1
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Manongi N, Byrns K, Fulman M, Jaffer A. Inferior mesenteric vein thrombosis in the setting of testosterone therapy. BMJ Case Rep 2022; 15:e251886. [PMID: 36517081 PMCID: PMC9756151 DOI: 10.1136/bcr-2022-251886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Inferior mesenteric vein thrombosis (IMVT) is a rare and potentially lethal complication that can progress to mesenteric ischaemia if left untreated. We report a case of a man in his 70s with a history of polycythaemia vera (PV) with a known negative Janus kinase-2 mutation (JAK2V617) who was started on testosterone therapy 2 months before presenting with left lower quadrant abdominal and flank pain. Evaluation revealed thrombocytosis and IMVT on CT scan. A non-operative approach was deferred for anticoagulation therapy. Within 24 hours, the patient demonstrated significant clinical improvement, and he subsequently made a full recovery. The patient underwent 6 months of anticoagulation therapy with Apixaban. This case documents the first case of IMVT in the setting of PV and testosterone therapy in the literature.
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Affiliation(s)
- Ngoda Manongi
- Internal Medicine, NewYork-Presbyterian Queens, Flushing, New York, USA
| | - Kory Byrns
- Internal Medicine, NewYork-Presbyterian Queens, Flushing, New York, USA
| | - Malvina Fulman
- Internal Medicine, NewYork-Presbyterian Queens, Flushing, New York, USA
| | - Amir Jaffer
- Internal Medicine, NewYork-Presbyterian Queens, Flushing, New York, USA
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2
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Affirming Hormone Treatment for a Transgender Adolescent After a Venous Thromboembolic Event. J Pediatr Hematol Oncol 2022; 44:e892-e895. [PMID: 35293883 DOI: 10.1097/mph.0000000000002442] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 01/31/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Medical affirmation, including gender-affirming hormones, is an essential component in the treatment of many transgender and gender-diverse youth. The risk of venous thromboembolism (VTE) during testosterone therapy for gender-affirming care is not fully elucidated. OBSERVATION The case describes a 17-year-old transgender male treated with testosterone therapy who presented with an occlusive deep vein thrombosis of right axillary and subclavian veins. Testosterone level was 920 ng/dL at the time of the deep vein thrombosis, and he had no risk factors for VTE. A complete hypercoagulable workup was negative. CONCLUSIONS The possibility of testosterone therapy as a risk factor for VTE may suggest the need to include this information during informed consent discussions. Long-term anticoagulation may be considered for those restarting testosterone therapy.
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Badescu MC, Rezus E, Ciocoiu M, Badulescu OV, Butnariu LI, Popescu D, Bratoiu I, Rezus C. Osteonecrosis of the Jaws in Patients with Hereditary Thrombophilia/Hypofibrinolysis-From Pathophysiology to Therapeutic Implications. Int J Mol Sci 2022; 23:ijms23020640. [PMID: 35054824 PMCID: PMC8776054 DOI: 10.3390/ijms23020640] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 12/29/2021] [Accepted: 01/04/2022] [Indexed: 12/24/2022] Open
Abstract
Osteonecrosis of the jaws (ONJ) usually has a clear etiology. Local infection or trauma, radiotherapy and drugs that disrupt the vascular supply or bone turnover in the jaws are its major contributors. The thrombotic occlusion of the bone’s venous outflow that occurs in individuals with hereditary thrombophilia and/or hypofibrinolysis has a less known impact on jaw health and healing capability. Our research provides the most comprehensive, up-to-date and systematized information on the prevalence and significance of hereditary thrombophilia and/or hypofibrinolysis states in ONJ. We found that hereditary prothrombotic abnormalities are common in patients with ONJ refractory to conventional medical and dental treatments. Thrombophilia traits usually coexist with hypofibrinolysis traits. We also found that frequently acquired prothrombotic abnormalities coexist with hereditary ones and enhance their negative effect on the bone. Therefore, we recommend a personalized therapeutic approach that addresses, in particular, the modifiable risk factors of ONJ. Patients will have clear benefits, as they will be relieved of persistent pain and repeated dental procedures.
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Affiliation(s)
- Minerva Codruta Badescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.P.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Elena Rezus
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
- I Rheumatology Clinic, Clinical Rehabilitation Hospital, 14 Pantelimon Halipa Street, 700661 Iasi, Romania
- Correspondence: (E.R.); (O.V.B.)
| | - Manuela Ciocoiu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
| | - Oana Viola Badulescu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
- Hematology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
- Correspondence: (E.R.); (O.V.B.)
| | - Lacramioara Ionela Butnariu
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
| | - Diana Popescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.P.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Ioana Bratoiu
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
- I Rheumatology Clinic, Clinical Rehabilitation Hospital, 14 Pantelimon Halipa Street, 700661 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.P.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
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4
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Spini A, Giudice V, Brancaleone V, Morgese MG, De Francia S, Filippelli A, Ruggieri A, Ziche M, Ortona E, Cignarella A, Trabace L. Sex-tailored pharmacology and COVID-19: Next steps towards appropriateness and health equity. Pharmacol Res 2021; 173:105848. [PMID: 34454035 PMCID: PMC8387562 DOI: 10.1016/j.phrs.2021.105848] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/21/2021] [Accepted: 08/22/2021] [Indexed: 12/12/2022]
Abstract
Making gender bias visible allows to fill the gaps in knowledge and understand health records and risks of women and men. The coronavirus disease 2019 (COVID-19) pandemic has shown a clear gender difference in health outcomes. The more severe symptoms and higher mortality in men as compared to women are likely due to sex and age differences in immune responses. Age-associated decline in sex steroid hormone levels may mediate proinflammatory reactions in older adults, thereby increasing their risk of adverse outcomes, whereas sex hormones and/or sex hormone receptor modulators may attenuate the inflammatory response and provide benefit to COVID-19 patients. While multiple pharmacological options including anticoagulants, glucocorticoids, antivirals, anti-inflammatory agents and traditional Chinese medicine preparations have been tested to treat COVID-19 patients with varied levels of evidence in terms of efficacy and safety, information on sex-targeted treatment strategies is currently limited. Women may have more benefit from COVID-19 vaccines than men, despite the occurrence of more frequent adverse effects, and long-term safety data with newly developed vectors are eagerly awaited. The prevalent inclusion of men in randomized clinical trials (RCTs) with subsequent extrapolation of results to women needs to be addressed, as reinforcing sex-neutral claims into COVID-19 research may insidiously lead to increased inequities in health care. The huge worldwide effort with over 3000 ongoing RCTs of pharmacological agents should focus on improving knowledge on sex, gender and age as pillars of individual variation in drug responses and enforce appropriateness.
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Affiliation(s)
- Andrea Spini
- University of Siena, Department of Medicine, Surgery and Neuroscience, 53100 Siena, Italy; University of Bordeaux, Bordeaux Population Health Center, UMR 1219, 33000 Bordeaux, France
| | - Valentina Giudice
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081 Baronissi, Italy
| | - Vincenzo Brancaleone
- Department of Science, University of Basilicata, via Ateneo Lucano, 85100 Potenza, Italy
| | - Maria Grazia Morgese
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Silvia De Francia
- Department of Clinical and Biological Sciences, S. Luigi Hospital, University of Turin, Italy
| | - Amelia Filippelli
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081 Baronissi, Italy
| | - Anna Ruggieri
- Center for Gender Specific Medicine, Istituto Superiore di Sanità, Rome, Italy
| | - Marina Ziche
- University of Siena, Department of Medicine, Surgery and Neuroscience, 53100 Siena, Italy; University of Bordeaux, Bordeaux Population Health Center, UMR 1219, 33000 Bordeaux, France; Centro Studi Nazionale Salute e Medicina di Genere, Italy
| | - Elena Ortona
- Center for Gender Specific Medicine, Istituto Superiore di Sanità, Rome, Italy; Centro Studi Nazionale Salute e Medicina di Genere, Italy
| | - Andrea Cignarella
- Department of Medicine, University of Padova, via Giustiniani 2, 35128 Padova, Italy; Centro Studi Nazionale Salute e Medicina di Genere, Italy
| | - Luigia Trabace
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy; Centro Studi Nazionale Salute e Medicina di Genere, Italy.
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Poirier-Blanchette L, Koolian M, Schwartz BC. Testosterone Replacement Therapy Causing Extensive Portal and Mesenteric Vein Thrombosis. Am J Med 2021; 134:e426-e427. [PMID: 33444584 DOI: 10.1016/j.amjmed.2020.12.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 11/26/2022]
Affiliation(s)
| | - Maral Koolian
- Department of Medicine, McGill University, Montreal, Quebec, Canada; Division of General Internal Medicine; Division of Thrombosis, Center of Excellence in Thrombosis and Anticoagulation Care
| | - Blair Carl Schwartz
- Department of Medicine, McGill University, Montreal, Quebec, Canada; Division of General Internal Medicine; Division of Adult Critical Care, Jewish General Hospital, Montreal, Quebec, Canada.
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6
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Abstract
PURPOSE OF REVIEW Hormonal therapy is administered for multiple indications including contraception, alleviation of menopausal symptoms, hypogonadism, and more recently, gender-affirming care. Data suggest varying degrees of increased risk for venous thromboembolism (VTE). RECENT FINDINGS While oral progestin only methods do not appear to increase the risk of VTE, an association was seen with injection progestin contraception. Combined oral contraception with low-dose ethinyl estradiol and most types of progestin increased the risk of VTE compared with levonorgestrel-containing oral therapies. While transdermal hormonal contraception has been previously associated with increased VTE, a recently approved levonorgestrel and ethinyl estradiol transdermal patch reported low rates (<0.2%) in a large single-arm open-label study. Women receiving postmenopausal HRT experienced an increased risk of VTE in a dose-dependent manner when using oral hormonal therapy while nonoral methods, such as topical estrogen, did not appear to increase the risk of VTE. Some studies suggest no increased risk of VTE with testosterone therapy, however, a recent case-crossover study suggested higher VTE risk in men on testosterone, particularly men less than age 65 without hypogonadism. Route of administration had no effect on VTE rates. The estimated incidence rate of VTE risk in transgender women receiving estrogen therapy is 2.3 per 1000 person years, but may be imprecise due to heterogeneity in studies included in published meta-analyses. Surgical risk estimates are primarily indirect data drawn from cisgender patients receiving hormone therapy in the perioperative setting. SUMMARY Hormonal therapy affects VTE risk to varying degrees dependent on specific type of hormone, formulation, and occasionally route of delivery.
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7
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Venous Thromboembolism in a Transgender Adolescent on Testosterone Therapy: A Case Report and Literature Review. J Pediatr Hematol Oncol 2020; 42:e352-e354. [PMID: 32079984 DOI: 10.1097/mph.0000000000001755] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The incidence of pediatric venous thromboembolism (VTE) has been increasing in the past few decades and can be associated with significant mortality and morbidity. There are known risk factors associated with VTE, including estrogen therapy. However, the relationship between testosterone and VTE remains unclear. Here, we present a 17-year-old female-to-male transgender patient without a history of inherited thrombophilia, who developed pulmonary embolism while receiving testosterone injections for gender dysphoria. Despite the limited data on testosterone and the risk of VTE, health care providers should counsel patients and family about the possible increased risk of VTE when starting testosterone.
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8
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Anoop P, Malmande V, Prakash Kumar MN, Rao N. Successful penile reconstruction following prior arteriovenous loop thrombosis due to undiagnosed protein-S deficiency and exogenous testosterone. Indian J Plast Surg 2019; 49:268-270. [PMID: 27833295 PMCID: PMC5053005 DOI: 10.4103/0970-0358.191307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Flap failure from microvascular thrombotic occlusion is a rare but significant cause for unsuccessful reconstructive surgery. We encountered thrombosis of arteriovenous loop in a patient undergoing phallus reconstruction. Further investigations revealed underlying previously asymptomatic hypercoagulable state due to protein-S deficiency in addition to long-term exogenous testosterone administration. Role of thrombophilia testing, thrombogenic potential of testosterone and the need for therapeutic perioperative anti-coagulation in such situations are described here.
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Affiliation(s)
| | - Vithal Malmande
- Department of Plastic Surgery, Apollo Hospitals, Bengaluru, Karnataka, India
| | - M N Prakash Kumar
- Department of Plastic Surgery, Apollo Hospitals, Bengaluru, Karnataka, India
| | - Naveen Rao
- Department of Plastic Surgery, Apollo Hospitals, Bengaluru, Karnataka, India
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9
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Abstract
Over the past decade, there has been a substantial increase in the number of men who are treated with testosterone. Despite this increase in the use of testosterone, the risks of adverse cardiovascular events are unclear as meta-analyses have reported conflicting findings and no clinical studies have been large enough or long enough to adequately assess for cardiovascular risks. The goal of this paper is to review large prescription database studies of testosterone treatment and adverse cardiovascular events and mortality with the aim of providing some guidance for clinicians and researchers in this controversial area.
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Affiliation(s)
- Molly M Shores
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, VA Puget Sound Health Care System, 1660 South Columbian Way Seattle, WA 98108, USA
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10
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Testosterone Therapy, Thrombophilia, Venous Thromboembolism, and Thrombotic Events. J Clin Med 2018; 8:jcm8010011. [PMID: 30577621 PMCID: PMC6352146 DOI: 10.3390/jcm8010011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 12/11/2018] [Accepted: 12/18/2018] [Indexed: 01/24/2023] Open
Abstract
In our sequential studies of 67 and 21 patients, testosterone therapy (TT) interacted with thrombophilia⁻hypofibrinolysis, leading to venous thromboembolism (VTE). Compared to 111 VTE controls not taking TT (VTE-no TT), the 67 and 21 cases were more likely (p < 0.05 for all) to have Factor V Leiden (FVL) heterogeneity (24% and 33% vs. 12%), the lupus anticoagulant (14% and 33% vs. 4%), and high lipoprotein(a) (33% vs. 13%, n = 21). After a first VTE and continuing TT, 11 thrombophilic cases had a second VTE despite adequate anticoagulation, 6 of whom, still anticoagulated, had a third VTE. The greatest density of thrombotic events was at three months after starting TT, with a rapid decline by 10 months. From <1 to 8 months after starting TT, 65% of VTE occurred, which may reflect TT-induced depletion of susceptible thrombophilic patients, leaving a winnowed residual group with fewer VTE events despite the continuation of TT. Before starting TT, we suggest screening for FVL, lipoprotein(a), and the lupus anticoagulant to identify patients at increased VTE risk, with an adverse risk-to-benefit ratio for TT. We suggest that TT should not be started in patients with known thrombophilia⁻hypofibrinolysis, and should not be continued after a first VTE. When TT is given to patients with thrombophilia⁻hypofibrinolysis, VTE may occur and then recur despite adequate anticoagulation.
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11
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Houghton DE, Alsawas M, Barrioneuvo P, Tello M, Farah W, Beuschel B, Prokop LJ, Layton JB, Murad MH, Moll S. Testosterone therapy and venous thromboembolism: A systematic review and meta-analysis. Thromb Res 2018; 172:94-103. [PMID: 30396049 PMCID: PMC10601700 DOI: 10.1016/j.thromres.2018.10.023] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 10/17/2018] [Accepted: 10/24/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Testosterone prescribing for men has dramatically increased, and there have been concerns about inappropriate use and adverse events. While regulatory bodies have warned about increased risk of venous thromboembolism (VTE), published clinical data supporting an increased risk for VTE are limited. OBJECTIVE To conduct a systematic review of studies examining the association between testosterone therapy in men and VTE. METHODS Comprehensive searches of multiple databases were performed from inception through October 3rd, 2018. Randomized control trials (RCTs) and observational studies examining the association between exogenous testosterone (any route) and VTE. Study selection and data extraction were performed by two independent investigators. Random-effect model meta-analyses were used to estimate pooled odds ratios (OR) and 95% confidence intervals (CIs). Heterogeneity among studies was evaluated using the I2 statistic. Risk of bias was assessed using the Cochrane and Newcastle-Ottawa tools. RESULTS Six RCTs (n = 2236) and 5 observational studies (n = 1,249,640) were included. Five RCTs were performed in men with documented hypogonadism. The observational studies included: 2 case-control studies, 2 retrospective cohorts, and 1 retrospective cohort with a nested case-control study. There was no evidence of a statistically significant association between VTE and testosterone (OR 1.41, 95%CI 0.96-2.07). Heterogeneity was high (I-squared = 84.4%). The association remained nonsignificant when the analysis was stratified by study design: RCTs (2.05, 95% CI 0.78-5.39); cohort (1.06, 95% CI 0.85-1.33); and case-control (1.34, 95% CI 0.78-2.28). The overall risk of bias was moderate. CONCLUSIONS The current evidence is of low certainty but does not support an association between testosterone use and VTE in men.
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Affiliation(s)
- Damon E Houghton
- Mayo Clinic, Department of Cardiovascular Diseases, Division of Vascular Medicine & Department of Internal Medicine, Division of Hematology/Oncology, 200 1st St SW, Rochester, MN 55905, USA.
| | - Mouaz Alsawas
- Mayo Clinic, Evidence-based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 1st St SW, Rochester, MN 55901, USA
| | - Patricia Barrioneuvo
- Mayo Clinic, Evidence-based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 1st St SW, Rochester, MN 55901, USA
| | - Mouaffaa Tello
- Mayo Clinic, Evidence-based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 1st St SW, Rochester, MN 55901, USA
| | - Wigdan Farah
- Mayo Clinic, Evidence-based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 1st St SW, Rochester, MN 55901, USA
| | - Brad Beuschel
- Mayo Clinic, Evidence-based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 1st St SW, Rochester, MN 55901, USA
| | - Larry J Prokop
- Mayo Clinic Libraries, 200 1st St SW, Rochester, MN 55901, USA
| | - J Bradley Layton
- RTI Health Solutions, Research Triangle Park, NC 27709-2194, USA
| | - M Hassan Murad
- Mayo Clinic, Evidence-based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 1st St SW, Rochester, MN 55901, USA
| | - Stephan Moll
- University of North Carolina School of Medicine, Department of Medicine, Division of Hematology/Oncology, Chapel Hill, NC, USA
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Goldman A, Basaria S. Adverse health effects of androgen use. Mol Cell Endocrinol 2018; 464:46-55. [PMID: 28606866 DOI: 10.1016/j.mce.2017.06.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 06/08/2017] [Indexed: 01/21/2023]
Abstract
Anabolic androgenic steroids (AAS) are performance enhancing drugs commonly used by athletes and bodybuilders to improve appearance and athletic capability. Unfortunately, these testosterone derivatives can be associated with serious and potentially irreversible side effects, and can impact multiple organ systems. It is important that physicians be familiar with these adverse consequences so that they can appropriately counsel patients whom they suspect of AAS-abuse. In this chapter, we will review the negative effects of these compounds on various organ systems in men using AAS.
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Affiliation(s)
- Anna Goldman
- Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shehzad Basaria
- Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Abstract
Venous thromboembolism can be precipitated by both genetic and acquired factors, but the role of testosterone therapy is less clear. Here, we present a 17-year-old transgender adolescent, transitioning from female to male, receiving both estrogen and testosterone therapy, who developed a pulmonary embolism without an underlying genetic thrombophilic condition. As transgender medical care evolves, the use of testosterone as cross-sex hormone therapy in adolescents is likely to increase. Our review suggests that care must be taken when initiating treatment with testosterone, and modification of other thrombophilic risks should be explored before starting therapy in this population.
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14
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Glueck CJ, Goldenberg N, Wang P. Thromboembolism peaking 3 months after starting testosterone therapy: testosterone–thrombophilia interactions. J Investig Med 2017; 66:733-738. [DOI: 10.1136/jim-2017-000637] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2017] [Indexed: 11/03/2022]
Abstract
We assessed time of thrombotic events (venous thromboembolism (VTE)) after starting testosterone therapy (TT) in 21 men who sustained 23 VTE. The density of thrombotic events was greatest at 3 months after starting TT, with a rapid decline in events by 10 months. The 21 cases with VTE on TT differed from 110 patient controls with unprovoked VTE, not taking TT (VTE-no TT) for Factor V Leiden heterozygosity (FVL) (33 per cent vs 13 per cent, P=0.037), for high lipoprotein (a) (Lp(a)) (55 per cent vs 17 per cent, P=0.012), and for the lupus anticoagulant (33 per cent vs 4 per cent, P=0.003). These differences between cases and VTE-no TT controls were independent of age and gender. TT can interact with underlying thrombophilia–hypofibrinolysis promoting VTE. We suggest that TT should not be started in subjects with known thrombophilia. Coagulation screening, particularly for the FVL , Lp(a), and the lupus anticoagulant should be considered before starting TT, to identify men at high VTE risk who have an adverse risk/benefit ratio for TT.
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15
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Nguyen SM, Ko Ko N, Sattar AS, Gucuk Ipek E, Ali S. Pulmonary Embolism Secondary to Testosterone-Enhancing Herbal Supplement Use. Cureus 2017; 9:e1545. [PMID: 29018642 PMCID: PMC5630464 DOI: 10.7759/cureus.1545] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Decreased testosterone levels in men are often a normal sign of aging. Testosterone replacement therapy (TRT) is a well-established option for those with symptomatic hypogonadism related to low testosterone levels. Conversely, designer herbal supplements in the context of testosterone supplementation are poorly studied, yet remain popular among aging men who seek the well-known, often enhancing, effects of testosterone that involve muscle mass and sexual function/drive. In 2014, the Food and Drug Administration (FDA) issued a warning about the significant risk of venous clots secondary to testosterone product use. Testosterone-induced polycythemia is one of the proposed mechanisms for this increased clotting propensity. Increased thromboxane A2 receptor density on platelets and increased platelet aggregation have also been linked to testosterone treatment in men. Fenugreek extract is a common active ingredient in commercially available herbal supplements that are often marketed as testosterone enhancers. It is thought that certain fenugreek compounds inhibit aromatase and 5-alpha-reductase activity, leading to diminished testosterone breakdown. However, the efficacy and safety profile of this agent in its use for boosting testosterone levels are unclear. In this case report, we present a patient with new-onset, bilateral pulmonary embolism possibly associated with the daily use of fenugreek-containing testosterone supplements.
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Affiliation(s)
| | - Nway Ko Ko
- Internal Medicine, University of Central Florida College of Medicine
| | - Asad S Sattar
- Internal Medicine, University of Central Florida College of Medicine
| | - Esra Gucuk Ipek
- Internal Medicine, University of Central Florida College of Medicine
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Martinez C, Suissa S, Rietbrock S, Katholing A, Freedman B, Cohen AT, Handelsman DJ. Testosterone treatment and risk of venous thromboembolism: population based case-control study. BMJ 2016; 355:i5968. [PMID: 27903495 PMCID: PMC5130924 DOI: 10.1136/bmj.i5968] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine the risk of venous thromboembolism associated with use of testosterone treatment in men, focusing particularly on the timing of the risk. DESIGN Population based case-control study SETTING: 370 general practices in UK primary care with linked hospital discharge diagnoses and in-hospital procedures and information on all cause mortality. PARTICIPANTS 19 215 patients with confirmed venous thromboembolism (comprising deep venous thrombosis and pulmonary embolism) and 909 530 age matched controls from source population including more than 2.22 million men between January 2001 and May 2013. EXPOSURE OF INTEREST Three mutually exclusive testosterone exposure groups were identified: current treatment, recent (but not current) treatment, and no treatment in the previous two years. Current treatment was subdivided into duration of more or less than six months. MAIN OUTCOME MEASURE Rate ratios of venous thromboembolism in association with current testosterone treatment compared with no treatment were estimated using conditional logistic regression and adjusted for comorbidities and all matching factors. RESULTS The adjusted rate ratio of venous thromboembolism was 1.25 (95% confidence interval 0.94 to 1.66) for current versus no testosterone treatment. In the first six months of testosterone treatment, the rate ratio of venous thromboembolism was 1.63 (1.12 to 2.37), corresponding to 10.0 (1.9 to 21.6) additional venous thromboembolisms above the base rate of 15.8 per 10 000 person years. The rate ratio after more than six months' treatment was 1.00 (0.68 to 1.47), and after treatment cessation it was 0.68 (0.43 to 1.07). Increased rate ratios within the first six months of treatment were observed in all strata: the rate ratio was 1.52 (0.94 to 2.46) for patients with pathological hypogonadism and 1.88 (1.02 to 3.45) for those without it, and 1.41 (0.82 to 2.41) for those with a known risk factor for venous thromboembolism and 1.91 (1.13 to 3.23) for those without one. CONCLUSIONS Starting testosterone treatment was associated with an increased risk of venous thromboembolism, which peaked within six months and declined thereafter.
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Affiliation(s)
- Carlos Martinez
- Institute for Epidemiology, Statistics and Informatics GmbH, 60388 Frankfurt, Germany
| | - Samy Suissa
- Centre For Clinical Epidemiology, Lady Davis Research Institute - Jewish General Hospital, McGill University, Montreal, Quebec H3T 1E2, Canada
| | - Stephan Rietbrock
- Institute for Epidemiology, Statistics and Informatics GmbH, 60388 Frankfurt, Germany
| | - Anja Katholing
- Institute for Epidemiology, Statistics and Informatics GmbH, 60388 Frankfurt, Germany
| | - Ben Freedman
- ANZAC Research Institute, University of Sydney, Concord Hospital, Concord NSW 2139, Australia
- Heart Research Institute, Charles Perkins Centre, University of Sydney, NSW 2006 Australia
- Concord Hospital Dept of Cardiology, Sydney Medical School, University of Sydney, Sidney NSW 2006, Australia
| | - Alexander T Cohen
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
| | - David J Handelsman
- ANZAC Research Institute, University of Sydney, Concord Hospital, Concord NSW 2139, Australia
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Treatable high homocysteine alone or in concert with five other thrombophilias in 1014 patients with thrombotic events. Blood Coagul Fibrinolysis 2016; 26:736-42. [PMID: 25699608 DOI: 10.1097/mbc.0000000000000276] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In 1014 patients with thrombotic events, we determined how often treatable high serum homocysteine alone, or in concert with five other thrombophilias, was associated with thrombotic events. We studied 1014 outpatients sequentially referred for evaluation of thrombotic events, all having six measures of thrombophilia--three PCR (methylenetetrahydrofolate reductase C677T-A1298C, factor V Leiden G506A, prothrombin G20210A), and three serologic (factors VIII, XI, homocysteine). Of the 1014 patients, 198 (20%) had atherothrombosis, 199 (20%) ocular vascular thrombosis, 211 (21%) osteonecrosis, 180 (18%) pseudotumor cerebri, and 123 (12%) recurrent miscarriage. In 434 of 1014 (43%) patients, all six thrombophilic measures were normal. High homocysteine, present in 126 of 1014 patients (12.4%), was the sole thrombophilia in 50 (5%), accompanied only by methylenetetrahydrofolate reductase homozygosity-compound heterozygosity in 22 (2.2%), and accompanied by other thrombophilias in 54 (5%). Patients were more likely than 110 healthy controls to have high homocysteine (12 vs. 5%; P = 0.02) and high factor VIII (21 vs. 7%; P = 0.0003). On treatment for a median of 18 months with L-methyl folate (5 mg), vitamin B6 (100 mg), and vitamin B12 (2 mg/day), in 74 homocysteinemic patients, median homocysteine fell from 15.6 to 10.0 μmol/l (P < 0.0001), and in 56 (76%), homocysteine fell to normal on treatment. When homocysteinemia was the sole thrombophilia, normalization of homocysteine was accompanied by freedom from new thrombotic events in 38 of 41 patients (93%). In evaluation of 1014 patients with thrombotic events, 126 (12%) had treatable high serum homocysteine, and in 50 (5%), high homocysteine was the sole treatable thrombophilia.
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Glueck CJ, Lee K, Prince M, Jetty V, Shah P, Wang P. Four Thrombotic Events Over 5 Years, Two Pulmonary Emboli and Two Deep Venous Thrombosis, When Testosterone-HCG Therapy Was Continued Despite Concurrent Anticoagulation in a 55-Year-Old Man With Lupus Anticoagulant. J Investig Med High Impact Case Rep 2016; 4:2324709616661833. [PMID: 27536705 PMCID: PMC4971595 DOI: 10.1177/2324709616661833] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 06/29/2016] [Accepted: 07/02/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND When exogenous testosterone or treatments to elevate testosterone (human chorionic gonadotropin [HCG] or Clomid) are prescribed for men who have antecedent thrombophilia, deep venous thrombosis and pulmonary embolism often occur and may recur despite adequate anticoagulation if testosterone therapy is continued. CASE PRESENTATION A 55-year-old white male was referred to us because of 4 thrombotic events, 3 despite adequate anticoagulation over a 5-year period. We assessed interactions between thrombophilia, exogenous testosterone therapy, and recurrent thrombosis. In 2009, despite low-normal serum testosterone 334 ng/dL (lower normal limit [LNL] 300 ng/dL), he was given testosterone (TT) cypionate (50 mg/week) and human chorionic gonadotropin (HCG; 500 units/week) for presumed hypogonadism. Ten months later, with supranormal serum T (1385 ng/dL, upper normal limit [UNL] 827 ng/dL) and estradiol (E2) 45 pg/mL (UNL 41 pg/mL), he had a pulmonary embolus (PE) and was then anticoagulated for 2 years (enoxaparin, then warfarin). Four years later, on TT-HCG, he had his first deep venous thrombosis (DVT). TT was stopped and HCG continued; he was anticoagulated (enoxaparin, then warfarin, then apixaban, then fondaparinux). One year after his first DVT, on HCG, still on fondaparinux, he had a second DVT (5/315), was anticoagulated (enoxaparin + warfarin), with a Greenfield filter placed, but 8 days later had a second PE. Thrombophilia testing revealed the lupus anticoagulant. After stopping HCG, and maintained on warfarin, he has been free of further DVT-PE for 9 months. CONCLUSION When DVT-PE occur on TT or HCG, in the presence of thrombophilia, TT-HCG should be stopped, lest DVT-PE reoccur despite concurrent anticoagulation.
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Affiliation(s)
| | - Kevin Lee
- Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | | | - Vybhav Jetty
- Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Parth Shah
- Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Ping Wang
- Jewish Hospital of Cincinnati, Cincinnati, OH, USA
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19
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Girolami A, Cosi E, Tasinato V, Santarossa C, Ferrari S, Girolami B. Drug-Induced Thrombophilic or Prothrombotic States: An Underestimated Clinical Problem That Involves Both Legal and Illegal Compounds. Clin Appl Thromb Hemost 2016; 23:775-785. [DOI: 10.1177/1076029616652724] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Vascular thrombosis, both arterial and venous, is a condition associated with significant morbidity and mortality. There are multiple risk factors for thrombosis, both congenital and acquired, and in the majority of cases, these risk factors are not modifiable. Over the past 2 decades, multiple drugs (both illegal and legal) have been associated with increased risk of thrombosis. However, due to limited scientific literature regarding the prothrombotic tendencies of these drugs, there is a concomitant limited understanding of the pathophysiology of drug-induced thrombosis. As drugs are one of the few modifiable risk factors for thrombosis, further study and dissemination of knowledge regarding drug-associated and drug-induced thrombosis are essential and have the potential to lead to decreased future incidence of thrombosis. The mechanisms at the basis of the thrombophilic activity of these drugs are variable and sometimes still ill recognized. Increased levels of clotting factors, reduction in coagulation natural inhibitors, decreased fibrinolysis, activated clotting factors, increased blood viscosity, endothelial damage, and increased platelet number and activation are the most frequent causes. Arterial steal or coronary arteries no flow has also been implicated. In some cases due to the intake of several drugs, more than one mechanism is present in a given patient. The purpose of the present review is to analyze all the drugs demonstrated to be potentially thrombotic. It is hoped that a prudent use or nonuse of these drugs might result in a reduction of thrombosis-associated diseases.
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Affiliation(s)
- A. Girolami
- Division of Medicine, University of Padua Medical School, Padua, Italy
| | - E. Cosi
- Division of Medicine, University of Padua Medical School, Padua, Italy
| | - V. Tasinato
- Division of Medicine, University of Padua Medical School, Padua, Italy
| | - C. Santarossa
- Division of Medicine, University of Padua Medical School, Padua, Italy
| | - S. Ferrari
- Division of Medicine, University of Padua Medical School, Padua, Italy
| | - B. Girolami
- Division of Medicine, Padua City Hospital, Padua, Italy
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20
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Association Between Testosterone Replacement Therapy and the Incidence of DVT and Pulmonary Embolism: A Retrospective Cohort Study of the Veterans Administration Database. Chest 2016; 150:563-71. [PMID: 27179907 DOI: 10.1016/j.chest.2016.05.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 03/07/2016] [Accepted: 05/02/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Testosterone replacement therapy (TRT) prescriptions have increased several-fold in the last decade. There have been concerns regarding a possible increased incidence of DVT and pulmonary embolism (PE) with TRT. Few data support the association between TRT and DVT/PE. We evaluated the incidence of DVT and PE in men who were prescribed TRT for low serum total testosterone (sTT) levels. METHODS This is a retrospective cohort study, conducted using data obtained from the Veterans Affairs Informatics and Computing Infrastructure. We compared the incidence of DVT/PE between those who received TRT and subsequently had normal on-treatment sTT levels (Gp1), those who received TRT but continued to have low on-treatment sTT (Gp2), and those who did not receive TRT (Gp3). Those with prior history of DVT/PE, cancer, hypercoagulable state, and chronic anticoagulation were excluded. RESULTS The final cohort consisted of 71,407 subjects with low baseline sTT. Of these, 10,854 did not receive TRT (Gp3) and 60,553 received TRT. Of those who received TRT, 38,362 achieved normal sTT (Gp1) while 22,191 continued to have low sTT (Gp2). The incidence of DVT/PE was 0.5%, 0.4%, and 0.4% in Gp1, Gp2, and Gp3, respectively. Univariate, multivariate, and stabilized inverse probability of treatment weights analyses showed no statistically significant difference in DVT/PE-free survival between the various groups. CONCLUSIONS This study did not detect a significant association between testosterone replacement therapy and risk of DVT/PE in adult men with low sTT who were at low to moderate baseline risk of DVT/PE.
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21
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Li H, Benoit K, Wang W, Motsko S. Association between Use of Exogenous Testosterone Therapy and Risk of Venous Thrombotic Events among Exogenous Testosterone Treated and Untreated Men with Hypogonadism. J Urol 2016; 195:1065-72. [DOI: 10.1016/j.juro.2015.10.134] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2015] [Indexed: 12/29/2022]
Affiliation(s)
- Hu Li
- Lilly Research Laboratories, Eli Lilly and Co., Indianapolis, Indiana
| | - Karin Benoit
- Lilly Research Laboratories, Eli Lilly and Co., Indianapolis, Indiana
| | - Wei Wang
- Lilly Research Laboratories, Eli Lilly and Co., Indianapolis, Indiana
| | - Stephen Motsko
- Lilly Research Laboratories, Eli Lilly and Co., Indianapolis, Indiana
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22
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Prince M, Glueck CJ, Shah P, Kumar A, Goldenberg M, Rothschild M, Motayar N, Jetty V, Lee K, Wang P. Hospitalization for pulmonary embolism associated with antecedent testosterone or estrogen therapy in patients found to have familial and acquired thrombophilia. BMC HEMATOLOGY 2016; 16:6. [PMID: 26958344 PMCID: PMC4782383 DOI: 10.1186/s12878-016-0045-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 02/27/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND In patients hospitalized over a 4 year period for pulmonary embolism (PE), we assessed relationships of testosterone (TT) and estrogen therapy (ET) anteceding PE in patients found to have familial-acquired thrombophilia. METHODS From 2011 through 2014, 347 patients were hospitalized in Cincinnati Mercy Hospitals with PE. Retrospective chart review was used to identify patients receiving TT or ET before PE; coagulation studies were done prospectively if necessary. RESULTS Preceding hospitalization for PE, 8 of 154 men (5 %) used TT, and 24 of 193 women (12 %) used ET. The median number of months from the initiation of TT or ET to development of PE was 7 months in men and 18 months in women. Of the 6 men having coagulation measures, all had ≥ 1 thrombophilia, and of the 18 women having measures of coagulation, 16 had ≥ 1 thrombophilia. The sensitivity of a previous history of thrombosis to predict PE was low, 25 % (2/8 men), 4 % (1/24 women). CONCLUSIONS Of 154 men hospitalized for PE, 8 (5 %) used TT, and of 193 women, 24 (12 %) used ET. Our data suggests that PE is an important complication of TT in men and ET in women, in part reflecting an interaction between familial and acquired thrombophilia and exogenous hormone use.
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Affiliation(s)
- Marloe Prince
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
| | - Charles J. Glueck
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
| | - Parth Shah
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
| | - Ashwin Kumar
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
| | - Michael Goldenberg
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
| | - Matan Rothschild
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
| | - Nasim Motayar
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
| | - Vybhav Jetty
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
| | - Kevin Lee
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
| | - Ping Wang
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
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Abstract
As testosterone replacement therapy (TRT) has emerged as a commonly prescribed therapy for symptomatic low testosterone, conflicting data have been reported in terms of both its efficacy and potential adverse outcomes. One of the most controversial associations has been that of TRT and cardiovascular morbidity and mortality. This review briefly provides background on the history of TRT, the indications for TRT, and the data behind TRT for symptomatic low testosterone. It then specifically delves into the rather limited data for cardiovascular outcomes of those with low endogenous testosterone and those who receive TRT. The available body of literature strongly suggests that more work, by way of clinical trials, needs to be done to better understand the impact of testosterone and TRT on the cardiovascular system.
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Glueck CJ, Riaz R, Prince M, Freiberg RA, Wang P. Testosterone Therapy Can Interact With Thrombophilia, Leading to Osteonecrosis. Orthopedics 2015; 38:e1073-8. [PMID: 26652327 DOI: 10.3928/01477447-20151120-03] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 04/08/2015] [Indexed: 02/03/2023]
Abstract
Although this effect is not widely recognized, testosterone therapy can interact with thrombophilia, causing osteonecrosis. In 12 men and 4 women who had idiopathic osteonecrosis a median of 6 months after the onset of testosterone therapy, the authors examined the interaction between testosterone therapy and previously undiagnosed thrombophilia. The authors hypothesized that patients who had osteonecrosis after starting testosterone therapy were more likely than 110 normal control subjects or 48 patients who had osteonecrosis and were not receiving testosterone therapy to have thrombophilia. Measures of thrombophilia included Factor V Leiden, prothrombin, PAI-1 gene mutations, Factor VIII, Factor XI, anticardiolipin antibody immunoglobulin G or immunoglobulin M, and homocysteine values. In 10 cases, osteonecrosis occurred 6 months or less after the onset of testosterone therapy, and in all 16 cases, it occurred after a median of 6 months of testosterone therapy. Of the 16 cases, 5 (31%) were Factor V Leiden heterozygotes vs 2 of 109 (2%) healthy control subjects (P=.0003) and 4 of 48 patients who had osteonecrosis and were not receiving testosterone therapy (P=.04). Of the 16 cases, 4 (25%) had high (>150%) Factor VIII levels vs 7 of 103 (7%) healthy control subjects (P=.04), and 3 (19%) had high (>150%) Factor XI levels vs 3 of 101 (3%) healthy control subjects (P=.03). Of the 16 patients with osteonecrosis, 14 (88%) had at least 1 abnormal procoagulant value (of the 8 measured) vs 47 of 110 (43%) healthy control subjects (P=.0009). Of the 5 men whose serum estradiol level was measured while they were receiving testosterone therapy, this level was high (≥42.6 pg/mL) in 4. When testosterone therapy is given to patients with thrombophilia, they are at increased risk for osteonecrosis.
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Glueck CJ, Prince M, Patel N, Patel J, Shah P, Mehta N, Wang P. Thrombophilia in 67 Patients With Thrombotic Events After Starting Testosterone Therapy. Clin Appl Thromb Hemost 2015; 22:548-53. [PMID: 26620418 DOI: 10.1177/1076029615619486] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We compared thrombophilia in 67 cases (59 men and 8 women) with thrombotic events after starting testosterone therapy (TT) versus 111 patient controls having unprovoked venous thrombotic events without TT. In the 67 patients, thrombosis (47 deep venous thrombosis-pulmonary embolism, 16 osteonecrosis, and 4 ocular thrombosis) occurred 6 months (median) after starting TT. Cases differed from controls for factor V Leiden heterozygosity (16 of the 67 [24%] vs 13 [12%] of the 111, P = .038) and for lupus anticoagulant (9 [14%] of the 64 vs 4 [4%] of the 106, P = .019). After a first thrombotic event and continuing TT, 11 cases had a second thrombotic event, despite adequate anticoagulation, 6 of whom, still anticoagulated, had a third thrombosis. Screening for thrombophilia before starting TT should identify men and women at high risk for thrombotic events with an adverse risk-benefit ratio for TT. When TT is given to patients with familial and acquired thrombophilia, thrombosis may occur and recur in thrombophilic men despite anticoagulation.
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Affiliation(s)
- Charles J Glueck
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Marloe Prince
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Niravkumar Patel
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Jaykumar Patel
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Parth Shah
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Nishi Mehta
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Ping Wang
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
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Renukanthan A, Quinton R, Turner B, MacCallum P, Seal L, Davies A, Green R, Evanson J, Korbonits M. Kallmann syndrome patient with gender dysphoria, multiple sclerosis, and thrombophilia. Endocrine 2015; 50:496-503. [PMID: 25739677 DOI: 10.1007/s12020-015-0562-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 02/21/2015] [Indexed: 10/23/2022]
Abstract
One of the challenging issues in patients with complex problems is that the various diseases and their treatment can influence each other and present unusual hurdles in management. We investigated one such complex case. A 34-year-old XY male presented with azoospermia, detected on semen analysis for pre-orchidectomy sperm banking. He had a 20-year history of gender dysphoria and bilateral breast swelling. The patient suffered a deep vein thrombosis at the age of 19 years. Examination confirmed clinical features of Kallmann syndrome including unilateral cryptorchidism, micropenis, congenital anosmia, and bimanual synkinesis (mirror movements), with reduced serum testosterone and normal gonadotropin levels demonstrating hypogonadotropic hypogonadism. MRI showed missing olfactory bulbs. Osteopenia and reduced vitamin D levels of 21 nmol/L were identified. He was found to harbor a heterozygous factor-V-Leiden mutation. The genetic basis of Kallmann syndrome remains unknown: his screening tests were negative for mutations in CHD7, FGF8, FGFR1, GNRH1, GNRHR, HS6ST1, KAL1, KISS1R, KISS1, NELF, PROK2, PROKR2, TAC3, and TACR3. The patient initially declined testosterone therapy with a view to undergo gender reassignment. Over the next 2 years, the patient experienced recurrent episodes of weakness and paresthesia, associated with classical MRI appearances of multiple sclerosis-related demyelination in the spinal cord and brain. Although it was difficult to elucidate an association between the patient's gender dysphoria and untreated congenital hypogonadism, his desire to become female together with his co-existing thrombophilia, presented challenges to the administration of hormone treatment. Furthermore, we have considered an association between multiple sclerosis and hypogonadotropic hypogonadism.
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Affiliation(s)
- Aniruthan Renukanthan
- Department of Endocrinology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK
| | - Richard Quinton
- Institute of Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK
| | - Benjamin Turner
- Department of Neurology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Peter MacCallum
- Department of Haematology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Leighton Seal
- Department of Endocrinology, St George's University of London, London, UK
| | - Andrew Davies
- Gender Identity Clinic Service, West London Mental Health NHS Trust, London, UK
| | - Richard Green
- Faculty of Medicine, Imperial College London, London, UK
| | - Jane Evanson
- Department of Neuroradiology, Barts Health NHS Trust, London, UK
| | - Márta Korbonits
- Department of Endocrinology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK.
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Freedman J, Glueck CJ, Prince M, Riaz R, Wang P. Testosterone, thrombophilia, thrombosis. Transl Res 2015; 165:537-48. [PMID: 25639953 DOI: 10.1016/j.trsl.2014.12.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 12/16/2014] [Accepted: 12/17/2014] [Indexed: 10/24/2022]
Abstract
We screened previously undiagnosed thrombophilia (V Leiden-prothrombin mutations, Factors VIII and XI, homocysteine, and antiphospholipid antibody [APL] syndrome) in 15 men and 2 women with venous thromboembolism (VTE) or osteonecrosis 7 months (median) after starting testosterone therapy (TT), gel (30-50 mg/d), intramuscular (100-400 mg/wk), or human chorionic gonadotropin (HCG) (6000 IU/wk). Thrombophilia was studied in 2 healthy control groups without thrombosis (97 normal controls, 31 subjects on TT) and in a third control group (n = 22) with VTE, not on TT. Of the 17 cases, 76% had ≥1 thrombophilia vs 19% of 97 normal controls (P < 0.0001), vs 29% of 31 TT controls (P = 0.002). Cases differed from normal controls by Factor V Leiden (12% vs 0%, P = 0.021), by high Factor VIII (>150%) (24% vs 7%, P = 0.058), by high homocysteine (29% vs 5%, P = 0.007), and from both normal and TT controls for APL syndrome (18% vs 2%, P = 0.023, vs 0%, P = 0.04). Despite adequate anticoagulation with TT continued after the first deep venous thrombosis-pulmonary embolus (DVT-PE), 1 man sustained 3 DVT-PEs 5, 8, and 11 months later and a second man had 2 DVT-PEs 1 and 2 months later. Of the 10 cases with serum T measured on TT, 6 (60%) had supranormal T (>800 ng/dL) and of 9 with estradiol measured on TT, 7 (78%) had supranormal levels (>42.6 pg/mL). TT interacts with thrombophilia leading to thrombosis. TT continuation in thrombophilic men is contraindicated because of recurrent thrombi despite anticoagulation. Screening for thrombophilia before starting TT should identify subjects at high risk for VTE with an adverse the risk to benefit ratio for TT.
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Affiliation(s)
- Joel Freedman
- Jewish Hospital Internal Medicine Residency Program, Cincinnati, Ohio
| | - Charles J Glueck
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, Ohio.
| | - Marloe Prince
- Jewish Hospital Internal Medicine Residency Program, Cincinnati, Ohio
| | - Rashid Riaz
- Jewish Hospital Internal Medicine Residency Program, Cincinnati, Ohio
| | - Ping Wang
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, Ohio
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Glueck CJ, Friedman J, Hafeez A, Hassan A, Wang P. Testosterone therapy, thrombophilia, and hospitalization for deep venous thrombosis–pulmonary embolus, an exploratory, hypothesis-generating study. Med Hypotheses 2015; 84:341-3. [DOI: 10.1016/j.mehy.2015.01.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 01/15/2015] [Indexed: 11/26/2022]
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Long term anticoagulation (4-16 years) stops progression of idiopathic hip osteonecrosis associated with familial thrombophilia. Adv Orthop 2015; 2015:138382. [PMID: 25709842 PMCID: PMC4325553 DOI: 10.1155/2015/138382] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 12/23/2014] [Indexed: 11/17/2022] Open
Abstract
In 6 patients with familial thrombophilia (5 Factor V (FV) Leiden heterozygotes, 1 with resistance to activated protein C (RAPC)), we prospectively assessed whether continuous longterm (4–16 years) anticoagulation would prevent progression of idiopathic osteonecrosis (ON), ameliorate pain, and facilitate functional recovery. Four men and 2 women (9 hips, 8 Ficat stage II, 1 stage I) were anticoagulated with enoxaparin (60 mg/day) for 3 months and subsequently with Coumadin, Xarelto, or Pradaxa, warranted by ≥2 prior thrombotic events. Anticoagulation was continued for 4, 4, 9, 13, 13, and 16 years, with serial clinical and X-ray follow-up. On 4–16-years anticoagulation, 9 hips in the 6 patients (8 originally Ficat II, 1 Ficat I) remained unchanged, contrasted to untreated ON Ficat stage II, where 50%–80% of hips progress to collapse (Ficat stages III-IV) within 2 years after diagnosis. Within 3, 3, 3, 9, and 16 months after starting anticoagulation, 5 patients became pain-free and remained asymptomatic throughout follow-up; the 6th patient required Percocet for pain. There were no significant bleeding episodes. Long term (4–16 years) anticoagulation initiated in Ficat stages I-II of idiopathic hip ON in patients with FV-RAPC changes the natural history of ON, stopping progression, resolving pain, and restoring function.
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Glueck CJ, Freiberg RA, Wang P. Medical treatment of osteonecrosis of the knee associated with thrombophilia-hypofibrinolysis. Orthopedics 2014; 37:e911-6. [PMID: 25275980 DOI: 10.3928/01477447-20140924-59] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 02/20/2014] [Indexed: 02/03/2023]
Abstract
In 6 patients with stage II knee osteonecrosis, all 6 with thrombophilia and 4 with concurrent hypofibrinolysis, the authors prospectively determined whether anticoagulation with enoxaparin could prevent collapse and progression to osteoarthritis, ameliorate pain, and restore function. The 6 patients were treated with enoxaparin (40 to 60 mg/d for 3 or more months) as mandated by a US Food and Drug Administration-approved protocol. In post-enoxaparin prospective follow-up, patients were reassessed clinically every 4 to 6 months, and radiographs were obtained every year. The 6 patients followed up at 15.1, 7.5, 3.9, 2.25, 2, and 1 year, respectively. None progressed to joint collapse or severe osteoarthritis. Four became and remained asymptomatic at 2-, 3.9-, 7.5-, and 15.1-year follow-up, respectively. A fifth patient did not progress to collapse or severe osteoarthritis but had residual pain at 2.25-year follow-up. The sixth patient had no symptomatic benefit on enoxaparin but improved on rivaroxaban at 1-year follow-up. Two patients had recurrences of knee pain 1 and 4 years after their initial treatment with enoxaparin. One resolved after a second course of enoxaparin, and the other, with a second recurrence 1 year after the second course, resolved after a third course. Pretreatment, all 6 patients required canes, crutches, or wheelchairs, but after enoxaparin, no patient required them, and walking was unrestricted. Thrombophilia-hypofibrinolysis contributes to the pathogenesis of knee osteonecrosis. Thrombophilic-hypofibrinolytic patients with stage II knee osteonecrosis treated with enoxaparin have had no collapse or progression to severe osteoarthritis, and most have had resolution of pain and restoration of full function. This represents a major improvement compared with the natural history of untreated spontaneous knee osteonecrosis.
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Pelusi C, Costantino A, Martelli V, Lambertini M, Bazzocchi A, Ponti F, Battista G, Venturoli S, Meriggiola MC. Effects of three different testosterone formulations in female-to-male transsexual persons. J Sex Med 2014; 11:3002-11. [PMID: 25250780 DOI: 10.1111/jsm.12698] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Gender dysphoria is characterized by a strong discomfort with the gender assigned at birth and the urge to live as a member of the opposite gender. The acquisition of phenotypic features of the desired gender requires the use of cross-sex hormones. Female-to-male (FtM) transsexual persons are treated with testosterone to induce virilization. AIM The aim of the study was to assess the effects of three different testosterone formulations on body weight and composition and metabolic and bone parameters. METHODS Forty-five FtM transsexuals were randomly assigned to receive testoviron depot (i.m.: 100 mg/10 days; n = 15), testosterone gel (50 mg/die; n = 15), and testosterone undecanoate (i.m.: 1,000 mg every 6 weeks for the first 6 weeks and then every 12 weeks, n = 15). FtM individuals were studied before, at week 30, and at week 54 of testosterone treatment. MAIN OUTCOME MEASURES Anthropometric, metabolic, bone, hematological, and biochemical parameters were evaluated at baseline and after 12 months of treatment. RESULTS Lean body mass significantly increased and fat mass decreased in all groups. No modifications were reported in fasting insulin and insulin sensitivity index. High-density plasma lipoprotein levels declined significantly and low-density lipoprotein concentrations increased significantly in the three groups. The activated partial thromboplastin time and factor I did not change while prothrombin time significantly increased in all groups. At week 54, all subjects were amenorrheic and time to amenorrhea did not differ between the three groups. Current general life satisfaction was increased in all subjects after 1 year of treatment. CONCLUSIONS One-year testosterone administration in FtM transsexuals appears to be very safe with no differences among the testosterone formulations used. Our study is preliminary, and the detection of subtle or long-term differences in the effects of the three formulations may require further larger and longer term studies in this and other populations.
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Affiliation(s)
- Carla Pelusi
- Division of Endocrinology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Glueck CJ, Wang P. Testosterone therapy, thrombosis, thrombophilia, cardiovascular events. Metabolism 2014; 63:989-94. [PMID: 24930993 DOI: 10.1016/j.metabol.2014.05.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 05/06/2014] [Accepted: 05/11/2014] [Indexed: 12/13/2022]
Abstract
There are similar time intervals between starting testosterone therapy (TT) and development of thrombotic (~4.5 months) or cardiovascular (CVD) events (~3 months) which may, speculatively, reflect a shared pathophysiology. We have described thrombotic events 5 months (median) after starting TT in 38 men and 4 women, including 27 with deep venous thrombosis-pulmonary embolism, 12 with osteonecrosis, 1 with central retinal vein thrombosis, 1 with amaurosis fugax, and 1 with spinal cord infarction. In 8 men whose TT was continued, second thrombotic events occurred despite adequate anticoagulation with Coumadin in 8 men, 3 of whom had a third thrombotic event. Of these 42 cases, 40 had measures of thrombophilia-hypofibrinolysis, and 39 were found to have previously undiagnosed thrombophilia-hypofibrinolysis. Before beginning TT, especially in men with previous history of thrombotic events, we suggest that, at a minimum, measurements be made for the Factor V Leiden and Prothrombin mutations, Factors VIII and XI, and homocysteine, to identify men who should not receive TT. We need prospective data focused on whether there should be pre-TT screening based on history of previous venous thromboembolism or for all subjects for major gene thrombophilias. To better resolve questions about TT and all cause and cardiovascular morbidity and mortality and thrombosis, a long term, prospective, randomized, blinded study following the example of the Women's Health Initiative is needed. While we wait for prospective placebo-controlled TT outcome data, TT should be restricted to men with well-defined androgen deficiency syndromes.
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Affiliation(s)
- Charles J Glueck
- Jewish Hospital Cholesterol, Metabolism, Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA.
| | - Ping Wang
- Jewish Hospital Cholesterol, Metabolism, Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
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Testosterone, anastrozole, factor V Leiden heterozygosity and osteonecrosis of the jaws. Blood Coagul Fibrinolysis 2014; 25:286-8. [DOI: 10.1097/mbc.0000000000000047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Venous thromboembolism caused by testosterone abuse in a young man with previously undiagnosed genetic thrombophilia. REV ROMANA MED LAB 2014. [DOI: 10.2478/rrlm-2014-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Ruige JB, Ouwens DM, Kaufman JM. Beneficial and adverse effects of testosterone on the cardiovascular system in men. J Clin Endocrinol Metab 2013; 98:4300-10. [PMID: 24064693 DOI: 10.1210/jc.2013-1970] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
CONTEXT The widespread use of T therapy, particularly in aging males, necessitates knowledge of the relationship between T and the cardiovascular system. EVIDENCE ACQUISITION The review is based on a 1970 to 2013 PubMed search with terms related to androgens in combination with cardiovascular disease, including T, dihydrotestosterone, trial, mortality, cardiovascular disease, myocardial infarction, blood pressure, endothelial function, dyslipidemia, thrombosis, ventricular function, and arrhythmia. Original articles, systematic reviews and meta-analyses, and relevant citations were screened. EVIDENCE SYNTHESIS Low T has been linked to increased blood pressure, dyslipidemia, atherosclerosis, arrhythmia, thrombosis, endothelial dysfunction, as well as to impaired left ventricular function. On the one hand, a modest association is suggested between low endogenous T and incident cardiovascular disease or cardiovascular mortality, implying unrecognized beneficial T effects, residual confounding, or a relationship with health status. On the other hand, treatments with T to restore "normal concentrations" have so far not been proven to be beneficial with respect to cardiovascular disease; neither have they definitely shown specific adverse cardiovascular effects. The cardiovascular risk-benefit profile of T therapy remains largely evasive in view of a lack of well-designed and adequately powered randomized clinical trials. CONCLUSIONS The important knowledge gap as to the exact relationship between T and cardiovascular disease would support a cautious, restrained approach to T therapy in aging men, pending clarification of benefits and risks by adequately powered clinical trials of sufficient duration.
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Affiliation(s)
- Johannes B Ruige
- MD, PhD, Department of Endocrinology, Ghent University Hospital, De Pintelann 185, B9000 Gent, Belgium.
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Glueck CJ, Richardson-Royer C, Schultz R, Burger T, Bowe D, Padda J, Wang P. Testosterone Therapy, Thrombophilia–Hypofibrinolysis, and Hospitalization for Deep Venous Thrombosis-Pulmonary Embolus. Clin Appl Thromb Hemost 2013; 20:244-9. [DOI: 10.1177/1076029613499819] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In our study of 596 men hospitalized in the last 3 years for deep venous thrombosis-pulmonary emboli (DVT-PE), we determined the prevalence of exogenous testosterone (T) use with subsequent development of DVT-PE. Of the 596 men, 110 were now dead, 97 had cancer thought to cause DVT-PE, 250 could not be contacted, leaving 139, of whom 7 had taken T before and at the time of their admissions, 1.2% of the total cohort, a conservative estimate of the prevalence of T-associated DVT-PE. In all, 5 of the 7 DVT-PE events occurred within 3 months of initiation of T, with mean and median intervals between initiation of T and hospitalization with DVT-PE 6.7 and 2 months. Of the 7 men treated with exogenous T, all 5 men who had evaluation of thrombophilia–hypofibrinolysis were found to have previously undiagnosed familial or acquired thrombophilia or hypofibrinolysis, suggesting a thrombotic interaction between exogenous T and thrombophilia–hypofibrinolysis.
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Affiliation(s)
- Charles J. Glueck
- Jewish Hospital Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Caitlin Richardson-Royer
- Jewish Hospital Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
- Internal Medicine Residency Program, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Reiker Schultz
- Jewish Hospital Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
- Internal Medicine Residency Program, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Tim Burger
- Jewish Hospital Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
- Internal Medicine Residency Program, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Dedrick Bowe
- Jewish Hospital Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
- Internal Medicine Residency Program, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Jagjit Padda
- Jewish Hospital Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
- Internal Medicine Residency Program, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Ping Wang
- Jewish Hospital Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
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Glueck CJ, Bowe D, Valdez A, Wang P. Thrombosis in Three Postmenopausal Women Receiving Testosterone Therapy for Low Libido. WOMENS HEALTH 2013; 9:405-10. [DOI: 10.2217/whe.13.31] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Our hypothesis was that thrombosis occurring in postmenopausal women given testosterone (T) or testosterone–estradiol (TE) to improve libido was associated with a prothrombotic interaction between T or TE with underlying inherited procoagulants. In three previously healthy, postmenopausal, Caucasian women with no antecedent thrombosis and previously undiagnosed G20210A prothrombin gene heterozygosity, hyperhomocysteinemia and 4G4G homozygosity of the PAI-1 gene, we describe central retinal vein thrombosis and osteonecrosis that developed at 16 days, 2 months and 11 months in the three cases, respectively, after T or TE therapy was started. Exogenous T or TE in postmenopausal women may be associated with thrombosis, speculatively when it is superimposed on underlying procoagulants. This small observational case series can serve as a starting point for a larger observational study with greater detail on patient history, serum T and estradiol levels, and detailed PCR and serologic assessment of thrombophilia and hypofibrinolysis.
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Affiliation(s)
- Charles J Glueck
- Jewish Hospital Cholesterol Center, Keystone Parke, 2135 Dana Avenue, Cincinnati, OH 45207, USA
| | - Dedrick Bowe
- Jewish Hospital Cholesterol Center, Keystone Parke, 2135 Dana Avenue, Cincinnati, OH 45207, USA
- Internal Medical Residency Program, Jewish Hospital of Cincinnati, OH, USA
| | - Alejandro Valdez
- Jewish Hospital Cholesterol Center, Keystone Parke, 2135 Dana Avenue, Cincinnati, OH 45207, USA
- Internal Medical Residency Program, Jewish Hospital of Cincinnati, OH, USA
| | - Ping Wang
- Jewish Hospital Cholesterol Center, Keystone Parke, 2135 Dana Avenue, Cincinnati, OH 45207, USA
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Glueck CJ, Richardson-Royer C, Schultz R, Burger T, Labitue F, Riaz MK, Padda J, Bowe D, Goldenberg N, Wang P. Testosterone, Thrombophilia, and Thrombosis. Clin Appl Thromb Hemost 2013; 20:22-30. [DOI: 10.1177/1076029613485154] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We describe thrombosis, deep venous thrombosis (DVT) pulmonary embolism (PE; n = 9) and hip-knee osteonecrosis (n = 5) that developed after testosterone therapy (median 11 months) in 14 previously healthy patients (13 men and 1 woman; 13 Caucasian and 1 African American), with no antecedent thrombosis and previously undiagnosed thrombophilia–hypofibrinolysis. Of the 14 patients, 3 were found to be factor V Leiden heterozygotes, 3 had high factor VIII, 3 had plasminogen activator inhibitor 1 4G4G homozygosity, 2 had high factor XI, 2 had high homocysteine, 1 had low antithrombin III, 1 had the lupus anticoagulant, 1 had high anticardiolipin antibody Immunoglobulin G, and 1 had no clotting abnormalities. In 4 men with thrombophilia, DVT-PE recurred when testosterone was continued despite therapeutic international normalized ratio on warfarin. In 60 men on testosterone, 20 (33%) had high estradiol (E2 >42.6 pg/mL). When exogenous testosterone is aromatized to E2, and E2-induced thrombophilia is superimposed on thrombophilia–hypofibrinolysis, thrombosis occurs. The DVT-PE and osteonecrosis after starting testosterone are associated with previously undiagnosed thrombophilia–hypofibrinolysis. Thrombophilia should be ruled out before administration of exogenous testosterone.
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Affiliation(s)
| | | | - Reiker Schultz
- The Jewish Hospital Cholesterol Center, Cincinnati, OH, USA
- The Internal Medical Residency Program, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Tim Burger
- The Jewish Hospital Cholesterol Center, Cincinnati, OH, USA
- The Internal Medical Residency Program, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Fanta Labitue
- The Jewish Hospital Cholesterol Center, Cincinnati, OH, USA
- The Internal Medical Residency Program, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Muhammad K. Riaz
- The Jewish Hospital Cholesterol Center, Cincinnati, OH, USA
- The Internal Medical Residency Program, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Jagjit Padda
- The Jewish Hospital Cholesterol Center, Cincinnati, OH, USA
- The Internal Medical Residency Program, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Dedrick Bowe
- The Jewish Hospital Cholesterol Center, Cincinnati, OH, USA
- The Internal Medical Residency Program, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | | | - Ping Wang
- The Jewish Hospital Cholesterol Center, Cincinnati, OH, USA
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Abstract
The aim of this review was to provide information about the variety of thrombophilic and hypofibrinolytic markers that are possible risk factors for the development of osteonecrosis and bone marrow edema syndrome. A total of 48 parameters were identified in 45 studies that included 2163 patients. The most frequently reported laboratory findings included altered serum concentrations of lipoproteins, decreased concentration and function of fibrinolytic agents, increased levels of thrombophilic markers, and several single nucleotide polymorphisms. Despite inhomogeneities in reported parameters, results, patients' collectives, and treatment strategies, these data suggest that coagulation abnormalities may play an important role in the emergence of osteonecrosis and bone marrow edema syndrome.
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Affiliation(s)
- Patrick Orth
- Department of Orthopaedic Surgery, Saarland University Medical Center, Homburg, Saar, Germany
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Glueck CJ, Freiberg RA, Boriel G, Khan Z, Brar A, Padda J, Wang P. The role of the factor V Leiden mutation in osteonecrosis of the hip. Clin Appl Thromb Hemost 2012; 19:499-503. [PMID: 22696591 DOI: 10.1177/1076029612449901] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
We examined the hypothesis that the factor V Leiden (FVL) and G20101A prothrombin gene mutations are commonly associated with hip osteonecrosis. We prospectively evaluated 244 consecutively referred adults with osteonecrosis (ON), 161 idiopathic and 83 secondary. Cases (n = 244) did not differ from 104 normal controls by race. Of the 244 patients, 23 (9.4%) were FVL heterozygotes versus 2 of 104 controls (1.9%), P = .013, risk ratio (RR) = 4.90, 95% confidence interval (CI) 1.18 to 20.4. Of the 161 patients with idiopathic ON, 15 (9.3%) were FVL heterozygotes versus 2 of 104 normal controls (1.9%), P = .017, RR = 4.84, 95% CI 1.13 to 20.8. Of the 83 patients with secondary ON, 8 (9.6%) FVL heterozygotes versus 2 of 104 normal controls (1.9%), P = .024, RR = 5.01, 95% CI 1.09 to 23.0. Prothrombin gene heterozygosity in normal controls (2.9%) did not differ from ON cases (3.4%), P = 1.0. The thrombophilic FVL mutation is commonly associated with and may be pathoetiologic for hip osteonecrosis.
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Affiliation(s)
- Charles J Glueck
- 1Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
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