No Venous Thromboembolism Increase Among Transgender Female Patients Remaining on Estrogen for Gender-Affirming Surgery

Abstract

Background Both surgery and exogenous estrogen use are associated with increased risk of venous thromboembolism (VTE). However, it is not known whether estrogen hormone therapy (HT) exacerbates the surgery-associated risk among transgender and gender nonbinary (TGNB) individuals. The lack of published data has contributed to heterogeneity in perioperative protocols regarding estrogen HT administration for TGNB patients undergoing gender-affirming surgery. Methods A single-center retrospective chart review was performed on all TGNB patients who underwent gender-affirming surgery between November 2015 and August 2019. Surgery type, preoperative HT regimen, perioperative HT regimen, VTE prophylaxis management, outcomes, and demographic data were recorded. Results A total of 919 TGNB patients underwent 1858 surgical procedures representing 1396 unique cases, of which 407 cases were transfeminine patients undergoing primary vaginoplasty. Of the latter, 190 cases were performed with estrogen suspended for 1 week prior to surgery, and 212 cases were performed with HT continued throughout. Of all cases, 1 patient presented with VTE, from the cohort of transfeminine patients whose estrogen HT was suspended prior to surgery. No VTE events were noted among those who continued HT. Mean postoperative follow-up was 285 days. Conclusions Perioperative VTE was not a significant risk in a large, homogenously treated cohort of TGNB patients independent of whether HT was suspended or not prior to surgery.

“Affirming” journey: Narrative review and practice considerations on gender affirming care

“…This patient belonged to the cohort that had their hormone therapy suspended for 1 week prior to surgery. Of patients who continued hormone therapy, no VTE events were reported 50 . The VTE incidence rate in this study was comparable to the VTE incidence of 0% to 2% noted among patients undergoing similar surgeries 51 …”

Risk of Venous Thromboembolism in Transgender People Undergoing Hormone Feminizing Therapy: A Prevalence Meta-Analysis and Meta-Regression Study

“…811 papers were excluded as irrelevant, based on title and abstract reading. Hence, as shown in Figure 1, 99 studies were identified, of which 18 met the inclusion criteria (17,(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49). The studies by Asscheman and colleagues published in 1989 (50) and 2011 (51) were excluded since the population under investigation was already included in the paper by van Kesteren et al, 1997 (47).…”

Gender‐affirming hormone therapy: An updated literature review with an eye on the future

“…Only 0.2% of trans men on testosterone ( n = 1893, median age = 26) developed thromboembolism in this study [88]. A retrospective study investigated the effect of estrogen (oral, transdermal, or intramuscular) therapy on the postoperative risk of developing VTE events in adult trans women ( n = 662), trans men ( n = 232), and nonbinary persons ( n = 25) [89]. Seventy‐one percent of trans women were taking spironolactone and 19% were on CPA in combination with estrogen therapy.…”

“…Kozato et al. reported no increased risk of VTE when estrogen treatment was continued throughout surgery compared to suspended estrogen treatment [89]. No difference was detected in VTE rates among different routes of estradiol administration.…”

“…Seventyone percent of trans women were taking spironolactone and 19% were on CPA in combination with estrogen therapy. Kozato et al reported no increased risk of VTE when estrogen treatment was continued throughout surgery compared to suspended estrogen treatment [89]. No difference was detected in VTE rates among different routes of estradiol administration.…”