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LISBON -- Diabetes mellitus risk factors were elevated for the transgender population, even when under the care of a multidisciplinary team, researchers reported here.

Hormone therapy -- estrogen therapy in transwoman (male to female) and testosterone therapy in transman (female to male) -- was associated with modifiable risk factors, such as HbA1c, cardiovascular markers, and vitamin D levels, according to Patricia Kapsner, MD, of the University of New Mexico, and colleagues.

"We known the metabolic effects of estrogen and testosterone -- the most frequent cross-sex hormone therapies used -- from animal studies, as well as studies in the non-transgender populations," she said during a press conference at the meeting. However, there is a dearth of outcomes studies available among the transgender population with diabetes, she added.

What is known about hormone therapy in the overall transgender population is an association between ethinyl estradiol use in transwomen with an increased risk for clotting leading to an increased risk for heart attack and stroke, increased risk for central adiposity, low vitamin D levels, and possible risk of higher triglycerides. "Studies in the transgender population are inconsistent and we seem to think this risk is related to the type of estrogen used, as well as the way it's administered -- either orally or transdermally," Kapsner explained.

Among transman on hormone therapy, prior studies have suggested an increased risk for total weight gain, higher LDL and triglycerides, and a decrease in HDL cholesterol.

The research group assessed a small group of transpeople with diabetes mellitus: 1 transman with type 1 diabetes (T1D), three transwomen with type 1 diabetes, and five transwomen with type 2 diabetes (T2D).

They found that even while under the direct care of a multidisciplinary team providing care according to the American Diabetes Association's guidelines, which included endocrine, pharmacological, nutritional, diabetes, nursing, and psychiatric care, in addition to social services, none of the participants were able to achieve target HbA1c levels: 8.2 for transman with T1D, mean of 9.6 for transwomen with T1D, 9.0 for transwomen with T2D.

Similarly, all groups had LDL cholesterol levels out of target range (113, 129, 88.6, respectively). Both groups of transwomen also reported higher than recommended triglycerides (mean of 166 for T1D, 183 for T2D), and lower than recommended vitamin D levels (mean of 22 for T1D, 14 for T2D).

Only four of the nine patients received statin therapy, which they suspected may be due to the study population's age. Out of the study population, only one patient, who had type 2 diabetes and obesity, received antihypertensive therapy. This may be attributed to the use of the anti-androgen therapy spironolactone in transwomen, which also acts as a diuretic and can be used as an anti-hypertensive, the authors explained.

Behavioral and substance abuse issues also complicate diabetes care for the transgender population who are already at a higher risk due to a combination of diabetes, depression, and distress due to gender dysphoria, they noted.

Although studies in the diabetic, transgender population are difficult to both recruit for and follow-up, Kapsner told MedPage Today. "Maybe we can use a surrogate marker such as calcium artery scores [in a future study] to assess whether younger patients are at risk," she stated, adding that "in this population, we need to start younger," regarding screening and treatment for increased associated risk factors.

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