Heavy menstrual bleeds while on anticoagulants can be managed conservatively

Heavy menstrual bleeding in women on anticoagulants such as rivaroxaban or apixaban can usually be managed conservatively, however anatomical abnormalities should be considered in women with heavy bleeding that persists across menstrual cycles.

A German study of 178 women under 50 years of age treated with direct oral factor Xa inhibitors mostly for VTE, found about a third (32%) experienced heavy vaginal bleeding during menstruation.

Consultant haematologist Dr Peter Davidson from QML Pathology told the limbic the study was small but provided some guidance on appropriate patient management.

“65-70% of women won’t experience any major issues but if they do, it may be important to look at some short-term modification of their anticoagulant dose on the first couple of days of their period.”

He said some women might opt to cut their tablet in half to reduce the dose or skip a dose to limit the bleeding.

“Alternatively, rather than modifying their anticoagulant, manipulation of hormonal therapy such as using a progesterone only contraception like an implant or IUD might be an option where there are no intrinsic uterine abnormalities,” Dr Davidson said.

Five bleeding events in the study were managed with a change to the woman’s method of contraception.

He added that most women who had an episode of heavy bleeding on rivaroxaban subsequently coped quite well with the treatment.

“Anticoagulation treatment is often of a short duration or finite period such as six months which makes the side effects somewhat limited in nature and easier to deal with.”

The study found all affected women were able to continue on their anticoagulant therapy for the intended treatment duration.

Women with second and third bleeding events or more intense bleeding were more likely to be identified with anatomical abnormalities such as endometrial hyperplasia or uterine myomas requiring surgical intervention.

Dr Davidson said studies in older women with AF had found less bleeding with apixaban than rivaroxaban.

“For younger women on anticoagulation for more than six months who are experiencing ongoing menstrual problems, a switch to apixaban or warfarin may be an option.”

“Unfortunately, dabigatran which does not appear to increase the risk of heavy menstrual bleeding, is not PBS listed for treatment of DVT/PE,” he said.

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