How would you manage VTE risk in a transgender patient who needs hormone replacement therapy?

Here’s how readers responded to a You Make the Call question about venous thromboembolism (VTE) risk in a transgender patient who needs hormone replacement therapy.


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I would do six months of anticoagulation and remove IVC filter once the patient is stable. Avoid HRT if feasible. If the patient wants to continue on HRT then probably do lifelong anticoagulation, knowing that the patient will always be at a higher risk of venous thromboembolism (VTE).

Bijoy P. Telivala, MD, MBBS
Jacksonville, FL

Yes, I would allow her to resume HRT as long as she is apprised of and agrees to the potential increased risk of another thrombotic event. I would also recommend continued anticoagulation for at least six to 12 months and reassess at that time.

David H. Gordon, MD
Cancer Care Centers of South Texas
San Antonio, TX  

I assume that her VTE was pathogenetically related to the severe trauma, immobilization, and, possibly, HRT. This was clearly a VTE associated with mainly temporary risk factors, and her recurrence risk may not be very high. Still, I would continue anticoagulant therapy, ideally with a direct oral anticoagulant (DOAC), for infinite time (as long as she is on HRT).

Bernhard Lämmle, MD
Center for Thrombosis and Hemostasis, University Medical Center Mainz
Mainz, Germany

Reversible cause of thrombosis. I would give six months of anticoagulation and continue hormonal therapy. If possible, I would remove the IVC filter.

Jason Gonsky, MD, PhD
SUNY Downstate Medical Center
New York, NY

She does not need to be on lifelong anticoagulation. She can certainly go back on HRT, but will need to be on anticoagulation for a minimum of six months based on how long it takes to normalize D-dimers and clear DVT by doppler ultrasound.

Muthalagu Ramanathan, MD
UMass Memorial Health Care
Worcester, MA

I would try to remove the IVC filter before the second month of anticoagulation, preferably while on low-molecular-weight heparin (LMWH). Then switch to oral anticoagulants, either DOACs or anti-vitamin K. After three to six months, stop them and start HRT. Long-term, full-dose anticoagulation is probably excessive in this case. Low-dose DOAC has no place for provoked VTE; however, if the patient is very concerned about recurrence during HRT, it could constitute a reasonable intermediate solution.

Jorge David Korin, MD
Buenos Aires, Argentina

No, because of the risk factor of prolonged hospitalization.

Eric M. Feldman, MD
Overlake Medical Center
Seattle, WA

The IVC filter insertion was likely inappropriate. Unless there were major extenuating circumstances not mentioned in the case summary, she should have been therapeutically anticoagulated when the VTE was diagnosed. As demonstrated by two multicenter clinical trials, there is no indication for a filter in patients who are anticoagulated for VTE. The filter should have been removed as soon as it was realized that it had been inserted inappropriately and when therapeutic anticoagulation was initiated. If it hasn’t been removed, it should be immediately. She can start back on HRT anytime – there was no reason to hold it at all. She clearly had a provoked DVT/PE. Anticoagulation duration of approximately three months if she is reasonably mobile at that time – up to six months if mobility is still severely limited or DVT is very extensive. Did she get appropriate thromboprophylaxis after her trauma (mechanical prophylaxis about 5 days after trauma and then LMWH while in hospital)?

Bill Geerts, MD
Sunnybrook Health Sciences Centre
Toronto, Canada

Since she had not had a thrombotic episode prior to her trauma and multiple surgeries, I see no reason to withhold anticoagulation. Lifelong anticoagulation is an option given the HRT.

Geoffrey K. Sherwood, MD
Brigham and Women’s Faulkner Hospital
Waban, MA

Yes, l would put her back on hormone therapy and start anticoagulants.

Hani G. Jumean, MD
Coral Gables, FL 

Immobilization will play a big part in management and reversal to 100 percent normal plus discoverable lab data:

  • interrogate current hormonal therapies to assess incidence of PE
  • check type or manufacturer of IVC filter and assess incidence of PE
  • order echocardiogram of abdomen and legs to see if residual clot remains
  • examine leg swelling
  • test for procoagulants (i.e., anticardiolipins) or deficit of normal factors
  • check for history of gastrointestinal bleeding

John P. Hanson Jr., MD
Milwaukee, WI

I would consult the patient. I would discuss the pros and cons of continued hormonal therapy. If she is willing to take some risk, it would be reasonable to resume hormonal therapy since the thrombosis was provoked.

Gerhard J. Johnson, MD
Minneapolis, MN

Yes.

Mohammad Qasim, MD
Denton, TX

This is a provoked DVT. She can go back to hormone treatment after recovery and a period of treatment.

Robert G. Lerner, MD
Westchester Medical Center
Valhalla, NY

It would be inhumane not to allow her to continue on HRT. I have safely continued HRT in similar situations as long as the patient remains under the cover of full-dose anticoagulation. One can take some comfort that this was a provoked clot and that hopefully the described series of events would be unlikely to recur.

Kelty R. Baker, MD
Houston, TX 

Provoked clot, so three months of anticoagulation or longer if still bedridden.

Evan D. Slater, MD
Ventura, CA

Yes, I would continue lifelong anticoagulant with HRT.

Vinod K. Bhuchar, MD
Houston, TX 

I would treat for three months for provoked PE. Okay to continue estrogen if anticoagulation is started and continued afterwards. I would switch the patient to transdermal estrogen as this is the least thrombogenic. She does not need lifelong anticoagulation.

Joseph Shatzel, MD
Oregon Health Science University Hospital
Portland, OR

This is a provoked thromboembolism, so I would consider a limited period of anticoagulation. I might consider extended therapy. I would feel comfortable eventually starting hormone therapy.

Jyothi Dodlapati, MD
Central Texas Veterans Health Care System
Temple, TX 

I would remove the IVC filter. Three months of anticoagulation and then resume HRT as soon as possible since the patient is already on anticoagulation.

Steven Sandler, MD
Skokie, IL

I would consider lifelong anticoagulant therapy with close monitoring and dose adjustment. HRT can resume.

Salahuddin Shah, MBBS
Bangabandhu Sheikh Mujib Medical University
Dhaka, Bangladesh

I would argue that this is a provoked clot, and she does not need lifelong anticoagulation. I would also argue for the IVC filter to be removed when clinically appropriate. Risks include MVA, HRT, history of DVT, and perhaps the IVC filter because it’s a foreign object in her body. She tolerated hormones in the past, and has no personal history of DVT and no family history that would prompt thrombophilia testing. I would anticoagulate for three months, then stop and remove the filter. I also suggest a HERDOO2 score and a D-dimer, and would consider prophylactic dosing with apixaban or rivaroxaban. However, there is no data for using D-dimers in transgender persons.

Arpan Patel, MD
University of Florida
Gainesville, FL 

Anticoagulate for six months. Remove IVC filter. I would advise against resuming HRT, even though the life-threatening VTE was attributable to other factors. If patient believes HRT critical to quality of life, then negotiate resumption of HRT, explaining risks.

Michael Pidcock, MBBS
Canberra, Australia

The reported history suggests that she might need anticoagulation for life, and I think it is better to exclude HRT.

Giulio De Rossi, MD
Rome, Italy

This patient has an indication for hormonal therapy, and that indication continues despite the incidence of provoked DVT. She has provoked DVT due to multiple issues, and hopefully once recovered and active, some provoking factors will be ameliorated. Conditions three months out need be considered before discontinuation of anticoagulants, and I might scan legs to evaluate her or get a D-dimer before discontinuing anticoagulation. Thus, the duration of anticoagulation is undefined. However, while on anticoagulants, hormones can be given.

Kenneth D. Friedman, MD
Blood Center of Wisconsin
Milwaukee, WI

I would suggest edoxaban or apixaban in the preventive dose while on the HRT for the foreseeable future. No lifelong commitment to the anticoagulation is needed at this point. We never expect a lifelong decision from a young patient in this setting.

Sabine I. Heine, MD
Saarland University Medical Center
Saarland, Germany

This incident was provoked after car accident. I would not give lifelong anticoagulation; patient can resume HRT.

William Caceres, MD
San Juan VA Medical Center
Río Piedras, Puerto Rico

This appeared to be a provoked VTE (from surgery, trauma, immobilization), and while HRT could certainly have contributed to this risk, she’s been without any incident for eight years, and this was stopped about 26 days prior to her event. I do not think her HRT caused this.

I question the necessity of the IVC filter. I would certainly opt to have that retrieved (otherwise she would require long-term anticoagulation).

As for duration of anticoagulation, for provoked VTEs I would recommend at least three to six months. D-dimer can be used to determine duration. I also suggest ultrasonography to guide the decision as to when to stop anticoagulation. As a transgender person, she needs to be on HRT. Risks about higher incidence of VTE while on HRT should be discussed. If she does develop another VTE on or off HRT, she would then need long-term anticoagulation, and another discussion regarding long-term use of HRT can be had at that point.

Stanlee Lu, MD
Salish Cancer Center
Fife, WA

This was a provoked thrombosis, and the provocative event can be expected not to recur. On that basis, anticoagulation should not be lifelong. However, there was presumably some permanent damage from her severe trauma and operative intervention. The degree to which the vasculature is now compromised and abnormally pro-thrombotic must be considered an ongoing provoking event. Or, it lowers the threshold for some future event to provoke thrombosis. Careful review of her current vascular status may help with this. For instance, is there remaining edema? Is her hepatic function fully normal? Does a computed tomography scan show tortuous and potentially thrombogenic vasculature? Then one can decide how long to anticoagulate.

Same issue with HRT. What is the long-term thrombotic risk?

Joel D. Bessman, MD
University of Texas Medical Branch
Galveston, TX

It’s obvious that this patient had an episode of provoked DVT. I would continue desired choice of anticoagulant for three months. In the meantime, HRT should continue.

Kaipol Takpradit, MD
Bhumibol Adulyadej Hospital
Bangkok, Thailand
 

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