Management of Heavy Menstrual Bleeding in Patients Receiving NOACs
This section discusses heavy menstrual bleeding management options for women treated with NOACs
In this section:
- Use of hormones to manage heavy menstrual bleeding
- Other strategies to manage heavy menstrual bleeding
Numerous strategies can be used to manage heavy menstrual bleeding associated with anticoagulant use. These include:
- Diagnosis and treatment of any underlying conditions predisposing to abnormal uterine bleeding (e.g. anaemia or gynaecological abnormalities such as uterine fibroids)
- Use of hormonal preparations or haemostatic agents
- Potential modification of anticoagulant treatment
- Surgical intervention, such as uterine artery embolization, myomectomy and hysterectomy (an option in some instances in women with underlying gynaecological conditions)
Use of hormones to manage heavy menstrual bleeding
Hormonal preparations considered suitable for use in anticoagulated women with heavy menstrual bleeding include gonadotrophin-releasing hormone receptor agonists and hormonal contraceptives not associated with an increased risk of VTE. The latter include progestogen-releasing intrauterine devices (e.g. a levonorgestrel-releasing intrauterine system), which are recommended by the UK National Institute of Health and Care Excellence (NICE) as a first-line option for the treatment of heavy menstrual bleeding in women who also require contraception. However, it may take up to 6 months for this approach to reduce menstrual bleeding, limiting its usefulness if the anticipated duration of anticoagulant therapy is ≤6 months.
Combined hormonal contraceptives are also frequently used to minimize heavy menstrual bleeding. However, because they are associated with a 2–8-fold increased risk of VTE, controversy exists over their use in women receiving anticoagulation for VTE treatment. The World Health Organization (WHO) advises that combined hormonal contraceptives should not be used with anticoagulant therapy, whereas International Society on Thrombosis and Haemostasis (ISTH) guidance suggests that hormonal contraceptives can be used in women receiving an anticoagulant because any prothrombotic effect of hormonal therapy is likely to be suppressed by therapeutic-intensity anticoagulation.
Other strategies to manage heavy menstrual bleeding
As an alternative second-line therapy to progestogen-releasing intrauterine devices, NICE recommends the use of the anti-fibrinolytic agent tranexamic acid to treat heavy menstrual bleeding. Available data do not show an increased risk of thrombosis with its use, making it a reasonable option for the treatment of heavy menstrual bleeding in women receiving an anticoagulant. NSAIDs have also been shown to reduce heavy menstrual bleeding by up to 40% and are also recommended by NICE as a second-line therapy option.However, NSAIDs should be used with caution in patients treated with NOACs because of an increased risk of generalized bleeding.
Another approach that has been used for the management of heavy menstrual bleeding in women treated with NOACs in routine clinical practice is modification of anticoagulant therapy, including temporary dose reduction or interruption of NOAC therapy and switching of anticoagulants. However, temporary dose reduction/interruption potentially leaves patients at increased risk of blood clots, especially during the acute phase of VTE treatment when the risk of recurrent blood clots is high. Prospective data from one small single-centre study, which included 76 women treated with rivaroxaban and 45 women treated with a VKA, suggested that heavy menstrual bleeding during rivaroxaban treatment, but not VKA treatment, predisposed women to recurrent VTE; the women treated with rivaroxaban were more likely to have interruptions in anticoagulant treatment for 2–3 days (24% of rivaroxaban-treated women versus 9% of VKA-treated women).
Approval No.: G.COM.GM.XA.10.2017.1875
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