How I treat heavy menstrual bleeding associated with anticoagulants

Hormonal contraceptive use after a first venous thrombotic event and the risk of recurrence in premenopausal women

BACKGROUND

Extensive evidence is available on hormonal contraceptive (HC) use and the risk of a first venous thromboembolism (VTE) event. Despite recommendations to discontinue combined HC (CHC) use, some women continue or start its use after a first VTE.

OBJECTIVES

We aimed to evaluate the VTE recurrence risk associated with HC use in premenopausal women.

METHODS

Premenopausal women with a first VTE included in the Multiple Environmental and Genetic Assessment of Venous Thrombosis study between 1999 and 2004 were followed for a recurrence until 2010. Data on HC use were available through linkage to the Dutch Foundation for Pharmaceutical Statistics. The risk of recurrence was assessed 1) during anticoagulant therapy and 2) after cessation of anticoagulant therapy. Time-dependent Cox proportional hazards models were used to estimate hazard ratios (HRs) with 95% CIs adjusted for age and body mass index at baseline and thromboprophylaxis use during follow-up.

RESULTS

Six hundred fifty women were uniquely linked and followed for a total of 3538 person-years (median, 6.1 years), during which 57 VTE recurrences occurred. Five occurred (8.8%) during anticoagulation treatment, with no clear risk difference for CHC use vs nonuse (HR, 0.8; 95% CI, 0.1-8.2). After anticoagulation cessation, CHC use was associated with a 2.4-fold higher risk of recurrence (HR, 2.4; 95% CI, 1.2-5.0) compared with nonuse. Recurrence risk for levonorgestrel-releasing intrauterine device use was similar to that for nonuse (HR, 0.9; 95% CI, 0.3-3.1).

CONCLUSION

CHC use after a first VTE is safe during anticoagulant use but substantially increases the risk of a recurrent VTE event in absence of anticoagulant use. This study adds to the evidence regarding the use of a levonorgestrel-releasing intrauterine device as a safe alternative.

Abnormal uterine bleeding in anticoagulated patients by drug class: outcomes and management

BACKGROUND

Although abnormal uterine bleeding is a known adverse effect of anticoagulant drugs, true rates have not been widely studied. Society-backed recommendations and guidelines do not yet exist for prevention and management of abnormal uterine bleeding among anticoagulated patients.

OBJECTIVE

This study aimed to describe the incidence of new-onset abnormal uterine bleeding among patients receiving therapeutic anticoagulation by anticoagulant class, and to evaluate gynecologic treatment patterns.

STUDY DESIGN

We conducted an institutional review board-waived retrospective chart review of female patients aged 18 to 55 years and prescribed therapeutic anticoagulants, including vitamin-K antagonists, low-molecular-weight heparins, and direct oral anticoagulants, in an urban hospital network from January 2015 through January 2020. We excluded patients with antecedent abnormal uterine bleeding and menopause. Associations between abnormal uterine bleeding, anticoagulant class, and other covariates were evaluated with Pearson chi-square and analysis-of-variance tests. The primary outcome, abnormal uterine bleeding odds by anticoagulant class, was modeled with logistic regression. Age, antiplatelet therapy, body mass index, and race were included in our multivariable model. Secondary outcomes included emergency department visits and treatment patterns.

RESULTS

Of the 2479 patients who met the inclusion criteria, 645 were diagnosed with abnormal uterine bleeding after initiating therapeutic anticoagulation. After adjusting for age, race, body mass index, and concurrent use of antiplatelet therapy, those receiving all 3 classes of anticoagulants had higher odds of experiencing abnormal uterine bleeding (adjusted odds ratio, 2.63; confidence interval, 1.70-4.08; P<.001), whereas those taking only direct oral anticoagulants had the lowest odds (adjusted odds ratio, 0.70; confidence interval, 0.51-0.97; P=.032), with vitamin-K antagonists as the reference group. Race other than White was associated with higher odds of abnormal uterine bleeding, as was lower age. The most common hormone therapies used among patients with abnormal uterine bleeding were levonorgestrel intrauterine devices (7.6%; 49/645) and oral progestins (7.6%; 49/645). Sixty-eight patients (10.5%; 68/645) had an emergency department visit for abnormal uterine bleeding; 29.5% (190/645) of patients received a blood transfusion; 12.2% (79/645) began any pharmacologic therapy for bleeding; and 18.8% (121/645) underwent any gynecologic procedure.

CONCLUSION

Abnormal uterine bleeding occurs frequently among patients on therapeutic anticoagulation. Incidence in this sample varied considerably by anticoagulant class and race; use of single-agent direct oral anticoagulation carried the lowest risk. Important sequelae such as bleeding-related emergency department visits, blood transfusions, and gynecologic procedures were common. Balancing bleeding and clotting risk in patients on therapeutic anticoagulation requires a nuanced approach and should involve collaborative management between hematologists and gynecologists.

How do anticoagulants impact menstrual bleeding and quality of life? - The PERIOD study

Background

There is increasing recognition that menstruating women prescribed anticoagulants experience heavy menstrual bleeding.

Objectives

The aim of this study is to report the extent of bleeding in menstruating women after commencing anticoagulants and the impact it has on their quality of life.

Methods

Women aged 18 to 50, initiated on anticoagulant therapy, were approached to take part in the study. In parallel, a control group of women was also recruited. Women were asked to complete the menstrual bleeding questionnaire and a pictorial blood assessment chart (PBAC) during their next 2 menstrual cycles. Differences between the control and anticoagulated group were compared. Significance was considered at < .05. Ethics committee approval: REC reference: 19/SW/0211.

Results

Fifty-seven women in the anticoagulation and 109 women in the control group returned their questionnaires. Women in the anticoagulated group reported an increase in the median length of their menstrual cycle from 5 to 6 days after commencing anticoagulation, compared to 5 days for women in the control group (P < .05). Anticoagulated women reported significantly higher PBAC scores as compared to the control group (P < .05), with two-thirds of women in the anticoagulation group reporting heavy menstrual bleeding. Women in the anticoagulation group reported worsening quality of life scores following the initiation of anticoagulation, compared with women in the control group (P < .05).

Conclusion

Heavy menstrual bleeding occurred in two-thirds of women commencing anticoagulants, who completed a PBAC, which had negative impact on their quality of life. Clinicians commencing anticoagulation therapy should be mindful of this, and recognized measures should be taken to help minimize this problem for menstruating individuals.

Incidence and impact of anticoagulation-associated abnormal menstrual bleeding in women after venous thromboembolism

Preliminary data and clinical experience have suggested an increased risk of abnormal uterine bleeding (AUB) in women of reproductive age treated with anticoagulants, but solid data are lacking. The TEAM-VTE study was an international multicenter prospective cohort study in women aged 18 to 50 years diagnosed with acute venous thromboembolism (VTE). Menstrual blood loss was measured by pictorial blood loss assessment charts at baseline for the last menstrual cycle before VTE diagnosis and prospectively for each cycle during 3 to 6 months of follow-up. AUB was defined as an increased score on the pictorial blood loss assessment chart (>100 or >150) or self-reported AUB. AUB-related quality of life (QoL) was assessed at baseline and the end of follow-up using the Menstrual Bleeding Questionnaire. The study was terminated early because of slow recruitment attributable to the COVID-19 pandemic. Of the 98 women, 65 (66%) met at least one of the 3 definitions of AUB during follow-up (95% confidence interval [CI], 57%-75%). AUB occurred in 60% of women (36 of 60) without AUB before VTE diagnosis (new-onset AUB; 95% CI, 47%-71%). Overall, QoL decreased over time, with a mean Menstrual Bleeding Questionnaire score increase of 5.1 points (95% CI, 2.2-7.9), but this decrease in QoL was observed only among women with new-onset AUB. To conclude, 2 of every 3 women who start anticoagulation for acute VTE experience AUB, with a considerable negative impact on QoL. These findings should be a call to action to increase awareness and provide evidence-based strategies to prevent and treat AUB in this setting. This was an academic study registered at www.clinicaltrials.gov as #NCT04748393; no funding was received.

Venous Thromboembolism in Women with Cancer with an Additional Focus on Breast and Gynecological Cancers

Cancer-associated venous thromboembolism (VTE) is common in women with cancer. Many clinical practice guidelines provide guidance for prevention and treatment; however, there are no specific recommendations for women. This is unfortunate because the proportion of women with breast- and gynecological cancers is high among patients with cancer-associated VTE. Thromboembolism often heralds cancer progression and poor prognosis and should—besides adequate anticoagulant management—also prompt reassessment and, if necessary, changes in cancer treatment. Recently, the new class of direct-acting oral anticoagulants (DOACs) has started to replace low-molecular-weight heparin as standard thromboprophylaxis and therapy in cancer patients. They are very effective, but they also carry a relevant risk of bleeding. Therefore, despite their ease of use, not every tumor patient qualifies for a DOAC, and this is especially true for gynecological tumor patients. Each prescription must be weighed individually. This review addresses specific aspects of VTE prophylaxis and management in women with cancer. Every physician who treats breast and gynecological cancers should be familiar with prophylaxis, diagnosis, and therapy of cancer-associated VTE. At the same time, patients should be informed by their physician what symptoms to look for and whom to contact if these symptoms occur, even outside of office hours and on weekends.

Challenging clinical scenarios for therapeutic anticoagulation: A practical approach

Therapeutic anticoagulation remains a fundamental backbone in the treatment and prevention of venous thromboembolism. However, while modern therapies are increasingly safe, anticoagulation is not without risks, particularly in those at high risk for or with recent bleeding. When weighing concurrent risks and benefits in each challenging clinical scenario, an individualized assessment of the risk and acuity of bleeding should be balanced by the indication for anticoagulation. Addressing modifiable risk factors and routine re-evaluation of any changes in this balance is critical. This review outlines available data and current guidelines for the management of anticoagulation in high-risk populations, including those with thrombocytopenia, elderly and high-fall risk, inherited bleeding disorders, and in acute coronary syndrome. We also examine management after clinically significant bleeding episodes, including intracranial hemorrhage, gastrointestinal bleeding, hemoptysis, retroperitoneal bleeding, hematuria, and abnormal uterine bleeding. The aim is to provide a comprehensive review of available literature to guide clinicians in providing optimal, safe, and individualized care for patients in these challenging scenarios.

A quality-of-life questionnaire for heavy menstrual bleeding in Thai women receiving oral antithrombotics: Assessment of the translated Menstrual Bleeding Questionnaire

BACKGROUND

Heavy menstrual bleeding (HMB) is common among reproductive-aged women receiving oral antithrombotics and frequently results in a negative impact on quality of life.

METHODS

We translated the Menstrual Bleeding Questionnaire (MBQ) into Thai by forward translation, back-translation, pretesting, and cognitive interviewing. The translated questionnaire was content validated by a gynecologist. A validation study was conducted for the translated MBQ and defined the optimal score for the diagnosis of HMB. We then performed a cross-sectional study to determine the prevalence of HMB using the translated MBQ. Reproductive-aged Thai women who visited outpatient clinics receiving oral antithrombotics were asked to assess menstrual characteristics after receiving antithrombotics. The impact of menstruation on quality of life was assessed by using the MBQ.

RESULTS

The translated MBQ had excellent reliability (intraclass correlation coefficient = 0.93) and discriminated between women with and without HMB (area under the receiver operating characteristic curve = 0.93). A score of 21.5 had 82.9% sensitivity and 83.1% specificity in the diagnosis of HMB. The mean (standard deviation) of the score was significantly higher in the HMB group than in the normal menstrual bleeding group (30.4 [9.4] vs 15.4 [5.6]; P < .001, respectively). Of the 49 women, the prevalence of HMB in patients receiving warfarin (n = 29), direct oral anticoagulants (n = 4), or antiplatelet agents (n = 16) was 27.6%, 25.0%, and 25.0%, respectively.

CONCLUSIONS

MBQ is a simple and valid tool that can be applied to screen women experiencing HMB. One-fourth of reproductive-aged women who received oral antithrombotics experienced HMB that impacted their quality of life.

Reproductive issues in women on direct oral anticoagulants

Direct oral anticoagulants (DOACs) are replacing warfarin and other vitamin K antagonists for a wide range of indications. Advantages of DOAC therapy are fewer food and drug interactions and fixed dosing without routine laboratory monitoring, making DOACs the perfect choice especially for younger patients, in whom the main indication for anticoagulation is prevention and treatment of venous thromboembolism (VTE). Although DOACs are safer and much more convenient than other anticoagulant alternatives, their profile may have drawbacks, especially for younger female patients in whom reproductive issues need special considerations. These may include the issue of heavy menstrual bleeding (HMB) during anticoagulant therapy, the embryotoxicity risk from inadvertent DOAC exposure during pregnancy, and the prevention or planning of pregnancies during DOAC therapy. This review summarizes the most relevant evidence in this increasingly important field of women's health.

Management of anticoagulation associated reproductive tract bleeding in adolescent and young adult females - Results of a multinational survey

INTRODUCTION

Reproductive tract bleeding (RTB) is an important outcome in menstruating females on anticoagulant therapy (AC). The diagnosis and management of AC-RTB in adolescent and young adult (AYA) females is unknown.

AIMS

The aim of this study was to survey the contemporary patterns of diagnosis and management of AC-RTB in AYA females.

METHODS

SurveyMonkey® questions were sent to members of 1) Pediatric and Neonatal Thrombosis Hemostasis Subcommittee and Women's Health Subcommittee of the International Society on Thrombosis and Haemostasis and 2) Hemostasis and Thrombosis Research Society. Results are reported using descriptive statistics.

RESULTS

Response rate was 33% (251 out of 753). AC-RTB was infrequently reported. Menstrual history was not routinely reviewed prior to initiation of AC. Respondents indicated a differential risk of AC-RTB, most frequently with Rivaroxaban. Respondents continued hormonal therapy (HT) if an AYA female was on it at the start of AC. When AC-RTB occurred, management strategies were variable with initiation of HT or antifibrinolytic therapy being the most frequent. The timing of AC-RTB after the thrombotic event influenced the respondents' choice of therapy. Differences were seen in the management strategies between US and non-US participants, with more US respondents initiating HT while more non-US respondents modifying the AC regimen. Respondents uniformly reported complications with AC-RTB and with its treatment.

CONCLUSION

This survey highlights the need to review menstrual history at the start of and during AC and for future research into choosing the optimal AC in AYA females. The results can inform the design of future studies.

Gynecologic Care for Pediatric and Adolescent Patients Undergoing Hematopoietic Stem Cell Transplantation

Hematopoietic stem cell transplantation is used to treat many chronic and acute malignant and nonmalignant conditions. We review hematopoietic stem cell transplantation and its effect on the gynecologic health of pediatric and adolescent patients, including pretransplantation evaluation, contraception, menstrual suppression, sexual health, fertility, primary ovarian insufficiency, and graft vs host disease. Comprehensive and team-based care provides optimal anticipatory counseling, evaluation, and management of acute and ongoing gynecologic issues.

Heavy menstrual bleeding on direct factor Xa inhibitors: Rationale and design of the MEDEA study

BACKGROUND

In premenopausal women, treatment with direct oral factor Xa inhibitors is associated with an increased risk of heavy menstrual bleeding (HMB) compared with vitamin K antagonists (VKA). Treatment with the direct oral thrombin inhibitor dabigatran appears to be associated with a reduced risk of HMB compared with VKA. These findings come from small observational studies or post hoc analyses of trials in which HMB was not a primary outcome. Use of tranexamic acid during the menstrual period may be effective in patients with HMB, but prospective data regarding efficacy and safety in patients on anticoagulant treatment are lacking.

RATIONALE AND DESIGN

A direct comparison of a factor Xa inhibitor and a thrombin inhibitor with HMB as primary outcome, as well as an evaluation of the effects of adding tranexamic acid in women with anticoagulant-associated HMB is highly relevant for clinical practice. The MEDEA study is a randomized, open-label, pragmatic clinical trial to evaluate management strategies in premenopausal women with HMB associated with factor Xa inhibitor therapy.

OUTCOMES

Women using factor Xa inhibitors with proven HMB, as assessed by a pictorial blood loss assessment chart (PBAC) score of >150, will be randomized to one of three study arms: (i) switch to dabigatran; (ii) continue factor Xa inhibitor with addition of tranexamic acid during the menstrual period; or (iii) continue factor Xa inhibitor without intervention. The primary outcome is the difference in PBAC score before and after randomization. Here, we present the rationale and highlight several unique features in the design of the study.

Current opinion and emerging trends on the treatment, diagnosis, and prevention of pregnancy-associated venous thromboembolic disease: a review

Pregnancy associated venous thromboembolism (PA-VTE) is a leading cause of maternal morbidity and mortality worldwide. Despite the availability of international guidance on the prevention, diagnosis and treatment, practice differs between countries and clinical institutions. The evidence base in this area is limited due to the vulnerable population who are affected, with the majority of guidelines deriving their recommendations from experience in surgical and medical venous thromboembolic disease. This review includes best evidence in PA-VTE management, highlighting specific literature which supports current diagnosis, prevention, and treatment strategies. Additionally, we hope to demonstrate emerging trends in the field through discussion of ongoing trials designed to progress towards evidence-based practice in the context of PA-VTE.

Safety and bleeding patterns of the levonorgestrel 52-mg intrauterine system among women with thrombosis or coagulopathy

OBJECTIVE

To assess the safety of the levonorgestrel 52-mg intrauterine system (LNG-IUS) in women with a history of thrombosis or coagulopathy and to evaluate bleeding patterns.

METHODS

A retrospective chart review was conducted of 117 women attending a clinic between 2007 and 2019. Their sociodemographic characteristics, hematologic status, reasons for using LNG-IUS, duration of use, use of oral anticoagulants, complications, and bleeding patterns were analyzed.

RESULTS

Ninety-nine women had a history of thrombosis (71.7% in use of oral anticoagulants) and 18 had coagulopathies. No bleeding or any other complications occurred during placement of the LNG-IUS. Around two-thirds of the women reported amenorrhea or oligomenorrhea at 12, 24, and 54 months of follow-up, with no difference between the groups using the IUS for contraception or to treat heavy menstrual bleeding (HMB) (P=0.07), those with a history of thrombosis or coagulopathy (P=0.53), and users or non-users of oral anticoagulants (P=0.59).

CONCLUSION

The LNG-IUS is safe for women with hematologic disorders. It was associated with amenorrhea or oligomenorrhea in a large proportion of users up to 54 months of follow-up regardless of use of oral anticoagulants, reason for use of LNG-IUS (contraception or HMB), or history of coagulopathy or thrombosis.

How I assess and manage the risk of bleeding in patients treated for venous thromboembolism

For patients with venous thromboembolism (VTE), prediction of bleeding is relevant throughout the course of treatment, although the means and goal of this prediction differ between the subsequent stages of treatment: treatment initiation, hospital discharge, 3-month follow-up, and long-term follow-up. Even in the absence of fully established risk prediction schemes and outcome studies using a prediction scheme for treatment decisions, the present evidence supports screening for and targeting of modifiable risk factors for major bleeding, as well as the application of decision rules to identify patients at low risk of bleeding complications, in whom long-term anticoagulant treatment is likely safe. Moving forward, prediction tools need to be incorporated in well-designed randomized controlled trials aiming to establish optimal treatment duration in patients at high risk of recurrent VTE. Moreover, the benefit of their longitudinal assessment rather than application as stand-alone baseline assessments should be studied, because changes in bleeding risk over time likely constitute the best predictor of major bleeding. We provide the state-of-the-art of assessing and managing bleeding risk in patients with acute VTE and highlight a practical approach for daily practice illustrated by 2 case scenarios.

Descriptive study of the general practitioners' perception of direct oral anticoagulants and the risk of genital bleeding in women of childbearing age

AIM OF THE STUDY AND PATIENTS

Direct oral anticoagulants (DOA) tend to replace antivitamins K (VKA). The incidence of major and minor hemorrhages is higher in women, a difference potentially linked to genital hemorrhages. The objective is to assess the practices and perception of general practitioners of the use of oral anticoagulant therapy in women of childbearing age.

MATERIALS AND METHODS

Descriptive, observational, transversal and monocentric study. An 11-items questionnaire was sent to 900 randomized general practitioners, assessing the type of patient, the type of anticoagulant prescribed, the management of genital bleeding, and the assessment of the quality of life of anticoagulated patients.

RESULTS

DOA were the most prescribed anticoagulants. Genital hemorrhage was the second leading cause of minor hemorrhage. Most doctors (60.6%) believed they were due to VKAs. 25% reported an alteration in the quality of life of patients following these genital hemorrhages and 47.5% addressed this subject in consultation.

CONCLUSION

Our study suggests that, according to the general practitioners interviewed, genital hemorrhage is more frequent on VKA than on DOA in women of reproductive age, which is contradictory with the data in the literature. The probably taboo subject is rarely mentioned in consultation and is responsible for a deterioration in the quality of life in these young patients. No recommendation exists on the management of this type of genital hemorrhage in these women. An algorithm is proposed for their management.

Optimal management of hormonal contraceptives after an episode of venous thromboembolism

Optimal management of hormonal contraception in patients with venous thromboembolism (VTE) requires an individualized approach considering its potential benefits and complications during and after anticoagulant treatment. Potential benefits include prevention of pregnancy and mitigation of menstrual bleeding that is often worsened after start of anticoagulation therapy. Current evidence suggests that patients may opt for a continuation of (all forms of) hormonal contraception during anticoagulant treatment, provided that they are adequately informed by the treating physicians. Combined oral contraceptives should be stopped before anticoagulant therapy may be discontinued, preferably after the second last menstrual cycle of the intended anticoagulant treatment period. If hormonal contraceptive treatment needs to be initiated in patients with a history of VTE, oral prostagen-only therapy or intra-uterine devices are to be preferred: this may be independent of the anticoagulation status and in light of a negligible risk of (recurrent) VTE associated with their use.

Treatment of venous thromboembolism in pediatric patients

Venous thromboembolism (VTE) is rare in healthy children, but is an increasing problem in children with underlying medical conditions. Pediatric VTE encompasses a highly heterogenous population, with variation in age, thrombosis location, and underlying medical comorbidities. Evidence from pediatric clinical trials to guide treatment of VTE is lacking so treatment is often extrapolated from adult trials and expert consensus opinion. Aspects unique to children include developmental hemostasis and the major role of central venous access devices. There is an absence of information regarding the optimal target levels of anticoagulation for neonates and infants and lack of suitable drug formulations. Anticoagulants, primarily low-molecular-weight heparin and warfarin, are used to treat children with symptomatic VTE. These drugs have significant limitations, including the need for subcutaneous injections and frequent monitoring. Randomized clinical trials of direct oral anticoagulants in pediatric VTE are ongoing, with results anticipated soon. These trials will provide new evidence and options for therapy that have the potential to improve care. International collaborative registries offer the ability to study outcomes of rare subgroups of pediatric VTE (eg, renal vein thrombosis), and will be important to ultimately guide therapy in a more disease-specific manner.

[Anticoagulation in Venous Thromboembolism: How Long and Which Dose?]

Anticoagulation in Venous Thromboembolism: How Long and Which Dose? Abstract. Venous thromboembolism is quite common in daily practice. As soon as the diagnosis is confirmed, anticoagulation should be started immediately. Nowadays DOACs are the first choice for treatment of VTE. An important issue is the duration of anticoagulation in an individual patient. Generally, the anticoagulation should be continued for at least three months in any patient. While anticoagulation can be safely stopped after three months in patients with isolated distal DVT it should be continued for an unlimited period in persons with unprovoked proximal DVT and PE. In the vast majority of cases making that decision is not straightforward. Decision making involves assessing risks and benefits on an individual basis. Another important issue is dose reduction of the DOACs during treatment. The goal of this article is to show the factors that must be considered for decision making.

​Challenge in managing abnormal uterine bleeding in a patient on novel oral anticoagulant therapy

This is a case report of a 48-year-old woman who presented with heavy per vaginal bleeding to the emergency department after being commenced on direct oral anticoagulants (DOACs) for venous thromboembolism. She had significant bleeding which initially required resuscitation and stabilisation. Her symptoms were ultimately managed by changing her anticoagulation agent to therapeutic low molecular weight heparin with Clexane^© the agent of choice. This case study highlights the complexity of managing these patients as well as highlighting the need for ongoing research into DOACs in this area.

Sex matters: Practice 5P's when treating young women with venous thromboembolism

Sex matters when it comes to venous thromboembolism (VTE). We defined 5P's - period, pill, prognosis, pregnancy, and postthrombotic syndrome - that should be discussed with young women with VTE. Menstrual blood loss (Period) can be aggravated by anticoagulant therapy. This seems particularly true for direct oral anticoagulants. Abnormal uterine bleeding can be managed by hormonal therapy, tranexamic acid, or modification of treatment. The use of combined oral contraceptives (Pill) is a risk factor for VTE. The magnitude of the risk depends on progestagen types and estrogen doses used. In women using therapeutic anticoagulation, concomitant hormonal therapy does not increase the risk of recurrent VTE. Levonorgestrel-releasing intrauterine devices and low-dose progestin-only pills do not increase the risk of VTE. In young women VTE is often provoked by transient hormonal risk factors that affects prognosis. Sex is incorporated as predictor in recurrent VTE risk assessment models. However, current guidelines do not propose using these to guide treatment duration. Pregnancy increases the risk of VTE by 4-fold to 5-fold. Thrombophilia and obstetric risk factors further increase the risk of pregnancy-related VTE. In women with a history of VTE, the risk of recurrence during pregnancy or post partum appears to be influenced by risk factors present during the first VTE. In most women with a history of VTE, antepartum and postpartum thromboprophylaxis with low-molecular-weight heparin is indicated. Women generally are affected by VTE at a younger age then men, and they have to deal with long-term complications (Post-thrombotic syndrome) of deep vein thrombosis early in life.

Comparison of rivaroxaban and dalteparin for the long-term treatment of venous thromboembolism in patients with gynecologic cancers

Objectives

Two randomized, controlled studies comparing outcomes in patients treated with direct oral anticoagulants or low-molecular weight heparin for cancer-associated venous thromboembolism (VTE) have previously been performed. However, gynecologic cancers accounted for approximately 10% of the study populations. We compared the outcomes of patients with primary gynecological cancers who were treated for cancer-associated VTE with either rivaroxaban or dalteparin.

Methods

The 162 eligible patients with gynecologic cancers who were treated with either dalteparin (n=60) or rivaroxaban (n=102) were reviewed. The primary outcome was a composite event, which included recurrence or clinically relevant bleeding events during the therapeutic period. Secondary outcomes were recurrence, clinically relevant bleeding events, and mortality.

Results

During the therapeutic period, there were no significant differences between the groups in the proportion of composite events, recurrence, or clinically relevant bleeding. Multivariate analysis using the Cox proportional hazards model also showed no significant difference in the number of composite events and clinically relevant bleeding between the groups. In the rivaroxaban group, 44.0% of patients experienced gastrointestinal bleeding and 24.0% experienced urinary tract bleeding. In the dalteparin group, bleeding was most common in the urinary tract (44.4%) and at the injection site (22.2%).

Conclusion

In this study, although there were no significant differences in effectiveness or safety between the rivaroxaban and dalteparin groups, rivaroxaban use was associated with a higher rate of clinically relevant bleeding than dalteparin. Therefore, caution should be taken when prescribing rivaroxaban for gynecologic cancer-associated VTE and bleeding events should be carefully monitored.

The effect of oral progesterone for the treatment of abnormal uterine bleeding in women taking warfarin following prosthetic valve replacement

Objectives:

To evaluate the effect of oral progesterone for the treatment of abnormal uterine bleeding in patients taking warfarin after prosthetic valve replacement.

Methods:

A total of 85 women of reproductive age, who were on warfarin due to prosthetic valve replacement were enrolled in the study. After detailed evaluation, their menstrual bleeding was quantified using Pictorial Bleeding Evaluation Chart. The patients were then prescribed an oral progesterone (Norethisterone) 5mg three times daily. The first follow up was done after one-month then at 3-months and at six months. The improvement in PBAC score was recorded at each visit. Data was entered and analyzed using SPSS (version 23.0). The mean ± Standard Deviation were calculated for quantitative variables while qualitative variables were presented in frequency table. The normality of data was checked using Kolmogorov-Smirnov test. Due lack of normal distribution of data in various groups, the Wilcoxon Sign Rank test was used to test the significance before and after treatment. The p-value of <0.05 was taken as statistically significant.

Results:

The mean age of the patients was 30.13±7.69 years. The mean PBAC score was 162.8 ± 24.86 before initiation of treatment while at the end of the treatment it was 105.48 ± 8.38. Forty-six (54.1%) patients had continuous per vaginal bleeding, 33 (38.8%) had menorrhagia, 4 (4.7%) had inter-menstrual bleeding and 2 (2.4%) had menorrhagia along with polymenorrhea. The mean dose of warfarin taken by the patients was 5.85 ± 2.69 mg. The median parity of the patients was 2. The Wilcoxon Sign Rank test showed p-value of <0.00001 for comparison of the pre-treatment PCBA values with those of one, three and six-months after the treatment. The Friedman’s test also had a p-value of <0.00001. This confirmed that the post treatment bleeding was significantly less than pretreatment bleeding.

Conclusion:

The warfarin induced abnormal uterine bleeding can be controlled effectively and safely with low dose of oral progesterone.

Managing Heavy Menstrual Bleeding in Women at Risk of Thrombosis

Management of heavy menstrual bleeding (HMB) in a woman with a history of thrombosis, or who is otherwise at high risk of thrombosis, or who takes medications for anticoagulation can present a challenge to health care providers. The goal of treating HMB is to reduce menstrual blood loss. First-line therapy is typically hormonal, and hormonal therapy can be contraindicated in women with a history of thrombosis unless they are on anticoagulation. As 70% of women on anticoagulation experience HMB, successful management of HMB may involve a modification in the anticoagulation or antiplatelet regimen, hormonal therapy tailored to the patient's situation, and/or surgical therapy.

The Management of Heavy Menstrual Bleeding After Percutaneous Coronary Intervention in a Woman of Reproductive Age

Heavy menstrual bleeding (HMB), previously known as menorrhagia, is in place with heavy flow and longer lasting days of bleeding during menstrual period, sequentially leading to anemia. We reported a rare case of HMB in a 33-year-old patient after percutaneous coronary intervention (PCI), who presented with acute coronary syndromes (ACS), uremia and systemic lupus erythematosus before PCI. This patient received three times of hemodialysis weekly (Monday, Wednesday, and Friday). On the next day after PCI, this patient began to have menstruation. On the fifth day of menstruation, the patient complained of HMB and physical discomfort, with an urgent need for consultation of gynecologist. After gynecologist consultation, this patient was under oxytocin treatment. However, 2 days of oxytocin treatment did not significantly improve HMB. Afterward, the menstrual volume of patients was significantly reduced on eighth day of menstruation after once therapy of testosterone propionate and norethindrone. Regarding the reasons of HMB, heparin in hemodialysis and antiplatelet drugs utilized (aspirin and clopidogrel) after PCI may be contributors to the HMB. In addition, uterine myoma, cervical canal cyst, renal insufficiency and CYP2C19^∗2 heterozygous are also possible contributors to HMB. There is no such case of whom had HMB in reproductive age with ACS, uremia and systemic lupus erythematosus under hemodialysis and antiplatelet therapy. More clinical safety data on HMB of reproductive age women who are under antithrombotic therapy are required.

Abnormal vaginal bleeding in women of reproductive age treated with edoxaban or warfarin for venous thromboembolism: a post hoc analysis of the Hokusai-VTE study

Objective

To investigate the characteristics and outcome of abnormal vaginal bleeding in women receiving edoxaban or warfarin for treatment of venous thromboembolism (VTE).

Design and setting

Post hoc analysis of the Hokusai‐VTE study, a multicentre, randomised, double‐blind trial comparing edoxaban with warfarin for acute symptomatic VTE.

Population

Women below 50 years receiving edoxaban or warfarin for treatment of VTE.

Methods

We collected data on diagnostic measures, treatment, and clinical outcome of abnormal vaginal bleeding events.

Main outcome measures

Occurrence of major and clinically relevant nonmajor (CRNM) abnormal vaginal bleeding events.

Results

In all, 628 women aged under 50 years were treated with edoxaban and 665 with warfarin. The rate of abnormal vaginal bleeding was 15/100 person‐years (py) (95% CI 11–19) in women receiving edoxaban and 9/100 py (95% CI 6–12) in the warfarin group (hazard ratio: 1.7, 95% CI 1.1–2.5). Major abnormal vaginal bleeding occurred in eight (1.3%) women on edoxaban and in three (0.9%) women receiving warfarin [odds ratio (OR) 2.8; 95% CI 0.8–10.8], and CRNM abnormal vaginal bleeding occurred in 53 (8.4%) women treated with edoxaban and in 37 (5.6%) on warfarin therapy (OR 1.6, 95% CI 1.0–2.4). Over 85% of all vaginal bleeds were characterised by heavy menstrual bleeding. Major bleeds frequently required treatment, and in more than 75% of patients anticoagulant therapy was adjusted. The severity of clinical presentation and course of major and CRNM bleeds was mild in most patients.

Conclusions

Abnormal vaginal bleeding occurred more frequently in women treated with edoxaban than with warfarin. Reassuringly, most events could be managed conservatively and had a mild outcome.

Tweetable abstract

Abnormal vaginal bleeding occurred more frequently in women treated with edoxaban than with warfarin.

Abnormal vaginal bleeding occurred more frequently in women treated with edoxaban than with warfarin.