Is HRT Safe During and Before a Full Face Lift?

Question

my present physician , to my surprise, told me i must be entirely off all hrt for both 2 weeks post and pre op to achieve significant results. i have not heard this before ever, from all the doctors i have consulted with.. my condition is closely monitored and hrt is well within normal limits and helps me greatly.my condition is stable.. my pcp or hormone sees no justifiable medical reason to warrent d/c hormones, as they pose an insignificant risk.What are the consensue of opinion out here?

Larry S. Nichter, MD, MS, FACS · Answer

After going through the informed consent process (see below), my experience is that most of my patients continue to take Hormone Replacement Therapy (HRT) during their surgery . I do recommend that high risk patients (see below) stop HRT prior to surgery.  Knowing your risk vs benefit information is the key to making the right decision.  Like all medical decisions an informed consent is needed with your surgeon and/or other physicians most knowledgeable about Hormone Replacement Therapy and long surgical procedures (e.g. hematologist or gynecologist with special interest in HRT). Ask them to provide you with data from studies to support their recommendations.

	Here is some helpful information for you and others out there with similar concerns. First of all what is HRT.  HRT is a generic term  encompassing either  unopposed estrogen therapy, or a combinations of estrogen and progesterone. Unopposed estrogen is generally used in women after a hysterectomy. Cyclical use of progesterone has the  disadvantage for non-hysterectomy women of cyclical withdrawal bleeding. This can be avoided by continuous use of the drug. HRT may be taken as a transderm patch, orally, or as a subcutaneous implant. Each different type of therapy and dosage has a different risk profile.

	 

	Estrogen and Progesterone used for HRT are chemically different from  those used in the oral contraceptive pill (OCP), and are of significantly lower potency.  The doses used in HRT are most  often at the lower end of the normal pre‐menopausal range whereas the OCP  is designed to suppress the natural ovulatory cycle. 

	Several large studies have consistently demonstrated an increased risk of venous thromboembolism occurence (g.g. Deep Venous Thromosis (DVT) and/or Pulmonary Embolus (PE)) in women using HRT. However, HRT risk appears to be restricted to the first year of HRT use, and is estimated at 2&ndash;3 times that of non‐HRT users. It is important to appreciate that although a 2‐ to 3‐fold increase in risk appears high,and yes, a PE could prove to be a fatal complication; but in reality, it has been estimated that this only represents one or two additional cases of venous thromboembolism per 10,&thinsp;000 women per year. In addition, studies differ in their conclusions about the relative importance of the different HRT regimens in current use. Further, it is a general maxim that the longer the surgery (especially after 2 hrs) the greater the risk with or without HRT. IF these statistics seem like undue risk then you should either stop HRT prior to surgery or seek council from an expert.

	Here is what I recommend to my patients based on my understanding of the literature:  I suggest that my patients seek the council of their prescribing doctor and if they feel more comfortable a hematologist for patients taking HRT. My practice is that I recommend that  patients I consider at high risk to  stop HRT if possible a month prior to surgery. High risk include but are not limited to  the following reasons:  if started within a year of the proposed surgery, or if they have co-morbid conditions making them  hypercoaguable such as in all smokers, obesity,  past medical history of blood clots (especially DVT, or PE), genetic tendency for hypecoagulation,   vericose veins, COPD, heart disease, sedentary life style or if their is chronic lower extremity edema. Perhaps most important is that I use DVT preventative measures such as intermittent calf/foot compression devices for all of my patients with IV sedation or under general anesthesia, and antiembolism stockings, "TED's" for all of my patients and have them worn for at least 10 days or until they are walking normal daily amounts.

	 

	Bottom Line -Make your decision wisely based on available information and the advise of your experts.

Ben Lee, MD · Answer

You will find varying answers to the question of whether to discontinue hormone therapy prior to a facelift. Clearly, HRT increases the rate of blood clots in patients undergoing prolonged surgeries. Orthopedic and general abdominal surgeries are at risk for venous thrombosis, as are abdominoplasty and body contouring operations. It is wise in these patients to discontinue hormone therapy before surgery. On the other hand, there are  several studies in the literature that clearly demonstrate an exceedingly low rate of venous thrombosis in facelift surgery. Nevertheless, I think it is wise to take measures to reduce venous thrombosis in face lifts that will last over five hours. Operative times vary widely among surgeons, from as little as two hours in  very experienced hands and up to ten hours for others. Discontinuing HRT is therefore something you should discuss with your individual surgeon

Kenneth Hughes, MD · Answer

Hormone replacement therapy is one risk factor for blood clots.  Even though a patient may be low risk, reducing the risk as much as possible is not unreasonable.  Kenneth Hughes, MD Los Angeles, CA

Earl Stephenson, Jr., MD, DDS, MBA · Answer

Dr. Morgan is correct that HRT has an increased risk of blood clots.  There recommendations in place to place patients in to categories(low - high) for blood clots (DVT).  If you are healthy and have no previous history of DVT then strategies such as TED hose (like panty hose) and compression devices (squeezes on lower legs) and early frequent walking after surgery can help reduce the chances of DVT developing.  Additionally, a healthy suspicion by your PS to monitor for DVT during your healing process.  The need to stop your HRT may not be necessary.

	Dr. ES

Frank P. Fechner, MD · Answer

My patient continue their HRT in preparation of their facelift surgery. Your surgeon may have a good reason for his request - ask him.

Ralph R. Garramone, MD · Answer

HRT is certainly safe, you have been on a regimen which is monitored and you are stable.  That being said you are going to have a surgical procedure, under anesthesia which will last several hours and HRT has been linked to an increased risk of blood clots which begin in the legs, but which can move to your lung a problem called a pulmonary embolus.  That is not a problem you want to have.

	Your plastic surgeon is aware of this and has recommended you stop it.  You pcp is not performing your surgery. Certainly there are risk factors which could increase the risk of blood clots in addition to the HRT. You haven't stated whether or not you have any of these additional factors.

	Please remember that this is an entirely elective procedure and everything should be optimal to have a good result with the lowest possible chance of problems.  That is why your surgeon is recommending this and that is why you should listen.

	Thank you for your question and good luck.

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