Gender-Affirming Hormone Therapy and Risk of Hypertension in Transgender Adults: A Systematic Review

Gender-affirming hormone therapy (GAHT) aims to help transgender individuals achieve physical changes that reflect their gender identity. Although sex hormones can affect blood pressure (BP) and cardiovascular function, their influence on hypertension is unclear. This systematic review and meta-analysis explored changes in BP before and after starting GAHT in transgender adults and examined whether GAHT is associated with the risk of developing hypertension. Cohort studies with before-and-after measurements of BP in transgender adults undergoing GAHT were included. We excluded case reports, reviews, and randomized trials. A systematic search of PubMed, Scopus, Web of Science, CENTRAL, ClinicalTrials.gov, and the WHO ICTRP was conducted from database inception to July 22, 2025. The risk of bias was assessed independently by two reviewers using the Risk of Bias in Non-randomized Studies of Interventions, version 2 (ROBINS-I v2). Studies with a serious or critical risk of bias were excluded from the meta-analysis. Changes in systolic blood pressure (SBP) and diastolic blood pressure (DBP) before and after GAHT were pooled using random-effects meta-analysis models. Results were expressed as mean differences (MD) with 95% confidence intervals (CI), and heterogeneity was assessed using the I² statistic. The quantitative synthesis included 11 studies on SBP and 12 on DBP in transgender men (TM) and nine on transgender women (TW), all with a 12-month follow-up. TM showed a small but statistically significant increase in SBP (MD = +3.8 mmHg; 95% CI 1.6–6.0) and a slight, non-significant increase in DBP. In contrast, TW presented opposite and non-significant trends for SBP and DBP. The observational design of most studies, small sample sizes, and heterogeneity in GAHT regimens and blood pressure measurements limited the available evidence. Overall, GAHT appeared to cause a mild increase in BP among TM and no significant change among TW. These findings suggest that GAHT may have only minor effects on BP; however, larger and better-controlled studies are needed to confirm these results.