Managing the risk of venous thromboembolism in transgender adults undergoing hormone therapy
Open accessAbstract
Introduction: Venous thromboembolism (VTE) is a potential risk of estrogen therapy. However, data show an improvement in the quality of life for transgender people who use feminizing hormone therapy. With few transgender-specific data, guidance may be drawn from cisgender (nontransgender) data, with a focus on hormonal birth control and postmenopausal hormone replacement therapy (HRT). The aim of this review is to examine the degree to which routes of administration, patient comorbidities, and type of hormone utilized affect the safety of estrogen therapy. Methods: We identified 6,349 studies by searching PubMed with the terms “transgender”, “estrogen”, “VTE”, and “HRT”. Of these, there were only 13 studies between 1989 and 2018 that investigated the effects of hormone therapy, including types of estrogens used, in transgender women and men. Results: The data suggest that the route of hormone administration, patient demographics, and patient comorbidities all affect estrogen’s link with VTE. For example, avoiding ethinyl estradiol might make the use of hormone therapy in trans feminine individuals safer than oral birth control. Data from both cis and trans groups suggest additional VTE risk associated with the use of progestins. While transdermal estrogens dosed up to 0.1 mg/day or below appear lower risk for VTE than other forms of estrogen, it is unclear whether this is related to the delivery method or a dose effect. Finally, even if the risk from exogenous estrogen use remains significant statistically, the absolute clinical risk remains low. Conclusion: Clinicians should avoid the use of ethinyl estradiol. Additionally, data suggest that progestins should be avoided for transgender individuals. Further study of the relationship between estrogen use and the risk of VTE will serve to inform the safest care strategies for transgender individuals. Keywords: transgender, estrogen therapy, venous thromboembolism
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Oral estrogens have similar effects on surrogate inflammatory endpoints in transgender women as in cisgender women, including elevation in proinflammatory cytokines IL-1, IL-6, IL-8, and TNF-α.
“Oral estrogens seem to have similar effects on surrogate inflammatory endpoints in transgender women as they do in cisgender women [117], such as elevation in proinflammatory cytokines IL-1, IL-6, IL-8, and tumor necrosis factor-α [118].”
From Estrogen and thrombosis: a bench to bedside review (2020) · cites this paper as [117]
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Oh, J., Yun, Y., & Lee, E. S. (2022) · Journal of Menopausal Medicine · doi:10.6118/jmm.22039 · Cited by 4 · see citing works
Schachter, H., Blaszczak, J., & Barnes, G. D. (2025) · Vascular Medicine · doi:10.1177/1358863x251334141 · Cited by 3 · see citing works
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Medical Care of Transgender Athletes and Policy Implications: ACSM Contemporary Issue Statement
Marra, J., Christensen, D. A., Harper, J. M., Iwamoto, S. J., Ryan, W., Safer, J. D., Streed, C. G., Nokoff, N., & Moreau, K. L. (2026) · Translational Journal of the American College of Sports Medicine · doi:10.1249/tjx.0000000000000336 · Cited by 1 · see citing works
Self-citationGender Affirming Surgeries of the Trunk
Park, R. H., & Stranix, J. T. (2024) · Current Surgery Reports · doi:10.1007/s40137-024-00388-x · Cited by 1 · see citing works
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Beyond the Binary: Considerations About Gender-affirming Care for the General Surgeon
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Yu, J. L., Lane, M. E., Roach, G. D., & Morrison, S. D. (2022) · Thrombosis Research · doi:10.1016/j.thromres.2022.12.006
Riesgo de enfermedad cardiovascular en la población transgénero
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Considerations in Care of the Transgender Orthopedic Patient
Jacobson, A. R., Goodrich, E., Feroe, A. G., & Rahman, A. (2025) · Current Reviews in Musculoskeletal Medicine · doi:10.1007/s12178-025-09984-5
Risk of venous thromboembolism in the transgender population on hormone therapy: A systematic review
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The Impact of Prior Substance Use on Postoperative Outcomes Following Gender-Affirming Surgery
Alexander, C., Henry, A., Nuamah, D., Lewis, J. E., Gantt, B., Green, K. M., Alexis, M. M., & Ibidapo-Obe, O. (2025) · Therapeutics · doi:10.3390/therapeutics2030014
Enhancing Care: Caring for Transgender and Gender Diverse Patients in the Emergency Department
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Contraceptive Needs of the Transmasculine Patient
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Breaking barriers: navigating cardiovascular health in the transgender community
Gupta, P., Diwan, D., Naveya, Siddiqui, A. N., Dhingra, G., Sinha, K. R., Asif, A., Mahajan, V., Bajwa, B., & Karmani, V. K. (2026) · Internal and Emergency Medicine · doi:10.1007/s11739-026-04484-x
- Authors
- Goldstein, Z., Khan, M., Reisman, T., & Safer, J. D.
- Affiliations
- Mount Sinai Health System (US)
- New York Medical College (US)
- Corresponding author
- Safer, Joshua D
- Venue
- Journal of Blood Medicine
- Publisher
- Informa UK Limited
- Published
- 2019-07
- Volume
- Volume 10
- Pages
- 209-216
- ISSN
- 1179-2736 (ISSN-L)
- PMC
- PMC6628137
- OpenAlex
- W2957469563
- Cited by
- 63
- References
- 38
- Citations by year
- 2026: 5 · 2025: 8 · 2024: 9 · 2023: 9 · 2022: 12 · 2021: 12 · 2020: 8
- FWCI
- 6.13
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Journal of Blood Medicine (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- Touro Scholar (Touro College) (submittedVersion)
- Topics
- Health Sciences › Medicine › Internal Medicine › Venous Thromboembolism Diagnosis and Management
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Menopause: Health Impacts and Treatments
- Social Sciences › Psychology › Social Psychology › LGBTQ Health, Identity, and Policy
- Keywords
- venous thromboembolism, transgender adults, feminizing hormone therapy, estrogen therapy, ethinyl estradiol, progestins, transdermal estrogen, hormone replacement therapy, hormonal contraception, thrombosis risk
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