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Paper Chase #3 | PERC Negative Patients Receive Excessive Testing

Nate Finnerty, MD and Brett Ebeling, MD
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A significant proportion of PERC-negative patients underwent testing for PE, suggesting an opportunity to better risk stratify these patients and reduce testing.

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Sam S. -

One part of PERC rule is hormone use, such as OCP. Can you apply the PERC rule to a patient with IUD or Nexplanon or is that considered the same as OCP?

Mizuho M., DO -

HI Sam - Good question! Hormone use is any type of hormone replacement therapy (HRT). Estrogen is the main thrombogenic culprit here, but progesterone can also have thrombogenic effects. So yes "nexplanon" or any HRT containing compound is included, regardless of the way it is delivered (oral, SubQ etc). When it comes to IUD's, it will depend if it is hormone containing or not. The classic copper IUD does not increase your PE risk, however even "levonorgesteral IUD" which theoretically only works locally along the endometrial lining has a thromboembolism warning. Perimenopausal women on HRT are also at risk. So back to PERC, its important to ask if a woman is on hormone supplementation and if so what type/form. Hope that helps! ~Miz

Mike W., MD -

Hi Sam,
Thx for the question - active search in progress!

Mike W., MD -

Here is the answer/comments by Brett Ebeling:
PERC includes any exogenous estrogen exposure, which includes not only oral contraceptive pills but also topical preparations. As such, I absolutely include these when assessing patients using PERC. In fact, some studies indicate an even higher risk of VTE with topical formulations such as vaginal rings and patches.
More complicated is the question of non-estrogen hormonal birth control agents- there is no real consensus as of yet but at this point it seems that there is an increased risk of VTE with these medications; just how much of an increase is hard to say at this point.
In short, my interpretation of the current literature: any estrogen not coming from the patient’s ovaries=increased risk, PERC positive. Non-estrogen hormonal birth control use=not technically covered by PERC but be aware of likely increased risk and thus increased pre-test probability.
Thanks for the question and thanks for listening!

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