Would you consider using transdermal estrogen in a patient with “high risk” APLS patient on warfarin?

Given her clinical diagnosis of high-risk APS, I would first trial nonhormonal therapies or progesterone-only therapies for management of her post-menopausal symptoms. Current ACR guidance recommends against hormone replacement therapy in patients with APS on anticoagulation (Sammaritano et al., PMI...

The ACR guidelines apply to 1) patients with a Rheumatic/Musculoskeletal disease (RMD) AND APS/+aPLs. This short case stem doesn't mention an RMD. 2) Not those on anticoagulation, so really can't be referenced here.

We also know that the route of estrogen delivery greatly impacts VTE risk and that tr...

I wouldn't categorically rule out its use, but I would be very frank with the patient about risks and benefits. While transdermal estrogen is felt to have a much better VTE risk profile than oral estrogen, there is still largely a sense that there is some risk. In a patient with multiple types of th...