May 17, 2011 Elsevier announced the publication of an important position statement from the European Menopause and Andropause Society (EMAS) in the journal Maturitas on managing menopausal women with a personal or family history of venous thromboembolism (VTE). The statement includes summary recommendations as a quick aid for the busy clinician.
"The expanding aging female population means that clinicians increasingly have to deal with post-reproductive health problems," said Professor Serge Rozenberg, President of EMAS. "EMAS has risen to the challenge and is providing clear guidance on the position statements covering hormone and non hormone therapy (HT) options, as well as complementary and alternative therapies."
Venous thromboembolism, including deep venous thrombosis (DVT) and pulmonary embolism (PE), is a serious cardiovascular event whose incidence rises with increasing age. Randomized controlled trials have shown an increased risk of VTE in oral hormone therapy (HT) users. There are no randomized trial data on the effect of transdermal estrogen on VTE. Recent observational studies and meta-analyses suggest that transdermal estrogen does not increase VTE risk. These clinical observations are supported by experimental data showing that transdermal estrogen has a minimal effect on hepatic metabolism of hemostatic proteins as the portal circulation is bypassed.
A personal or family history of VTE, especially in individuals with a prothrombotic mutation, is a strong contraindication to oral HT but transdermal estrogen can be considered after careful individual evaluation of the benefits and risks. Transdermal estrogen should be also the first choice in overweight/obese women requiring HT. Observational studies suggest that micronized progesterone and dydrogesterone might have a better risk profile than other progestins with regard to VTE risk.
Although these findings should be confirmed by randomized clinical trials, they strongly suggest that both the route of estrogen administration and the type of progestin may be important determinants of the overall benefit-risk profile of HT.
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- Florence Tremollieres, Marc Brincat, C. Tamer Erel, Marco Gambacciani, Irene Lambrinoudaki, Mette H. Moen, Karin Schenck-Gustafsson, Svetlana Vujovic, Serge Rozenberg, Margaret Rees. EMAS position statement: Managing menopausal women with a personal or family history of VTE. Maturitas, 2011; DOI: 10.1016/j.maturitas.2011.03.011
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