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Case Report: L. Chen and D. Soares Fatal pulmonary embolism following ankle fracture in a 17-year-old girl J Bone Joint Surg Br 2006; 88-B: 400-401 [Abstract] [Full text] [PDF]

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Hormonal Considerations

Daniel C Perry, Marcus R. Cope, Simon J Scott.   (12 May 2006)

Hormonal status: a risk factor for venous thromboembolism following lower limb trauma

Peter J. Kempshall MRCS, Mrs. Judith M. Murray FRCS   (19 April 2006)

Hormonal Considerations 12 May 2006
Daniel C Perry, Senior House Officer , Marcus R. Cope, Simon J Scott. Send letter to journal: Re: Hormonal Considerations danperry{at}doctors.org.uk Daniel C Perry, et al.	Sir, In the case report by Chen and Soares published in March 2006, the authors clearly outlined the nature of the injuries which they believe contributed to the development of a thrombus, and began to explore the nature of other haematological risk factors involved. They failed, however, to comment on what role hormonal influences may have played. This was perhaps the most likely risk factor for an otherwise healthy 17-year-old female. It is well known and widely reported that the oral contraceptive pill (OCP) is associated with a two- to three-fold increase in venous thromboembolism, and is even higher in those who are obese or who also smoke.1 Indeed, there are numerous case reports of fatal pulmonary embolisms related exclusively to the OCP. The use of the OCP, and indeed pregnancy itself are therefore crucial variants in ascertaining the true aetiology of thrombi in females of childbearing age. D.C. Perry MRCS, Senior House Officer, M.R. Cope, S.J. Scott. 1. Moores L, Bilello KL, Murin S. Sex and gender issues and venous thromboembolism. Clin Chest Med 2004;25:281–7.
Hormonal status: a risk factor for venous thromboembolism following lower limb trauma 19 April 2006
Peter J. Kempshall MRCS, Specialist Registrar Department of Orthopaedic Surgery, Royal Glamorgan Hospital, Llantrisant, Mrs. Judith M. Murray FRCS Send letter to journal: Re: Hormonal status: a risk factor for venous thromboembolism following lower limb trauma Peterjkempshall{at}hotmail.com Peter J. Kempshall MRCS, et al.	Sir, I read this case report with interest. I note the discussion about obesity which is a significant predisposing factor, but there was no comment in the case report or discussion regarding hormonal factors. The oral contraceptive pill (OCP), pregnancy and HRT are all recognised risk factors for venous thromboembolic events.1-3,6,7 With three and a half million women currently taking the oral contraceptive pill in the UK, hormonal status should be considered when managing patients with traumatic or elective orthopaedic conditions. It has been shown that the risk of venous thromboembolism is influenced by duration of use of the OCP and the oestrogen dose.2,3 Recently, studies have shown that there is an interaction between oral contraceptives and high levels of pro-coagulant factor II.4 The risk is much greater if factor V Leiden is present.5 Hormone replacement therapy, although now going out of fashion, is also a risk factor that should be considered in patients that are rendered immobile from lower limb trauma. The reported incidence of venous thromboembolism is high (10.7%); five times higher than in the general population.6 It is well documented that pregnancy is a risk factor for venous thromboembolism, which is the leading cause of maternal mortality in the developed world.7 It has now been accepted that low molecular weight heparin is suitable for use in the prophylaxis and treatment of venous thromboembolism in pregnancy.7 The senior author has experience of a pregnant patient at 24 weeks, who suffered a fatal pulmonary embolus on day three following internal fixation of an unstable ankle fracture. No chemoprophylaxis was used, as at the time low molecular weight heparin was not licensed for use. A further young woman taking the OCP suffered a significant pulmonary embolus following ankle fracture. In light of these experiences, hormonal states need to be considered in all patients that have lower limb trauma in order to avoid further morbidity. Hormonal risk factors cannot be ignored. P.J. Kempshall, MRCS, Specialist Registrar, J.M. Murray, FRCS, Department of Orthopaedic Surgery, Royal Glamorgan Hospital, Wales, UK. 1. Skouby SO. Oral contraceptives and venous thrombosis: end of the debate? Eur J Contracept Reprod Health Care 1998;3:50-64. 2. Lidegaard O, Edstrom B, Kreiner S. Oral contraceptives and venous thromboembolism: a five-year national case-control study. Contraception 2002;65:187-96. 3. Lidegaard O, Edstrom B, Kreiner S. Oral contraceptives and venous thromboembolism. A case-control study. Contraception 1998;57:291-301. 4. Van Hylckama Vlieg A, Rosendaal FR. Interaction between oral contraceptive use and coagulation factor levels in deep venous thrombosis. J Thromb Haemost 2003;1:2186-90. 5. Hirsch DR, Mikkola KM, Marks PW, et al. Pulmonary embolism and deep venous thrombosis during pregnancy or oral contraceptive use: prevalence of factor V Leiden. Am Heart J 1996;131:1145-8. 6. Hoibraaten E, Qvigstad E, Arnesen H, et al. Increased risk of recurrent venous thromboembolism during hormone replacement therapy - results of the randomized, double-blind, placebo-controlled estrogen in venous thrombembolism trial (EVTET). Thromb Haemost 2000;84:961-7. 7. Greer IA. Anticoagulants in pregnancy. J Thromb Thrombolysis 2006;21:57-65.