Gender-affirming hormone therapy is no longer a brief stage in the life of a transgender person. As the general population ages, more and more trans and gender-diverse (TGD) people reach 60, 70 and beyond while continuing hormone treatments they started decades earlier, and with them come the conditions of their age: cognitive decline, cardiovascular disease, prostate cancer, osteoporosis or menopause. So what happens to the hormones then?
An article in the journal Journal of Clinical Endocrinology and Metabolism (JCEM) addresses precisely that scenario. Its authors —Michel S. Rothman, Jason O. van Heesewijk, Danit Ariel and Sean J. Iwamoto— present it as an Approach to the Patient paper: five clinical cases of older trans people, each with an age-related disease, and a proposed hormonal management plan for each situation.
A case-based article, not a clinical trial
It is worth making this clear from the start: this work does not provide new laboratory data or results from a study in patients. It is a case-based clinical review, designed to guide endocrinologists and other professionals who care for older trans adults. It develops five scenarios: neurocognitive impairment, increased cardiovascular risk, prostate cancer, bone health and menopause.
The authors acknowledge a fundamental limitation: there are no specific guidelines for managing these diseases in older TGD people. They therefore combine what is known from clinical practice and from studies carried out in both transgender and cisgender populations, and they call for dedicated research so that those guidelines can be written in the future.
Why age changes the rules
In a cisgender person, sex hormone production changes with age gradually and naturally. In a transgender person receiving hormone treatment, that balance is sustained exogenously and deliberately, and decisions about dose, route of administration or continuity must be integrated with the diseases that appear over time. The central question is not only whether hormone therapy is safe at 70, but what to do when a condition emerges that forces a review of it.
Brain: when cognitive impairment arrives
A diagnosis of dementia or mild cognitive impairment raises dilemmas that go beyond the prescription. The person may lose the ability to manage their own treatment —for instance, to give themselves injections or to attend follow-up appointments—, and abruptly stopping estradiol is associated with vasomotor symptoms and bone loss. In such cases, the review proposes individualised decisions centred on care goals, quality of life and the role that gender identity has played in the person’s life course.
Heart and clotting
Cardiovascular risk increases with age, and in transgender women a well-known factor is added: estradiol, especially by the oral route, raises the likelihood of venous thrombosis. That risk multiplies with smoking, a sedentary lifestyle, obesity or recent surgery. The transdermal route, by avoiding first-pass metabolism in the liver, is usually considered more favourable when risk factors are present. In transgender men, testosterone calls for monitoring of haematocrit and haemoglobin, because it can increase red blood cell production, as well as lipids and blood pressure.
Prostate and screening
Transgender women retain their prostate unless it has been surgically removed, and with age they can develop prostate cancer. The difficulty lies in interpreting the tests: prostate-specific antigen (PSA) is an androgen-dependent protein, so therapy with estradiol and antiandrogens tends to keep it very low, and cisgender male reference values do not apply in the same way. The review insists on individualising screening and on not abandoning examination when symptoms appear. The same principle holds for the breasts and the cervix in those who retain those tissues.
Bone: estradiol is not an add-on
Bones depend on sex hormones to maintain themselves. In a transgender woman whose testes have been removed, estradiol is not a cosmetic supplement: it is the treatment that prevents accelerated bone loss. In transgender men, testosterone sustains bone mineral density, although prolonged puberty suppression and periods without treatment require follow-up. Densitometry, vitamin D and calcium are part of routine monitoring as the years go by.
Menopause in trans men
Transgender men with ovaries experience menopause like anyone else with those organs, and testosterone does not prevent it. The problem is that it usually goes unnoticed: without a menstrual cycle there is no clear signal of its onset, and hot flushes, insomnia or mood changes may be attributed to hormone therapy. When symptoms are intense or the risk of osteoporosis is high, assessment includes the possibility of adding estradiol or progestogens, weighing the effect on any retained breast and uterine tissue.
What is still unwritten
The article closes with the same idea it opens with: specific evidence is lacking. Most studies on gender-affirming hormone therapy have been conducted in young or middle-aged adults, and data on older people come largely from clinical experience or from research carried out in cisgender populations. Growing old while trans is, increasingly, a demographic reality; the medical response to it is still a work in progress.
Source: Approach to the Patient: cases of hormonal management in older transgender and gender diverse adults. Rothman MS, van Heesewijk JO, Ariel D, Iwamoto SJ. Journal of Clinical Endocrinology and Metabolism 2026;111(10):e2281-e2289. DOI: 10.1210/clinem/dgag231.
Read the publication: Journal of Clinical Endocrinology and Metabolism.
Article published at dosier.es. Image generated with artificial intelligence (marta ai → marta.syf.es).
