Case Report: Ischemic stroke in a young transgender woman due to unsupervised estrogen therapy

Stroke is often associated with the elderly population, but recent epidemiological data indicate an increasing incidence among young adults. Among the risk factors, estrogenic hormone therapy (HT) has been linked to cerebrovascular events. This report presents the case of a transgender woman who suffered an ischemic stroke during the inappropriate use of HT, highlighting the importance of medical follow-up and risk assessment in gender-affirming therapy.

A 30-year-old transgender female patient had been using estrogenic HT purchased on the black market (cyproterone 2 mg + ethinyl estradiol 0.035 mg/day) since the age of 17, without medical supervision. She had a history of HIV infection under irregular treatment and previously treated syphilis. She developed sudden-onset right-sided hemiparesis and homonymous hemianopsia. The initial computed tomography scan revealed no abnormalities, but magnetic resonance imaging showed ischemia in the territory of the left posterior cerebral artery. Etiological investigation with echocardiography, carotid and vertebral Doppler ultrasound, electrocardiogram, Holter monitoring, and thrombophilia panel revealed no abnormalities. The final etiological diagnosis was classified according to the TOAST criteria as "other causes," attributed to the inappropriate use of estrogenic therapy. She was discharged with antiplatelet therapy, a statin, and fluoxetine, along with the discontinuation of hormone therapy and referral to transgender and vascular neurology outpatient clinics.

HT is essential in gender affirmation; however, its use is associated with increased risks of thromboembolic and cerebrovascular events. The patient in this case did not present traditional risk factors for stroke, reinforcing the suspicion of estrogen's role in the event. Studies suggest that supervised hormone therapy carries a lower risk of complications compared to indiscriminate use. Nonetheless, there are still gaps in the literature regarding the correlation between HT and stroke in transgender individuals.

This case highlights the risks of inappropriate use of gender-affirming hormone therapy and the need for rigorous medical supervision. Given the growing access to this treatment, continuous monitoring is essential to minimize complications. Further research is needed to establish safer guidelines for the use of hormone therapy in the transgender population.