So, thanks for having us. I've enjoyed very much for years being a member of AOSSM and ANNA and the forum, so this is a wonderful opportunity to report on our results of this study, looking at management of hormonal contraceptives during the perioperative period for anterior cruciate ligament reconstruction. This is a survey of the ANNA membership, and I want to thank the research committee for approving a distribution of that. I want to thank my co-authors, some of which are here, including some of my current fellows seated over there, Dr. Christian and Lander, former fellow Dr. Benazza, our research lead at Duke, Emily Renke, and this has been a great collaboration for me, also with some fellow forum members, including Dr. Mary Mulcahy and Dr. Julie Dodds, as well as Women's Health at Duke University Medical Center. So, by way of introduction, of course, VTE events are rare, but potentially catastrophic in serious complications after ACL surgery. The rates of DVT have been reported roughly in the range of a quarter of a percent to one percent. And if you think about how many ACL reconstructions are done per year, if we're talking about, say, 40,000, that could be ranging from 1,000 to 4,000 DVTs just for this surgery alone in our patient population. And, of course, PEs are less common. Rates for that range from .05 to roughly .2 percent among ACL reconstructions. Interestingly, the use of oral contraceptives, specifically combined oral contraceptives, is associated in and of itself with thromboembolic events, as is ACL reconstruction in low numbers. But when you kind of take the intersection point of these two risk factors, they probably then amplify each other. Also interesting, you know, the most common group of patients to be undergoing ACL reconstruction are younger women, who are then that same group who are also the most likely people to be utilizing these medications. Combine the fact that many of us treating these patients are not necessarily familiar with these medications, you know, it's an area of risk, really. So just kind of overview of, you know, what are hormonal contraceptives. These are medications that women utilize to prevent pregnancy, of course, but they have various forms. They could be oral contraceptives. Most of these are combined, meaning they include some form of exogenous estrogen. But they can also be transdermal. They can be delivered by a vaginal ring. And all of these things can be forms of combined hormonal contraceptives that include exogenous estrogen, which is the source of this increased risk for VTE events. So the exogenous estrogen increases plasma fibrinogen activation, which decreases antithrombin 3, which increases platelet aggregation. So these medications alone are, you know, even just as something to provide to patients, are contraindicated generally in women over 35 and smokers, because they increase this risk. So combine that with your surgical risk, and, you know, it's just something to think about. This recent study in arthroscopy, looking at the Truven database, showed that the use of combined oral contraceptives increases risk of VTE after ACL. Interestingly, among their subjects, one quarter of these patients were on combined oral contraceptives. So that's a large part of your population that are exposed to this risk. The risk of DVT or PE was twice as high in the patients on these combined oral contraceptives. And the patient was obese. It was three times as high if they were a smoker and on these medications, which, again, is generally contraindicated. So why are these people on it? You know, it's a question, but it was four times as high. So it really is elevating the risk. One thing I just wanted to put out there for people who are not familiar with these medications, a common medication you will see is called Mirena IUD. This is a progestin-only IUD, and it is not in that category of risk. It's not one of those combined oral contraceptives or combined, you know, any route of contraceptive. So our purpose was that we wanted to evaluate the management practices of orthopedic surgeons performing ACL reconstruction of female patients using hormonal contraceptives, including standard prophylaxis that they use, and how are they managing these medications perioperatively in terms of holding them or allowing patients to continue them. Our hypothesis is that there's really not a standard of care about how to manage these medications perioperatively, and that some surgeons may change their management based on the presence of risk factors, including hormonal contraceptives, and may alter their prophylaxis in relation to this. So this is a cross-sectional study, survey-based, of the ANA members. The survey was done through REDCap using branching logic. This was IRB-approved, developed by our research team, which included Women's Health as well as a few of our members here. And the study is designed to identify respondents' clinical decision-making regarding use of VTE prophylaxis after ACL reconstruction in patients without the added risk factor of contraceptives. The counseling of patients about the risk associated with hormonal contraceptives, and then practices in terms of do they modify their VTE prophylaxis in the presence of this risk factor, and what are their practices in terms of withholding these perioperatively. So looking at our respondents, we had 94, 63 percent male, 37 percent female, and fairly mixed practice types, but most commonly academic and private practice, followed by hospital employed, military, and other. In terms of ACLs performed per year, the overwhelming majority were doing over 30, but you can see 40 percent were doing greater than 50 of these per year. So this is a group of surgeons doing a fairly high number of these procedures. We found that in about two-thirds, pharmacologic prophylaxis was used at baseline in patients without any added risk factors. Reasons for using pharmacologic VTE prophylaxis were largely to reduce risk of a thrombobolic event, and 37 percent also to address medical legal concerns. In terms of VTE prophylaxis after ACL reconstruction, the most common regimens were aspirin-based. Clearly, the overwhelming majority of people who are using some sort of pharmacologic means were using aspirin with 325 daily being the most common. In terms of duration, really the most commonly reported duration was 14 days, but overall, the most common pattern is to use aspirin 325 daily for at least 14 days. You can see that some people are doing this longer in terms of the distribution of duration, with 47 percent of providers doing this for essentially a whole month. When we look at the concept of how often does a surgeon ask a female patient about hormonal contraceptive medications, you can see that about 10 percent of us never do, 14 percent of us rarely do, 9 percent sometimes do, 27 percent frequently do, and then 40 percent of us always do. We did ask our survey participants in terms of what patient population they've seen a VTE event in, and some of us have never apparently had a VTE after an ACL reconstruction, but two-thirds of us have. Among those who reported having had a VTE event after an ACL reconstruction, 32 percent said only in male patients, 24 percent had had them only in a female patient, and a third of those responding to this question had it in both male and female patients. In terms of how does the presence of a hormonal contraceptive perioperatively change your care plan in female patients, we know that among 55 percent of us, it doesn't, we're not altering what we do. Twelve percent said it depends on the type, meaning is it oral versus transdermal versus a vaginal ring, and a third of us said, yes, but I change my care plan in the same way no matter what way this hormonal contraceptive is administered. So of those said yes, how do you then change your care plan? Thirty percent said I asked the patient to stop the hormonal birth control perioperatively. Thirty-seven percent prescribed a pharmacologic prophylaxis even though they would not do so routinely. So this would be like, say, the person who doesn't use aspirin, but then they're going to use it in this population. Seven percent increased the dose of what they were already using. Ten percent increased the duration, and 23 percent used a different pharmacologic prophylaxis, so say someone who was normally using aspirin, but they might change it to Eliquis or something. So among those who, you know, don't always ask, you'd say, well, why might you not ask your patient about the use of these medications, seeing as they're a risk for a VTE event? Sixty-seven percent said it doesn't change my treatment, so I don't ask because I do the same thing anyway. Fifteen percent said the risk of the blood clots associated with these medications is low. Eighteen percent said I adjust my perioperative prophylaxis based on the medications listed in the medical records, so essentially a chart review to get this information. Six percent, interesting to say, it's just an uncomfortable subject, don't ask about it. Nine percent, parents with a minor presence, so not a good time to ask about it. And two percent said I don't think my patient would have any reason to be on this, so maybe like a much younger population, I would assume, or, you know, something like that. So among those who said, yes, I changed my plan for prophylaxis, but it depends on the type, meaning was it oral, was it transdermal, was it vaginally delivered, there's a lot of information up there, but I want to kind of summarize it for you on the left-hand panel there, which is basically that overall among those of us who kind of change our strategy based on the route, we tend to change it more aggressively if it's an oral contraceptive, so more likely to ask the patient to stop it, and more likely to prescribe prophylaxis even though we don't otherwise if it's an oral contraceptive. And this was a learning point for me, I have to say, working directly with our women's healthcare team at Duke, they have really enlightened me that these combined contraceptives, whether oral, transdermal, or vaginal, actually do create the same systemic effect in terms of exogenous estrogen, so they're all really a risk. But our answers to this question make me think that maybe we don't appreciate that as much and focus more on the oral contraceptives. So in terms of the effect of male versus female surgeon and the male versus female patients that we have had our own experiences with, we found that female surgeons were four times more likely to ask about hormonal contraceptive than male surgeons, and that female surgeons were almost three times more likely to change their prophylaxis if there was use of hormonal contraceptive. And that surgeons that have a female patient that had had a VTE after ACL reconstruction were three times more likely to ask about hormonal contraceptives, and that surgeons that had a female patient with a VTE event after ACL reconstruction were almost five times as likely to change their prophylaxis as a result of the patient being on hormonal contraceptive. So my takeaway from this is I think it's probably our own experiences, whether it's, you know, we had a female patient that had a DVT or a PE, and then we looked into the source, did a root cause analysis, and perhaps we learned about hormonal contraceptive as a risk. Or maybe it's because you are a female surgeon, and at some point in your own healthcare journey you were maybe personally counseled about risk benefits in all terms of these medications. But in any case, I would couch these as experiences that we have one way or another, either as an individual or in our female patients, perhaps, leading to these effects. So discussion and conclusions. There isn't a clear standard of care of what to do with hormonal contraceptive perioperatively in terms of do we hold it perioperatively, how long do we hold it pre and post, how do we need to adjust our prophylactic plan, and you can see a lot of us are using different strategies in response to our concerns about this. We do see that a surgeon's sex and prior clinical experience, meaning if they've had a female patient with a VTE event, does influence the likelihood to consider hormonal contraceptive in your care plan and to consider what is the risk of VTE after ACL reconstruction. And I think future research is needed to determine which patients of increased risk would benefit from altering their prophylaxis and really to determine what regimen we need to recommend in terms of timeframe of holding these medications that are a risk. Here's some references, and thanks for listening. I just want to add, the reason to do this study was in no way to point fingers at people who aren't asking these questions or aren't altering their treatment, but more to I think kind of assess what we know and don't know, and I just think it's a really great area that we can all learn more about. Thank you.

hormonal contraceptives

perioperative period

ACL reconstruction

thromboembolic events

management strategies