Perioperative Care of Transgender and Gender-Diverse Patients: A Biopsychosocial Approach

Climacteric and fibromyalgia: a review

Fibromyalgia (FM) and climacteric conditions share common epidemiological and clinical features, with FM symptoms often beginning during menopause. Musculoskeletal pain, arthralgia, myalgia and other symptoms are frequently seen in both conditions. Some research suggests a link between the cessation of sex hormones and FM symptoms. Women with FM tend to experience more severe symptoms after menopause, and the severity of FM symptoms can worsen in women who have had a hysterectomy with or without oophorectomy. Despite these similarities, it is essential to treat FM and climacteric conditions separately and follow established guidelines for management. However, it is also important to recognize that both conditions can coexist in the same patient. It is crucial to note that there is limited evidence supporting the effectiveness of menopausal hormone therapy for primary FM management. Therefore, menopausal hormone therapy should not be recommended for FM unless the patient also has climacteric syndrome.

Enhanced Recovery After Gender-Affirming Surgery

The adoption of enhanced recovery after surgery (ERAS) protocols in multiple surgical disciplines has revolutionized perioperative care, demonstrating reduced complications and shorter hospital stays across surgical specialties. ERAS protocols have increasingly been incorporated in plastic surgery, yet a notable gap in the literature on ERAS for gender-affirming surgery (GAS) still exists. A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies on ERAS protocols in GAS. The aim of this review was to assess the current status of ERAS adoption in GAS, evaluate its impact on perioperative care, and provide recommendations for future research and clinical practice. While there is an overall scarcity of evidence-based ERAS protocols across GAS, published studies on the application of ERAS in GAS have demonstrated promising early outcomes and illustrate an area for further investigation and innovation in plastic surgery.

LEVEL OF EVIDENCE: 5

Sugammadex and oral contraceptives

PURPOSE OF REVIEW

This review article explores the evidence regarding sugammadex (MSD Australia) and its potential interaction with hormonal contraceptives. The impact of recent clinical trials and review articles is examined.

RECENT FINDINGS

Recent clinical data suggest that the interaction between sugammadex and estrogen and progesterone concentrations may not be clinically significant and may confer some protection against ovulation. There are no clinical trials reporting interactions between sugammadex and the exogenous hormonal compounds found in oral contraceptive pills. The method of contraception is an important consideration, as sugammadex theoretically affects oral and nonoral, and combined versus single agent methods differently. Two large retrospective database studies have reported two cases of pregnancy postoperatively in patients on hormonal contraceptives whose anesthetic included sugammadex.

SUMMARY

Strong clinical evidence to support or refute claims of a significant impact of sugammadex on contraceptive efficacy in women on contraception is lacking. The existing evidence does not suggest a basis for concern regarding the impact of sugammadex on contraception in the perioperative setting.

Optimal Perioperative Pain Management of the Transgender Patient for Gender Affirming Surgery: A Scoping Review

INTRODUCTION

As we increasingly encounter transgender patients in the perioperative setting, it is important to be cognizant of appropriate medical management of the transgender patient. There is limited literature on the appropriate perioperative techniques to implement for adequate pain control in the transgender patient presenting for gender affirming procedures.

METHODS

In this scoping review, the authors identify publications that address perioperative pain control techniques that can be implemented by the anesthesiologist such as regional anesthesia, multimodal medications, or non-pharmacologic modalities.

RESULTS

This scoping review included two retrospective reviews, two case reports, and one letter to the editor. There are no prospective, randomized controlled trials on this topic. The limitations of this scoping review include the limited publications that are available to analyze as this is a growing area of medicine.

CONCLUSION

There are numerous variables that may play a factor in the pain experience of the transgender patient including biological factors, psychological and social factors. Techniques that are necessary for comprehensive pain management include pharmacologic, injections, physical therapy, acupuncture, massage, and more. There are limited publications on the comprehensive pain management of the transgender patient; therefore, the authors advocate that as perioperative physicians, anesthesiologists implement comprehensive preemptive analgesia techniques to avoid progression to chronic pain. Clearly more research is necessary to standardize acute pain management techniques in the transgender patient.

Anesthesia for gender-affirming surgery: a practical review

PURPOSE OF REVIEW

Gender-affirming surgery (GAS) is an effective, well studied, and often necessary component of gender-affirming care and mitigation of gender dysphoria for transgender and gender-diverse (TGD) individuals. GAS is categorized as chest surgeries, genitourinary surgeries, facial feminization/masculinization, and vocal phonosurgery. Despite increased incidence of GAS during recent years, there is a gap in knowledge and training on perioperative care for TGD patients.

RECENT FINDINGS

Our review discusses the relevant anesthetic considerations for the most common GAS, which often involve highly specialized surgical techniques that have unique implications for the anesthesia professional.

SUMMARY

Anesthesiology professionals must attend to the surgical and anesthetic nuances of various GAS procedures. However, as many considerations are based on common practice, research is warranted on anesthetic implications and outcomes of GAS.

Ethical Principles Do Not Support Mandatory Preanesthesia Pregnancy Screening Tests: A Narrative Review

Respect for patient autonomy is a pillar of medical ethics, manifested predominantly through informed consent. Mandatory (routine) nonconsented preoperative urine pregnancy testing does not adequately respect patient autonomy, is potentially coercive, and has the potential to cause harm medically, psychologically, socially, and financially. Inaccuracies in pregnancy testing can result in false-positive and false-negative results, especially in early pregnancy. There is substantial scientific evidence that anesthesia is not harmful to the fetus, raising the question of whether pregnancy testing provides substantial benefit to the patient. Not performing a preanesthesia pregnancy test has not been associated with significant medicolegal consequences. We review the ethical implications of mandatory preanesthesia pregnancy testing in light of these facts.

Implementation of an Enhanced Recovery after Surgery Pathway for Transgender and Gender-Diverse Individuals Undergoing Chest Reconstruction Surgery: An Observational Cohort Study

Enhanced Recovery After Surgery (ERAS) protocols are associated with improved clinical outcomes in cisgender breast surgery patients. However, a paucity of research exists regarding transgender and gender-diverse individuals (TGD) in the ERAS framework. The primary objective of this observational cohort study is to describe the implementation of a gender-affirming ERAS protocol and its relationship to hospital length of stay (LOS) in TGD patients following chest reconstruction surgery. The secondary aim is to identify intraoperative predictors of LOS and define variables associated with adverse outcomes. We identified 362 patients in three epochs: a traditional group (n = 144), a partial ERAS implementation group (n = 92), and an ERAS group (n = 126). Exploratory multivariable median regression modeling was performed to identify independent predictors of LOS. We report that the traditional group's median hospital LOS was 1.1 days compared to 0.3 days in the ERAS group. Intraoperative tranexamic acid administration was associated with significantly shorter LOS (p < 0.001), reduced postoperative drainage (p < 0.001), and fewer returns to the operating room within 24 h (p = 0.047). Our data suggest that implementing a multimodal ERAS gender-affirming pathway was associated with improved patient-centered surgical outcomes such as decreased return to the operating room for hematoma evacuation, higher rates of discharge home, and reduced postoperative drainage output.