Perioperative venous thromboembolism risk considerations in the gender diverse patient – Should we consider more than just estrogen?

Published:December 21, 2022DOI:
      A 20-year-old assigned female at birth (AFAB) transmasculine individual was evaluated to undergo gender-affirming mastectomy. He was on oral ethynodiol-ethinyl estradiol (a combination oral contraceptive), testosterone cypionate injections, oral paroxetine, and oral trazodone. The patient's preoperative body mass index (BMI) was 40 kg/m2. His preoperative Caprini score was 4. He was deemed an appropriate operative candidate and underwent gender-affirming mastectomy as an outpatient surgery. Eight days postoperatively, he presented with acute chest and back pain with dyspnea. He was found to have bilateral pulmonary emboli on computed tomography angiography (CTA). The patient later recalled that other family members experienced prior thrombotic events; therefore, the patient's true preoperative Caprini score was 7. His thrombophilia workup was negative. The patient received a 6-month course of anticoagulation. Additionally, cessation of the oral contraceptive and alternative menstrual suppression management and contraceptive options were discussed with the patient. He ultimately chose to have an etonogestrel implant placed.


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