What is the management approach for a patient experiencing menorrhagia with thrombi, treated with Provera (medroxyprogesterone), and having a history of hypertension with a previous embolic event?

From the Guidelines

For a patient with excessive vaginal bleeding with blood clots, hypertension, and a history of embolism, the most critical consideration is to avoid treatments that may increase the risk of thrombosis, and thus, alternative treatments to hormonal therapies like Provera should be prioritized. Given the patient's history of embolism, it is crucial to consider the potential risks associated with hormonal treatments, such as Provera (medroxyprogesterone acetate), which may increase the risk of thrombosis 1.

Treatment Options

• Alternative treatments include tranexamic acid (1000mg three times daily during bleeding) which works by stabilizing blood clots,
• Non-hormonal anti-inflammatory medications like ibuprofen (400mg every 6 hours) which reduce prostaglandin production and decrease bleeding. The underlying cause of bleeding must be determined through evaluation including:
• Blood tests
• Ultrasound
• Possibly endometrial biopsy Severe bleeding may require emergency intervention including:
• IV fluids
• Blood transfusion
• Surgical options like endometrial ablation or hysterectomy in certain cases.

Considerations

The combination of hypertension and previous embolism significantly impacts treatment decisions, as some hormonal treatments may worsen these conditions 1. Regular monitoring of blood pressure and vigilance for signs of thrombosis (leg pain, swelling, chest pain, shortness of breath) is crucial during treatment. The patient's history of hypertension and embolism necessitates careful consideration of the potential risks and benefits of any treatment, and a thorough evaluation to determine the underlying cause of the bleeding is essential. In terms of contraception, given the patient's history of hypertension and embolism, it is recommended to avoid combined hormonal contraceptive pills and transdermal patches due to the increased risk of thromboembolism 1. Instead, alternative contraceptive methods such as intrauterine devices, subdermal implants, or barrier methods may be considered. Ultimately, the treatment plan should be individualized to the patient's specific needs and medical history, and regular follow-up with a healthcare provider is necessary to monitor the patient's condition and adjust the treatment plan as needed.

From the FDA Drug Label

CONTRAINDICATIONS Active thrombophlebitis, or current or past history of thromboembolic disorders, or cerebral vascular disease The patient has a history of hypertension with embolism, which is a type of thromboembolic disorder.

• The FDA drug label for medroxyprogesterone acetate (PO), also known as Provera, lists a contraindication for patients with a current or past history of thromboembolic disorders 2. The use of Provera is contraindicated in this patient due to the history of embolism.

From the Research

Excessive Vaginal Bleeding with Blood Clots and Treatments with Provera

• Excessive vaginal bleeding with blood clots can be a symptom of various conditions, and treatment with Provera (medroxyprogesterone acetate) may be prescribed to manage this symptom 3.
• However, it is essential to consider the patient's history of hypertension and embolism, as hormone replacement therapy (HRT) with conjugated estrogen plus medroxyprogesterone acetate may not impair blood flow through microchannels in hypertensive postmenopausal women, but warrants caution against the occurrence of thromboembolic events 3.

History of Hypertension with Embolism

• Hypertension is a prothrombotic condition, and the use of oral estrogens, such as those found in HRT, can further increase the risk of venous thromboembolism (VTE) 4, 5.
• The combination of oral estrogen use and either obesity or thrombogenic mutations can enhance the VTE risk, whereas transdermal estrogens may not confer additional risk in women at high VTE risk 4.
• Medroxyprogesterone acetate, the progestogen used in Provera, has been shown to have a deleterious effect on VTE risk, and its use may increase the risk of thromboembolic events in women with a history of hypertension and embolism 5, 6.

Management and Prevention

• Regular exercise, such as brisk walking, can help reduce blood pressure and decrease the risk of cardiovascular disease, including hypertension and embolism 7.
• When contemplating hormonal contraception or HRT, clinicians must consider a variety of factors, including hormone type, dose, route, personal and family history of thrombosis, and other prothrombotic risk factors to make informed, personalized decisions regarding the risk of venous thrombosis 6.