From the Guidelines
Women with a history of pulmonary embolism should not take hormone replacement therapy (HRT) due to the increased risk of recurrent blood clots, as HRT significantly increases the risk of venous thromboembolism, including pulmonary embolism, as demonstrated by studies such as 1 and 1.
Key Considerations
- The risk of venous thromboembolism is highest in the first year of HRT treatment and in women with previous clotting disorders, as noted in 1.
- Estrogen in HRT promotes blood clot formation by increasing coagulation factors and reducing natural anticoagulants in the body, as discussed in 1.
- Non-hormonal alternatives should be considered for menopausal symptom management, such as:
- Selective serotonin reuptake inhibitors (SSRIs) like paroxetine or escitalopram for hot flashes
- Vaginal moisturizers or lubricants for vaginal dryness
- Lifestyle modifications including regular exercise and avoiding triggers like alcohol and spicy foods
Special Cases
- In rare cases where HRT benefits might outweigh risks, consultation with both a hematologist and gynecologist is essential, and anticoagulation therapy might be required concurrently, as suggested in 1.
- HRT is contraindicated in survivors with a history of hormonally mediated cancers, abnormal vaginal bleeding, active or recent history of thromboembolic event, pregnancy, and active liver disease, as stated in 1.
Evidence-Based Recommendations
- The most recent and highest quality study, 1, provides evidence that HRT can be used in appropriate female cancer survivors, but alternatives to HRT should typically be tried first, and patients should be referred to an appropriate specialist for dosing and management of HRT.
- Estrogen transdermal formulations may be preferred over other formulations due to lower rates of venous thromboembolism and stroke, as noted in 1.
From the Research
Hormone Replacement Therapy (HRT) and Pulmonary Embolism
- A woman who had a pulmonary embolism can consider HRT, but the risk of another pulmonary embolism should be taken into account 2, 3, 4, 5, 6.
- The risk of pulmonary embolism is higher with oral HRT than with transdermal HRT 2, 3, 5, 6.
- Transdermal HRT may be a safer option for women with a history of pulmonary embolism, as it does not increase the risk of venous thromboembolism 2, 3, 4.
- The risk of pulmonary embolism is also influenced by the type of progestin used in combination with estrogen, with some progestins potentially increasing the risk more than others 2, 3.
- Women with a history of thrombosis or thrombophilia should be carefully assessed before starting HRT, and the benefits and risks should be individualized 4, 5, 6.
Factors Influencing the Risk of Pulmonary Embolism with HRT
- The risk of pulmonary embolism is highest in the first year of HRT use 3, 5, 6.
- Increasing age and weight can further increase the risk of pulmonary embolism with HRT 3, 5, 6.
- The presence of thrombophilia, such as factor V Leiden, can significantly increase the risk of pulmonary embolism with HRT 5, 6.
- The type of estrogen and progestin used, as well as the dose and duration of HRT, can also influence the risk of pulmonary embolism 2, 3, 5, 6.