title: EMAS position statement: Managing menopausal women with a personal or family history of VTE.
abstract: BACKGROUND
  Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), is a serious cardiovascular event whose incidence rises with increasing age.
  
  
  OBJECTIVE
  To formulate a position statement on the management of the menopause in women with a personal or family history of VTE.
  
  
  METHODS
  Literature review and consensus of expert opinion.
  
  
  CONCLUSIONS
  Randomized controlled trials have shown an increased risk of VTE in oral hormone therapy (HT) users. There are no randomized trial data on the effect of transdermal estrogen on VTE. Recent observational studies and meta-analyses suggest that transdermal estrogen does not increase VTE risk. These clinical observations are supported by experimental data showing that transdermal estrogen has a minimal effect on hepatic metabolism of hemostatic proteins as the portal circulation is bypassed. A personal or family history of VTE, especially in individuals with a prothrombotic mutation, is a strong contraindication to oral HT but transdermal estrogen can be considered after careful individual evaluation of the benefits and risks. Transdermal estrogen should be also the first choice in overweight/obese women requiring HT. Observational studies suggest that micronized progesterone and dydrogesterone might have a better risk profile than other progestins with regard to VTE risk. Although these findings should be confirmed by randomized clinical trials, they strongly suggest that both the route of estrogen administration and the type of progestin may be important determinants of the overall benefit-risk profile of HT.
authors.affiliation: Florence Tremollieres Menopause and Metabolic Bone Disease Unit, Hôpital Paule de Viguier, Toulouse, France. tremollieres.f@chu-toulouse.fr
authors.forename: Florence
authors.initials: F
authors.lastname: Tremollieres
authors.forename: Marc
authors.initials: M
authors.lastname: Brincat
authors.forename: C Tamer
authors.initials: CT
authors.lastname: Erel
authors.forename: Marco
authors.initials: M
authors.lastname: Gambacciani
authors.forename: Irene
authors.initials: I
authors.lastname: Lambrinoudaki
authors.forename: Mette H
authors.initials: MH
authors.lastname: Moen
authors.forename: Karin
authors.initials: K
authors.lastname: Schenck-Gustafsson
authors.forename: Svetlana
authors.initials: S
authors.lastname: Vujovic
authors.forename: Serge
authors.initials: S
authors.lastname: Rozenberg
authors.forename: Margaret
authors.initials: M
authors.lastname: Rees
mesh_terms: D000279:Administration, Cutaneous; D000075202:Contraindications; D004198:Disease Susceptibility; D015914:Estrogen Replacement Therapy; D004967:Estrogens / Q000008:administration & dosage* / Q000627:therapeutic use; D005260:Female; D006801:Humans; D008593:Menopause; D009765:Obesity; D018579:Patient Selection; D011372:Progestins / Q000009:adverse effects / Q000627:therapeutic use; D012307:Risk Factors; D012955:Societies, Medical; D054556:Venous Thromboembolism / Q000139:chemically induced / Q000235:genetics / Q000517:prevention & control
chemical_list: D004967:Estrogens; D011372:Progestins