You Make the Call
Each month in “ You Make the Call ,” we ’ ll pick a challenging clinical question submitted through ASH ’ s Consult a Colleague program and post the expert ’ s response , but we also want to know what you would do . Send in your responses to next month ’ s clinical dilemma and see how your answer matches up to the experts ’ in the next print issue .
This month , Kenneth A . Bauer , MD , discusses venous thromboembolism ( VTE ) risk in a transgender patient who needs hormone replacement therapy .
TRAINING and EDUCATION
Clinical Dilemma :
A 33-year-old transgender female patient was involved in a motor vehicle accident that resulted in severe liver laceration , bile duct injury , and a subdural hematoma . She required multiple surgeries and was hospitalized for 91 days , followed by inpatient rehabilitation . At the time of the accident , she was on hormone replacement therapy ( HRT ), which was stopped during her stay in the intensive care unit . About 26 days into her hospitalization , she had a deep vein thrombosis ( DVT ) and pulmonary embolism ( PE ). She had an inferior vena cava ( IVC ) filter placed and was started on anticoagulation . I saw her for the first time last week . Will she be able to go back on HRT ? Would you consider lifelong anticoagulation in this patient who needs HRT ? She had been on HRT for eight years with no problems prior to this event . There is no family history of thromboembolic disease .
Expert Opinion
Kenneth A . Bauer , MD Professor of Medicine Beth Israel Deaconess Medical Center Harvard Medical School
VTE is multi-causal . The greater the number of bona fide risk factors one has for developing DVT and / or PE , the greater the overall risk . In this case , the patient sustained major trauma , underwent multiple surgeries , and had a prolonged period of immobilization . These together constitute a strong transient stimulus for the development of VTE that is far greater than the risk associated with HRT , which she had been taking for several years . The risk of VTE in association with estrogens is doserelated ; HRT is known to confer about a two- to four-fold increased risk for developing VTE , compared with healthy controls of similar age not taking HRT . This episode of VTE would be regarded as a provoked VTE event . Following three to six months of anticoagulation and her recovery , the annual risk of recurrent VTE should be low , at about 1 percent per year . The resumption of HRT will minimally increase this risk .
While it is general practice ( and arguably standard of care ) to discontinue estrogen in any woman with estrogen-associated VTE ( or arterial thrombosis for which there is a much weaker association ), it is possible to reintroduce or even continue estrogens in patients with a first episode of VTE on an individualized basis . For this patient , the resumption of estrogens is important to her well-being and identity . The benefits and risks of estrogen therapy require discussion with the patient and documentation of the decision-making process . The patient must be counseled that she is subsuming a small increased risk for developing a recurrent DVT or PE by taking estrogen . It is not necessary to continue anticoagulation long-term once HRT is resumed . While this would be highly effective in mitigating the thrombotic risk of HRT , it exposes the patient to the increased bleeding risk of continued anticoagulation .
I would definitely remove the IVC filter ( presumably it ’ s a retrievable one ). For periods of increased thrombotic risk in the future ( major surgery , hospitalization , etc .), appropriate VTE prophylaxis should be administered . Finally , I would avoid the temptation to evaluate this patient for an underlying thrombophilic defect . Testing
for thrombophilia in patients with VTE in association with strong transient risk factors ( which was the case here with the mortor vehicle accident / surgeries / immobilization ) is on the list of items not recommended by the ASH Choosing Wisely ® initiative .
Next Month ’ s Clinical Dilemma :
I am treating a 20-year-old pregnant woman at seven weeks gestation who was found to have chronic myeloid leukemia . Her white blood cell count is 300,000 /µ L with less than 5 percent blasts . The patient would like to keep the pregnancy and understands the risks . Leukapheresis did not provide much reduction in her counts . She remains asymptomatic with a relatively stable peripheral blood picture . Options that I have been considering include interferon now and hydroxyurea or imatinib starting in the second trimester .
How would you respond ? Email us at ashclinicalnews @ hematology . org . ●
Consult a Colleague Through ASH
Consult a Colleague is a service for ASH members that helps facilitate the exchange of information between hematologists and their peers . ASH members can seek consultation on clinical cases from qualified experts in 11 categories :
• Anemias
• Hematopoietic cell transplantation
• Hemoglobinopathies
• Hemostasis / thrombosis
• Lymphomas
• Lymphoproliferative disorders
• Leukemias
• Multiple myeloma & Waldenström macroglobulinemia
• Myeloproliferative disorders
• Myelodysplastic syndromes
• Thrombocytopenias
Assigned volunteers (“ colleagues ”) will respond to inquiries within two business days ( either by email or phone ).
Have a puzzling clinical dilemma ? Submit a question , and read more about Consult a Colleague volunteers at hematology . org / Clinicians / Consult . aspx or scan the QR code .
* If you have a request related to a hematologic disorder not listed here , please email your recommendation to ashconsult @ hematology . org so it can be considered for addition in the future .
DISCLAIMER : ASH does not recommend or endorse any specific tests , physicians , products , procedures , or opinions , and disclaims any representation , warranty , or guaranty as to the same . Reliance on any information provided in this article is solely at your own risk .
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