NEW YORK (Reuters Health) – Transgender women can safely maintain their estrogen hormone therapy during gender-affirming surgery without an increased risk of venous thromboembolism (VTE), according to a new study.
Both exogenous estrogen therapy and surgery can increase VTE risk, but it’s unclear whether estrogen therapy exacerbates the surgery-associated risk among transgender and gender non-binary (TGNB) individuals.
“It’s common practice to stop estrogen therapy prior to trans women undergoing gender-affirming surgery but there are no guidelines on this and that’s a problem,” Dr. John Henry Pang of Icahn School of Medicine at Mount Sinai and the Center for Transgender Medicine and Surgery, in New York City, told Reuters Health by phone.
“Our study calls into question the practice of holding estrogen in patients who are undergoing gender-affirming surgery and for the most part suggests we should not be stopping it,” he said.
The researchers examined VTE risk associated with suspending versus continuing estrogen therapy in the perioperative period for gender-affirming surgeries. They took a look back at all TGNB patients who underwent gender-affirming surgery at Mount Sinai between 2015 and 2019.
Altogether, 919 TGNB individuals underwent 1,858 surgical procedures representing 1,396 unique cases, of which 407 cases were transfeminine patients undergoing primary vaginoplasty surgery at a mean age of 35.6 years.
In these 407 cases, 190 surgeries were performed with estrogen suspended for one week prior to surgery and 212 cases were performed with estrogen continued throughout. The remaining five cases were not on estrogen at the time of surgery. Average postoperative follow-up for primary vaginoplasty patients was 313 days.
Of all 1,396 cases, only one patient presented with VTE and this individual was from the cohort of transfeminine patients whose estrogen was stopped prior to surgery. No VTE events occurred among those who continued estrogen therapy.
“Exogenous hormone administration, including estrogen hormone therapy, does not appear to alter the risk of postoperative VTE for transfeminine patients who undergo vaginoplasty,” Dr. Pang and colleagues conclude in the Journal of Clinical Endocrinology and Metabolism.
Therefore, “estrogen HT suspension is not necessary for the transfeminine patient undergoing vaginoplasty,” they say.
“Hormone therapy is not as risky as it’s perceived to be,” Dr. Pang told Reuters Health, “and so we have to ask ourselves, what are we protecting our patients from by holding estrogen? And by the same token, what harms may we be causing our patients by stopping estrogen therapy prior to gender-affirming surgery, because holding estrogen can cause quite a bit of discomfort and emotional distress.”
Strengths of the study include the large number of surgeries from a single center following a consistent VTE prophylaxis regimen. Limitations include the retrospective and observational nature of the study.
“More large-scale multicenter studies are needed to further elucidate the association, if any, of patient demographics and HT regimen with postoperative VTE risk,” the researchers say.
SOURCE: https://bit.ly/2Korm42 Journal of Clinical Endocrinology and Metabolism, online January 15, 2021.