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

Abstract

Sex matters when it comes to venous thromboembolism (VTE). We defined 5P'speriod, 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. K E Y W O R D Santicoagulants, contraceptives, female, pregnancy, venous thromboembolism

Which patients are at high risk of recurrent venous thromboembolism (deep vein thrombosis and pulmonary embolism)?

“…Low HERDOO2 risk: ≤1 HERDOO2 criteria (hyperpigmentation, edema, or redness in either leg; D-dimer level ≥ 250 μg/L; obesity with body mass index ≥ 30 kg/m 2 ; or older age ≥ 65 years). 18 Women with a personal VTE history have a high VTE recurrence risk during pregnancy 21,22 and require special attention, because VTE remains a leading cause of maternal death as a direct consequence of pregnancy. 2 Pregnant women who are at highest risk are those with a prior history of an unprovoked or a hormone-provoked VTE.…”

“…In the meantime, the consultation process ( Figure 2) should include discussion of risk factors for VTE recurrence, sex-specific bleeding risk (including abnormal uterine bleeding), adequate contraception, methods and preconceptual counseling. 22…”

Which patients are at high risk of recurrent venous thromboembolism (deep vein thrombosis and pulmonary embolism)?

“…Women with a personal VTE history have a high VTE recurrence risk during pregnancy 21,22 and require special attention, because VTE remains a leading cause of maternal death as a direct consequence of pregnancy. 2 Pregnant women who are at highest risk are those with a prior history of an unprovoked or a hormone-provoked VTE.…”

“…For women, VTE events occurring in the context of hormone use have traditionally been regarded as provoked events for the purposes of decision making surrounding duration of anticoagulation. 22 Studies evaluating the impact of hormone use on VTE recurrence risk have reported conflicting results (Table 4). Absolute reported recurrence risks in hormonal contraceptive users also vary widely between studies (Table 4).…”

“…In the meantime, the consultation process ( Figure 2) should include discussion of risk factors for VTE recurrence, sex-specific bleeding risk (including abnormal uterine bleeding), adequate contraception, methods and preconceptual counseling. 22 VTE recurrence risk in nonpregnant women whose initial event was provoked by pregnancy…”