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Hormones and thrombosis: risk across the reproductive years and beyond

Nicoletta Machin 1Margaret V Ragni 2

Transl Res. 2020 Nov;225:9-19.doi: 10.1016/j.trsl.2020.06.011. .

Abstract

Endogenous and exogenous hormones have significant effects on coagulation and may tip the hemostatic balance toward thrombosis. The endogenous hormonal changes in pregnancy and polycystic ovary syndrome, and exogenous hormonal contraception, menopause replacement, and transgender cross-hormone replacement may increase thromboembolism risk. Using the lowest effective dose is critical for prevention, but once thrombosis occurs, anticoagulation may be required, in some, long term. We review the relative risk of thrombosis in these conditions, risk factors, and anticoagulation treatment and prevention. Implementation of lowest effective hormonal therapies, thrombosis reduction strategies, and current anticoagulation management are critical for optimal patient outcomes.

Conclusion: With their range of clinical applications, estrogen-, progestin-, and testosterone-based therapies will continue to have a prominent role for women and men across the reproductive spectrum and beyond. The thrombosis risk associated with these hormonal therapies has been better defined, allowing for more clear risk-benefit conversations with patients considering treatment. As each formulation and method of delivery carry varying degrees of risk, clinicians are faced with a myriad of treatment choices, which will require ongoing research to ensure that VTE risk is clearly defined as new generations of hormonal therapies come to market. Finally, it will be important to determine whether thrombophilia screening at the initiation of exogenous hormone therapy is cost effective, as has been shown in relatives of factor V Leiden carriers initiating oral contraceptives.