Warfarin (coumadin®, Janotven®) and other blood thinners often increase the amount of bleeding during menses and sometimes the number of days that a woman bleeds. However, this does not happen in everyone – in some women there is no change in the bleeding pattern. In general, the more vaginal bleeding a woman has, the more cramping she experiences. Since warfarin may increase the vaginal bleeding, more cramps may also result. A pre-existing bleeding disorder should be considered by the evaluating physician, and a detailed history about (a) the degree of menstrual bleeding prior to “blood thinner” therapy, as well as (b) other bleeding (with teeth extractions, surgery of the tonsils, childbirth, etc.) or a family history of bleeding should be taken. After all: Bleeding disorders in women (not on warfarin) with heavy menstrual bleeding (=menorrhagia) are common [ref. 1,2]. However, they are often not considered by physicians [ref 3].
If a bleeding disorder is present, then consideration of treatment for the disorder is appropriate (for example use of the medication DDAVPor Lysteda® in women with von Willebrand’s disease). If no bleeding disorder is present and the bleeding is significant enough to require intervention, there are several treatment options that can be discussed with the Ob-Gyn and hematologist [ref 4,5,7,8]. They are either (a) hormone treatment, (b) so called ablation procedures during which the superficial layer of the uterus is destroyed, or (c) hysterectomy. If a woman does not plan to have more children, the ablation procedures are, generally, a very good option to prevent or decrease the bleeding. For the woman who still wants to be able to have children, the Mirena® intrauterine device (IUD) is a good first choice. If these methods fail, oral progestin medications or continuous estrogens could be considered. However, the woman needs to be aware that these may increase the risk for thrombosis. However, in the person on warfarin and other “blood thinners” this may not be a clinically relevant risk.
- Mirena® IUD
The Mirena® IUD is a device that continuously releases very low doses of progestins in the uterus. This leads to a suppression of build-up of the layering of the uterus (endometrium) and, thus, to a decrease and, eventually, disappearance of bleeding. Only little of the released progestins is absorbed into the blood stream; therefore, Mirena® does not lead to an increased risk for blood clots and appears to be a good choice to control bleeding or to use as a birth control method in women with (a) thrombophilia (such as factor V Leiden), (b) a history of blood clots (deep vein thrombosis or pulmonary embolism), and (c) the woman on “blood thinners”, such as warfarin (coumadin®, Jantoven®). IUDs releasing progestins have been found to be safe from a clotting point of view – they do not increase the risk for blood clots [ref 6]. They have been found to be effective in deceasing menstrual bleeds on warfarin [ref 5,7,8]. Further information on the Mirena® IUD can also be found at www.mirena-us.com/index.html.
Continuous progestins (for example Aygestin® 2.5 mg per day to start off with; may have to be increased to 10-15 mg per day) sometimes work with heavy menstrual bleeding, but this is a trial-and-error approach. Some women will develop breakthrough bleeding and spotting and will, therefore, not find this a suitable option. Because continuous progestins can cause breakthrough bleeding and spotting (from atrophy=thinning of the endometrium), it can be considered to discontinue them every 3-4 months, to let the woman have a period; progestins can then be restarted. However, Progestins can also be taken without a break. High doses of progestins increase the risk for blood clots [ref 8]. However, one may argue that the person on warfarin is protected, to a large degree, from further blood clots and that the slightly increased risk that occurs with high doses of progestins may clinically not be important.
- Continuous estrogens
Taking the usual birth control pill (combined estrogen-progestin pill) may be attempted and may result in lighter periods because there is less build-up of the endometrial layer while on the pill. For those with continued heavy bleeding, continuous estrogen pills can be considered. To achieve continuous estrogen-progestin dosing a woman would either need to take (a) regular birth control pill packs and discard the pills of the last week (placebo pills) and start a new pack every 3 weeks, or (b) take a prepackaged continuous estrogen-progestin pill that does not contain placebo pill (for example Seasonale®). Since estrogens increase the risk for blood clots, this is to be kept in mind when considering an estrogen-containing pill, and they are, therefore, typically not the first choice of treatment.
- Hot balloon ablation
This procedure is also called “endometrial ablation” or “thermal balloon ablation” or Thermachoice™. It is performed as an outpatient procedure in the operating room. A balloon is inserted into the uterus and a hot fluid is filled into it, which burns and destroys (ablates) the lining of the uterus. Thus, the build-up of the lining of the uterus (endometrium) that typically occurs is prevented. The discomfort experienced during this procedure is easily controlled with minimal sedation or pain killers. Usually, a woman who has had this procedure done can not get pregnant any more. The procedure should therefore, obviously, not be chosen by women who still want to have children. More information is at http://www.pelvichealthsolutions.com/thermachoice.
This method/device is also called “Uterine Electrofrequency ablation”. This is an outpatient procedure performed in the operating room. The lining of the uterus is destroyed (ablated) by application of radiofrequency waves that dry out and destroy the endometrial lining; menstrual bleeding is thus prevented. Usually, a woman who has had this procedure done can not get pregnant any more. The procedure should therefore not be chosen by women who still want to have children. For details see http://www.novasure.com.
- Her Option™
This method/device is also called “Uterine Cryoablation Therapy™ System”. This is an outpatient procedure performed in the operating room. The lining of the uterus is destroyed (ablated) by application of extreme cold; menstrual bleeding is, thus, prevented. Usually, a woman who has had this procedure done can not get pregnant any more. The procedure should therefore not be chosen by women who still want to have children. For details see http://www.heroption.com.
- Hysteroscopic endometrial ablation procedure
This is a surgical procedure performed under general or epidural anesthesia, during which a video scope is introduced into the uterus. The inner layer of the uterus (endometrium) is then destroyed (ablated) with an electrode loop, roller ball, or laser. The procedure should, therefore, not be chosen by women who still want to have children.
Surgical removal of the uterus can also be considered. However, this is, obviously, an invasive procedure and, as any major surgery, has a risk for deep vein thrombosis and pulmonary embolism. This may, therefore, not be a good choice, in the patient who already has a history of venous blood clots or has a thrombophilia
- Philipp CS et al.: Age and the prevalence of bleeding disorders in women with menorrhagia. Obstet Gynecol 2005;105:61-6.
- Philipp CS et al: Platelet functional defects in women with unexplained menorrhagia. J Thromb Haemost 2003;1:477-84.
- Dilley A et al: A survey of gynecologists concerning menorrhagia: perceptions of bleeding disorders as a possible cause. J Womens Health Gend Based Med 2002;11:39-44.
- Barrington JW et al.: Comparison between the levonorgestrel intrauterine system (LNG-IUS) and thermal balloon ablation in the treatment of menorrhagia. Eur J Obstet Gynecol Reprod Biol 2003;108:72-4.
- Hurskainen R et al.: Clinical outcomes and costs with the levonorgestrel-releasing intrauterine system or hysterectomy for treatment of menorrhagia: randomized trial 5-year follow-up. JAMA 2004;24;291:1503-4.
- van Hylckama Vlieg A et al: The risk of deep venous thrombosis associated with injectable depot-medroxyprogesterone acetate contraceptives or a levonorgestrel intrauterine device. Arterioscler Thromb Vasc Biol. 2010 Nov;30(11):2297-300. Epub 2010 Aug 26.
- Pisoni CN et al. Treatment of menorrhagia associated with oral anticoagulation: efficacy and safety of the levonorgestrel releasing intrauterine device (Mirena coil). Lupus 2006;15(12):877-80.
- Culwell KR et al: Use of contraceptive methods by women with current venous thrombosis on anticoagulant therapy: a systematic review. Contraception 2009 Oct;80(4):337-45. Epub 2009 Jun 10.
- Vasilakis C et al.: Risk of idiopathic venous thromboembolism in users of progestagens alone. Lancet 1999;354:1610-1611.
For health care providers
This same information, written for health care providers, is available at http://clotconnectmd.wordpress.com/2010/11/25/heavy-menstrual-bleeds-on-anticoagulants-–-treatment-options/
Disclosure: I have no financial conflict of interest to this blog entry.
Last updated: Nov 26th, 2010