Hormonal contraception and thromboembolic disease: effects of the oral contraceptives on hemostatic mechanisms. A review of the literature

Oral Contraceptive Pills and Hypertension: A Review of Current Evidence and Recommendations

Oral contraceptive pills (OCPs) have been used as effective and popular forms of contraception since the middle of the last century. By 2019, over 150 million reproductive-aged individuals were using OCPs to prevent unintended pregnancies worldwide. Safety concerns regarding the effects of OCPs on blood pressure were reported soon after these pills gained approval. Although OCP doses were subsequently reduced, epidemiologic evidence continued to support a smaller, but significant association between OCPs and hypertension. Given the rising prevalence of hypertension, as well as the adverse effects of cumulative exposure to blood pressure elevations on cardiovascular disease risk, understanding the nature of the association between OCPs and hypertension is important for clinicians and patients to assess the risks and benefits of use, and make individualized decisions regarding contraception. Therefore, this review summarizes the current and historical evidence describing the association between OCP use and blood pressure elevations. Specifically, it identifies the pathophysiologic mechanisms linking OCPs to hypertension risk, describes the magnitude of the association between OCPs and blood pressure elevations, and distinguishes the effects of various OCP types on blood pressure. Finally, it describes current recommendations regarding hypertension and OCP use, as well as identifies strategies, such as over-the-counter OCP prescribing, to safely and equitably improve access to oral contraception.

Psychobehavioral Effects of Hormonal Contraceptive Use

Although female use of hormonal contraceptives (HCs) has been associated with a variety of physical side effects, the psychological and behavioral side effects have received comparatively little attention until recently. Indeed, the long-term impact of HC use on human psychology has been vastly under-researched and has only recently become a focus for mainstream scholars. Women who use HCs report higher rates of depression, reduced sexual functioning, and higher interest in short-term sexual relationships compared to their naturally-cycling counterparts. Also, HC use may alter women's ability to attract a mate, as well as the mate retention behaviors in both users and their romantic partners. Some evidence even suggests that HC use alters mate choice and may negatively affect sexual satisfaction in parous women, with potential effects on future offspring. Interestingly, HCs have become a standard method of population control for captive nonhuman primates, opening up exciting avenues for potential comparative research. Here, the existing literature on the psychobehavioral effects of HCs in humans and nonhuman primates is reviewed and discussed. The potential resulting downstream consequences for the path of human evolution and recommendations for how future research could tease apart the underlying causes of these psychobehavioral effects of HC use are discussed, including suggestions for research involving nonhuman primates.

Effects of oral contraceptives on coagulation factors in African women

Despite overwhelming evidence that the use of oral contraceptive pills (OCP) may lead to thrombotic episodes, no studies have been performed to investigate the effect of OCP on the coagulation profile in African women. We assessed the levels of fibrinogen, factors VIIc, and VIIIc as well as the fibrinolytic activity in 100 African women on OCP. Fibrinogen levels were significantly increased (p<0.001) and factors VIIc, VIIIc, and fibrinolytic activity significantly decreased (p<0.001) when compared with those of healthy women not on OCP. We conclude that the combination of hyperfibrinogenaemia and decreased fibrinolytic activity combined with a decrease in factor VIIc and VIIIc levels reflects a hemostatic imbalance in African women on OCP that needs to be investigated.

The effect of medroxyprogesterone acetate and clomiphene citrate on platelet function in menopausal women

OBJECTIVE

We sought to determine if antiestrogens such as clomiphene citrate (CC) and medroxyprogesterone acetate (MPA) affect platelet activity in postmenopausal patients before and after treatment with estrogens.

METHODS

Using an incubation study, we analyzed the effects of CC and MPA on adenosine diphosphate and adrenaline-induced platelet aggregation and on the release of adenosine triphosphate in postmenopausal patients, using a platelet study, we analyzed the effect of these drugs on platelet function.

RESULTS

Platelets were inhibited by MPA and CC in the incubation study but not significantly affected in the platelet study. Platelets previously incubated with estrogen were less inhibited by CC than by MPA.

DISCUSSION

Thus, platelet study to determine the optimal combination therapy for menopausal patients has indicated that CC has a non-significantly less beneficial in vitro effect on platelet function than MPA.

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.

Influence of oral contraceptives on coagulation tests in native blood and plasma

Routine coagulation laboratory tests, clotting times in native (not anticoagulated) whole blood, platelet-rich and platelet-poor plasma, and recalcification times in citrated whole blood, platelet-rich and platelet-poor plasma were performed in 14 healthy premenopausal women. Blood was taken before and after one or two cycles of low-dose oral contraceptives. After oral contraceptives a reduction in clotting time in native platelet-rich plasma and activated partial thromboplastin time were observed. Recalcification times in whole blood and platelet-rich plasma were shorter than clotting times in their native counterparts. The observed changes are compatible with a procoagulant effect seen soon after the start of oral contraceptive use. The absence of these changes in the recalcification times in citrate systems suggests a masking effect of citrate. The reduction in clotting times in native platelet-rich but not in platelet-poor plasma indicates that the hypercoagulability in oral contraceptives users is mainly related to platelets.

17 alpha-ethinylestradiol decreases production and release of prostacyclin in cultured human umbilical vein endothelial cells

Human umbilical vein endothelial cells (HUVEC) were incubated with the estrogen 17 alpha-Ethinylestradiol (30 ng/ml) in order to examine its regulating influence on synthesis and release of prostacyclin (PGI2). ATP (1 mg/ml) was used to stimulate PGI2-production through the purine receptors. We demonstrated that this level of estrogen decreases PGI2-synthesis by 11% and PGI2-release by 32% within 300 sec. Longer incubation times (48 hrs) resulted in the same inhibitory effect. Intracellular ATP content and methyl-3H-thymidine uptake demonstrated that the decrease of prostacyclin-concentration is not caused by reduced viability of the cells but by a direct inhibitory effect on prostacyclin synthesis and release.

Veno-occlusive disease of the liver in captive cheetah

Liver tissues from 126 captive cheetah were evaluated by light microscopy and histochemistry; eight animals were evaluated by electron microscopy. The main hepatic lesion, a vascular lesion resembling veno-occlusive disease (VOD) of the liver and characterized by subendothelial fibrosis and proliferation of smooth muscle-like cells in the central veins, was seen in 60% of the sexually mature cheetah. Although this hepatic vascular lesion was seen in cheetah as young as 1 year of age, the most severe lesions, usually associated with liver failure, were found in cheetah between the ages of 6 and 11. There was no sex predisposition, and in approximately 40% of the VOD cases, liver disease was not suspected clinically or at necropsy. VOD was found in other felidae, especially in the snow leopard. High levels of vitamin A in livers, as well as in diets of the cheetah, could be a contributing factor in the development of VOD in some groups of cheetah.

Oral contraceptive steroid induced platelet coagulant hyperactivity: dissociation of in vivo and in vitro effects

The use of oral contraceptives (OC) has been associated with an increased risk of thromboembolic events in a subset of women. Factors predisposing to this problem are still not clearly defined although an increased platelet coagulant activity (CA) has been reported. This study was designed to evaluate the CA of platelets from asymptomatic current OC users compared with control subjects. The asymptomatic OC users were found to have evidence of hypercoagulability in the form of increased availability of platelet CA. These findings were present in both collagen stimulated and unstimulated platelets. In order to understand the mechanism we examined the in vitro effects of estradiol and/or progesterone on platelets. Platelets from normal males were incubated for one hour with estrogen and/or progesterone. There was no significant difference in CA of hormone treated platelets compared with control platelets from the same donor. CA was analyzed in platelets exposed to epinephrine, adenosine diphosphate, and collagen in the platelet aggregometer. Although a dose dependent effect was observed on CA of platelets exposed to the range of aggregating agents, the results show no significant difference between CA of the hormone treated and control platelets (p greater than 0.05). Likewise, platelet aggregation and release of nucleotide were not different between hormone treated and control platelets. Thus a direct effect of the hormones on platelets is an unlikely mechanism causing the increased CA seen in OC users.

Dietary estrogens--a probable cause of infertility and liver disease in captive cheetahs

The cheetah in the wild is "racing towards extinction" mostly due to habitat destruction. Its survival will probably depend on accelerated captive breeding. At this time, however, reproductive failure and liver disease threaten the future of the captive cheetah population. Histopathological evaluation of more than 100 cheetah livers identified venocclusive disease as the main hepatic lesion responsible for liver disease in this species. Analysis of the commercial feline diet by high-performance liquid chromatography and gas-liquid chromatography-mass spectrometry revealed large amounts of two phytoestrogens identified as daidzein and genistein. These compounds were found to be derived from a soybean product that was a component of the cheetah diet, and their concentrations both ranged from 18 to 35 micrograms/g diet. The adult cheetah consequently consumes approximately 50 mg/day of these weak estrogens. When extracts of the diet were tested for estrogenicity using a bioassay, a dose-related increase in uterine weight was observed. In 4 cheetahs studied, withdrawal of this feline diet by substitution with a chicken diet resulted in an improvement in conventional liver function tests and a normalization in the appearance of hepatic mitochondria. We conclude that the relatively high concentrations of phytoestrogens from soybean protein present in the commercial diet fed to captive cheetahs in North American zoos may be one of the major factors in the decline of fertility and in the etiology of liver disease in this species. The survival of the captive cheetah population could depend upon a simple change of diet by excluding exogenous estrogen.

The effect of low-dose estroprogestinic preparations on prothrombin complex factors: no significant increase after an 8-month trial

The behavior of the prothrombin complex factors in 16 healthy women during low-dose estroprogestinic treatment (laevonorgestrel 0.15 mg and ethynilestradiol 0.30 mg) at basal conditions and during 8 months of therapy has been investigated. We found a statistically significant decrease of the PTT (Partial Thromboplastin Time). The prothrombin time, on the other hand, became slightly decreased, but not to a statistically significant extent. Among the prothrombin time derived tests for evaluating the prothrombin complex only the PP test (Prothrombin Proconvertin test) was significantly shortened. Of the coagulation factors (factors II, VII and X) only a modest, but not statistically significant, increase in Factor VII and Factor X was noted. We conclude that, during the 8 month observation period, prothrombin complex factors are not altered substantially.

Alteration of platelet responses to metabolites of arachidonic acid by oral contraceptives

The effects of oral contraceptive (OC) usage on platelet responsiveness to arachidonic acid metabolites was investigated. Platelets obtained from women who had been taking oral contraceptives for at least 3 months were compared with those of age-matched controls. Both the basal and prostacyclin (PGI2)-stimulated platelet cAMP levels were significantly lower in OC users than in non-users. There was no significant difference in the PGD2-stimulated cAMP levels between the two groups. Furthermore, platelet aggregability to U46619, a TXA2 agonist, was greatly enhanced by OCs. Our data suggests that OC usage can specifically enhance platelet responsiveness to TXA2 while suppressing platelet responsiveness to PGI2. Thus their overall effect would be a disruption of normal platelet responses in favour of thrombus formation.

Managing drug interactions with oral contraceptives

An increasing concern to nurses is the possibility of drug interactions involving oral contraceptives. Information regarding the mechanisms, significance, and management of drug interactions with oral contraceptives is provided. Approaches to counseling patients also are discussed.

Effect of conjugated estrogens on vaginal blood flow in surgically menopausal women

The effect of an intravenous bolus of 25 mg of conjugated estrogen (Premarin) on vaginal blood flow in seven surgically menopausal women was measured by a thermal conductance probe. Electrical power (0.8 W) was supplied to a resistance wire incorporated in the surface of the probe, and its surface temperature was monitored continuously for 30 minutes six times daily for 3 days. The mean temperature difference (delta T) between the heated probe surface and the vagina remained unchanged during a preinjection control day. While there were individual differences in response, analysis of mean delta T during the first day following the injection of the estrogen revealed a significant linear downward trend at delta T, indicating a rise in vaginal blood flow. Delta T plateaued on day 2 and showed a slight rise in the morning of day 3. It may be concluded that estrogen administered in this dose and form markedly increases vaginal blood flow.

Oral contraceptives, clotting factors, and thrombosis

Oral contraceptives (OCs) raise the plasma levels of some clotting factors, especially factor VII. Until recently, however, there has been no evidence for a relationship between high levels of clotting factor and the onset of clinically manifest vascular disease. It has not been established, on a preliminary basis, that high levels of factors VII and VIII and of fibrinogen in men are associated with an increased risk of death from cardiovascular disease. There is a strong relationship between OC estrogen dose and the level of factor VII, a clotting factor with a number of other characteristics, suggesting that high levels would be thrombogenic. A strong relationship also exists between OC estrogen dose and the risk of thromboembolism. The thrombotic effects of OC are probably mediated, at least partly, through their effects on the coagulation system.

Response of blood coagulation parameters to elevated endogenous 17 beta-estradiol levels induced by human menopausal gonadotropins

To elucidate the relationship between estrogen and thrombosis, we studied blood coagulation parameters in women whose ovaries were stimulated with human menopausal gonadotropins (hMG). Daily hMG administration over 1 to 2 weeks in seven anovulatory women increased plasma 17 beta-estradiol levels fivefold over the pretreatment value. Of the coagulation parameters, the fibrinogen level increased significantly from an initial value of 248 +/- 11.7 mg/dl (mean +/- SEM) to 353 +/- 32.2 mg/dl after hMG treatment (P less than 0.05), with a significant positive correlation between estrogen and fibrinogen levels (r = +0.762). In addition, a thrombokinetics study showed that the maximal rate of change in optical density of the prothrombin time and activated partial thromboplastin time was significantly increased, suggesting that the coagulation factors involved in extrinsic, intrinsic, and common pathways could be increased by estrogen. Antithrombin III levels decreased gradually during hMG administration. Thus, increased endogenous estrogen levels appear to induce the so-called "hypercoagulable state" through both an increase in coagulation factors in the coagulation cascade system and a decrease in antithrombin III, a potent natural inhibitor of activated coagulation factors. Patients on a regimen of hMG treatment for induction of ovulation serve as excellent models for the study of alteration of "natural" estrogen-mediated coagulation parameters.

Testosterone inhibits prostacyclin production by rat aortic smooth muscle cells in culture

The effects of testosterone on cell proliferation and prostacyclin production were investigated using rat aortic smooth muscle cells in culture. Testosterone at 10(-10)-10(-6) M did not have any significant effect on cell proliferation, but it significantly inhibited prostacyclin production by the cells. Maximal inhibition of prostacyclin production (70%) was observed when cells were treated with a physiological concentration of 19(-8) M testosterone for 5 consecutive days. These results suggest that testosterone may stimulate thrombus formation and accelerate atherosclerosis by suppressing prostacyclin production in arterial smooth muscle cells.

Altered haemorheology in oral-contraceptive users

The haemorheological profile of the menstrual cycle was determined in 12 women who did not take oral contraceptives and compared with that in two groups of women (n = 8 and n = 30) who had been taking oral contraceptives for at last six months. Packed cell volume, platelet count, erythrocyte deformability, plasma fibrinogen concentration, and plasma and whole-blood viscosity varied cyclically throughout the menstrual cycle in the 12 non-users. This variation was abolished by the use of oral contraceptives, and the values of these indices were raised by an amount likely to predispose to thrombosis.

Focal nodular hyperplasia of the liver. An electron microscopic study of the vascular lesions

Localized myointimal proliferation with narrowing of blood vessels is frequently seen associated with focal nodular hyperplasia of the liver. The apparent increase in the incidence of focal nodular hyperplasia in women may be associated with the oral use of contraceptive medications, and it has been suggested that the nodules could be areas of focal cirrhosis following liver infarction. A light and electron microscopic study was undertaken to try to determine the pathogenesis of the vascular abnormalities. The observation of intravascular coagulation, recurrent endothelial damage, and myointimal proliferation about bifurcations suggests that the changes could be produced by repeated platelet-fibrin aggregate embolic injury.

Oral-contraceptive use in relation to myocardial infarction

The effect of oral-contraceptive use on the risk of myocardial infarction and, in particular, the possible accentuation of that effect by cigarette smoking, was investigated in 234 premenopausal women with a first infarction and 1742 hospital controls. The overall rate ratio estimate of acute myocardial infarction for women who had used oral contraceptives in the preceding month was 4.0 (95% confidence interval, 2.5--6.3). Women who smoked heavily and used oral contraceptives had a point estimate of 39 (lower two-sided 95% confidence limit, 22) compared with those who did neither. This value was appreciably larger than could be accounted for by the separate effects of cigarettes and oral contraceptives, and this suggests a considerable accentuation by cigarette smoking of the effect of oral contraceptive use on myocardial infarction.

The influence of age, sex, and the use of oral contraceptives on the inhibitory effects of endothelial cells and PGI2 (prostacyclin) on platelet function

The inhibitory effects of human endothelial cells (ECM) and PGI2 (prostacyclin) on platelet function have been examined in 60 healthy subjects. 5 groups were studied. I. 10 women (19-33 yrs.); II. 10 women (21-31 yrs.) using combined oral contraceptives; III. 10 postmenopausal women (45-66 yrs.); IV. 20 men (24-48 yrs.) and V. 10 men (48-71 yrs.). Spontaneous platelet aggregation in platelet-rich plasma (PRP) was commonly observed in groups II, III, and V. This was prevented when PRP was incubated with ECM, aspirin (ASA), or PGI2. ADP-induced platelet aggregation (PA) was always reduced by ECM, but significantly less in groups II and III. Collagen-induced PA was inhibited by ECM, but less in groups I, II, III and V than in young men (IV). ECM significantly reduced collagen-induced prostaglandin (MDA) production in platelets. Again, the inhibitory effect was significantly reduced in groups II and III. Platelet factor 3 activity, measured after exposure of PRP to ADP, was significantly reduced by ECM, but was significantly less in groups II, III, and V than in group I. Less of an inhibitory, effect of PGI2 upon ADP-induced PA was shown by all groups of females than by the two groups of males.

Morphological effects of estrogen on the female rat liver nucleolus

Prolonged administration of nonphysiological amounts of estrogen induced markedly enlarged nucleoli volumes in rat hepatocytes, indicative of increased nucleolar RNA synthesis. Physiological amounts of drug had no apparent morphological effects on the hepatocytes.

Oral contraceptive use alters the balance of platelet prostaglandin and thromboxane synthesis

The ability of platelet microsomes to generate platelet aggregating activity on addition of arachidonic acid was evaluated in women taking oral contraceptives and in controls taking no medication but matched for age, sex, and family history. Oral contraceptive users generated significantly more platelet aggregating activity per 100 ug of platelet microsomal protein than controls. Variation in generation of platelet aggregating activity during the menstrual cycle was also observed with highest activity during the third week. These studies show an altered balance of platelet prostaglandin and thromboxane synthesis in oral contraceptive users which may contribute to their increased incidence of thromboembolic phenomena.

Effect of the menstrual cycle, oral contraception and pregnancy on forearm blood flow, venous distensibility and clotting factors

Forearm blood flow, venous distensibility and various clotting factors were determined in 118 apparently healthy women (mean age 26 years), either during the menstrual cycle, or while taking a combined contraceptive (A) with high progestin:estrogen ratio (d-norgestrel 0.125 mg + ethinylestradiol 0.03 mg), or a sequential contraceptive (B) with low progestin: estrogen ratio (megestrol 0.1/1 mg + ethinylestradiol 0.1 mg), or in the 1st, 2nd and 3rd trimester of pregnancy. Venous distensibility in women taking contraceptive A was higher than in other women during the follicular phase of a normal menstrual cycle. Venous distensibility was not affected by contraceptive B. Blood flow and blood pressure remained unchanged by contraceptives A and B. Fibrinogen concentration was increased by both contraceptives, factor VII was either decreased (A) or unchanged (B), and factor X was either unchanged (A) or increased (B). The oral contraceptive with the high progestagen component appeared to increase venous capacitance and may induce venous stasis, whereas coagulability was particularly enhanced by the estrogen-type contraceptive. Pregnant women differed from women on oral contraceptives in regard to peripheral circulation; they showed a tremendous increase of blood flow with secondary vasodilation.

The haemolytic uraemic syndrome and oral contraceptives

A case of haemolytic uraemic syndrome is described in a young woman in whom the illness was apparently precipitated by the change from a low to a high oestrogen containing oral contraceptive agent.

An epidemiological study of the haemostatic and other effects of oral contraceptives

Factors V, VII and VIII (each determined by biological assay), fibrinogen, platelet count and adhesiveness, and fibrinolytic activity were measured in 234 white pre-menopausal women, of whom 57 (24%) were on oral contraceptives and 177 (76%) were not. Cholesterol, triglyceride and blood pressure levels were also recorded. In 20 of the women on oral contraceptives, and in an age-matched group of 20 who were not, prothrombin, factor X, antithrombin III and alpha 2-macroglobulin levels were determined, and factors VII and VIII were also measured immunologically. For the majority of the variables studied, the differences between those using and not using oral contraceptives were greater in younger than older women; in the case of factor VII (biological assay) and fibrinogen, the differences between the regression slopes on age were statistically significant, and mean values were substantially higher in those on oral contraceptives. There was also a significant difference between regression slopes on age for cholesterol. Mean levels of prothrombin, factors VII (immunological assay) and X, triglycerides and blood pressure were significantly higher, and mean levels of antithrombin III significantly lower, in those on oral contraceptives compared with those not. Overall, fibrinolytic activity was significantly higher in the women on oral contraceptives; this difference was, however, almost entirely due to the greatly increased fibrinolytic activity of the non-smokers on oral contraceptives, activity in the smokers on oral contraceptives being similar to that of the women not on these preparations. There were no significant differences in mean platelet count or adhesiveness, or in haemoglobin, packed cell volume, uric acid and blood sugar levels. Among the women on oral contraceptives, there was a significant negative correlation between factor VIII and fibrinolytic activity; this was largely due to five women all of blood groups A and B, in whom, besides high factor-VIII levels and poor fibrinolytic activity, other variables (e.g. fibrinogen) were raised in a direction that might be expected to favour thrombogenesis. It is possible that it is those women whose fibrinolytic activity does not increase in order to compensate for the effects of oral contraceptives on clotting factors, lipids and blood pressure, who are at special risk of thromboembolic episodes. The differential effects of oral contraceptives by age must be borne in mind in evaluating the effects of these preparations on the haemostatic and lipid systems.

Myocardial infarction in younger women. Associated clinical features and relationship to use of oral contraceptive drugs

In a study of thromboembolism and oral contraceptive drugs, 136 cases of myocardial infarction in women aged 30 to 44 years were identified, a rare disease in women of this age group. Data from their hospital medical records were compared with those of several other groups, including women without chronic disease admitted for various acute or elective conditions unrelated to thromboembolism, patients with thromboembolic disease other than myocardial infarction, and women queried or examined in the National Health Survey. The following attributes were found to be associated with myocardial infarction in younger women: presence of diabetes; hypertension; history of increased cigarette smoking; and hypercholesterolemia. A history of the use of oral contraceptive drugs was found with greater frequency in cases than in controls. The literature on the possible association of myocardial infarction and the use of oral contraceptives was reviewed.

Response of plasma fibrinogen and plasminogen to hormone treatment and the relation of pretreatment values to mortality in patients with prostatic cancer

Fibrinogen and plasminogen were measured in plasma samples from prostatic cancer patients before and after 3 months of treatment with either Premarin, Provera, Provera and diethylstilbestrol, one of three doses of diethylstilbestrol, or placebo. Plasminogen levels generally were increased significantly with the estrogens but were unchanged following placebo or Provera treatment. Pretreatment plasminogen levels in Study 3 were significantly lower (p less than .001) than in Study 2. Plasminogen pretreatment levels were significantly correlated with age, hemoglobin, body weight, and blood pressure. Fibrinogen pretreatment levels were significantly elevated above normal. They were not significantly with age, hemoglobin, body weight, or blood pressure. Fibrinogen levels generally were significantly decreased by the estrogens. Comparisons of means of pretreatment fibrinogen and plasminogen levels from patients dying during the first year of the study with the mean pretreatment levels of the patient group alive after 1 year on study yielded no significant differences. Death rates were calculated by pretreatment plasminogen or fibrinogen for all treatments of all Stage III and Stage IV patients combined for Study 2 and Study 3 separately. Such rates were calculated for all causes combined and for deaths from prostatic cancer or cardiovascular disease separately. The levels of plasminogen were significnatly negatively correlated with death rate from all causes combined and with cardiovascular disease considered separately, but not with death from prostatic cancer. The levels of fibrinogen were signigicantly positively correlated with death rates from all cuses and nearly significantly with prostatic cancer, but not cardiovascular disease. Elvated pretreatment fibrinogen levels were associated with an increased proportion of deaths at 1 year from all causes and from cancer of the prostate.

Disseminated intravascular coagulation in the urologic patient

Gram-negative septicemia and metastatic prostatic cancer are frequent causes of disseminated intravascular coagulation. The clinical manifestations of this condition as well as the laboratory data vary considerably, depending on the patient's compensatory mechanisms in relation to the magnitude and duration of the thromboplastin or endotoxin release. Treatment centers primarily on correcting the underlying disorder. Secondly, deficient clotting factors and platelets should be replaced in the appropriate patient. Heparinization is often unnecessary. The use of drugs that inhibit the protective fibrinolytic mechanism is contraindicated in disseminated intravascular coagulation.

Massive colonic bleeding and oral contraceptive "pills"

Two patients on oral contraceptives who developed massive colonic bleeding have been presented. The clinical course and various studies suggest the mesenteric insufficiency syndrome as being a possible result of oral contraceptive effect on mesenteric vasculature. Although no definite histologic confirmation is available, the onset, course, and follow-up of these patients suggest contraceptive-induced massive colonic bleeding. The spectrum of oral contraceptive-induced colonic bleeding may vary from mucosal injury with massive colonic bleeding to transmural infarction. Only the clinical follow-up would determine the severity of the involvement and that would determine whether surgical intervention will be necessary.

Why do women live longer than men?

In the contemporary United States, males have 60 percent higher mortality than females. In Part I, published in the previous issue, we showed that 40 percent of this sex differential in mortality is due to a twofold elevation of arteriosclerotic heart disease among men. Major causes of higher rates of arteriosclerotic heart disease in men include greater cigarette smoking among men; probably a greater prevalence of the competitive, aggressive Coronary Prone Behavior Pattern among men; and possibly a protective role of female hormones. In addition, men have higher death rates for lung cancer and emphysema, primarily because more men smoke cigarettes. In Part II we analyze the other major causes of men's higher death rates: accidents, suicide, and cirrhosis of the liver. Each of these is related to behaviors which are encouraged or accepted more in men than in women in our society--for example, using guns, being adventurous and acting unafraid, working at hazardous jobs and drinking alcohol. We conclude with suggestions for reducing male mortality; for example, by changing the social conditions which foster in men the behaviors that elevate their mortality.

[Blood coagulation and fibrinolysis in women receiving estrogen, gestagen and estrogen-gestagen-contraceptives (author's transl)]

Eight femal subjects received a contraceptive with a low estrogen content (Neogynon), the estrogen component (50 mug ethinylestradiol) and consecutively the gestagen component (250 mug D-Norgestrel) of the contraceptive. Each treatment cycle was followed by a control cycle. At various times of the control and therapy cycles several coagulation and fibrinolytic parameters were investigated. Statistical analyses were performed by multivariate two-factorial analysis of variance. Plasminogen exhibities a statistically significant increase during the treatment with ethinylestradiol and the combination of this steroid with D-norgestrel. No significant changes were found for all other parameters, including partial thromboplastin time, fibriogen, factors X, IX, VIII, factor VIII-related antigen, antithrombin III and fibrin(ogen)degradation products.

Why do women liver longer than men?

In the contemporary United States, mortality is 60% higher for males than for females. Forty percent of the excess of male mortality is due to arteriosclerotic heart disease, which is more common among men in part because they smoke cigarettes more than women do, and apparently also because they more often develop the competitive, aggressive Coronary Prone Behavior Pattern. Men who do not develop this Behavior Pattern may have as low a risk of coronary heart disease as comparable women. Oophorectomy of young women may increase the risk of coronary heart disease, but administration of female hormones generally does not reduce risk. One third of the sex differential in mortality is due to men's higher rates of suicide, fatal motor vehicle and other accidents, cirrhosis of the liver, respiratory cancers and emphysema. Each of these causes of death is linked to behaviours which are encouraged or accepted more in males than in females: using guns, drinking alcohol, smoking, working at hazardous jobs, and seeming to be fearless. Thus, the behaviors expected of males in our society make a major contribution to their elevated mortality.