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Review
. 2023 Sep 2;7(6):102197.
doi: 10.1016/j.rpth.2023.102197. eCollection 2023 Aug.

Thromboembolic risk with gender-affirming hormone therapy: potential role of global coagulation and fibrinolysis assays

Emma G Bouck  1 , Eduarda Grinsztejn  2 , Megan Mcnamara  3   4 , Evi X Stavrou  5   6 , Alisa S Wolberg  1
Affiliations
Review

Thromboembolic risk with gender-affirming hormone therapy: potential role of global coagulation and fibrinolysis assays

Emma G Bouck et al. Res Pract Thromb Haemost. .

Abstract

Gender-affirming hormonal therapies are a critical component of the care of transgender individuals. Transgender people are commonly prescribed estrogen or testosterone to promote male-to-female or female-to-male transitions and to preserve gender-specific characteristics long-term. However, some exogenous hormones, especially certain estrogen preparations, are an established risk factor of thrombosis. As the number of individuals seeking gender-based care is rising, there is an urgent need to identify and characterize the mechanisms underlying hormone-associated thrombosis and incorporate this information into clinical algorithms for diagnosis and management. Herein, we discuss historical evidence on the incidence of thrombosis and changes in plasma composition in transgender and cisgender cohorts. We present 3 case studies to demonstrate knowledge gaps in thrombosis risk stratification and prediction tools. We also present data from in vitro coagulation and fibrinolysis assays and discuss how information from these kinds of assays may be used to help guide the clinical management of transgender individuals.

Keywords: estrogens; fibrinolysis; risk factors; thrombosis; transgender.

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Figures

Figure
Figure
Global plasma coagulation analyses. Citrated plasmas from cases #1 (green) and #2 (blue) and reference cisgender individuals (females, solid black; males, dashed black) were diluted 1:1. Thrombin generation was triggered with the addition of calcium (16.67 mM, final), phospholipids (4 μM, final), and tissue factor (Innovin diluted 1:15,000, final) in the (A) absence or (B) presence of rabbit thrombomodulin (5 nM, final). (C) Fibrin formation and (D) fibrinolysis were followed by turbidity at 405 nm triggered with calcium (10 mM, final), phospholipids (4 μM, final), and tissue factor (Innovin diluted 1:15,000, final) without and with tissue plasminogen activator ([tPA] 0.31 μg/mL, final), respectively. TG, thrombin generation; TM, thrombomodulin.
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