Use of a hormone-eluting vaginal ring for 1.5 months, compounded by immobility from a recent foot fracture, was associated with a massive pulmonary embolism in a 26-year-old woman.
Case Report (n=1)
Hormone-eluting vaginal rings can be associated with life-threatening massive pulmonary embolism, highlighting the need to reassess their use when additional prothrombotic risk factors like immobility arise.
Abstract Combination hormone-eluting vaginal rings are a popular non-oral combined hormonal contraceptive used by approximately 1.5 million women worldwide. Although their use is known to increase the risk of venous thromboembolism (VTE), reports of massive pulmonary embolism (PE) are rare. This case describes a massive PE in a young woman who had recently begun using a hormone-eluting vaginal ring.A 26-year-old woman with a history of abnormal uterine bleeding began using a hormone-eluting vaginal ring (etonogestrel/ethinyl estradiol) 1.5 months prior to presentation. Her medical history included asthma, anxiety, depression, PTSD, and a recent left foot fracture requiring a hard walking boot. That morning, she experienced blurry vision and dizziness followed by a syncopal episode while showering. In the emergency department, she was tachycardic to 119 but hemodynamically stable on room air. D-dimer was elevated at 6,319. CT pulmonary angiography revealed a severe acute PE involving bilateral main pulmonary arteries with a saddle thrombus extending into lobar, segmental, and subsegmental branches. The pulmonary trunk measured 3.8 cm (upper normal limit 2.7 cm for females), with interventricular septal bowing and an RV:LV ratio of 2.0. Point-of-care ultrasound showed severe RV dilation, septal bulging, and estimated pulmonary artery pressure of 65 mmHg. Lower extremity ultrasound demonstrated a left popliteal deep vein thrombosis. She was started on a heparin infusion and remained stable before undergoing thrombectomy the following morning, which revealed a significant clot burden. A formal echocardiogram three days later showed recovered RV function. She was discharged on apixaban with instructions to avoid hormonal contraception. Follow-up with hematology revealed a hypercoagulable workup negative for Factor V Leiden, Prothrombin gene mutation, anticardiolipin antibodies, and B2 glycoprotein.The vaginal ring delivers etonogestrel 0.120 mg and ethinyl estradiol 0.015 mg daily. Studies indicate similar VTE risk between oral and vaginal combination contraceptives; however, few case reports describe massive PE or discuss its severity. In this patient, a recent lower extremity fracture and limited mobility likely compounded the prothrombotic risk of hormonal contraception. This raises questions about when to discontinue the vaginal ring in patients with new risk factors. Clinicians should counsel patients using hormone-eluting vaginal rings on VTE risk and reassess use when additional risk factors arise. Early discontinuation during periods of immobility or trauma may help prevent life-threatening thromboembolic events. This abstract is funded by: None
Herman et al. (Fri,) conducted a case report in Massive pulmonary embolism (n=1). Hormone-eluting vaginal ring (etonogestrel/ethinyl estradiol) was evaluated. Use of a hormone-eluting vaginal ring for 1.5 months, compounded by immobility from a recent foot fracture, was associated with a massive pulmonary embolism in a 26-year-old woman.