How long should a transgender male pause testosterone (hormone replacement therapy) after a pulmonary embolism (PE)?

Duration of Testosterone Therapy Pause After Pulmonary Embolism in Transgender Males

Transgender males should discontinue testosterone therapy for at least 3-6 months after a pulmonary embolism (PE), with consideration for permanent discontinuation in those with underlying thrombophilia or recurrent thrombotic events. 1

Risk Assessment and Initial Management

• Immediately discontinue testosterone upon PE diagnosis
• Begin standard anticoagulation therapy according to PE treatment guidelines
• Evaluate for underlying thrombophilia that may have contributed to PE development:
  • Factor V Leiden
  • Lupus anticoagulant
  • Other hereditary or acquired thrombophilias 2, 3

Duration of Testosterone Discontinuation

Minimum Duration (3-6 months)

• All transgender males with PE should discontinue testosterone for at least 3-6 months 1
• This aligns with standard anticoagulation duration for provoked PE 1
• During this period, complete the initial course of anticoagulation therapy

Risk Stratification for Resumption

1. Low Risk for Resumption (consider after 3-6 months):

   • First-time PE
   • No identified thrombophilia
   • PE clearly provoked by a transient risk factor other than testosterone
   • No other cardiovascular risk factors

2. High Risk - Consider Extended Pause or Permanent Discontinuation:

   • Unprovoked PE (testosterone likely primary contributor)
   • Identified thrombophilia (Factor V Leiden, lupus anticoagulant) 2, 3
   • Recurrent VTE events
   • Multiple cardiovascular risk factors

Evidence for Testosterone as a Thrombotic Risk Factor

• Testosterone therapy in transgender men has been associated with increased risk of venous thromboembolism (VTE) 1
• Case reports document recurrent thrombotic events when testosterone therapy is continued despite adequate anticoagulation 2, 3
• Testosterone can cause polycythemia (increased red blood cell count), which increases thrombotic risk 4
• Multiple studies have documented PE occurring after initiation of testosterone therapy 5, 6

Considerations for Resumption of Testosterone

If resumption is considered after 3-6 months:

• Switch to transdermal preparations (patches, gels) rather than injectable forms 4

  • Lower peak levels and more stable hormone concentrations
  • May reduce thrombotic risk compared to injectable forms

• Implement enhanced monitoring:

  • Regular hematocrit/hemoglobin checks (every 3 months)
  • Target testosterone levels in the lower half of male reference range (300-500 ng/dL)
  • Consider extended anticoagulation if testosterone is resumed 1

• Implement risk reduction strategies:

  • Smoking cessation
  • Weight management if BMI is elevated
  • Regular physical activity
  • Avoid other prothrombotic medications

Special Considerations

• If PE was unprovoked and testosterone is the suspected primary risk factor, permanent discontinuation may be safest 2, 3
• In cases with identified thrombophilia, the risk-benefit ratio strongly favors permanent discontinuation 2, 3
• For patients with recurrent thrombotic events while on testosterone, evidence strongly suggests permanent discontinuation 2

Follow-up Monitoring

• Regular follow-up at 3-month intervals initially
• Monitor for symptoms of recurrent VTE
• Regular hematocrit/hemoglobin checks if testosterone is resumed
• Consider periodic D-dimer testing to detect subclinical thrombosis

The decision to resume testosterone therapy must carefully weigh the psychological benefits against the potentially life-threatening risk of recurrent PE, with the understanding that testosterone may have contributed to the initial thrombotic event.