Transgender patients and the role of the coagulation clinician

Abstract

The medical care of transgender patients relies on the use of sex hormones to develop and maintain the physical characteristics consistent with gender identity as the first step in transitioning. Hormonal therapy is usually continued indefinitely, even following gender‐affirming surgeries. The use of hormonal treatments is associated with a multitude of positive effects as well as complications and side effects. The risk of venous thromboembolism (VTE) is a major concern. Transgender patients are often referred to coagulation specialists for advice regarding an individual patient's risk for VTE, especially if there is a personal or family history of VTE. Coagulation specialists need to be familiar with endocrine therapy including the goals of treatment and the VTE risks associated with currently used hormone regimens. We will review common referral questions and the available data and their limitations for the use of hormonal therapy in transgender patients focusing on the risk of VTE.

Which patients are at high risk of recurrent venous thromboembolism (deep vein thrombosis and pulmonary embolism)?

“…30 More recently, the Registro Informatizado de Enfermedad TromboEmbólica (Computerized Registry of Patients with Venous Thromboembolism) investigators reported a 2-year VTE recurrence rate of 3.3% for women whose initial event was pregnancy (or postpartum) associated. 31 Collectively, these data suggest that limited duration anticoagulation may be appropriate for most women with prior pregnancy-associated VTE, after close follow-up and personalized assessment of risk factors as outlined in Figure 2.…”

Affirming Hormone Treatment for a Transgender Adolescent After a Venous Thromboembolic Event

“…A recent retrospective cohort study showed no cases of VTE among TGD adolescents on testosterone therapy in one clinical setting 20. Overall, conclusions from the literature regarding testosterone therapy have been conflicting, and case reports for the adolescent TGD population may suggest an association of testosterone and VTE 21–23. Among adolescents, one case report describes a 17-year-old transgender male receiving masculinizing therapy for male gender affirmation who presented with bilateral pulmonary emboli 21.…”

Sex‐specific aspects of venous thromboembolism: What is new and what is next?

“…On the risk of venous and arterial thrombotic events in transmen (persons born with female sex assigned and male gender identity) who use testosterone as gender‐affirming hormone therapy, only few data are available 31,33‐35 . In the available studies, there does not seem to be an increased risk of thrombotic events compared with control ciswomen (persons born with female sex assigned at birth and a female gender identity) 31,33,34 .…”