Superficial thrombophlebitis (superficial venous thrombosis)
BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h2039 (Published 22 June 2015) Cite this as: BMJ 2015;350:h2039
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In reply to E Grant's response to our article, thank you for your interest and comments. You make a very valid observation and point regarding the role of hormone therapies and venous thrombosis.
Competing interests: No competing interests
Nasr and Scriven include oestrogen based hormone therapy (HT) as a cause of superficial venous thrombosis.1 Only progestogen dominant HT is used for women with an intact uterus because of the high risk of endometrial cancer with oestrogen dominant HT. All hormonal contraceptives are progestogen dominant to prevent pregnancy and progestogens can cause vasodilation also increase the risk superficial or deep venous thrombosis. 1,2
In 1969, progestogens with inherent estrogenic activity, norethisterone acetate and ethynodiol diacetate, cause most veins complaints, especially when combined with higher doses of oestrogens. Vein complaints, including painful distended veins, varicose veins, leg cramps, superficial thrombophlebitis and thromboembolism, related to dilated endometrial sinusoids with or without stromal condensation.3
In 2011, Thomson et al discovered that desogestrel 150ug and drospirenone 3 mg increased endothelium-dependent vasodilation in large and small peripheral microvasculature further confirming the importance of vasodilation in the aetiology of progestogen/oestrogen induced thrombosis. Acne-treating oestrogenic drospirenone and desogestrel cause more thrombosis than acne-causing androgenic levonorgestrel.
In 2015, Vinogradova et al found that any current exposure to combined oral contraceptives gave a 3-fold increased risk of idiopathic venous thromboembolism compared with no use in the past year. Newer third generation progestins doubled the risk compared with older progestins. Risks were for desogestrel (x4.28), gestodene (x4.27), drospireone (4.12) and cyproterone (4.27) compared with levonorgestrel (2.38), norethisterone (2.56) and norgestimate (2.53).
It is important to that hormone use should be discontinued, along with symptomatic control or anticoagulants, to prevent continuing venous vasodilation leading to venous pulmonary thromboembolism.
1 Nasr H, Scriven JM. Superficial thrombophlebitis (superficial venous thrombosis). BMJ2015;350:h2039.
2 Grant ECG. Hormone balance of oral contraceptives. BJOG 1967;74:908-18.
3 Grant ECG. Venous effects of oral contraceptives. BMJ 1969;2:73-7.
4 Thompson AK, Przemska A, Vasiloupou D, Newens KJ, Williams CM.
Combined oral contraceptive pills containing desogestrel or drospirenone
enhance large vessel and microvasculature vasodilation in healthy
premenopausal women. Microcirculation 2011 Mar 7. doi: 10.1111/j.1549-
8719.2011.00094.x.
5 Vinogradova Y, Coupland C, Hippisley-Cox J. Use of combined oral contraceptives and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases.BMJ 2015;350:h2135
Competing interests: No competing interests
Superficial vein thrombosis: primary care data are available
In their practice update, Nasr and Scriven highlighted recent knowledge on superficial vein thrombosis (SVT), which was long considered to be benign.1 Unfortunately, we have noted elements that do not seem congruent with current data, potentially misleading practitioners, and through them, in turn, patients.
The incidence of SVT is no longer unclear, since the publication of the STEPH study, one year ago.2 In this first community-based study, the annual diagnosis rate of SVT was not only no higher, but in fact two times less prevalent than that of deep vein thrombosis, and close to that of pulmonary embolism (0.64 per thousand, 1.24 per thousand and 0.60 per thousand, respectively).2
These recent epidemiological data in primary care contribute major elements for the management of SVT in daily practice. It is usually acknowledged that diseases are less developed and less severe in primary care than in secondary or tertiary care. So far, data showing the potential severity of SVT, such as the rate of concomitant deep vein thrombosis and pulmonary embolism, originated from studies implemented in secondary/tertiary care.3 As a consequence, one would imagine that SVT warrants less attention in a primary care setting. Surprisingly, in the STEPH study, the rates of concomitant deep vein thrombosis and pulmonary embolism at first presentation in patients with SVT were similar to rates found in previous studies (24.6% and 4.7%, respectively).2 This finding emphasises the need, for any clinical suspicion of SVT, to investigate pulmonary embolism symptoms and to perform a complete compression ultrasonography examination of the lower limbs.
Finally, it seems potentially dangerous to suggest a prophylactic dose of low molecular weight heparin for treatment of SVT near the sapheno-femoral junction. This location, present in 20% of cases3, is considered to present the same complication rate as DVT (10%-70%), and is therefore a traditional criterion for exclusion from interventional studies. Thus, anticoagulant at a curative dose is currently recommended for these patients.4, 5
As the authors of this submission, we endorse the affirmation that wide areas remain to be explored, in particular the cost-effectiveness of SVT treatment, and treatment strategies in specific clinical subgroups, such as cancer, or for pregnant patients.
1. Nasr H, Scriven JM. Superficial thrombophlebitis (superficial venous thrombosis). BMJ 2015;350:h2039.
2. Frappé P, Buchmuller-Cordier A, Bertoletti L, et al. Annual diagnosis rate of superficial vein thrombosis of the lower limbs: the STEPH community-based study. J Thromb Haemost 2014;12:831‑8.
3. Decousus H, Quéré I, Presles E, et al. Superficial venous thrombosis and venous thromboembolism: a large, prospective epidemiologic study. Ann Intern Med 2010;152:218‑24.
4. Kalodiki E, Stvrtinova V, Allegra C, et al. Superficial vein thrombosis: a consensus statement. Int Angiol 2012;31:203‑16.
5. Tait C, Baglin T, Watson H, et al. Guidelines on the investigation and management of venous thrombosis at unusual sites. Br J Haematol 2012;159:28‑38.
Competing interests: No competing interests