Journal of the Endocrine Society, Volume 3, Issue Supplement_1, April-May 2019, MON-197, https://doi.org/10.1210/js.2019-MON-197

“Continuing feminizing hormone therapy before vaginoplasty is not associated with an increased risk for complications in women under the age of 50.”

Yale J Biol Med. 2020 Sep; 93(4): 539–548.

“Feminizing genitoplasty is associated with a low thromboembolic risk. However, many patients are instructed to cease estradiol therapy several weeks preoperatively based on reports of increased thrombotic risk in trans people undergoing feminizing hormone therapy and hemostatic changes with the oral contraceptive pill. This can result in psychological distress and vasomotor symptoms. There is insufficient evidence to support routine discontinuation of estradiol therapy in the perioperative period . There is a need for high-quality prospective trials evaluating the perioperative risk of estradiol therapy in trans people undergoing feminizing hormone therapy to formulate evidence-based recommendations.”

“Due to the potential thrombotic complications of estradiol therapy and the increased risk of thrombosis perioperatively, guidelines including the Italian Society of Andrology and Sexual Medicine and National Observatory of Gender Identity recommend cessation of estradiol 2-4 weeks prior to feminizing genitoplasty or other major surgery [9-11]. However, these recommendations are based on evidence including estradiol formulations which are no longer used and many studies informing these recommendations were performed prior to introduction of routine VTE prophylaxis. ”

“In summary, studies evaluating the perioperative risk of estradiol are largely based on ethinyl estradiol, which is no longer recommended as part of GAHT regimens. Similarly, many of these studies were performed prior to introduction of routine VTE prophylaxis. Limited evidence with modern GAHT regimens have not documented an increased risk. ”

“In a more recent retrospective analysis of 330 trans individuals who underwent penile inversion vaginoplasty between 2011-2015, there were no reported cases of DVT [57]. This was despite a perioperative estradiol regimen that involved continuation of estradiol tapered to 2mg at least 2 weeks prior to surgery. Similarly, there were no reports of DVT using a protocol in which those under 50 (n=49) continued estradiol until surgery, and people aged 50 years or older (n=10) discontinued estradiol 6 weeks preoperatively but could choose to continue transdermal estradiol until 2 weeks preoperatively [58].”

“ Cessation of estradiol 2 or 6 weeks preoperatively results in virilization with testosterone and estradiol concentrations near the male reference range [59]. (…) In a retrospective analysis, among participants who discontinued hormones preoperatively, 74 (35%) reported that this had been difficult [12]. The most common symptoms reported by participants who stopped taking hormones were hot flushes (43 participants, 20% of those who stopped), mood swings or irritability (42 participants, 20% of those who stopped), and increases in facial or body hair growth (12 participants, 6% of those who stopped) [12]. ”

The Journal of Clinical Endocrinology & Metabolism, Volume 106, Issue 4, April 2021, Pages e1586–e1590 https://doi.org/10.1210/clinem/dgaa966

“A total of 919 TGNB patients underwent 1858 surgical procedures representing 1396 unique cases, of which 407 cases were transfeminine patients undergoing primary vaginoplasty. Of the latter, 190 cases were performed with estrogen suspended for 1 week prior to surgery, and 212 cases were performed with HT continued throughout. Of all cases, 1 patient presented with VTE, from the cohort of transfeminine patients whose estrogen HT was suspended prior to surgery. No VTE events were noted among those who continued HT. Mean postoperative follow-up was 285 days.”

“Perioperative VTE was not a significant risk in a large, homogenously treated cohort of TGNB patients independent of whether HT was suspended or not prior to surgery.”

“Seventy-three percent of cases were undergone by patients under the age of 40, and 37% of cases were undergone by patients under the age of 30. The average age of the primary vaginoplasty patients was 35.6 years and the average BMI of the primary vaginoplasty patients was 25.7 kg/m2.”

“Of all 1396 cases, only 1 patient presented with VTE (Table 3). This patient belonged to the cohort whose estrogen HT had been suspended for 1 week prior to surgery. She underwent primary vaginoplasty and presented on postoperative day 20 to the emergency department with VTE.”

“ Zero VTE events were recorded among the patients who remained on HT, including the 576 transfeminine cases in which estrogen HT was continued throughout. Of these, 212 patients underwent primary vaginoplasty with estrogen HT continued throughout .

The most common form of estrogen HT among primary vaginoplasty patients was estradiol (97%). Seven patients not on estradiol were taking oral conjugated estrogens (Premarin) instead. Spironolactone was taken by 71%, and progesterone by 19%.

The most common routes of administration for estradiol among primary vaginoplasty patients were oral (52%), injection (32%), and those who switched between oral and injection products (8.6%) (Table 4). The average dosage of oral estradiol was 5.0 mg daily (range, 1 mg weekly to 16 mg daily). The average dosage of injectable estradiol was 54 mg per month (range, 10 mg every 4 weeks to 100 mg every 2 weeks). Less common routes of administration included transdermal (4.7%), those who switched between transdermal and injection (1%), and those who switched between transdermal and oral (0.7%).”

“Exogenous hormone administration, including estrogen HT, does not appear to alter the risk of postoperative VTE for transfeminine patients who undergo gender-affirming surgery. The authors conclude that estrogen HT suspension is not necessary for the transfeminine patient undergoing gender-affirming surgery. ”

I met with three surgeons so far and I got a different answer each time. The first one said I should stop everything two weeks before. The second said that I should continue HRT. And the third one said I should drop the blocker a month and E a couple days before surgery.

It's almost the one thing I'm worried about the most. It seems that no one has a clue. I want to be safe from blood clots but I also don't want to experience weeks of bad mood because I'm needlessly off of E. Right now I think I'll ask my Endo and trust him. He's my hormone guy, surgeons are just the flesh persons.

We are advised to stop taking estradiol, specifically, because it raises blood clotting risk. It's not about "bleeding out" (whose risk is raised by things like anti-inflammatory foods and NSAID medications), it's exactly the opposite of that, and it's only the estradiol.

An increasing number of surgeons are aware that the clotting risk may not be raised for those of us who inject our estradiol. But old protocols die hard, and let's be real about this: there's only one published study saying that injected estradiol doesn't raise blood clotting risk. That's not high enough standard of proof for surgery.

However, I wasn't a very compliant patient. I met them in the middle. I reduced my injections to .05ml (.1mg) every 5 days for the 2 weeks before and after my surgery. That's more than enough to prevent menopause symptoms and allay any remasculinization concerns.

A month prior is quite common, in the end I was without HRT for 2-months before, and another 2-weeks after. I don't think it was too bad, but my wife disagrees! 🤣

I did not stop HRT before, but just because nobody talked to me about it.

I got a theory that pausing HRT and resuming some days later kickstarts it to another level. There is a rumor about a feminization boost after GRS, and also people talk about after they stopped for some reason that they got better feminization. Maybe something with the estrogen receptors recalibrating or something I don't know.

Just my thoughts. I hope you get the information you want from other people.

I stopped. My AA a week before, but stayed on estradiol. No real issues.

My surgeon has you discontinued blockers and drop your estrogen to no more than 4 mg per day. That's how I did it for both FFS and GCS.

I would recommend following your surgeon's instructions, as long as they're a reputable surgeon. I also wouldn't be worried about remasculinization within 2 weeks, especially if you're not on blockers.

I'm having my SRS next year and I'll have to stop my blocker injections a month before surgery and estrogen a week before. I'm worried about stopping the blockers, because a month is a long time, but i'm hoping that I'll have fried my hormonal production systems enough over 4.5 years that my body would take longer than that to start producing testosterone again.

I also don't necessarily think menopausal symptoms are as bad as they're made out to be. I had some when I first went on Lupron, and I definitely felt it (hot flashes and all) but it was certainly very manageable. I'm sure you'll be fine for 2 weeks, and it'll probably blend in to the overall pre surgery stress.

For me I stopped 20 days prior to my SRS as per my doctor, largely because I was on pills and was going to be bedridden for a week after. I started it back up as soon as I was up walking. For my FFS the year before SRS I talk to my surgeon but he was fine with not stopping and for my SRS revision my HRT never came up as an issue so it continued. All of those surgeries were preformed by the same doctor so he was well aware of my HRT regime at all times. As for today if I need surgery it won't even be brought up by me and if the doctor says something tough I won't be stopping.

If you want an honest answer there isn't a single reason to stop. There are however valid reasons NOT TO stop. If you are on injections and are doing them yourself no one will know and you simply don't say. The fear of estrogen is from the WHI study from 2001 and from the approval studies for Premerin and EE. Those studied are also the reason why the "standards" for MTF HRT are so low, sometimes to the point of not letting us actually transition hormonally.

I have had three surgeries while on HRT and every time I was told I was to stop estrogen 15 days prior. I did this each time and I had no negative lasting effects accept that it doesn't feel great. They won't do the surgeries if you don't. There may not be any issue, but the chance of estrogen increasing blood clotting is too great for them to risk.

If your surgeon follows this procedure, there may be nothing you can show them to change their minds. They are already performing a procedure on you that has plenty of risks, lessening any risks is what they are going to shoot for.

I agree with you that stopping it probly isn't going to change anything one way or another, but you won't be off it long enough for it to undo your changes. I was off 3 weeks total and aside from hot flashes I ended up fine. To be honest, I started my shot back 5 days ago and today I feel a surge in my breasts that feels indicative of possible new growth?! Otherwise, if comparing a pic of me from a month ago and today, I look just as feminine as I did then, if not more.

Concerns on both side of this I believe are null - you probly won't have a clot issue - and you won't revert your 21 months of progress.

Definitely stop before, I've heard of people who haven't and they almost bled out during the surgery