Stopping HRT Before Surgery: What the Guidelines Say

Hormone replacement therapy (HRT) is an important part of care for many people experiencing menopause symptoms. It helps manage health risks related to low hormone levels, such as bone loss, cardiovascular changes, and emotional well-being. However, when surgery is planned, conversations about HRT and surgery become especially important.

Surgical teams will evaluate medications, including HRT, to reduce any possible risks during and after an operation. Discussing HRT use early with the healthcare team ensures the best care and helps avoid preventable complications. Clear communication about stopping HRT before surgery — or continuing it safely — is a vital step toward a smooth recovery from surgery.

Why Some Surgeries Require Pausing HRT

Certain surgeries may require temporarily stopping the use of HRT. This decision is based on personal health factors to minimize potential risks while protecting long-term health.

Clotting Risk

Studies have shown that estrogen therapies, especially oral forms, may increase the risk of venous thromboembolism (VTE) — the development of blood clots in the veins. Since surgery itself carries a minor clot risk, combining the two factors may amplify concern, especially during major operations or when mobility is reduced after surgery. This is why many specialists recommend pausing HRT before surgery or switching to other options, like transdermal patches, when appropriate.^(1)(2)(3)(4)

Interaction with Anesthesia

General anesthesia can affect how the body handles blood flow, and hormone levels can sometimes influence how the body responds to general anesthesia. Though rare, elevated estrogen levels may impact the way the body metabolizes anesthetic drugs. In cases where these concerns apply, stopping HRT for surgery can help improve anesthesia safety.⁽²⁾

Impact on Specific Hormones

Estrogen is usually the hormone that needs to be paused before surgery. Progesterone generally presents a lower clotting risk and may not need to be paused. Testosterone (and DHEA) is usually safe to continue when preparing for surgery. However, each patient's hormone regimen and personal health profile should guide these decisions.

Medical Guidelines Regarding HRT and Surgery

NICE Guidelines Overview

The National Institute for Health and Care Excellence (NICE) guidelines on HRT and surgery emphasize personalized care. While they do not require stopping HRT before all surgeries, they recommend assessing VTE risk individually. Discussions about stopping HRT for surgery should be part of preoperative planning for anyone using hormone-based therapies.⁽²⁾⁽⁵⁾

Differences by Region, Surgical Site, and Procedure Type

Guidelines for managing HRT before surgery can vary based on location, where the surgery is in the body, and how invasive the procedure is. In Europe, doctors often recommend stopping oral estrogen four weeks before a major surgery.⁽²⁾⁽³⁾ 

In North America, decisions are usually based more on each patient’s risks and the type of surgery planned. Surgeries on the lower body, like the hips or legs, and surgeries in the pelvic area can cause an increased risk of blood clots because patients are less mobile after the operation. More invasive surgeries also increase clotting risk compared to smaller, less invasive procedures. Because of these differences, patients and surgical teams must talk openly and plan carefully to make surgery as safe as possible.⁽¹⁾⁽²⁾

Insights from Endocrinologists and Surgeons

Both endocrinologists and surgeons agree that there’s no universal rule for HRT and surgery. Instead, they recommend reviewing factors like the type of HRT (oral vs. transdermal), the surgery’s complexity, and the patient’s clotting history. Transdermal estrogen (patches, gels, and creams) generally poses a lower clot risk and may be continued more often than oral estrogen. An individualized, evidence-based approach remains the gold standard.^(1)(2)(3)(5)

HRT and Specific Procedures

Surgical type plays a significant role in deciding whether to stop HRT.

• General Surgery: Major surgeries require a discussion about how long before surgery the patient should stop HRT. Temporary pausing may be recommended. For minor procedures with low immobility, stopping HRT may not be necessary.⁽³⁾

• Orthopedic Surgery: Total joint replacement surgeries have a naturally high clot risk. HRT and orthopedic surgery management often involve careful timing adjustments or a temporary hold on estrogen therapy.⁽²⁾

• Heart Surgery: Cardiothoracic procedures — like bypass surgery or valve replacement — often involve longer recovery, immobility, and higher clotting risk. In these cases, doctors tend to recommend stopping estrogen therapy to lower the risk of clots after the procedure. Coordination with both the cardiac and menopause care teams is essential to minimize cardiovascular and hormonal complications.

• Emergency vs. Elective Surgery: In emergency surgeries, the focus is on immediate safety, and there’s usually no time to pause HRT beforehand. Preventive measures, like using blood thinners postoperatively, become more critical. In elective surgeries, there’s more opportunity to plan, including when to stop HRT before surgery if needed.⁽³⁾

Risks of Continuing HRT vs. Risks of Stopping

An individualized care approach balances risk factors. Health teams weigh surgical complexity, the patient's clotting history, and the benefits of HRT to make a decision that supports both surgical success and hormonal well-being.

Resuming HRT After Surgery

Timing recommendations vary based on the procedure, but most guidelines suggest resuming HRT once the patient is mobile again and clotting risks have decreased. This may happen a few days to a few weeks after the procedure, depending on recovery progress.

Monitoring hormone levels after surgery is helpful, especially for those with surgical menopause or primary ovarian insufficiency and individuals who experience symptoms like severe hot flashes or mood shifts. Adjustments to dose or formulation may be necessary to ease back into therapy safely and effectively.⁽⁴⁾

Possible Side Effects or Complications Post-Op

Temporary return or worsening of menopause symptoms, such as hot flashes or sleep disturbances, may occur while off HRT. These symptoms typically improve once HRT is safely resumed. It’s important to inform the healthcare team of any new or worsening symptoms during the postoperative period.

Special Considerations for Transgender, Nonbinary, and Intersex People Before Surgery

While basic surgical risks like clotting apply to everyone, the emotional, psychological, and functional importance of HRT differs significantly for transgender, nonbinary, and intersex individuals.⁽¹⁾

HRT is often essential in transgender individuals as an ongoing care rather than as elective symptom management (as in cisgender menopausal care). Intersex individuals may use HRT for many reasons, including management of natural hormone insufficiency, general endocrine balance, or gender affirmation.^(4)(6)(7)

Stopping hormones is often more profound and less temporary in transgender, nonbinary, and intersex patients than in cisgender patients managing menopause. For these groups, interrupting HRT can deeply impact identity, body image, and emotional stability, triggering both physical and psychological concerns (e.g., dysphoria, anxiety, reappearance of unwanted secondary sex characteristics).^(4)(6)(7)

Key Points:

• HRT formulations and goals are different for these populations; stopping HRT can mean a loss of medically necessary treatment, not just elective symptom management.

• Gender-affirming surgeries may have specific HRT continuation protocols, while general surgeries typically treat HRT as optional background therapy.

Staying Safe with HRT and Surgery

Stopping HRT before surgery is not always necessary, but careful planning and open discussions are key. Letting the surgical team know about all medications — including HRT — before any procedure remains a vital step toward safe surgical outcomes. 

The prescribing physician can also help determine the safest plan for each individual, whether that involves continuing therapy, stopping temporarily, or switching to a lower-risk option. Recovery plans should always include a thoughtful discussion about resuming HRT after surgery, ensuring that hormonal health is preserved.

Clear communication and personalized care allow individuals to protect their surgical outcomes and ensure long-term health when facing surgery.