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Management of Women on Hormonal Therapy or Contraception in Women Undergoing Surgery

9/1/2015 - Amanda Murchison, MD

Editor: Martin E. Olsen, MD

Hormone therapy and use of combination hormonal contraceptives are associated with an increased risk of venous thromboembolism. Menopausal women taking estrogen plus progesterone therapy are twice as likely to experience a venous thromboembolic event compared to women not on hormone therapy. Women on combination hormonal contraceptives are four times more likely than nonusers to develop venous thromboembolism.

Venous thromboembolism and pulmonary embolism are serious complications of surgery causing significant morbidity and mortality. To date, no studies exist that show preoperative discontinuation of menopausal hormone therapy reduces venous thromboembolism, so this should not be routine practice. Some studies show a small increase in postoperative venous thromboembolism in reproductive aged combination oral contraceptive users. It is not necessary to discontinue combination hormonal contraceptives prior to brief surgeries, including minor laparoscopic procedures such as tubal sterilization, as they are associated with a low venous thromboembolism risk. When women of reproductive age undergo major surgical procedures, the risk of stopping a combined hormonal contraceptive to decrease the venous thromboembolism risk will need to be weighed against the risk of unintended pregnancy. It takes six weeks or more for procoagulant changes associated with combination hormonal contraceptives to return to baseline after their discontinuation. For women on combination hormonal contraceptives undergoing major surgery, perioperative venous thromboembolism prophylaxis with mechanical and/or pharmacologic methods should be based on procedure type and duration, age of the patient, and venous thromboembolism risk factors. Heparin prophylaxis should be considered.

Further Reading:

Prevention of deep vein thrombosis and pulmonary embolism. ACOG Practice Bulletin No. 84. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:429-40. PMID: 27892904 DOI: 10.1097/AOG.0000000000001229

Clark-Pearson D, Abaid L. Prevention of venous thromboembolic events after gynecologic surgery. Obstet Gynecol. 2012 Jan;119(1):155-67. doi: 10.1097/AOG.0b013e31823d389e.

Initial approval September 2015. Reaffirmed 9/2016. Revised March 2018.

 

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