How long before surgery with a risk of blood clots should a patient stop using a 0.0375mg estradiol (estrogen) patch twice weekly and 200mg of progesterone?

Perioperative Management of Estradiol Patch and Progesterone Before Surgery with Risk of Blood Clots

Estradiol patches (0.0375mg) should be discontinued 4-6 weeks before surgery associated with increased risk of thromboembolism, and progesterone (200mg) should be stopped at the same time. 1, 2

Rationale for Discontinuation Timing

• Estrogen therapy increases the risk of venous thromboembolism (VTE), and FDA labeling specifically states: "If feasible, estrogens should be discontinued at least 4 to 6 weeks before surgery of the type associated with an increased risk of thromboembolism, or during periods of prolonged immobilization." 1

• Progesterone used in combination with estrogen also carries thrombotic risk, with FDA labeling similarly recommending: "If feasible, estrogens with progestins should be discontinued at least 4 to 6 weeks before surgery of the type associated with an increased risk of thromboembolism, or during periods of prolonged immobilization." 2

• The American College of Chest Physicians (ACCP) guidelines for perioperative management of antithrombotic therapy emphasize the importance of managing risk factors for arterial vascular disease and venous thromboembolism appropriately before surgery. 3

Route of Administration Considerations

• While transdermal estrogen administration generally has a lower thrombotic risk compared to oral estrogen, the recommendation to discontinue hormone therapy 4-6 weeks before high-risk surgery still applies to all estrogen formulations when there is significant risk of thromboembolism. 4, 5

• Transdermal estradiol may have less impact on coagulation factors than oral estrogen, but should still be discontinued before surgeries with high thrombotic risk. 4

Specific Recommendations Based on Surgery Type

• For surgeries with high risk of blood clots (e.g., orthopedic, abdominal, pelvic, or neurological procedures):

  • Stop estradiol patch and progesterone 4-6 weeks before surgery 1, 2
  • Do not use bridging therapy with other hormones 3

• For minor procedures with low bleeding risk (e.g., dental, dermatologic, or cataract procedures):

  • Discontinuation may not be necessary, but given the specific concern about blood clots mentioned in the question, the 4-6 week discontinuation is still recommended 3

Resumption After Surgery

• Resume hormone therapy only after adequate mobilization is achieved and when the immediate risk of thrombosis has decreased, typically 1-2 weeks after surgery 3

• Consider thromboprophylaxis according to standard surgical protocols during the perioperative period 3

Special Considerations

• Patients with additional risk factors for VTE (obesity, personal or family history of VTE, advanced age, systemic lupus erythematosus) may require more careful management and potentially longer discontinuation periods 1, 2

• If surgery is urgent and cannot be delayed for the full 4-6 week period, inform the surgical team about current hormone use so appropriate thromboprophylaxis measures can be implemented 3

Common Pitfalls to Avoid

• Do not assume that transdermal estrogen is completely safe regarding thrombotic risk; while it has lower risk than oral formulations, it still carries some risk that warrants discontinuation before high-risk surgery 5, 4

• Do not restart hormone therapy too soon after surgery, as the postoperative period continues to be a high-risk time for thrombotic events 3

• Do not overlook the need for appropriate VTE prophylaxis during the perioperative period, especially in patients who have been on hormone therapy 3