Perioperative Management of Hormone Therapy

Introduction to Hormone Therapy Management

The American College of Cardiology recommends that postmenopausal hormone therapy (estrogen/progesterone) should not be administered to women undergoing CABG and should be discontinued preoperatively, with a Class III: HARM recommendation, indicating the highest level of evidence against continuation 1, 2

Postmenopausal hormonal therapy (estrogen/progesterone) should not be administered to patients undergoing coronary artery bypass graft (CABG) surgery, representing a Class III: HARM recommendation, with the highest level of evidence against continuation 1, 2

Hold estrogen-containing therapy 3-4 weeks preoperatively in situations with major surgery and prolonged immobility expected, patients with severe hypercortisolism (Cushing's disease) awaiting surgery, and patients with additional VTE risk factors 3
Estrogen therapy may be continued with appropriate thromboprophylaxis in transgender patients on gender-affirming hormone therapy, major surgery without prolonged immobility, and patients where psychological harm from discontinuation outweighs thrombotic risk 4, 5

All progestogen-only therapy should be continued regardless of surgery type, including progestogen-only contraceptives (pills, DMPA injections, implants) and levonorgestrel IUDs 4, 5

Implement low molecular weight heparin, early ambulation, and compression stockings for all patients, with individualized timing of anticoagulant discontinuation before surgery to minimize bleeding risk 3

Avoid estrogen-containing agents in patients with decompensated cirrhosis, Budd-Chiari syndrome, hepatocellular adenomas, or transplant recipients with graft failure, and prefer progestogen-only methods 5
No evidence supports routine discontinuation of feminizing hormones for vaginoplasty or other gender-affirming procedures, and the decision requires individualized discussion of benefits versus risks with appropriate thromboprophylaxis 4