Transgender venous thrombosis

Abstract

53-year-old male-to-female transgender patient on cross-sex hormone replacement therapy (CSHT), estradiol 8 mg daily, presented to the emergency department (ED) with acute-onset headache and left visual field disturbances after a recent mechanical fall with head trauma. The medical history was notable for hyperlipidemia. There was no personal or family history of clotting disorders and no history of tobacco use.In the ED, the patient experienced a generalized tonic-clonic seizure characterized by forced left gaze deviation lasting 1 minute. Neurologic examination was notable for left inferior quadrantanopia. Noncontrast CT of the head showed a right parietal hypodensity. MRI revealed infarction involving the left parietal-occipital cortex in a nonarterial distribution suggesting venous infarction. Magnetic resonance venography (MRV) confirmed a cortical vein thrombosis with cortical microhemorrhage (figure).Hospital management included cessation of CSHT and initiating systemic anticoagulation with heparin as a bridge to warfarin with goal international normalized ratio 2-3.Laboratory evaluation for hypercoagulability was negative. The patient's headache and visual field deficits improved and she was discharged home without functional deficit.At 90-day follow-up, the patient's headache and vision continued to subjectively improve. Interval MRV showed recanalization of the cortical vein (figure). Repeat serologic evaluation for hypercoagulability was negative. With resolution of the thrombus, anticoagulation was discontinued, aspirin 81 mg daily was started for antithrombotic effect, and CHST with lower dose estradiol 4 mg daily was resumed.

Cerebral Venous Thrombosis and Hypercoagulability Associated With In Vitro Fertilization

“…1,5 CVST can occur in the setting of primary or inherited thrombophilia (antithrombin III, protein C and S deficiencies, and factor V Leiden), acquired thrombophilias such as thrombocytopenia or disseminated intravascular coagulation, trauma, malignancy, dehydration, or changes in hormone levels caused by pregnancy or oral hormonal supplementation with estrogen. [1][2][3][4]6,7 Estradiol is an essential sex steroid in women, mainly secreted from ovarian follicles during the follicular phase of the menstrual cycle. 8 Exogenous estrogen is used for oral contraception, treatment of symptoms related to menopause, IVF, and gender transitioning.…”

“…8 Exogenous estrogen is used for oral contraception, treatment of symptoms related to menopause, IVF, and gender transitioning. 2,3,6 The adverse effects of estrogen are complicated and involve disruption of the balance between procoagulation and anticoagulation factors. 3 Other procoagulant risk factors such as increased age, an underlying preexisting hypercoagulable state, and smoking can synergistically increase the hypercoagulability associated with exogenous hormone use.…”

Neurological Health in Sexual and Gender Minority Individuals

“…Lastly, there have been case reports of transwomen presenting with cerebral venous thrombosis in the setting of estrogen GAHT and with no other known risk factors for hypercoagulability. 37,38 Treatment Considerations…”

Thromboembolic risk with gender-affirming hormone therapy: potential role of global coagulation and fibrinolysis assays

“…Thromboembolic events were documented as early as the 1970s in MTF-transitioning individuals receiving GAHT. Most studies have reported venous thrombosis or thromboembolism, including deep vein thrombosis with or without pulmonary embolism [ [14] , [15] , [16] , [17] ], cerebral venous thrombosis [ [18] , [19] , [20] ], and retinal vein occlusion [ 21 ]. MTF patients have also presented with arterial thrombosis, including myocardial infarction and ischemic stroke [ 22 , 23 ].…”