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Bouck EG, Arvanitis M, Osburn WO, Sang Y, Reventun P, Ahmadzia HK, Smith NL, Lowenstein CJ, Wolberg AS. High risk oral contraceptive hormones do not directly enhance endothelial cell procoagulant activity in vitro. PLoS One 2023; 18:e0284333. [PMID: 37075041 PMCID: PMC10115293 DOI: 10.1371/journal.pone.0284333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/28/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Oral contraceptive (OC) use increases venous thromboembolism risk 2-5-fold. Procoagulant changes can be detected in plasma from OC users even without thrombosis, but cellular mechanisms that provoke thrombosis have not been identified. Endothelial cell (EC) dysfunction is thought to initiate venous thromboembolism. It is unknown whether OC hormones provoke aberrant procoagulant activity in ECs. OBJECTIVE Characterize the effect of high-risk OC hormones (ethinyl estradiol [EE] and drospirenone) on EC procoagulant activity and the potential interplay with nuclear estrogen receptors ERα and ERβ and inflammatory processes. METHODS Human umbilical vein and dermal microvascular ECs (HUVEC and HDMVEC, respectively) were treated with EE and/or drospirenone. Genes encoding the estrogen receptors ERα and ERβ (ESR1 and ESR2, respectively) were overexpressed in HUVEC and HDMVEC via lentiviral vectors. EC gene expression was assessed by RT-qPCR. The ability of ECs to support thrombin generation and fibrin formation was measured by calibrated automated thrombography and spectrophotometry, respectively. RESULTS Neither EE nor drospirenone, alone or together, changed expression of genes encoding anti- or procoagulant proteins (TFPI, THBD, F3), integrins (ITGAV, ITGB3), or fibrinolytic mediators (SERPINE1, PLAT). EE and/or drospirenone did not increase EC-supported thrombin generation or fibrin formation, either. Our analyses indicated a subset of individuals express ESR1 and ESR2 transcripts in human aortic ECs. However, overexpression of ESR1 and/or ESR2 in HUVEC and HDMVEC did not facilitate the ability of OC-treated ECs to support procoagulant activity, even in the presence of a pro-inflammatory stimulus. CONCLUSIONS The OC hormones EE and drospirenone do not directly enhance thrombin generation potential of primary ECs in vitro.
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Affiliation(s)
- Emma G. Bouck
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Marios Arvanitis
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - William O. Osburn
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Yaqiu Sang
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Paula Reventun
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Homa K. Ahmadzia
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, George Washington University, Washington, DC, United States of America
| | - Nicholas L. Smith
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, United States of America
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA, United States of America
| | - Charles J. Lowenstein
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
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Douxfils J, Morimont L, Bouvy C. Oral Contraceptives and Venous Thromboembolism: Focus on Testing that May Enable Prediction and Assessment of the Risk. Semin Thromb Hemost 2020; 46:872-886. [DOI: 10.1055/s-0040-1714140] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AbstractCombined oral contraceptives (COCs) induce several changes in the levels of coagulation factors. The levels of procoagulant factors are often increased, while levels of anticoagulant factors are decreased. Fibrinolysis is also affected, even if the effect seems to be more counterbalanced by opposite regulation of profibrinolytic and antifibrinolytic factors. These effects on hemostasis are more pronounced with third- or fourth-generation COC compared with second-generation COC. Venous thromboembolism (VTE) risk increases when multiple risk factors, including genetic and environmental, are present simultaneously. COC use causes changes in coagulation that modify the prothrombotic state induced by preexisting hemostatic alterations in a supra-additive manner. Therefore, testing appears to be of importance not only before implementing COC but also to monitor any potential thrombogenicity induced by COC therapy. Inherited genetic factors, such as factor V Leiden, G20210A prothrombin mutation, antithrombin, protein C or protein S deficiencies, non-O blood group, as well as CYP2C9*2 and the rs4379368 mutations, have all been identified as genetic predictive risk factors of VTE in women. Nevertheless, the screening of these genetic biomarkers is not capable of assessing the phenotypic expression of the risk. This review will focus on the different options for screening the thrombogenic status in this population. Specific attention will be given to the endogenous thrombin potential-based activated protein C resistance, a test aiming at assessing the thrombogenicity induced by hormonal therapies and inherited or acquired thrombophilia.
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Affiliation(s)
- Jonathan Douxfils
- QUALIblood s.a., Namur, Belgium
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Faculty of Medicine, University of Namur, Namur, Belgium
| | - Laure Morimont
- QUALIblood s.a., Namur, Belgium
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Faculty of Medicine, University of Namur, Namur, Belgium
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Farris M, Bastianelli C, Rosato E, Brosens I, Benagiano G. Pharmacodynamics of combined estrogen-progestin oral contraceptives: 2. effects on hemostasis. Expert Rev Clin Pharmacol 2017; 10:1129-1144. [DOI: 10.1080/17512433.2017.1356718] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Manuela Farris
- Department of Gynecology, Obstetrics and Urology, Sapienza, University of Rome, Rome, Italy
- AIED, Rome, Italy
| | - Carlo Bastianelli
- Department of Gynecology, Obstetrics and Urology, Sapienza, University of Rome, Rome, Italy
| | - Elena Rosato
- Department of Gynecology, Obstetrics and Urology, Sapienza, University of Rome, Rome, Italy
| | - Ivo Brosens
- LIFE, Leuven Institute for Fertility and Embryology, Leuven, Belgium
| | - Giuseppe Benagiano
- Department of Gynecology, Obstetrics and Urology, Sapienza, University of Rome, Rome, Italy
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Rühl H, Schröder L, Müller J, Sukhitashvili S, Welz J, Kuhn WC, Oldenburg J, Rudlowski C, Pötzsch B. Impact of hormone-associated resistance to activated protein C on the thrombotic potential of oral contraceptives: a prospective observational study. PLoS One 2014; 9:e105007. [PMID: 25121606 PMCID: PMC4133351 DOI: 10.1371/journal.pone.0105007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 07/15/2014] [Indexed: 11/18/2022] Open
Abstract
Introduction The increased thrombotic risk of oral contraceptives (OC) has been attributed to various alterations of the hemostatic system, including acquired resistance to activated protein C (APC). To evaluate to what extent OC-associated APC resistance induces a prothrombotic state we monitored plasma levels of thrombin and molecular markers specific for thrombin formation in women starting OC use. Elevated plasma levels of thrombin have been reported to characterize situations of high thrombotic risk such as trauma-induced hypercoagulability, but have not yet been studied during OC use. Patients and Methods Blood samples were collected prospectively from healthy women (n = 21) before and during three menstruation cycles after start of OC. APC resistance was evaluated using a thrombin generation-based assay. Plasma levels of thrombin and APC were directly measured using highly sensitive oligonucleotide-based enzyme capture assay (OECA) technology. Thrombin generation markers and other hemostasis parameters were measured additionally. Results All women developed APC resistance as indicated by an increased APC sensitivity ratio compared with baseline after start of OC (p = 0.0003). Simultaneously, plasma levels of thrombin, prothrombin fragment 1+2, and of thrombin-antithrombin complexes did not change, ruling out increased thrombin formation. APC plasma levels were also not influenced by OC use, giving further evidence that increased thrombin formation did not occur. Conclusions In the majority of OC users no enhanced thrombin formation occurs despite the development of APC resistance. It cannot be ruled out, however, that thrombin formation might occur to a greater extent in the presence of additional risk factors. If this were the case, endogenous thrombin levels might be a potential biomarker candidate to identify women at high thrombotic risk during OC treatment. Large-scale studies are required to assess the value of plasma levels of thrombin as predictors of OC-associated thrombotic risk.
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Affiliation(s)
- Heiko Rühl
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
- * E-mail:
| | - Lars Schröder
- Department of Gynecology and Obstetrics, Center for Integrated Oncology (CIO) Köln/Bonn, University Hospital Bonn, Bonn, Germany
| | - Jens Müller
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Shorena Sukhitashvili
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Julia Welz
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
- Department of Gynecology and Obstetrics, Center for Integrated Oncology (CIO) Köln/Bonn, University Hospital Bonn, Bonn, Germany
| | - Walther C. Kuhn
- Department of Gynecology and Obstetrics, Center for Integrated Oncology (CIO) Köln/Bonn, University Hospital Bonn, Bonn, Germany
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Christian Rudlowski
- Department of Gynecology and Obstetrics, Center for Integrated Oncology (CIO) Köln/Bonn, University Hospital Bonn, Bonn, Germany
| | - Bernd Pötzsch
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
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Idiopathic acute renal vein thrombosis in a young healthy woman with no hypercoagulable state taking oral contraceptives. Am J Med Sci 2010; 339:380-2. [PMID: 20228670 DOI: 10.1097/maj.0b013e3181ce4f34] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Renal veins rarely thrombose. However, when they do, the cause is almost always obvious. The clinical circumstances underlying acute or chronic renal vein thrombosis are well defined. Interestingly, the use of oral contraceptive medications is not recognized among the risk factors for renal vein thrombosis. We report a case of spontaneous renal vein thrombosis in an otherwise healthy young woman taking an oral contraceptive. This report is intended to alert clinicians to a previously unknown and serious event associated with the use of a common medication.
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Dompmartin A, Ballieux F, Thibon P, Lequerrec A, Hermans C, Clapuyt P, Barrellier MT, Hammer F, Labbé D, Vikkula M, Boon LM. Elevated D-dimer level in the differential diagnosis of venous malformations. ARCHIVES OF DERMATOLOGY 2009; 145:1239-44. [PMID: 19917952 PMCID: PMC5561655 DOI: 10.1001/archdermatol.2009.296] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate if elevated D-dimer level is specific for venous malformations (VMs) and thus useful for differential diagnosis, which can be problematic even in specialized interdisciplinary centers. Localized intravascular coagulopathy, characterized by elevated D-dimer levels, has been observed in approximately 40% of patients with VMs. DESIGN Prospective convenience sample accrued from 2 interdisciplinary sites. SETTING Two interdisciplinary centers for vascular anomalies in Brussels, Belgium, and Caen, France PARTICIPANTS The study population comprised 280 patients with clinical data, Doppler ultrasonograms (for 251 patients), and coagulation parameter measurements. Main Outcome Measure Measurement of D-dimer levels. RESULTS A VM was diagnosed in 195 of 280 patients (69.6%), and 83 of them had elevated D-dimer levels; the sensitivity of D-dimer dosage was 42.6% (95% confidence interval, 35.6%-49.5%). Among the 85 patients without VM, D-dimer levels were elevated only in 3 patients; the specificity of the dosage was 96.5% (95% confidence interval, 92.5%-100%). CONCLUSIONS Elevated D-dimer level is highly specific for VMs (pure, combined, or syndromic), and therefore this easy and inexpensive biomarker test should become part of the clinical evaluation of vascular anomalies. It can detect hidden VMs and help differentiate glomuvenous malformation (normal D-dimer levels) from other multifocal venous lesions. Elevated D-dimer level also differentiates a VM from a lymphatic malformation. Moreover, slow-flow Klippel-Trenaunay syndrome (capillaro-lymphatico-venous malformation with limb hypertrophy) can be distinguished from fast-flow Parkes Weber syndrome (capillary malformation with underlying multiple microfistulas and limb hypertrophy). For these reasons, D-dimer level measurement is a useful complementary tool for diagnosing vascular anomalies in everyday practice.
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Affiliation(s)
- Anne Dompmartin
- Department of Dermatology, Université de Caen Basse Normandie, CHU Caen, Av Georges Clémenceau, 14033 Caen, France
| | - Fanny Ballieux
- Center for Vascular Anomalies, Division of Plastic Surgery, Université catholique de Louvain, Cliniques universitaires St Luc
| | - Pascal Thibon
- Department of Hygiene, Université de Caen Basse Normandie, CHU Caen, Av Georges Clémenceau, 14033 Caen, France
| | - Agnès Lequerrec
- Department of Hematology, Université de Caen Basse Normandie, CHU Caen, Av Georges Clémenceau, 14033 Caen, France
| | - Cédric Hermans
- Hematosis and Thrombosis Unit, Division of Haematology & Laboratory of Thrombosis and Haemostasis, Division of Biological Chemistry, Université catholique de Louvain, Cliniques universitaires St Luc
| | - Philippe Clapuyt
- Department of Radiology, Université catholique de Louvain, Cliniques universitaires St Luc
| | - Marie-Thérèse Barrellier
- Department of Dermatology, Université de Caen Basse Normandie, CHU Caen, Av Georges Clémenceau, 14033 Caen, France
| | - Franck Hammer
- Department of Radiology, Université catholique de Louvain, Cliniques universitaires St Luc
| | - Daniel Labbé
- Department of Plastic Surgery, Université de Caen Basse Normandie, CHU Caen, Av Georges Clémenceau, 14033 Caen, France
| | - Miikka Vikkula
- Laboratory of Human Molecular Genetics, Université catholique de Louvain, de Duve Institute, B-1200 Brussels, Belgium
| | - Laurence M Boon
- Center for Vascular Anomalies, Division of Plastic Surgery, Université catholique de Louvain, Cliniques universitaires St Luc
- Laboratory of Human Molecular Genetics, Université catholique de Louvain, de Duve Institute, B-1200 Brussels, Belgium
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Weiss C, Walter B, Dorsch MF, Bärtsch P. Fibrinolytic response to exercise in women using third-generation oral contraceptives. Blood Coagul Fibrinolysis 2006; 17:563-8. [PMID: 16988552 DOI: 10.1097/01.mbc.0000245301.10387.83] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The use of oral contraceptives (OC) is associated with an increased risk of thrombosis, suggesting OC exert procoagulant and/or antifibrinolytic effects. Given that physical exercise physiologically leads to an activation of blood coagulation and fibrinolysis, this study tested the hypothesis that OC might compromise the fibrinolytic response to exercise. Fibrinolytic variables were measured in 10 women (24 +/- 2 years) using OC (a formulation containing 30 micro g ethinylestradiol and 150 micro g desogestrel) and in 11 women without OC (mean +/- SD, 27 +/- 3 years) before, during and after a 1-h run on a treadmill at a velocity corresponding to an oxygen demand of 75-80% of maximum (anaerobic threshold). Exercise testing gave rise to considerable increases of tissue-type plasminogen activator antigen by seven-fold to eight-fold in women taking and not taking OC alike. In the presence of unchanged plasma levels of plasminogen activator inhibitor-1, exercise-induced release of tissue-type plasminogen activator led to enhanced plasmin formation with respect to plasmin-antiplasmin complexes, rising by (mean +/- standard error) 701 +/- 77 ng/ml (P < 0.001) in women using OC and by 695 +/- 117 ng/ml (P < 0.001 versus baseline; NS versus OC users) in controls. The fibrinolytic response to intensive physical exercise is preserved in women using OC and is similar to women not using OC.
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Affiliation(s)
- Claus Weiss
- Department of Internal Medicine VII/Sportsmedicine, University Hospital Heidelberg, Germany
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The effects of seven monophasic oral contraceptive regimens on hemostatic variables: conclusions from a large randomized multicenter study. Contraception 2003; 67:173-85. [PMID: 12618251 DOI: 10.1016/s0010-7824(02)00476-6] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We investigated the effects of ethinylestradiol dose (50, 30 and 20 microg) and progestogen type [desogestrel (DSG), gestodene (GSD), levonorgestrel (LNG) and norgestimate (NGM)] in oral contraceptives on 24 hemostatic variables. In a multicenter, randomized, comparative study, 707 healthy, nonsmoking, nulliparous women were treated for six cycles with one of the seven monophasic oral contraceptives tested. Significantly greater increases in prothrombin fragment 1+2 and factor VII (activity and antigen), were found in the DSG, NGM and GSD groups compared to the LNG group. Similarly, significantly lower levels of protein S (free and total) and increased APC-sr (endogenous thrombin potential based) were found in the same groups compared with the LNG group. In addition, the estradiol dose (50 vs. 30 microg) significantly influenced these parameters. All changes were within the normal range and have not been associated with an increased risk of venous thromboembolic event (VTE). However, raised levels of these variables are associated with prothrombotic states such as pregnancy. The significance of the haemostatic changes found in this study in relation to VTE risk remains to be determined, but results of this study probably cannot explain the differences in risk of VTE between OCs containing different progestogens.
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Hilberg T, Nowacki PE, Müller-Berghaus G, Gabriel HH. Changes in blood coagulation and fibrinolysis associated with maximal exercise and physical conditioning in women taking low dose oral contraceptives. J Sci Med Sport 2000; 3:383-90. [PMID: 11235004 DOI: 10.1016/s1440-2440(00)80005-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Blood coagulation parameters (thromboplastin time. PT; activated partial thromboplastin time, aPTT; fibrinogen; antithrombin III, ATIII; von Willebrand factor-concentration, vWF; factor VIII-activity, FVIII) and fibrinolytic parameters (plasminogen; (alpha-antiplasmin; euglobulin-lysis-time, Elt; tissue plasminogenactivator-antigen, tPA-antigen; plasminogenactivator-1-antigen, PAI-1-antigen) were evaluated in 34 women on low-dose oral contraceptives (OC) twice at intervals of 12 weeks each time before and after maximal exercise. During the 12 weeks, 24 women took part in an aerobic conditioning program and 10 women were requested to avoid any kind of sports activity for this period. Blood samples were taken before training and before and after maximal treadmill exercise. This procedure was repeated after the training program. After maximal exercise we found a significant reduction of aPTT and PT (increase in %), a decrease in ATIII, vWF, fibrinogen, plasminogen and alpha2-antiplasmin but an increase in fibrinolytic activity (all p<0.05). Maximal exercise is associated with an increase in blood coagulation and fibrinolysis also in women taking OC. After the physical conditioning program an increase in fibrinolytic activity at rest was noted in the training group. Opposed to that the fibrinolytic activity at rest decreased in the control group after abstinence of sports activity over this period (p<0.05, MANOVA).
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Affiliation(s)
- T Hilberg
- Department of Sports Medicine, Friedrich-Schiller-University Jena, Germany
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Riese H, Van Doornen LJ, Houtman IL, De Geus EJ. Job strain and risk indicators for cardiovascular disease in young female nurses. Health Psychol 2000; 19:429-40. [PMID: 11007151 DOI: 10.1037/0278-6133.19.5.429] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study examined the possible effects of job demands, decision latitude, and job-related social support on risk indicators for cardiovascular disease (CVD) in 165 female nurses. Job strain was measured with the Job Content Questionnaire; CVD risk was measured with insulin, total cholesterol, triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), fibrinogen, tissue-type plasminogen activator (tPA) antigen, tPA activity, plasminogen activator inhibitor-1 antigen, and blood pressure. Multivariate analysis of covariance and regression analyses revealed no effects of either job strain or social support on these risk indicators. All risk indicators deteriorated with age and body mass index. Oral contraceptive use improved fibrinolytic potential and increased HDL-C but had adverse effects on TG levels. Results suggest that in healthy young women job strain is not associated with an unfavorable metabolic or fibrinolytic risk profile.
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Affiliation(s)
- H Riese
- Department of Biological Psychology, Vrije Universiteit, Amsterdam, The Netherlands.
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Archer DF, Mammen EF, Grubb GS. The effects of a low-dose monophasic preparation of levonorgestrel and ethinyl estradiol on coagulation and other hemostatic factors. Am J Obstet Gynecol 1999; 181:63-6. [PMID: 10561678 DOI: 10.1016/s0002-9378(99)70366-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study was undertaken to evaluate the effects on hemostatic factors of a low-dose preparation of levonorgestrel and ethinyl estradiol in a 12-cycle study. STUDY DESIGN Thirty healthy women began taking 100 microg levonorgestrel and 20 microg ethinyl estradiol on the first day of the menstrual cycle, continued to take the preparation for the next 21 days, and then took placebo for 7 days. Mean changes in prothrombin time, partial thromboplastin time, and levels of factors VII and X, antithrombin, plasminogen, fibrinogen, protein S, thrombin-antithrombin complexes, and D-dimer were analyzed at baseline and at cycles 3, 6, and 12 with paired Student t tests. RESULTS Factor X, plasminogen antigen and activity, and D-dimer levels were significantly increased (P </=.01) during all 3 cycle periods. Antithrombin antigen and protein S total antigen levels were significantly (P </=.001 ) decreased at cycles 3, 6, and 12, whereas factor VII and protein S activity levels were significantly (P </=.05) decreased at cycle 3 and at cycles 3 and 6, respectively. CONCLUSION The effects on hemostatic factors in healthy women of a monophasic preparation of 100 microg levonorgestrel and 20 microg ethinyl estradiol were similar to those of other low-dose oral contraceptives.
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Affiliation(s)
- D F Archer
- Jones Institute for Reproductive Medicine, Eastern Virginia Medical School, Norfolk 23507-1627, USA
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Otterstetter R, Szymanski LM, Kamimori GH, Kessler CM, Gold MR, Fernhall B. Hemostatic responses to maximal exercise in oral contraceptive users. Am J Obstet Gynecol 1999; 181:958-63. [PMID: 10521761 DOI: 10.1016/s0002-9378(99)70332-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study examined the effect of exercise on markers of fibrinolysis and coagulation in users and nonusers of oral contraceptives. STUDY DESIGN Fourteen oral contraceptive users and 14 nonusers performed a maximal exercise test on a cycle ergometer. Blood samples were collected before and immediately after the completion of the test. A repeated-measures analysis of variance was used for statistical analysis with values considered significant at P =.05. RESULTS Acute maximal exercise resulted in significant increases in tissue plasminogen activator activity in both groups. There was a trend toward a smaller increase in tissue plasminogen activator activity in oral contraceptive users, but the difference between groups was not statistically significant. Plasminogen activator inhibitor 1 activity was reduced with exercise in both groups but with a significantly greater decrease observed in the nonusers (P <.0001). Prothrombin fragment 1+2 was significantly higher (P <.0001) in the oral contraceptive group but did not change with exercise. Epinephrine levels before and after exercise were similar between the 2 groups, but postexercise norepinephrine concentrations were significantly lower (P =.026) in the oral contraceptive users. CONCLUSION These data suggest that oral contraceptive use blunts the fibrinolytic response to exercise. This, together with increased coagulation activation in oral contraceptive users, may alter the hemostatic balance during exercise.
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Affiliation(s)
- R Otterstetter
- Exercise Science Programs, The George Washington University Medical Center, Washington, DC, USA
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Increased Clearance Explains Lower Plasma Levels of Tissue-Type Plasminogen Activator by Estradiol: Evidence for Potently Enhanced Mannose Receptor Expression in Mice. Blood 1999. [DOI: 10.1182/blood.v94.4.1330.416k19_1330_1336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Several clinical studies have demonstrated an inverse relationship between circulating levels of estrogen and tissue-type plasminogen activator (t-PA). The present study was designed to test the hypothesis that estrogens lower plasma levels of t-PA by increasing its clearance from the bloodstream. 17-Ethinyl estradiol (EE) treatment resulted in a significant increase in the clearance rate of recombinant human t-PA in mice (0.46 mL/min in treated mice v 0.32 mL/min in controls; P < .01). The clearance of endogenous, bradykinin-released t-PA in rats was also significantly increased after EE treatment (area under the curve [AUC], 24.9 ng/mL · min in treated animals v 31.9 ng/mL · min in controls; P < .05). Two distinct t-PA clearance systems exist in vivo: the low-density lipoprotein receptor-related protein (LRP) on liver parenchymal cells and the mannose receptor on mainly liver endothelial cells. Inhibition of LRP by intravenous injection of receptor-associated protein (RAP) as a recombinant fusion protein with Salmonella japonicum glutathione S-transferase (GST) significantly retarded t-PA clearance in control mice (from 0.41 to 0.25 mL/min; n = 5, P < .001) and EE-treated mice (from 0.66 to 0.35 mL/min; n = 5, P < .005), but did not eliminate the difference in clearance capacity between the 2 experimental groups. Similar results were obtained in mice in which LRP was inhibited via overexpression of the RAP gene in liver by adenoviral gene transduction. In contrast, administration of mannan, a mannose receptor antagonist, resulted in identical clearances (0.22 mL/min in controls and 0.24 mL/min in EE-treated mice). Northern blot analysis showed a 6-fold increase in mannose receptor mRNA expression in the nonparenchymal liver cells of EE-treated mice, whereas the parenchymal LRP mRNA levels remained unchanged. These findings were confirmed at the protein level by ligand blotting and Western blotting analysis. Our results demonstrate that EE treatment results in increased plasma clearance rate of t-PA via induction of the mannose receptor and could explain for the inverse relationship between estrogen status and plasma t-PA concentrations as observed in humans.
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Increased Clearance Explains Lower Plasma Levels of Tissue-Type Plasminogen Activator by Estradiol: Evidence for Potently Enhanced Mannose Receptor Expression in Mice. Blood 1999. [DOI: 10.1182/blood.v94.4.1330] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractSeveral clinical studies have demonstrated an inverse relationship between circulating levels of estrogen and tissue-type plasminogen activator (t-PA). The present study was designed to test the hypothesis that estrogens lower plasma levels of t-PA by increasing its clearance from the bloodstream. 17-Ethinyl estradiol (EE) treatment resulted in a significant increase in the clearance rate of recombinant human t-PA in mice (0.46 mL/min in treated mice v 0.32 mL/min in controls; P < .01). The clearance of endogenous, bradykinin-released t-PA in rats was also significantly increased after EE treatment (area under the curve [AUC], 24.9 ng/mL · min in treated animals v 31.9 ng/mL · min in controls; P < .05). Two distinct t-PA clearance systems exist in vivo: the low-density lipoprotein receptor-related protein (LRP) on liver parenchymal cells and the mannose receptor on mainly liver endothelial cells. Inhibition of LRP by intravenous injection of receptor-associated protein (RAP) as a recombinant fusion protein with Salmonella japonicum glutathione S-transferase (GST) significantly retarded t-PA clearance in control mice (from 0.41 to 0.25 mL/min; n = 5, P < .001) and EE-treated mice (from 0.66 to 0.35 mL/min; n = 5, P < .005), but did not eliminate the difference in clearance capacity between the 2 experimental groups. Similar results were obtained in mice in which LRP was inhibited via overexpression of the RAP gene in liver by adenoviral gene transduction. In contrast, administration of mannan, a mannose receptor antagonist, resulted in identical clearances (0.22 mL/min in controls and 0.24 mL/min in EE-treated mice). Northern blot analysis showed a 6-fold increase in mannose receptor mRNA expression in the nonparenchymal liver cells of EE-treated mice, whereas the parenchymal LRP mRNA levels remained unchanged. These findings were confirmed at the protein level by ligand blotting and Western blotting analysis. Our results demonstrate that EE treatment results in increased plasma clearance rate of t-PA via induction of the mannose receptor and could explain for the inverse relationship between estrogen status and plasma t-PA concentrations as observed in humans.
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Lundberg V, Asplund K, Evrin PE, Eliasson M. Oral contraceptives and oestrogen replacement therapy as determinants of plasma fibrinogen level and fibrinolytic activity the northern sweden MONICA study. ACTA ACUST UNITED AC 1998. [DOI: 10.1016/s0268-9499(98)80389-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Gebara OC, Mittleman MA, Walsh BW, Lipinska I, Welty FK, Bellotti G, Muller JE, Sacks FK, Tofler GH. Fibrinolytic potential is significantly increased by oestrogen treatment in postmenopausal women with mild dyslipidaemia. Heart 1998; 80:235-9. [PMID: 9875081 PMCID: PMC1761087 DOI: 10.1136/hrt.80.3.235] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To study the effects of oestrogen replacement treatment on fibrinolytic potential in postmenopausal women. DESIGN Randomised, double blind, placebo controlled trial of oral 17 beta-oestradiol. SETTING Subjects were evaluated in the outpatient setting. PATIENTS Nineteen postmenopausal women with mild dyslipidaemia, aged 44 to 69 years (mean (SD) 55.7 (6.7)). MAIN OUTCOME MEASURES Fibrinolytic activity (fibrin plate assay) and tissue plasminogen activator (t-PA) antigen were measured at baseline and after three, six, and nine weeks of each treatment. RESULTS After nine weeks of 2 mg oestradiol treatment, there was a significant increase in fibrinolytic potential compared with placebo, as indicated by an increase in fibrinolytic activity (mean (SEM), 80 (9) v 54 (5) mm2 of lysis in the fibrin plate, 2 mg v placebo, p = 0.002) and a decrease in t-PA antigen (5.8 (0.9) v 8.4 (1.2) ng/ml, 2 mg v placebo, p < 0.001). There was a similar trend with the 1 mg dose but the changes were less noticeable. CONCLUSIONS Hormone replacement treatment with 17 beta-oestradiol for nine weeks significantly increased fibrinolytic potential in postmenopausal women with mild dyslipidaemia. This suggests that the cardioprotective effect of oestrogen may be mediated, in part, by an increase in fibrinolytic potential.
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Affiliation(s)
- O C Gebara
- Institute for Prevention of Cardiovascular Disease, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Giri S, Thompson PD, Taxel P, Contois JH, Otvos J, Allen R, Ens G, Wu AH, Waters DD. Oral estrogen improves serum lipids, homocysteine and fibrinolysis in elderly men. Atherosclerosis 1998; 137:359-66. [PMID: 9622279 DOI: 10.1016/s0021-9150(98)00022-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The effects of estrogen on cardiovascular risk factors have been less well defined in men than in women. We measured lipid and lipoprotein concentrations, lipoprotein particle size distributions, lipoprotein (a), homocysteine, and markers of thrombosis and fibrinolysis in 18 [corrected] healthy elderly men (age 74 +/- 3 years, mean +/- S.D.) before and after 9 weeks of treatment with 0.5, 1 or 2 mg/day of oral micronized 17beta-estradiol. LDL-C (-6%), apo B (-9%), triglyceride (-5%), and homocysteine (-11%) concentrations decreased with estradiol, whereas HDL-C (+14%) increased. Intermediate-size VLDL subclass concentrations were lowered and LDL and HDL subclass levels altered in such a way as to cause average LDL and HDL particle size to increase. Lipoprotein (a) did not change. Fibrinogen (-13%) and plasminogen activator inhibitor-1 (PAI-1) concentrations (-26%) decreased, but there were no changes in thrombotic markers including thrombin-antithrombin III complex, prothrombin fragment 1.2, D-dimer, antithrombin activity, protein-C and S and von Willebrand factor antigen. Breast tenderness occurred in four men and heartburn in five but did not require discontinuation of treatment. We conclude that oral estrogen in men reduces homocysteine, fibrinogen, and PAI-1 concentrations and favorably influences VLDL, LDL and HDL subclass levels without increasing markers of thrombotic risk.
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Affiliation(s)
- S Giri
- Division of Cardiology, Hartford Hospital, CT 06102-5037, USA.
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19
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Norris LA, Bonnar J. Haemostatic changes and the oral contraceptive pill. BAILLIERE'S CLINICAL OBSTETRICS AND GYNAECOLOGY 1997; 11:545-64. [PMID: 9488791 DOI: 10.1016/s0950-3552(97)80027-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Oral contraceptives have been linked to an increased incidence of thrombovascular disease. This may be mediated by their effects on the haemostatic system. An increase in the activity of coagulation Factors VII, X and fibrinogen occur with pill usage. Increased Factor VII levels are dependent on both the oestrogen and progestogen component of the oral contraceptive. A reduction in antithrombin III levels has also been observed in some but not all studies. Increased fibrinolysis has also been shown in oral contraceptive users which should balance the changes in the coagulation pathway. The increase in fibrinolytic potential is thought to be due to a decrease in the levels of plasminogen activator inhibitor I combined with an increase in the levels of plasminogen; tissue plasminogen activator antigen is decreased in most studies. The increased levels of endpoints of coagulation and fibrinolysis in pill users indicate that enhanced activity of both systems is occurring in vivo. The increased coagulation activity appears to be balanced by the rise in fibrinolytic activity, so preserving haemostatic balance. Enhanced platelet activity has also been shown in women taking oral contraceptives. Thrombus formation can result, however, when local vascular wall damage exists, or when other risk factors for thrombo-embolism, such as older age and smoking, coexist and create a local activation resulting in a thrombus. In these situations, the small differences in levels of coagulation factors in women taking different oral contraceptive formulations may be important. Pills containing the lowest doses of oestrogen (20 micrograms ethinyloestradiol) have shown the least changes in haemostatic factors. The progestogen component of the pill modifies the effect of oestrogen on the haemostatic system.
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Affiliation(s)
- L A Norris
- Department of Obstetrics and Gynaecology, St James's Hospital, Dublin, Ireland
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20
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Quehenberger P, Loner U, Kapiotis S, Handler S, Schneider B, Huber J, Speiser W. Effects of third generation oral contraceptives containing newly developed progestagens on fibrinolytic parameters. ACTA ACUST UNITED AC 1997. [DOI: 10.1016/s0268-9499(97)80101-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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21
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Houlihan CM, Knuppel RA, Vintzileos AM, Guo JZ, Hahn DW. The effect of specific hormones on fibrinolysis in pregnancy. Am J Obstet Gynecol 1996; 175:168-72. [PMID: 8694045 DOI: 10.1016/s0002-9378(96)70269-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Plasminogen activator inhibitor-1, the major serum protease inhibitor of fibrinolysis, increases steadily during pregnancy. The study objective was to examine four hormones, namely, estradiol-17 beta, progesterone, prolactin, and hydrocortisone to determine their individual contributions in the production of tissue plasminogen activator antigen, plasminogen activator inhibitor-1 antigen, and plasminogen activator inhibitor-1 activity. STUDY DESIGN Human umbilical vein endothelial cells were grown with physiologic third-trimester concentrations of the above hormones, and fibrinolytic parameters were measured. RESULTS Of the four hormones evaluated, only hydrocortisone significantly increased plasminogen activator inhibitor-1 antigen and activity at both concentrations tested (p < 0.001). Estradiol-17 beta significantly increased tissue plasminogen activator antigen and progesterone significantly decreased tissue plasminogen activator antigen, but neither affected the overall fibrinolytic balance. CONCLUSION Hydrocortisone demonstrated antifibrinolytic properties at physiologic concentrations in pregnancy, suggesting that there may be a role for hydrocortisone in the prothrombotic tendency associated with pregnancy. The overall process of fibrinolysis was unaffected by estradiol-17 beta, progesterone, or prolactin.
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Affiliation(s)
- C M Houlihan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, St. Peter's Medical Center, USA
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Beer NA, Jakubowicz DJ, Matt DW, Beer RM, Nestler JE. Dehydroepiandrosterone reduces plasma plasminogen activator inhibitor type 1 and tissue plasminogen activator antigen in men. Am J Med Sci 1996; 311:205-10. [PMID: 8615394 DOI: 10.1097/00000441-199605000-00002] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Dehydroepiandrosterone (DHEA) may help prevent heart disease in men. To test the hypothesis that DHEA might exert its effects by enhancing endogenous fibrinolytic potential, a double-blind, placebo-controlled study was conducted that assessed the effects of DHEA administration on plasma plasminogen activator inhibitor type 1 (PAI-1) and tissue plasminogen activator (tPA) antigen. Eighteen men received 50 mg DHEA orally and 16 men received a placebo capsule thrice daily for 12 days. Serum DHEA-sulfate and plasma PAI-1 and tPA antigen were measured before and after treatment. In the DHEA group, serum DHEA-sulfate (from 7.5 +/- 1.2 micromol/L to 20.2 +/- 1.5 micromol/L (P < 0.0001), androstenedione (from 2.6 +/- 0.2 nmol/L to 4.0 +/- 0.4 nmol/L; P < 0.005) and estrone (from 172 +/- 21 pmol/L to 352 +/- 28 pmol/L; P < 0.005) increased, whereas plasma PAI-1 (from 55.4 +/- 3.8 ng/mL to 38.6 +/- 3.3 ng/mL; P < 0.0001) and tPA antigen (from 8.1 +/- 1.9 ng/mL to 5.4 +/- 1.3 ng/mL; P < 0.0005) decreased. In the placebo group, serum DHEA-sulfate declined slightly from 8.0 +/- 3.3 micromol/L to 7.3 +/- 3.4 micromol/L (P < 0.05), but no other measured steroid changed. Plasma PAI-1 and tPA antigen did not change in the placebo group. These findings suggest that DHEA administration reduces plasma PAI-1 and tPA antigen concentrations in men.
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Affiliation(s)
- N A Beer
- Department of Internal Medicine, Hospital de Clinicas Caracas, Fundación Cardiovascular Congreso National, Venezuela
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23
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Dehydroepiandrosterone Reduces Plasma Plasminogen Activator Inhibitor Type 1 and Tissue Plasminogen Activator Antigen in Men. Am J Med Sci 1996. [DOI: 10.1016/s0002-9629(15)41696-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Vegeto E, Wagner BL, Imhof MO, McDonnell DP. The molecular pharmacology of ovarian steroid receptors. VITAMINS AND HORMONES 1996; 52:99-128. [PMID: 8909158 DOI: 10.1016/s0083-6729(08)60408-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- E Vegeto
- Milano Molecular Pharmacology Laboratory, University of Milan, Italy
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25
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Gebara OC, Mittleman MA, Sutherland P, Lipinska I, Matheney T, Xu P, Welty FK, Wilson PW, Levy D, Muller JE. Association between increased estrogen status and increased fibrinolytic potential in the Framingham Offspring Study. Circulation 1995; 91:1952-8. [PMID: 7895352 DOI: 10.1161/01.cir.91.7.1952] [Citation(s) in RCA: 186] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Although extensive evidence indicates that estrogen is responsible for the markedly decreased cardiovascular risk of premenopausal women, the mechanism through which estrogen might exert its protective effect has not been adequately explained. Since thrombosis is now recognized to play an important role in the onset of cardiovascular disease, we investigated the relation between estrogen status and fibrinolytic potential, a determinant of thrombotic risk. METHODS AND RESULTS We determined levels of plasminogen activator inhibitor (PAI-1) antigen and tissue plasminogen activator (TPA) antigen in 1431 subjects from the Framingham Offspring Study. Fibrinolytic potential was compared between subjects with high estrogen status (premenopausal women and postmenopausal women receiving hormone replacement therapy) and low estrogen status (men and postmenopausal women not receiving hormone replacement therapy). In all comparisons, subjects with high estrogen status had greater fibrinolytic potential (lower PAI-1 levels) than subjects with low estrogen status. First, postmenopausal women receiving estrogen replacement therapy had lower levels of PAI-1 than those not receiving therapy (13.0 +/- 0.5 versus 19.5 +/- 1.0 ng/mL, P < .001). Second, premenopausal women had lower levels of PAI-1 than men of a similar age (14.8 +/- 0.6 versus 20.3 +/- 0.8 ng/mL, P < .001); this sex difference diminished when postmenopausal women not receiving hormone replacement therapy were compared with men of a similar age (19.6 +/- 0.7 versus 21.1 +/- 0.7 ng/mL, P = .089). Third, premenopausal women had markedly lower levels of PAI-1 antigen than postmenopausal women not receiving estrogen therapy (14.8 +/- 0.6 versus 19.5 +/- 1.0 ng/mL, P < .001). The between-group differences observed for TPA antigen were similar to those for PAI-1 antigen. CONCLUSIONS Each of these comparisons indicates that the cardioprotective effect of estrogen may be mediated, in part, by an increase in fibrinolytic potential. These findings might provide at least a partial explanation for the protection against cardiovascular disease experienced by premenopausal women, and the loss of that protection following menopause.
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Affiliation(s)
- O C Gebara
- Institute for Prevention of Cardiovascular Disease, Deaconess Hospital, Boston, Mass 02215
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