As with most surgeries, venous thromboembolism is always a potential risk and transgender surgical procedures are no different. A new study published in The Journal of Clinical Endocrinology & Metabolism shows no increased clot risk while maintaining hormone therapy during gender affirming surgery.
Transgender medicine continues to grow and evolve – more and more people are presenting to clinics for hormone therapies and gender affirming surgeries. A 2018 report from the American Society of Plastic Surgeons found that from 2017 to 2018, gender confirmation surgeries increased from 8,304 to 9,576, and those numbers have continued to rise. But, as with any kind of growth, there has been some pain.
Knowledge gaps persist. For instance, any surgery carries the risk of venous thromboembolism (VTE), but according the authors of a paper recently published in The Journal of Clinical Endocrinology & Metabolism, little is known about VTE incidence in a transgender surgical patient, and that gap has led to providers separating into two camps about how to reduce the risk of VTE in these patients. One group advocates for withholding hormone therapy for two to four weeks prior to surgery, while the other group says there is little evidence to support suspending hormones.
So a multidisciplinary team of researchers at the Icahn School of Medicine at Mount Sinai and Center for Transgender Medicine and Surgery in New York wanted to set the record straight, since suddenly stopping hormone therapy in a transgender patient can result in withdrawal symptoms and significant psychological distress. Suddenly stopping estrogen therapy in a transgender woman could be just like stopping estrogen in a cisgender woman – severe menopause.
“The discomfort and the distress for our patients in stopping their hormone therapy is not insignificant harm,” says John Henry Pang, MD, assistant professor of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai and Center for Transgender Medicine and Surgery and senior author of the JCEM paper. “We really wanted to reassess our practices and better understand what it is we’re really trying to protect our patients from, does this harm actually exist.”
Improving Care and Safety
For this study, Pang and his team evaluated data from 919 transgender patients who underwent gender affirming surgery at Mount Sinai’s Center for Transgender Medicine and Surgery between November 2015 and August 2019 – including 407 cases of transgender women who underwent primary vaginoplasty surgery. The researchers found no difference in blood clots when estrogen hormone therapy was maintained during gender affirming surgery. Only one blood clot occurred during the entire period reviewed, in a patient who had stopped her estrogen for the surgery. The authors write that the VTE incidence in their patient cohort was comparable to the VTE incidence seen in patients undergoing benign gynecologic surgeries.
Pang points to how well Mount Sinai as an institution focuses on reducing clots in surgical patients, no matter what procedure they underwent – using medications to protect against clots, getting patients out of bed and moving around quicker, modifying already-established risk factors for clots. “We focused our energies on things that we know actually do cause blood clots and modifying those versus focusing on things that may not directly impact the incidence of blood clots in our patient population,” he says.
“Precedent gives us a foundation from which we can question existing policies and practices, and then adjust them according to better data and experience as it comes along. And a willingness to question that and to adjust as we learn more is really the bet is really the way that we can provide better care for our patients.” – John Henry Pang, MD, assistant professor of Plastic and Reconstructive Surgery, Icahn School of Medicine, Center for Transgender Medicine and Surgery Mount Sinai, New York, N.Y.
The authors of the study note that there are some limitations, such as its retrospective nature, and the fact that these findings represent one institution, but that just means more large-scale multicenter studies are needed to reproduce the results of this novel study. “I’d say the power of publishing more about the surgeries and publishing more about our work with the community is to make it safer for our patients,” Pang says. “Because the more doctors and the more healthcare professionals are talking about how to better provide care and safe care for our patients, the better and safer care becomes. The more you talk about it, the more it becomes a known and safer practice. I think that’s the benefit of publishing data.”
The first rule of medicine is “Do no harm.” If a transgender woman can continue her estrogen therapy throughout her gender-affirming surgery, she shouldn’t be made to go through sudden, severe menopause or suffer psychological distress. Pang tells Endocrine News that not only have his patients responded positively to the idea the authors of the JCEM paper have even received calls from other providers and medical directors at large healthcare systems throughout the U.S. wanting to talk about the paper’s findings and the researchers’ experiences. “Now they are rethinking their policies in place,” Pang says. “They are with their surgeons now realizing, ‘Oh, this policy that we had in place may not be entirely necessary and we can also provide care that is not distressing to our patients.’ There is change occurring and that’s a very positive thing that we see.”
“The Mount Sinai study is a practice-changing advance in care for transgender people undergoing surgery,” says Joshua D. Safer, MD, FACP, FACE, executive director of the Center for Transgender Medicine and Surgery at Mount Sinai Health System, professor of Medicine at Icahn School of Medicine at Mount Sinai and co-author of the JCEM paper. “The weeks with sex hormone therapy suspended have been a source of misery for our patients. It is a relief that such an approach is not necessary. The Mount Sinai study also adds to the literature that suggests that the risk of VTE from exogenous estrogens might be less than we’ve suspected for all women, not just transgender women.”
The meaning of “research” is to look again. Pang warns against physicians relying too much on precedent and to continue to ask questions about protocols and guidelines that are in place. Of course, there’s nothing wrong with a physician wanting to err on the side of caution. Until now, most surgical centers have taken a mixed-bag approach on advising their patients whether to stop or continue their hormone therapies prior to surgery.
Pang says he hopes this study can dispel any pervading fear of a harm that may not even exist. “Precedent gives us a foundation from which we can question existing policies and practices, and then adjust them according to better data and experience as it comes along,” he says. “And a willingness to question that and to adjust as we learn more is really the bet is really the way that we can provide better care for our patients.”
— Bagley is the senior editor of Endocrine News. In the March issue, he wrote about how COVID-19 has made health disparities in obesity treatment more apparent.