Association of Surgical Risk With Exogenous Hormone Use in Transgender Patients: A Systematic Review

JAMA Surg. 2019 Feb 1;154(2):159-169. doi: 10.1001/jamasurg.2018.4598.


Importance: A growing number of transgender patients are receiving gender-affirming hormone treatments. It is unclear whether the evidence supports the current practice of routinely discontinuing these hormones prior to surgery.

Objective: To determine how medications used in cross-sex hormone treatment (CSHT) affect perioperative risk.

Evidence review: A series of searches were carried out in PubMed and Excerpta Medica Database to identify articles using each of the terms testosterone, estrogen, estradiol, oral contraceptive, spironolactone, cyproterone acetate, finasteride, dutasteride, leuprolide, goserelin, and histrelin, in combination with the terms surgery, perioperative, thrombosis, thromboembolism, and operative. The search was not restricted to perioperative outcomes in transgender populations because many surgeons routinely discontinue hormone use prior to surgery in this population, which makes it impossible to study how hormones affect outcomes. Additional sources were also identified from the texts of reviewed articles. Articles were excluded if they were animal studies or case reports, did not explicitly discuss surgical outcomes, or were restricted to removal of hormonally sensitive tissues.

Findings: Eighteen articles addressing perioperative outcomes were identified by this systematic review, including 1 on CSHT, 12 on estrogens and progesterones, 1 on testosterone, and 4 on spironolactone and antiandrogens. Data were limited, but use of exogenous testosterone was not found to be associated with an increased risk of venous thromboembolism or other complications during surgery. Moderate evidence suggests that spironolactone is not associated with negative surgical outcomes. The data linking estrogen use and thrombosis is inconsistent in the perioperative period and does not address the types of estrogens most often used for CSHT.

Conclusions and relevance: Current evidence does not support routine discontinuation of all CSHT prior to surgery, particularly given the lack of information on risks associated with resuming these medications after they have been stopped. Evidence suggests there is no need to discontinue either testosterone or spironolactone, although their association with perioperative outcome quality has not been studied in depth. Most of the evidence that supports discontinuation of estrogen prior to surgery is based on oral estrogen regimens that are not typically used in transgender patients, and even with those formulations, there are conflicting reports on perioperative risk. Further research is needed to determine the safety of continuing hormone treatment and elucidate risks of short-term discontinuation.

Publication types

  • Systematic Review

MeSH terms

  • Drug Substitution
  • Female
  • Gender Dysphoria / drug therapy
  • Gender Dysphoria / mortality
  • Gonadal Steroid Hormones / adverse effects*
  • Humans
  • Intraoperative Complications / etiology
  • Male
  • Observational Studies as Topic
  • Practice Patterns, Physicians'
  • Preoperative Care / methods*
  • Transgender Persons*
  • Transsexualism / drug therapy
  • Transsexualism / mortality


  • Gonadal Steroid Hormones