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Revisão da Endocrine Society: só evidências de baixa qualidade sobre riscos cardíacos dos hormônios, poucos eventos

Esteroides sexuais e desfechos cardiovasculares em indivíduos transgênero: uma revisão sistemática e metanálise

Revisões sistemáticas e de evidênciasHormônios do sexo oposto
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

  • A revisão foi paga pela Endocrine Society para apoiar sua diretriz de 2017 sobre o tratamento da disforia de gênero (sofrimento em relação ao próprio sexo) com hormônios.
  • Incluiu 29 estudos abrangendo 3.231 mulheres trans e 1.500 homens trans; apenas 1 designou o tratamento aleatoriamente, 17 apenas compararam as pessoas antes e depois e apenas 4 tinham um grupo de comparação.
  • Em homens trans, após 2 anos ou mais, a testosterona foi ligada a gorduras no sangue mais altas (triglicerídeos, aumento de 21,4 mg/dL), colesterol 'ruim' mais alto (aumento de 17,8 mg/dL) e colesterol 'bom' mais baixo (queda de até 8,5 mg/dL).
  • Em mulheres trans, as gorduras no sangue estavam mais altas após 2 anos ou mais (aumento de 31,9 mg/dL), sem mudança clara no colesterol.
  • Entre as mulheres trans, os estudos relataram 56 coágulos em 1.767 pessoas, 14 infartos em 1.073, 8 derrames em 859 e 139 mortes em 1.486, incluindo 23 mortes relacionadas ao coração e 26 suicídios.
  • Entre os homens trans, os estudos relataram apenas 1 coágulo em 771, 1 infarto em 478, nenhum derrame em 340 e 13 mortes em 651.
  • Os revisores classificaram a evidência geral como de baixa qualidade, provavelmente afetada por relato seletivo, com poucos dados sobre os eventos de saúde que mais importam para os pacientes.

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.