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Heavy menstrual bleeding (HMB) is defined as blood loss of >80 mL per cycle or bleeding that interferes with a woman's physical, social, and emotional well-being. It also complicates anticoagulant therapy in premenopausal women, as persistent hemorrhage produces anemia and impairs quality of life, but discontinuing or reducing the anticoagulant dose risks recurrent thrombosis.
A recent review discusses the role of hormonal agents, tranexamic acid, reductions in anticoagulant dose, and surgical interventions for the management of HMB in anticoagulated patients. Key observations were as follows:
The frequency of anticoagulant-associated HMB is 22% to 65% with warfarin, 32% with rivaroxaban, 28% with apixaban, and 25% with edoxaban.
High-dose progestin, depot medroxyprogesterone acetate, and the levonorgestrel intrauterine system appear to be less thrombogenic than combined oral contraceptives.
Tranexamic acid in oral doses every 6 to 8 hours or a single 10-mg/kg intravenous dose can be used to control acute hemorrhaging.
Anticoagulant dose reduction of rivaroxaban (20 to 10 mg) or apixaban (5 to 2.5 mg twice daily) decreases bleeding intensity.
Surgical measures include endometrial ablation and uterine artery embolization.
Boonyawat K et al. How we treat heavy menstrual bleeding associated with anticoagulants. Blood 2017 Nov 1; [e-pub]. (http://dx.doi.org/10.1182/blood-2017-07-797423)
Comment
HMB occurring within the first 3 months after a thrombotic episode poses a difficult management problem. If major bleeding requires discontinuation of anticoagulants, a temporary vena caval filter and high-dose hormonal agents or intravenous tranexamic acid are options. Anticoagulants should be resumed as soon as bleeding is controlled. Long-term management is generally guided by the risk for thrombosis and the severity of bleeding.