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Transgender Adults, Gender-Affirming Hormone Therapy and Blood Pressure: a Review Systematic

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Transgender Adults, Gender-Affirming Hormone Therapy and Blood Pressure: a Review Systematic View metadata, citation andReview similar papers at core.ac.uk brought to you by CORE provided by Enlighten Transgender adults, gender-affirming hormone therapy and blood pressure: a systematic review Paul J. Connelly, Anna Clark, Rhian M. Touyz, and Christian Delles estrogen, gonadotropin-releasing hormone (GnRH) ana- Objectives: Gender-affirming hormone therapy (GHT) is 04/14/2021 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= by http://journals.lww.com/jhypertension from Downloaded logues and antiandrogens, aims to align the characteristics utilized by people who are transgender to align their of transgender people with their gender identity [1]. Downloaded secondary sex characteristics with their gender identity. The recent substantive increases in population preva- Data relating to cardiovascular outcomes in this population lence of transgender people requires the implementation of are limited. We aimed to review the impact of GHT on the from evidence-based guidance to better protect the health of this http://journals.lww.com/jhypertension blood pressure (BP) of transgender individuals. population [2–4]. However, due to a paucity of epidemio- Methods: We searched PubMed/MEDLINE, SCOPUS and logical and mechanistic data, there is considerable uncer- Cochrane Library databases for articles published relating tainty surrounding the impact of GHT on the cardiovascular to the BP of transgender adults commencing GHT. health of transgender individuals [5–7]. Existing data sug- Methodological quality was assessed via the ‘Quality gest that the use of estrogens in transgender women confers Assessment Tool for Before–After (Pre–Post) Studies with an increased risk of myocardial infarction and ischemic by No Control Group’. stroke. Conversely, transgender men receiving testosterone BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= Results: Six hundred articles were screened, of which 14 lack any consistent evidence of an increased risk of cardio- studies were included in this systematic review encompassing vascular or cerebrovascular disease [7]. However, in the 1309 individuals (50% transgender men and women) absence of randomized controlled trials or comprehensive treated with GHT between 1989 and 2019. These articles prospective longitudinal studies, ambiguity remains regard- were all pre–post observational studies without control ing whether such risk exists, and by which interventions groups. Mean ages ranged between 23.0–36.7 years this risk can be ameliorated. (transgender men) and 25.2–34.8 years (transgender Consequently, international guidelines, set out by the women). Interventions were diverse and included oral, Endocrine Society and World Professional Association for transdermal and injectable hormonal preparations with 4 Transgender Health, have been cautious in their recommen- months to 5 years follow-up. Most studies in transgender dations regarding modifiable risk factors for cardiovascular men did not demonstrate a change in BP, whereas disease in this population [8,9]. Hypertension remains the transgender women on GHT demonstrated both increases most important modifiable risk factor for the development of and decreases in SBP. These studies were heterogenous with cardiovascular disease. Therefore, these organizations have significant methodological limitations and only two were not unreasonably recommended that blood pressure (BP) is determined to have a good quality rating. monitored in transgender people receiving GHT. However, these guidelines do not provide any indication of the effect Conclusion: There is currently insufficient data to advise size of this treatment on BP, treatment targets for this patient the impact of GHT on BP in transgender individuals. Better group, or the levels of evidence for this recommendation. quality research is essential to elucidate whether A comprehensive overview is therefore required to exogenous sex hormones modulate BP in transgender assess the impact of GHT on the BP. Our aim was to people and whether this putative alteration infers poorer perform a systematic review of the relationship of exoge- cardiovascular outcomes. nous sex hormones and SBP and DBP in transgender men Keywords: blood pressure, estrogen, testosterone, and women commencing treatment. on transgender 04/14/2021 Abbreviations: BP, blood pressure; GHT, gender-affirming hormone therapy; GnRH, gonadotropin-releasing hormone; Journal of Hypertension 2021, 39:223–230 VSMC, vascular smooth muscle cell Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK Correspondence to Christian Delles, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK. Tel: +44 141 330 2749; e-mail: [email protected]; Paul J. Connelly, University of Glasgow, INTRODUCTION Glasgow, United Kingdom. E-mail: [email protected] Received 22 June 2020 Revised 20 July 2020 Accepted 28 July 2020 ransgender people experience gender dysphoria J Hypertens 39:223–230 Copyright ß 2020 The Author(s). Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the Creative due to incongruence between their gender identity Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribu- T and the sex they were assigned at birth [1]. Gender- tion, and reproduction in any medium, provided the original work is properly cited. affirming hormone therapy (GHT), including testosterone, DOI:10.1097/HJH.0000000000002632 Journal of Hypertension www.jhypertension.com 223 Connelly et al. METHODS Before–After (Pre–Post) Studies with No Control Group was utilized [11]. This tool is comprised of 12 questions used Eligibility criteria to assess the risk of types of bias, such as selection, We included randomized trials and observational studies of reporting or observer bias. The methodological quality of transgender individuals who used GHT regardless of gen- included studies was assessed by two authors (P.J.C. and der-reassignment surgery status. Eligible studies included A.C.) separately. Each study was defined as poor, fair or transgender men prescribed testosterone and transgender good based on the answers compiled from this tool. To women prescribed estrogen, antiandrogens (cyproterone determine the level of agreement between assessing acetate, finasteride or spironolactone) or GnRH agonists. authors, Cohen’s kappa was calculated [12]. A score less Studies were included regardless of dose of GHT. Studies than 0.4 is considered poor, between 0.4 and 0.8 fair to were required to provide a comparison of BP before and substantial, and above 0.8 as almost perfect interrater after/during treatment for a minimum of 3 months. Articles agreement. A meta-analysis of uncontrolled pre–post stan- with participants under the age of 16 were excluded in dardized mean differences in BP was not performed as they addition to review articles, commentaries and letters that lack independence and fail to discern between intra-indi- did not contain original data. BP measurements could vidual and interventional effects [13]. include manual, automated or ambulatory recordings. Many transgender individuals receiving GHT may be gen- RESULTS der non-binary (e.g. their gender identity or expression does not confirm to typical binary gender), and may not Study selection and characteristics consider themselves as simply men or women [3]. However, Our multidatabase literature search identified 600 nondu- for the purposes of this systematic review, transgender plicated potentially relevant records (Fig. 1). No records people treated with estrogen (with or without antiandro- were identified through other resources. Following the gens and GnRH analogues) were considered transgender screening of these records’ titles and abstracts, 84 full text women, whereas transgender individuals treated with tes- articles were assessed for eligibility; however, 70 articles tosterone were considered transgender men. were excluded due to not being original investigations, not assessing relevant outcomes, not obtaining pre-GHT out- Search strategy come measurements [14] or including adolescent popula- The current systematic review adhered to the Preferred tions [15–18]. Reporting Items for Systematic Reviews guidelines [10]. Consequently, 14 studies were included in this system- PubMed/MEDLINE, SCOPUS and Cochrane Library data- atic review encompassing 1309 individuals (50% trans- bases were searched for articles published until 13 January gender men and women) treated with GHT between 1989 2020. The search was limited to English language articles. and 2019. Follow-up ranged between 4 months and 5 years. The following medical subject headings were used in the 11 of the included studies were undertaken in Europe and search: ‘blood pressure’ AND ‘transgender’ OR ‘transgender three in North America. Mean ages ranged between 23.0– person’ OR ‘person, transgender’ OR ‘persons, transgender’ 36.7 years in transgender men and 25.2–34.8 years in OR ‘transgender persons’ OR ‘transmasculine’ OR ‘trans- transgender women. feminine’ OR ‘trans masculinization’ OR ‘trans feminization’ Of the included studies, all studies were pre–post obser- OR ‘gender incongruent’ OR ‘gender dysphoric’ OR ‘gender vational studies without control groups. Only one study affirming’ OR ‘transsexual persons’ OR ‘person, transsexual’ provided the device used to measure
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