warfarin and Menorrhagia

The association between the progestin-only pill used for treatment of menstrual disorders and central venous sinus thrombosis (CVST) has rarely been reported in the literature. This report describes a case of central venous sinus thrombosis following intake of norethindrone acetate for dysfunctional uterine bleeding secondary to polycystic ovary syndrome in a young woman with undiagnosed underlying hyperhomocysteinemia.. A 23-year-old woman presented with severe headache, followed by hemiparesis, seizures, and altered sensorium. She had been prescribed norethindrone acetate for the management of dysfunctional uterine bleeding secondary to polycystic ovary syndrome. Investigations revealed acquired hyperhomocysteinemia, presumably due to nutritional deficiencies, and evidence of CVST on MRI and magnetic resonance venography. Investigations showed no evidence of inherited thrombophilia. The patient was treated with low molecular weight heparin, followed by warfarin, vitamin B12, vitamin B6, and folic acid, and recovered successfully.. Although venous thrombosis is usually linked to the ingestion of estrogen, rather than progestogen, this case illustrates that patients who are prescribed progestogen-only pills for gynaecological disorders may develop thrombosis, especially if they have predisposing metabolic disorders.

Topics: Contraceptives, Oral, Synthetic; Female; Heparin, Low-Molecular-Weight; Humans; Hyperhomocysteinemia; Magnetic Resonance Angiography; Magnetic Resonance Imaging; Menorrhagia; Norethindrone; Nutrition Disorders; Polycystic Ovary Syndrome; Sinus Thrombosis, Intracranial; Treatment Outcome; Warfarin; Young Adult

Estrogen exposure, in the setting of pregnancy, the postpartum state, combined hormonal contraceptives (CHCs), or hormone therapy use, has been clearly associated with increased rates of venous thromboembolism (VTE). Although recurrence rates are low in these settings, up to 70% of anticoagulated menstruating individuals experience abnormal or heavy menstrual bleeding (HMB), which commonly results in iron deficiency with or without anemia. Patients taking rivaroxaban appear to experience higher rates of HMB compared with those on apixaban, dabigatran, or warfarin. HMB can often be diagnosed in a single visit with a good menstrual history assessing for factors with a known association with increased or heavy bleeding, such as changing pads or tampons more often than every 2 hours, clots larger than a quarter, and iron deficiency (ferritin <50  ng/mL). HMB can be managed with hormonal therapies, including those associated with VTE risk, such as CHCs and depot-medroxyprogesterone acetate (DMPA). In many cases, continuing CHCs or DMPA while a patient is therapeutically anticoagulated is reasonable, so long as the therapy is discontinued before anticoagulation is stopped. Modification of the anticoagulation regimen, such as decreasing to a prophylactic dose in the acute treatment period, is not currently recommended. For patients who are currently pregnant, low-molecular-weight heparin (LMWH) is still standard of care during pregnancy; routine monitoring of anti-factor Xa levels is not currently recommended. Warfarin or LMWH may be considered in the postpartum setting, but direct-acting oral anticoagulants are currently not recommended for lactating patients.

Topics: Anticoagulants; Female; Heparin, Low-Molecular-Weight; Humans; Iron Deficiencies; Lactation; Menorrhagia; Pregnancy; Venous Thromboembolism; Warfarin

Essentials Factor Xa inhibitors cause more abnormal menstrual bleeding (AUB) than vitamin-K antagonists (VKA). We analyzed data of AUB in women, evaluating dabigatran versus VKA. We observed a 41% lower risk of AUB in women on dabigatran compared to those on VKA. Our findings of lower AUB risk on dabigatran should be corroborated in future studies.. Introduction Although direct oral anticoagulants (DOACs) are associated with a better safety profile than warfarin in patients with acute venous thromboembolism (VTE), direct factor Xa inhibitors involve a higher risk of abnormal uterine bleeding (AUB). We aimed to determine the risk of AUB during anticoagulation with dabigatran compared with warfarin. Methods Post-hoc analysis of the pooled RE-COVER studies and the RE-MEDY trial. Incidences of AUB, based on a defined preferred terms search for adverse events, in female patients aged 18-50 years treated with dabigatran, were compared with those in women treated with warfarin. Results Of the 2964 women included in the above-mentioned trials, 1280 women were in the relevant age category (18-50 years) and included in the current analysis. A total of 643 patients were randomized to treatment with dabigatran and 637 to treatment with warfarin. The overall rate of AUB was 8.1%, 5.9% for the women treated with dabigatran and 9.6% in those treated with warfarin, for an odds ratio for dabigatran-treated patients of 0.59 (95% confidence interval [CI], 0.39-0.90; P = 0.015). In the dabigatran-treated patients, three (0.5%) suffered major bleeding (MB) vs. five (0.8%) in the warfarin-treated patients (HR, 0.65; 95% CI, 0.15-2.72). MB or non-major relevant bleeding occurred in 30 (4.7%) patients randomized to receive dabigatran and 57 (8.9%) randomized to receive warfarin (HR, 0.53; 95% CI, 0.34-0.83). None of the bleeding events was fatal. Conclusion Dabigatran treatment was associated with a significantly (41%) lower risk of AUB than warfarin. Future studies in daily practice are needed to corroborate these findings.

Topics: Adolescent; Adult; Anticoagulants; Clinical Trials as Topic; Contraceptives, Oral, Hormonal; Dabigatran; Factor Xa Inhibitors; Female; Humans; Incidence; Menorrhagia; Middle Aged; Multicenter Studies as Topic; Uterine Hemorrhage; Venous Thromboembolism; Vitamin K; Warfarin; Young Adult

Pulmonary embolism (PE) is a common and life-threatening condition. The British Thoracic Society PE guidelines state that PE is reliably excluded in patients with low-intermediate clinical probability and a negative D-dimer. We are reporting the case of a 47-year-old lady, taking tranexamic acid for menorrhagia, who presented with shortness of breath and was diagnosed with extensive bilateral PE. She had a low clinical risk of PE as determined by her Wells score, and a subsequent negative D-dimer. This patient's D-dimer value of 15 ng/ml (HemosIL DD HS assay) was the lowest associated with any CT pulmonary angiogram (n=1645) recorded at our trust over a 2-year period. This lady was successfully treated with a heparin infusion and warfarin. No further thromboembolic events had occurred by 18-month follow-up. To our knowledge, this is the first case report to describe tranexamic acid causing an extremely low false-negative D-dimer masking PE.

Topics: Anticoagulants; False Negative Reactions; Female; Fibrin Fibrinogen Degradation Products; Heparin; Humans; Infusions, Intravenous; Menorrhagia; Middle Aged; Pulmonary Embolism; Tomography, X-Ray Computed; Tranexamic Acid; Warfarin

The aim of this study was to review a consecutive cohort of adolescent females on warfarin to determine the effect of warfarin on menstruation, management options and their perceived efficacy.. All female patients on warfarin, over the age of 10 years, as of 31 August 2006, were identified using the Department of Haematology (Royal Children's Hospital) warfarin database. The presence of menorrhagia was defined by clinical indicators.. Of 81 adolescent females on warfarin, 24 (30%) were referred to gynaecology due to a concern about heavy periods and one for anticipatory guidance, on the basis of impending menarche. In 18 cases (22% of the cohort), menorrhagia could be substantiated on the basis of clinical indicators. Nineteen patients required treatment for menorrhagia with the options for treatment being the combined oral contraceptive pill, subdermal hormone administrations, tranexamic acid and the progesterone-only contraceptive pill. Significant adolescent psychosocial stresses were identified in those adolescents taking warfarin.. Adolescent females on warfarin commonly suffer from menorrhagia. Adolescent review of all teenage girls receiving warfarin therapy is indicated.

Topics: Adolescent; Anticoagulants; Contraindications; Databases, Factual; Female; Humans; Medical Audit; Menorrhagia; Warfarin; Young Adult

Oral anticoagulation is associated with increased bleeding complications. The aim of this study was to assess the changes in menstrual loss and pattern in women taking anticoagulant treatment.. Women on oral anticoagulant (OA) treatment at the Royal Free Hospital were interviewed and completed a questionnaire about their menstrual cycle before and after commencing oral anticoagulation treatment. They were then asked to complete a pictorial bleeding assessment chart (PBAC) during their next menstrual bleeding episode.. Fifty-three women between the ages of 20 and 50 years participated in the study. Of these, 47 women completed a PBAC. The mean duration of menstruation increased from 5 days before starting OA therapy to 7 days after the commencement of treatment. Thirty-one (66%) of the 47 women who completed the PBAC had a score that was greater than 100. The number of women who experienced flooding or clots during menstruation and intermenstrual or postcoital bleeding also increased. In total, 29 (54.7%) women changed their method of contraception during OA treatment. Seventeen women who did not want to become pregnant were not using contraception, including 10 women who were on hormonal contraception prior to starting anticoagulant therapy.. Women of reproductive age experience heavy and prolonged menstrual bleeding whilst on OA therapy. Women of reproductive age on OA therapy should be monitored for menstrual disorders to ensure that prompt and appropriate treatment is instituted. Advice about appropriate contraception should also be part of the medical care provided for these women. Barrier contraception, sterilization and progestin-only contraception are all suitable methods of contraception in this patient group.

Topics: Administration, Oral; Adult; Anticoagulants; Contraception Behavior; Female; Humans; Menorrhagia; Menstruation; Middle Aged; Warfarin; Young Adult

Agenesis of the inferior vena cava (IVC) is an uncommon congenital vascular malformation. We report a case in a teenage female recently started on oral contraception.. Because of menorrhagia, the patient had begun an oral contraceptive pill (OCP) 1(1/2) months prior to presentation. She initially presented with pelvic and lower back pain, and imaging showed a pelvic deep venous thrombosis (DVT) and an interrupted IVC. Anticoagulation was started, the OCP was discontinued, and a discussion occurred regarding the treatment options for her menorrhagia following her recent diagnosis.. The case presented shows the rare occurrence of the congenital absence of an IVC with pelvic thrombosis in a young female with a history of menorrhagia and new onset of pelvic pain. The evaluation of this case report leads to a comprehensive review in the treatment choice for menorrhagia with the preceding history of a thrombotic event.

Topics: Adolescent; Anticoagulants; Contraceptives, Oral; Contraindications; Female; Humans; Magnetic Resonance Imaging; Menorrhagia; Pelvic Pain; Tomography, X-Ray Computed; Vena Cava, Inferior; Venous Thrombosis; Warfarin

Menorrhagia is common in women receiving oral anticoagulation. In healthy women, reductions of up to 90% of menstrual loss have been described with the levonorgestrel releasing intrauterine device (LNG-IUS). However there is no data about the use of LNG-IUS in women receiving oral anticoagulation and so we assessed the efficacy and safety of LNG-IUS in this setting. Patients with menorrhagia who used LNG-IUS and warfarin were contacted by post and asked to complete a questionnaire assessing the extent and duration of menstrual bleeding, quality of life and treatment satisfaction. The questionnaire was sent to 23 patients and returned by 17. The amount of bleeding was reduced with the LNG-IUS in 10 (58.8%) women; amenorrhea occurred in four (23.5%), no change in blood loss in one (5.9%) and greater blood loss in two (11.8%) patients. The number of sanitary pads used was less in 12 (70.6%) patients; same in one (5.9%) patient, more in two (11.8%) patients and two (11.8%) did not remember. Five patients (29.4%) had shorter duration of bleeding, four (23.5%) had amenorrhoea, four (23.5%) had longer periods and four (23.5%) had same duration by subjective assessment. Eight (47.1%) patients felt very satisfied, four (23.5%) felt satisfied, two (11.8%) felt dissatisfied with the treatment, one felt very dissatisfied (5.9%) and two (11.8%) did not respond to the question. This small study suggests LNG-IUS is effective in reducing the duration and amount of menstrual bleeding in women with menorrhagia associated with oral anticoagulation. We feel the use of LNG-IUS is a major advance in reducing menorrhagia in women on oral anticoagulation as the previous alternative--hysterectomy--is associated with an increased risk of thrombosis and bleeding.

Topics: Administration, Oral; Adult; Anticoagulants; Contraceptive Agents, Female; Female; Humans; Intrauterine Devices; Levonorgestrel; Menorrhagia; Middle Aged; Patient Satisfaction; Surveys and Questionnaires; Thrombosis; Treatment Outcome; Warfarin

To study the demographic and clinical characteristics of patients with antiphospholipid syndrome (APS) with serious haemorrhagic complications of anticoagulant treatment in an attempt to establish risk factors for bleeding.. Patients with APS who were attending our lupus unit and who presented with severe bleeding while receiving oral anticoagulation were studied retrospectively. Severe bleeding was defined by the need for admission to hospital. Demographic data, clinical features, concomitant diseases and drugs, warfarin doses, duration of anticoagulation, and International Normalised Ratios (INR) at the time of bleeding were collected.. Fifteen patients were included in the study (12 with systemic lupus erythematosus (SLE) plus APS and 3 with primary APS). The median age was 41.7 (range 27-66) and the median duration of the disease was 12.9 years (range 3-22). Duration of anticoagulation was between 10 days and 17 years. The INR at the time of bleeding was under 3 in 4 patients, between 3 and 4 in 5 patients and above 4 in 6 patients. There were 4 episodes of subdural haematoma, 4 episodes of renal haematoma (two after renal biopsy), 2 episodes of ovarian haemorrhage, 2 episodes of rectal haemorrhage, 1 episode of menorrhagia, 1 episode of haemarthrosis, and 1 episode of spinal haematoma. Concomitant drugs were aspirin in 9 patients, antibiotics in 2 patients, and azathioprine in 3 patients. In 6 patients hypertension was present as a concomitant disease. There were no deaths due to bleeding. Anticoagulant treatment was restarted in all patients and 3 of them had a new episode of bleeding.. No relation was established between age, duration of oral anticoagulant treatment, and bleeding. Concomitant drugs, mainly aspirin, and high blood pressure were present at the time of bleeding in a large number of patients.

Topics: Adult; Aged; Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Antiphospholipid Syndrome; Aspirin; Female; Hemarthrosis; Hematoma; Hematoma, Subdural; Hemorrhage; Humans; Hypertension; Kidney Diseases; Male; Menorrhagia; Middle Aged; Ovarian Diseases; Recurrence; Risk Factors; Thrombosis; Warfarin

The advent of hysteroscopic laser surgery has provided an alternative to hysterectomy in women with menorrhagia refractory to other forms of treatment. This procedure has been used with considerable success to reproduce the signs and symptoms of Asherman's syndrome when combined with pretreatment using the synthetic steroid Danocrine (danazol). Experience with 335 patients treated with danazol, 800 mg/d, for 25 days before undergoing hysteroscopy with a neodymium:yttrium-aluminum-garnet laser demonstrated that excellent results (amenorrhea or limited spotting) were achieved in 97% of cases. All 46 patients with clotting disorders did well after surgery. The major complications associated with this procedure were fluid overload, profuse bleeding, postoperative urinary tract infections and postoperative hematometra, all of which were controlled successfully. Only one patient had to discontinue danazol treatment because of an adverse reaction.

Topics: Adolescent; Adult; Danazol; Drug Synergism; Endometriosis; Female; Humans; Hysteroscopy; Laser Therapy; Medroxyprogesterone; Medroxyprogesterone Acetate; Menorrhagia; Middle Aged; Pregnadienes; Premedication; Uterine Hemorrhage; Warfarin

The difficulty in the treatment of patients undergoing Warfarin therapy for mitral stenosis, is underlined and cases treated with Danazol in sideropenic anaemia caused by menometrorrhagia are reported.

Topics: Anemia, Hypochromic; Danazol; Drug Evaluation; Drug Interactions; Female; Heart Valve Prosthesis; Humans; Menorrhagia; Mitral Valve; Mitral Valve Stenosis; Pregnadienes; Warfarin

Topics: Adult; Female; Humans; Menorrhagia; Substance-Related Disorders; Warfarin

A case report of overt bleeding in a young woman on warfarin given the anabolic steroid danazol for menorrhagia is reported. This interaction appears to be poorly recognised and we suggest that when commencing such a treatment the dose of anticoagulant should initially be halved and thereafter tailored to the thrombotest.

Topics: Administration, Oral; Adult; Anticoagulants; Blood Coagulation Tests; Danazol; Drug Interactions; Female; Hematuria; Humans; Menorrhagia; Pregnadienes; Pulmonary Embolism; Warfarin

Topics: Adult; Doxycycline; Drug Synergism; Female; Humans; Menorrhagia; Prothrombin Time; Warfarin

A young woman presented with a 2 year history of a severe bleeding disorder and marked deficiencies in all four vitamin-K-dependent factors. Metabolic studies with tracer doses of tritium-labelled vitamin K1 suggested that the patient might be taking an oral anticoagulant; and subsequently her plasma was found to contain a substance identical to phenindione in its spectrophotometric and chromatographic properties. The half-disappearance times of factors II, IX, X were measured after the administration of a concentrate of these factors and were found to conform with published figures. The concentrate controlled the patient's excessive bruising and prolonged skin and gingival bleeding. It would therefore seem that factor VII may not be essential in reversal of the bleeding disorder induced by anticoagulant overdose.

Topics: Adult; Anemia; Blood Coagulation Disorders; Blood Coagulation Factors; Blood Coagulation Tests; Chromatography, Gas; Chromatography, Thin Layer; Diabetes Complications; Female; Glucosephosphate Dehydrogenase; Hematemesis; Hematuria; Humans; Menorrhagia; Phenindione; Self Medication; Spectrum Analysis; Substance-Related Disorders; Vitamin K; Warfarin

Topics: Blood Coagulation Disorders; Blood Coagulation Tests; Diagnosis, Differential; Ecchymosis; Female; Humans; Menorrhagia; Minnesota; Thromboplastin; Toxicology; Warfarin