Do you need to hold estrogen and progesterone (hormone therapy) pre-operatively for a patient undergoing surgery?

Perioperative Management of Estrogen and Progesterone Therapy

Postmenopausal hormone therapy (estrogen/progesterone) should not be administered to women undergoing CABG and should be discontinued preoperatively, while the decision for other surgical contexts requires risk stratification based on surgery type, thrombotic risk, and patient-specific factors. 1

Clear Contraindication: Cardiac Surgery

For patients undergoing coronary artery bypass graft (CABG) surgery, the evidence is unequivocal: postmenopausal hormonal therapy (estrogen/progesterone) should NOT be administered and represents a Class III: HARM recommendation. 1 This is the highest level of evidence against continuation, specifically addressing combined estrogen/progesterone therapy in the cardiac surgical population.

Risk-Stratified Approach for Other Surgical Contexts

High-Risk Scenarios: Discontinue Hormones

Hold estrogen-containing therapy 3-4 weeks preoperatively in the following situations:

• Major surgery with prolonged immobility expected 1
• Patients with severe hypercortisolism (Cushing's disease) awaiting surgery, where some experts discontinue estrogen due to compounded hypercoagulable state 1
• Cosmetic/elective surgery in otherwise healthy patients, where stopping 3 weeks before to 2 weeks after surgery is recommended 2
• Patients with additional VTE risk factors: history of thromboembolism, abnormal coagulation testing, poor mobility, extended hospital stays 1

Moderate-Risk Scenarios: Consider Continuation with Prophylaxis

Estrogen therapy may be continued with appropriate thromboprophylaxis in:

• Transgender patients on gender-affirming hormone therapy, where evidence does not support routine discontinuation, particularly for transdermal estradiol formulations 1, 3, 4
• Major surgery without prolonged immobility, where the American College of Obstetricians and Gynecologists does not recommend discontinuation 1
• Patients where psychological harm from discontinuation outweighs thrombotic risk 1

Low-Risk Scenarios: Continue Therapy

All progestogen-only therapy should be continued regardless of surgery type:

• Testosterone therapy is continued perioperatively without increased VTE risk 1, 3
• Progestogen-only contraceptives (pills, DMPA injections, implants) should be continued 1
• Levonorgestrel IUDs should remain in place 1
• Spironolactone and antiandrogens are not associated with negative surgical outcomes 3

Critical Nuances in the Evidence

The Estrogen Formulation Problem

The data linking estrogen to perioperative thrombosis is inconsistent and largely based on older oral estrogen regimens (ethinyl estradiol in oral contraceptives) that are not typically used in modern hormone replacement therapy or transgender care. 3, 4 Transdermal estradiol, the preferred formulation for transgender patients and many menopausal women, has a more favorable thrombotic profile but lacks robust perioperative outcome data. 1, 4

The Pregnancy Risk Trade-Off

A major pitfall in discontinuing oral contraceptives preoperatively is the risk of unintended pregnancy, which itself carries significant thrombotic risk. 5, 6 If estrogen-containing contraceptives are discontinued, alternative highly effective contraception (barrier methods plus backup) must be implemented immediately. 5

Thromboprophylaxis Strategy

When continuing estrogen therapy perioperatively, implement:

• Low molecular weight heparin (preferred over oral anticoagulants due to shorter half-life and reversibility) 1
• Early ambulation and compression stockings for all patients 1
• Duration: 2-4 weeks postoperatively for high-risk patients 1
• Individualized timing of anticoagulant discontinuation before surgery to minimize bleeding risk 1

Specific Clinical Scenarios

Cushing's Disease Surgery

Some experts hold estrogen therapy due to the compounded hypercoagulable state from hypercortisolism plus exogenous estrogen, though this remains low-quality evidence requiring individualized discussion. 1

Gender-Affirming Surgery

No evidence supports routine discontinuation of feminizing hormones for vaginoplasty or other gender-affirming procedures, and the psychological benefits may outweigh thrombotic risk. 1 The decision requires individualized discussion of benefits versus risks with appropriate thromboprophylaxis. 1

Liver Disease/Transplant

Avoid estrogen-containing agents in patients with decompensated cirrhosis, Budd-Chiari syndrome, hepatocellular adenomas, or transplant recipients with graft failure. 1 Progestogen-only methods are preferred. 1

Common Pitfalls to Avoid

1. Assuming all hormone therapy carries equal risk: Transdermal estradiol ≠ oral ethinyl estradiol; progesterone-only ≠ combined therapy 3, 4
2. Discontinuing without contraceptive backup: Always provide alternative contraception if stopping oral contraceptives 5
3. Applying cardiac surgery guidelines universally: The Class III recommendation is specific to CABG, not all surgeries 1
4. Ignoring psychological impact: Abrupt hormone cessation in transgender patients may exacerbate gender dysphoria 1, 4
5. Failing to implement thromboprophylaxis when continuing therapy: If hormones are continued, prophylactic anticoagulation is essential for high-risk patients 1