Anticoagulation stewardship from menstruation to menopause: a toolkit for clinical management

The care of menstruating individuals on anticoagulation is complex and often overlooked in current clinical guidelines. Although existing recommendations address anticoagulant use broadly, they provide little guidance on managing menstrual bleeding, contraception, or reproductive transitions in this population. To address these gaps, we developed a practical clinical toolkit focused on anticoagulation stewardship for individuals who menstruate-from adolescence through menopause. This expert-driven resource outlines the best practices for identifying and managing heavy menstrual bleeding, optimizing contraceptive counseling, and coordinating care during high-risk periods such as pregnancy, surgery, and perimenopause. It also offers guidance for special populations, including adolescents, transgender and gender-diverse individuals, and those with limited access to care. Key topics include medication selection, dose adjustment, screening for anemia, and referral to gynecology when appropriate. The toolkit emphasizes the role of multidisciplinary teams-including hematology, gynecology, primary care, and anticoagulation services-in delivering patient-centered, equitable care. It also highlights practical strategies for integrating menstrual health into routine anticoagulation management, promoting shared decision making, and improving quality of life for affected individuals.