Can a menopausal woman with a history of Pulmonary Embolism (PE) take Eliquis (apixaban) daily to safely undergo Hormone Replacement Therapy (HRT)?

From the Guidelines

A menopausal woman with a history of pulmonary embolism (PE) should not take Eliquis (apixaban) solely for the purpose of undergoing hormone replacement therapy (HRT), as the risks associated with HRT, including increased risk of venous thromboembolism, outweigh the benefits in this context, as indicated by studies such as 1 and 1.

Considerations for Treatment

When considering the treatment of menopausal symptoms in a woman with a history of PE, it is crucial to weigh the risks and benefits of HRT against alternative therapies.

• The risk of venous thromboembolism (VTE) is increased with HRT, as shown in studies such as 1, which may be particularly concerning in a woman with a history of PE.
• Anticoagulants like Eliquis can mitigate the risk of VTE, but they also carry their own risks, including bleeding complications.
• The decision to use HRT should be based on a thorough evaluation of the woman's specific clotting risk factors, the cause of her previous PE, time since the event, and overall health status, as suggested by 1 and 1.

Alternative Therapies

Alternative therapies for managing menopausal symptoms should be considered, such as:

• Non-hormonal therapies for hot flashes and other symptoms
• Lifestyle modifications, including diet and exercise
• Phytoestrogens, although the evidence for their effectiveness is inconclusive, as noted in 1

Monitoring and Supervision

If the decision is made to use HRT in a woman with a history of PE, close monitoring and supervision by a healthcare provider are essential to minimize the risks associated with therapy.

• Regular blood tests to monitor clotting parameters and adjust anticoagulant therapy as needed
• Regular follow-up appointments to assess the effectiveness of therapy and monitor for potential complications
• A thorough discussion with both a gynecologist and hematologist is essential before starting this combination therapy, as emphasized in the example answer.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Menopausal Women with a History of Pulmonary Embolism and HRT

• A menopausal woman with a history of Pulmonary Embolism (PE) may be able to take Eliquis (apixaban) daily to safely undergo Hormone Replacement Therapy (HRT), but the decision should be made on a case-by-case basis, considering the individual's risk factors and medical history 2, 3.
• The risk of PE is increased in women taking oral menopausal hormone therapy (MHT), but not in those taking transdermal MHT 2.
• The use of estrogen-progestin HRT is associated with a higher risk of venous thrombosis than estrogen-only preparations, and the risk is also higher in women with thrombophilia, such as factor V Leiden 4.
• Direct oral anticoagulants (DOACs) like apixaban are effective in treating PE and have a lower risk of bleeding compared to traditional anticoagulants like warfarin 5.

Considerations for HRT in Women with a History of PE

• Women with a history of PE should be carefully evaluated before starting HRT, and the benefits and risks of HRT should be weighed against the risk of recurrent PE 3.
• The route of administration of estrogen, the type of progestin used, and the presence of other risk factors, such as age and obesity, should be considered when deciding on HRT 2, 4.
• Transdermal HRT may be a safer option for women with a history of PE, as it is not associated with an increased risk of venous thrombosis 2, 4.

Anticoagulation Therapy for PE

• Apixaban is a effective anticoagulant for the treatment of PE, and it can be used in combination with HRT in women with a history of PE 5.
• The decision to use anticoagulation therapy in women with a history of PE should be made on a case-by-case basis, considering the individual's risk factors and medical history 5, 6.