Cardiovascular disease in transgender individuals

Transgender healthcare: metabolic outcomes and cardiovascular risk

Transgender identity is often associated with gender dysphoria and minority stress. Gender-affirming hormone treatment (GAHT) includes masculinising or feminising treatment and is expected to be lifelong in most cases. Sex and sex hormones have a differential effect on metabolism and CVD in cisgender people, and sex hormone replacement in hypogonadism is associated with higher vascular risk, especially in ageing individuals. Using narrative review methods, we present evidence regarding metabolic and cardiovascular outcomes during GAHT and propose recommendations for follow-up and monitoring of metabolic and cardiovascular risk markers during GAHT. Available data show no increased risk for type 2 diabetes in transgender cohorts, but masculinising GAHT increases lean body mass and feminising GAHT is associated with higher fat mass and insulin resistance. The risk of CVD is increased in transgender cohorts, especially during feminising GAHT. Masculinising GAHT is associated with a more adverse lipid profile, higher haematocrit and increased BP, while feminising GAHT is associated with pro-coagulant changes and lower HDL-cholesterol. Assigned male sex at birth, higher age at initiation of GAHT and use of cyproterone acetate are separate risk factors for adverse CVD markers. Metabolic and CVD outcomes may improve during gender-affirming care due to a reduction in minority stress, improved lifestyle and closer surveillance leading to optimised preventive medication (e.g. statins). GAHT should be individualised according to individual risk factors (i.e. drug, dose and form of administration); furthermore, doctors need to discuss lifestyle and preventive medications in order to modify metabolic and CVD risk during GAHT. Follow-up programmes must address the usual cardiovascular risk markers but should consider that biological age and sex may influence individual risk profiling including mental health, lifestyle and novel cardiovascular risk markers during GAHT.

The prevalence, phenotype and cardiometabolic risk of polycystic ovary syndrome in treatment-naïve transgender people assigned female at birth

PURPOSE

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among women of reproductive age. We aimed to investigate the prevalence and phenotypic characteristics of PCOS in testosterone treatment-naïve transgender people assigned female at birth (AFAB), as well as to determine whether cardiometabolic risk factors vary based on the presence of PCOS and its components.

METHODS

Evaluation of 112 testosterone treatment-naïve transgender adults AFAB for PCOS and its individual components, including androgen excess, ovulatory dysfunction and polycystic ovarian morphology (PCOM).

RESULTS

In our cohort, 79.5% of transgender individuals AFAB had at least one component of PCOS. The prevalence of PCOS was 38.4% (43/112). Phenotype C was the most common phenotype (17.8%), followed by phenotype B (10.7%). Transgender individuals AFAB with at least one component of PCOS had higher blood pressure (BP) measurements and higher fasting plasma glucose levels compared to those with none. Sixty-one subjects (54%) had hyperandrogenism (HA), with 20 (17.9%) having HA without other components of PCOS. When compared to those without HA, transgender individuals AFAB with HA had higher body mass index (BMI), BP, triglyceride and lower HDL-cholesterol levels.

CONCLUSION

PCOS and androgen excess appear to be prevalent among transgender people AFAB. Transgender individuals AFAB with HA or PCOS may exhibit an unfavorable cardiometabolic risk profile compared to those without any PCOS component. Assessment of androgen excess and the specific components of PCOS at baseline could inform long-term management.

Sex-specific differences in cardiovascular risk factors and implications for cardiovascular disease prevention in women

Cardiovascular disease (CVD) is the leading cause of mortality for women globally. Sex differences exist in the relative risks conferred by traditional CVD risk factors, including diabetes, hypertension, obesity, and smoking. Additionally, there are female-specific risk factors, including age of menarche and menopause, polycystic ovary syndrome, infertility and the use of assisted reproductive technology, spontaneous pregnancy loss, parity, and adverse pregnancy outcomes, as well as female-predominant conditions such as autoimmune diseases, migraines, and depression, that enhance women's cardiovascular risk across the lifespan. Along with measurement of traditional risk factors, these female-specific factors should also be ascertained as a part of cardiovascular risk assessment to allow for a more comprehensive overview of the risk for developing cardiometabolic disorders and CVD. When present, these factors can identify women at elevated cardiovascular risk, who may benefit from more intensive preventive interventions, including lifestyle changes and/or pharmacotherapy such as statins. This review describes sex differences in traditional risk factors and female-specific/female-predominant risk factors for CVD and examines the role of coronary artery calcium scores and certain biomarkers that can help further risk stratify patients and guide preventive recommendations.