Transgender adults, gender-affirming hormone therapy and blood pressure: a systematic review

Abstract

Objectives: Gender-affirming hormone therapy (GHT) is utilized by people who are transgender to align their secondary sex characteristics with their sex identity. Data relating to cardiovascular outcomes in this population are limited. We aimed to review the impact of GHT on the blood pressure (BP) of transgender individuals. Methods: We searched PubMed/MEDLINE, SCOPUS and Cochrane Library databases for articles published relating to the BP of transgender adults commencing GHT. Methodological quality was assessed via the 'Quality Assessment Tool for Before-After (Pre-Post) Studies with No Control Group'. Results: Six hundred articles were screened, of which 14 studies were included in this systematic review encompassing 1309 individuals ($50% transgender men and women) treated with GHT between 1989 and 2019. These articles were all pre-post observational studies without control groups. Mean ages ranged between 23.0-36.7 years (transgender men) and 25.2-34.8 years (transgender women). Interventions were diverse and included oral, transdermal and injectable hormonal preparations with 4 months to 5 years follow-up. Most studies in transgender men did not demonstrate a change in BP, whereas transgender women on GHT demonstrated an increase in SBP but not DBP. These studies were heterogenous with significant methodological limitations and only two were determined to have a good quality rating. Conclusion: There is currently insufficient data to advise the impact of GHT on BP in transgender individuals. Better quality research is essential to elucidate whether exogenous sex hormones modulate BP in transgender people and whether this putative alteration infers poorer cardiovascular outcomes.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

“…A retrospective study of the effects of estrogen- and testosterone- based GAHT regimens on blood pressure found a slight reduction in systolic blood pressure with the initiation of estrogen-based regimens; while there was a slight elevation (4 mm Hg) in mean systolic blood pressure on long term follow-up of testosterone-based regimens, this difference was at the margin of statistical significance and of limited clinical relevance (Banks et al., 2021 ). A systematic review concluded, given the limited quality of the studies, there is insufficient data to reach conclusions on the effects of gender-affirming hormone therapy on blood pressure (Connelly et al., 2021 ). Spironolactone, often used as an androgen blocker in feminizing GAHT, is a potassium sparing diuretic and may increase potassium when used in conjunction with ACE inhibitors or angiotensin receptor blocker medications, as well as salt substitutes.…”

2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension

“…testosterone, estrogens, antiandrogens and gonadotropin-releasing hormone analogs) is used in transgender individuals to favorably modulate their secondary sex characteristics in line with gender identity. There is conflicting evidence from small studies of limited duration on the direction or extent of BP changes in transgender individuals receiving gender-affirming therapies [1027]. It is also undetermined whether transgender hormonal treatments are associated with increased CV risk.…”

Sex steroids receptors, hypertension, and vascular ageing

“…This putative interaction may be of particular importance to the long-term vascular health of transgender individuals receiving gender-affirming hormonal therapy. There is currently insufficient data to advise the impact of sex steroids on blood pressure in this population, however, some studies suggest a higher rate of hypertension [ 75 , 76 ]. It remains unclear to what effect the administration of physiological concentrations of estrogen or testosterone has in natal males and females, respectively, on sex steroid receptor expression or function.…”