LETTER
Hypercoagulable States
Susan R. Kahn, MD, MSc
15 December 1997 | Volume 127 Issue 12 | Page 1128
TO THE EDITOR:
In their review of hypercoagulability in venous and arterial thrombosis, Thomas and Roberts [1] stress the importance of assessing the ongoing risk for venous thrombosis in individual patients with hereditary defects that predispose to thrombosis in guiding the management of these patients. An example of their approach is to dissuade women with resistance to activated protein C from using oral contraceptives. Related issues that were not addressed in their review are of greater magnitude: 1) how to advise women who are known to have these defects and wish to begin postmenopausal hormone replacement therapy [HRT] and 2) whether to test all women with a personal or family history of venous thromboembolism for hereditary defects that predispose to thrombosis before beginning HRT.
Unlike oral contraceptives, HRT is being advocated for use in the general population of postmenopausal women as a preventive therapy, the exposure period may last up to 30 years, and the target population is aging and has consequently higher baseline risk for venous thromboembolism because of age and comorbid conditions. Although the literature had previously suggested that, unlike oral contraceptives, HRT was associated with little risk for venous thromboembolism [2], three recent studies showed a two-to fourfold risk for venous thromboembolism in women who receive HRT compared with those who do not [3-5]. Studies are clearly needed to define the risk for venous thromboembolism with HRT in women with inherited defects that predispose to thrombosis. Until such time, what are the authors' recommendations on this issue?
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Author and Article Information
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Sir Mortimer B. Davis Jewish General Hospital; Montreal, Quebec H3T 1E2, Canada
1. Thomas DP, Roberts HR. Hypercoagulability in venous and arterial thrombosis. Ann Intern Med. 1997; 126:638-44.
2. Devor M, Barrett-Connor E, Renvall M, Feigal D, Ramsdell J. Estrogen replacement therapy and the risk of venous thrombosis. Am J Med. 1992; 92:275-82.
3. Daly E, Vessey MP, Hawkins MM, Carson JL, Gough P, Marsh S. Risk of venous thromboembolism in users of hormone replacement therapy. Lancet. 1996; 348:977-80.
4. Jick H, Derby LE, Wald Myers M, Vasilakis C, Newton KM. Risk of hospital admission for idiopathic venous thromboembolism among users of postmenopausal oestrogens. Lancet. 1996; 348:981-3.
5. Grodstein F, Stampfer MJ, Goldhaber SZ, Manson JE, Colditz GA, Speizer FE, et al. Prospective study of exogenous hormones and risk of pulmonary embolism in women. Lancet. 1996; 348:983-7.
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