonen
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

  • De review werd betaald door de Endocrine Society ter ondersteuning van haar richtlijn uit 2017 over de behandeling van genderdysforie (nood over het eigen geslacht) met hormonen.
  • Ze omvatte 29 studies over 3.231 transvrouwen en 1.500 transmannen; slechts 1 wees behandeling willekeurig toe, 17 vergeleken alleen mensen voor en na, en slechts 4 hadden een vergelijkingsgroep.
  • Bij transmannen hing testosteron na 2 of meer jaar samen met hogere bloedvetten (triglyceriden, 21,4 mg/dL hoger), hoger 'slecht' cholesterol (17,8 mg/dL hoger) en lager 'goed' cholesterol (tot 8,5 mg/dL lager).
  • Bij transvrouwen waren bloedvetten na 2 of meer jaar hoger (31,9 mg/dL hoger), zonder duidelijke verandering in cholesterol.
  • Bij transvrouwen meldden studies 56 bloedstolsels bij 1.767 mensen, 14 hartaanvallen bij 1.073, 8 beroertes bij 859 en 139 sterfgevallen bij 1.486, waaronder 23 hartgerelateerde sterfgevallen en 26 suïcides.
  • Bij transmannen meldden studies slechts 1 bloedstolsel bij 771, 1 hartaanval bij 478, geen beroertes bij 340 en 13 sterfgevallen bij 651.
  • De beoordelaars beoordeelden het bewijs over het geheel als lage kwaliteit, waarschijnlijk beïnvloed door selectieve rapportage, met weinig gegevens over de gezondheidsgebeurtenissen die voor patiënten het belangrijkst zijn.

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.