Special Considerations for Women of Reproductive Age on Anticoagulation

Abstract

Anticoagulation poses unique challenges for women of reproductive age. Clinicians prescribing anticoagulants must counsel patients on issues ranging from menstruation and the possibility of developing a hemorrhagic ovarian cyst to teratogenic risks and safety with breastfeeding. Abnormal uterine bleeding affects up to 70% of young women who are treated with anticoagulation. As such, thoughtful clinical guidance is required to avoid having young women who are troubled by their menses, dose reduce, or prematurely discontinue their anticoagulation, leaving them at increased risk of recurrent thrombosis. Informed by a review of the medical literature, we present current recommendations for assisting patients requiring anticoagulation with menstrual management, prevention of hemorrhagic ovarian cysts, and avoiding unintended pregnancy. The subdermal implant may be considered a first-line option for those requiring anticoagulation, given its superior contraceptive effectiveness and ability to reliably reduce risk of hemorrhagic ovarian cysts. All progestin-only formulations—such as the subdermal implant, intrauterine device, injection, or pills—are generally preferred over combined hormonal pills, patch, or ring. Tranexamic acid, and in rare cases endometrial ablation, may also be useful in managing menorrhagia and dysmenorrhea. During pregnancy, enoxaparin remains the preferred anticoagulant and warfarin is contraindicated. Breastfeeding women may use warfarin, but direct oral anticoagulants are not recommended given their limited safety data. This practical guide for clinicians is designed to inform discussions of risks and benefits of anticoagulation therapy for women of reproductive age.

Posttraumatic Lip Replantation in a Pregnant Woman

“…23 DOACs have been implicated in possible embryopathy and are contraindicated. 24,25 Lowdose aspirin is preferred in pregnancy, as 325-mg aspirin may increase fetal heart issues in the third trimester. 26 The use of leeches in pregnancy is not well studied and reported as a contraindication.…”

Uso de anticoagulante no ciclo gravídico-puerperal e os efeitos adversos relacionados: revisão de literatura

“…Já a Apixabana não deve ser usada durante o período de amamentação, pois níveis altos foram encontrados no leite de materno. Não é recomendado o uso de Edoxabano, pois existem poucos dados disponíveis sobre o uso seguro durante a amamentação (Azenkot & Schwarz, 2022).…”

“…Sendo a Varfarina a representante dessa classe, demonstrou-se capaz de atravessa a placenta uterina, resultando em malformações congênitas, hemorragia fetal no útero e um aumento do risco de aborto espontâneo ou mortalidade fetal. Já para o período de amamentação, os resultados demonstraram níveis baixos no leite materno e não apresentou reação adversa em lactentes amamentados por mães em tratamento com Varfarina, mesmo com doses diárias de 25mg durante 7 dias (Azenkot & Schwarz, 2022).…”

Management of heavy menstrual bleeding in women on long term anticoagulants

“…It is seen in about 33% of women in the general population. 1 Many women need to be started on anticoagulation due to certain medical conditions like placement of prosthetic valve, stroke, and as a treatment for deep vein thrombosis (DVT)/pulmonary embolism (PE). These women experience an increased risk for HMB especially when they already suffer from conditions like fibroid, adenomyosis, polyps and endometriosis.…”

“…In general, anticoagulation is associated with HMB in 20-70% of patients. 1 Hepatic/ renal impairment/concomitant use of drugs like aspirin/clopidogrel also increases anticoagulant associated bleeding.…”