Written by Dr. Madalyn Otto, ND
A 19-year-old female patient named Jane who was otherwise quite healthy began having arm and shoulder pain suddenly without having injured it. For several days, the pain became worse and her primary care doctor was initially stumped. As the pain worsened, additional testing revealed a blood clot in one of the blood vessels in her arm and she was promptly prescribed an anti-clotting drug to dissolve the clot. The patient’s only prescription medication at the time was the birth control pill. Around the same time, a 56-year-old woman named Maggie began experiencing pain and swelling in her left leg. She suspected that it might be a blood clot, which was confirmed one day later on ultrasound and was followed by anti-clotting medication to dissolve the clot. One of the patient’s prescription medications at the time was oral estrogen replacement therapy prescribed because of hot flashes and mood changes the patient had been experiencing when she entered menopause seven years prior. These two women have one thing in common: They both were taking oral estrogen that ultimately led to dangerous clots forming in their blood vessels. In both cases, the clots were identified before they dislodged and became lethal.
The ability of your body to form a blood clot is incredibly important. Whenever there is an injury in the body whether to a blood vessel, your skin, or any other tissue, your body needs to be able to patch up the injury and repair it quickly. This is where clotting comes in handy. Tissue injury triggers a cascade of different molecules to come into play and synergistically form a clot. If we have too many of these molecules present, we can produce too many clots. If we have too few of these molecules present, we can fail to form a clot causing profuse bleeding. If a clot forms abnormally in a vessel, it is at risk of dislodging from the vessel wall and can circulate through the body. If it subsequently becomes stuck in a smaller vessel, it can cut off oxygen and nutrient supply to all of the areas of the body that the vessel supplies. If this occurs in the heart, it causes a myocardial infarction (heart attack); If it occurs in the lungs, it causes a pulmonary infarct and destroys lung function; If it occurs in the brain, it causes a stroke…and so on.
The primary mechanism by which birth control pills and hormone replacement therapy increase risk of clotting is via the body’s clotting mechanism. Estrogen in particular increases several clotting factors and decreases several anti-clotting proteins. Because of these interferences, birth control pills increase your risk of venous thromboembolism (clot in the blood vessel) by approximately 5x when compared to an average woman not on birth control. Even certain synthetic progesterone-like hormones found in birth control, e.g. desogestrel, can increase certain clotting factors. Typically, this side effect will occur within the first months to two years of starting that form of birth control. Studies that evaluate oral estrogen replacement therapy in postmenopausal women also find an increase in thromboembolic events (clots in the blood vessels) in susceptible individuals.
What makes a patient susceptible to forming clots too easily? There are several factors to acknowledge, but I want to focus on estrogen’s interference on clotting proteins. The standard of care does not include testing the patient to look at genetic mutations that predispose a patient to forming clots before prescribing estrogen therapy. This means that many young women making decisions about their birth control options as well as peri/post-menopausal women making decisions about hormone replacement therapy are not getting all the information they need to make the right decision for their bodies. These different elements are easily evaluated through a blood test. We can know if your blood is “thicker”, or if your genetics put you in a position to react negatively to hormones. Knowing this information gives both the patient and her doctor valuable data to help make the right decision for her individually.
How about our two patients, Jane and Maggie who had blood clots in their limbs? Upon investigation, we found that Jane had a homozygous gene mutation affecting her ability to methylate and metabolize a substance called homocysteine, which results in an increased risk for clot formation even at a young age. This mutation is actually quite common, though not always as severe. Maggie was found to have increased fibrinogen and a heterozygous Leiden Factor V mutation, both increasing her likelihood of forming a clot. A better understanding of their family history or genetics may have made a difference in the hormone prescription that was chosen for each of them.
As naturopathic doctors, our goal is to look at the whole picture and individualize treatment to each patient. Genetic testing, supplementation to support methylation pathways, or a lower estrogen dose may make a be beneficial for these patients. At Whole Health, we want to prevent health problems and achieve long-term health improvement. Hormone therapy is an incredibly useful tool and provides many benefits…. when used safely. I encourage all of my current patients and prospective patients to ask questions and start this conversation about hormone safety if she hasn’t already. Stay tuned for future articles that will be exploring different elements of hormone therapy and safety.