Coumadin and menopause

[JenniferO]

As a 50-year-old pre-menopausal person who will be undergoing mitral valve repair or replacement in the near future, I am wondering what efffect Coumadin has on women going through menopause and whether it increases the risks of heavy bleeding which might result in higher chance of hysterectomy etc. Any females out there who can comment?

[Gail in Ca]

Hi,
After I was placed on coumadin (warfarin) I noticed a big change in my blood loss.
The first period after my surgery, it was so heavy, I had never experienced any period like it.
I have lived with 10-11 day periods for 1 1/2 years now. Recently, I saw a gynecologist who put me on Prometrium and this seems to lessen the heaviness for the 1st few days, but they still go on for 10 or more days.
Just last Aug I ended up in ER in Fl while on vacation. I began to bleed and clot very heavy, soaking thru every 45 minutes for many hours.
And this was 4 days after my period had already started. I was nervous to say the least. It began to slow up after 2 days, changing pads every 1.2 hours, ugh!
I have looked into ablation but am not ready to have another surgical procedure.
The prometrium is easing it , so I will give it a few more months to see if it gets any better. I am 47 and really this is not fun!!!!
I read a post from Mara that being on coumadin does affect premenopausal women, and I need to get more info on that.
Gail

[allodwick]

I am not a woman, but a pharmacist who specializes in warfarin therapy. I have a website www.warfarinfo.com
Warfarin should have very little effect on menstrual blood flow. This is because the lining of the uterus is not shed until there is new tissue below it. You are not having actual bleeding but are seeing blood in the old tissue that is being shed. This is unlike a cut.
Many women who are pre-menopausal have irregular and very heavy blood flows, (my wife who did not take Coumadin included.)
Warfarin gets prescribed at the time of life when this is happening, so it often gets the blame. It is usually an innocent bystander who just happens along and gets blamed.

[Tammy]

It seems to vary from person to person but I did not notice any significant change upon starting the Coumadin almost 13 years ago.

Tammy

[Gail in Ca]

I was just reading one of the booklets that come with the protime machine. Under signs of too much coumadin it lists minor bleeding, and one of the signs is prolonged mentrual bleeding.
Also, my cardiologist is keeping my inr at 2.5-3.0 rather than up to 3.5 ( which is where he would rather have it), because of my heavy period bleeding. It seems that they think it does have an effect on monthly bleeding.
I realize that the surgery does put our bodies thru the ringer, and that may be part of what is causing my problem, but I think the coincidence is too great, having the huge bleeding problem the 1st month after my surgery and taking coumadin.
Just some thoughts....
Gail

[allodwick]

I'll stick by my statement for 2 reasons.
The statement probably comes from the legal department rather than the medical department.
You did not associate this with a high INR, in fact you say that they are trying to keep it low.

[allodwick]

100% agreement

[Lisa in Katy]

I have to agree that there is definitely an effect. I don't know how old the other women are, but Gina and I were definitely not near menopause when we had the valves replaced (I was 36 and she was younger), and we have experienced similar problems with periods. Remember, with INRs of 2.5 - 3.5, we are high and at risk of bleeding. The hemotologist that I was sent to said there is definitely a connection, but they don't have much data because not many premenopausal women are put on Coumadin.

After my surgery, my periods were much heavier, longer, with lots of clots. One Saturday, I had a test in the morning. During that 3 hours, I had to excuse myself at least 10 times and was still having overflow. They thought I was cheating! I twice had to have D & C to stop bleeding (after about 14 days of profuse bleeding each time) and then a few months later had a hysterectomy to cure the problem, which was about 2 years after my valve surgery, so I was still a long way from menopause. I was very anemic by that time. They wouldn't put me on any medicine to lessen the bleeding because of my moderately high blood pressure, and many of those meds put you at higher risk of blood clots, just like birth control pills. I'm not sure about the one that was mentioned, but you should probably check. If your OB/GYN prescribed it, he may not have thought it through!

Frankly, the hysterectomy is one of the best decisions I ever made!

[allodwick]

I'll still stick by my original statement. If it was a problem which could be relieved by a D&C then it was not caused by warfarin. A D&C has to do with abnormal cell growth, not a clotting problem.

[Lisa in Katy]

I say that I had a D & C, but they also cauterized the blood vessels and did something else to stop it. I went to the hospital on Saturday evening, where they gave me Vitamin K to lower my INR. I skipped Coumadin dose that night. I had another Vitamin K shot the next day a few hours prior to the procedure. I was at 1.8 for the procedure on Sunday afternoon. I went back on Coumadin that evening, so I only missed one dose.

I'll stick with what my doctors said - definitely a connection, and there was no safe way to fix it aside from the hysterectomy. Look how many of us "young girls" on Coumadin have the problem and we never had it before.

[allodwick]

The safest way to handle warfarin around a D&C is to stop the warfarin three days prior to the procedure. The next day after the warfarin is stopped, start a low-molecular weight heparin. Skip the dose of LMWH priot to the surgery. Take the next LMWH dose due after the surgery and start warfarin at the same time. Continue both until the INR is therapeutic again, then stop the LMWH.

The fact that there was something there to cauterize proves that warfarin was only the secondary cause. The tissue split open THEN the warfarin caused bleeding. This is an entirely different thing than a period. The only relationship is that it was in the same place. Sure women will have more problems with this than if they were not on warfarin. But this an abnormal condition that is treatable, whereas a period is not.

[Lisa in Katy]

Whatever! I'm sure that you weren't in the room during the procedure, so I don't think you really know. From what I understand, there was no split in the tissue, they cauterized blood vessels. My doctor was there, and he says that the primary cause was Coumadin, as did the Hematologist that I was referred to. They both said they'd seen it before. If you'd like, I can give you their phone numbers, and you can argue with them.

If I'd had time, I'm sure that I would have gone through the heparin procedure that you suggested. But, I was severely anemic and losing blood fast, so in this case, the benefits outweighed the risks and I was only off Coumadin for 1 day. In fact, they gave me the shots in the hospital, just like after the valve surgery. I did go through the Heparin procedure (I can't remember what it was actually called) with the hysterectomy.

[allodwick]

I have spent many hours and been paid very well giving talks to groups of doctors who want to learn about warfarin. One of the reasons commonly given for referring patients to my clinic is the doctor saying, "I've got them all screwed up, see what you can do."

[allodwick]

With your tamponade episode, did you recover immediately after it was drained? I have a man who had an episode too. He was OK one day, almost died the next and was OK the next day. He has been OK for about 3 years now.

I think that the really good doctors realize that when they do not know much about a subject, then they seek help. When patients get into trouble is quite often when doctors try to do something that they know little about.

Our city of 100,000 has 7 cardiologists - all partners. At least 5 of them have told me that they do not like warfarin dosing. The only reason that they managed the patients on it was because the primary care docs were worse at it than they were. When I started my clinic, I was all but overwhelmed. The cardiologists referred every patient as they came to the office. In fact one day, the secretary called me and said, "I've run out of fax paper. Don't send any more reports until I call and tell you that I have borrowed some. You reports make it look like it is snowing in here."

[Rain]

Hey Gina,

We could start Pro Time clinics! I’m positive we understand it better than some doctors. Every doctor should have to eat it (coumadin) for a couple of months before being qualified to monitor other people.

Okay.... here’s Rain’s top ten rules for ‘The It’s Never Right (INR) Clinic’.
.................................................. .................................................. ..................................

1) Keep that darn dog out of the flower bed. (Very likely the most important rule of all!)

2) NO stress... be happy. Plenty of sleep helps too.

3) Coumadin... NOT warfarin. (I’m speaking from experience here)

4) Eat in a three meals a day. (I only eat two but I do it CONSISTENTLY!)

5) NEVER miss your exercise class. (Don’t ask me to explain it, but I swear it makes a difference!)

6) Eat plenty of fruit & veggies... CONSISTENTLY. (Rain’s a vegetarian)

7) ALWAYS have a drink (or two) before dinner. (missing a day can really screw you up.)

8) Don’t forget to take your coumadin... DAILY. (Very important, this can be a killer)

9) Ladies... get a hysterectomy. (Believe me, you’ll wonder why you didn’t do it sooner)

10) Eat the same amount of coumadin daily, even if you have to cut those pills into 1/8s or 1/16ths! (How can doctors preach consistency in one breath and tell you to take 5mgs three days and 2mgs four days in the next??!!)

Oops... forgot the pill box! Exactly why you should have one! And get a Pro Time machine!! A MUST HAVE! Geez.... there’s no way I can whittle it down to ten......


I know the rules..... The irony is that if I was able to live by them, I wouldn’t be a heart patient!! :confused:

Rains going to chase the dog out of the flower bed.....

[Marty]

I am an MD-radiologist and I too found out the hard way that anticoagulant therapy is terribly mismanaged by a high percentage of my fellow professionals.I was sent home from the hospital in the AM of my fourth post op day after mitral valve replacement(non-Silzone St. Jude mechanical) having been prescribed 7.5mgm warfarin daily. I took this dose and a visiting nurse came to draw blood for a check of the PT. She had a hard time and I finally had to stick myself.I went back to the hospital for a routine two week checkup not feeling all that good but I didn't expect to.I got the first look at my chest Xray and was horrified to see fluid filling the my entire left chest. When my surgeon saw the films he went "oooh". I had 4 1/2 pints of nice bright red blood withdrawn through a big needle. My Inr was only 5 something.
To shorten this up I never did get stabilized by my cardiologists office- up and down, up and down.It was a great day when the Coaguchek prescribed by my cardiologist arrived. I've been fine these last three years self regulating which I think can be done by most patients. Look these cardiologists are busy guys working day and night in the ER and ICU with life and death matters. PT and INR is not high on their list of important duties.Many of their office personnel are not the sharpest knives in the drawer.I discussed all this with my surgeon who listened carefully. I reviewed the literature and found a paper that said 70+ mitrals like myself should be loaded with 2.5mgm not 10 or even 7.5. To his credit he arranged for me to make a presentation to his staff and he said he was aware of many problems particularly when the patients left the hospital and were handed off to the internists.I work for a big HMO which has pharmacists like Al monitor the patients and as I have stated previously they do the best job except for the patients that do it themselves.

[Nancy]

Just wanted to say that there are some doctors who are pretty fine at Coumadin.

It just happens that Joe's internist monitors his Coumadin. The blood is drawn in the hospital lab which is in the same building and the doctor has his nurse call that afternoon with the dosage. He's been stable for many years. His cardiologist also has a fine monitoring situation, and Joe would be equally well taken care of in that setting.

For the smaller community we live in, we have some very fine care.

If it were otherwise, I'd be pushing for home monitoring also.

[Rain]

I hope it didn’t sound like I was bad mouthing doctors. Like any profession there are good ones and bad ones. And sometimes the really good ones make mistakes too. Personally I think my cardiologist is great! The PCP I have now is good too, but I think I know more about my life with coumadin and what effects it has on me than he does.... or anyone else, for that matter. The PCP I had before him ... is a quack!! The woman almost killed me!

Coumadin isn’t really all that bad... Thank goodness I’m around to take it every day. I just have to whine about it a little bit every now and then. :)

[Gail in Ca]

Thanks ladies for agreeing with me about the monthly bleeding issue!
I think men often read something and think it must be true and could not possibly be anything else, especially where women are concerned.
In '88 when I first saw my cardiologist, he listened and then in a condesending way said, you only have mitral valve prolapse, and will just need to take antibiotics before dental work. When I tried to explain symtoms of my heart rate really going up during exercise, he sort of dismissed what I had to say. Luckily, I had brought him the tape of my echo, he looked at it the next day, and must've felt like an idiot. I had a aneurism of 6 and my aortic valve was leaking, heart enlarged.
He's been very supportive and even takes time to listen to me now. But when in the hospital in '00, I had his associate, another unwarm person. Since I had come in as an emergency , I was concerned because I hadn't met my surgeon, yet,( my appointment wasn't for another month) and hadn't asked some important questions ,like would I get someone to give me a good scar. He said to me that's not important. What an unfeeling guy,who didn't know women at all!
Just venting about how male doctors and other professionals in the health field can dismiss women's symtoms and feelings, even intuitions.
Thanks again, fellow heart surgery ladies!!
Go Raiders!
Gail

[Lisa in Katy]

I've always had some very good heart doctors, all associated in some way with the Texas Heart Center, many trained by DeBakey and Cooley, so I have faith in them. Since I "received" my bad valve in 1976, I've seen many cardiologists, and all have been good. I worked for 15 years in the medical profession, so I know there are quacks out there, but I also know how to investigate a doctor before I ever step foot in his office.

Yes, I've had some problems with my INR and sometimes I get bad advice, not from the doctor, but the nurse. They're busy and don't always look at the history. But, that is when I speak up and say, no, it didn't work the last time, so let's do something different now. They do listen to me. Actually, I've been regulated for about 5 months, so I'm happy.

I too believe that males have a tendency to gloss over problems that pertain to females because they don't get it. They don't know much about women and heart disease, and yet, women die of it every day. I had an ER doc tell me that women in labor can't possibly be in that much pain because it's only stomach cramps!

So, I take responsibility for my own care, not with a home monitoring unit, but by knowing how various foods, exercise, drug interactions, coumadin dosages, etc. affect my INR. I get regular checkups and INR monitoring (although it has been 5 weeks). I don't let doctors, nurses, pharmacists or anyone else tell me that they know more about my body than I do.

[cookie]

Hey Gina M,
I also couldn't figure out why after 2 weeks post surgery I couldn't breathe! Went to PCP and he told me it was just taking time to recover from surgery. Went to cardio and he did an echo and sent me directly to the hospital,which was next door.Couldn't walk without passing out! They infused me with fresh frozen plasma and off I went to surgery again to have a chest tube put in. That was more painful than the open-heart!! After they drained what my Husband said was 11 pounds of fluid from around my heart I was feeling really good and recovery took it's normal course. When I went to the surgeon that put in the chest tube he told me someone wasn't watching my INR levels very well!! Holy Cow! What did I know! This was all new to me also. Like you, I trusted all my docs. Of course my cardio never once came in to see me when I was in the hospital so I now have a new cardio!
My PCP was monitoring my INR but was too busy for all the parients he had so when an anti-coagulation clinic opened up affiliated with the hospital, he immediately sent me to them. The Pharmacist that manages the clinic took extra training especially for INR management. He is wonderful and very concientious! I love him. I can call him any time with any question I have no matter how dumb. I feel much better being handled by him than my Doc because thats all he does. Things have been going well and it has been a year and a half since surgery. :D

[JenniferO]

Wow, these latest horror stories which of course go way beyond "female" worries have really scared me about the Coumadin.

I hope these are the exception and not the rule.

[Christina]

I agree with Gina. Excellent doctors with excellent bedside manners are far and few in between. I am on my 4th doctor since my surgery last year and I think this one looks like a keeper. It took a year to find this one, but I am glad I persisted.
It doesn't pay to put up with a jerk and his bad behaviour, I can tell you this from experience. The doctors that I encountered were indifferent towards me, and had no personality. Also had way too many Coumadin patients and seemed uninterested in what I had to say and what I felt comfortable with. The last one took the cake though, he was the jerk of jerks.

To Jennifer.. Coumadin is not that difficult to regulate. You just have to find the right doctor who knows what he's doing and is not intimidating towards you.
I home test with the Protime and have been stable since I fired the last jerk. I test once or twice a week, and call it in to the office, and they call me back the same day with any dosage changes. I haven't gone to the lab since the end of June and am doing fine. So once in a while when my diet is a bit off, and if I don't consume the same amounts of vitamin K the INR gets a bit higher than normal, but my new doctor doesn't have a hissy fit about it and doesn't chew me out. I am so much more at ease now and not so nervous. Before I was a nervous wreck and had a lot of anxiety.
I thank God for giving me the courage to stand up for my rights as a patient.

Christina
Aortic Stenosis
AVR's 8/7/00 & 8/18/00
St.Jude's Mechanical
Coumadin 20 mg a day.

[Doris]

I also have suffered prolonged menstrual bleeding and increase in flow since July of this year. At present my gyn placed me on low dose birth control pills to control the bleeding problem. My last two INR readings have been exceedingly high 3.8 and then 4.8. They have reduced my coumadin intake. I was taking 6mg coumadin now I'm down to 3 1/2 mg tablets. My INR range should be 2.5. My doctors can't figure out why my readings are so high. Since I had this valve replacement I havn't been right, I'm tired and weak all the time. I'm hoping with time and God's help I can get back to normal.

Doris Smith
Woodbridge, Va
MVR/4-6-2000

[LUVMyBirman]

Hi Doris

It takes time for most to get regulated. In my case, longer than usual it seems. Funny thing is...I am on the original dose they started me out on post op. Post surgery it was too much.... now it seems to fit. Go figure. Coumadin is a touchy medication.

Hope you get your other issues under control. Unfortunately my doctors will not allow me to take birth control do to the increased risks of clotting. Was surprised to see that you are taking them. I am sure you doctor has good reason.

Good luck....

[KristyW]

All,

I had AVR surgery in June, and I am taking 5mg per day of warfarin. I can honestly say that my menstrual cycles have not changed one bit. They are exactly the same as before my surgery. I'm 39 years old and not in the early stages of menopause as far as I can tell.

I also have been on the same dosage of warfarin since I got out of the hospital.

Maybe I'm just one of those people whose body is easy to regulate.I thought that there should be an opposing view about this from a woman who has "been there" for those who are researching their valve options.

Not all women experience the same things on warfarin.

[Rain]

Hey everyone,

I had my mitral valve replaced with a mechanical valve 4-6-00. My menstrual cycle is also EXACTLY the same as before my surgery. I was 39 years old at the time and have recently turned 41. As of about 4 months ago a blood test confirmed I am not in menopause.

I came home from the hospital taking 2 ½ mgs a day. I wasn’t eating a lot at the time, I think that’s why it was so low. My dose now fluctuates between 21mgs a week and 24.5 mgs a week.

I feel bad every time I belly ache about coumadin here in the forum. It really isn’t all that bad. I am perfectly happy with my choice to have a mechanical valve and taking coumadin.

I think most people do not have a problem maintaining their INR levels. But those people are not here grumbling about it like us lucky few who do have problems. I hope people researching valves realize that.

I think you are right Kristy, it’s good to hear from people who do not have the problems. Maybe we should take a poll. I betcha there would be a LOT more people who say they don’t have significant problems, than those who do. It would be interesting.

Oh, did I mention I had a hysterectomy when I was 35? One of the smartest things I ever did, and not just because it got rid of the cancer. :D

Rain

[Lisa in Katy]

Rain, you are so funny!

[allodwick]

Thanks Janie,

I wanted to ask but didn't want to risk an answer that men just did not understand.

[Rain]

Hey there, Janie lady!

It’s true! :) “My menstrual cycle is also EXACTLY the same as before my surgery”

Don’t bet on the ‘Immaculate conception’! lol Sara was born in June 1993, I had my last menstrual period in September 1995. Yippee!!

Al, I don’t believe there IS a question our Janie won’t ask! :eek: It’s probably best not to test her!!! :D

Rain

[allodwick]

Look where Kristy and Rain live. It must be the altitude. We get more radiation or something since the air is thinner.

[Rain]

Y’all got a lot of turnip trucks down there in Texas? :confused: Hmmm...... don’t think I’ve ever seen one in Cortez. :D