Gender-Affirming Hormone Therapy and Cardiovascular Disease Risk

Does gender-affirming hormone therapy affect the risk of cardiovascular disease in transgender people? Little research to date has been done on this question. Clinicians have had to make treatment decisions based on limited knowledge of hormone effects on cis-gender people. (Cis-gender people maintain the same sex and gender assigned at birth.) But a research team from the Department of Internal Medicine, the Centre of Expertise on Gender Dysphoria, and the University Medical Centre, all at Vrije Universiteit in Amsterdam, recently conducted a systematic review and meta-analysis to address these concerns. The European Journal of Endocrinology published their study in February 2024. (van Zijverden et al., 2024)

This benchmark review compares cardiovascular risk between transgender and cisgender people of the same birth sex. For trans women (assigned male at birth), hormone therapy typically consists of estradiol or other estrogen preparations, usually combined with medications to suppress testosterone. Testosterone suppression agents have been used for years to treat prostate cancer and adrenal diseases, as well as to provide gender affirming care. For trans men (assigned female at birth) hormone therapy typically consists of testosterone preparations.

Experts had long hypothesized that estrogen protects heart health. That was partly because cisgender women experience an increased risk of cardiovascular disease after menopause, when estrogen declines. Yet research has demonstrated that cisgender women and cisgender men are actually at similar risk for developing heart disease. And clinical trials failed to show that estrogen protected against this future risk. (Grady et al., 2002)

Overall, both trans men and trans women have higher risks of cardiovascular disease than their cisgender counterparts do but this increased risk is not fully explained by gender-affirming hormone therapy. For example,  although feminizing hormone therapy improves blood pressure and lipid profiles, transgender women still seem to experience more cardiovascular events than ciswomen and cismen do. (Matsumori and Nakatsuka, 2023) Perhaps not surprisingly, testosterone use in transgender men is associated with lipid and blood pressure increases, which increase their risk of heart disease. (Connelly et al., 2019)

The review authors, led by Lieve Mees Van Zijverden, searched for previous studies that evaluated cardiovascular events in transgender women and men. They identified and analyzed twenty-two studies involving a total of 19,893 transgender women, 14,840 transgender men, 371,547 cisgender men, and 434,700 cisgender women.

This review did not address the questions of how and why hormonal therapy might affect heart health. Rather, it focused specifically on cardiovascular risk factors for transgender people undergoing hormone therapy. Its main points concerned major cardiovascular events, such as stroke, heart attack, blood clots in the lungs and legs. The researchers found that both trans women and trans men have an increased risk for blood clots in the lungs and legs, compared to cisgender people. Trans people may also have a weakly increased risk for stroke but the data is not decisive. The difference in risk for stroke and heart attack was not statistically significant in the study.

The review and meta-analysis does not answer the question of causality. However, the publication is a valuable first step in identifying and mitigating risk in the trans community. Regardless of the method of gender affirming care an individual chooses, it is imperative to manage known cardiovascular risk factors including cholesterol, blood sugar, and blood pressure. (Asamoah, 2025; Masamora and Nakatsuka, 2023)

We need more extensive clinical trials in order to better understand the risks -- as well as the benefits -- of gender-affirming hormone therapy for transgender people. Additional studies should also consider the potential influence of social, economic, and lifestyle factors on cardiovascular risk in the transgender community.

Asamoah, E. (2025). Enhancing cardiovascular health outcomes: The role of digital health in the 8 essential life factors. Medical Research Archives, 13(6). full article

Connelly, P. J., Marie Freel, E., Perry, C., Ewan, J., Touyz, R. M., Currie, G., & Delles, C. (2019). Gender-affirming hormone therapy, vascular health and cardiovascular disease in transgender adults. Hypertension, 74(6), 1266–1274. full article

Grady, D., Herrington, D., Bittner, V., Blumenthal, R., Davidson, M., Hlatky, M., Hsia, J., Hulley, S., Herd, A., Khan, S., Newby, L., Waters, D., Vittinghoff, E., Wenger, N., & for the HERS Research Group. (2002). Cardiovascular disease outcomes during 6.8 years of hormone therapy. JAMA, 288(1), 49. full article

Masumori, N., & Nakatsuka, M. (2023). Cardiovascular Risk in Transgender People With Gender-Affirming Hormone Treatment. Circulation reports, 5(4), 105–113. full article

van Zijverden, L., Wiepjes, C., van Diemen, J., Thijs, A., & den Heijer, M. (2024). Cardiovascular disease in transgender people: A systematic review and meta-analysis. European Journal of Endocrinology, 190(2), S13–S24. full article