Transgender individuals, or those whose gender identity does not match with the identified sex at birth, are more susceptible and prone to experience adverse health outcomes. Gender-affirming hormone therapy targets a phenotypic change to pair up with the gender identity. In the case of transgender females (TGF), it is common to use different estrogen preparations, even when data limitations exist about the repercussions on cardiovascular health. Despite the need for more evidence, it is assumed TGFs are at a higher risk of stroke. However, this evidence only exists for relatively older populations in the long term.
CASE: A 23-year-old transgender female with no past medical history presented to the emergency service with left facial asymmetry and left hemiparesis. On admission, her NIHSS score was 5. Initial head CT without ischemic changes and CTA positive for right M2 occlusion. The patient underwent tPA administration without thrombectomy. Subsequent MRI exhibited an established right MCA stroke. Extensive studies to rule out coagulopathies and lipid disorders were shown to be unremarkable, with no laboratory parameters compatible with the Sapporo criteria for antiphospholipid syndrome. By further inquiring, the patient reported to have consulted an online center for a transition of care during the past year and started on spironolactone and estradiol valerate injections of 20 mg/ml, to take 0.25 ml (5 mg) every week. She reported compliance with the medications, though she took 1ml (20 mg) of estradiol each week, four times the therapeutic dose. Hormone therapy was suspended, antiplatelet agent started, and the patient was sent to rehabilitation.