No, Xulane (ethinyl estradiol/norelgestromin transdermal patch) should NOT be resumed in this patient with a history of DVTs currently on Xarelto post-TKA.
Primary Contraindication
Combined hormonal contraceptives containing estrogen are absolutely contraindicated in patients with a history of venous thromboembolism. The presence of prior DVTs represents an unacceptable thrombotic risk that is significantly amplified by estrogen-containing contraceptives, regardless of concurrent anticoagulation 1, 2.
Evidence Supporting This Recommendation
Thrombotic Risk with Estrogen-Containing Contraceptives
- Ethinyl estradiol-containing contraceptives, including the transdermal patch formulation (Xulane), carry inherent VTE risk with incidence rates of approximately 41-53 per 100,000 women-years in otherwise healthy users 2, 3
- This baseline risk becomes unacceptably elevated in patients with prior VTE history, as these patients already demonstrate a prothrombotic phenotype 1
- The transdermal patch delivers systemic estrogen exposure that impairs fibrinolysis and increases thrombotic potential 1
Anticoagulation Does Not Eliminate Risk
- While rivaroxaban provides effective VTE prophylaxis post-TKA and treatment for existing DVT 4, 5, concurrent anticoagulation does not negate the prothrombotic effects of exogenous estrogen 1
- The 2021 CHEST guidelines recommend rivaroxaban as appropriate treatment-phase anticoagulation for VTE, but this does not address the additional thrombotic stimulus from hormonal contraception 4
- Patients with breakthrough thrombosis despite therapeutic anticoagulation represent very high recurrence risk and require indefinite anticoagulation 6
Post-Surgical Context
- Following TKA, patients face elevated VTE risk during the initial 3-month period, which is precisely when rivaroxaban thromboprophylaxis is most critical 4
- Adding estrogen-containing contraception during this vulnerable period compounds an already elevated thrombotic risk 4, 7
- The perioperative management guidelines emphasize minimizing thrombotic risk factors during the post-surgical period 4
Clinical Pitfalls to Avoid
- Do not assume that therapeutic anticoagulation provides adequate protection against estrogen-induced thrombosis - these are independent and potentially synergistic thrombotic mechanisms 1
- Do not restart estrogen-containing contraceptives even after completing the initial 3-month post-TKA anticoagulation course - the patient's history of DVTs represents a permanent contraindication 4
- Recognize that the patient's need for ongoing anticoagulation (whether for DVT history or post-TKA prophylaxis) does not modify the contraindication to estrogen-containing contraceptives 4, 1
Alternative Contraceptive Options
Recommend progestin-only contraceptive methods that do not carry the same VTE risk as combined hormonal contraceptives:
- Progestin-only pills, implants, or intrauterine devices are safer alternatives in patients with VTE history 1
- These methods do not contain ethinyl estradiol and therefore lack the prothrombotic effects of combined hormonal contraceptives 1
Duration of Anticoagulation Considerations
- For unprovoked DVT or recurrent VTE, indefinite anticoagulation is recommended over stopping after 3 months 4
- This patient's DVT history may warrant extended or indefinite anticoagulation beyond the post-TKA period, particularly if the prior DVTs were unprovoked 4
- Annual reassessment of bleeding risk versus thrombotic risk should guide continuation of anticoagulation 4