Objective:

To report a case of transient ischemic attack in a transgender woman, highlighting the importance of cerebrovascular risk stratification in the transgender population prior to the intiation of hormone therapy.

Background:

Transgender women are those who were medically assigned male at birth and identify as a woman. This population often undergoes the process of transitioning, which can involve the use of hormone therapy, termed Gender-Affirming Hormone Therapy (GAHT). The use of exogenous hormones may increase the risk of thrombosis. There are currently no guidelines to assess cerebrovascular risk prior to initiation of exogenous hormones, indicating a gap in the care of transgender individuals utilizing GAHT.

Design/Methods:

Case report.

Results:

This is a 27-year-old transgender woman with a history of hypothyroidism, migraine, utilizing GAHT (estrogen 5-6 mg daily for 4 years) who presented to an Emergency Department (ED) for transient left facial weakness and hemiparesis concerning for transient ischemic attack. Symptoms consisted of a visual disturbance progressing to left facial weakness and then left hemiparesis. Her symptoms had resolved prior to arrival to the Emergency Department. Testing in the ED did not reveal findings of ischemic infarction. ED discharge diagnosis was transient ischemic attack versus migraine equivalent with aura. During outpatient work up she was found to have a bidirectional patent foramen ovale at rest and was noted to be heterozygous for prothrombin mutation. Given these vascular risk factors and the use of exogenous estrogen, a discussion with the patient was conducted and the decision was made to temporarily hold GAHT and initiate anti-platelet therapy.

Conclusions:

Literature review reveals that there are no consensus guidelines evaluating cerebrovascular risk factors prior to initiation of gender affirming hormone therapy. This case highlights the need to devote further research to the interplay between cerebrovascular risk factors, GAHT and biologic hormones in transgender individuals.