Conjugated estrogens and hypercoagulability

Impact of Sex Differences on Mortality in Patients With Sepsis After Trauma: A Nationwide Cohort Study

Objective

Sepsis is the leading cause of death in intensive care units, and sepsis after trauma is associated with increased mortality rates. However, the characteristics of sepsis after trauma remain unknown, and the influence of sex on mortality remains controversial. This study aimed to assess the role of sex in in-hospital mortality in patients with sepsis after trauma.

Methods

We performed a retrospective cohort study involving several emergency hospitals (n=288) in Japan. The data of patients with trauma who developed sepsis after admission from 2004 to 2019 were obtained from the Japan Trauma Data Bank. We divided the patients into two groups according to sex and compared their in-hospital mortality. We also performed subgroup analysis limited to the elderly population (age ≥ 65 years) and evaluated in-hospital mortality between men and women.

Results

A total of 1935 patients met the inclusion criteria during the study period. Of these, 1204 (62.2%) were allocated to the male group and 731 (37.8%) to the female group. Multivariable Cox proportional-hazards analysis showed a significantly lower risk of in-hospital mortality in the female group than in the male group (hazard ratio (HR): 0.74, 95% confidence interval (CI): 0.62–0.89; p=0.001). In the subgroup analysis, multivariable Cox proportional hazards still showed significantly lower risks of in-hospital mortality in the female group than in the male group (HR: 0.72, 95% CI: 0.58–0.88; p=0.002).

Conclusion

The present study shows a significantly increased survival in the female group when compared to that in the male group of patients with sepsis after trauma. The underlying mechanism remains unclear, and further investigations are required.

Female platelets have distinct functional activity compared with male platelets: Implications in transfusion practice and treatment of trauma-induced coagulopathy

BACKGROUND

Females are hypercoagulable and have survival benefit in trauma-induced coagulopathy (TIC). The mechanism for this sex-specific hypercoagulability is unknown. Platelets and platelet function are central in providing hemostatic potential and are the largest contributor to clot strength. Ligands (adenosine diphosphate [ADP] and platelet-activating factor [PAF]) bind distinct platelet receptors to potentiate activation and aggregation. We hypothesize that female platelets have a differential response to ADP and PAF, resulting in greater aggregation and activation compared to males, and that estradiol pretreatment of male or female platelets enhances this activity.

METHODS

Platelets were collected from healthy volunteers: premenopausal/postmenopausal females (≤54 years, >54 years) and similarly aged males. Platelet aggregometry and flow cytometry (fibrinogen binding capacity) were examined. After treatment with ADP or PAF, platelet aggregation was assessed with Chronolog and activation assessed by CD41 receptor surface expression using flow cytometry. Aggregation and activation were again assessed after platelet pretreatment with estradiol.

RESULTS

Healthy volunteers included 12 premenopausal and 13 postmenopausal females and 18 similarly aged males. Female platelets (combined premenopausal and postmenopausal) had increased aggregation with ADP stimulation, as compared to male platelets. Male and female platelets had differential fibrinogen receptor expression, with female platelets (combined premenopausal and postmenopausal) demonstrating robust activation with ADP versus male platelets with PAF. In the presence of estradiol incubation, male platelets' activation with PAF approximated that of females (combined premenopausal and postmenopausal) and activation with PAF was enhanced in both male and female platelets.

CONCLUSION

Male and female platelets have differential response to stimuli, suggesting sex-dependent signaling and cellular activation. Female platelets have both increased aggregation and activation potential, and estradiol pretreatment feminizes male platelets to approximate female platelet activation with PAF. These findings offer potential explanation for sex-based differences in hemostatic potential in TIC and question whether donor sex of transfused platelets should be considered in resuscitation. Estradiol may also serve as a novel therapeutic adjunct in TIC.

Thromboelastographic and hemostatic characteristics in pediatric patients with sickle cell disease

CONTEXT

Patients with sickle cell disease suffer from a variety of vaso-occlusive events that may be related to activation of the hemostatic system. Thromboelastography assesses the functionality of this system from a global standpoint and has demonstrated some utility in detecting hypercoagulable states in varied clinical settings, but it has not been systematically evaluated in patients with sickle cell disease.

OBJECTIVE

To characterize the findings of thromboelastography in patients with sickle cell disease during periods of steady state and illness, to compare these results with those of healthy controls, and to correlate these profiles with other measured hemostatic parameters.

DESIGN

In this cross-sectional study, we obtained thromboelastographic and other hemostatic data on specimens from 46 patients with sickle cell disease (35 with hemoglobin SS, 7 with hemoglobin SC, and 4 with hemoglobin S-beta thalassemia) and 20 healthy race-matched controls. Data were obtained from patients with sickle cell disease at baseline conditions (n = 41) and in the setting of acute illness (n = 5).

RESULTS

Patients with hemoglobin SS had lower reaction time and higher angle, maximum amplitude, and coagulation index values on thromboelastography than the control group. Hemoglobin SC patients had higher angle, maximum amplitude, and coagulation index values than controls. Hemoglobin S-beta thalassemia patients showed no significant differences compared with controls. Five hemoglobin SS patients with recent or current illness demonstrated increased maximum amplitude and coagulation index compared with hemoglobin SS patients at baseline conditions.

CONCLUSIONS

Patients with sickle cell disease demonstrated a significant hypercoagulable state in thromboelastography profiles, with the degree of abnormality dependent on the type of sickle cell disease and perhaps the presence of acute illness. Continued follow-up of this patient cohort, as well as further study of larger and more homogeneous patient groups, is required to adequately assess the utility of thromboelastography in predicting complications of sickle cell disease.

Low-dose oral contraceptive effects on thromboelastogram criteria and relationship to hypercoagulability

OBJECTIVE

The study was undertaken to assess hypercoagulability, by using thromboelastography, in women who use low-dose oral contraceptives (OCs).

STUDY DESIGN

Forty-three women using low-dose OCs (<or=35 microg ethinyl estradiol) underwent thromboelastography before starting OCs and again during the third month of OC use. Prior and 3-month mean values of four thromboelastogram parameters (maximum amplitude [MA], K time, alpha angle, and R time) were compared by using paired t tests. Comparison according to progestin type was also performed with unpaired t tests.

RESULTS

Prior versus 3-month values for MA, alpha, and K were not significantly different (P values-K: 0.8; alpha:.34; MA: 0.49); power was adequate to detect small differences. The 3-month R time was decreased compared with pre-OC values (P =.025), although the magnitude of this change was not characteristic of hypercoagulability. Comparison according to progestin type demonstrated no difference.

CONCLUSION

We found no significant trend toward hypercoagulability in women who used low-dose OCs and who otherwise had no known thromboembolic risks.

Ischemic colitis associated with pseudoephedrine: four cases

OBJECTIVE

There is one previously reported case linking ischemic colitis and orally administered nasal decongestants containing pseudoephedrine (MEDLINE 1974-1998). We aimed to document an association between pseudoephedrine ingestion and ischemic colitis.

METHODS

We reviewed the cases of four women (ages, 37-50 yr) who presented with the sudden onset of colicky abdominal pain followed by hematochezia. Three patients had used medicine containing pseudoephedrine daily for approximately 1 wk before admission. The fourth patient had used pseudoephedrine chronically for 6 months. Two patients had no significant past medical history. One woman had presented 6 months earlier with ischemic colitis while taking both pseudoephedrine and hormone replacement therapy. This time she presented with ischemic colitis while not taking hormone replacement therapy, but still taking decongestants. Another woman had a history of ulcerative colitis, which had been quiescent for 10 yr. One patient had been a smoker; however, like the other patients she had no evidence of systemic vascular disease. On colonoscopy, all four patients had colitis, primarily affecting the splenic flexure in the anatomical watershed area. Other causes of segmental colitis, including infectious colitides, pseudomembranous colitis, and Crohn's disease, were not evident. Colonoscopic biopsies were consistent with ischemic injury.

RESULTS

All cases responded to abstinence from pseudoephedrine and medical supportive therapy. None has had a relapse since discontinuing the pseudoephedrine (8-12 months).

CONCLUSIONS

The vasoconstrictive action of pseudoephedrine may predispose susceptible patients to develop ischemic colitis in the watershed area of the splenic flexure. Perimenopausal women may be especially susceptible because of irregular ovulation. This may result in relative vasoconstriction when estrogen levels are low or a hypercoagulable state when estrogen levels are excessive.

Thrombosis and hormone replacement therapy in postmenopausal women

OBJECTIVE

The effects of postmenopausal hormone replacement therapy on thrombosis remain controversial. We tested the hypothesis that estrogen or progesterone has no significant effect on thrombosis by means of newly developed markers of blood clotting, specifically prothrombin fragment 1 + 2, a marker of factor Xa generation, and thrombin-antithrombin III complex, a marker of thrombin generation.

STUDY DESIGN

A prospective study that included 106 women, 68 postmenopausal women on hormone replacement therapy and 38 postmenopausal controls, was performed. Plasma levels of prothrombin fragment 1 + 2 and thrombin-antithrombin III complex were measured by enzyme-linked immunosorbent assay. Multivariate analysis of the covariance was used for statistical analysis, controlling for patient's age because the hormone replacement therapy group was older.

RESULTS

There were no statistically significant differences between the hormone replacement therapy and control groups in either of the clotting parameters measured. A comparison of the levels of prothrombin fragment 1 + 2 and thrombin-antithrombin III complex in patients receiving estrogen alone or estrogen plus progestin also revealed no differences.

CONCLUSIONS

Current doses of postmenopausal hormone replacement therapy do not appear to enhance in vivo clotting. Thromboembolic complications among postmenopausal women receiving hormone replacement therapy may therefore be secondary to congenital or other acquired coagulation defects.

The effect of oestrogen on the female cardiovascular system

OBJECTIVE

To review the present state of knowledge regarding the effect of oestrogen on the female cardiovascular system (e.g. atherosclerosis, myocardial infarction, hypertension and thrombosis).

DATA SOURCES

Over 100 articles (most published over the last 10 years) were reviewed. They included epidemiological, biochemical, physiological, animal and clinical studies which related to the effect oestrogens have on the cardiovascular system of postmenopausal women. These data contained a wide cross-section of results and outcomes and each study was summarised to provide the most relevant information. Where a particular study provided an opinion or result at variance with the majority opinion, that study has been discussed in greater detail.

STUDY SELECTION

All published papers which appeared to be relevant to an understanding of the clinical implications of oestrogen replacement therapy and its impact on the female cardiovascular system were included in this analysis. Some papers which appeared to repeat data and results previously published were not included.

DATA SYNTHESIS

The overwhelming eight of evidence from this literature review supports the concept that oestrogen reduces the risk of atherosclerosis and myocardial infarction. It also confirms that postmenopausal "natural" oestrogen is a vasodilating agent which will lead to a fall in blood pressure and an improvement in blood flow and the pulsatility index. Although oral oestrogen did appear to increase thrombogenic activity, there was no clinical evidence that "natural" oestrogen taken after the menopause increased the risk of venous thrombosis.

CONCLUSIONS

The consensus of the published data is that oestrogen conveys a highly protective effect on the cardiovascular system of postmenopausal women. There will be a reduction of up to 50% in myocardial infarction and stroke, a reduction in the incidence of hypertension and an improvement in blood flow. Some of the data suggest that even for women who have suffered from an infarct, their long-term survival is enhanced by oestrogen therapy. The medical myth that oestrogen has a deleterious effect on the cardiovascular system of women is finally laid to rest.

Estrogen replacement therapy and the risk of venous thrombosis

PURPOSE

Estrogen replacement therapy is believed by many physicians to cause thrombophlebitis and to be contraindicated in women at risk for this disease. However, clinical data supporting this assumption are scant, and further investigation is required.

PATIENTS AND METHODS

We tested the estrogen-thrombophlebitis association in a case-control study. Charts of all consecutive women aged 45 years or older with a primary or secondary discharge diagnosis of thrombophlebitis, venous thrombosis, or pulmonary embolism were reviewed; 121 cases and 236 controls matched for age, year of admission, admitting service, and socioeconomic status were obtained. Hormone use and nonuse were validated in a subset of randomly selected women.

RESULTS

Cases and controls, whose average age was 65 years, did not differ significantly on matching variables or on current use of exogenous estrogen (5.1% of cases versus 6.3% of controls). Other analyses that variously excluded women with a past history of thrombosis, women less than 50 years of age, women with thrombosis occurring after admission, and women whose estrogen use was indeterminate also did not support an increased risk of thrombotic disease. Adjustment for the presence of independent thrombotic risk factors did not alter the odds ratio for estrogen use.

CONCLUSION

This case-control study of older women, unselected for other thrombotic risk factors, does not support the commonly held assumption that replacement estrogen increases the risk of venous thrombosis.

Estrogen replacement therapy is not conducive of venous thromboembolism

Continued resistance to the use of hormone replacement therapy in menopausal women persists, in part because of concern over a possible relationship between estrogen use and venous thromboembolism. Numerous studies, both retro- and prospective, have failed to yield any evidence of increased relative risk for thrombosis: specific investigations have consistently failed to link estrogen use to clinically significant adverse changes in coagulation factors. We feel that any linkage of menopausal estrogen use and risk of venous thromboembolism is based on anecdotal comments and medical superstition.

Blood coagulation profile in long-term hormone replacement therapy with mestranol

The coagulation profile of oophorectomised women on long-term (15 yr) hormone replacement therapy with mestranol (30 micrograms/day) is compared to that of women on long-term placebo. Analysis of these data showed no significant difference in prothrombin time, partial thromboplastin time or in anti-thrombin III level in these groups.

Effects of long-term Org OD 14 administration on blood coagulation in climacteric women

98 post-menopausal women were randomly allocated to either Org OD 14 [(7 alpha, 17 alpha)-17-hydroxy-7-methyl-19-norpregn-5(10)-en-20-yn-3-one] 2.5 mg/day or placebo. Treatment was continued for up to 6 yr. Any thromboembolic episode that occurred was recorded. Prothrombin time (PT), partial thromboplastin time (PTT), factor VII level and factor X level were measured prior to treatment and at yearly intervals. Antithrombin III level was measured in the last two yr of the study. There was one cerebrovascular accident after 3 months of placebo therapy but no other thromboembolic episodes. No significant difference was found between the effects of Org OD 14 and placebo with regard to any clotting factors at any time interval, although factor VII and factor X levels were consistently lower in the OD 14 group than in the placebo group. Antithrombin III levels measured after 5 and 6 yr were significantly higher (P less than 0.01) in the OD 14 group, suggesting a reduced risk of thrombosis in the treatment group.

Oestrogen replacement therapy: physiological considerations and new applications

The total impact of the menopause on the health of women and the ultimate benefit/risk ratio of oestrogen replacement therapy are yet to be defined completely. Until these are accomplished, broad general guidelines for the use of oestrogen replacement therapy in all patients cannot be given. Treatment should be individualized to the patient's specific needs. Use of appropriate dosages of oestrogen in combination with progestin administration should reduce risk and enhance benefits for those subjects requiring its use. The development of new non-oral methods of administration should also help.

Effects of percutaneous estradiol and conjugated estrogens on the level of plasma proteins and triglycerides in postmenopausal women

Percutaneous administration of estradiol (E2) is a new substitutive treatment for postmenopausal women. In order to compare hepatic action of percutaneous E2 with that of conjugated estrogens, 18 postmenopausal women were allocated at random to receive one of these two types of natural estrogens for 21 days. Eight patients (group I) received conjugated estrogens orally, 1.25 mg daily. Ten patients (group II) were told to apply percutaneous E2 ointment, 5 gm (i.e., 3 mg of E2), each evening on the abdominal skin. E2, estrone (E1), follicle-stimulating hormone (FSH), and luteinizing hormone (LH), and several markers of estrogen action were evaluated before and after treatment. Both types of treatment were biologically effective, as indicated by the decrease in plasma gonadotropins and the increase in estrogen levels. However, conjugated estrogens produced a greater increase in E1 than in E2; hence, the E2/E1 ratio was 0.57 in group I, whereas it was approximately 1 in group II. Plasma renin substrate increased significantly (by 180%) in group I but not in group II. In the same way, conjugated estrogens produced a modest (12%) but significant decrease in antithrombin III, whereas there was no variation with percutaneous E2. Sex steroid-binding protein was the most sensitive parameter for the hepatic action of estrogen, and increased by 18.66% with percutaneous E2 and by 150% with conjugated estrogens. Plasma triglycerides tended to increase in group I and to decrease in group II, but not significantly. Therefore, percutaneous administration of of E2, in contrast to conjugated estrogens, can produce plasma levels of estrogens closer to those observed in the follicular phase and less alterations in protein synthesis. This lesser toxicity may be explained partially by the route of administration, since with percutaneous administration of E2, the steroid bypasses the liver.

Effects of conjugated equine oestrogens and oestriol on blood clotting, plasma lipids and endometrial proliferation in post-menopausal women

The effects on blood-clotting factors, plasma lipids and endometrial proliferation of two types of oral oestrogen therapy (a) cyclical therapy with 0.625 mg/day conjugated equine oestrogens for 3 wk followed by 1 wk without treatment, and (b) continuous therapy with 2 mg/day oestriol) were investigated in a 5-mth study involving 22 post-menopausal women. Assays were performed in order to measure blood-clotting factors (activity of the factor II-VII-X complex, anti-thrombin III, euglobulin lysis time) and plasma lipids (total cholesterol, triglycerides, lipoprotein electrophoresis) before treatment and after 3 and 4 mth of treatment. The only significant change found to have occurred was a decrease in the beta: alpha lipoproteins ratio; this was greater in the group treated with conjugated equine oestrogens, but was also statistically significant in the group treated with oestriol. Endometrial proliferation was investigated indirectly by means of the medroxyprogesterone acetate (MPA) test before treatment and after 5 mth of treatment. The response to MPA at the end of 5 mth of treatment in patients previously unresponsive, showed endometrial proliferation to have occurred during treatment with conjugated equine oestrogens but not during treatment with oestriol.

Ischemic colitis in young adult patients

A retrospective study of ten patients suggests a possible causal relationship between the thrombogenic properties of estrogen-containing drugs and ischemic colitis, a disease entity believed to be related to occlusion of small blood vessels. We also emphasize that ischemic colitis is a disease limited not only to the elderly, and that it should be included in the differential diagnosis of colitis with bleeding in younger patients.

Considerations in the management of patients taking oral contraceptives

Among the undesirable effects associated with the use of oral contraceptives are an increased incidence of thromboembolic events, an increased risk of myocardial infarction, and, in certain users, a significant elevation in blood pressure. An altered fibrinolytic activity may have a direct effect on the occurrence of localized osteitis, "dry sockets." It is also possible that gingival inflammation and loss of attachment may occur even under conditions of adequate plaque control. Salivary changes and alterations in the bony trabecular pattern of the mandible have been observed, but the clinical significance is as yet undetermined (Illustration).

A study of blood coagulation parameters

The object of this study was to determine the presence or absence of abnormalities in a variety of blood coagulation parameters in women on contraceptive medication. A prospective double-blind study involving a control group with a total study enrollment of 211 women during a 29 month period was established. Although research has not proved that changes in coagulation parameters will cause abnormal clotting in normal patients, a pattern appears to be developing involving antithrombin III determinations. Corresponding patterns do not appear to be developing in the other blood coagulation parameters.