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Heavy Menstrual Bleeds on Anticoagulants – Treatment Options

Evaluation
Anticoagulants often increase the amount of bleeding during menses and sometimes the number of days that a woman bleeds. However, this does not happen in every woman.  In general, the more vaginal bleeding a woman has, the more cramping she experiences. Since warfarin may increase the vaginal bleeding, more cramps may also result.  A pre-existing bleeding disorder should be considered and a detailed history about (a) the degree of menstrual bleeding prior to anticoagulant therapy, as well as (b) other bleeding (with teeth extractions, tonsillectomy, childbirth, etc.) or a family history of bleeding should be taken.  After all:  Unrecognized bleeding disorders, such as von Willebrand’s disease of platelet disorders in women (not on anticoagulants) with menorrhagia are common, but often not considered by physicians [ref 1-3]. If a bleeding disorder is present, then consideration of treatment for the disorder is appropriate (such as DDAVP or Lysteda® [=tranexamic acid] in von Willebrand’s disease).  If no bleeding disorder is present and the bleeding is significant enough to require intervention, there are several treatment options that can be considered [ref 4,5,7,8]. They are either (a) hormone treatment, (b) endometrial ablation procedures, or (c) hysterectomy.  If a woman does not plan to have further children, the ablation procedures are, generally, a very good option to prevent or decrease the bleeding.  For the woman who still wants to be able to have children the Mirena® intrauterine device (IUD) is a very good first choice.  If these methods fail, progestins or continuous estrogens could be considered.  However, the woman needs to be aware that progestins and estrogens increase the risk for thrombosis.  However, whether this is clinically relevant in the woman who is on anticoagulants, is not known.

Treatment

  1. Mirena® IUD
    The Mirena® IUD continuously releases very low doses of progestins in the uterus.  This leads to a suppression of build-up of the endometrium and, thus, to a decrease and, eventually, a disappearance of bleeding.  Only little of the released progestins is absorbed into the blood stream; therefore, Mirena® does not lead to an increased risk for thrombosis and appears to be a good choice to control bleeding or to use as a birth control method in women with (a) thrombophilia, (b) a history of thrombosis, and (c) the woman on anticoagulants.  IUDs releasing progestins do not increase the risk of DVT and PE [ref 6].  They have been found to be effective in deceasing menstrual bleeds on warfarin [ref 5,7,8]. Further information on the Mirena® IUD can also be found at www.mirena-us.com/index.html.
  2. Progestins
    Continuous progestins (for example Aygestin® 2.5 mg per day to start off with; may have to be increased to 10-15 mg per day) sometimes work with heavy menstrual bleeding, but this is a trial-and-error approach.  Some women will develop breakthrough bleeding and spotting and will, therefore, not find this a suitable option.  Because continuous progestins can cause breakthrough bleeding and spotting (from atrophy of the endometrium), it can be considered to discontinue them every 3-4 months, to let the woman have a period; progestins can then be restarted.  However, progestins can also be taken without a break. High doses of progestins increase the risk for blood clots [ref 8].  However, one may argue that the person on warfarin is protected, to a large degree, from further blood clots and that the slightly increased risk that occurs with high doses of progestins may clinically not be important.
  3. Continuous estrogens
    Taking the usual birth control pill (combined estrogen-progestin pill) may be attempted and may result in lighter periods because there is less build-up of endometrium while on the pill. For those with continued heavy bleeding, continuous estrogen pills can be considered.  To achieve continuous estrogen-progestin dosing a woman would either need to take (a) regular birth control pill packs and discard the pills of the last week (placebo pills) and start a new pack every 3 weeks, or (b) take a prepackaged continuous estrogen-progestin pill that does not contain placebo pill (for example Seasonale®).  Estrogens increase the risk for thrombosis, and this is to be kept in mind when considering an estrogen-containing pill.  They are, therefore, typically not the first choice of treatment.
  4. Hot balloon ablation
    This procedure is also called “endometrial ablation” or “thermal balloon ablation” or Thermachoice™.  It is performed as an outpatient procedure in the operating room.  A balloon is inserted into the uterus and a hot fluid is filled into it, which burns and destroys (ablates) the endometrium.  The discomfort experienced during this procedure is easily controlled with minimal sedation or pain killers.  Usually, a woman who has had this procedure done can not get pregnant any more.  The procedure should therefore, obviously, not be chosen by women who still want to have children.  More information is at http://www.pelvichealthsolutions.com/thermachoice.
  5. NovaSure™
    This method/device is also called “Uterine Electrofrequency ablation”.  This is an outpatient procedure performed in the operating room.  The endometrium is destroyed by application of radiofrequency waves.  Menstrual bleeding is, thus, prevented.  Usually, a woman who has had this procedure done can not get pregnant any more.  The procedure should therefore not be chosen by women who still want to have children.  For details see http://www.novasure.com.
  6. Her Option™
    This method/device is also called “Uterine Cryoablation Therapy™ System”.  This is an outpatient procedure performed in the operating room.  The endometrium is destroyed by application of extreme cold; menstrual bleeding is, thus, prevented.  Usually, a woman who has had this procedure done can not get pregnant any more.  The procedure should therefore not be chosen by women who still want to have children.  For details see http://www.heroption.com.
  7. Hysteroscopic endometrial ablation procedure
    This is a surgical procedure performed under general or epidural anesthesia, during which a video scope is introduced into the uterus.  The endometrium is then destroyed with an electrode loop, roller ball, or laser.  The procedure should, therefore, not be chosen by women who still want to have children.
  8. Hysterectomy
    Surgical hysterectomy can also be considered.  However, as this is a significant invasive and carries a risk for DVT and PE, it is not be good choice in the patient who already has a history of venous thromboembolism or has a thrombophilia

References

  1. Philipp CS et al.: Age and the prevalence of bleeding disorders in women with menorrhagia. Obstet Gynecol 2005;105:61-6.
  2. Philipp CS et al: Platelet functional defects in women with unexplained menorrhagia. J Thromb Haemost 2003;1:477-84.
  3. Dilley A et al: A survey of gynecologists concerning menorrhagia: perceptions of bleeding disorders as a possible cause. J Womens Health Gend Based Med 2002;11:39-44.
  4. Barrington JW et al.: Comparison between the levonorgestrel intrauterine system (LNG-IUS) and thermal balloon ablation in the treatment of menorrhagia. Eur J Obstet Gynecol Reprod Biol 2003:108:72-4.
  5. Hurskainen R et al.: Clinical outcomes and costs with the levonorgestrel-releasing intrauterine system or hysterectomy for treatment of menorrhagia: randomized trial 5-year follow-up. JAMA 2004;24;291:1503-4.
  6. van Hylckama Vlieg A et al: The risk of deep venous thrombosis associated with injectable depot-medroxyprogesterone acetate contraceptives or a levonorgestrel intrauterine device. Arterioscler Thromb Vasc Biol 2010 Nov;30(11):2297-300. Epub 2010 Aug 26.
  7. Pisoni CN et al. Treatment of menorrhagia associated with oral anticoagulation: efficacy and safety of the levonorgestrel releasing intrauterine device (Mirena coil). Lupus 2006;15(12):877-80.
  8. Culwell KR et al: Use of contraceptive methods by women with current venous thrombosis on anticoagulant therapy: a systematic review. Contraception 2009 Oct;80(4):337-45. Epub 2009 Jun 10.
  9. Vasilakis C et al.: Risk of idiopathic venous thromboembolism in users of progestagens alone. Lancet 1999;354:1610-1611.

For patients

This same information, written for patients and other non-health care professionals, is available at http://clotconnect.wordpress.com/2010/11/25/heavy-menstrual-bleeds-on-blood-thinners-–-what-to-do/

Disclosure: I have no financial conflict of interest to this blog entry.

Last updated: Nov 26th, 2010

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