What are the recommendations for progesterone (Progesterone) use in patients with a history of Spontaneous Coronary Artery Dissection (SCAD)?

Progesterone Use in SCAD Patients

Systemic progesterone therapy (oral or transdermal) should generally be avoided in patients with a history of spontaneous coronary artery dissection (SCAD), and if a patient experiences SCAD while on hormone therapy containing progesterone, it should be discontinued unless there are compelling reasons to continue. 1

General Approach to Hormonal Therapy After SCAD

Avoidance is the default strategy:

• Exogenous exposure to systemically absorbed hormones, including progesterone for contraceptive and postmenopausal therapy, is usually avoided if possible 1
• Nonhormonal options should be considered first, and progesterone-containing therapy should only be used if nonhormonal options have been exhausted and benefits clearly outweigh potential risks 1

If SCAD occurs while on hormone therapy:

• Indications for hormone therapy must be reassessed immediately 1
• Unless there are compelling reasons to continue, hormone therapy should be discontinued 1

Acceptable Uses of Progesterone in SCAD Patients

Intrauterine Progestin Delivery (Preferred Method)

Levonorgestrel-releasing intrauterine devices are the preferred progesterone-containing option:

• Intrauterine devices with local delivery of progestin (levonorgestrel 20 μg/day) are acceptable for contraception 1
• These devices result in minimal systemic progesterone absorption, with the main effect at the endometrial level 1
• The levonorgestrel 20 μg/day device is highly effective for managing heavy menstrual bleeding (71-95% reduction in blood loss), which is common in SCAD patients on antiplatelet therapy 1
• A lower-dose device (levonorgestrel 14 μg/day) may offer advantages due to even lower hormonal absorption, though efficacy data for abnormal uterine bleeding is limited 1

Systemic Progesterone (Use with Extreme Caution)

Cyclic oral progestin may be considered in specific circumstances:

• Although there are theoretical safety concerns, cyclic oral progestin treatment can reduce bleeding by 87% in patients with heavy menstrual bleeding 1
• This should only be considered when intrauterine devices are not feasible and bleeding is significantly impacting quality of life 1

High-dose progestin for acute bleeding:

• In hemodynamically unstable women with uncontrolled bleeding, high-dose oral or injectable progestin-only medications may be considered for short-term use only 1

Postmenopausal Hormone Therapy Considerations

Initiation of progesterone-containing HT requires strict criteria:

• Acceptable indications include premature or early surgical menopause, severe vasomotor symptoms unmanageable with lifestyle or nonhormonal treatments, and local treatment of genitourinary syndrome of menopause 1
• Decisions must be made in collaboration with both cardiovascular and menopause specialists 1
• Use the lowest effective dose consistent with treatment goals 1
• Transdermal systemic agents are preferred over oral formulations to minimize activation of thrombotic factors 1
• Indications, benefits, and risks must be reviewed periodically 1

Locally applied vaginal estrogen is generally safe:

• Vaginal estrogen for genitourinary symptoms is considered safe due to minimal systemic absorption 1

Alternative Contraceptive Methods (Preferred Over Systemic Progesterone)

Nonhormonal contraception should be prioritized:

• Vasectomy for male partners is a preferred option 1
• Tubal ligation (preferably performed after dual-antiplatelet therapy has been stopped) 1
• Copper-containing intrauterine devices may be used but can worsen cramping and menorrhagia, particularly in women on aspirin or dual-antiplatelet therapy 1

Management of Heavy Menstrual Bleeding Without Systemic Hormones

Surgical options may be preferable to systemic progesterone:

• Second-generation endometrial ablation techniques (thermal balloon, microwave, radiofrequency) have greater long-term efficacy than oral medical treatment 1
• These procedures are effective for managing bleeding, reduce pregnancy risk, and avoid exogenous hormone exposure 1

Avoid certain nonhormonal medications:

• Nonsteroidal anti-inflammatory drugs and tranexamic acid should generally be avoided in SCAD patients due to their association with myocardial infarction and thrombosis 1

Key Clinical Pitfalls

• Do not assume postmenopausal hormone therapy formulations are safe simply because they contain lower hormone levels than contraceptives—the uncertain effects on SCAD incidence and recurrence remain a concern 1
• Do not overlook the option of levonorgestrel-releasing IUDs for both contraception and management of heavy menstrual bleeding—this is the most acceptable progesterone-containing option 1
• Remember to reassess the indication for ongoing antiplatelet therapy in patients with heavy menstrual bleeding, as discontinuation may resolve the bleeding without need for hormonal intervention 1