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

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.