A transgender patient taking oestrogen therapy is scheduled for oral surgery. All of the following are increased perioperative risks EXCEPT one. Which is the EXCEPTION?

Correct answer: D. Haemorrhage

• A. This IS increased. Oestrogen is an established risk factor for alveolar osteitis, through its effect on fibrinolysis — the same reason dry socket is more common in women taking combined oral contraceptives, and why extractions are timed to the last week of the cycle where possible.
• B. This IS a recognised concern. Sex-hormone therapy influences tissue healing, and the associated gingival inflammatory response and any concurrent smoking further impair it.
• C. This IS increased, and it is the principal concern. Exogenous oestrogen raises venous thromboembolism risk several-fold, and the risk is compounded by smoking, immobility and surgery itself.
• D. CORRECT — this is the EXCEPTION. HAEMORRHAGE is not increased by oestrogen therapy. Oestrogen shifts the haemostatic balance toward CLOTTING, not bleeding: it raises fibrinogen and factors VII, VIII and X and lowers antithrombin III and protein S. If anything, the risk runs in the opposite direction.

Note: Practical management: identify all hormone therapy at the medical history stage; discuss with the prescriber before major surgery; encourage early mobilisation; and combine smoking cessation counselling with the thromboembolic risk discussion, since the two multiply.