I have had a DVT or pulmonary embolism. Can I take HRT?

I have had a DVT or pulmonary embolism. Can I take HRT?

Until just a few years ago hormone replacement therapy - HRT - was contraindicated for women who had a history of a clot in a leg vein or the pelvis (deep venous thrombosis) or a blood clot that had travelled to the lungs (pulmonary embolism): A pulmonary embolism can be fatal. It was known that the combined oral contraceptive pill increased the risks (Q15.14) and as HRT also contained oestrogen it was assumed that the risks would be too high. The changes in the blood clotting mechanism seen with the combined oral contraceptive pill, however,  have been shown to be minimal with HRT and for the last ten years HRT has no longer been contraindicated. The pendulum always seems to be swinging. The latest recommendation is to avoid HRT as far as possible when there is a history of Deep Venous Thrombosis or Pulmonary Embolism.

Soon after my appointment as a consultant, I was asked to see a lady of seventy who was a piano teacher. She had been taking HRT for ten years and she was certain that this maintained her mental ability and dexterity. Sadly, she sustained a DVT and required Warfarin to thin her blood. The physicians had appropriately stopped her HRT but some months later she wanted to recommence it. We were reluctant to go against the rules although the evidence about the risks in this situation wasQuite reassuring. The lady explained that without her HRT she could not play the piano never mind teach it. She promised me that, even if she died from her HRT she would not consult her lawyers! My legal advisers assured me that provided the patient was fully aware of the implications, I was entitled to prescribe HRT for her from a medico-legal point of view. Happily, she attended my clinics for many more years and no doubt played and taught beautiful music.

A 50-year old lady, who's last period had occurred 7 years earlier, was referred to me for consideration of hormone replacement therapy. Before the age of 40 she had five episodes of deep venous thrombosis. A 'thrombophilia screen' demonstrated a predisposition to thrombosis. Our haematologists (specialists in disorders of the blood) commenced her on Warfarin which reduces blood clotting and she was then started on HRT without problems.

In 1996, three papers appeared in 'The Lancet' indicating a small increased risk of thromboembolism in current HRT users. We know that the risk of thromboembolism is 1 person in 10,000 per year and the risk of dying from a thromboembolism is 1 in a million. HRT increases these risks three-fold that is to say that the risk of dying from a blood clot as a result of the HRT is 3 in a million per year. This risk should be seen in the context of other causes of mortality (Figure 27.4). The risks of dying from an accident are not high but your risk of dying from an accident are greater than your risk of dying from pulmonary embolism. The Committee on Safety of Medicines has commented that this new data does not change the overall positive balance between the benefits and risks of treatment for most women.

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