EMAS position statement: Managing menopausal women with a personal or family history of VTE

Florence Tremollieres Menopause and Metabolic Bone Disease Unit, Hôpital Paule de Viguier, Toulouse, France.
Maturitas (Impact Factor: 2.94). 06/2011; 69(2):195-8. DOI: 10.1016/j.maturitas.2011.03.011
Source: PubMed


Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), is a serious cardiovascular event whose incidence rises with increasing age.
To formulate a position statement on the management of the menopause in women with a personal or family history of VTE.
Literature review and consensus of expert opinion.
Randomized controlled trials have shown an increased risk of VTE in oral hormone therapy (HT) users. There are no randomized trial data on the effect of transdermal estrogen on VTE. Recent observational studies and meta-analyses suggest that transdermal estrogen does not increase VTE risk. These clinical observations are supported by experimental data showing that transdermal estrogen has a minimal effect on hepatic metabolism of hemostatic proteins as the portal circulation is bypassed. A personal or family history of VTE, especially in individuals with a prothrombotic mutation, is a strong contraindication to oral HT but transdermal estrogen can be considered after careful individual evaluation of the benefits and risks. Transdermal estrogen should be also the first choice in overweight/obese women requiring HT. Observational studies suggest that micronized progesterone and dydrogesterone might have a better risk profile than other progestins with regard to VTE risk. Although these findings should be confirmed by randomized clinical trials, they strongly suggest that both the route of estrogen administration and the type of progestin may be important determinants of the overall benefit-risk profile of HT.

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    ABSTRACT: The original conclusions of the Women's Health Initiative study have been questioned as a result of the availability of age-stratified data. Initial concerns regarding the risk of coronary heart disease (CHD) in association with the use of hormone replacement therapy (HRT) have been replaced with concerns regarding thromboembolic disease, encompassing venous thromboembolism (VTE), particularly in younger postmenopausal women, and stroke, particularly in older women. The original publication of the study results led to a dramatic decrease in the use of oral HRT; however, the use of transdermal HRT has increased over recent years. Guidelines from the North American Menopause Society, the Endocrine Society, the International Menopause Society, and specific guidelines from the European Menopause and Andropause Society for the management of menopausal women with a personal or family history of VTE all contain positive statements regarding both transdermal estradiol and micronized progesterone. Unlike oral estrogens, transdermal estradiol has been shown not to increase the risk of VTE, or stroke (doses ≤ 50 μg), and to confer a significantly lower risk for gallbladder disease. Unlike some progestogens, progesterone is also not associated with an increased risk of VTE, or with an increased risk of breast cancer. Based on these data, which are now included in the guidelines, the use of transdermal estradiol and micronized progesterone could reduce or possibly even negate the excess risk of VTE, stroke, cholecystitis, and possibly even breast cancer associated with oral HRT use.
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    ABSTRACT: Venous thromboembolism (VTE) is both a contraindication and a complication of menopausal hormone therapies (MHT). This article presents a review of up-to-date literature on VTE epidemiology and its risk factors, paying attention mostly to the impact of MHT on VTE risk, starting from the 1970s reports to the North American Menopause Society position statement of 2012. The risk of VTE is minimized by the proper patients' qualification (e.g. elimination of risk factors, 50-59-aged patients), choice of transdermal MHT, hormone dose reduction and proper progestogen choice.
    No preview · Article · Feb 2013 · Menopausal Review
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    ABSTRACT: New data and guidelines on menopausal hormone therapy have become available since the publication of the Women's Health Initiative study. This article is aimed to update information regarding the recommendations for the administration route and benefit-risk profile of menopausal hormone therapy. The clinical guidelines generally do not recommend any particular route as better than the others. Available data show that use of transdermal estradiol and micronized progesterone may reduce the risk of venous thromboembolism, breast cancer, stroke, and coronary heart disease.
    No preview · Article · Feb 2013 · Menopausal Review
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