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  • Author
    Christos Haveles
  • Co-author

    Christos S. Haveles, BS; Maxwell M. Wang, BA; Arpana Arjun, BA; Justine C. Lee, MD, PhD

  • Title

    Effect of cross-sex hormone therapy on venous thromboembolism risk in male-to-female gender-affirming surgery: A systematic review

  • Abstract

    PURPOSE: An estimated 1.4 million Americans identify as transgender, often seeking hormone treatment and surgery to live as their identified gender. Cross-sex hormone therapy (CSHT) typically consists of various estrogen formulations that confer varying risks of venous thromboembolism (VTE). Currently, there is no standard practice by surgeons regarding the preoperative gender-affirming surgery (GAS) hormone regimen of male-to-female (MTF) patients to minimize thromboembolic postoperative complications. The purpose of this review is to examine the current literature on venous thromboembolism (VTE) occurring in MTF transgender patients on CSHT specifically when undergoing various gender-affirming surgeries - facial feminization surgery (FFS), top surgery (TS), and bottom surgery (BS) - to understand how evidence-based recommendations regarding perioperative hormone regimens can be established to improve clinical outcomes.

    METHODS: A systematic review was performed to identify articles examining the incidence of VTE in MTF transgender patients following three major categories of GAS: facial feminization surgery (FFS), top surgery (TS), and bottom surgery (BS). Within the past 25 years, two hundred eighty-five studies were identified and seven met inclusion criteria by examining the incidence of VTE in MTF patients undergoing GAS procedures. Two reviewers independently assessed all articles for methodological quality (weighted Cohen κ for interrater reliability = 0.80).

    RESULTS: Together, these studies included 1,500 patients and found 60 total VTE events. Twelve of these VTE events were attributed to GAS, of which 10 were associated with BS, one was associated with FFS, and one was associated with a patient who received BS and FFS in the same period. VTE risk, even without preoperative CSHT suspension, was particularly low with FFS while there was a slightly higher risk with BS. This review also highlights that surgeons who perform GAS are divided on their preferred CSHT protocols, with some requiring patients to suspend their CSHT weeks prior to surgery and others allowing patients to continue CSHT through the day of surgery. Three of the seven studies detailed a CSHT perioperative regimen which suspended CSHT before surgery; one study tapered CSHT to lower levels before surgery; the remaining three studies did not specify a CSHT perioperative regimen.

    CONCLUSIONS: Taken together, our findings demonstrate a lack of compelling data supporting CSHT suspension prior to GAS for the purpose of VTE prophylaxis - particularly when other effective intraoperative prophylactic measures are already standard of surgical care. We conclude that in the absence of definitive VTE risk factors, surgeons may engage MTF patients in joint decision-making process to determine the most optimal perioperative CSHT management plan on a case-by-case basis. While multiple studies supported no increased risk of VTE with preoperative CSHT suspension, no standard measurement was available for meta-analysis. Future studies are warranted in order to further evaluate VTE risk based on patient age, type of surgery, operating time, prophylactic measures, follow-up time, and CSHT perioperative regimens.

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