Hormones and Surgery
Almost everyone I help plan gender-affirming surgery is already on hormones, and one of the first questions they ask is whether they have to stop. The honest answer is that it depends on the surgeon, the operation and your own health, and that the answer has changed over the past decade. Many surgeons who once asked everyone to stop estrogen weeks before an operation now ask far fewer people to, and some ask no one.
This page explains why the question comes up at all, what surgeons weigh, and what changes with your hormones after an operation that removes the testes or ovaries. It is the ground I know best from a decade of coordinating patients through Bangkok hospitals, but I am not a surgeon or a prescriber.
The rule that runs through everything below: whether you pause, for how long and what you take afterwards is decided by your surgeon and your prescriber, together. Do not stop or change hormones before surgery on your own, and do not assume the instructions from someone else's operation apply to yours.
On this page
Why surgeons ask about hormones at all
The main concern is blood clots. Any operation raises the risk of a deep vein thrombosis, a clot in a leg vein that can travel to the lungs, because you lie still for hours and then move less for days. Estrogen taken by mouth also raises clot risk. For a long time the reasoning was simple: stop the estrogen and you remove one of the risk factors.
On testosterone, the concern is different. A high hematocrit, thicker blood, is a clot risk of its own, and surgeons and anaesthetists want to see it in a sensible range before they operate.
Neither concern is new, and both are well managed in hospitals that operate on trans patients regularly. What has changed is how much weight surgeons put on stopping hormones compared with everything else they can do.
Estrogen before surgery
Practice varies more than most people expect, even between surgeons in the same hospital.
Some surgeons still ask patients to pause estrogen for a period before and after surgery, commonly a few weeks each side, especially for long operations such as vaginoplasty. Many others now ask most patients to keep taking it, particularly those on transdermal estrogen (patches or gel), which is generally considered to carry less clot risk than tablets. Some switch people from tablets to patches or gel ahead of surgery rather than stopping entirely.
The reason for the shift is that stopping has costs of its own. Weeks off estrogen, especially for someone who still has testes, can bring back testosterone and with it mood changes, hot flushes, and the return of the very symptoms the person started hormones to end, at a stressful time. Surgeons increasingly judge that for many patients, the extra clot risk from continuing is smaller than it was once thought to be and can be managed in other ways.
In the Bangkok hospitals I have worked with, I have seen instructions range from "stop four weeks before" to "keep taking everything", depending on the surgeon, the operation and the patient's own risk factors. That is normal. Ask your surgeon for their specific instruction, in writing, well before you book flights.
When you book surgery
Tell the surgeon exactly what you take, the dose and how (tablets, patches, gel or injections), and ask what they want you to do with each. Then tell your prescriber what the surgeon said. The two do not always talk to each other unless you make them.
Testosterone before surgery
Most surgeons do not ask people to stop testosterone before chest surgery or a hysterectomy. What they usually want is a recent blood test showing your hematocrit is not too high, and they may ask your prescriber to adjust things if it is.
Some surgeons ask about the timing of injections, preferring not to operate at the very peak of an injection cycle. For longer operations such as phalloplasty, some have their own protocols. As with estrogen, the instruction comes from the surgeon, and it is worth asking for it early.
How clot risk is managed instead
Hospitals have several tools for reducing clot risk that have nothing to do with hormones, and they are routine for longer operations whether the patient is trans or not.
Compression stockings and mechanical calf pumps keep blood moving in the legs during and after surgery. Blood-thinning injections, usually given for some days after an operation, reduce the chance of a clot forming. Getting up and walking early, often the day after surgery, matters more than most people realise. Hospitals also assess the other risk factors that often matter more than hormones: smoking, weight, previous clots, family history, and long flights close to the operation date.
That last one is specific to travelling for surgery. A long-haul flight followed by a long operation and then another flight home adds up. Surgeons who treat international patients usually build in time before and after, and often advise stockings and moving about on the plane.
If you are flying for surgery
Ask the surgeon how many days they want between landing and the operation, and between discharge and flying home. Build those into your plan before you book anything, not after.
After an orchiectomy or vaginoplasty
Once the testes are removed, whether as an orchiectomy on its own or as part of vaginoplasty, the body makes very little testosterone. Most people no longer need an anti-androgen such as spironolactone or cyproterone acetate, and many find their estrogen dose changes too.
What people often do not expect is that they still need estrogen. Without testes and without estrogen, the body has almost no sex hormones at all, which is bad for bones and for how people feel. Estrogen after surgery is usually continued for the long term, as monotherapy.
Your prescriber will adjust your medicines after surgery, usually with blood tests in the months that follow. If you had surgery abroad, make sure your prescriber at home knows exactly what was done and when.
After a hysterectomy and oophorectomy
If the ovaries are removed, the body stops making most of its estrogen, and testosterone becomes the main sex hormone. For most people already on testosterone, that means carrying on, sometimes with a dose adjustment. Staying on testosterone matters more after the ovaries are gone, because without either hormone bones thin quickly.
If the uterus is removed but the ovaries are kept, the hormone picture changes much less. Periods stop permanently, and the ovaries keep working in the background as before.
Anyone considering stopping testosterone for good after oophorectomy needs to talk to a prescriber about how their bones and general health will be protected. That is a real conversation, not a reason to stay on something you do not want.
Frequently asked questions
Do I have to stop estrogen before surgery?
Not always. Some surgeons still ask for a pause, and many now ask most patients to continue, often on patches or gel. Your surgeon decides. See estrogen before surgery.
Do I have to stop testosterone before top surgery?
Usually not, though most surgeons want a recent blood test showing your hematocrit is in range. See testosterone before surgery.
Will I still need hormones after bottom surgery?
Usually yes. After the testes or ovaries are removed, the body makes very little of its own sex hormones, and most people stay on estrogen or testosterone long term. See after an orchiectomy or vaginoplasty and after a hysterectomy and oophorectomy.
What else lowers clot risk around surgery?
Compression stockings, blood-thinning injections, walking early and avoiding long flights close to the operation. See how clot risk is managed instead.