Transforming Culture: Postoperative Venous Thromboembolism Prophylaxis in a Transgender Patient on Estrogen

Abstract

Case Presentation

A 40-year-old transgender patient (assigned male at birth, pronouns: they/them) with paroxysmal atrial fibrillation presented for elective transoral chondrolaryngoplasty. They had been on gender-affirming hormone therapy with intramuscular estradiol valerate and oral progesterone for 16 months and their atrial fibrillation was managed with flecainide and aspirin. The otolaryngology team recommended holding estrogen postoperatively to reduce venous thromboembolism (VTE) risk, but the patient expressed concern about withdrawal-related gender dysphoria and vasomotor symptoms.

Discussion

Transfeminine patients on estrogen are at higher risk of VTE compared to the general population Goodman M, Zhang Q. Stroke and Blood Clot Risk in Transgender Women Taking Hormones. Patient-Centered Outcomes Research Institute (PCORI); 202 Accessed November 18, 2024. http://www.ncbi.nlm.nih.gov/books/NBK593552/. There has historically been concern about perioperative VTE in these patients in the context of gender affirming vaginoplasty, which is considered to have risk factors associated with VTE (lengthy pelvic surgery with prolonged bedrest) Coleman et al. in Int J Transgender Health. 23:S1–S259, 2022. Previously, it was routine practice to hold gender affirming estrogen perioperatively for vaginoplasty. However, newer literature has shown no increased risk with estrogen maintenance during vaginoplasty Coon et al. in Plast Reconstr Surg Glob Open. 11:e5033, 2023;Lee and Spiegel in The Laryngoscope. 132:918–919, 2022;, with the World Professional Association for Transgender Health (WPATH) guidelines now recommending the continuation of estrogen perioperatively Kozato et al. in J Clin Endocrinol Metab. 106:e1586–e1590, 2021 to avoid symptoms of estrogen withdrawal including gender dysphoria with increased risk of suicide, and vasomotor symptoms. Unfortunately, the practice of holding estrogen therapy perioperatively persists, and has been applied to many surgeries outside of vaginoplasty, even those with little VTE risk, such as this patient’s facial feminization surgery Badreddine et al. in Eur Rev Med Pharmacol Sci. 26:2511–2517, 2022.

Conclusions

Despite evidence and WPATH guidelines, discontinuation of estrogen therapy perioperatively remains common Lee and Spiegel in The Laryngoscope. 132:918–919, 2022. For this patient, the low bleeding and VTE risk allowed for a tailored approach. After discussing risks, the team opted for 2-week VTE chemoprophylaxis with Enoxaparin 40 mg daily. The patient recovered well without bleeding or thromboembolic events. This case underscores the need to update surgical practices based on current evidence and prioritize patient-centered care.

SHARED DECISION-MAKING IN CLINICAL PRACTICE

Decision

The clinical decision facing the patient and the care team was whether to continue or hold gender-affirming estrogen therapy perioperatively for a transgender patient undergoing elective transoral chondrolaryngoplasty. The surgical team was concerned about the risk of venous thromboembolism (VTE) associated with estrogen, while the patient was worried about experiencing gender dysphoria and vasomotor symptoms if their estrogen therapy was withheld.

Participants

The patient was a 40-year-old transgender individual (assigned male at birth, pronouns: they/them) with a history of paroxysmal atrial fibrillation and depression. They had been on gender-affirming hormone therapy with intramuscular estradiol valerate and oral progesterone for approximately 16 months. Their care team included the otolaryngology surgical team, who would perform the chondrolaryngoplasty, as well as a perioperative hospital medicine group that provided input on the management of estrogen therapy in the perioperative period. The patient actively participated in the decision-making process, emphasizing concerns about the impact of estrogen cessation on their mental and emotional well-being.

Pros and Cons of the Medically Reasonable Options

Option 1: Hold Estrogen Therapy Perioperatively

• Pros:

  • May reduce VTE risk, as prior studies have suggested an increased risk of VTE in transfeminine individuals on estrogen therapy.¹
  • Historically, estrogen therapy was withheld perioperatively for vaginoplasty due to concerns about prolonged immobilization and increased thrombotic risk.^{2, 3}
• Cons:

  • Holding estrogen therapy could lead to estrogen withdrawal symptoms, including vasomotor symptoms (hot flashes, night sweats) and worsened gender dysphoria.
  • Increased dysphoria and emotional distress have been linked to a higher risk of suicidal ideation.
  • Newer literature suggests that estrogen continuation perioperatively does not increase VTE risk in transfeminine patients undergoing surgeries with low VTE risk, such as facial feminization procedures.^4–6

Option 2: Continue Estrogen Therapy Perioperatively

• Pros:

  • Maintains the patient’s hormonal stability, reducing the risk of withdrawal symptoms and dysphoria.
  • Aligns with the World Professional Association for Transgender Health (WPATH) guidelines, which recommend continuing estrogen perioperatively in the absence of other contraindications.⁷
  • Some studies suggest that bioidentical estrogen formulations, such as estradiol valerate, have a lower thrombotic risk compared to older conjugated estrogens.^{8, 9}
• Cons:

  • Surgical teams may be hesitant due to longstanding concerns about estrogen-associated VTE risk.¹⁰
  • If VTE did occur, estrogen continuation might be viewed as a contributing factor, complicating postoperative care.
  • Limited data specifically evaluating VTE risk in transfeminine patients undergoing non-pelvic surgeries.

Preferences of the Patient

The patient strongly preferred to continue their gender-affirming estrogen therapy due to concerns about dysphoria and vasomotor symptoms if it were discontinued. They were willing to accept the potential risks of estrogen continuation and sought a solution that would allow them to proceed with surgery without interruption to their hormonal regimen.

Decision Process: Sharing Information, Confirming Understanding, and Getting to a Decision

The perioperative hospital medicine team reviewed the available literature on perioperative estrogen use, including recent studies showing no increased risk of VTE in transfeminine patients undergoing gender-affirming facial feminization surgery.^4–6 They also discussed the differences in thrombotic risk between older estrogen formulations and newer bioidentical estrogens like estradiol valerate.

A shared decision-making approach was used, where the surgical team, hospital medicine team, and patient discussed the potential risks and benefits of continuing estrogen versus holding it perioperatively. The surgical team initially preferred withholding estrogen, but after reviewing newer evidence and considering the patient’s concerns, they agreed to proceed with the surgery if a compromise could be reached.

The agreed-upon strategy was to continue estrogen therapy perioperatively while implementing post-operative VTE chemoprophylaxis with Enoxaparin 40 mg subcutaneously daily for 2 weeks which has a < 0.5% bleeding risk.^{11, 12} The patient was involved in every step of the decision-making process and ultimately endorsed this plan as the best option for their overall well-being.

Outcomes of the Decision

The patient underwent chondrolaryngoplasty with continued estrogen therapy and short-term postoperative VTE prophylaxis. They recovered well postoperatively without complications, including no evidence of thromboembolism or excessive bleeding. Importantly, the patient did not experience worsening gender dysphoria or significant withdrawal symptoms, affirming the decision to continue estrogen therapy.

Reflections on the Case

This case highlights the evolving standards of care regarding perioperative estrogen management in transgender patients. Historically, the practice of withholding estrogen therapy in transfeminine patients was based on concerns about VTE risk, but newer research and clinical guidelines now support its continuation in many surgical settings.

The case also underscores the importance of shared decision-making in transgender healthcare. By incorporating patient preferences alongside medical evidence, the care team was able to find a solution that balanced safety with the patient’s quality of life. This case suggests that more surgical teams should re-evaluate their perioperative estrogen management protocols and consider the use of postoperative anticoagulation as an alternative to withholding gender-affirming hormone therapy.

Data Availability

The data that supports the findings of this case report are available from the corresponding author upon reasonable request.

Declarations

Conflict of Interest

All authors declare no conflicts of interest in the production of this article.