Management of Heavy Menstrual Bleeding on Anticoagulation

Heavy menstrual bleeding (HMB) is a well-known adverse effect of anticoagulant therapy. As women do not necessarily spontaneously report their menstrual bleeding patterns and physicians may not inquire about them, HMB may be missed during clinic visits, and potentially useful treatment options may therefore not be considered, discussed, and implemented.

In this context, the current publication by Dr. Kochawan Boonyawat and colleagues, while not presenting any original data, is a welcome summary of the present knowledge of anticoagulant-associated HMB. It should heighten awareness of the impact of anticoagulants on menstrual bleeding and existing treatment options, and supplement a previously published systematic review and expert panel opinion publication on the same topic.¹ 

Dr. Boonyawat and colleagues cover key points with respect to definition and etiology of HMB: 1) The term menorrhagia has been discarded and replaced with heavy menstrual bleeding (HMB); 2) in a clinically meaningful way, HMB is defined as menstrual blood loss that interferes with a woman’s physical, social, emotional, and/or material quality of life; 3) HMB associated with anticoagulant use is common; 4) vitamin K antagonists significantly increase the duration of menstruation, flooding, passage of clots, and intermenstrual bleeding; 5) HMB seems to be more common with direct factor X inhibitors than with warfarin, but may be less common with dabigatran compared with warfarin; 6) although direct oral anticoagulants (DOACs) have not been directly compared with one another in clinical trials, prospective real-world data (of mostly rivaroxaban-treated patients) have suggested that HMB may be comparable for all factor Xa inhibitors.²  7) and based on an abstract-only publication, the lower dose of rivaroxaban (10 mg once daily, as used in the EINSTEIN CHOICE trial, compared with 20 mg once daily) leads to less menstrual flow length and intensity.³  Importantly, the authors summarize multiple options for treatment of HMB (Table). Progestin intrauterine devices (IUDs) can be used safely, and combined estrogen-progestin contraceptives are treatment options as long as reliable and full-dose anticoagulation is given. The effect of the anticoagulant is sufficient to overcome the incremental prothrombotic risk associated with the hormonal contraceptives. In some cases, a switch to a different anticoagulant can be considered or a reduced-dosed DOAC can be used (apixaban 2.5 mg twice daily or rivaroxaban 10 mg once daily) once the full-dose treatment period of three to six months for venous thromboembolism (VTE) has been completed. Finally, tranexamic acid can be considered.