Perioperative Venous Thromboembolism in Transfeminine Patients on Exogenous Estrogen Undergoing Feminizing Genital Surgery

INTRODUCTION: Currently, there is no standard of care regarding exogenous estrogen continuation versus cessation in transfeminine patients undergoing genital reconstructive surgery, as there remains very little aggregate data on the risk of venous thromboembolism (VTE) in this patient population. Careful consideration must still be given to all women on estrogen therapies, as the American College of Chest Physicians (ACCP) lists the use of exogenous estrogens as a known risk factor for perioperative VTE. OBJECTIVE: The primary objective was to compare the incidence of VTE between transfeminine patients undergoing genital reconstructive surgery who experienced estrogen cessation preoperatively and those who continued a low-dose regimen. The secondary objective was to compare the incidence of adverse events. METHODS: This was a retrospective cohort study of transfeminine patients undergoing genital reconstructive surgery by a single surgeon at a single tertiary care referral center. Patients were included if they underwent vaginoplasty, vulvoplasty only, orchiectomy, or genital revision surgery between January 2016 and January 2024. Patients who had undergone surgery between 2016 and 2020 were part of an estrogen cessation protocol where all exogenous estrogen therapy was ceased 3–4 weeks prior to surgery with resumption 2 weeks postoperatively. Patients who underwent surgery between 2020 and 2024 did not completely stop estrogen therapy and instead were transitioned to 1 mg of exogenous estrogen therapy 3–4 weeks preoperatively until 2 weeks postoperatively, when they were allowed to resume their original dose. Outcomes following surgery were compared between the two cohorts of patients. Postoperative VTE was the primary outcome of study. RESULTS: 348 patients met inclusion criteria and were included in this study: 131 in the estrogen cessation group and 217 in the low-dose estrogen group. 85.4% (182) of patients underwent vaginoplasty, 14.6% (31) vulvoplasty, 16.6% (58) orchiectomy, and 22.3% (78) revision surgery. The mean age and BMI of the cohort were 38 (15) years and 26.4 (5) kg/m2, respectively. 96.3% (337) of patients were on exogenous estrogen prior to surgery. The majority of patients were ASA Class II or lower (87.6% (305)), and the median Caprini score was 4 (2–6). Patients in the estrogen cessation group were older than the low-dose estrogen group and had a higher median Caprini score: 40 vs 36 years, p=0.02, and 4 vs 3, p=0.01, respectively. Otherwise, characteristics were statistically similar between the groups. The overall incidence of VTE in this cohort was 0.3% (95% CI 0.15–0.78), with 1 patient experiencing a postoperative pulmonary embolus. This patient was in the estrogen cessation group. The incidence of postoperative complications was statistically similar between the groups (5.3% vs 1.8%, p=0.39). CONCLUSIONS: The overall incidence of VTE in transfeminine patients undergoing genital reconstructive surgery is low. Patients may remain on low-dose estrogen perioperatively without increasing the risk of VTE and other complications.Table 1Table 2