EXCLUSIVE: Menopause and Thrombosis: 5 things you should know according to an expert

What is HRT?
During menopause, the ovaries gradually stop producing the hormones that regulate the reproductive cycle: oestrogen, progesterone and testosterone. Most menopausal symptoms are caused by low oestrogen, which forms the main part of hormone replacement therapy (HRT). In women who have not had a hysterectomy (surgery to remove the womb), progesterone is given to keep the womb lining healthy. Sometimes, testosterone is also needed.

What is thrombosis?
The term ‘thrombosis’ describes clots in blood vessels. Clots can form in the deep veins of the legs (‘deep vein thrombosis or ‘DVT). If part of the clot breaks off and travels to the lung, this is called ‘pulmonary embolism’ or PE. The ‘umbrella’ term for DVT and PE is ‘venous thromboembolism’ or VTE.  Thrombosis relating to HRT tends to be VTE.

Does HRT increase the risk of thrombosis?
Women have a small background risk of having VTE: about 1 in 10,000. This risk increases with age, obesity, smoking, being admitted to hospital, and HRT use increases the risk of VTE approximately 2-fold. The risk is restricted to ‘older’ HRT preparations with oral estrogen and older artificial progestogen. When taken as a tablet, the way estrogen is handled by the body makes the blood more ‘sticky’ which does not seem to happen when oestrogen is given transdermally i.e. through the skin (as a patch, gel or spray) in combination with micronized progesterone (Utrogestan).

What are the treatment options?
Treatments for menopause should be individualised and can include lifestyle and dietary changes, complementary therapies, and HRT. For most women, the benefits of HRT outweigh the risks. In addition to relieving menopausal symptoms, HRT can help prevent osteoporosis and heart disease. The safest choice of HRT is a transdermal estrogen, plus micronized progesterone (where needed).

Is HRT safe in women with an increased risk of thrombosis?
Transdermal oestrogen (plus micronised progesterone) appears to be safe in most women, including those with an increased risk of thrombosis. Laboratory studies (that have examined how ‘sticky’ the blood gets after taking HRT) and population studies (looking at the number of cases of VTE that occur in women taking HRT) are reassuring in showing that this combination does not increase the thrombosis risk over the background risk. Specialist advice should be sought for specific concerns.

About the author: Roopen Arya, India Spokesperson World Thrombosis Day, Prof. Of Thrombosis & Haemostasis, King's College Hospital, London.

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