Venous thromboembolism

Women should be assessed for VTE risk factors prior to starting HRT.

Consider referring a woman, or seeking advice from a menopause specialist or haematologist prior to initiating HRT, so that more detailed counselling can be given, where:

• A moderate or high risk factor for VTE is present.
• Multiple risk factors for VTE are present.
• A transient risk factor for VTE is present.

In a woman with a minor risk factor for VTE, transdermal oestrogen should be prescribed in preference to oral oestrogen. This includes women with a raised BMI >30 kg/m2 or aged >60 years.

Micronised progesterone, dydrogesterone, a 52mg levonorgestrel intrauterine device and transdermal combination patches represent options that are unlikely to significantly increase VTE risk above an individual’s own intrinsic risk. These can be considered in individuals with a minor risk factor for VTE.

Dydrogesterone is only available in the UK in the oral preparation Femoston and is not available as a stand alone preparation.

NICE GUIDANCE

NICE says:

• For women with multiple or very high risk factors for VTE, such as those with a strong family history of VTE or a confirmed hereditary thrombophilia consider referring to a haematologist for assessment before considering HRT.
• Consider transdermal rather than oral HRT for people with menopause who are at increased risk of VTE.