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Little evidence supports the practice of suspending hormone therapy prior to surgery for transgender individuals, according to a new systematic review.

The analysis, published online in and conducted by Elizabeth Boskey, PhD, of Boston Children's Hospital, and colleagues, included 18 studies assessing the perioperative risks associated with the use of various hormones.

"As part of starting our Center for Gender Surgery, we reviewed other surgeons' policies and protocols," Boskey told 麻豆传媒, adding that one thing that was particularly noteworthy to her was that the vast majority of surgeons required individuals to stop cross-sex hormone therapy before gender-affirming surgery and to remain off of it for some time following surgery.

"Since I'd spoken to many transgender people about how dysphoric and generally unpleasant this was, I suggested looking at the evidence to see if stopping hormone use was actually necessary," she explained. "That way, our policies could be based on evidence and, ideally, not cause unnecessary harm to our patients."

Most studies included in the analysis looked at these perioperative risks among the general population, since there is only limited data available solely on the transgender population due to the routine practice of suspending cross-sex hormone treatment prior to surgery, Boskey noted.

"In general, the thing that surprised me most about the findings was how few studies really looked at the risk of exogenous hormones and surgery," she continued. "A lot of research stopped after the 1980s, but hormone regimens continued to change, and their risks have changed as well. However, there is surprisingly little data about those risks in the perioperative period."

One that exclusively looked at transgender men found that testosterone cross-sex hormone treatment was not tied to an increase in complications during chest reconstruction surgery. Although transgender men who continued testosterone at the time of surgery tended to have a higher risk for hematoma compared with those who suspended testosterone therapy, but this difference was not statistically significant.

In looking at testosterone use, but this time in cisgender men, those who continued testosterone therapy at the time of surgery did not show any differences in in-hospital mortality or cardiac outcomes compared with those who suspended testosterone prior to surgery.

The review by Boskey and co-authors included 11 studies -- a mix of case-control, prospective, and retrospective cohort studies ranked from low to very low quality of evidence -- looking at estrogen and progestogen use in cisgender women, and generally found inconsistent evidence between estrogen and perioperative complications. Few of these studies reported an increased risk between oral contraceptive use and postoperative venous thromboembolism, while other studies found no significant risk differences associated with continuing therapy.

As for spironolactone, three studies in the review found no link with postoperative atrial fibrillation or , although this quality of evidence was also ranked low. Only one study assessed , including tamoxifen and the aromatase inhibitors anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin). In this study, there was an increase in complications related to wound healing after breast reconstruction, including infection, fat necrosis, and delayed healing.

Because of the inconsistent and insufficient data on continued cross-sex hormone treatment use among the transgender population, the researchers ultimately recommended that the risks should be weighed on an individual basis until further research is done.

"The biggest gaps in the research are around the perioperative risks of the estrogens most often prescribed to transgender women," Boskey said. "What research is out there suggests that topical estrogens, in particular, are likely to have a much lower risk of thrombogenesis due to the lack of a hepatic first-pass effect. However, the routine discontinuation of estrogens means there's no way to determine the actual risk."

"Some doctors might ask, 'what's the harm?' -- and that's the other big gap," she added. "Anecdotally, there are many reports of transgender women experiencing significant side effects, both physiological and psychological, from stopping their estrogen prior to surgery; however, there's almost nothing in the published literature."

Boskey said that in order to address these lingering questions, her team is currently working on designing a study to both "assess and quantify these effects" so healthcare providers can more accurately weigh the risks and benefits of suspending cross-sex hormone therapy.

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