# Presentation: 099261

## Women’s Issues and Venous Thromboembolism

**Suman Rathbun, MD, MS**
**University of Oklahoma Health Sciences Center**

## Lifetime hormonal exposure

**Lifetime hormonal exposure**

**Adolescence**

**Adult**

**Child-bearing**

**Menopause**

**HRT**

**Pregnancy**

**OCPs**

## Risk of VTE with OCPs

**Risk of VTE with OCPs**

**Relative Risk:**** 2 to 8-fold**
**Absolute Risk:**** 2 to 8/10,000 **
**woman-years**

**Smoking: 2-fold**

**Age: 3-fold**
**> Age 40**

**Obesity:**
**5 to 10-fold**
**> 30kg/m****2**

**First-time user**
**First 6 months**

## OCP formulation

**OCP formulation**

**Mestranol**
**100 μg**

**Ethinyl estradiol **
**30-50 ****μ****g**
**+**
**Levonorgestrel**

**Ethinyl estradiol**
**+**
**Desogrestrel**
**or**
**Genstodene**

**Drospirenone**
**or**
**Cyproterone**

**Transdermal**
**Injectable**
**Intrauterine device**

**Progestin-only**
**Medroxyprogesterone**
**Levonorgestrel**
**Norethindrone**
**Norgestrel**

**First**

**Second**

**Third**

**Fourth**

## OCPs and Thrombophilia

**Mutation**

**No. Studies**

**Cases**

**Controls**

**OR (95% CI)**

**None**

**Factor V L**

**Prothrombin G**

**AT3**

**Protein C**

**Protein S**

**Fact V + Pro G**

**7**

**6**

**3**

**1**

**1**

**2**

**2**

**411/733**

**69/365**

**30/260**

**5/60**

**17/60**

**21/85**

**5/220**

**529/1797**

**73/1252**

**64/760**

**4/144**

**20/144**

**13/250**

**3/621**

**3.1**** ****(2.17, 4.42)**

**3.78**** (2.22, 6.42)**

**1.34**** (0.81, 2.23)**

**3.18**** (0.82, 12.29)**

**2.45**** (1.18, 5.11)**

**5.31**** (2.48, 11.37)**

**4.03**** ****(1.01, 16.01)**

**Adapted from Wu, et al.  Thromb Haemost 2005;94**

## VTE Risk During Pregnancy

**VTE Risk During Pregnancy**

**Relative risk:**** 5-fold**
**Absolute risk:**
**18-1900/100,000 women**

**Age**
**Immobilization**
**Preeclampsia**
**Obesity**

**Smoking**
**Previous VTE**

**Antepartum**

**Postpartum**

## Pregnancy and Thromphobilia

**Mutation**

**No. Studies**

**Cases**

**Controls**

**OR (95% CI)**

**FVL (Homo)**

**Fact V L (Hetero)**

**Prothrombin G**

**MTHFR (Homo)**

**AT 3**

**Protein C**

**Protein S**

**5**

**6**

**4**

**4**

**3**

**3**

**3**

**29/91**

**96/226**

**42/61**

**20/128**

**8/11**

**23/32**

**15/28**

**145/1248**

**263/1595**

**277/1005**

**89/543**

**242/815**

**232/715**

**250/911**

**34.4**** (9.86, 120.05)**

**8.32**** ****(5.44, 12.7)**

**6.8**** (2.46, 18.77)**

**0.74**** (0.22, 2.48)**

**4.69**** (1.30, 16.96)**

**4.76**** ****(2.15, 10.57)**

**3.19**** (1.48, 6.89)**

**Adapted from Robertson, et al.  BJH 2006;132**

## Prevention during pregnancy

**Risk Group**

**Recommendation**

**Single VTE / No Thrombophilia**

**Single VTE / Thrombophilia**

**Multiple VTE**

**Surveillance**

**LMWH or UFH Prophylaxis**

**LMWH or UFH Treatment**

_**Treatment**_

## Risk of VTE with HRT

**Relative Risk:**** 2 to 4-fold**
**Absolute Risk:**** 20 per 10,000 **
**woman-years**

## HRT and Thrombophilia

**Mutation**

**Estrogen**

**Cases**

**Controls**

**OR (95% CI)**

**FVL**

**Protein G**

**None**

**Oral**

**Transdermal**

**None**

**Oral**

**Transdermal**

**16**

**11**

**8**

**15**

**5**

**6**

**18**

**3**

**6**

**7**

**0**

**7**

**2.6**** (1.3, 5.4)**

**16.4**** (4.3, 62.2)**

**4.6**** (1.6, 13.8)**

**6.4**** (2.5, 16.5)**

**3.3**** (1.1, 10.2)**

**Adapted from Straczek, Celine et al., “Prothrombotic Mutations, Hormone Therapy, and Venous Thromboembolism among Postmenopausal Women: Impact of the Route of  Estrogen Administration,”  Circulation 2005; 112:3495-3500**

## Prevention with HRT

**Stratify**

**High Risk:**
**Thrombophilia**
**History of VTE**

**Low Risk:**
**Low-dose estrogen**
**Estrogen-only**
**Transdermal estrogen**
**Short duration**
**Young post-menopause**