My team said stop oestrogen before surgery, my friend's team said carry on. Why do the instructions differ so much?

Pre-op letter arrived this week and buried in the middle of it is an instruction to stop my oestrogen before the operation. No explanation, no reasoning, just a date to stop.

I mentioned it to a friend who had the same operation last year at a different centre, and she said her team told her explicitly to keep taking hers right through. Not "we forgot to say", she asked and they said continue.

So now I am sitting here with two opposite instructions from two sets of professionals and a genuinely upsetting mental image of coming off hormones for weeks right before the biggest thing I have ever done. I have waited years to not feel like that again. Is one of them wrong? Is this a clot thing? Does it depend on whether it is patches or tablets, because we are on different ones.

I will obviously do what my own team says. I would just like to understand WHY, because right now it feels arbitrary and that is what is upsetting me more than the instruction itself.

Mine said stop, and I will be honest, those weeks were not my favourite. Not catastrophic, but flat and hot and weepy in a way I had not braced for because the letter made it sound like a formality.

The thing that helped was knowing the date I would restart. Ask them that if it is not written down. Having an end point turned it from "I have been switched off" into "I am doing a fortnight of something unpleasant for a reason", which my brain coped with much better.

Piling on with a third version because apparently we are collecting them: I was told to switch from tablets to patches for the run-up rather than stop altogether. Which suggests the route matters, and that "stop or continue" is not even the only option on the table.

Kerry-Anne, for what it is worth, I do not think either team is wrong. I think they are managing the same risk with different house policies. But I would love someone who actually knows to explain the risk, because I only half understand it myself.

This is a fair question and it deserves a proper answer rather than a shrug, so let me set out what the disagreement is actually about. As always, your own team's instruction is the one that governs you, because they know your history and I do not.

The direct answer: the concern is venous thromboembolism, meaning a clot forming in a deep vein and potentially travelling to the lungs. Oestrogen therapy raises that risk somewhat, and so does major surgery, and so does lying still for hours during and after an operation. When those stack, the traditional response was to remove the one you can remove, which is the oestrogen, for a period before and after the operation. That is where the "stop" instruction comes from, and it is not superstition.

The reason practice has moved is that the picture turned out to be more nuanced. Route of administration matters: transdermal oestrogen, meaning patches or gel, does not pass through the liver first the way oral oestrogen does, and is generally regarded as carrying a lower thrombotic risk. Perioperative clot prevention has also improved a great deal, with pharmacological thromboprophylaxis, compression stockings and intermittent compression devices, and a strong emphasis on getting people moving early. So a number of centres now continue hormones through surgery, particularly transdermal ones, judging that the clot risk is manageable and the harm of an abrupt hormonal drop before a major operation is not trivial.

What it depends on, named plainly, so you can see why two teams differ. Personal risk factors: previous clot, a known thrombophilia, smoking, significant obesity, cancer history, family history. The operation itself: length, how much time you spend immobile, whether there is a long flight involved afterwards. The route and preparation you are on. And the local protocol, which is genuinely a policy decision made by an institution weighing the same evidence, not a fact about your body. Two competent teams can read the same literature and land differently, and both instructions can be reasonable for the patient in front of them.

A few exceptions and practical points. Anti-androgens are usually handled differently from oestrogen, so if only one of your medications is mentioned in a letter, that may be deliberate rather than an omission. If you are told to stop, ask for the restart date in the same conversation, because Mara is right that the plan matters as much as the pause. And if you have any personal or family history of clots, say so explicitly at your pre-operative assessment even if you think it is already in your notes.

What I would not do is take a different centre's instruction because it sounds kinder. Mismatched advice is worth asking about, not acting on. Ask your team the reason, and ask what tips their protocol one way rather than the other. The site's guide to preparing for gender-affirming surgery covers where in the pre-operative assessment this decision usually gets made.

Mr Tobias Lindgren said:

a policy decision made by an institution weighing the same evidence, not a fact about your body

That sentence has done more for my mood than anything else this week, thank you. Not arbitrary, just two houses with two rulebooks. I can live with that.

I have written down the questions and I am ringing the pre-op nurse on Monday to ask for the reason and the restart date. Will report back.

From the other side of the pharmacy, my testosterone was not touched at all for my surgery, which surprised me at the time because I had assumed all hormones got paused. Different hormone, different risk profile, apparently.

Worth saying because I nearly stopped mine off my own bat, based on a forum post much like this one, without asking anybody. Do not be me. Ask.

As promised. Rang, asked, got a proper answer.

Their protocol is to stop oral oestrogen for a set period because of the clot risk during and after an operation of that length, and yes, they restart it at a defined point afterwards, which is now written on my copy of the plan. The nurse also said if I had been on patches the conversation might have been different, which lines up exactly with what was said above.

Still not looking forward to the pause. But understanding it has taken the sting out, and I am no longer lying awake convinced one of the two teams is incompetent. Six weeks to go.