Menopause medicine: Resolving three treatment dilemmas in older women.

May 1, 2008

Should hormone therapy be stopped before surgery? Does low libido in women require testosterone testing? The pelvic exam: At what age should it be discontinued?

The following questions and answers summarize cases discussed in Menopause e-Consult, a newsletter of the North American Menopause Society (NAMS).

Should women stop hormone therapy before surgery?

A healthy, active, 53-year-old postmenopausal woman is scheduled for gallbladder surgery. She has been receiving oral estrogen plus progestogen therapy (EPT) for 2 years to treat severe hot flashes. Should she discontinue EPT before surgery to reduce the risk of venous thromboembolism (VTE)?

THIS QUESTION has no definitive answer because venous thromboembolism (VTE) following surgery in postmenopausal women taking hormones has not been studied. The decision whether to discontinue EPT preoperatively rests on weighing the risks in the context of the patient's specific situation.

Many studies, including the Women's Health Initiative (WHI), point to an increased risk of VTE with postmenopausal hormone therapy (HT), primarily during the first 2 years of treatment.1,2 Like estrogen, raloxifene and tamoxifen also increase the risk about twofold.3

Because VTE occurs rarely, the actual risk is very low. A twofold increase in the relative risk would raise the incidence of VTE by about 2 cases per 10,000 women per year of HT use. Although only about 1% of patients who develop VTE die, most deaths occur after trauma, surgery, or major illness. Deep vein thrombosis (DVT) has been reported in 15% to 40% of patients after major gynecologic surgery.4

Of the approximately one third of patients with asymptomatic DVT who develop a pulmonary embolism, 11% to 12% die, usually within 30 minutes. The most effective intervention is to identify patients at high risk and institute prophylaxis.

Risk factors for hospitalized medical patients include acute infectious disease, age older than 75 years, cancer, obesity, and history of VTE.5 An acquired predisposition to VTE (from lupus anticoagulant, malignancy, immobility, or trauma) is also a risk factor. Varicose veins, unless extensive, do not increase risk; smoking is, at most, a weak risk factor for VTE (unlike arterial thrombosis).

All patients older than 40 years who are at risk of VTE-including women treated with estrogen, raloxifene, or tamoxifen-should receive perioperative prophylaxis.4 I recommend prophylaxis for women using HT who face immobility in the hospital and have other risk factors, especially obesity. The method of prophylaxis-including graduated compression stockings, pneumatic compression, low-dose unfractionated heparin, and low-molecular-weight heparin-depends on cost, feasibility, and clinical circumstances. Although statins and low-dose aspirin are associated with a lower risk of VTE, their efficacy in protecting against HT-related risk is not known.6,7

Some women may choose to discontinue HT 4 weeks before major surgery if they anticipate prolonged immobility, but the decision is empiric and individual. Once ambulatory, the patient can resume HT.

DISCLOSURE: Dr. Speroff reports: Warner Chilcott (consultant). (This case report was derived from Menopause e-Consult, Volume 3, Issue 4, October 2007.)