Assessing Cardiovascular Risk in Individuals Seeking Gender-Affirming Care

Overview

Gender-affirming hormone therapy (GAHT) influences cardiovascular risk profiles in transgender and gender-diverse (TGD) individuals, with oestrogen and testosterone therapies exerting distinct effects. Current cardiovascular risk assessment tools, designed for cisgender populations, inadequately capture these dynamic changes, underscoring the need for tailored risk models.

Background

Gender incongruence affects approximately 0.5–1.3% of the global population, with increasing numbers seeking gender-affirming care including hormone therapy. GAHT typically involves oestrogen and antiandrogens for TGD women and testosterone for TGD men, both of which impact cardiovascular health through changes in coagulation, lipid profiles, and hematologic parameters. Traditional cardiovascular risk assessment tools are binary and based on sex assigned at birth, limiting their applicability to TGD individuals undergoing hormonal transition.

Data Highlights

Oestrogen therapy in TGD women is associated with increased pro-thrombotic factors and endothelial dysfunction but may improve lipid profiles by lowering LDL and raising HDL cholesterol. Testosterone therapy in TGD men increases hematocrit and promotes an atherogenic lipid profile with higher LDL and lower HDL cholesterol. Observational studies indicate increased cardiovascular risk in both groups, though long-term data remain limited. Baseline cardiovascular risk factors may also be elevated in TGD individuals due to minority stress and reduced physical activity.

Key Findings

• GAHT induces significant changes in cardiovascular risk factors: oestrogen increases thromboembolic risk while improving some lipid parameters; testosterone increases hematocrit and worsens lipid profiles.
• Current cardiovascular risk assessment tools (e.g., SCORE2) do not account for the dynamic effects of GAHT and rely on binary sex classification, limiting their accuracy in TGD populations.
• TGD individuals often have higher baseline cardiovascular risk factors due to social stressors and physical inactivity prior to GAHT initiation.
• Risk profiles may shift during gender transition, with TGD women potentially experiencing reduced lipid-related risk but increased thrombotic risk, and TGD men showing increased risk due to hypertension and lipid changes.
• There is a critical need for new, tailored cardiovascular risk models incorporating GAHT type, duration, body composition changes, and psychosocial factors specific to TGD individuals.

Clinical Implications

Clinicians should recognize that traditional cardiovascular risk tools may underestimate or misclassify risk in TGD patients undergoing hormone therapy. Comprehensive cardiovascular risk assessment should consider the type and duration of GAHT, baseline risk factors, and psychosocial determinants. Until tailored models are developed, individualized monitoring and preventive strategies are essential to optimize cardiovascular health in this population.

Conclusion

GAHT significantly alters cardiovascular risk profiles in TGD individuals, challenging the applicability of existing risk assessment tools. Development of dedicated, inclusive cardiovascular risk models is imperative to improve prevention and management strategies in gender-affirming care.

References

1. Source 1 -- Gender incongruence prevalence and care
2. Source 2 -- Effects of GAHT on cardiovascular risk
3. Source 3-5 -- Metabolic and fitness impacts of hormone therapy
4. Source 6 -- Limitations of cardiovascular risk tools
5. Source 7 -- Minority stress and baseline risk factors
6. Source 8 -- Need for tailored risk assessment models