Menstrual Abnormalities and Gynaecological Problems in Women on Anticoagulant and Antiplatelet Therapy: Management Options

Abstract

Introduction: The aim of this study was: 1) To study the pattern of menstrual abnormality and severity in women on anticoagulant and antiplatelet drugs. 2) To analyze the correlation of prothrombin time (PT), International Normalised ratio (INR) and the bleeding severity. 3) To discuss the various management options in unexpected emergencies and menstrual complications in this subset of women on anticoagulants. Material & Methods: It is a prospective study, over a period of 18 months from July 2011 to december 2012. We had 44 women on antithrombotic therapy. 32 women were on anticoagulants and 12 were on antiplatelet agents. The severity of bleeding pattern was assessed with pictoral bleeding assessment chart (PBAC). 1) Out of 44 women studied, 32 women were on anticoagulants and 12 were on antiplatelet agents. 26 (81.25%) were on acenocoumarol, 5 (15.62%) on warfarin, 1 (3.12%) on heparin, among the 12 antiplatelet users, 8 (66.66%) were on aspirin and 4 (33.33%) on clopidogrel. 2) The indication for anticoagulants was mitral valve replacement (MVR) in 9, double valve replacement (DVR) in 6, aortic valve replacement (AVR) in 3, severe pulmonary artery hypertension (PAH) in 2, severe mitral stenosis (MS) with atrial thrombus in 2, deep vein thrombosis (DVT) in 5, severe mitral regurgitation (MR) in one, the other indications were subdural hematoma, thromboendarterectomy, chronic kidney disease (CKD) stage V, coarction of aorta, one each. The indication for antiplatelet therapy was percutaneous transluminal coronary angioplasty (PTCA) in 3, Wolf Parkinson White (WPW) syndrome + atrial fibrillation (AF), acute myocardial infarction (AMI), coronary artery bypass graft (CABG), mid basilar artery aneurysm, renal allograft recipient, dialated cardiomyopathy, aortic aneurysm repair, hypertension and unstable angina one each. Results: In women on anticoagulants (32), the main complaint was menorrhagia/heavy menstrual bleeding (HMB) in 20, polymenorrhoea with menorrhagia in 4, How to cite this paper: Devabhaktuni, P., Thomas, P., Kapadia, A., Sridevi and Bhupatiraju, S. 582continuous per vaginal (PV) bleeding in 6. One lady had postmenopausal bleeding. Among the 12 antiplatelet users the main complaint was menorrhagia in 8, polymenorrhoea with menorrhagia in 2, postmenopausal bleeding in one. While on antithrombotic therapy apart from heavy menstrual bleeding, two women had intraperitoneal bleeding, two had post menopausal bleeding, two had secondary postpartum bleeding (PPH). CVA due to embolic stroke occurred in three, one during the study period. Subchoroidal haemorrhage causing choroidal detachment was noted in one. Conclusions: In patients with prolonged INR, excessive uterine bleeding can be an alerting initial manifestation. Antithrombotic therapy can cause HMB or exaggerate the symptom of HMB due to an underlying gynaec pathology. Mefanamic acid and norethisterone were used to arrest heavy menstrual bleeding. Antithrombotic therapy in women needs special consideration with alterations in menstrual patter...

A quality‐of‐life questionnaire for heavy menstrual bleeding in Thai women receiving oral antithrombotics: Assessment of the translated Menstrual Bleeding Questionnaire

“…In addition, we demonstrated a comparable prevalence of HMB in women receiving antiplatelet and anticoagulant therapy. This finding aligns with a previous study that reported a high frequency of menstrual problems in those receiving antiplatelets and anticoagulants 11 . However, this number was almost twofold higher than in the general population which is estimated at 9% to 18% 23‐25 .…”

“…This finding aligns with a previous study that reported a high frequency of menstrual problems in those receiving antiplatelets and anticoagulants. 11 However, this number was almost twofold higher than in the general population which is estimated at 9% to 18%. 23 , 24 , 25 This indicates that physicians should be aware of HMB as a prevalent and morbid bleeding complication in women receiving anticoagulant and antiplatelet therapy.…”

“…As for direct oral anticoagulants (DOACs), the prevalence of abnormal uterine bleeding (AUB) associated with factor Xa inhibitors was higher compared to warfarin, while AUB was lower with the direct thrombin inhibitor dabigatran etexilate compared to warfarin 10 . Women treated with antiplatelet agents also reported having HMB 11 . The duration of menstruation also increased with the use of oral anticoagulants 12 .…”

“… 10 Women treated with antiplatelet agents also reported having HMB. 11 The duration of menstruation also increased with the use of oral anticoagulants. 12 In these studies, the definition of HMB varied.…”

The effect of oral progesterone for the treatment of abnormal uterine bleeding in women taking warfarin following prosthetic valve replacement

“…A study of 90 women, aged 15–49 years, reported that the abnormal uterine bleeding was reported by 17.8% women before use of anticoagulation therapy while 29.5% women reported this problem after the start of anticoagulants 12. The treatment of HMB is quite challenging and the efficacy of commonly used medicines like Tranexamic acid is not well established 13. The other pharmacological options include Levonorgestrel intrauterine system, high dose progestin-only therapy, and combined hormonal contraceptives.…”