| Continuing "The Pill" or Not?: VTE Treatment and Exogenous Hormones Marie-Claude Pelland Marcotte. |
Abstract
Combined hormonal contraception (CHC) is very commonly used in adolescents and young adults but is associated with a 2 to 9-fold increase in the risk of venous thrombo-embolism (VTE). The risk of VTE is influenced by the estrogen dose (with increasing doses associated with higher risk of VTE) and type of progesterone (with 3rd and 4th generation progesterone associated with higher VTE risk).
Once a VTE has occurred in an adolescent on CHC, it is safe and acceptable to continue CHC while the patient is receiving anticoagulation, to prevent abnormal uterine bleeding (AUB). However, once anticoagulation is discontinued, the risk of thrombotic recurrence with concurrent estrogen therapy is unacceptably high, and CHC should be stopped and/or changed for methods which do not put the patient at increased VTE risk, such as levonorgestrel intra-uterine device, implant, or progestin-only pill.
AUB is common in young women receiving anticoagulation and may negatively impact their quality of life. Adolescents on anticoagulation should be screened for AUB. Treatment options for AUB include: tranexamic acid during menstrual flow, hormonal therapy, treatment of anemia and iron deficiency, and/or adjustment of anticoagulation, as some anticoagulants appear to be more commonly associated with AUB than others. Referral to gynecology and screening for coagulopathy can be considered.
While they do not constitute absolute contra-indications to CHC, several conditions may increase the risk of VTE in adolescents, such as obesity, thrombophilia, or history of superficial vein thrombosis. In these adolescents, individualized, shared decision-making should inform the choice of contraception.
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