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[TrishaB]

Hello, I have just joined this forum which was suggested to me by my GP as I am trying to decide what I should do. I am having a hip replacement on 3 April and have only been taking oestrogel since November 2018 along with the Mirena which I have had for ages and always got on with.

I didn't even realise the symptoms I was having, that started very suddenly late summer/autumn 2018, were menopausal (though I knew I was peri-menopausal), so the oestrogel was a trial and it sorted them out within a week. It was during that week that I had my only ever hot flush.

So my dilemma is that the consultant advised I should come off the oestrogel 6 weeks before surgery. This really worries me as the symptoms I did have prior to starting it, were anxiety, palpitations, severe joint cramps and lack of sleep. I have since seen my GP who told me I only need to come off the oestrogel a week before the surgery date and see how things go.

I am guessing the risk is mainly during the surgery due to the anaesthetic and increased risk of thrombosis if still taking the oestrogel? So I would welcome any thoughts and advice as I am concerned the symptoms will come flooding back just as I am starting to recover from surgery. Can I start taking the oestrogel once I am home after the operation or should I wait for the 6 weeks recovery period if I can manage this? I understand that there is no risk just having the mirena and not using the oestrogel? Also how soon can I take my usual supplements after surgery which are: turmeric, glucosamine and magnesium?

I look forward to your thoughts and sorry about the War & Peace first post.
TrishaB

[Wrensong]

Hello TrishaB 

Sorry to hear you have major surgery coming up, but hopefully you'll feel so much better for the hip replacement given time.  I was in your position recently, having been advised to stop HRT prior to major surgery before Xmas.  And yes it is because of the risk of thrombosis. 

I'd researched as best I could, the risks associated with GA & surgery in relation to HRT & came across a BMJ article (below) that confirmed what I already thought to be the case, that transdermal HRT (I am on patches) didn't pose an increased VTE risk.  I discussed this with my surgeon as, like you, I was reluctant to stop use for surgery.  He was sympathetic to my situation but said his hands were tied as it was hospital policy that all patients should stop HRT prior to surgery.  He said I could choose not to if I wished, but he would have to document in my records that he had advised me to stop & I had refused & I would have to sign a disclaimer to the effect that I understood the risks.  He also said the risk from HRT was very low & he had never had a patient develop a PE, but we concluded that may well have been because all his patients were advised to stop HRT before surgery!  I was already very grateful to him, as the decision to offer me surgery had been at his discretion, so I really didn't want to blemish his record by becoming his first patient to get a PE - nor potentially to lose my life from one, as sadly had a friend of mine.

So, agreed with the surgeon I should stop 2 weeks before & I was tapering off when the hospital wrote with pre-op assessment date & details including that I should stop HRT a month before surgery!   However, their letter was sent only 2 1/2 weeks before op date!  I stopped immediately & flagged up to them the discrepancy in advice & they were happy for me still to have the surgery, though frustratingly, given I had complied with the surgeon's advice, it was documented that I hadn't stopped HRT in time.

Surgery (upper body) & recovery went well.  Surgeon was happy for me to resume HRT straight afterwards, in his words as soon as I was mobile.  I was up & about the next day, but actually waited a few weeks before starting HRT again as I was sent home with a drain for a fortnight & that meant I was less mobile than usual. 

So you will need to discuss timing of resuming HRT after surgery with your surgeon, as with a new hip they will want you up & about, but for a while you will almost certainly not be as mobile as I was. 

Incidentally, I also had major surgery a year before that & the discharge instructions to my GP included that they should report to the hospital any instance of DVT/PE etc that occurred up to 3 months after surgery.  So I imagine that to be the period during which we are assumed to be at increased risk post-op.

I would also ask your surgeon about the timing of resuming any supplements.  They like usually like patients to stop anything that's not on prescription (such as Vit D or B12). Knowing fish oils thin the blood & could potentially increase bleeding, I asked my surgeon whether I should stop those I'd been advised to take (but not prescribed) by Ophthalmology.  But he was happy for me to continue with them - I wondered whether reasoning fish oils might offset any clotting risk from any residual HRT in my system!  You should be able to get advice by ringing your surgeon's secretary who'll relay your questions to the surgeon if you're not due to see him/her again before the day of surgery.

There are a couple of relevant papers here if you have time & are interested in the detail:-

https://academic.oup.com/bja/article/86/5/709/355016

https://www.bmj.com/content/364/bmj.k4810

The first, from the British Journal of Anaesthesia is rather old, 2001, so possibly out of date -  but concludes "There is no evidence to support stopping HRT pre‐operatively."

The conclusion in the second (from the BMJ 2019) is "transdermal HRT or tibolone, used much less frequently, are not associated with any increased VTE risk."

Both are reassuring, but I would nevertheless follow your surgeon's advice for your own safety & peace of mind.

I hope all goes well with your op & that your time without HRT will be bearable.

[TrishaB]

Thank you so much for such a detailed reply, I really appreciate you going to so much trouble.

I have my pre-op on Monday, so I will ask in more detail then though it is already less that 6 weeks as my surgery is on 3rd April, all being well anyway as I'm not sure if timings will be disrupted with the corona virus invasion.

I have already cut down in the last month and no side effects so far, so I will carry on reducing the amount and stop completely about 10 days before and take their advice on when it is advisable to resume. My GP was very certain it would be fine to stop just a week before, especially as the symptoms I did have originally were anxiety, palpitations etc, fingers crossed I have got passed that phase anyway.

I hope you are fully mobile again by now and your surgery has been a success.
Thanks again for your thoughts 

[Dotty]

Hi up to date guidance is that you don't have to stop using transdermal HRT before surgery, as transdermal does not pose a risk of clotting . X

[Wrensong]

Hi Dotty, yes as I'm on transdermal oestradiol I put that to my surgeon (a top bloke in terms of credentials) but though he sympathised with my position he said it was still hospital policy to stop HRT before surgery.  That was Nov 2019 - so fairly recent.  If you know of a change in guidelines (nationally) since then, would be interested to know.
Wx

[Wrensong]

No trouble TrishaB .  These things are a worry that affect many of us, so I think it can only help to exchange experiences.  Yes the virus is a consideration for your op timing.  I do hope it won't be deferred.  Hope your meno symptoms remain tolerable too.

Yes, fully mobile once the drain was removed after a fortnight & surgery was well worth it, thank you!

Would be interested in the advice you get at pre-op as regards timing of stopping HRT & from your surgeon about resuming afterwards.  I hope it all goes well & you'll soon be feeling much better.
Wx

[TrishaB]

Hello again, well I had my pre-op this morning and after explaining the whole background I was advised that it would be fine to carry on using the oestrogel throughout, as the risk is not related to the topical version of the HRT.

I have virtually cut down to half a pump dosage in the last week or so and will continue with that. If there are any signs of symptoms, I will return to one pump daily but hopefully I won't need to as the GP told me I would be aware of any symptoms within a week of stopping.

So I am quite happy with that result as I really didn't want to stop using quite so soon seeing that I've only been using it just over a year.
Thanks again so much Wrensong and Dotty for your thoughts and I hope things work out for you too 

[Dotty]

Good news TrishaB x

[Wrensong]

Thank for the update TrishaB but I'm a bit confused by the use of the term topical here.  Oestrogel is a systemic preparation so I wonder whether the nurse who did your pre-op misunderstood, thinking the gel was for local/topical/vaginal use?  Please don't be unnerved by my querying this, we know that Oestrogel, being transdermal, is thought unlikely to increase clotting risk & you have also cut right down.  Good luck with the op anyway, I hope it will go ahead on the planned date, soon be behind you & that you can then get on with life feeling much better for your new hip.
Wx

[Hurdity]

I think it's a question of nomenclature and defintion. I just looked it up as i wondered, and apparently one definition of topical can also include application to the skin ie transdermal but also having a systemic effect. Wise also to check as Wrensong suggests that she did in fact mean what most of us (and medical professionals it seems) refer to as transdermal oestrogen/HRT not local (vaginal) treatments.

Hurdity x