Feb 10, 2023 Lisa Jaffe Freelance Medical Writer
Hormone therapy benefits continue to outweigh risks for many trans women as they age.
What we know about transgender and gender queer people is vastly greater now than it was even a decade ago. And yet, there are still significant gaps in knowledge. It is exceptionally evident in issues related to hormone therapy and how it affects those who seek feminizing treatment for gender dysphoria as they age. At the most recent North American Menopause Society (NAMS) conference, Sarah Pickle, MD, associate professor of family and community medicine at the University of Cincinnati, outlined what we know about hormones and aging trans women.
There are 1.3 million adults¹ who are known to identify as trans in the United States, and that is probably a significant undercount, she said. Many patients are first seen after the age of 50, or even 60, and currently, there is no FDA-approved treatment for patients of any age experiencing gender dysphoria. It is all done off-label. Most patients seeking feminizing treatment are put on estrogen and anti-androgen regimens. Progesterone is not often included in treatment, in part because there is no data to support its use, and there may be risk of venous thromboembolism (VTE) associated with using medroxyprogesterone.²
Balancing Risks and Benefits of Hormone Therapy
Even if there were data that supported that use, the choice would still need to be personal, Dr. Pickle said. The decision of how best to balance risk with living a life that is authentic varies among individuals. While some patients may opt for higher estrogen doses in order to get the maximum benefit, others may want to keep their testosterone levels higher in order to preserve fertility. Some may want to stay stealth at work and only live as a woman or gender queer person outside of those hours. “This is where treatment is individualized,” she said.
Changes do not happen immediately from hormone use. They happen over years – time that can increase risks of adverse effects. But Dr. Pickle said there is no evidence to suggest that patients should stop taking hormones based on age alone. “There isn’t a clear target goal for hormone levels in trans women over 50,” she said. “We measure it in trans medicine, but among cis-gendered women past menopause, we don’t.”
Though specific optimal levels remain unknown, what is known is that hormone therapy has health benefits for trans women, she continued. “Removing that option for many is life-endangering,” she said. Quality of life scores for trans women over 60 who started hormone therapy in the previous two years are higher than those who did not use hormones.³⁻⁵ “Patients believe the medications are safe and medically necessary regardless of age or socioeconomic status. And our patients’ beliefs about these medications play into decisions,” she said. “The bottom line is that the benefits of hormone therapy outweigh possible risks across all ages.”
None of this is to deny the risks that do exist, among them:
- VTE: For those taking estradiol orally who are over 45, there is twice the VTE risk of a cis-gendered person. However, using a patch formula of 17 beta estradiol or injection of it makes the risk equivalent to that of cis peers. Dr. Pickle said newer studies show that VTE risk can increase over time, with four times greater risk after eight years of therapy than it is after two. Providers should review the signs of VTE at every appointment and consider non-oral routes of therapy such as patches, which can reduce risk to the equivalent of non-trans women. ⁶⁻⁹
- Heart attack and stroke: Risk of heart attack and stroke in trans women on estrogen is twice that of cis-gendered women, she said. The highest risk for stroke seemed to occur in those using estrogen injections for more than 7 years. Those with certain risk factors, or who are over 45, should consider other options.¹⁰
- Cardiovascular disease: Risk of cardiovascular disease is linked to more than just estrogen, Dr. Pickle said. Among them are the usual suspects, such as hypertension, diabetes, HIV, smoking, sleep problems, and substance use. Additionally trans people often also have risk due to the psychosocial stresses of living with a marginalized identity and often face violence and discrimination. Patients living their best, most authentic lives always have better outcomes than those who do not, so she advised addressing other risk factors before considering changes to estrogen use. “It can make them less likely to be misgendered, less likely to face violence, and that means less stress. That’s a good thing.”
- Breast cancer: Data related to the risk of breast cancer from hormone treatment in the trans community is conflicting. Some studies suggest no greater risk than that of cis men, or 1.2 per 100,000. In cis women, it is 170 per 100,000. For trans women, the rate of cancer falls between, at 31.4.¹¹⁻¹³ “We need to screen trans women, but the recommendations differ,” Dr. Pickle said. In her practice, she said she starts talking about breast cancer screening at age 40, and she considers breast density before deciding on a screening method.
- Bone health: Both estrogen and testosterone play fundamental roles in bone health. In those who have natal gonads removed, bone density will change. If they are not on hormone therapy and no longer have natal gonads, Dr. Pickle said to consider screening in five years after treatment. If they are on hormone therapy, there will be higher bone density. “Always screen after 65, and from 45 to 64 screen those with higher risk, those who take medications that can impact bone density, or those with a fracture history.”
A Lack of Transgender Health Data and Training
“We need more data for trans health in general,” Dr. Pickle noted. “To be epidemiologically invisible limits us as physicians. How can we have accurate conversations with our patients?” Studies that look at how risk is impacted if someone goes from a 0.1 mg estrogen patch to a 0.05 mg patch are non-existent. There is no good science on risk stratification, and a lack of data related to the risks of anti-androgens. “We need more robust, randomized controlled trials so we can talk more eloquently about how the population data translates to the individual,” Dr. Pickle said in a post-conference interview with EndocrineWeb Pro.
She said that often, when talking about the statistics of medications, the focus is on how many people are harmed. “I like to think about how many we have helped. If we provide hormone therapy to one patient, we have helped that patient. There may be risk, and given the individual patient, we may have to adapt treatment to minimize it. But the benefits outweigh the risks in these patients.”
Even when risk factors are considered, trans patients say resolutely that hormone therapy is necessary. “This is life saving and life altering medicine. Research evolves – and it is a dynamic area of medicine. But medicine hasn’t caught up with that,” Dr. Pickle said.
A third of medical schools have zero hours dedicated to trans health, she noted, and the average is about 5 hours for all LGBTQIA education.¹⁴ She believes that providers need to “operate from the mindset that the benefits of hormone therapy likely outweigh the risks of most patients over their lifetime. The conversation is about how to work on other risk factors so that this medication that is critical for their life works for you with the least amount of risk. Don’t be scared to treat the patient. Believe them when they say this is critical to their health.”
NO COAST MENOPAUSE 