Postmenopausal hormone replacement and venous thromboembolism following hip and knee arthroplasty

Abstract

Hormone replacement therapy has been associated with venous thromboembolism. Controversy exists regarding the appropriate management of hormone replacement in the perioperative setting and in other situations--such as acute illness--predisposing to acute venous thromboembolism. We performed a case-control study to determine whether perioperative hormone replacement is associated with venous thromboembolism following hip and knee arthroplasty. 108 patients with postoperative venous thrombosis were matched by age, date and type of surgery, and surgeon with 210 controls without thrombosis. Perioperative hormone replacement use was no more prevalent in patients with postoperative thrombosis than those without. Eighteen (16.7%) women with post-operative thrombosis had taken perioperative hormone replacement compared to 49 (23.3%) of controls: odds ratio = 0.66; (95% CI 0.35-1.18; p=0.17). After multivariate analysis, the adjusted odds ratios were similar. Variables predicting post-operative thrombosis included: prior venous thromboembolism (OR = 2.3; p = 0.02), rheumatologic disease (OR = 2.2; p = 0.03), and absence of pharmacologic antithrombotic prophylaxis (OR = 13.4; p = 0.005). Cases and controls were otherwise similar. Users of hormone replacement were similar to non-users except that they were less likely to have coronary disease (OR 0.34; p = 0.03) or prior thrombosis (OR = 0.28; p = 0.04), and were younger (median age 67 versus 74 years; p <0.0001). We found no association between perioperative hormone replacement and post-operative thrombosis in patients undergoing major orthopaedic surgery. Routine discontinuation of these medications preoperatively--and possibly in other situations predisposing to thrombosis, such as acute medical illness--may be unnecessary in patients receiving appropriate pharmacologic antithrombotic prophylaxis.

Perioperative medication management: a case-based review of general principles.

“…A recent case-control study with 108 cases and 210 controls found no association between perioperative HRT use and postoperative venous thromboembolism. 9 At The Cleveland Clinic's IMPACT (Internal Medicine Preoperative Assessment, Consultation, and Treatment) Center and at many other institutions across the country, patients are typically seen 1 to 2 weeks before surgery. In that situation, the prothrombotic state that HRT produces is not going to dissipate if the patient stops the drug 1 week prior to surgery; this prothrombotic state actually takes a few weeks to dissipate.…”

“…Several experts feel that routine HRT discontinuation may be unnecessary in patients receiving appropriate pharmacologic antithrombotic prophylaxis. 9…”

Duration of Anesthesia and Venous Thromboembolism After Hip and Knee Arthroplasty

“…This study is a secondary analysis of a study that examined risk factors for postoperative VTE in postmenopausal women (≥50 years), particularly the relationship between hormone replacement therapy and postoperative VTE. 22 Cases were identified by searching the CCF International Classification of Diseases, Ninth Revision database for women older than 50 years who underwent hip or knee arthroplasty between January 1997 and July 2002. Total, partial, and revision elective arthroplasty were included for both joints.…”

Guidelines for the management of chronic medication in the perioperative period: systematic review and formal consensus

“…The two studies concluded that HRT administration had no effect on mortality or morbidity rates in women undergoing vascular surgery. One case–control study found no association between perioperative HRT and post‐operative thrombosis in patients undergoing major orthopaedic surgery (19).…”

“…Extrapolated evidence form one cohort study (17) (evidence level 2 ++ ) and from one case–control study (19) (evidence level 2 + ) recommend continuation of HRT in the perioperative period with strength classification of C. However, the formal consensus panel defended withdrawal of HRT before surgery, because of higher risk of thromboembolism with this therapy compared with OC. Oestrogen dosages in HRT are higher and the target population is older.…”