Published reports have described the development of hypercoagulable states in patients who have been hospitalized with the novel coronavirus disease 2019 (COVID-19), prompting several experts and organizations to suggest the routine prophylactic use of coagulation with low-molecular weight heparin (LMWH) or unfractionated heparin in these patients.
According to authors of a new commentary published in Endocrinology, several questions remain regarding the effect of COVID-19 infection and hypercoagulation in the management of patients taking oral contraceptives, estrogen therapy, and patients who are pregnant.1
Combined oral contraceptives, for instance, can increase a patient’s risk of venous thromboembolism (VTE), and the risk of stroke is also increased in women and transgender women taking oral hormone replacement therapy or oral estrogen therapy. In addition to these concerns, a recent study has indicated that infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may be associated with increased thromboinflammation.2
Currently, there have been no published reports of increased VTE incidence in either pregnant women or women who take estrogen therapies who also have COVID-19. Regardless, concerns about how SARS-CoV-2 and estrogen may affect coagulation and VTE or stroke risk persist.
It may be important to note that researchers still do not know whether the microvascular thrombosis observed in severe COVID-19 can affect placental vasculature, and there is little understanding regarding the mechanisms underlying hypercoagulability alongside estrogen therapies and pregnancy in patients with COVID-19. Some reports have linked COVID-19-related coagulation-related abnormalities in hospitalized patients with increased D-dimer, fibrin, fibrinogen degradation products, and cytokines, among other factors.
There is also a lack of knowledge about the differences between pregnant women with COVID-19 and women with COVID-19 who receive estrogen therapies in terms of coagulation markers. Additionally, exact measures to reduce the risks of hypercoagulability in patients with COVID-19 who take oral contraceptives or estrogen therapies or in women who are pregnant have not been fully elucidated.
During this preliminary observational stage, clinicians and clinical investigators around the world continue to learn more about manifestations of hypercoagulability in patients with COVID-19. The authors of the Endocrinology commentary suggest that discussions between front-line clinicians and researchers as well as between “endocrinologists and hematologists should be nurtured to explore potential interactions between SARS-CoV-2 and pregnancy or estrogen therapy that could guide clinical management.”
1. Spratt DI, Buchsbaum RJ. COVID-19 and hypercoagulability: potential impact on management with oral contraceptives, estrogen therapy and pregnancy. Commentary. Endocrinology. Published online July 29, 2020. doi:10.1210/endocr/bqaa121
2. Manne BK, Denorme F, Middleton E, et al. Platelet gene expression and function in COVID-19 patients. Blood. Published only June 23, 2020. doi:10.1182/blood.2020007214/461106