MON-197 Peri-operative Outcomes of Vaginoplasty Using an Individualized Approach to Hormone Management in Transgender Women

For transgender and gender diverse individuals, gender identity is not congruent with the sex assigned at birth. Cross sex hormone therapy (HT) and gender affirming surgery can relieve significant dysphoria associated with gender incongruence and improve health outcomes. With changes in private insurance, state and federal regulations to cover gender-affirming treatments and procedures, there has been an increasing need and demand for trained providers and centers to provide gender-affirming health care. However, there is little data to guide management of peri-operative HT with regards to limiting risks. Most surgeons follow a protocol to stop feminizing HT 2 weeks before vaginoplasty with little data that this is effective and necessary or whether this might provoke significant dysphoria peri-operatively. We sought to determine if an age-specific and route-specific peri-operative protocol for feminizing HT was associated with increased risk for complications, changes in hormone concentrations or cardiometabolic profile. At our tertiary care academic center, transgender women over the age of 50 discontinued oral estradiol 6 weeks prior to surgery to allow enough time for clotting factors to normalize but could choose to switch to transdermal estradiol until 2 weeks prior to surgery. Younger women continued estradiol until surgery. All women restarted estradiol upon discharge from the hospital. We performed a retrospective review of pre and postoperative body mass index (BMI), blood pressure (BP), estradiol (E2) and total testosterone (TT) concentrations, fasting glucose and lipids 6 months before and after vaginoplasty. Results: A total of 59 transgender women underwent vaginoplasty over 20 months. Ten women age ≥ 50 (O) had a median age of 58 [Interquartile range (IQR) 56-62]. 49 women < age 50 (Y) had a median age of 31 [IQR 27-37]. O had significantly higher BMI than Y [29.7(IQR 28.3-34.2) vs 24.6 (21.6-28.4), p<0.01 and significantly higher BP, triglycerides, and LDL. More Y women were taking oral estradiol (53% vs 20%). There was no difference in baseline or post-surgical E2 or TT concentrations or fasting glucose. There were no complications of deep venous thrombosis, cardiovascular events or significant changes in BMI, BP, fasting glucose or lipids. In both age groups, only about half were able to decrease their estrogen dose post operatively (Y 57% vs O 44%, p=0.5). Conclusions: 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. Why estrogen doses could not be reduced more frequently after orchiectomy requires further investigation.