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. 2025 Jun 17;16(1):44.
doi: 10.1186/s13293-025-00726-3.

Association between serum testosterone and measures of cardiovascular health among transgender individuals using gender-affirming testosterone therapy: a cross-sectional study

Badal S B Pattar  1   2   3 , Tyrone G Harrison  1   2   3   4   5 , Nathalie Saad  1   4 , Sandra M Dumanski  1   2   3   4 , A J Lowik  6 , Paul E Ronksley  1   3   5 , Dina N Greene  7 , Cameron T Whitley  8 , Chantal L Rytz  1   2   3 , Keila Turino Miranda  9 , Lindsay Peace  10 , Amelia M Newbert  10 , Darlene Y Sola  1 , Sofia B Ahmed  11   12   13
Affiliations

Association between serum testosterone and measures of cardiovascular health among transgender individuals using gender-affirming testosterone therapy: a cross-sectional study

Badal S B Pattar et al. Biol Sex Differ. .

Abstract

Background: Gender-affirming testosterone therapy (GATT) use may be associated with increased systolic blood pressure (SBP). The association between serum testosterone and cardiovascular health in individuals using GATT is unknown. The objective of this study was to estimate the association between serum testosterone and validated measures of cardiovascular health, including SBP and arterial stiffness, in persons assigned female sex at birth using GATT.

Methods: Healthy participants assigned female sex at birth on a stable GATT regimen for ≥ 4 months were recruited to this community-partnered exploratory cross-sectional study. Exposures of interest were total and free serum testosterone concentration. As our primary outcome, SBP was measured by an automated sphygmomanometer, and carotid-radial pulse wave velocity (PWVcr) and aortic augmentation index (AIx) were used to measure arterial stiffness via applanation tonometry.

Results: Participants (n = 18, median age 28 years, range: 18, 50) who predominantly self-identified as white (94%) and had been using GATT for a median of 48 months (range: 5, 84) were studied. Resting SBP, PWVcr, and AIx were 113 mmHg (range: 102, 129), 7 m/s (range: 4, 9), and 9% (range: - 10, 23), respectively. Total and free serum testosterone were not significantly associated with SBP or PWVcr. Free, but not total, serum testosterone was positively associated with AIx (p = 0.03). Sensitivity analyses did not modify any results.

Conclusions: In healthy transgender individuals, serum testosterone concentrations may not be associated with measures of cardiovascular health. However, these results need to be interpreted with caution given the limited sample size.

Keywords: Arterial stiffness; Blood pressure; Cardiovascular health; Gender-affirming hormone therapy; Serum testosterone; Testosterone; Transgender.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The study protocol was approved by the Conjoint Health Research Ethics Board of the University of Calgary (REB19-0460). Written informed consent was obtained from all study participants in accordance with the Declaration of Helsinki. Consent for publication: All authors have given their consent for publication of the manuscript in Biology of Sex Differences. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Time between last study day and corresponding total testosterone concentration of 17 transgender study participants. Results are stratified by route of administration. Dashed lines indicate reference range for total testosterone (14–24 nmol/L) suggested in the Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline [7, 9]
Fig. 2
Fig. 2
Association between total testosterone and A SBP (n = 17), B PWVcr (n = 16), C AIx (n = 16), with 95% confidence band. Total testosterone demonstrated a non-linear relationship with SBP. A square transformation was applied to correct the violated assumption. Abbreviations: AIx: Aortic Augmentation Index. CI: Confidence Interval. PWVcr: Carotid-Radial Pulse-Wave Velocity. SBP: Systolic Blood Pressure
Fig. 3
Fig. 3
Association between free testosterone and (A) SBP (n = 16), (B) PWVcr (n = 15), (C) AIx (n = 15), with 95% confidence band. Abbreviations: AIx: Aortic Augmentation Index. CI: Confidence Interval. PWVcr: Carotid-Radial Pulse-Wave Velocity. SBP: Systolic Blood Pressure
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