Menstruation, anticoagulation, and contraception: VTE and uterine bleeding.

Abnormal or excessive menstrual bleeding affects one-third of reproductive-aged women. This number increases to 70% among women on direct oral anticoagulants (DOACs). While there is some variation in frequency of heavy menstrual bleeding (HMB) with different DOAC options, all menstruating individuals should receive counseling about the risk of HMB at the time of DOAC initiation. Management options include progestin-only therapies such as the levonorgestrel intrauterine system and etonogestrel subdermal implant or the progestin-only pill. Combined hormonal contraceptives and depot medroxyprogesterone acetate are associated with increased rates of thrombosis in nonanticoagulated women but may be continued, or even initiated, so long as therapeutic anticoagulation is ongoing. Procedural therapies, such as endometrial ablation, uterine artery embolization, or hysterectomy, are considerations for women who have completed childbearing and for whom more conservative measures are objectionable or ineffective. Given the high rates of HMB in women on DOACs, management strategies should be discussed even before heavy bleeding is diagnosed, particularly in women who experienced HMB prior to DOAC initiation. As iron deficiency with or without anemia is a common complication of HMB, complete blood count and ferritin levels should be monitored periodically, and iron deficiency should be treated with oral or intravenous iron supplementation.

Heavy menstrual bleeding (HMB) is bleeding that interferes with physical, social, emotional, or material quality of life.

Seventy percent of women taking warfarin will experience HMB; rates are higher with rivaroxaban.

Both hormonal contraceptives and tranexamic acid are effective treatments for HMB.

Menstruating individuals on anticoagulation should be screened for HMB and iron deficiency.

For References 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15

RELATIONSHIP DISCLOSURE

The authors have no conflicts to report.

AUTHOR CONTRIBUTIONS

BSB, CM, and PJ wrote the manuscript.