Signs of transgender heart attack not yet known

Dear Dr. Roach: I am a 51-year-old male-to-female transgender woman. According to my doctor, I am in very good health, and my body has adapted to the traditional regimen of hormone replacement therapy quite well. I have been on HRT for almost five years now.

As you know, men and women at risk of heart attack display different warning signs. My question is, now that I have chemically changed genders, should I expect my body to warn me of an impending heart attack as it would for a cisgender women, or would any warning signs be in keeping with the typical male response?

M.A.R. The classic presentation of a heart attack is described as a person suddenly clutching his or her chest with pain on the left side, radiating down the inside of the left arm. It’s associated with sweating, shortness of breath and palpitations.

While it is true that women are less likely to have this typical presentation, the fact remains that both men and women may have more subtle symptoms. I far more often hear people describe sensations in the chest as “pressure” or “tightness” rather than “pain.” The discomfort may not radiate anywhere, or it may radiate to the jaw, back or upper abdomen. Women are more likely than men to have no symptoms in the chest at all.

However, many older men, and men with diabetes, also have no chest symptoms. Women are more likely to have just nausea and vomiting. In both men and women, a sensation of not being able to catch your breath, like you just went up a flight or two of stairs, is common.

Symptoms are almost always worse with exertion, and usually begin gradually.

I could not find out much about symptoms of heart disease specifically in transgender people.

I did see that the heart disease risk is higher in male-to-female transgender women treated with anti-androgens and estrogens than it is in female-to-male transgender men treated with testosterone. Whether this reflects the underlying vascular biology or an effect of the hormones is unknown.

I would guess that if you were to develop symptoms of angina, and I hope you never do, they likely would be less typical than those of cisgender men.

(The term “cis-” is borrowed from chemistry, as differentiated from “trans-.” Both are types of carbon bonding. “Cis” in this context means the sex you are assigned at birth.)

As more transgender people live into the age where heart disease becomes more likely, we expect to gain a better understanding of symptoms in transgender people. Dear Dr. Roach: My sister-in-law was diagnosed with ovarian cancer, and she says she is going to drink all these herbal teas and go on a special anti-chemo diet to reduce the side effects of treat- ment. Smart? Not smart?

J.I.

I am routinely asked about complementary treatments for cancer, but the best use for them, in my opinion, is the one your sister-in-law is considering.

If she can find a healthy diet and teas that help her get through her chemotherapy, it can help. The only concern I have is that some herbals potentially can interact with the chemotherapy, which must be dosed precisely in order to treat the cancer effectively while minimizing toxicity. Her oncologist absolutely needs to know about any herbal preparations and supplements she takes.