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A journal club style critical review of current publications in evidence-based transgender medical care.

Wednesday, May 30, 2012

Perioperative Hormones: What are Plastic Surgeons Doing?

Survey of the attitudes of British plastic surgeons with respect to menopausal hormone replacement therapy finds a wide range of practices.  (1)

Given the ongoing lack of clear evidence based recommendations regarding the use of perioperative combined oral contraceptives (OCP) or menopausal hormone replacement therapy (HRT) in the context of venous thromboembolism (VTE), the authors distributed a mailed 2004 survey of 285 consultant plastic surgeons in the UK in with respect to their individual practices.  Of the 53% that responded, 50% believed that HRT was a risk factor for VTE but only 20% considered cessation of therapy to their patients.  This is compared with 90% who believed OCP was a VTE risk factor, and 54% considered cessation of this treatment.

     The authors conclude by recommending that barring quality evidence, risks associated with OCP should be extrapolated to HRT, and that all perioperative estrogen of any type should be stopped for 4 weeks before and 2 weeks after any major surgery, any lower limb surgery, or any general anesthesia lasting > 1 hour.


      The authors make several “leaps of faith” in their recommendations.  While they admit that there is little if any evidence linking HRT with perioperative VTE, and also point out that even older (and more thrombogenic) generation OCP preparations from the 1960’s only increase DVT risk from 5/100,000 to 15/100,000 – startling 200% increase to be sure, however an absolute risk still well within reason when operating in the context of informed consent.  It is asserted that anesthesia >1 hr or age >40 raises an individual VTE risk to “intermediate” – which should serve to remind us more about the background morbidity associated with major surgery rather than cause us to attribute all postoperative VTE in transwomen to estrogen treatment (in other words, people get VTE’s postoperatively, estrogen or no estrogen).  

     Oddly, the British National Formulary states that “evidence associating [HRT with] an increase in DVT is questionable”, yet goes on to list thrombophlebitis and thromboembolic disorders as contraindications to usage and (even though they are very different medicines) generalizes recommendations for OCP’s to HRT as well.  In any case, this practice pattern survey with a 53% response rate should serve more to identify the need for evidence-based guidelines rather than serve to inform best practices.


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