Prof Angela Maas, The Netherlands

Within the ongoing war for the leading positions of novel oral anticoagulants (NOAC’s) in Cardiology there is a striking silence on the potential risk for uterine bleeding in premenopausal women and safety data are lacking. Due to the increasing prevalence of obesity, diabetes and hypertension in younger women, the number of strokes and the incidence of atrial fibrillation (AF) is rising. Also for other indications, such as congenital heart disease and premature ACS, the use of vitamin K antagonists or (dual)anti-platelet therapy has gradually increased in younger women over the past decades. Nearly one third of women in their reproductive years are affected by disabling menstrual bleeding disorders, often related to the presence of uterine myomas. About 10% suffer from ‘heavy’ menstrual bleeding, resulting in iron deficiency in 10–20% and anemia in 2.5%. This may lead to severe symptoms of fatigue and dyspnea and may induce recurrent AF or provoke ischemia in women with coronary artery disease. As the use of combined oral contraceptives is often contraindicated in cardiac patients, alternative gynecology treatment with intrauterine devices, endometrium ablation or even hysterectomy may be needed for excessive uterine bleeding problems.

In the current era, the various indications for the use of NOAC’s, vitamin K antagonists and (dual) platelet therapy in young women are increasing. Although the majority cardiovascular specialists will never ask about menstrual problems, more awareness is needed with early referral to gynecologists when abnormal uterine bleeding is reported. Further, in the various guideline committees that interfere with all kinds of antithrombotic therapy the uterus should be considered as a serious and potential bleeding-site. It may be helpful to encourage a higher participation of females in the boards to encourage a better position for the uterus in Cardiology.


Maas AHEM, von Euler M, Bongers M, Rolden HJA, Grutters, JPC, Ulrich L, Schenck-Gustafsson K. Practice points in gynecardiology: Abnormal uterine bleeding in premenopausal women taking oral anticoagulant or antiplatelet therapy. Maturitas 2015; 82: 355-359.