A 20-year-old transgender woman presents to urgent care with unilateral calf pain and swelling that began the previous day. She recently restarted estrogen therapy obtained online after losing access to her previous clinician. She denies chest pain, shortness of breath, fever, trauma, or recent immobilization. Her vital signs are temperature, 98.4˚F; heart rate, 96 beats/min; blood pressure, 122/78 mm Hg; respiratory rate, 16 breaths/min; and oxygen saturation, 99% on room air. Examination reveals mild swelling of the left calf compared to the right, tenderness along the posterior calf, and no erythema, fluctuance, open wound, or bony tenderness. Distal pulses are intact.
Which of the following is the most appropriate next step?
- Reassure her that calf pain is unrelated to gender-affirming hormone therapy and recommend NSAIDs.
- Tell her to stop all hormone therapy immediately and follow up with her primary care doctor, as needed.
- Treat empirically with antibiotics for cellulitis and discharge.
- Assess for venous thromboembolism risk, explain the concern, and refer her for same-day diagnostic evaluation.
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Correct answer: d. Assess for venous thromboembolism risk, explain the concern, and refer for same-day diagnostic evaluation.
Rationale: Estrogen therapy can be associated with venous thromboembolism, although serious complications are uncommon. Urgent care clinicians should avoid reflexively attributing unrelated symptoms to gender-affirming therapy while remaining alert to serious medication-related complications when suggested by the clinical presentation. Unilateral calf pain and swelling warrant timely evaluation for deep vein thrombosis, and patients using self-managed or unsupervised hormone therapy may also benefit from counseling and connection to appropriate follow-up care.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
