Transgender individuals may decide to seek gender-affirming care to transition their physical characteristics to match their gender identity. Two standard gender-affirming treatment options are gender-affirming hormone therapy (GAHT) and gender-affirming surgery (GAS). Individuals may choose to use GAHT as a standalone therapy or in combination with GAS.

For transwomen, GAHT involves taking the hormone estrogen as well as androgen/testosterone-blocking medications to promote the development of feminine secondary sex characteristics. Some GAS clinics recommend that patients temporarily discontinue GAHT before surgery due to a potentially higher risk of venous thromboembolism (blood clots in the veins). However, the research on this possible risk is limited, and not all GAS clinics require patients to stop GAHT before surgery.

To garner insights into how continuing or discontinuing GAHT before surgery impacts patients’ hormone profiles, the authors of a recent study in the Journal of Sexual Medicine compared the extended serum steroid hormone profiles of 77 transwomen from three different clinics in Germany.

Individuals undergoing GAS at the first clinic were required to discontinue GAHT 4-6 weeks before surgery, patients at the second clinic discontinued GAHT 2 weeks before surgery, and those at the third clinic continued GAHT up to the day of surgery. Included in this study were 13 patients from the first clinic, 51 patients from the second clinic, and 13 patients from the third clinic.

The researchers measured the patients’ steroid hormone concentrations from blood samples that were obtained on the day of surgery. As anticipated, the individuals who stopped GAHT 4-6 weeks before surgery had the highest testosterone levels, which is not desirable for transwomen. Conversely, the transwomen who continued GAHT for the entire period until surgery had the highest levels of estradiol, which is a form of estrogen. Interestingly, the patients who continued GAHT also had higher cortisone levels than the patients who temporarily discontinued GAHT. The authors speculated that this could be due to an enzyme that can convert cortisol to cortisone that is affected by estrogens.

In the end, the investigators confirmed that continuing GAHT until GAS is the better option for patients who wish to maintain feminized steroid hormone profiles, but they did not comment on the possibility of an increased risk of venous thromboembolism. Nevertheless, they pointed out that discontinuing GAHT 4-6 weeks before GAS resulted in decreased levels of cortisone, which may be desirable for patients undergoing surgery. Further research on the hormone profiles of transwomen before and after GAS as well as research on the psychological components of undergoing GAS would expand these findings and could help clarify best practices for GAS moving forward.

Resources:

• Schneider, F., Wistuba, J., Holterhus, P.M., Kulle, A., Schlatt, S., Kliesch, S., Neuhaus, N., & Zitzmann, M. (2021). New Insights Into Extended Steroid Hormone Profiles in Transwomen in a Multi-Center Setting in Germany. The journal of sexual medicine, 18(10), 1807-1817. DOI: https://doi.org/10.1016/j.jsxm.2021.08.004