Fifteen years ago, a blood clot formed after I broke my leg. Before I got pregnant, I worked with a hematologist to understand if I needed specific care during pregnancy. Because blood tests didn’t show an elevated clotting risk, the protocol was six weeks postpartum on Lovenox. Now I am in perimenopause and having some rough symptoms (insomnia, hot flushes). My gynecologist has told me that HRT is not an option due to my clot history. However, my hematologist is comfortable with it because the clot was provoked. How can I best navigate this difference of opinion between my doctors?
—Anonymous
It is challenging as a patient to be caught between the differing opinions of two doctors. On one hand, your gynecologist is concerned that estrogen in the form of hormone therapy could increase your risk of forming a blood clot. On the other hand, your hematologist believes the risk of forming a clot is low because you don’t have a clotting disorder — we know people are at high risk for blood clots after certain types of fractures.

Estrogen, particularly oral conjugated equine estrogen, has been shown to increase the risk of blood clots in all women. However, transdermal estradiol in the form of a patch or gel has not been shown to do so. Based on that evidence, the Endocrine Society guidelines do not list a history of blood clot as an absolute contraindication to hormone therapy. Instead, they recommend using transdermal estrogen at the lowest dose that controls a patient’s symptoms.
That doesn’t solve your problem, though. Your doctors don’t agree on a recommended treatment course. The first step I would recommend would be to clarify your gynecologist’s concerns. Schedule a visit and prepare your questions in advance. Is it just that she feels your risk of forming a blood clot is too high to recommend hormone therapy, or does she have other concerns? What is her general opinion of hormone therapy? If hormone therapy is not an option for you, what non-hormonal options would she recommend?
Another option would be to ask your hematologist if they would be comfortable communicating with your gynecologist directly. Sometimes a quick phone call between doctors can help get everyone on the same page. I am always happy to reach out to a colleague to discuss a patient’s care and make sure we are all in agreement.
The goal of this conversation is not necessarily for the hematologist to convince the gynecologist to prescribe an estrogen patch. Rather, my approach is typically to understand why another doctor has reservations about a treatment. If I disagree, I am typically ready with data to support my opinion. Recently I wanted to prescribe estrogen for a patient, but her gynecologist was opposed. The patient wasn’t sure why. A quick call to the gynecologist revealed that the patient had a history of recurrent uterine polyps and estrogen could cause more polyps to grow. Once I understood her concern, I could adjust my recommendations accordingly.
If a conversation between your doctors does not resolve the issue, you could consider getting a second opinion from another gynecologist, another hematologist, or both. This may take an investment of time on your part, but if it helps you get your symptoms managed, it could definitely be worthwhile.
Ultimately, it can be frustrating to be stuck between two doctors’ opinions. Consider scheduling a visit to understand why your doctor is opposed to a treatment, ask the doctors to have a conversation about your case and see if they can reach a consensus, or seek a second opinion. Hopefully you can all arrive at a satisfactory plan.
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