Menstrual Abnormalities and Gynaecological Problems in Women on Anticoagulant and Antiplatelet Therapy: Management Options

Introduction: The aim of this study was: 1) To study the pattern of menstrual abnormality and severity in women on anticoagulant and antiplatelet drugs. 2) To analyze the correlation of prothrombin time (PT), International Normalised ratio (INR) and the bleeding severity. 3) To discuss the various management options in unexpected emergencies and menstrual complications in this subset of women on anticoagulants. Material & Methods: It is a prospective study, over a period of 18 months from July 2011 to december 2012. We had 44 women on antithrombotic therapy. 32 women were on anticoagulants and 12 were on antiplatelet agents. The severity of bleeding pattern was assessed with pictoral bleeding assessment chart (PBAC). 1) Out of 44 women studied, 32 women were on anticoagulants and 12 were on antiplatelet agents. 26 (81.25%) were on acenocoumarol, 5 (15.62%) on warfarin, 1 (3.12%) on heparin, among the 12 antiplatelet users, 8 (66.66%) were on aspirin and 4 (33.33%) on clopidogrel. 2) The indication for anticoagulants was mitral valve replacement (MVR) in 9, double valve replacement (DVR) in 6, aortic valve replacement (AVR) in 3, severe pulmonary artery hypertension (PAH) in 2, severe mitral stenosis (MS) with atrial thrombus in 2, deep vein thrombosis (DVT) in 5, severe mitral regurgitation (MR) in one, the other indications were subdural hematoma, thromboendarterectomy, chronic kidney disease (CKD) stage V, coarction of aorta, one each. The indication for antiplatelet therapy was percutaneous transluminal coronary angioplasty (PTCA) in 3, Wolf Parkinson White (WPW) syndrome + atrial fibrillation (AF), acute myocardial infarction (AMI), coronary artery bypass graft (CABG), mid basilar artery aneurysm, renal allograft recipient, dialated cardiomyopathy, aortic aneurysm repair, hypertension and unstable angina one each. Results: In women on anticoagulants (32), the main complaint was menorrhagia/heavy menstrual bleeding (HMB) in 20, polymenorrhoea with menorrhagia in 4, continuous per vaginal (PV) bleeding in 6. One lady had postmenopausal bleeding. Among the 12 antiplatelet users the main complaint was menorrhagia in 8, polymenorrhoea with menorrhagia in 2, postmenopausal bleeding in one. While on antithrombotic therapy apart from heavy menstrual bleeding, two women had intraperitoneal bleeding, two had post menopausal bleeding, two had secondary postpartum bleeding (PPH). CVA due to embolic stroke occurred in three, one during the study period. Subchoroidal haemorrhage causing choroidal detachment was noted in one. Conclusions: In patients with prolonged INR, excessive uterine bleeding can be an alerting initial manifestation. Antithrombotic therapy can cause HMB or exaggerate the symptom of HMB due to an underlying gynaec pathology. Mefanamic acid and norethisterone were used to arrest heavy menstrual bleeding. Antithrombotic therapy in women needs special consideration with alterations in menstrual pattern and contraception. Pregnancy and postpartum period present special challenges.

Uterine Fibromyoma and Intravascular Thrombosis—Eight Cases

Objectives: We present eight cases of vascular thrombosis of the pelvic vessels and deep venous thrombosis (DVT) of the lower limb, secondary to compression of the pelvic vessels by the uterine fibroid, managed over a span of twelve years from 2001 to 2013. We discuss the mean size of the leiomyoma, the prediliction for DVT of the left lower limb, the role of oral contraceptives when used in women with large fibroids, to increase the risk of DVT and present a brief literature review.?Results:?Age,?the mean age of our patients was—41.12 yrs, range—18 yrs to 50 yrs.?Parity and Menopausal Status: Seven were parous women. One was unmarried, nulligravid.?Seven were premenopausal and one was postmenopausal.?Vascular Thrombosis:?In one it was arterial thrombosis and in seven it was venous thrombosis.?DVT was on the left side in -6/8?-?75%. Clinical Complaints:?The presenting complaints were heavy menstrual bleeding in three,?severe dysmenorrhoea and heavy bleeding in one,?mass per abdomen in one, heavy menses and abdominal mass in one, no complaints apart from DVT in one.?Uterine Enlargement:?The size of the uterus was between 12 to 26 weeks. The mean size was 20 weeks.?It was a single fibromyoma in six and multiple, two in two.?Use of Oral Contraceptives:?OC pills were used to control heavy menstrual bleeding in three cases—3/8, 37.5%.?Discussion:?The DVT was on the left side in six of our cases,?75% were on the left side in our series. Menstrual problems like heavy bleeding can be secondary to fibromyoma. Three of the eight—37.5%,?women used OC pills to control menorrhagia. One developed DVT after one cycle of use of OC pills;?the second developed arterial thrombosis of the pelvic vessels after four cycles of OC pill use;?the third used OC pills for a longer period, on and off. The woman who developed arterial thrombosis was using OC pills with 50 mcgs of oestrogen and 0.5 mg norgestrel. Conclusions: Uterine leiomyoma can cause vascular thrombosis secondary to compression of the pelvic vessels. The mean size of the uterine enlargement by the fibromyoma was 20 weeks and in 6/8, it was a solitary fibromyoma. DVT was on the left side in 75% of our cases. Use of OC pills in women with an enlarged uterus with leiomyoma can increase the risk of DVT.