Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons: A Cohort Study

Ann Intern Med. 2018 Aug 21;169(4):205-213. doi: 10.7326/M17-2785. Epub 2018 Jul 10.


Background: Venous thromboembolism (VTE), ischemic stroke, and myocardial infarction in transgender persons may be related to hormone use.

Objective: To examine the incidence of these events in a cohort of transgender persons.

Design: Electronic medical record-based cohort study of transgender members of integrated health care systems who had an index date (first evidence of transgender status) from 2006 through 2014. Ten male and 10 female cisgender enrollees were matched to each transgender participant by year of birth, race/ethnicity, study site, and index date enrollment.

Setting: Kaiser Permanente in Georgia and northern and southern California.

Patients: 2842 transfeminine and 2118 transmasculine members with a mean follow-up of 4.0 and 3.6 years, respectively, matched to 48 686 cisgender men and 48 775 cisgender women.

Measurements: VTE, ischemic stroke, and myocardial infarction events ascertained from diagnostic codes through the end of 2016 in transgender and reference cohorts.

Results: Transfeminine participants had a higher incidence of VTE, with 2- and 8-year risk differences of 4.1 (95% CI, 1.6 to 6.7) and 16.7 (CI, 6.4 to 27.5) per 1000 persons relative to cisgender men and 3.4 (CI, 1.1 to 5.6) and 13.7 (CI, 4.1 to 22.7) relative to cisgender women. The overall analyses for ischemic stroke and myocardial infarction demonstrated similar incidence across groups. More pronounced differences for VTE and ischemic stroke were observed among transfeminine participants who initiated hormone therapy during follow-up. The evidence was insufficient to allow conclusions regarding risk among transmasculine participants.

Limitation: Inability to determine which transgender members received hormones elsewhere.

Conclusion: The patterns of increases in VTE and ischemic stroke rates among transfeminine persons are not consistent with those observed in cisgender women. These results may indicate the need for long-term vigilance in identifying vascular side effects of cross-sex estrogen.

Primary funding source: Patient-Centered Outcomes Research Institute and Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Brain Ischemia / chemically induced
  • Brain Ischemia / epidemiology*
  • California / epidemiology
  • Electronic Health Records
  • Estradiol Congeners / adverse effects
  • Female
  • Follow-Up Studies
  • Gonadal Steroid Hormones / adverse effects*
  • Gonadal Steroid Hormones / therapeutic use
  • Humans
  • Incidence
  • Longitudinal Studies
  • Male
  • Middle Aged
  • Myocardial Infarction / chemically induced
  • Myocardial Infarction / epidemiology*
  • Transsexualism / drug therapy*
  • Venous Thromboembolism / chemically induced
  • Venous Thromboembolism / epidemiology*
  • Young Adult


  • Estradiol Congeners
  • Gonadal Steroid Hormones