Ask an Expert: Q&A – November 2022

Question 1

I am seeing a 47-year-old perimenopausal woman who developed a pulmonary embolism (PE) within four weeks of COVID-19 infection and then a long-haul flight (Darwin to London). She is still anticoagulated and otherwise well.

She has significant menopausal symptoms that were well controlled on Slinda prior to the PE, ceased when PE developed. Would like to resume MHT but frightened.

Please advise of risks of recurrent VTE if resuming MHT – oral vs transdermal progesterone only.

Answer

From Jean Hailes endocrinologist Dr Sonia Davison

I am assuming this patient has had a negative thrombophilia screen and that there is evidence that the pulmonary embolus has resolved and there is no residual clot evident.

It’s interesting that her menopausal symptoms were controlled on Slinda; this is a progestogen only contraceptive product that is not intended as a menopausal hormone therapy, and it would be unusual that this medication on its own would be useful for menopausal symptom control.

With that in mind I suspect her symptoms could be controlled via other measures. My tendency would be to pursue non-hormonal medications for symptom control.

Here is a podcast on this topic from our website and an excellent information sheet from the Australasian Menopause Society website.

The medication options include any of an SNRI, an SSRI, gabapentin or clonidine. Cognitive behavioural therapy or hypnotherapy may also be useful. If she remains anticoagulated and if her haematologist is happy with the plan, she could possibly have a trial of transdermal combined oestradiol/ norethisterone acetate patch. However bleeding may be an issue, given she is anticoagulated.

Question 2

I am a GP with a 51-year-old patient with menopausal symptoms. She is currently trialling non-hormonal therapy for her symptoms and seeing how that goes.

She has a history of antiphospholipid antibodies detected during investigation for subfertility (never had a blood clot) and no other cardiovascular risks.

I'm getting different opinions about safety of transdermal hormonal therapy for this patient. Do you have any advice with clear evidence?

Answer

From Jean Hailes endocrinologist Dr Sonia Davison

The evidence shows that there is no increase in venous clot risk associated with transdermal hormone therapy, and amongst progestogens, the VTE risk associated with micronized progesterone is low. Hence if hormone therapy is being considered for bothersome menopausal symptoms, a transdermal approach would be recommended.

My advice would be for this woman to consult a haematologist for general advice about the general VTE risks associated with having antiphospholipid antibodies, and particularly in regard to menopausal hormone therapy use.

Non-hormonal medications (see question above), cognitive behavioural therapy or hypnotherapy may all be useful strategies to reduce symptoms, and hence avoid an increase in VTE risk.

Here is an excellent information sheet from APS Support UK.

For further reading, see the following links:

1. Venous thrombosis/thromboembolism risk and menopausal treatments - AMS information sheet
2. Risks and benefits of MHT - AMS information sheet.

Question 3

I have a 47-year-old female who is struggling with hot flushes and mood changes. She has a Mirena IUD in situ.

Would it be appropriate to trial transdermal oestrogen given a history of Factor V leiden heterozygote (no previous DVT/PE), migraine and Sjogren's syndrome

We have trialled SNRI and clonidine with no effect. My understanding is that the transdermal route avoids the risk of VTE?

Answer

From Jean Hailes endocrinologist Dr Sonia Davison

See more detail in answers above.

There is no evidence that shows an increase in VTE risk on transdermal menopausal hormone therapy. As the Mirena is providing the endometrium with adequate progestogen this patient only needs the addition of oestrogen. An oestradiol patch or gel could be used, starting with low dose. I always refer these patients to a haematologist, to advise about VTE risk and management in the setting of future travel/ surgery/ potential menopausal hormone therapy use, and how to advise family members.

Other options for her may include any of the SSRI group, gabapentin, oxybutynin or non-medication options such as cognitive behavioural therapy or hypnotherapy.