Clinicians generally recommend that patients discontinue use of exogenous hormones such as estrogen and testosterone before undergoing surgical procedures, due to the potential increased risk of blood clots and other complications. Yet there’s little evidence to support this practice in transgender people, according to a new systematic review by Elizabeth Boskey, PhD, and her colleagues in the Center for Gender Surgery at Boston Children’s Hospital. In fact, there may be possible psychological harm in requiring trans patients to halt hormone therapy, she says.
Along with two of the center’s co-directors, Oren Ganor, MD, and Amir Taghinia, MD, Boskey reviewed data from 18 previously published studies on perioperative outcomes in people taking supplemental hormones. “As part of starting our center, we reviewed other surgeons’ policies and protocols. One of the things which we found was that the vast majority of surgeons required individuals to stop cross-sex hormone therapy prior to gender-affirming surgery and stay off it for some time after,” explains Boskey.
“Since I’d spoken to many transgender people about how dysphoric and generally unpleasant this was, I suggested looking at the evidence to see if stopping hormone use was actually necessary,” she says. “That way, our policies could be based on evidence and, ideally, not cause unnecessary harm to our patients.”
A dearth of concrete information
Boskey and her colleagues found that few of the studies involved transgender patients and instead looked at the risks of hormone replacement therapy or oral contraceptives in cisgender individuals. What’s more, much of this research ended after the 1980s, yet hormone regimens — and their risks — have continued to change over time. For instance, most of the evidence that supports discontinuing estrogen prior to surgery is based on oral estrogen, yet transgender women typically use topical estrogen, which likely has a much lower risk of blood clots.
The results were no more illuminating for trans or cisgender men. One study of trans men found no significant link between testosterone treatment and post-operative complications, nor did a study in cisgender men who didn’t discontinue testosterone prior to surgery. The team’s findings were published online in JAMA Surgery on December 5, 2018.
“Some doctors might ask, “What’s the harm in stopping hormones?” she explains. “But there are many anecdotal reports of transgender women experiencing significant side effects, both physiological and psychological, from stopping their estrogen prior to surgery.”
The team is currently working on designing a study to assess and quantify these effects so that providers can more accurately weigh the risks and benefits of stopping cross-sex hormone therapy. In the meantime, they recommend that clinicians weigh the potential risks and benefits of stopping hormone treatment with their patients.
“Boston Children’s has long been at the forefront of gender-affirming care for young patients,” says Boskey. “We hope that our research can continue to raise the bar on evidenced-based practice with this growing population.”
Learn about the Center for Gender Surgery.