Ha Ri-su, 51, says it has been 30 years since her gender-affirming surgery — what transgender people often overlook in long-term health care

Transgender broadcaster Ha Ri-su has opened up about the health challenges she has faced since her gender-affirming surgery, drawing renewed attention to hormone therapy and long-term health management. Experts say that after gender-affirming surgery, consistently monitoring bone health, cardiovascular and metabolic health, and liver function is important, depending on the scope of the procedure and the individual's hormonal status.

Ha recently appeared on the YouTube channel TG Girls, where the first-generation transgender celebrity spoke about health management and life after gender-affirming surgery. When asked about her secret to staying healthy, the 51-year-old said bluntly, "Honestly, I don't exercise."

She added, "I had my gender reassignment surgery early — in 1995. It has been exactly 30 years since then."

Ha also explained why she had not consistently received female hormone therapy after her surgery. "At the time, I heard that getting female hormones consistently after gender reassignment surgery could be bad for your liver, so I just lived without them," she said.

Over time, however, other health problems emerged. "I was diagnosed with early-stage osteoporosis six years ago," Ha said. "My bones were worse than those of an 80-year-old grandmother." She added that resuming female hormone therapy now was something she felt conflicted about.

Sex hormone balance is one of the most important aspects of health management after gender-affirming surgery. When the gonads — such as the testes or ovaries — that produce sex hormones are removed, a prolonged deficiency can significantly increase the risk of bone density loss. The American Endocrine Society recommends bone density testing for those with osteoporosis risk factors, including people who have discontinued hormone therapy after gonadectomy.

Bone density is heavily influenced by sex hormones such as estrogen and testosterone, which help prevent bones from breaking down too rapidly and play a role in maintaining bone strength. The elevated risk of osteoporosis in postmenopausal women is also linked to declining estrogen levels. Transgender women can similarly experience effects on bone health if sex hormone levels fall due to surgery, medication, or the discontinuation of hormone therapy.

The University of California, San Francisco transgender care guidelines also identify insufficient or absent hormone replacement after gonadectomy as a risk factor for osteoporosis. They further note that individuals without gonads who are not receiving hormone replacement — regardless of their assigned sex — should be evaluated for osteoporosis prevention and screening based on their state of sex hormone deficiency.

Those who have discontinued or gone without hormone therapy for an extended period after gender-affirming surgery should have their bone density checked to assess their current condition. Particular attention is warranted for those who have lost height, experience recurring back pain, have suffered fractures from minor impacts, have a family history of osteoporosis, or have risk factors such as smoking, heavy drinking, low body weight, or vitamin D deficiency.

Ha's concern that hormone therapy could harm the liver is worth discussing with a medical professional. In the past, high-dose estrogen and certain medications raised significant concerns about liver dysfunction, blood clots, and cardiovascular risk. Today, however, treatment is tailored to each individual's health status, with formulations and dosages adjusted accordingly. The UCSF guidelines note that the risk of liver damage under modern estrogen therapy differs from earlier approaches, and that drug selection and monitoring are key.

That does not mean hormone therapy is safe for everyone, however. The risks of estrogen therapy can vary depending on age, smoking status, history of blood clots, high blood pressure, diabetes, liver disease, cardiovascular conditions, and current medications. Effects on the body and the management approach can also differ depending on the formulation — oral tablets, patches, gels, or injections. Anyone who underwent surgery in the past or has gone without hormone therapy for a long time and is now considering resuming treatment should consult an experienced specialist in endocrinology, gynecology, or urology.

The American Endocrine Society recommends that those undergoing gender-affirming hormone therapy have their hormone levels, physical changes, and any adverse reactions checked regularly during the first year, with periodic follow-up thereafter. Metabolic abnormalities, changes in bone density, and cancer screenings should also be managed based on the individual's surgical history and risk factors.

Maintaining bone health also requires lifestyle management, regardless of whether hormone therapy is being used. Strength training and weight-bearing exercises such as walking and stair climbing stimulate bones and muscles and help preserve bone density. Adequate calcium and vitamin D intake, protein supplementation, quitting smoking, and limiting alcohol are also important. For those already diagnosed with osteopenia or osteoporosis, medication may be necessary depending on fracture risk.

For those who are not exercising at all, starting with light walking, resistance band exercises, and lower-body strength training is better than jumping straight into high-intensity workouts. For people with osteoporosis, fall prevention is particularly important, making balance exercises and lower-body strengthening especially beneficial. Those with spinal osteoporosis or a high risk of compression fractures should avoid strong spinal bending or twisting and seek guidance from a medical professional or exercise specialist.

Liver health also warrants regular monitoring. People in middle age and beyond — not only those on hormone therapy — can see elevated liver enzyme levels due to fatty liver disease, alcohol consumption, medication use, or metabolic syndrome. For those on hormone therapy, liver function, blood lipids, blood sugar, and blood pressure should be checked before and after treatment begins, and adjustments to the formulation or dosage may be needed if abnormalities arise.

Ha also said during the broadcast that she has had difficulty accessing relevant information. "I've been living outside the gender community, so I just don't have the information," she said. "I don't know where to get hormones or anything like that."

Experts emphasize that transgender health care does not end at the point of surgery or hormone therapy — it requires long-term follow-up. The standards of care set by the World Professional Association for Transgender Health also state that physical health, mental health, and preventive care must all be considered together to ensure safe and effective treatment for transgender and gender-diverse people.

Those who underwent gender-affirming surgery long ago or have since discontinued hormone therapy should check bone density, liver function, blood pressure, blood sugar, and lipid levels even in the absence of obvious symptoms. The key is not to start or abandon hormone therapy based solely on outdated information or the experiences of others. Appropriate management varies depending on the scope of surgery, age, overall health, and bone density results, so consulting an experienced medical professional to develop a personalized long-term health care plan is the safest course.