Aspirin-Induced Bleeding

Introduction to Aspirin-Induced Bleeding

Aspirin causes bleeding through its antiplatelet effects, which inhibit blood clotting, with the risk of aspirin-induced bleeding, including vaginal spotting, increasing with age (adjusted incidence rate ratio of 1.05 for each increasing year) 1

Concurrent medications, such as anticoagulants, increase the risk of aspirin-induced bleeding (pooled odds ratio of 1.36-1.42) 1
The risk of bleeding also increases when aspirin is combined with NSAIDs, anticoagulants, and selective serotonin reuptake inhibitors, as noted by the American Heart Association 1
Women with a history of gastrointestinal ulcers or upper GI pain, those taking other medications that affect clotting, and older women are at higher risk of aspirin-induced bleeding 2

The American College of Obstetricians and Gynecologists recommends ruling out other gynecological causes of spotting (hormonal imbalances, structural abnormalities, pregnancy complications, and infections) before attributing the cause to aspirin 1, 3
The optimal approach for women taking aspirin is to use the lowest effective dose that balances cardiovascular protection with bleeding risk, as the risk of bleeding is dose-dependent 1, 2
Even low-dose aspirin (75-100mg/day) can cause significant bleeding events, and aspirin increases the risk of major bleeding events in both men and women, including vaginal bleeding, due to its antiplatelet effects 2, 4
If aspirin is determined to be the cause of vaginal spotting, consider reducing the aspirin dose if clinically appropriate, or discontinuing aspirin in low-risk individuals after discussing risks and benefits 2, 5
For women with underlying bleeding disorders or those on other medications affecting hemostasis, aspirin's effect on vaginal bleeding may be more pronounced 2
Tranexamic acid is contraindicated in women taking aspirin due to thrombosis risk 6
In severe cases of persistent problematic bleeding, endometrial ablation or other interventions might be considered for women with completed childbearing who require continued aspirin therapy, although this is based on limited sources 6

The U.S. Preventive Services Task Force notes that aspirin use in women is associated with increased risk of major bleeding events (OR, 1.68 [CI, 1.13 to 2.52]) 2
The benefits of aspirin for secondary prevention of cardiovascular disease likely outweigh the risk of spotting, but the risks and benefits should be discussed with the patient 4