TY - JOUR
T1 - Assessing and Addressing the Risk of Venous Thromboembolism Across the Spectrum of Gender Affirming Care
T2 - A Review
AU - Arrington-Sanders, Renata
AU - Connell, Nathan T.
AU - Coon, Devin
AU - Dowshen, Nadia
AU - Goldman, Anna L.
AU - Goldstein, Zil
AU - Grimstad, Frances
AU - Javier, Noelle Marie
AU - Kim, Ellie
AU - Murphy, Martina
AU - Poteat, Tonia
AU - Radix, Asa
AU - Schwartz, Aviva
AU - St. Amand, Colt
AU - Streed, Carl G.
AU - Tangpricha, Vin
AU - Toribio, Mabel
AU - Goldstein, Robert H.
N1 - Funding Information:
All authors had full access to all study data, take full responsibility for the accuracy of the analysis, and have authority over manuscript preparation and decisions to submit the manuscript for publication. Grants or contracts from any entity not listed in grant support section: for C.S.: grants from NHLBI, AHA, and NIAAA; for A.S.: grants from United Therapeutics, Bayer, Acceleron, Altavant, RareGen LLC, Alexion, Janssen, Cardinal Health, AstraZeneca, PeerView, PriMed, Boston Scientific, Abbott Medical, Temple Health, Bristol Myers Squibb, BMS Foundation, Bristol Myers Squibb-Pfizer Alliance; for V.T.: grants from Cystic Fibrosis Foundation, NIH; for M.T.: Harvard University Center for AIDS, NIH/NHLBI, Robert Wood Johnson Foundation and American Heart Association, MGH Department of Medicine. Consulting fees: for C.S.: EverlyWell, LLC.; for F.G.: Next Gen Jane; For TP: Merck, ViiV Healthcare; for Z.G.: Thunermist Health Center, WPATH; for R.G.: Best Doctors, LLC. Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events: for M.M.: Medpage Today, Integrity CME; for V.T.: American Association of Clinical Endocrinology; for A.G.: Cooper Hospital, NJ. Payment for expert testimony: for V.T.: Kirkland Ellis; for R.G.: Kellog and Van Aiken, LLP. Support for attending meetings and/or travel: for V.T.: American Association of Clinical Endocrinology. Patents planned/issued/pending: none. Participation on a data safety monitoring board or advisory board: for N.C.: on advisory board of Takeda; for M.T.: Data Safety Monitoring Board Member for the Lite Plus Study. Leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid: for N.C.: on board of Michael H. Flanagan Foundation; for C.S.: on board of USPATH; for A.S.: on board of NATF; for V.T.: WPATH, Southern Society of Clinical Investigation; for M.T.: American Heart Association Bioethics Subcommittee Member and Diversity and Inclusion Working Group Member; Women in Endocrinology Membership Committee Chair and Executive Board Member; Nutrition and Obesity Research Center NIH/NIDDK Diversity and Inclusion Working Group; Nutrition and Obesity Research Center at Harvard Associate Member Council Co-Director and Executive Board Member; MGH Internal Medicine Residency Interview and Selection Committee Member; MGH Endocrinology Fellowship Interview and Selection Committee member and URIM Subcommittee member; for Z.G.: USPATH; for R.G.: HIVMA, MassEquality. Stock or stock options: for N.C.: stock in Doximity. Receipt of equipment, materials, drugs, medical writing, gifts, or other services no. Other financial or non-financial interests: none.
Funding Information:
We thank the North American Thrombosis Forum, in Brookline, Massachusetts, as well as Troy Keyser and Andrea Martinez for their invaluable comments and support during this work. This work was supported by an educational grant from Bristol Myers Squibb to the North American Thrombosis Forum . The funder of this work had no role in the design, preparation, or writing of the report.
Publisher Copyright:
© 2022 AACE
PY - 2023/4
Y1 - 2023/4
N2 - Objective: Accumulating evidence demonstrates that gender affirming hormone therapy (GAHT) improves mental health outcomes in transgender persons. Data specific to the risks associated with GAHT for transgender persons continue to emerge, allowing for improvements in understanding, predicting, and mitigating adverse outcomes while informing discussion about desired effects. Of particular concern is the risk of venous thromboembolism (VTE) in the context of both longitudinal GAHT and the perioperative setting. Combining what is known about the risk of VTE in cisgender individuals on hormone therapy (HT) with the evidence for transgender persons receiving HT allows for an informed approach to assess underlying risk and improve care in the transgender community. Observations: Hormone formulation, dosing, route, and duration of therapy can impact thromboembolic risk, with transdermal estrogen formulations having the lowest risk. There are no existing risk scores for VTE that consider HT as a possible risk factor. Risk assessment for recurrent VTE and bleeding tendencies using current scores may be helpful when assessing individual risk. Gender affirming surgeries present unique perioperative concerns, and certain procedures include a high likelihood that patients will be on exogenous estrogens at the time of surgery, potentially increasing thromboembolic risk. Conclusions and Relevance: Withholding GAHT due to potential adverse events may cause negative impacts for individual patients. Providers should be knowledgeable about the management of HT in transgender individuals of all ages, as well as in the perioperative setting, to avoid periods in which transgender individuals are off GAHT. Treatment decisions for both anticoagulation and HT should be individualized and tailored to patients’ overall goals and desired outcomes, given that the physical and mental health benefits of gender affirming care may outweigh the risk of VTE.
AB - Objective: Accumulating evidence demonstrates that gender affirming hormone therapy (GAHT) improves mental health outcomes in transgender persons. Data specific to the risks associated with GAHT for transgender persons continue to emerge, allowing for improvements in understanding, predicting, and mitigating adverse outcomes while informing discussion about desired effects. Of particular concern is the risk of venous thromboembolism (VTE) in the context of both longitudinal GAHT and the perioperative setting. Combining what is known about the risk of VTE in cisgender individuals on hormone therapy (HT) with the evidence for transgender persons receiving HT allows for an informed approach to assess underlying risk and improve care in the transgender community. Observations: Hormone formulation, dosing, route, and duration of therapy can impact thromboembolic risk, with transdermal estrogen formulations having the lowest risk. There are no existing risk scores for VTE that consider HT as a possible risk factor. Risk assessment for recurrent VTE and bleeding tendencies using current scores may be helpful when assessing individual risk. Gender affirming surgeries present unique perioperative concerns, and certain procedures include a high likelihood that patients will be on exogenous estrogens at the time of surgery, potentially increasing thromboembolic risk. Conclusions and Relevance: Withholding GAHT due to potential adverse events may cause negative impacts for individual patients. Providers should be knowledgeable about the management of HT in transgender individuals of all ages, as well as in the perioperative setting, to avoid periods in which transgender individuals are off GAHT. Treatment decisions for both anticoagulation and HT should be individualized and tailored to patients’ overall goals and desired outcomes, given that the physical and mental health benefits of gender affirming care may outweigh the risk of VTE.
KW - clinical risk
KW - gender affirming hormone therapy
KW - transgender
KW - venous thromboembolism
UR - http://www.scopus.com/inward/record.url?scp=85149667110&partnerID=8YFLogxK
U2 - 10.1016/j.eprac.2022.12.008
DO - 10.1016/j.eprac.2022.12.008
M3 - Review article
C2 - 36539066
AN - SCOPUS:85149667110
SN - 1530-891X
VL - 29
SP - 272
EP - 278
JO - Endocrine Practice
JF - Endocrine Practice
IS - 4
ER -