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Samuelson Bannow BT. Starving in the land of plenty: the challenge of studying menstruation in anticoagulated patients. Res Pract Thromb Haemost 2024; 8:102500. [PMID: 39091720 PMCID: PMC11293560 DOI: 10.1016/j.rpth.2024.102500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 05/30/2024] [Accepted: 06/02/2024] [Indexed: 08/04/2024] Open
Affiliation(s)
- Bethany T. Samuelson Bannow
- Correspondence Bethany T. Samuelson Bannow, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, OC14HO, Portland, OR 97239, USA. @bsamuelson_md
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Hamulyák EN, Wiegers HM, Hutten BA, de Lange ME, Timmermans A, Westerweel PE, Nijziel MR, Klok FA, Hovens MM, Kamphuisen PW, Büller HR, Middeldorp S, Scheres LJ. Heavy menstrual bleeding on direct factor Xa inhibitors: the MEDEA randomized clinical trial. Res Pract Thromb Haemost 2024; 8:102448. [PMID: 38953049 PMCID: PMC11215107 DOI: 10.1016/j.rpth.2024.102448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/27/2024] [Accepted: 05/13/2024] [Indexed: 07/03/2024] Open
Affiliation(s)
- Eva N. Hamulyák
- Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Hanke M.G. Wiegers
- Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Barbara A. Hutten
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Diabetes & Metabolism, Amsterdam, The Netherlands
| | - Maria E. de Lange
- Department of Gynecology and Obstetrics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Anne Timmermans
- Department of Gynecology and Obstetrics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter E. Westerweel
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Marten R. Nijziel
- Department of Hematology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Frederikus A. Klok
- Department of Medicine – Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcel M. Hovens
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Pieter W. Kamphuisen
- Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Department of Internal Medicine, Tergooi Hospital, Hilversum, The Netherlands
| | - Harry R. Büller
- Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Luuk J.J. Scheres
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Clinical Epidemiology, Leiden, University Medical Center, Leiden, The Netherlands
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de Winter MA, Xu Y, Stacey D, Wells PS. Qualitative experiences, values, and decisional needs of patients with unprovoked venous thromboembolism who suffer bleeding-"This pill will keep you alive tonight". Res Pract Thromb Haemost 2024; 8:102360. [PMID: 38559571 PMCID: PMC10978529 DOI: 10.1016/j.rpth.2024.102360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/25/2024] [Accepted: 01/28/2024] [Indexed: 04/04/2024] Open
Abstract
Background Contemporary guidelines recommend extended-duration anticoagulation among patients with a first unprovoked venous thromboembolism (VTE). Little is known about whether this recommendation aligns with patient values after a bleeding complication. Objectives To explore the experiences, values, and decisional needs of patients with unprovoked VTE related to extended-duration treatment after an anticoagulant-associated bleed. Methods In this descriptive, qualitative study, face to face online semistructured interviews were conducted with patients with unprovoked VTE who had experienced bleeding and continued anticoagulant treatment in one academic hospital in Canada. Data were analyzed using directed content analysis to identify themes. Themes were mapped onto the Ottawa Decisional Support Framework to identify decisional needs. Results Between September and December 2021, 14 patients were interviewed (age 41-69 years; 9 females). Many patients were not aware of the option to stop anticoagulation and had limited understanding of the decision about treatment duration. Despite the negative quality-of-life impact of clinically relevant bleeding during VTE treatment, the majority continued anticoagulation due to emotional trauma of VTE diagnosis, a perception that bleeding would be more manageable than VTE recurrence, a desire to maintain a connection to subspecialty care or non-VTE related benefits (eg, cancer diagnosis, protection from COVID-19). Patients' decisional needs included lack of choice awareness, inadequate support for participation, lack of personalized risk stratification, and inadequate information on monitoring and managing heavy menstrual bleeding. Conclusion Despite the impact of anticoagulant-associated bleeding on quality of life, patients preferred continuing with anticoagulation for reasons extending beyond secondary VTE prevention. Effective decision-support interventions are needed to address unmet decisional needs.
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Affiliation(s)
- Maria A. de Winter
- Department of Acute Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Internal Medicine, Diakonessenhuis, Utrecht, The Netherlands
| | - Yan Xu
- Department of Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dawn Stacey
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Philip S. Wells
- Department of Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Kempers EK, van der Zande JA, Janssen PM, Cornette JM, Roos-Hesselink JW, Kruip MJ. Effects of antiplatelet therapy on menstrual blood loss in reproductive-aged women: a systematic review. Res Pract Thromb Haemost 2024; 8:102295. [PMID: 38268520 PMCID: PMC10805676 DOI: 10.1016/j.rpth.2023.102295] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/31/2023] [Accepted: 11/26/2023] [Indexed: 01/26/2024] Open
Abstract
Background The effects of antiplatelet therapy on menstrual bleeding have not been well characterized. Objectives To systematically review the effects of antiplatelet therapy on menstrual bleeding. Methods A literature search was performed for studies of reproductive-aged women who received antiplatelet therapy. Characteristics of menstrual bleeding both before and after initiation of antiplatelet therapy and from comparison groups were collected. Two reviewers independently assessed the risk of bias in individual studies. Results Thirteen studies with a total of 611 women who received antiplatelet therapy were included. Types of antiplatelet drugs used were aspirin (n = 8), aspirin and/or clopidogrel (n = 2), prasugrel (n = 1), and not specified (n = 2). Risk of bias was assessed at moderate (n = 1), serious (n = 8), critical (n = 2), and no information (n = 2). Three studies reported changes in menstrual blood loss volume. One of these showed no increase during antiplatelet therapy; the other 2 studies suggested that aspirin may increase menstrual blood loss volume. In 3 studies that assessed the duration of menstrual bleeding, up to 13% of women reported an increased duration of menstruation. In 5 studies that reported the intensity of menstrual flow, 13% to 38% of women experienced an increase in the intensity of flow. Five studies reported the prevalence of heavy menstrual bleeding in women who received antiplatelet therapy, with estimates ranging from 7% to 38%. Conclusion There is lack of high-quality data on the effects of antiplatelet therapy on menstrual bleeding. Aspirin may increase menstrual blood loss, at least in a minority of women, whereas the effects of P2Y12 inhibitors are unknown.
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Affiliation(s)
- Eva K. Kempers
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Johanna A. van der Zande
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Obstetrics and Gynecology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Paula M. Janssen
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jérôme M.J. Cornette
- Department of Obstetrics and Gynecology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Marieke J.H.A. Kruip
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
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Shapiro M, Hamulyák EN, Leader A, Landau R, Middeldorp S, Gurevich-Shapiro A. Venous thromboembolism among physically active young adult females. Res Pract Thromb Haemost 2023; 7:102236. [PMID: 38193067 PMCID: PMC10772887 DOI: 10.1016/j.rpth.2023.102236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 10/06/2023] [Accepted: 10/10/2023] [Indexed: 01/10/2024] Open
Abstract
Background Young adult females are at risk of venous thromboembolism (VTE) due to various acquired and transient factors. In recent years, a growing number of females have engaged in strenuous physical activity, but its role as a risk factor for VTE is uncertain. Objectives To determine the incidence of VTE in young adult females engaged in strenuous physical activity. Methods A large national cohort of female individuals enlisted in the Israeli Defense Forces between 2012 and 2019 was analyzed. The study group consisted of participants undergoing strenuous physical training during their military service, while the control group maintained regular activity levels. We compared the incidence of VTE between the groups and adjusted for potential risk factors using a multivariate Cox analysis. Results The cohort included 160,718 female individuals aged 18 to 21years, of whom 11,745 engaged in strenuous physical activity and 148,973 served as controls. During a mean follow-up of 1.7 years, VTE occurred in 5 individuals (0.04%) in the strenuous activity group and 47 individuals (0.03%) in the control group. The incidence per 10,000 person-years was 2.41 (95% CI, 0.78-5.62) for the strenuous activity group and 1.82 (95% CI, 1.34-2.42) for the controls. Strenuous activity did not increase the risk for VTE in univariate or multivariate regression, with a hazard ratio (HR) of 1.27 (95% CI, 0.49-4.22). Use of oral contraceptives was the only significant risk factor, demonstrating dose effect; HR 1.95 (95% CI, 1.06-3.57) for low dose and HR 3.62 (95% CI, 1.40-9.37) for medium estrogen dose contraceptives. Conclusion Strenuous physical activity did not increase the risk for VTE among a large cohort of young adult female individuals.
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Affiliation(s)
- Michael Shapiro
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Internal Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Eva N. Hamulyák
- Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Avi Leader
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Regev Landau
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Endocrine Department, Shamir Medical Center, Be'er Ya'akov, Israel
- Medical Corps, Israel Defense Forces, Tzrifin, Israel
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anna Gurevich-Shapiro
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Department of Systems Immunology, Weizmann Institute of Science, Rehovot, Israel
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