What are the implications of Estrace (estradiol) on surgical outcomes?

From the Guidelines

Estrace (estradiol) should not be routinely discontinued before surgery, as the decision to continue or temporarily cease therapy requires an individualized discussion of the benefits and risks of therapy, considering the physical and mental health benefits of oestradiol therapy may outweigh the risk of thrombosis. When considering the management of Estrace in the context of surgery, it's crucial to weigh the risks of venous thromboembolism (VTE) against the benefits of continuing hormone therapy. The risk of VTE is a significant concern with estrogen-containing medications like Estrace, especially in the post-surgical period due to immobility and tissue trauma 1. However, recent guidance suggests that the benefits of oestradiol therapy may outweigh these risks, and therefore, Estrace should not be discontinued without careful consideration of the individual patient's circumstances 1.

Key Considerations

• The physical and mental health benefits of oestradiol therapy may outweigh the risk of thrombosis 1.
• Thromboprophylaxis strategies should be considered for patients at risk for VTE, including those with a history of embolism, abnormal coagulation testing, or current use of estrogen therapy 1.
• Early postoperative ambulation and use of compression stockings should be encouraged for all patients to reduce the risk of VTE 1.
• The decision to continue or temporarily cease oestradiol therapy requires an individualized discussion of the benefits and risks of therapy, taking into account the patient's specific circumstances and medical history 1.

Management Approach

• For patients who require hormone therapy for severe menopausal symptoms, the surgeon and prescribing physician may consider alternative approaches during the perioperative period, such as short-term use of non-hormonal medications for symptom management.
• Each case should be evaluated individually, weighing the risks of discontinuation against the increased surgical risks of continuing the medication.
• The timing of when to stop and when to reinitiate anticoagulation therapy after surgery is unclear, and therefore, should be determined on a case-by-case basis, considering the patient's risk factors for VTE and the type of surgery being performed 1.

From the Research

Estrace and Surgery

Estrace, a form of estrogen replacement therapy, may be used by women undergoing surgery. The management of Estrace in the perioperative period is crucial to minimize the risk of venous thromboembolism (VTE) and other complications.

• The risk of VTE associated with hormone replacement therapy (HRT) is similar to that of oral contraception and is close to that produced by pregnancy 2.
• The increased risk of thromboembolism is usually small, especially after the first year of administration of HRT, and should be compared with the occurrence of undesired symptoms after discontinuation of HRT 2.
• Maintaining HRT during the perioperative period may be legitimate, and strengthening prophylaxis is justified during the first year of oral HRT administration 2.
• Transdermal HRT may not need to be stopped and probably does not require any additional antithrombotic measure 2.

Perioperative Care

Perioperative care for patients taking Estrace or other forms of HRT involves careful evaluation and management of the risk of VTE and other complications.

• Surgery itself carries a risk of thromboembolism, the incidence of which varies with the nature of the procedure 3.
• The application of evidence-based guidelines for the prophylaxis of VTE in surgical patients must become a standard part of daily practice 4.
• Preoperative care and preparation of the patient are crucial to minimize the risk of complications associated with perioperative care 5.

Hormone Management

Hormone management in the perioperative period is critical to reduce the risk of VTE and other complications.

• Abrupt estrogen cessation may lead to adverse emotional and physiologic effects, including an exacerbation of gender dysphoria 6.
• The data on the relationship of feminizing hormones and VTE in the perioperative setting are largely based on extrapolation of hormone regimens that are no longer in use and may not accurately reflect the actual risk of VTE 6.
• Future studies will allow surgeons to engage in evidence-based, patient-centered, informed consent while also minimizing the risk of complications, such as VTE 6.