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9/1/2015

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

Author: Amanda Murchison, MD

Editor: Regan Theiler, MD, Maureen Farrell, MD

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Hormone therapy and use of combination hormonal contraceptives are associated with an increased risk of venous thromboembolism. Menopausal women taking oral estrogen plus progesterone therapy are twice as likely to experience a venous thromboembolic event compared to women not on hormone therapy. 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 oral combination hormonal contraceptive users.  This risk is directly related to the estrogen dose in the pill and is four times higher than for nonusers. Patients using progesterone only contraception do not have a higher risk of venous thromboembolism.

It is not necessary to discontinue combination hormonal contraceptives prior to brief surgeries, including minor laparoscopic procedures, as they are associated with a low venous thromboembolism risk. When women of reproductive age undergo major surgical procedures, the risk of stopping an oral combination hormonal contraceptive to decrease the venous thromboembolism risk will need to be weighed against the risk of unintended pregnancy. It takes four to six weeks for procoagulant changes associated with oral combination hormonal contraceptives to return to baseline after their discontinuation. For women on oral combination hormonal contraceptives undergoing major surgery, perioperative venous thromboembolism prophylaxis with mechanical or (rarely and) pharmacologic methods should be based on procedure type and duration, age of the patient, and venous thromboembolism risk factors.

Further Reading:

American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 84: Prevention of deep vein thrombosis and pulmonary embolism. Obstet Gynecol. 2016 Jan;127(1):166. Reaffirmed 2018

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; Revised March 2018; Reaffirmed May 2019; Revised May 2021

 

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