Chirurgie & arrêt de THS

# Chirurgie & arrêt de THS *Support de pair-aidance écrit par biyokea (📩 `@biyokea` sur discord) de l'association [Fransgenre](https://fransgenre.fr/), me contacter en cas d'erreur/imprécision ou pour toute suggestion* # Introduction & résumé Article sur la nécessité médicale ou non (notamment en terme de complications thrombo-emboliques et de cicatrisation) d'arrêter son traitement hormonal avant une chirurgie. :::success **Les exigences d'interruption de son THS avant une chirurgie ne sont généralement pas justifiées**, s'appuient sur des idées datées et fausses sur les complications thrombo-emboliques, et **ne prennent pas en compte les inconvénients d'imposer un arrêt de leur THS** aux personnes trans. - pour la testostérone : - pas plus d'évènements thrombo-emboliques sous T - complications, satisfaction et issues post-op similaires avec ou sans T - études supplémentaires sur l'impact éventuel de la T dans la cicatrisation à établir, mais données actuelles rassurantes - pour les oestrogènes : - pas plus d'évènements thrombo-emboliques sous estradiol - facteurs de risques individuels à prendre en compte & importance de la prophylaxie - surrisque liés aux oestrogènes synthétiques (éthinylestradiol) pas applicables aux THS modernes à base d'estradiol ::: # Rapide revue de littérature ## Testostérone :large_blue_diamond: [The Effect of Preoperative Gender-Affirming Hormone Therapy Use on Perioperative Adverse Events in Transmasculine Individuals Undergoing Masculinizing Chest Surgery for Gender Affirmation](https://doi.org/10.1093/asj/sjac091) : 2022, étude rétrospective *Mammectomies ; patient·es sous testostérone (n=236), avec arrêt 2 semaines pré-op (n=172) et sans arrêt pré-op (n=64)* > [...] cessation of GAHT preoperatively may have adverse psychosocial effects for many transgender patients. Abrupt hormone cessation may exacerbate gender dysphoria, emotional stability, sexual function, and quality of life. > [color=#907bf7] > There is no significant difference in the incidence of perioperative adverse events for patients who continue GAHT preoperatively vs patients who stop GAHT prior to MCS. > [color=#907bf7] :large_blue_diamond: [Perioperative Hormone Management in Gender-Affirming Mastectomy: Is Stopping Testosterone before Top Surgery Really Necessary?](https://doi.org/10.1097/PRS.0000000000009858) : 2023, étude rétrospective *Mammectomies ; patient·es (n=490), sous testostérone, avec arrêt 2 semaines pré-op (n=175) et sans arrêt pré-op (n=211) ; et pas sous testostérone (n=104).* > Abrupt cessation of hormone therapy is associated with its own potential adverse psychological and physiologic consequences, including worsened gender incongruence, mood, and energy levels. > [color=#907bf7] > Patients who continued testosterone, held testosterone, or were testosterone-naive demonstrated no differences in rates of hematoma requiring operative intervention or seroma requiring intervention. Rates of partial nipple-areola complex necrosis and surgical site infection were similar [...]. There was no difference in rates of VTE [...]. Overall complication rates were similar among patients who continued testosterone, held testosterone, or were testosterone-naive. > [color=#907bf7] > Our results demonstrate no difference in postoperative complication rates among groups. Whereas further investigation is warranted, our data suggest that routine cessation of testosterone in the perioperative period is not necessary for patients undergoing gender-affirming mastectomy. > [color=#907bf7] :large_blue_diamond: [Female-to-Male Gender Affirming Top Surgery: A Single Surgeon’s 15-Year Retrospective Review and Treatment Algorithm](https://doi.org/10.1093/asj/sjx116) : 2018, étude rétrospective *Mammectomies ; patient·es (n=679) sous testostérone (n=463) ou non (n=216)* > When complications were grouped by those taking masculinizing hormones (18.6%, 86/463) vs those that were not (17.1%, 37/216), the difference was not found to be statistically significant (P = 0.67). > [color=#907bf7] :large_blue_diamond: [Implications of testosterone therapy on wound healing and operative outcomes of gender-affirming chest masculinization surgery](https://doi.org/10.1016/j.bjps.2022.11.057) : 2023, étude rétrospective *Mammectomies ; patient·es (n=170), sous testostérone avec recommandation d'arrêt à 3 semaines pré-op (n=101) ou non sous testostérone (n=69)* > ⚠ Les auteur·es font des recommandations qui ne s'appuient pas sur leurs résultats > [color=orange] > [...] We did not find a statistically significant association between testosterone and increased surgical complications in gender-affirming mastectomies. > [color=#907bf7] > In our cohort, 22 (13%) patients developed hypertrophic scarring, distributed equally between the two groups. A statistically significant correlation was not observed between testosterone treatment and hypertrophic scar formation. > [color=#907bf7] > We believe that the statistically insignificant correlation observed in our cohort between testosterone therapy and hypertrophic scarring could be the result of testosterone secession 3 weeks before the operation. We, therefore, recommend the cessation of treatment several weeks preoperatively as an important clinical practice to improve the esthetic appearance of the surgical scar. > [color=#907bf7] :large_blue_diamond: [Androgen therapy worsens scar formation in masculinizing mastectomy](https://doi.org/10.1093/bjs/znad148) : 2023, étude prospective *Mammectomies ; patient·es (n=92) sous T (n=86) ou non (n=6)* > ⚠ Échantillon non sous T très faible > [color=orange] > On a mixed-effects regression, when controlling for significant covariates postoperative day and double-incision free nipple graft (DIFNG; incision type), the weekly testosterone dose was a significant predictor of worse MSS colour, MSS distortion, and MSS total score > [color=#907bf7] > It is important to note that the authors also recognize the negative effects that holding hormone regimens may have. By investigating dose-dependent effects, the authors hope to provide physicians and patients with information to allow an informed discussion on whether reducing or stopping testosterone aligns with a patient’s goals. Prospective studies to clarify the window in which scars can be ‘modified’ by testosterone exposure and whether there is a threshold level at which testosterone does not impair scarring will be critical. > [color=#907bf7] :large_blue_diamond: [Effect of testosterone replacement therapy on scar quality in gender-affirming mastectomies](https://doi.org/10.1016/j.bjps.2024.01.017) : 2024, étude rétrospective *Mammectomies ; patient·es (n=126) sous testostérone (n=63) ou non (n=63)* > The average scores for the scars in the testosterone group were [...] 2.74 for the cumulative average, and the scores in the non-testosterone groups were [...] 2.66, respectively. The scores were not found to be statistically different (P value = 0.52, 0.94 and 0.71, respectively). Additionally, when the SBSES scores were separated into individual components, the groups did not differ in terms of scar width (P value = 0.37), height (P value = 0.26), colour (P value = 0.07), suture marks (P value = 0.41), overall appearance (P value = 0.90) and total scores (P value = 1.00). > [color=#907bf7] > In conclusion, our study found no direct impact of TRT prior to gender-affirming mastectomies on the subsequent scar pattern and quality. > [color=#907bf7] ## Testostérone & oestrogènes :large_blue_diamond: [Association of Surgical Risk With Exogenous Hormone Use in Transgender Patients: A Systematic Review](https://doi.org/10.1001/jamasurg.2018.4598) : 2019, revue > ⚠ Revue un peu datée > [color=orange] > There is insufficient evidence to support routine discontinuation of exogenous hormones in transgender patients seeking surgery. > [color=#907bf7] > Current evidence does not support the need to routinely discontinue all cross-sex hormone therapy prior to surgery. Although it may seem like a straightforward decision to discontinue hormone use as a protective measure, it is important to balance the risks of thrombosis in the perioperative period with the risks of stopping therapy. Unfortunately, to date and to our knowledge, there are few data that directly address the question of how stopping CSHT in the perioperative period affects vascular, emotional, and general health. > [color=#907bf7] ## Oestrogènes :large_blue_diamond: [Hematologic concerns in transgender patients](https://www.hematologyandoncology.net/archives/august-2022/hematologic-concerns-in-transgender-patients/) : 2022, revue > Estrogen holding can result in undesirable effects of estrogen withdrawal. Symptoms of estrogen withdrawal, which can start in a few days, include depression, anxiety, and increased dysphoria. In contrast, studies have shown that the risk for thrombosis with gender-affirming surgery is low, usually less than 1%.[...] A reasonable recommendation would be to continue estrogens through surgery and use standard thrombosis prophylaxis when indicated by various scoring systems, such as the Caprini score. > [color=#907bf7] :large_blue_diamond: [Peri-operative Outcomes of Vaginoplasty Using an Individualized Approach to Hormone Management in Transgender Women](https://doi.org/10.1210/js.2019-MON-197) : 2019, étude rétrospective *Vaginoplasties ; patient·es (n=59) soit de plus de 50 ans (n=10) et arrêtant E2 orale 6 semaines avant, passage à E2 transdermal et arrêt 2 semaines avant chir ; soit femmes de moins de 50 ans (n=49) continuant leur THS > There were no complications of deep venous thrombosis [nor] cardiovascular events [...]. > [color=#907bf7] > Continuing feminizing hormone therapy before vaginoplasty is not associated with an increased risk for complications in women under the age of 50. An individualized approach could be considered to limit the risk of worsening dysphoria post-operatively while avoiding increased risks in older women. > [color=#907bf7] :large_blue_diamond: [No Venous Thromboembolism Increase Among Transgender Female Patients Remaining on Estrogen for Gender-Affirming Surgery](https://doi.org/10.1210/clinem/dgaa966) : 2021, étude rétrospective (n=407) *Vaginoplasties ; patient·es (n=407) avec soit arrêt THS 1 semaine pré-op (n=190), soit sans arrêt THS (n=212)* > Of all cases, 1 patient presented with VTE, [whose HT] was suspended prior to surgery. No VTE events were noted among those who continued HT. > [color=#907bf7] > Perioperative VTE was not a significant risk in a large, homogenously treated cohort of TGNB patients independent of whether HT was suspended or not prior to surgery. > [color=#907bf7] > Exogenous hormone administration, including estrogen HT, does not appear to alter the risk of postoperative VTE for transfeminine patients who undergo gender-affirming surgery. The authors conclude that estrogen HT suspension is not necessary for the transfeminine patient undergoing gender-affirming surgery. > [color=#907bf7] :large_blue_diamond: [Effect of Cross-Sex Hormone Therapy on Venous Thromboembolism Risk in Male-to-Female Gender-Affirming Surgery](https://doi.org/10.1097/SAP.0000000000002300) : 2021, revue > ⚠ Revue qui ne fait pas la différence entre éthinylestradiol et 17β-estradiol... > [color=orange] > This may certainly improve quality of life as current practices of suspending CSHT preoperatively cause significant shifts in hormone balance, especially in MTF GAS involving gonadectomy. These shifts are associated with serious physical and psychoemotional consequences, including rebound virilization, postoperative depression, mood lability, fatigue, anxiety, myalgia, and hot flashes. > [color=#907bf7] > There is no compelling data demonstrating that VTE is particularly increased in the postoperative period when patients undergo GAS with or without CSHT suspension. [...] In the absence of definitive VTE risk factors (e.g., smoking, clotting disorders, or malignancy), we conclude that surgeons may engage MTF patients in a joint decision-making process to determine the most optimal perioperative CSHT management plan on a case-by-case basis. [...] Nevertheless, future studies—ideally randomized control trials are needed to optimize transgender surgical outcomes and quality of life. > [color=#907bf7] --- *[Illustration :frame_with_picture:](https://www.piqsels.com/en/public-domain-photo-zkkuo) : piqsels*