Gender-affirming hormone therapy and vascular health: walking the line between caution and confidence

AIM: Cardiovascular (CV) risk assessment in transgender individuals remains poorly understood. Emerging data suggest a potential increase in CV risk associated with gender-affirming hormone therapy(GAHT). Conventional tools such as coronary artery calcium(CAC) scoring may underestimate risk in this young population. Advanced imaging techniques (coronary computed tomography angiography CCTA and 3-dimensional supra-aortic trunk ultrasonography SATUS) may provide more accurate evaluation, but their relevance in transgender cohorts has not yet been established. We aimed to assess early CV risk modification of GAHT using several innovative imaging techniques. METHODS: We conducted a prospective, single-center study at Bordeaux University Hospital, enrolling transgender individuals initiating or continuing GAHT. Participants undergone clinical and biological assessment and CV imaging(CAC, CCTA, SATUS) at baseline and after 18months. RESULTS: Thirty-four participants (17transmen (TM), 17transwomen (TW) were included. At baseline, TM were younger than TW (22.7±5.3 vs 29.7±9.7years,p=0.008), had higher HDLc (1.36 vs 1.18mmol/L,p=0.01), and higher smoking prevalence (70.6% vs 11.8%, p=0.001). Both groups had a CAC score and carotid plaque volume of zero. During follow-up, TW showed a modest increase in carotid plaque volume and CAC scores, whereas TM showed no change. Progression of coronary plaque volume was observed in 70% of TW compared with 22% of TM, indicating a clear, although non-significant, trend toward greater atherosclerotic development in TW. CONCLUSION: This pilot study suggests a more pronounced progression of atherosclerosis in TW undergoing GAHT, detectable particularly through CCTA. These findings support refined CV monitoring and highlight the need for larger, long-term studies to guide preventive strategies in transgender populations.