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December 5, 2018

Association of Surgical Risk With Exogenous Hormone Use in Transgender Patients: A Systematic Review

Author Affiliations
  • 1Center for Gender Surgery, Boston Children’s Hospital, Boston, Massachusetts
JAMA Surg. 2019;154(2):159-169. doi:10.1001/jamasurg.2018.4598
Key Points

Question  Is it necessary for transgender patients to discontinue exogenous hormone use before surgical procedures?

Findings  There has been insufficient research on how cross-sex hormone therapy affects surgical outcomes. Limited evidence suggests that exogenous testosterone is not associated with complications in the perioperative period, and spironolactone has not been associated with poor surgical outcomes; although oral estrogens have been associated with an increased risk of thrombosis, evidence is inconclusive about whether it is necessary to stop the use of commonly prescribed transdermal estrogens before surgery.

Meaning  There is insufficient evidence to support routine discontinuation of exogenous hormones in transgender patients seeking surgery.


Importance  A growing number of transgender patients are receiving gender-affirming hormone treatments. It is unclear whether the evidence supports the current practice of routinely discontinuing these hormones prior to surgery.

Objective  To determine how medications used in cross-sex hormone treatment (CSHT) affect perioperative risk.

Evidence Review  A series of searches were carried out in PubMed and Excerpta Medica Database to identify articles using each of the terms testosterone, estrogen, estradiol, oral contraceptive, spironolactone, cyproterone acetate, finasteride, dutasteride, leuprolide, goserelin, and histrelin, in combination with the terms surgery, perioperative, thrombosis, thromboembolism, and operative. The search was not restricted to perioperative outcomes in transgender populations because many surgeons routinely discontinue hormone use prior to surgery in this population, which makes it impossible to study how hormones affect outcomes. Additional sources were also identified from the texts of reviewed articles. Articles were excluded if they were animal studies or case reports, did not explicitly discuss surgical outcomes, or were restricted to removal of hormonally sensitive tissues.

Findings  Eighteen articles addressing perioperative outcomes were identified by this systematic review, including 1 on CSHT, 12 on estrogens and progesterones, 1 on testosterone, and 4 on spironolactone and antiandrogens. Data were limited, but use of exogenous testosterone was not found to be associated with an increased risk of venous thromboembolism or other complications during surgery. Moderate evidence suggests that spironolactone is not associated with negative surgical outcomes. The data linking estrogen use and thrombosis is inconsistent in the perioperative period and does not address the types of estrogens most often used for CSHT.

Conclusions and Relevance  Current evidence does not support routine discontinuation of all CSHT prior to surgery, particularly given the lack of information on risks associated with resuming these medications after they have been stopped. Evidence suggests there is no need to discontinue either testosterone or spironolactone, although their association with perioperative outcome quality has not been studied in depth. Most of the evidence that supports discontinuation of estrogen prior to surgery is based on oral estrogen regimens that are not typically used in transgender patients, and even with those formulations, there are conflicting reports on perioperative risk. Further research is needed to determine the safety of continuing hormone treatment and elucidate risks of short-term discontinuation.

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