Limited Data to Guide Transgender Hormonal Management Beyond Middle-Age

By Will Boggs MD

June 23, 2019

NEW YORK (Reuters Health) - Although the risks associated with transgender hormonal therapy likely change with age, current transgender therapy guidelines do not include specific recommendations for patients 50 years and older.

In a new report, online May 1 in Maturitas, Dr. Valerie Libby and colleagues from Case Western Reserve University School of Medicine, in Cleveland, Ohio, review changes in physiology with age, recommended maintenance therapy and safety evaluation to mitigate the risks of hormonal therapy for older transgender individuals.

For transgender men and women, it is important to use the minimum dose of transgender hormones to achieve desired effects because of the adverse effects that may result from hormonal therapy, especially at supratherapeutic levels.

While cardiovascular events do not appear to be increased among transgender men receiving testosterone therapy, there is evidence of increases in blood pressure and lipids.

Because polycythemia is a common adverse effect of gender-affirming testosterone therapy, surveillance should include a baseline hematocrit and subsequent hematocrit monitoring with the goal of maintaining it below 54%, the authors say.

Recommended screening for bone health does not differ for transgender men, except that earlier screening may be indicated for patients who had oophorectomy with a history of at least five years without hormone therapy or with some therapeutic testosterone levels.

Transgender women receiving estrogen and antiestrogens face an increased risk of venous thromboembolism and should be educated on signs and symptoms of cardiovascular events, including sudden chest pain, shortness of breath, hemoptysis and calf pain.

There are insufficient data regarding the risk of developing hormone-dependent malignancies in transgender persons, so routine screening for cancers should follow current cisgender guidelines, pending further study.

"It is important for physicians to understand these potential long-term risks and weigh them against the risk of mortality from suicide without hormone therapy in this vulnerable population," the researchers conclude. "Further research should focus on long-term outcomes and provide new reference ranges for appropriate laboratory monitoring in these patients as it may not be reliable to use gender-specific reference ranges."

"Providers should be aware of new study findings as research evolves in this area," they add.

Dr. Justine Defreyne from Ghent University in Belgium, who studies treatment of transgender persons, told Reuters Health by email, "In the absence of long-term data and/or data in older adults, data from short-term studies and/or surrogate populations are often applied to the transgender population. Therefore, we must remain cautious when interpreting guidelines and recommendations. However, we are quite optimistic about the future, as large prospective studies are nowadays including transgender people of all ages."

"I would also like to stress that being transgender is not a 'hype' of young people, but gender nonconformism and gender dysphoria may occur at any age," she said. "Also, older transgender people often kept quiet about their gender identities out of fear of stigmatization in the past, when they were younger. Luckily, many societies are becoming more open and tolerant towards the concept of different gender identities, which may encourage older transgender people to open up and to seek gender-affirming care, if desired."

"We must also keep in mind that it was only a couple of years ago that older transgender people were frequently denied gender-affirming care - which could be regarded as ageism - which had led to many older transgender people not seeking gender-affirming care," Dr. Defreyne said. "I think it would be important for geriatricians, gerontologists, and care facilities to become more aware of the concept of different gender identity groups, to be well informed, and to treat this population using the right pronouns, adverbs, and with the respect they deserve."

Dr. Libby did not respond to a request for comments.


Maturitas 2019.