Susan's Place Transgender Resources

Tomorrow is my last day taking hormones prior to my surgery on 30 April.  Any advice from those who have been through this pre-op process on coping?

Most women here report all sorts of issues but I was on HRT for 17 years prior to surgery last August and I had no issues at all . . .

I'm at the point where I have two weeks left before I go on my 30 day pre-op, no hormone regimen. I'm not crazy about it and expect some hot flash type issues. I've been on Estradiol and Spiro for the past couple of years. I'm currently down to 1/4 of my regular dose and no major changes yet. Next week down to 1/8 normal and then off to zero for a month. I hope things have worked out well for you. I'm thinking I'll start a thread on my journey through the next 6 weeks.
All the best!

Quote from: kat69 on April 07, 2018, 08:32:42 PM
Tomorrow is my last day taking hormones prior to my surgery on 30 April.  Any advice from those who have been through this pre-op process on coping?

Honestly I think most the issues are self inflicted.  This too shall pass.. its NOT the end of the world.  Personally I've been off & on HRT so many times my head spins.  Do I notice a difference?  Well.... yes? no?  I mean I'm a terrible example, but maybe hot flashes are more frequent off.   On, I'm more emotionally labile. Other than that?  My boobs hurt & ... other issues physically happen whether I'm on or off :)

I am on injectable Estrogen and Progesterone. I did not stop HRT, I also did not tell the surgeon I did not stop. One of the floor nurses figured I did not stop, long funny story. I had zero issues and healed quite well, my blood pressure was normal, had minimal swelling. It was my choice not to stop. I would never ever recommend going counter to doctors orders, however, I did what was best for me.

The reason for stopping estrogens is the possibility of blood clots post surgery. If you do not lower your estrogen blood levels pre-surgery you increase your risk. Yes some of us will get away with not stopping the estrogens, but not all of us.

If your estrogen is injectable Estradiol valerate, the long half life means that it will take a full month to lower your estrogen blood levels. If you are taking sublingual Estradiol, the short half life means that your blood levels will be almost nothing in just a few days. I have never heard of a surgeon differentiating between which route of administration for the  recommended withdrawal period. 

This applies to all types of surgery. Smoking tobacco is another risk factor for blood clots.

If you lie to your surgeon, you take your chances post op.

I have a 6 week no E rule with my surgeon but I am not impressed at all. Why would I be any more prone to clots than what any cis woman would be? They have plenty of E onboard when they have surgery and I would bet that their levels are not even checked. It never has made any sense to me and I would even doubt if they check it. I will, under real protest follow my surgeons request but I think its unnecessary. Maybe I am wrong on medical grounds and will happily defer to those with more knowledge. I would also not recommend going against your Drs request to stop. Personally I have made no decision either way.

I´m thankful, that I only need to be off from HRT for 10 days prior to surgery and 5 days after it.

It is just surprising, that there is such varioation how many days and weeks you need to be off. Guess it comes down to how long they want to keep you stationary at bed.

Quote from: ElizabethK on May 15, 2018, 04:54:07 AM
I have a 6 week no E rule with my surgeon but I am not impressed at all. Why would I be any more prone to clots than what any cis woman would be? They have plenty of E onboard when they have surgery and I would bet that their levels are not even checked. It never has made any sense to me ...

Holding Estradiol for a few days is an easy way to limit our risk factor for blood clots. Cis-women cannot stop their Estradiol production at will. They will have to wait until menopause sets in. In fact, post menopausal women on Estradiol are asked to hold their hormones for a few days before any scheduled surgeries.

Also, depending on the individuals Estradiol dose, blood levels are much higher in women with a TG history.

30 days? 6 weeks?! Anything more than 1 week prior to surgery seems ridiculous. I won't be stopping for any longer than that should any of my surgeons ask. And I'm going to have an E implant well and truly active at the time of my FFS, already approved by my endo who is transgender too. In my opinion the pros of continuing to have a supply of sex hormone in the body throughout the surgery period outweigh the cons. I don't want to go back to crying all the time and breaking out in hot sweats in the middle of the night.

I think I was 4 weeks before and 2 weeks after for a total of 6 weeks. GCS is very invasive and you are on your back for 3 days. Then the recovery and it is slow. I had a complication and I was on bed rest for 3 weeks. I had my catheter for 2 weeks and had a procedure to finish my GCS 1 week after the initial procedure.

I did not have hot flashes but I felt out of it. That most likely was from the experiences I went through. You can have a complication and the standard GCS can turn into a more complicated series of events. If you fly you will have a difference in pressure to contend with too.

I highly recommend you follow your doctors recommendations.

A great deal of the concern dates back to the use of horse estrogens. Human estradiol has been shown not to influence clotting factor however the other forms of estrogen such as estriol and estrone/estrone sulfates do. Metabolites of progesterone actually help to negate the clotting factor effect.
Funny how nature does it all on it own.

I recently had spine surgery and an orchiectomy. Neither the orthopedic surgeon or the urologist had any problems with me taking my hormones. The back surgery was pretty invasive also and I was chair bound for several days except I could still go use the bathroom. Both disc and bone were cut out.

It would be interesting to know, to which scientific fact such a long pauses are based on...if to any.

Because the half time of estrogen is quite fast and definitely doesn´t on that basis require such a pause.

Cyproteronacetat does accumulate into body an the half time is much much longer, but still not six weeks.

I'm one week post op as of today and my surgeon had me stop 4 weeks prior and 2 weeks after.  When I had my previous two procedures (Rhino and BA), neither surgeon had required me to stop. 

I haven't been on Spiro for over a year and my E levels have always been pretty high.  I didn't had hot flashes, but the hair shedding post has been significant. 

Looking forward to going back on E next week.

I think if you are going to be at bedrest recovering and not moving your extremities obviously your risk of blood clots is going to increase.. even more so if you have high blood pressure.  Take all this into account as you plan for surgery folks.

If, on the other hand, you get up an hour after the surgery, move in the bed a lot, and everything is hunky dory and your B/P is 120/60 and pulse 65 you probably have absolutely nothing to worry about.  Which ironically was my case hehe.   I wasn't the most mobile person but my cardiac functioning has always been great.

Just my thoughts :) I still wouldn't recommend going against what the doc wants.. but then again I've never been entirely compliant with them anyways.  Frankly I know a LOT more about my condition than most docs I've run into.  They refer me to a specialist who refers me to another specialist .......  :embarrassed:

Hey, everyone.  Just so you know I had my GCS with Dr Brassard on 30 April 2018 and have restarted my estrogen over a week ago.  Please feel free to continue the thread to assist others.

Kat

One of the advantages of estrogen implants is that you don't have to stop for surgery.

I've been off estrogen twice, your skin and hair gets oily, and you get a little cranky. It's not the end of the world.

Given the choice of possible blood clots or possible pimples, it's kind of easy to make the decision. For me, anyway. Your decision making ability may vary.  :)

Hugs, Devlyn

We had someone here reporting just in the last couple of weeks that they nearly died as a result of post-op blood clotting. There was no particular mention of whether she'd followed surgeon's instructions wrt HRT.

Incidence of venous thromboembolism post surgeries generally is around 1% and the ACS has been taking measures to reduce that number. 1% is the same fraction of GCS patients who will see a fistula connecting the colon to the neovagina. Nobody in their right minds wants either of these outcomes and ignoring your surgeon's instructions seems to me as incredibly short sighted.

@josie76 I wouldn't call a spinal procedure anywhere near as invasive as GCS, bone, and ligament tissues don't have anywhere near the degree of vascular perfusion as the work done in GCS.

I consider myself to have been at an extremely low objective risk, I take a tiny dose of IM estradiol valerate and I did discuss this with Dr Wittenberg. She told me to stick to protocol and I did. I'm glad of it, I was immobilized considerably longer than I'd expected post-op and my recovery was also harder than expected. I'm glad I didn't have a DVT to add to that.

Quote from: SadieBlake on May 16, 2018, 01:52:40 PM
Incidence of venous thromboembolism post surgeries generally is around 1% and the ACS has been taking measures to reduce that number. 1% is the same fraction of GCS patients who will see a fistula connecting the colon to the neovagina.

Where did you get 1% rate for fistula from? It seems very high.

SadieBlake yeh you are right. I would have stopped if the docs would have said to. I was thinking about the logic of why so many GCS docs say to stop. I also did not intend to imply that anyone should not do what the doctor says. I should have stated that.

It's still pretty invasive when you look at the work they do in there. Muscles have to get cut, nerves have to be rearranged without cutting. Appearently my sacral spinal canal is only about 10mm diameter where the average adult is 13mm. But no, there is not the large amount of skin and attached tissues to need cut and stitched or the very invasive sigmoid colon type. Still plenty of possibility to cause a clot and many day.s being immobile.

Quote from: AnonyMs on May 16, 2018, 02:55:27 PM
Where did you get 1% rate for fistula from? It seems very high.

It's the number my surgeon gave me, here's a reference for actually 2%

https://doi.org/10.1016/j.jpra.2015.09.003

Quote from: SadieBlake on May 16, 2018, 07:27:48 PM
It's the number my surgeon gave me, here's a reference for actually 2%

https://doi.org/10.1016/j.jpra.2015.09.003

Thanks for that. Here's a few more I found.

There's an interview with Dr Suporn where he says he's had 2 fistulas (in over 2700 surgeries), so less than 0.074%. To find the interview search for the pdf SRS with Dr Suporn 2015 3rd edition.

Gennaro Selvaggi and James Bellringer published a paper "Gender reassignment surgery: an overview",
doi:10.1038/nrurol.2011.46, there are 0.75%.

Quote
In our own unit, a 2008 audit revealed six fistulas in over 800 cases of MtF surgery

In this paper by Preecha in Thailand, there are 0 out of 395 cases.

https://www.ncbi.nlm.nih.gov/pubmed/25356769

A paper, "An Update on the Surgical Treatment for Transgender Patients" by Stan Monstrey among others. http://dx.doi.org/10.1016/j.sxmr.2016.08.001

Quote
A mean percentage of 1% (range 0.8% - 0.17%) was calculated from four studies (total = 917 transwomen).

It's almost certainly not the surgeon making the request, it's more than likely the anesthetist.

And to those of you who ignore the request to discontinue HRT prior to surgery, consider this, if there is a major problem leading to a law suit, you will lose. Failure to meet pre-op protocol absolves the doc, hospital and their insurance of any liability.

Quote from: Dani on May 15, 2018, 04:40:25 AM
The reason for stopping estrogens is the possibility of blood clots post surgery. If you do not lower your estrogen blood levels pre-surgery you increase your risk.

The risk of DVT (deep venous thrombosis) is not correlated with estrogen levels.

"This prospective study suggests that high endogenous concentrations of estradiol and testosterone in women and men in the general population are not associated with increased risk of VTE [VTE =venous thromboembolism], DVT or PE [PE =pulmonary embolism]."

Endogenous sex hormones and risk of venous thromboembolism in women and men
Journal of Thrombosis and Haemostasis, 2013, 12: 297–305

Risk of thromboembolisms is correlated with Activated Protein-C (APC) resistance.  APC resistance is dependent on the route of administration of estrogens, for bioidentical estrogen (estradiol) at least. For example, transdermal administration does not lead to increased risk of DVT.  [This does not apply to ethinyl estradiol, and maybe not conjugated equine estrogens, either.]

"Biologic evidence supports a differential effect of oral versus transdermal estrogen on hemostasis. Randomized trials have shown that oral ERT [ERT = estrogen replacement therapy] increases plasma levels of prothrombin fragment F1+2, which is a marker for in vivo thrombin generation and which was recently related to the risk of recurrent VTE.   Consistent data reported that transdermal ERT had no detrimental effect on coagulation, especially prothrombin fragment 1+2 plasma level, and our findings are in accordance with these results. Thus, oral ERT might impair the balance between procoagulant factors and antithrombotic mechanisms, whereas transdermal ERT appears to have little or no effect on hemostasis."

Differential Effects of Oral and Transdermal Estrogen/Progesterone Regimens on Sensitivity to Activated Protein C Among Postmenopausal Women
Arterioscler Thromb Vasc Biol., September 2003, pp 1672-76.

Quote from: Dani on May 15, 2018, 04:40:25 AM
I have never heard of a surgeon differentiating between which route of administration for the  recommended withdrawal period. 

Therein lies the problem.  It is oral administration of estrogens that is problematic, apparently related to first-pass liver metabolism.

"Conjugated equine extracts and 17-oestradiol are the two most widely used forms of oestrogen in postmenopausal women. Oestrogens are usually given orally, but such a delivery route has drawbacks, including intestinal and hepatic first-pass effects. Oral, but not transdermal, oestrogen administration leads to high hormone concentrations in the liver and promotes hepatic protein synthesis. Data for the pharmacokinetics of oral and transdermal oestradiol showed dose-dependent increase in serum oestradiol exposure. However, oral ERT results in a substantial increase in plasma oestrone concentration leading to non-physiological ratio of oestrone to oestradiol close to 5.18 By contrast, transdermal ERT leads to plasma oestrone to oestradiol ratios close to 1, which is similar to that in menstruating women."

Differential association of oral and transdermal oestrogen replacement therapy with venous thromboembolism risk
Lancet 2003 362: 428–32

Granted, these studies are on post-menopausal cis-females, but it is probably reasonable to assume liver physiology and metabolism is very similar to transgender women. It is quite likely that those patients using transdermal or parenteral (injectable) estradiol face no increased risk of blood clots. With this in mind, I switched from sublingual estradiol to transdermal estradiol before I had SRS.

And of course, I am not a doctor (of medicine, anyway) so this information is given only in the interest of being an informed patient.

With kindness,

Terri

Digestive (liver pass) of 17beta-estradiol also results in a large percent conversion to estrone and estrone sulfate both of which are a storable form of estrogen but both of which has a increased effect directly on platelet cell reactions.

To be honest, during my 2nd SRS (revision) I lied to my surgeon and keep taking my hormones daily until the day before the surgery. It did not affect the result nor made the surgery more complicated (my doctor did not even caught me lying) But then again it might vary on the patient's age as well.

Quote from: chinee on May 21, 2018, 05:06:31 PM
To be honest, during my 2nd SRS (revision) I lied to my surgeon and keep taking my hormones daily until the day before the surgery. It did not affect the result nor made the surgery more complicated (my doctor did not even caught me lying) But then again it might vary on the patient's age as well.

You were lucky.. If there had been an issue and it was found to be caused by the E you were told not to take, you'd be on your own..

To understand the risk your running when you disobey the doctors orders, look at what happens in the real world. Airline seats are being place closer to together in order to pack additional passengers on each flight. It has now reached the point where if I sit with my knees forward in the seat, my knees are pressed on the seat in front of me. This means I have little room to move around and it's never recommended you unfasten your seat belt in flight as you never know when turbulence might force you against the ceiling of the plane. Normally I beed like a stuck pig so all this means is I am uncomfortable for the flight.

For others, the lack of ability to freely move can cause blood clots to form on a relatively normal domestic flight. How often it happens, I don't know but often enough to make the paper from time to time. You face the same risk after surgery. For GCS you need normally to remain in bed for 2 days after surgery. They put a device on your legs to reduce the risk, how ever the risk is still there. For much of the population the risk is low. I spent 6 days in bed after surgery without any complications and without the device on my legs. The question is do you want to gamble that your not one of the ones with a high risk of clots? A little discomfort before surgery is a small price to pay for the additional assurance that you will survive the surgery without difficulty.

The only thing that I´m really worried about stopping the hormones, is that it hampers any changes in the future. Perhaps it´s not a rational fear, but I somehow believe or think, that it does.

I can survive through the hot flashes and endless stream of sweat during the night...but if feminization is hampered...

 :police:

I will remind people to be respectful in their posts and to follow the TOS.

There is no call for uncouth comments.

I just thought cis women were never asked by their doctors to lower their E if they will be doing a surgery. Also, I don't think having E in our system wont make us bloody when they cut us unlike vitamin E and other things which are understandable. But then again I may be wrong.

I did not want to stop taking hormones due to I am sensitive with it. Stopping it for even a week would make me crazy.

The request to stop HRT is based on old data, when Prmerian was the common drug. I talked to my gyno about going on implants and how would I stop HRT prior to surgery? She referred me to the surgeon. I called and they told me no need to stop if on implants as there was almost no risk of DVT as compared to ORAL medication. I than asked why if on IM I would need to stop, her words "It's been our protocol for the past 20+ years" She had NO other answer when pressed.
So next week when I see my MD will go over implanted vs IM. I would love to skip an injection every 3.5 days.

Dam you brought back bad memories. I dare say stopping hormones two weeks prior to srs was worse than the recovery of srs. I went a bit wacky and was disturbed at how stuff started working again. If I could do it over I would do what some women do and NOT completely stop the hormones. That would be MY AND my decision.

I had FFS two days ago and HRT was never mentioned or stopped - and that's a pretty major set of operations to open up and modify a skull.  I went under anesthesia at 8:30am, woke up at 7pm at the start of 4 hours of hair transplants, and didn't stand up until the following morning.  I'm sure a nurse or surgeon saw my estradiol patches, they're right above the area where someone installed a catheter and nobody removed or asked about the patches later. 

I was asked to stop HRT for GCS and for VFS.  I asked my GCS surgeon why they don't allow HRT, they said one of their GCS patients on HRT experienced life-threatening clotting a few years ago so they changed to a no-HRT surgery policy.