Does Hormone Replacement Therapy (HRT) need to be stopped perioperatively?

Perioperative Management of Hormone Replacement Therapy

Hormone replacement therapy (HRT) generally does not need to be discontinued perioperatively for most surgical procedures, but individualized risk assessment should be performed with consideration for thrombotic risk factors and the type of surgery. 1

Risk Assessment Framework

Patient-Related Risk Factors

• High thrombotic risk patients:
  • Personal or family history of venous thromboembolism (VTE)
  • Known thrombophilia
  • Active cancer
  • Obesity
  • Systemic lupus erythematosus
  • Immobility
  • Advanced age

Surgery-Related Risk Factors

• High bleeding risk procedures:
  • Major orthopedic surgery
  • Neurosurgery
  • Major cancer surgery
  • Procedures lasting >45 minutes
  • Vaginoplasty and other gender-affirming surgeries

Evidence-Based Recommendations

For Transgender and Gender-Diverse Individuals

• Testosterone therapy: Generally should be continued perioperatively 1
• Estradiol therapy:
  • Previous reviews have not found evidence to support routine discontinuation 1
  • Physical and mental health benefits may outweigh thrombosis risk 1
  • Discontinuation can cause significant psychological distress, including exacerbation of gender dysphoria 1

For Cisgender Women on HRT

• For most minor procedures:

  • Continue HRT with appropriate thromboprophylaxis
  • No clear guidelines exist specifically for HRT management perioperatively 2

• For high bleeding risk procedures or patients with multiple thrombotic risk factors:

  • Consider temporary discontinuation of oral estrogen preparations 2-4 weeks before surgery
  • If discontinuation is necessary, transdermal estrogen may be a safer alternative with lower thrombotic risk 3
  • Resume HRT when the patient is fully mobile, typically 1-2 weeks after surgery

For Women with Coronary Artery Disease

• HRT should be discontinued during hospitalization for acute coronary events due to increased risk of VTE 4
• If discontinuation is not feasible, VTE prophylaxis should be considered during immobilization 4

Important Considerations

Thrombotic Risk

• Oral estrogen formulations carry higher thrombotic risk than transdermal preparations 3
• Progestin compounds may have higher cardiovascular risk than micronized progesterone 3
• FDA labeling for estrogen products recommends discontinuation 4-6 weeks before surgery associated with increased thromboembolism risk 5

Mental Health Impact

• Abrupt discontinuation of HRT may lead to significant mood swings, anxiety, and depression 6
• For transgender patients, discontinuation can cause severe psychological distress 1

Common Pitfalls to Avoid

1. Automatic discontinuation without risk assessment: Not all patients or procedures require HRT discontinuation
2. Failure to consider alternative formulations: Transdermal estrogen has lower thrombotic risk than oral preparations
3. Neglecting thromboprophylaxis: When continuing HRT perioperatively, appropriate VTE prophylaxis is essential
4. Overlooking psychological impact: Especially important for transgender patients where HRT discontinuation can cause significant distress

Practical Algorithm

1. Assess patient's thrombotic risk profile
2. Evaluate surgical bleeding risk
3. For low-risk patients and minor procedures:
   • Continue HRT with standard thromboprophylaxis
4. For high-risk patients or major procedures:
   • Consider switching from oral to transdermal estrogen 4 weeks before surgery
   • If discontinuation is necessary, stop oral estrogen 2-4 weeks before surgery
   • Resume when patient is fully mobile (typically 1-2 weeks post-surgery)
5. For all patients continuing HRT:
   • Implement appropriate thromboprophylaxis measures
   • Monitor for signs of VTE postoperatively

The most recent evidence suggests that the benefits of continuing HRT, particularly for transgender patients, often outweigh the risks when appropriate thromboprophylaxis is implemented 1, 6.