Perioperative Estrogen Considerations for Transgender Women Undergoing Vaginoplasty

The mainstay of feminizing gender-affirming therapy for transgender people is a combination of estrogen and an adjunct anti-androgen. Exogenous estrogens are associated with greater risk of venous thromboembolism (VTE). The risk appears more significant with certain estrogens such as ethinyl estradiol. While ethinyl estradiol is the main estrogen used for oral contraceptive agents, there is no reason to accept its increased thrombogenicity for feminizing hormone therapy. For the estrogens studied, the risk seems to rise with higher doses and with the addition of progestins. That is the reason for the use of adjunct anti-androgens which may allow for similar benefits despite lower overall estrogen dosing. The absolute risk of VTE with exogenous estrogens, however, is small. Indeed, in the setting of major surgery, there does not appear to be any added benefit to holding estrogen therapy beyond standard perioperative VTE prophylaxis approaches.