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Practice Practice Pointer

Contraceptive and hormonal treatment options for women with history of venous thromboembolism

BMJ 2015; 351 doi: (Published 08 October 2015) Cite this as: BMJ 2015;351:h4847
  1. Manon C Stam-Slob, medical doctor and researcher12,
  2. Cornelis B Lambalk, medical doctor specialised in gynaecology3,
  3. Marcel A van de Ree, medical doctor specialised in internal and vascular medicine1
  1. 1Department of Internal Medicine, Diakonessenhuis Utrecht, Postbus 80250 3508TG, Utrecht, Netherlands
  2. 2University Medical Centre Utrecht, Utrecht, Netherlands
  3. 3Department of Obstetrics and Gynaecology, VU Medical Centre, Postbus 7057 1007 MB, Amsterdam, Netherlands
  1. Correspondence to: M C Stam-Slob mslob{at}
  • Accepted 6 August 2015

The bottom line

For women with a history of venous thromboembolism, we recommend:

  • Contraception—Non-hormonal contraception, a levonorgestrel intrauterine device, the progestogen only pill, or a subcutaneous progestogen implant; avoid combined oral contraceptives and injectable progestogens

  • Hormonal replacement therapy for postmenopausal women with severe vasomotor symptoms—Transdermal oestrogen therapy, with oral dydrogesterone, micronised progesterone, or medroxyprogesterone for women with an intact uterus

  • Menorrhagia—A levonorgestrel intrauterine device or the progestogen only pill

  • Disorders with female hormone deficiency—Transdermal oestrogen therapy in combination with a levonorgestrel intrauterine device or the progestogen only pill

A 28 year old woman, recently diagnosed as having a first deep venous thrombosis (DVT), visits her general practitioner. She has no predisposing factors (such as surgery, trauma, or malignancy), and tests show no familial thrombophilia risk factors, such as factor V Leiden. She had been using a combined oral contraceptive containing ethinylestradiol 30 µg and levonorgestrel 150 µg but was advised at the hospital to stop this as it increased her risk of getting another DVT. She now asks about contraceptive options that do not put her at risk for another DVT, particularly hormonal options, as she has been told they are more effective than non-hormonal contraceptives.

Venous thromboembolism (VTE) is a common disease with an overall annual incidence of 1 in 1000 people and an estimated mortality rate of 370 000 deaths per year in six European countries.1 2 The overall incidence of a recurrent thrombotic event is 20-30% in 10 years, with the highest rate in the months after discontinuation of anticoagulation therapy.3 As the risk of VTE is increased in women using combined oral contraceptives (that is, containing both oestrogen and progestogen) and hormone replacement therapy, this article aims to provide advice for women with a history of VTE who require contraception or hormone replacement therapy. …

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