Perioperative Hormone Management in Gender-Affirming Mastectomy: Is Stopping Testosterone Before Top Surgery Really Necessary?

Abstract

Background: Gender-affirming mastectomy, or “top surgery,” has become one of the most frequently performed procedures for transgender and nonbinary patients. However, management of perioperative testosterone therapy remains controversial. Despite a lack of supporting evidence, many surgeons require cessation of testosterone before top surgery. This is the first study to compare complication rates in patients undergoing gender-affirming mastectomy with and without discontinuation of perioperative testosterone. Methods: This retrospective review included patients undergoing top surgery by the senior author between 2017 and 2020. Reflecting a change in the senior author’s practice, before May of 2019, all patients were required to discontinue testosterone before surgery; all patients treated after this point continued their testosterone regimens throughout the perioperative period. Patients were stratified according to testosterone regimen and perioperative hormone management, with demographic characteristics and postoperative outcomes compared among groups. Results: A total of 490 patients undergoing gender-affirming mastectomy during the study period were included. Testosterone was held perioperatively in 175 patients and continued in 211 patients; 104 patients never received testosterone therapy. Demographic characteristics were similar among groups and there was no difference in rates of hematoma (2.9% versus 2.8% versus 2.9%, respectively; P = 0.99), seroma (1.1% versus 0% versus 1%, respectively; P = 0.31), venous thromboembolism (0% versus 0.5% versus 0%, respectively; P = 0.99), or overall complications (6.9% versus 4.3% versus 5.8%, respectively; P = 0.54). Conclusions: Our results demonstrate no difference in postoperative complication rates among groups. Whereas further investigation is warranted, our data suggest that routine cessation of testosterone in the perioperative period is not necessary for patients undergoing gender-affirming mastectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Patterns of Perioperative Hormone Therapy for Gender-Affirming Surgery

“…16 A recently published study comparing complication profiles in patients who discontinued testosterone versus patients who maintained on HRT found that there was no difference in postoperative complication rates including hematoma, seroma, VTE, and overall complications. 17 Boskey et al 4 synthesized all the surgical risks of exogenous hormones in transgender and gender-diverse patients and concluded that the current evidence does not support routine discontinuation of HRT before GAS. Despite the evidence, some surgeons remain concerned about continuing HRT, and our study demonstrated a wide variation of perioperative HRT usage among surgeons.…”

“…Rather, the strongest risk factor of developing a hematoma is due to the surgical technique of limited incision such as periareolar or circumareolar approaches 16 . A recently published study comparing complication profiles in patients who discontinued testosterone versus patients who maintained on HRT found that there was no difference in postoperative complication rates including hematoma, seroma, VTE, and overall complications 17 . Boskey et al 4 synthesized all the surgical risks of exogenous hormones in transgender and gender-diverse patients and concluded that the current evidence does not support routine discontinuation of HRT before GAS.…”

Androgenic steroids induce pathologic scarring in a preclinical porcine model via dysfunctional extracellular matrix deposition

“…It is, therefore, important to find therapeutic approaches that exert localized anti‐androgenic properties without systemic effects. The development of topical antiandrogens that competitively bind to androgen receptors represents a promising area of future research as a novel approach to controlling the tissue repair cascade through the sex hormone axis 38 …”

Androgenic Steroids Induce Pathologic Scarring in a Preclinical Swine Model Via Dysfunctional Extracellular Matrix Deposition

“…The development of topical antiandrogens that competitively bind to androgen receptors represents a promising area of future research as a novel approach to controlling the tissue repair cascade through the sex hormone axis. 32…”

“…Traditional practices of stopping testosterone perioperatively were based on concerns about thrombocytosis, hypertension and thromboembolic events, but recent studies suggest these concerns are largely theoretical. 28 Because hormone therapy provides TGD patients with psychological benefits, patients may experience distress if asked to pause an important aspect of gender-affirming care, and cessation is less common now. 29 However, these newer studies do not address scar results, potentially resulting in perioperative use of a medication that delays WH and increases scar hypertrophy.…”