presented at NTW’24 vc, this webinar considers the use of anticoagulation in women’s health. It is aimed at HCPs who are responsible for caring for women and/or who initiate and manage anticoagulation.The following topics will be covered:The management of heavy menstrual bleeding in patients taking anticoagulation.Advising women requesting contraception or HRT who have a history of VTE.
Chaired by Katherine Stirling with Rosalind Byrne, Wendy Sunter and Zoe Van-Zuylen.
afternoon everybody and welcome to the final session of the thr basis UK conference for 2024 hope you’ve made the most of it and if you’ve not managed to catch some of the sessions um they have been amazing and they are available to watch um up until the end of May so my name is Katherine Sterling I’m a consultant pharmacist in ant regulation and thrombosis at leads teaching hospitals and co-chair of the United Kingdom clinical Pharmacy Association hosis anticoagulation and thrombosis group I’m going to use uh acronyms after this because that’s too much to say in one go um our session today uh from the UK CPA is on anti-coagulation in women’s health and we’ve got two uh different sections on anti-coagulation and heavy menstral bleeding and then anti-coagulation imp uh sorry HRT and uh contraception in patients with the history of VTE so for this session I’m delighted to be welcomed by uh some members of the UK CPA committee so I have Ros Ben Who’s lead pharmacist for an regulation at Kings College Hospital in London and is the co-chair with me of the UK CPA hack group uh she runs outpatient clinics initiating reviewing patients and anti ciculation Wendy sun is also on the UK CPA H committee one of our education leads and is a consultant pharmacist and anti coagulation and thromboses at cdale and Huddersfield she manages a primary care-based anticoagulant service which delivers a One-Stop shop for anti-coagulation and from the UK CPA women’s group we’re delighted to have with us Zoe van zoan who’s the lead pharmacist for women’s and thees at Imperial College Healthcare NHS trust in London she’s co-chair and education lead of the UK CPA women’s group and research interest include medicines in pregnancy and breastfeeding so I’m going to hand over to Ros who’s preventing the first part of the session on uh heavy management of heavy menstrual bleeding in patients taking anticoagulation leading on very well from jig Patel’s session if you caught that yesterday on the period study thank you Ross thanks Katherine hi everyone um yes I’m going to talk about anti coagulation and heavy menstrual bleeding we’re going to start by attempting a poll so what percentage of women on dox experience abnormal or excessive menstrual bleeding so do you think it’s 2% 5% 50% or 70% I’ll give you a few minutes well a minute maybe it’s working [Music] I think that’s probably long enough is it for everyone to have voted Joe do you have the results of that I can’t see them yeah so I’ll end the poll and I can share the results if you can see so okay yeah you see them yes I can thank you so most people think 50% some 5% and a few 70% all right will be revealed okay so oh was my slide moving on yes so in terms of definition of normal menstrual bleeding so normal menstrual bleeding would be a cycle length of within 21 to 35 days um duration of bleed around 5 to seven days um and then about well not this is easy to judge but 53 Ms of blood loss per cycle actually around 30% of menstruating women suffer from heavy menstrual bleeding but this increases is 70% for women on anti coration so it’s a huge problem so yes the poll answer was 70% um okay so in terms of uh in terms of the uh incidents it’s so it’s very um common but only one in 20 women consult their GP about it so many women suffer in silence and there’s a recent Eclipse study which was a 10-year followup um to explore experience of experiences of heavy menstrual bleeding this isn’t for patients on anticoagulation necessarily um but this highlighted the need for better understanding that heavy menstrual breeding is not normal if it interferes with everyday activities and the research has called for initiatives to raise awareness among clinicians of the impact of heavy period that heavy period can have on women it’s very very underreported thing even in patients on anticoagulation so in terms of the definition of heavy menstrual bleeding um most importantly this is bleeding which interferes with physical social emotional or material quality of life over 80 Ms of blood loss per cycle changing the paddle Temple more than hourly changing the padle tampon overnight um leaking through clothing a period that lasts longer than seven days or passing clocks that are bigger than a 50 P piece um we know from the licensing studies for the doax um the incidence of um heavy menstrual bleeding or abnormal abnormal utrine bleeding so for River oxan it’s the highest at 99.5% similar for edoxaban and then lower for apixaban and to botran but we know that from observational studies there were they observed higher rates of heavy menstrual bleeding particularly with River oxan so 27% of patients um experienced bleeding for over eight days so a longer period and 41% had unscheduled contact with the provider of heavy metal bleeding 25% ended up with an intervention um and 15% resulted in adaption adaptation of the anti-coagulation regime and then you can see from this schematic here that River rockband was associated with more abnormal inter uterine bleeding than warrin and apixaban it’s interesting that there was a low incidence in the licensing studies compared to what’s been observed post studies um they weren’t really set up to report heavy menstrual bleeding as an outcome surprisingly um it’s missed out because the bleeding were really focused on new bleeding so the defin defs of clinically relevant non- major bleeding tend to focus on new bleeding rather than worsening of existing bleeding so sort of missed um postdoc analysis has now been done and I think it is true that women do under report and maybe put up with heavy menstrual bleeding even if it has got worse on anti coagulant it’s not necessarily something they would always bring up so this highlights the real importance of asking women about their experiences when they’re an on before anticoagulation and when they’re on anti-coagulation um more data on this from the period study which jig talked about I think yesterday um this study compared the extent of bleeding IM menting women newly started on anti-coagulation with a control group and in assess the impact on quality of life um and this found again that two out of three women newly started on anticoagulation experience heavy mental bleeding um manifesting as a longer period and showed a negative impact on quality of life and then similarly in the first study so the first study um reported safety and efficacy of river rockan in Daily care for VT in UK um over 1,200 patients over half the bleeding events for abnormal uterine bleeding you can see from this graph here so it’s looking basic basically at Patients the blue line and which shows the highest um rate of clinically relevant non major bleeding or major bleeding um shows female patients under 50 years so this is driven by heavy menstrual bleeding and you can see how that compares to men under 50 years and how much more so that’s a five-fold increase in bleeding for women and then the team VTE study um also looked at this so this is um an international multicenter observational prospective study in women aged 18 to 50 who have prescribed anti coagulation for VTE and you can see that they found that menstrual blood loss increased during the first cycle after VT diagnosis um abnormal utrine bleeding was associated with negative impact on quality of life again so seen this before um and treatment related to abnormally utr bleeding was initiated in 32% of women so quite High proportion of women needed treatment for it they did have pointed out that women treated with the big Trend showed no increase in blood loss during the first cycle and in contrast to patients treated with the 10 Inhibitors or vka but there are only seven patients on the big Trend in this study and all of those had a history of heavy menstrual bleeding the study didn’t actually meet the enrollment criteria for so it couldn’t really determine um the differences between the DOA so although there is some evidence to suggest that the big Trend shows um less problems with heavy menstrual bleeding and it might be related to its different mode of action and from this study we can’t conclude that okay in terms of consequences of heavy menstrual bleeding so obvious things like iron deficiency anemia impaired quality of life missing work or school Miss social events um potentially leading to hysterectomy um and then and its effect on on anti-coagulation so Mis doses an increased risk of recurrent VTE when we start patients on anticoagulation who menstruating women on anticoagulation we should check their history that’s really important to find out whether they already have a history of heavy menstrual bleeding and exactly what their history is um if they have a history of iron deficiency and then we would take a baseline full blood count and fertin and discuss with the patient the options for anticoagulation and the risk of heavy menstrual bleeding or or or of exacerbating heavy menstrual bleeding um what signs and symptoms to look out for what is normal what isn’t normal what they you know what they shouldn’t be putting up with um and then have a discussion around contraception which I will come on to the most important thing one of the most important things I’m going to say is to not stop oral contraceptives in therapeutically anti-coagulated women um we know and I will also come on to this later as well that patients aren’t at higher risk of recurrent VTE dis even if they’re on the combined oral contraceptive as long as they’re therapeutically anticoagulated and anti-coagulation prevents VT we know that they need to be on it um if you stop the pill um in someone who has a history of heavy menstrual bleeding then you’re going to potentially exacerbate the problem and whilst they’re on anti-coagulation they’re protected from recurrent VTE um so ongoing monitoring is extremely important so we would keep these patients under regular review um and they can always contact us to tell us about changes in their per periods symptoms of anemia we would check their full blood count in their fertin regularly um and when they stop anti-coagulation um we would discontinue estrogen therapies one month in advance if we know they’re going to stop offer estrogen free contraception and then preconception counseling if needed um just a note to say that we don’t automatically stop anticoagulation in patients you have a history of heavy menstrual bleeding because if we if we wouldn’t normally and we would have to think of strategy to try and minimize the heavy menstrual bleeding rather than thinking that we need to stop anticoagulation because we don’t want to increase the risk of VTE in patients at high risk of recurrence so in terms of treatments um patients can be offered the combined hormonal contraception so we know from Einstein um DVT and PE looking at women less than 60 um it didn’t show an increased risk of v in patients on combined or progesterone only contraceptives excuse me who were also on anti-coagulation therapy so we know that that is a safe treatment to use sorry um and then sometimes we’ve used tranexamic acid which has shown to improve quality of life um there is some talk about this being contraindicated in acute thrombosis sorry um but we would tend to use once again it’s a similar sort of things to to the pill once a patient’s anti-coagulated we wouldn’t be worried about any risk of thrombosis with tranexamic acid and we know that in highrisk settings I.E postpartum when tranexamic acid is used it’s not been shown to increase the risk of VT so we’re pretty relaxed about that now um when patients have heavy menstrual bleeding we would obviously treat ion deficiency with oral or parental ion supplementation they may need referral to gyy for surgical procedures um and some medications as well so they might have to undergo endometrial ablation um or hysterctomy po eventually um when we start patients on anticoagulation for uh who have a history of heavy menstrual bleeding or actually any menstruating women we would tend to start a pixan um rather than River oxan or edoxaban or sometimes we would use to botran so if someone was experienced heav menstrual breeding we would tend to switch if they weren’t already on a big span or to botran we may then switch them to a sort a lower risk anticoagulant um some patients after three months after the most high-risk period of treatment for VTE might reduce their dose um during during heavy um menstrual bleeding so just during the time of their period but we wouldn’t do this up front in the um acute period um there are some ongoing studies which will be interesting um to see the results of so rambol is looking at apixaban versus River oxan for heavy menstrual bleeding and that’s going to be reporting in 2026 and the medure is looking at De botran versus anti tenna Inhibitors with trxx with tranexamic acid during the during patient period versus anti antia Inhibitors on their own so they will be able to give us more guidance on treatment after that sorry our current practice um as I’ve said is to use a PIX span first line for menstruating women um we use a questionnaire which asks the patient about their periods um what the usual interval is how many days they normally bleed for and you know kind of Define what heavy menstrual bleeding is and then from that we can risk stratify patients who are more likely to experience problems and follow them up more frequently if necessary and we have a patient informationally lit um about anticoagulation and periods just to highlight the um importance of this and that patient shouldn’t be suffering a silence and this is not something they have to put up with we’ve also um just finished an animation which is available on YouTube which Joe I think is going to play now hopefully so I’ll pass hand over to Joe to play the animation just quickly maybe it’s not working well we might be able to play it at the end okay I’ll move on to a quick case just to go through everything I’ve been talking about so so a 39-year-old woman with a diagnosis of a small popal DVT post hernia repair and she has a history of heavy menstrual bleeding and she’s on the combined oral contraceptive and ferah sulfate so in terms of management of this patient we would take a full history of her heavy menstrual bleeding um we take a baseline full blood count and fertin and we would preferentially choose a pixan she would start with 10 milligrams twice a day for one week and then 5 milligrams twice a day for 11 weeks bigban also has the advantage of the high dose being just for one week rather than with River oxan where it’s for three weeks um we would counsel about the risk of heavy menstrual bleeding signs and symptoms we would give the patient contact and an information leaflet we wouldn’t stop Micron and we’d explain the rationale to the patient if they were concerned about that um we would make sure the patient had an early review regular monitoring for full blood count and then she would be reviewed at 12 weeks probably with a for this patient with a view to stopping anti calulation um because she had a provoked DVT so likelihood the risk of recurrence is low and the likelihood is that we’d stop it at 12 weeks if everything was okay which would hopefully hopefully um reduce the risk of having any more problems with menstrual breeding in the future okay thank you I will now hand back to Katherine I can share the film now I just just stop sharing the screen I didn’t realize oh sorry okay so if I stop sharing then you can po the fil okay thank you can you see now can you see yes yes Venus thrombo embolism VTE is common in patients who are in hospital and following discharge from hospital oh Joe I don’t think that’s the right one the risks oh sorry there it is sorry right now thank you anti-coagulants work by preventing clots from forming in your bloodstream but sometimes they can affect your periods too by making them heavier or longer so what are the typical signs of heavy periods if you have to change your Sanitary products every 2 hours or less if you experience flooding or blood leaking through your clothes or on your bedding if you have continuous bleeding that lasts a lot longer than your usual period if you pass clots bigger than a two-p coin or if the blood flow keeps you from getting out of the house or going to work if you have any of these signs speak to your anti-coagulation clinic or GP what can you do to help yourself you should let your anti-coagulation clinic or your GP know if you already have heavy periods or a condition known to affect periods this includes fibroids or adenomiosis if you take contraception don’t stop taking it before discussing with your anti-coagulation clinic or GP first if you begin to feel dizzy or faint become short of breath or if the bleeding is really worrying you you should seek medical help how might the anti-coagulation clinic or the GP be able to help PE you may need a blood test to check your blood counts and iron levels you might be given ion supplements they may also change your anticoagulant or add an extra tablet to help reduce your heavy bleeding in some cases taking hormones such as progesterone or having a coil fitted may help your symptoms these options may be discussed with you it is not uncommon for women prescribed anti-coagulants to develop problematic heavy periods if you are affected please don’t suffer in silence help is available through your anti-coagulation clinic or your GP thanks Joe so that that animation can be accessed on YouTube so people can use it in clinics if they need to it’s just about really ra raising awareness thank you thank you so much Ros for that thanks for Joe for all your it help on the polls in the video as well and I think yeah the raising awareness is really important and it’s great to um hear some options from Ros for that um there has been one question so far in the Q&A I think we’ll answer it at the end because I think it’s probably relevant to both sections um but please do keep asking any questions and say we’ll either answer them in the Q&A or um discussion at the end so thank you for those so now I’m going to pass over to Wendy and Zoe who are going to talk about contraception and HRT and options with for people with a history of VTE thank you very much thank you very much Katherine um so I’m going to talk about contraception first of all um and VTE and then um Wendy will talk about HRT um so oh that’s working yes um so this is a great slide because I think people get a bit boggled by by contraception options and they get a bit confused and and there are so many options that I I think that that that’s actually really valid um so when you’re thinking about I’m just going to do a little bit of an intro to contraception just so we can have like be all on the same page with with what we’re talking about so when we’re thinking about contraception we’re really thinking about um our hormonal versus our non- hormonal kind of contraception methods and our non- hormonal methods are things like barriers so like our male and female condoms diaphragms cups plus or minus sperm spermicides the copper IUD is also a non hor hormonal contraception and then things like natural Family Planning and the withdrawal method um and then when you’re thinking about hormonal contraception you’re really thinking about the combined or the progesterone only and I know with the combined there’s loads of different types of pills um but they they’re all basically a combined pill with AN estrogen and a progesterone and that’s kind of in in contrast with a progesterone only ones so even though there’s loads of different kinds of combines they all have estrogen in them plus progesterone and you get tablets and patches and you also get a ring for the combined ones whereas for the progesterone only ones you get the tablets and you get an implant um and the I us which is the little Marina coil that you can put inside there’s different kinds of coils but Marina is the one that’s most widely known um that goes inside the um inside the uterus and it has a kind of a dual action of the progesterone plus plus the actual having something in the uterus and then you get inject injections um and all of these um all of these methods kind of have different um different like advantages and disadvantages um and they all have different kind of effectivenesses um and if you’ll look at these if you see this um kind of list of of the most effective and least effective contraception methods you can see that really it’s it’s the um the non- hormonal ones that are are the least effective um and that’s things like the withdrawal um spermicide fertility awareness um and this is um the the effectivenesses there are are kind of based on 100% 100 people using that method for a year so for if you’re not using any method um for um 100 people using no method for protection you’d get um 85 pregnancy or 85% of people would be pregnant by the end of the year um and what this is showing is that if you used kind of the withdrawal meth method you would have probably about 30% of of people would be pregnant by the end of the year um but when you look at things like the IUD which could is which could be either the marina one or the copper one then you you getting up to really very very high effective um kind of rates with with um over 99 % so with the I um with the Marine in particular it’s over 99% um the numbers of people getting pregnant after a year are measured in the thousands rather than in the hundreds um so that’s really important to think about when you’re thinking about the contraception methods that you’re suggesting to people because giving somebody an ineffective or or somebody using an ineffective contraception method is obviously puts them at risk of pregnancy and pregnancy is is is way more um uh your risk of ET is way higher in pregnancy than it is even when you’re taking contraceptions so that’s and and that is also um true for early pregnancy um so there have been um in the Embrace report which is our our um our two two-yearly um review of all the um the deaths um the maternal deaths um there’s there have been women who have died from VTE in early pregnancy and following terminations of pregnancy in in in um early pregnancy so it’s it’s super important to understand that that pregnancy is is a very big risk for um for uh VTE um so the most common contraception is the is the oral Contra is the combined oral contraception that’s estrogen estrogen type plus the progesterone and it it really it’s really effective um and it has a lot of advantages over progesterone only pull it’s more effective there’s a lot more um flexibility in the way that you use it so if you miss pulls you have a a much wider um kind of um um sorry much wi wider um I forgotten the word um time there’s there’s more time that you can take the the um dose that you’ve missed so for instance for some progesterones um if you take a pull within if you don’t take a pull within the the same kind of three hours that you usually take it then the the effectiveness is is reduced um and that can be up to 12 hours with some other progesterones but but and now there’s a new progesterone which we’ll talk about in in a sec um that has has slightly more um leeway in Miss Missing pills um but the real advantage of the combined contraception is is that it’s it’s very effective and it’s a lot more um forgiving for if you if you’re not taking it correctly um so we most of them are are e um most of the estrogens are um ethal estrad and that’s ethanol estrad sorry that’s the estrogen that’s used predominantly um some of them are estrad but but really it’s it’s not too too it’s not it’s not too too important to know which ones what the estrogen is they all increase the risk of VTE um and then they are combined with a progesterone and you get a lot more variation in progesterones that are combined with estrogens and some of them have a greater or lesser kind of increase in in um in VTE risk um and it’s it’s the it’s the estrogen plus the progesterone that increases that risk the progesterone by itself doesn’t increase the risk so some examp examples are things like um uh um leor gestal which is a second generation um progesterone um it’s it’s increased the risk um from two in 10,000 which is which is um your underlying risk with no um with no contraception 25 to7 in 10,000 um so that’s quite a small um increase in Risk but things like the third generation the desol and gine they increase it to um from 2 in 10,000 to 9 to 12 in 10,000 so it’s quite a big difference between the the increase in in VTE risks with the different Generations there’s now fourth generation um uh Pro progesterones um and there’s a new progesterone only pull called slend um which is a fourth generation um progesterone and that hasn’t hasn’t shown to have any increase in e risk but um they haven’t done huge studies yet they they’re that’s quite new to the market um so just to be aware of that if if people are asking about that um the advantage of slend is that like I said before it’s got a a much it’s it’s much um more forgiving for incorrect use um so where would I go if I had a patient and I wanted to see um whether what kind of contraception would be the best option for them they either had a medical issue or a surgical issue or a they were um had a a large BMI or there their age um kind of was a risk factor for them um to get a BTE or to get one of the other complications of using a oral contraceptive I would go to the um faculty of sexual and reproductive Healthcare and they have this um guideline called um the UK Mech it’s the UK medical eligibility criteria for contraception use so if you Google UK Mech it will come up and basically they have categories of um of like suitability of a particular method in in a particular kind of situation um and the categories of go from one which is there’s no restriction of use for this method all the way to um c c category 4 where um they say that the method um represents an unacceptable health risk um and there’s a whole section on Venus um thrombo illism so um what um you’ll see you can see there um that if you have a history of um VTE then the combined hormonal contraception is considered a condition is considered to to pose an unacceptable health risk um so as you can see there are other options so our options for for that sorry the the ones at the top there are the CU the CU IUD is the copper IUD the LNG is the long acting um leog gestal um intrauterine um system which is the things like the marina the Imp is the is the progesterone implant the dmpa is the progesterone um injection and then the prop is the is the progesterone o’le so you can see from that that there’s that there’s options available um and but one of them is not the combined hormon trans contraception which is what she’s currently on so from there um we go back to our case study um and she’s a 39y old woman um and we wouldn’t want to be using microginin on her which is what she’s currently using so the the next thing really is is um to think about what her other options are so she has an option of a non hormonal she can have progesterone which would include I us um um the implant the next planon or um the the Min the progesterone only um pull um and we also um have an option of using the copper IUD the thing about the copper IUD is that that when with the copper IUD you you often get quite increased bleeding um so that’s one of the things um that makes it more difficult to use than things like the mar Marina and the marina or the um I us could be Marina or ler or the Jadis of V Alexa or whatever whichever one you’re using they’re actually one of our firstline um treatments of women with heavy menstrual bleeding so really with our lady we obviously need to have conversation with her um but um copper IUD for somebody with he existing heavy menstrual bleeding is is probably not our first choice um so it’s super important that that we we kind of individualize care for for um our ladies um and we really think about the risks versus benefits and we really include what what their um what their priorities are so things like um do do women feel very strongly about having regular periods or having a regular withdrawal bleed because some methods are are more appropriate for that um do they have a history of heavy menstrual bleeding would they like to reduce their their their periods um how did they feel about a tablet versus a a a kind of an implant something that more kind of um um forgetting the word again invasive um have they had their um family or are they still considering pregnancies in the future so all of these things we would we kind of have a discussion with them about and to decide what would would suit them best um in women’s health in general we we really do try and um especially if women are not planning a pregnancy in the next few years or if they have have finished their their families we we do like to encourage women to get I’s so something like Marino lot they have been um shown to be really very very cost- effective the vast majority of women who get I’s in really um find them very um effective um at reducing periods um so they’re very probably about 85% of women who get an IUS keep it in and and are happy with it so obviously they always be women who either don’t want it or who who have problems with it one of the um issues with it is that for especially for the first three to six months they can be unscheduled bleeding and obviously that’s something that that um women don’t like but that’s um quite common with all the progesterone um methods is that for the when you’re first establishing on it there’s there’s often um unscheduled bleeding um so for our lady um we I think this is pretty much what what I’ve said anyway um her family is complete um she’s very interested in the reliability of method um so she wants something that she can rely on um and we’ve discussed this increased risk of ette with her even in early pregnancy even if she was to for pregnant by mistaken and have a termination um and we’ve um discussed the stel management of her her history of heavy menstrual bleeding um and and contraception and she would consider an i or implant and that’s my bit so I’ll hand over to Wendy okay thank you Zoe that was great um so I’m G to be talking more about um sort of hormones VT in the menopause um so thinking about the hormones um generally then so estrogen and progest um know we know that they can both increase risk of clots um but it really the message that we want to get across today is it depends on the type that you’re using and the root of administration I think so he’s already eluded to um you know second generation prests being better than than other ones um not really going to cover testosterone too much um because when we’re using it in female doses it’s not uh associated with risk of clots so next slide please okay so just to um put some definitions around um per menopause and menopause so menopause um is where sorry per perimenopause is where you’ve got symptoms of the menopause but your periods haven’t stopped yet and then you go into the menopause when you’ve not had any periods for 12 months so I think sometimes you know symptoms can start years before your periods stop and continue um as as to get worse in some depending on the symptom as you estrogen levels drop um usually happens between 45 and 55 years old but it can happen earlier if somebody’s had surgery or the genetics or perhaps they’ve undergone chemotherapy things like that you can go into early menopause and it can have a huge impact on on a woman’s life um it includes relationships and work and looking at the symptoms um so next slide please um so the symptoms um when we think that estrogen actually affects um most cells in the body it’s not just to do with reproductive areas um so you can um categorize into physical symptoms or mental health um symptoms and um sometimes if it happens early people might not be aware that it is actually um as a result of reduced um levels of hormones so um I think most people if you ask them to describe a symptom they would talk about hot flushes and night sweats and that’s very common um but other things like headaches and migraines palpitations um muscle aches and joint pains it might be somebody thinking oh I’m just getting a bit old or I might have arthritis actually you going through the menopause um vaginal dryness and recurrent UTI is something that will get worse as the estrogen levels drop um control over your bladder skin changes all these things and being tired and having less energy um but then when you tie it in with um perhaps describing a brain fog you know um having increased anxiety and mood swings and um you can see how all these things could affect every aspect of your life and sometimes women find it very difficult um to continue um with their working or their family relationships and things like that so it’s really important um you know with all these things that um women feel you know it’s like with Ross said about the heavy menstrual beading that we talk about it so that people can um can get some some help with these things so next slide please so um this is a poll then for everybody um so what percentage of women do you think in the UK take HRT so would that be 2% 10% 40% or 70% so I’ll just wait I don’t know if you need to stop sharing for he doesn’t want to share at the moment I’m just trying um right in people’s um people see I can’t see that Joe at the moment should I should I just move on or yeah do it in the chat let people answer in the chat I am sorry if if you could just answer in the chat what do you think what percentage of of women take HRT so we’re getting 40% 70% most people are going to 40 somebody’s saying 10 somebody’s chosen 20 which isn’t on there that’s great so actually it it depends um it’s it’s estimated between 10 and 14% of women take HRT um and it depends on the areas as well in some deprived areas as little as 2% of women um take um the options of HRT and when you think about it it’s been reported about between 30 and 50% of women don’t seek help um for menopausal symptoms could I have the next slide please s so of the symptoms that we’ve described if some some of the reasons there’s lots of reasons why women might not want to ask for help um a lot of people want to deal with it themselves or they might be frightened if they’ve read about increased risks of of clots or risks of breast cancer and things like that um so the um there are non hormonal um treatments that we can use so for hot flushes um one option would be to use clonidine um it it sort of uh works on the periphery and and stops the blood vessels from reacting so you don’t get the hot fleshes as much but you’ve got to be careful um with cardiac people with cardiac disease or poor renal function and also because it’s a adrenergic receptor agonis it sort of affects your tears and things like that so contact lens wearers got to be aware um another drug that’s come out uh that works on um the Therma Therma regulatory Center is Fez Lin lant um so that’s quite new um some of the things that have been tried in the past like anti-depressants like the ssris aren’t really recommended um they’re not really show there’s not much evidence that they’ve shown to be helpful for hot flushes and things um or or sort of low mood um if somebody hasn’t already got depression so um if if you’re on an SSRI and you’ve already um for depression that’s different but you know if you’re feeling um down and it’s because of your your hormonal levels really it’s HRT and nice recommends you know as a first line treatment that we use HRT um lots and lots of people might women might try buying things over the counter so if it’s mild symptoms they might find um useful um relief with things like soy or red clover um but again there’s not much evidence out there and it would be for mild symptoms so next slide please so if we think of it as um the menopause we’re thinking of it as a hormone deficiency really so replacing the estrogen is is a way to help with those symptoms um you have to add in a progesterone if you’ve got an intact uterus um so and you would always try the combination of estrogen and progestogen before you um you added in testosterone um so in we weren’t talking much about testosterone but just completeness um you know that tends to be useful if you’ve got that uh brain fog and fatigue or a a low libido but you would always try the HRT combination excuse me of estrogen progest first testosterone does come in in various gels and creams and it’s not associated with an increased risk uh in VT in female doses so next slide please so that’s just some pretty pictures of um the different kinds of um progestogen estrogen packs that you can can get um next slide um and the MH um put something out in uh 2019 to show um the relative risks of VTE um with the um use of um oral estrogens and um we can see here that um so the combine estrogen and progest you’ve got um risks increasing with the amount of time that you’re on them and with age um and but the estrogen only one at the bottom I’m just thinking you can see again um you’ve got um increased extra cases of women using HRT so there is an increased risk um but as I said in a previous slide um it depends how you take it whether it’s oral or whether it’s um topical so next slide please so the difference is even the the lowd dose oral estrogen will increase your risk of e and that’s because um it’s um absorbed it’s processed in the liver and it leads to um a higher um a hypercoaguable state um so It All Leads to an increased risk of thrombosis so if somebody’s got a a a history of BTE we would avoid using oral estrogens if we can we but we would not use oral estrogens so uh next slide please but when you look at the transdermal or topical estrogen there’s no increased risk of BTE so this is where you absorb um the estrogen through the skin or the vaginal mucosa um it’s available in patches creams gel sprays or pessaries and I think um again as Zoe was saying it’s it’s important to speak to the woman and to find out you know what’s the um most um acceptable way of using that you know somebody might um be happy with a patch or other people might be happy with creams or gels um next slide please again when we’re looking at the um progestogens um there is an increased risk of clocked when it’s used with the estrogen compared to estrogen only um but that varies depending on the type of progest and um if we’re using a body identical micronized progest um that’s the safest type to use and there’s no increased risk of BTE and these um the brand that um was on the picture before the utron and that’s derived from yams um and it’s important to perhaps as a pharmacist point of view to note that if you’re allergic to peanuts you’ve got to be careful with that um and it’s usually taken orally um but it has been used um vaginally but that’s unlicensed um rout of administration okay next slide please so um looking at higher risk patients then so people with genetic factors um people with Factor five lien they’ve got an increased risk of VTE that’s a lot higher than the general population if you add in oral HRT that increases um by 25 times um but if you give transdermal estrogen and micronized progestogen there’s no increase in BT risk and the same with lupus they’ve got an increase or um antiphospholipid syndromes they’ve got 3 to four times higher the risk of ET but we don’t see the problem when we’re giving a transdermal estrogen or micronized progestogen I think you’ve got to be careful with people with um cancer and cancer related thrombosis um and the safest option really would be avoid HRT for estrogen dependent cancers but again everybody’s individual and we we need to look at at the um the history and and risks involved on a on a caseby Case basis for the people like that okay next slide please so women can actually help um themselves so um we know by maintaining a healthy weight um eating a good diet um and um exercising regularly stopping smoking and reducing your alcohol all those things can make you feel better in yourself um and so people with very very high risks who can’t have any hormonal uh treatment at all if they’re worried and they’ve got cancers and things like that they might um increase their exercise or take on us a um healthy diet and things like that and that can help them feel better in themselves okay next slide please um so just in summary then it’s important to individualize care to look at your risks and benefits um and for the patient and for the woman to have an informed Choice um thinking back to the beginning most women are not seeking out help you know 30 to 50% don’t go and and seek help um so we’re looking at the best option to alleviate symptoms so if for example if somebody’s symptoms were um vaginal dryness then they might want to go to um using a pessy or something like that I’ve lost my screen completely now I can’t see it um so oh there we go thank you so um use the best option to alleviate your symptoms and the most uh acceptable preparation so somebody might um not get on with the estrogen gel but they might like a patch or something like that so and and I know we’ve had supply issues with with lots of HRT um preparations as well so next slide I think that’s it for me actually um those were just some useful websites that people might be sign posted to um and then I think it’s any questions after that thank you thank you very much Wendy and Zoe lots of information there um on products and lots of depth which was great um there’s a few questions um in very places so we’ll get on with those please feel free if you there’s anything else you want to ask to put them in the Q&A and we’ll try and answer them at the end in the last seven minutes um there’s not a lot of detail on this so if I’m asking you a question and you want to add any more detail do do type it in um but the question is is there an increased risk of thrombosis in using neuroone and tranexamic acid in acute bleeding they put often the an coagulation has been held in the short term in these situations so I’m using this is heavy very heavy vaginal bleeding asking if uh those those options are appropriate anybody want to take that RSE thank you well there is an increased risk of ET with norona therapeutic doses as opposed to well I guess it’s all therapeutic but as opposed to contraception doses um I think it’s about a fivefold increased risk um but I guess when someone’s acute I mean it kind of depends on why they’re on anticoagulation that’s the big thing so if there’s is acute bleeding in a in a patient that has an acute BTE and that’s quite hard to manage because acute bleeding certainly causing a hemoglobin drop we would want to stop anticoagulation if we can but also we don’t want to give someone something that’s going to increase their risk of ET with tranexamic acid we’re pretty relaxed about that I would say there’s no even though I think it’s on the drug label that it I think on the SBC it says contraindicated in patients with um history of VTE but there is actually no definitive evidence that it increases the risk and actually it’s been used post surgery In Obstetrics and post surgery for trauma and not shown any increased risk of VTE so I think we’re pretty relaxed about using tranic tranic Amic acid actually really useful in those situations um but it kind of depends on why the patient is on it I mean if they’re on it for lowrisk AF then you’d be quite happy to stop it um for a short time and manage the bleeding however you need too but they’ got a massive PE that’s a completely different story yeah no thank you that’s a good answer hopefully covered what you wanted for the question I’ve got um I’ve got one here and I’m being a bit cheeky so from one of my colleagues um uh Zoe um Zoe’s gonna answer this one and but everyone else can chip in as well so this about patients with the history of provoke VTE P particularly when they’ve being associated with estrogen um and not on anti-coagulation now but they’ve got severe menopausal symptoms where topical HRT is insufficient could you add in a low dose of a pixan for example so to give the VTE prevention um with oral HRT um just to sort of try and see what is that other option so Zoe yeah so um I was I mean I was I suppose I think there’s a lot of questions here rather than than than I have specific answers and I I think that the the questions are are are things like you know what what have you tried what what why is she what is her her issue with with topical is it that she feels it isn’t working properly is it is it that she’s having reactions to certain to certain um kind of plasters can we can we look at other options so I think um and then um what her specific um what her specific um symptoms are I think is also important because as as um Wendy said there are there are multiple different symptoms and actually there might be different strategies to to dealing with certain symptoms so we could put her if her symptoms are are mainly those those kind of baso like the flushes can we give her and one of the new and non um non hormonal options if her if her her issues are libido low libido fatigue um is is testosterone perhaps something that we should be considering so so I do think um and then if if if topical yeah and especially with if she’s saying that topical isn’t kind of isn’t um uh isn’t kind of dealing with her symptoms I’m I I don’t know that she would necessarily get better symptom control with oral um I don’t think there’s anything necessary that would show that that that would be a better option for for symptom control so I think that it is a bit of an issue of of trying to optimize what her what her particular issues are and what we can do so things like we know that if you add in a progesterone or oral progesterone to an oral estrogen then then the risk increases so could we do something like put in an IUS and give her an oral estrogen to kind of lower that risk and so I think that there’s there’s a lot of different kind of questions that come up rather than that I can answer answer the the the question particularly particularly comprehensively I think yeah sorry it sounded a little bit like why was the topical not acceptable or not working because every woman’s different and it may be that the dose needs to be increased or decreased or it may be if she’s using patches they’re falling off and she’s not getting on with them or you know so it could be just a practical sort of pharmaceutical um approach to find out actually what the problem is to start with exactly yeah because there’s gels and there’s the spray as well so I yeah I think it’s often picking oh I know about anti coagulation so we could start that rather than you know actually going through maybe especially if you’re asking you know somebody in an anti coagulation service or hology team we know L less about HRT options and the different things there so it’s talking to our colleagues isn’t it and uh finding things out because we had Zoe and I talked about this earlier and gave you this great answer I thought ah I hadn’t thought about all those things but actually it’s very helpful and one more question from the chat again I’m not sure if I’m going to quite get the Nuance that you wanted but this is the women suffering from postnatal depression when given psychiatric drugs have en amena and menal irregularities are they prone to VTE and also the ones in menopausal age on psychiatric drugs so I think this is around um you your VTE risk with psychiatric drugs I don’t know if we’re trying to add in some um hormonal therapy as well I mean we when you look at the spcs for alanine and some of the other um psychiatric medications then it does suggest as an increased risk of VTE um as with a lots of things things often when you start it or if you’ve stopped it and gone back onto it I think um but any any uh ideas on this one around um I suppose especially if you’ve got someone with postnatal depression depending what that’s started and how they’re been treated if they’ve quite uh recent on recently delivered um then obviously their risk of VTE is already high and if they’re then being treated with psychiatric because that will increase it further so so there’s a balance around VT prevention if they are in a uh other risk factors as well Zoe is there anything from there yeah I mean I I I don’t think that’s something that we really consider as a particular risk factor when we’re assessing women for for for VTE risks but we would always assess a woman for for VTE risks um in the postnatal period and either give her 10 days or six weeks of of VT prophylaxis depending on on what her risk was I mean I I yeah and I don’t think that this is would be something that we would consider an additional risk factor and I imagine it would only be a very slight additional risk factor and probably in women that are quite high risk anyway but I also wonder if there’s an association with with postnatal depression and poor outcomes and and I imagine BTE might might be an a poor outcome in pregnancy and in the postnatal period so I I don’t I’ve from from my personal opinion as a as a kind of obstetric as a woman’s pharmacy specialist That’s not really something that we consider but it is is quite interesting and I did have little look around and and I couldn’t find anything specifically about anti-depressants in in the postnatal we we usually think about antidepressants as they risk AC for bleeding um during labor that’s kind of what we’re thinking about when when we thinking about anti-depressants in particular yeah thank you very much Zoe anyone else on that one quite a nuan question I think yeah from a menopausal point of view I think is they go for the topical and and the micronized progestogen then there’s no increased risk in VT so I would I would say that’s the way to go thanks very much sorry I’d also just add that post we would tend to go for progesterone only contraceptive any wayway we yeah we very R we wouldn’t suggest that women go on um combined once whilst they breastfeeding so yeah perfect thank you very much um so come to the end of our session thank you very much to everybody that’s attended today and asked questions and joined in thank you very much to our presenters Ros Wendy and Zoe