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Bouck EG, Grinsztejn E, Mcnamara M, Stavrou EX, Wolberg AS. Thromboembolic risk with gender-affirming hormone therapy: potential role of global coagulation and fibrinolysis assays. Res Pract Thromb Haemost 2023; 7:102197. [PMID: 37822706 PMCID: PMC10562871 DOI: 10.1016/j.rpth.2023.102197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/14/2023] [Accepted: 07/18/2023] [Indexed: 10/13/2023] Open
Abstract
Gender-affirming hormonal therapies are a critical component of the care of transgender individuals. Transgender people are commonly prescribed estrogen or testosterone to promote male-to-female or female-to-male transitions and to preserve gender-specific characteristics long-term. However, some exogenous hormones, especially certain estrogen preparations, are an established risk factor of thrombosis. As the number of individuals seeking gender-based care is rising, there is an urgent need to identify and characterize the mechanisms underlying hormone-associated thrombosis and incorporate this information into clinical algorithms for diagnosis and management. Herein, we discuss historical evidence on the incidence of thrombosis and changes in plasma composition in transgender and cisgender cohorts. We present 3 case studies to demonstrate knowledge gaps in thrombosis risk stratification and prediction tools. We also present data from in vitro coagulation and fibrinolysis assays and discuss how information from these kinds of assays may be used to help guide the clinical management of transgender individuals.
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Affiliation(s)
- Emma G. Bouck
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Eduarda Grinsztejn
- Department of Medicine, Hematology and Oncology Division, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Megan Mcnamara
- Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Evi X. Stavrou
- Medicine Service, Section of Hematology-Oncology, Louise Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA
- Department of Medicine, Hematology and Oncology Division, CWRU School of Medicine, Cleveland, OH, USA
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
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Bouck EG, Arvanitis M, Osburn WO, Sang Y, Reventun P, Ahmadzia HK, Smith NL, Lowenstein CJ, Wolberg AS. High risk oral contraceptive hormones do not directly enhance endothelial cell procoagulant activity in vitro. PLoS One 2023; 18:e0284333. [PMID: 37075041 PMCID: PMC10115293 DOI: 10.1371/journal.pone.0284333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/28/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Oral contraceptive (OC) use increases venous thromboembolism risk 2-5-fold. Procoagulant changes can be detected in plasma from OC users even without thrombosis, but cellular mechanisms that provoke thrombosis have not been identified. Endothelial cell (EC) dysfunction is thought to initiate venous thromboembolism. It is unknown whether OC hormones provoke aberrant procoagulant activity in ECs. OBJECTIVE Characterize the effect of high-risk OC hormones (ethinyl estradiol [EE] and drospirenone) on EC procoagulant activity and the potential interplay with nuclear estrogen receptors ERα and ERβ and inflammatory processes. METHODS Human umbilical vein and dermal microvascular ECs (HUVEC and HDMVEC, respectively) were treated with EE and/or drospirenone. Genes encoding the estrogen receptors ERα and ERβ (ESR1 and ESR2, respectively) were overexpressed in HUVEC and HDMVEC via lentiviral vectors. EC gene expression was assessed by RT-qPCR. The ability of ECs to support thrombin generation and fibrin formation was measured by calibrated automated thrombography and spectrophotometry, respectively. RESULTS Neither EE nor drospirenone, alone or together, changed expression of genes encoding anti- or procoagulant proteins (TFPI, THBD, F3), integrins (ITGAV, ITGB3), or fibrinolytic mediators (SERPINE1, PLAT). EE and/or drospirenone did not increase EC-supported thrombin generation or fibrin formation, either. Our analyses indicated a subset of individuals express ESR1 and ESR2 transcripts in human aortic ECs. However, overexpression of ESR1 and/or ESR2 in HUVEC and HDMVEC did not facilitate the ability of OC-treated ECs to support procoagulant activity, even in the presence of a pro-inflammatory stimulus. CONCLUSIONS The OC hormones EE and drospirenone do not directly enhance thrombin generation potential of primary ECs in vitro.
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Affiliation(s)
- Emma G. Bouck
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Marios Arvanitis
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - William O. Osburn
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Yaqiu Sang
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Paula Reventun
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Homa K. Ahmadzia
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, George Washington University, Washington, DC, United States of America
| | - Nicholas L. Smith
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, United States of America
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA, United States of America
| | - Charles J. Lowenstein
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
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Cheung NC, Noviasky JA, Ulen KR, Brangman SA. Efficacy and Safety of Megestrol in the Hospitalized Older Person. Sr Care Pharm 2022; 37:284-292. [DOI: 10.4140/tcp.n.2022.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objectives To evaluate the efficacy and safety of megestrol for off-label use in older patients with weight loss. Design Retrospective, nonblinded cohort study. Setting Upstate University Hospital is a 420-bed facility and academic
medical center with a level 1 trauma center. Upstate Community Hospital is a 314-bed acute care/hospital/ambulatory care center and long-term care hospital that also provides teaching services. Participants Patients 65 years of age and older without malignancy or acquired
immunodeficiency syndrome who were initiated and continued megestrol therapy at the Upstate University hospitals for at least two weeks were included. Of the 1,290 patients initially screened, 16 patients on megestrol were evaluated. An age- and gender-matched control group of 16 patients
was utilized for comparison of changes in weight and other variables. Interventions Patients in the megestrol group have received daily doses of megestrol between 160 mg to 800 mg for an average duration of 19 days. Patients in the control group had no history or current
use of megestrol utilization. Main Outcome Measurements The primary outcome was an increase in weight. Secondary outcome measures included albumin and thromboembolic events. Changes in weight and albumin were also compared with the control group. Results
At a mean duration of 19 days, there was no significant difference in weight gain (0.95 kg, OR = 1.33 [95% CI -1.615-3.527]). Albumin decreased by (0.4 g/dL OR = 0.916 [95% CI 0.12-0.78]) and none of the patients developed a thromboembolic event. Conclusion In older
hospitalized patients, megestrol did not increase weight, and did not improve albumin. No thromboembolic events were observed, but this may be because of a limited duration of observation of therapy and the routine use of anticoagulation prophylaxis in the inpatient setting.
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Affiliation(s)
- Nicole C. Cheung
- 1Florida Agricultural and Mechanical University, Tallahassee, Florida
| | - John A. Noviasky
- 2Upstate Community Hospital, Department of Pharmacy, Syracuse, New York
| | | | - Sharon A. Brangman
- 4SUNY Upstate Medical University Department of Geriatrics, Syracuse, New York
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Douxfils J, Morimont L, Bouvy C. Oral Contraceptives and Venous Thromboembolism: Focus on Testing that May Enable Prediction and Assessment of the Risk. Semin Thromb Hemost 2020; 46:872-886. [DOI: 10.1055/s-0040-1714140] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AbstractCombined oral contraceptives (COCs) induce several changes in the levels of coagulation factors. The levels of procoagulant factors are often increased, while levels of anticoagulant factors are decreased. Fibrinolysis is also affected, even if the effect seems to be more counterbalanced by opposite regulation of profibrinolytic and antifibrinolytic factors. These effects on hemostasis are more pronounced with third- or fourth-generation COC compared with second-generation COC. Venous thromboembolism (VTE) risk increases when multiple risk factors, including genetic and environmental, are present simultaneously. COC use causes changes in coagulation that modify the prothrombotic state induced by preexisting hemostatic alterations in a supra-additive manner. Therefore, testing appears to be of importance not only before implementing COC but also to monitor any potential thrombogenicity induced by COC therapy. Inherited genetic factors, such as factor V Leiden, G20210A prothrombin mutation, antithrombin, protein C or protein S deficiencies, non-O blood group, as well as CYP2C9*2 and the rs4379368 mutations, have all been identified as genetic predictive risk factors of VTE in women. Nevertheless, the screening of these genetic biomarkers is not capable of assessing the phenotypic expression of the risk. This review will focus on the different options for screening the thrombogenic status in this population. Specific attention will be given to the endogenous thrombin potential-based activated protein C resistance, a test aiming at assessing the thrombogenicity induced by hormonal therapies and inherited or acquired thrombophilia.
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Affiliation(s)
- Jonathan Douxfils
- QUALIblood s.a., Namur, Belgium
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Faculty of Medicine, University of Namur, Namur, Belgium
| | - Laure Morimont
- QUALIblood s.a., Namur, Belgium
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Faculty of Medicine, University of Namur, Namur, Belgium
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Morimont L, Bouvy C, Delvigne AS, Dogné JM, Douxfils J. Proof of concept of a new scale for the harmonization and the standardization of the ETP-based APC resistance. J Thromb Haemost 2020; 18:895-904. [PMID: 31984653 DOI: 10.1111/jth.14745] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/23/2019] [Accepted: 01/13/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The evaluation of the activated protein C resistance (APCr) based on the endogenous thrombin potential (ETP) is recommended during the development of steroid contraceptives. Results are usually expressed as "normalized APC sensitivity ratio" (nAPCsr) using a reference plasma that should achieve an ETP ratio of 0.1 in presence of exogenous APC. Because of the interassay variability, achieving exactly an ETP ratio of 0.1 in each run is almost impossible, which significantly affects the theoretical 0-10 scale of nAPCsr. OBJECTIVES To compare the nAPCsr to the nAPCsr10 , a newly proposed method to express the degree of APC resistance. METHODS Individual plasma samples (n = 854) were analyzed to compare nAPCsr and nAPCsr10 . These values were obtained using the validated ETP-based APCr assay. RESULTS The Spearman correlation between nAPCsr and nAPCsr10 had a coefficient of 0.99. Linear regression showed the following equation y = 0.9315*x + 0.03942 (r2 = .97). When differences (nAPCsr10 - nAPCsr) were plotted against nAPCsr10 , the mean difference equaled 0.16% or 4.95%. The correction obtained with the use of the nAPCsr10 showed that the results of the nAPCsr were statistically different (P < .0001). CONCLUSIONS This new scale provides a harmonization and normalization of the nAPCsr. Results show a better reproducibility with the nAPCsr10 . It avoids the additional variability and the unharmonized scale introduced by the use of a reference plasma. This adapted method for the calculation of the APC resistance could provide the regulatory and scientific bodies with more reproducible and harmonized evaluations.
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Affiliation(s)
- Laure Morimont
- Qualiblood sa, Namur, Belgium
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences, University of Namur, Namur, Belgium
| | | | | | - Jean-Michel Dogné
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences, University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- Qualiblood sa, Namur, Belgium
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences, University of Namur, Namur, Belgium
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Mohamed ABO, Kelchtermans H, Konings J, van Daal J, Al Marzouki A, Harakeh S, de Laat B. The effects of oral contraceptive usage on thrombin generation and activated protein C resistance in Saudi women, with a possible impact of the body mass index. PLoS One 2018; 13:e0206376. [PMID: 30359453 PMCID: PMC6201944 DOI: 10.1371/journal.pone.0206376] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 10/11/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The effect of oral contraceptive (OC) usage on coagulation has been studied worldwide. However, no such studies have been conducted in Saudi Arabia on Saudi women using OCs. The aim of this study was to investigate the effects of OC-induced changes of thrombin generation (TG) in the absence and presence of activated protein C (APC) or thrombomodulin (TM) in Saudi women. METHODS A total of 115 adult women, 47 on oral contraception (OC users) and 68 controls (not using OCs) were recruited from the obstetrics-gynecology outpatient clinic in Saudi Arabia. OCs that were used in this study include the following: Marvelon, Gynera, Cerrazetem, Yasmine, Microlut, Gracial and Diane. The plasma calibrated automated thrombinography (CAT) was used to determine TG which was expressed as endogenous thrombin potential (ETP; nM/min), lag time (min), peak (nM) and time-to-peak (ttpeak; min). In the presence of TM or APC, TG parameters were expressed relative to the parameters in the absence of TM or APC. RESULTS AND CONCLUSION As in other populations, our study demonstrated that OC usage induced prothrombotic changes in plasma of Saudi women, including resistance to the inhibitory actions of TM and APC. More specifically, OC usage in our population predominantly influenced TG and APC/TM sensitivity in overweight and obese individuals, a finding that needs confirmation in large cohort studies. The effects of APC and TM on TG parameters showed a positive association, and the correlation coefficients were higher in OC users for both ETP and peak values.
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Affiliation(s)
- Abdulrahman B. O. Mohamed
- Department of Pharmacology, King Abdul-Aziz University, Jeddah, Saudi Arabia
- Synapse Research Institute, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Hilde Kelchtermans
- Synapse Research Institute, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Joke Konings
- Synapse Research Institute, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Jamilla van Daal
- Synapse Research Institute, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Anas Al Marzouki
- Department of Obstetrics Gynecology, King Abdul-Aziz University, Jeddah, Saudi Arabia
| | - Steve Harakeh
- Special Infectious Agents Unit, King Fahd Medical Research Center, King Abdul-Aziz University, Jeddah, Saudi Arabia
| | - Bas de Laat
- Synapse Research Institute, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
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Piróg M, Jach R, Undas A. Effects of ultra-low-dose versus standard hormone therapy on fibrinolysis and thrombin generation in postmenopausal women. Eur J Obstet Gynecol Reprod Biol 2017; 217:77-82. [DOI: 10.1016/j.ejogrb.2017.08.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/02/2017] [Accepted: 08/12/2017] [Indexed: 10/19/2022]
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Tepper NK, Whiteman MK, Marchbanks PA, James AH, Curtis KM. Progestin-only contraception and thromboembolism: A systematic review. Contraception 2016; 94:678-700. [PMID: 27153743 PMCID: PMC11034842 DOI: 10.1016/j.contraception.2016.04.014] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 04/25/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Women with medical conditions associated with increased risk for thrombosis generally should not use estrogen-containing contraceptives; however, less is known about progestin-only contraceptives (POCs) and thrombosis risk. OBJECTIVES The objective was to identify evidence regarding the risk of venous thromboembolism (VTE) or arterial thromboembolism [stroke or acute myocardial infarction (AMI)] among women using POCs. METHODS We searched the PubMed database for all articles published from database inception through January 2016 for studies examining thrombosis among women using POCs. We included studies which examined women with medical conditions associated with thrombosis risk, as well as studies of women in the general population (either without these conditions or who were not specified to have these conditions). Hormonal contraceptives of interest included progestin-only pills (POPs), injectables, implants and levonorgestrel-releasing intrauterine devices (LNG-IUDs). Outcomes of interest included VTE, stroke and AMI. RESULTS There were 26 articles of good to poor quality that met inclusion criteria; 9 studies examined women with medical conditions and 20 examined women in the general population. Two studies found that, among smokers and women with certain thrombogenic mutations, use of depot medroxyprogesterone acetate (DMPA) had elevated odds of VTE compared with nonsmokers or those without mutations, although confidence intervals were wide and overlapped with odds among nonusers. One study found that, among women with previous VTE, use of POCs (including DMPA) was associated with a nonsignificant increased odds of recurrent VTE (all of which were among DMPA users); two other studies that examined POCs other than DMPA did not observe an association with recurrent VTE. Two studies found that use of DMPA among healthy women was also associated with increased odds of VTE. Two studies found that use of POCs for therapeutic indications was associated with increased odds of VTE. Studies did not find increased odds of VTE with POPs for contraceptive purposes, implants or LNG-IUDs nor were there increased odds of stroke or AMI with any POCs. CONCLUSION The majority of evidence identified by this systematic review did not suggest an increase in odds for venous or arterial events with use of most POCs. Limited evidence suggested increased odds of VTE with use of injectables (three studies) and use of POCs for therapeutic indications (two studies, one with POCs unspecified and the other with POPs). Any increase in risk likely translates to a small increase in absolute numbers of thrombotic events at the population level.
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Affiliation(s)
- Naomi K Tepper
- Division of Reproductive Health, US Centers for Disease Control and Prevention, Atlanta, GA, 30341, USA.
| | - Maura K Whiteman
- Division of Reproductive Health, US Centers for Disease Control and Prevention, Atlanta, GA, 30341, USA
| | - Polly A Marchbanks
- Division of Reproductive Health, US Centers for Disease Control and Prevention, Atlanta, GA, 30341, USA
| | - Andra H James
- Duke University School of Medicine, Durham, NC, 27710, USA
| | - Kathryn M Curtis
- Division of Reproductive Health, US Centers for Disease Control and Prevention, Atlanta, GA, 30341, USA
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Horton LG, Folger SG, Berry-Bibee E, Jatlaoui TC, Tepper NK, Curtis KM. Research gaps from evidence-based contraception guidance: the US Medical Eligibility Criteria for Contraceptive Use, 2016, and the US Selected Practice Recommendations for Contraceptive Use, 2016. Contraception 2016; 94:582-589. [DOI: 10.1016/j.contraception.2016.07.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 07/14/2016] [Accepted: 07/18/2016] [Indexed: 11/27/2022]
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10
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Hormonal contraception and thrombosis. Fertil Steril 2016; 106:1289-1294. [DOI: 10.1016/j.fertnstert.2016.08.039] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 08/17/2016] [Accepted: 08/18/2016] [Indexed: 11/21/2022]
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Archer D, Thomas M, Conard J, Merkatz R, Creasy G, Roberts K, Plagianos M, Blithe D, Sitruk-Ware R. Impact on hepatic estrogen-sensitive proteins by a 1-year contraceptive vaginal ring delivering Nestorone® and ethinyl estradiol. Contraception 2016; 93:58-64. [DOI: 10.1016/j.contraception.2015.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 09/18/2015] [Accepted: 09/21/2015] [Indexed: 10/23/2022]
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Maxwell WD, Jacob M, Spiryda LB, Bennett CL. Selection of Contraceptive Therapy for Patients with Thrombophilia: A Review of the Evidence. J Womens Health (Larchmt) 2014; 23:318-26. [DOI: 10.1089/jwh.2013.4479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Whitney D. Maxwell
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, University of South Carolina, Columbia, South Carolina
| | - Merna Jacob
- South Carolina College of Pharmacy, University of South Carolina, Columbia, South Carolina
| | - Lisa B. Spiryda
- Department of Obstetrics and Gynecology, University of Florida, College of Medicine, Gainesville, Florida
| | - Charles L. Bennett
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, University of South Carolina, Columbia, South Carolina
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Chabbert-Buffet N, Amy JJ. The combination of ethinylestradiol/cyproterone acetate is temporarily withdrawn from the market in France. Is the measure justified? EUR J CONTRACEP REPR 2013; 18:75-8. [DOI: 10.3109/13625187.2013.780203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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15
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La contraception estroprogestative remise en cause ? Presse Med 2013; 42:249-52. [DOI: 10.1016/j.lpm.2013.02.304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Raps M, Helmerhorst FM, Fleischer K, Dahm AEA, Rosendaal FR, Rosing J, Reitsma P, Sandset PM, van Vliet HAAM. The effect of different hormonal contraceptives on plasma levels of free protein S and free TFPI. Thromb Haemost 2013; 109:606-13. [PMID: 23407778 DOI: 10.1160/th12-10-0771] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 12/14/2012] [Indexed: 11/05/2022]
Abstract
Use of combined oral contraceptives is associated with a three- to six-fold increased risk of venous thrombosis. Hormonal contraceptives induce acquired resistance to activated protein C (APC), which predicts the risk of venous thrombosis. The biological basis of the acquired APC resistance is unknown. Free protein S (PS) and free tissue factor pathway inhibitor (TFPI) are the two main determinants of APC. Our objective was to assess the effect of both hormonal and non-hormonal contraceptives with different routes of administration on free TFPI and free PS levels. We conducted an observational study in 243 users of different contraceptives and measured APC sensitivity ratios (nAPCsr), free TFPI and free PS levels. Users of contraceptives with the highest risk of venous thrombosis as reported in recent literature, had the lowest free TFPI and free PS levels, and vice versa, women who used contraceptives with the lowest risk of venous thrombosis had the highest free TFPI and free PS levels. An association was observed between levels of free TFPI and nAPCsr, and between free PS and nAPCsr. The effect of oral contraceptives on TFPI and PS is a possible explanation for the increased risk of venous thrombosis associated with oral contraceptives.
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Affiliation(s)
- Marjolein Raps
- Marjolein Raps, Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.
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Plu-Bureau G, Maitrot-Mantelet L, Hugon-Rodin J, Canonico M. Hormonal contraceptives and venous thromboembolism: an epidemiological update. Best Pract Res Clin Endocrinol Metab 2013; 27:25-34. [PMID: 23384743 DOI: 10.1016/j.beem.2012.11.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Since the early 1960s, it has been well documented that combined hormonal contraceptives increase the risk of cardiovascular disease. Newer generation of oral formulations, as well as non-oral contraceptives (transdermal and vaginal), have been recently studied for thrombotic risk. This review provides a summary of the association between hormonal contraceptives and venous thromboembolism with emphasis on new formulations of hormonal contraceptives as well as route of administration. A systematic search of Medline database was done for all relevant articles which included women having used third generation pills, and the development of new progestins. Eligible articles published in English and reporting the risk of venous thromboembolism (VTE) (pulmonary embolism or deep venous thrombosis) among users of hormonal contraceptives were reviewed. A quantitative assessment was made from included studies. Current use of drospirenone or cyproterone oral combined contraceptives increased the risk of VTE compared with second generation pills (pooled OR: 1.7; 95% confidence interval [95% CI]: 1.4-2.2 and OR: 1.8; 95% CI: 1.4-2.3, respectively). In the context of contraceptive use, non-oral route of ethinyl-estradiol administration seems to be more thrombogenic than oral route. In contrast, low doses of both oral progestin contraceptives and intrauterine levonorgestrel could be safe with respect to VTE risk. In conclusion, newer generation formulations of hormonal contraceptives, as well as the non-oral hormonal contraceptive, seem to be more thrombogenic than second generation hormonal contraceptives.
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Affiliation(s)
- Genevieve Plu-Bureau
- Department of Gynecology and Endocrinology, Hôpital Universitaires Paris Centre, Paris-Descartes University, Paris, France.
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Gourdy P, Bachelot A, Catteau-Jonard S, Chabbert-Buffet N, Christin-Maître S, Conard J, Fredenrich A, Gompel A, Lamiche-Lorenzini F, Moreau C, Plu-Bureau G, Vambergue A, Vergès B, Kerlan V. Hormonal contraception in women at risk of vascular and metabolic disorders: Guidelines of the French Society of Endocrinology. ANNALES D'ENDOCRINOLOGIE 2012; 73:469-87. [DOI: 10.1016/j.ando.2012.09.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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19
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Oslakovic S, Zadro R. Comparison of the impact of four generations of progestins on hemostatic variables. Clin Appl Thromb Hemost 2012; 20:448-55. [PMID: 23091282 DOI: 10.1177/1076029612463426] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This study was undertaken to evaluate the impact of progestins as part of low-estrogen (ethinyl estradiol [EE2] ≤35 μg) combined oral contraceptives (COCs) on hemostatic variables. One hundred ninety-five healthy women took oral contraceptives with following formulations: 35 EE2/norgestimate (NGM), 35 EE2/cyproterone acetate, 35 EE2/norethisterone, 30 EE2/levonorgestrel, 30 EE2/drospirenone (DRSP), 20 EE2/gestodene, and 20 EE2/DRSP, for 6 months. Hemostatic assays (prothrombin time, activated partial thromboplastin time, fibrinogen, resistance to activated protein C ratio, protein C, protein S, factor VIII [FVIII], antithrombin, plasminogen, α2-antiplasmin, inhibitor of plasminogen activator type 1 [PAI-1] and d-dimers) were performed in 3 time points: at baseline, after 3, and 6 cycles. For each formulation, results were compared according to baseline values, intergroup analysis, and the amount of estrogen or progestin component. Most of the variables were changed except FVIII. Significant difference between oral contraceptives was found in antithrombin, protein C, protein S activities, and PAI-1 values, but changes were mostly within reference range.
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Affiliation(s)
- Sandra Oslakovic
- 1Department of Transfusion Medicine, Cakovec County Hospital, Cakovec, Croatia
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20
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Divani AA, Luo X, Brandy KR, Meyer RM, Joseph MS, Flaherty JD, Rao GHR, Datta YH. Oral versus vaginal combined hormonal contraceptives' effect on coagulation and inflammatory biomarkers among young adult women. Clin Appl Thromb Hemost 2012; 18:487-94. [PMID: 22431858 DOI: 10.1177/1076029612440036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
In order to compare the effect of combined oral contraceptive (COC) and combined vaginal contraceptive (CVC) methods on the inflammation and procoagulation, we recruited female participants in 3 groups: control participants, COC users, and CVC users. We measured different blood biomarkers. The users of both COC and CVC had higher levels of C-reactive protein (P < .0001) and factor VII (P < .0001). However, CD40 ligand was only higher for COC users (P < .0001) and not the CVC users. Even though the levels of thrombin/antithrombin III were not higher for COC and CVC users, as compared to the controls, CVC users had higher levels as compared to COC users (P = .0327). As compared to the control group, we observed higher levels von Willebrand factor among CVC users but not the COC users. Longitudinal studies with larger sample size are needed to better assess the inflammatory and procoagulation response due to CVC use.
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Affiliation(s)
- Afshin A Divani
- Department of Neurology, University of Minnesota, 420 Delaware Street S.E., MMC 295, Minneapolis, MN 55455, USA.
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21
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Delluc A, Le Ven F, Mottier D, Le Gal G. Épidémiologie et facteurs de risque de la maladie veineuse thromboembolique. Rev Mal Respir 2012; 29:254-66. [DOI: 10.1016/j.rmr.2011.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Accepted: 04/03/2011] [Indexed: 10/14/2022]
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Abstract
Estrogen and progestins have been used by millions of women as effective combined contraceptives. The safety of hormonal contraceptives has been documented by years of follow-up and serious adverse events that may be related to their use are rare in the young population exposed to these agents. The balance between the benefits and the risks of contraceptive steroids is generally positive in particular when comparing to the risks of pregnancy and especially in women with risk factors. The metabolic changes induced by the synthetic steroids used in contraception, such as lipoprotein changes, insulin response to glucose, and coagulation factors have been considered as potential markers of cardiovascular and venous risk. Observations of these effects have led to modifications of the composition of hormonal contraceptive in order to minimize these changes and hence potentially decrease the risks. The synthetic estrogen Ethinyl-Estradiol (EE) exerts a stronger effect that natural estradiol (E2) on hepatic metabolism including estrogen-dependent markers such as liver proteins. This stronger hepatic impact of EE has been related to its 17α-ethinyl group which prevents the inactivation of the molecule and results in a more pronounced hepatic effect of EE as compared to estradiol. Due to its strong activity, administering EE via a non-oral route does not prevent its impact on liver proteins. In order to circumvent the metabolic changes induced by EE, newer products using more natural compounds such as estradiol (E2) and estradiol valerate (E2V) have been introduced. The synthetic progestins used for contraception are structurally related either to testosterone (T) (estranes and gonanes) or to progesterone (pregnanes and 19-norpregnanes). Several new progestins have been designed to bind more specifically to the progesterone receptor and to minimize side-effects related to androgenic, estrogenic or glucocorticoid receptor interactions. Dienogest (DNG), and drospirenone (DRSP) and the 19-norpregnanes including Nestorone® (NES), nomegestrol acetate (NOMAc) and trimegestone (TMG) have been combined with estrogen either EE or E2 or estradiol valerate (E2V). Risks and benefits of the newer progestins used in contraception depend upon the type of molecular structure, the type and dose of estrogen associated in a combination and the route of administration. The lower metabolic impact of estradiol-based combinations may result in an improved safety profile, but large surveillance studies are warranted to confirm this plausible hypothesis. So far, the contraindications and warnings for use of current COCs also apply to the estradiol-based COCs.
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MESH Headings
- Animals
- Carbohydrate Metabolism/drug effects
- Contraceptives, Oral, Combined/adverse effects
- Contraceptives, Oral, Combined/pharmacology
- Contraceptives, Oral, Combined/therapeutic use
- Contraceptives, Oral, Hormonal/adverse effects
- Contraceptives, Oral, Hormonal/pharmacology
- Contraceptives, Oral, Hormonal/therapeutic use
- Estrogens/adverse effects
- Estrogens/therapeutic use
- Female
- Hemostasis/drug effects
- Homeostasis/drug effects
- Humans
- Lipid Metabolism/drug effects
- Liver/drug effects
- Liver/metabolism
- Progestins/adverse effects
- Progestins/therapeutic use
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Affiliation(s)
- Regine Sitruk-Ware
- Center for Biomedical Research, Population Council, Rockefeller University, New York, NY, USA,
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24
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Jackson E. Controversies in postpartum contraception: when is it safe to start oral contraceptives after childbirth? Thromb Res 2011; 127 Suppl 3:S35-9. [PMID: 21262436 DOI: 10.1016/s0049-3848(11)70010-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The timely initiation of contraception postpartum is an important consideration for breastfeeding and non-breastfeeding women; many women prefer oral contraceptive pills to other methods. In breastfeeding women, combined hormonal pills are not recommended prior to 6 weeks postpartum, due to effects on milk production. Although progestogen-only pills do not adversely affect milk, lack of data regarding possible effects on infants exposed to progestogens in breastmilk renders timing of initiation of this method controversial. In non-breastfeeding women, elevated risk of venous thromboembolism restricts use of combined hormonal pills prior to 21 days postpartum. From 21 to 42 days, use of combined hormonal pills should be assessed based on a woman's personal venous thromboembolism risk profile; after 42 days postpartum there is no restriction in the use of combined hormonal pills for otherwise healthy women. Non-breastfeeding women may safely use progestogen-only pills at any time during the postpartum.
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Affiliation(s)
- Emily Jackson
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
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25
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Exogenous hormones, the risk of venous thromboembolism, and activated protein C resistance. Menopause 2011; 17:1099-103. [PMID: 20975607 DOI: 10.1097/gme.0b013e3181fa264c] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Contraception hormonale. Contraception 2011. [DOI: 10.1016/b978-2-294-70921-0.00006-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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27
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Reid RL, Westhoff C, Mansour D, de Vries C, Verhaeghe J, Boschitsch E, Gompel A, Birkhäuser M, Krepelka P, Dulicek P, Iversen OE, Khamoshina M, Dezman LV, Fruzzetti F, Szarewski A, Wilken-Jensen C, Seidman D, Kaaja R, Shapiro S. Oral contraceptives and venous thromboembolism consensus opinion from an international workshop held in Berlin, Germany in December 2009. ACTA ACUST UNITED AC 2010; 36:117-22. [PMID: 20659363 DOI: 10.1783/147118910791749425] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Robert L Reid
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada.
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28
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Christiansen SC, Lijfering WM, Helmerhorst FM, Rosendaal FR, Cannegieter SC. Sex difference in risk of recurrent venous thrombosis and the risk profile for a second event. J Thromb Haemost 2010; 8:2159-68. [PMID: 20738758 DOI: 10.1111/j.1538-7836.2010.03994.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED BACKGROUND The risk of recurrent venous thrombosis is higher in men than in women, and this is so far unexplained. We set out to determine the influence of age, time between first and second event, type of first event, oral contraception, pregnancy and surgery. METHODS We performed a prospective follow-up study of 474 patients with a first objective diagnosis of deep vein thrombosis, aged 18-70 years (Leiden Thrombophilia Study cohort). RESULTS During 3477 person-years of follow-up, 90 recurrences occurred. The overall incidence rates of recurrence (IRs) were 40.9 per 1000 person-years in men and 15.8 per 1000 person-years in women. Men with an unprovoked first event had the highest risk of recurrence, with almost one-third experiencing a second unprovoked event within 8 years (IR 41.2 per 1000 person-years). This risk was three-fold lower in women [IR 14.2 per 1000 person-years; hazard ratio 2.8 (95% confidence interval 1.4-5.7)]. Age at diagnosis had little effect on recurrence rate, and nor had time elapsed since the first event. In women, almost half of the recurrences were provoked and were mainly related to oral contraceptive use or pregnancy. CONCLUSIONS The higher recurrence rate in men than in women is not the result of differences in the environmental or transient risk factors that we studied. The risk profile for a second thrombotic event is clearly different from that of a first.
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Affiliation(s)
- S C Christiansen
- Department of Clinical Epidemiology, Leiden University Medical Centre, the Netherlands
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29
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Tchaikovski SN, Rosing J. Mechanisms of estrogen-induced venous thromboembolism. Thromb Res 2010; 126:5-11. [PMID: 20163835 DOI: 10.1016/j.thromres.2010.01.045] [Citation(s) in RCA: 147] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Revised: 01/21/2010] [Accepted: 01/24/2010] [Indexed: 12/14/2022]
Abstract
The use of oral contraceptives (OC) is a well established risk factor for venous thrombosis. It has been known for many years that almost all haemostatic parameters i.e. plasma levels of coagulation factors, anticoagulant proteins and proteins involved in the fibrinolytic pathway change during OC use. The discovery of several risk factors of venous thrombosis in the 1990s shed new light on the association between the effects of OC on the haemostatic system and the increased risk of venous thrombosis. In this review, we summarize the current knowledge on the effects of different kinds of hormonal contraceptives (OC, transdermal contraceptives, vaginal ring and levonorgestrel-releasing intrauterine device) on haemostatic variables and the relationship between the changes of these variables and the risk of venous thrombosis.
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Affiliation(s)
- Svetlana N Tchaikovski
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
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30
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Canonico M, Fournier A, Carcaillon L, Olié V, Plu-Bureau G, Oger E, Mesrine S, Boutron-Ruault MC, Clavel-Chapelon F, Scarabin PY. Postmenopausal Hormone Therapy and Risk of Idiopathic Venous Thromboembolism. Arterioscler Thromb Vasc Biol 2010; 30:340-5. [DOI: 10.1161/atvbaha.109.196022] [Citation(s) in RCA: 189] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective—
Oral estrogen therapy increases venous thromboembolism risk among postmenopausal women. Although recent data showed transdermal estrogens may be safe with respect to thrombotic risk, the impact of the route of estrogen administration and concomitant progestogens is not fully established.
Methods and Results—
We used data from the E3N French prospective cohort of women born between 1925 and 1950 and biennially followed by questionnaires from 1990. Study population consisted of 80 308 postmenopausal women (average follow-up: 10.1 years) including 549 documented idiopathic first venous thromboembolism. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated using Cox proportional models. Compared to never-users, past-users of hormone therapy had no increased thrombotic risk (HR=1.1; 95% CI: 0.8 to 1.5). Oral not transdermal estrogens were associated with increased thrombotic risk (HR=1.7; 95% CI: 1.1 to 2.8 and HR=1.1; 95% CI: 0.8 to 1.8; homogeneity:
P
=0.01). The thrombotic risk significantly differed by concomitant progestogens type (homogeneity:
P
<0.01): there was no significant association with progesterone, pregnanes, and nortestosterones (HR=0.9; 95% CI: 0.6 to 1.5, HR=1.3; 95% CI: 0.9 to 2.0 and HR=1.4; 95% CI: 0.7 to 2.4). However, norpregnanes were associated with increased thrombotic risk (HR=1.8; 95% CI: 1.2 to 2.7).
Conclusions—
In this large study, we found that route of estrogen administration and concomitant progestogens type are 2 important determinants of thrombotic risk among postmenopausal women using hormone therapy. Transdermal estrogens alone or combined with progesterone might be safe with respect to thrombotic risk.
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Affiliation(s)
- Marianne Canonico
- From Inserm Unit 780, Cardiovascular Epidemiology Section (M.C., L.C., V.O., G.P.-B., E.O., P.-Y.S.), Cedex, France; University Paris-South 11 (M.C., L.C., V.O., E.O., P.-Y.S.), Cedex, France; Inserm ERI20/University Paris-South 11 (A.F., S.M., M.-C.B.-R., F.C.-C.), Villejuif, France; University Paris Descartes (G.P.-B.), Paris, France; and Centre Régional de PharmacoVigilance, Service de Pharmacologie (E.O.), CHU de Rennes, France
| | - Agnès Fournier
- From Inserm Unit 780, Cardiovascular Epidemiology Section (M.C., L.C., V.O., G.P.-B., E.O., P.-Y.S.), Cedex, France; University Paris-South 11 (M.C., L.C., V.O., E.O., P.-Y.S.), Cedex, France; Inserm ERI20/University Paris-South 11 (A.F., S.M., M.-C.B.-R., F.C.-C.), Villejuif, France; University Paris Descartes (G.P.-B.), Paris, France; and Centre Régional de PharmacoVigilance, Service de Pharmacologie (E.O.), CHU de Rennes, France
| | - Laure Carcaillon
- From Inserm Unit 780, Cardiovascular Epidemiology Section (M.C., L.C., V.O., G.P.-B., E.O., P.-Y.S.), Cedex, France; University Paris-South 11 (M.C., L.C., V.O., E.O., P.-Y.S.), Cedex, France; Inserm ERI20/University Paris-South 11 (A.F., S.M., M.-C.B.-R., F.C.-C.), Villejuif, France; University Paris Descartes (G.P.-B.), Paris, France; and Centre Régional de PharmacoVigilance, Service de Pharmacologie (E.O.), CHU de Rennes, France
| | - Valérie Olié
- From Inserm Unit 780, Cardiovascular Epidemiology Section (M.C., L.C., V.O., G.P.-B., E.O., P.-Y.S.), Cedex, France; University Paris-South 11 (M.C., L.C., V.O., E.O., P.-Y.S.), Cedex, France; Inserm ERI20/University Paris-South 11 (A.F., S.M., M.-C.B.-R., F.C.-C.), Villejuif, France; University Paris Descartes (G.P.-B.), Paris, France; and Centre Régional de PharmacoVigilance, Service de Pharmacologie (E.O.), CHU de Rennes, France
| | - Geneviève Plu-Bureau
- From Inserm Unit 780, Cardiovascular Epidemiology Section (M.C., L.C., V.O., G.P.-B., E.O., P.-Y.S.), Cedex, France; University Paris-South 11 (M.C., L.C., V.O., E.O., P.-Y.S.), Cedex, France; Inserm ERI20/University Paris-South 11 (A.F., S.M., M.-C.B.-R., F.C.-C.), Villejuif, France; University Paris Descartes (G.P.-B.), Paris, France; and Centre Régional de PharmacoVigilance, Service de Pharmacologie (E.O.), CHU de Rennes, France
| | - Emmanuel Oger
- From Inserm Unit 780, Cardiovascular Epidemiology Section (M.C., L.C., V.O., G.P.-B., E.O., P.-Y.S.), Cedex, France; University Paris-South 11 (M.C., L.C., V.O., E.O., P.-Y.S.), Cedex, France; Inserm ERI20/University Paris-South 11 (A.F., S.M., M.-C.B.-R., F.C.-C.), Villejuif, France; University Paris Descartes (G.P.-B.), Paris, France; and Centre Régional de PharmacoVigilance, Service de Pharmacologie (E.O.), CHU de Rennes, France
| | - Sylvie Mesrine
- From Inserm Unit 780, Cardiovascular Epidemiology Section (M.C., L.C., V.O., G.P.-B., E.O., P.-Y.S.), Cedex, France; University Paris-South 11 (M.C., L.C., V.O., E.O., P.-Y.S.), Cedex, France; Inserm ERI20/University Paris-South 11 (A.F., S.M., M.-C.B.-R., F.C.-C.), Villejuif, France; University Paris Descartes (G.P.-B.), Paris, France; and Centre Régional de PharmacoVigilance, Service de Pharmacologie (E.O.), CHU de Rennes, France
| | - Marie-Christine Boutron-Ruault
- From Inserm Unit 780, Cardiovascular Epidemiology Section (M.C., L.C., V.O., G.P.-B., E.O., P.-Y.S.), Cedex, France; University Paris-South 11 (M.C., L.C., V.O., E.O., P.-Y.S.), Cedex, France; Inserm ERI20/University Paris-South 11 (A.F., S.M., M.-C.B.-R., F.C.-C.), Villejuif, France; University Paris Descartes (G.P.-B.), Paris, France; and Centre Régional de PharmacoVigilance, Service de Pharmacologie (E.O.), CHU de Rennes, France
| | - Françoise Clavel-Chapelon
- From Inserm Unit 780, Cardiovascular Epidemiology Section (M.C., L.C., V.O., G.P.-B., E.O., P.-Y.S.), Cedex, France; University Paris-South 11 (M.C., L.C., V.O., E.O., P.-Y.S.), Cedex, France; Inserm ERI20/University Paris-South 11 (A.F., S.M., M.-C.B.-R., F.C.-C.), Villejuif, France; University Paris Descartes (G.P.-B.), Paris, France; and Centre Régional de PharmacoVigilance, Service de Pharmacologie (E.O.), CHU de Rennes, France
| | - Pierre-Yves Scarabin
- From Inserm Unit 780, Cardiovascular Epidemiology Section (M.C., L.C., V.O., G.P.-B., E.O., P.-Y.S.), Cedex, France; University Paris-South 11 (M.C., L.C., V.O., E.O., P.-Y.S.), Cedex, France; Inserm ERI20/University Paris-South 11 (A.F., S.M., M.-C.B.-R., F.C.-C.), Villejuif, France; University Paris Descartes (G.P.-B.), Paris, France; and Centre Régional de PharmacoVigilance, Service de Pharmacologie (E.O.), CHU de Rennes, France
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Dietrich JE, Yee DL. Thrombophilic conditions in the adolescent: the gynecologic impact. Obstet Gynecol Clin North Am 2009; 36:163-75. [PMID: 19344854 DOI: 10.1016/j.ogc.2008.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
As Virchow's triad suggests, a fine balance exists between the vascular wall, intravascular contents, and dynamic blood flow, such that a shift in this balance predisposes to thrombosis. Although thromboembolic events (TEs) are relatively infrequent in adolescents, the morbidity and mortality associated with TEs can be significant. Over the past 15 years, TEs and inherited and acquired thrombophilic conditions underlying them have become increasingly recognized in teens at risk, with combined hormonal contraception constituting one of the most significant of these risk factors. Therefore, managing gynecologic problems in teens who have thrombophilic conditions can be challenging. It is important to have a clear understanding about safe options available to help address adolescent gynecologic concerns in this setting and to manage situations collaboratively with a hematologist.
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Affiliation(s)
- Jennifer E Dietrich
- Department of Obstetrics and Gynecology, Baylor College of Medicine, 6620 Main Street, Suite 1450, Houston, TX 77030, USA.
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32
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Sex hormone-binding globulin: an adequate surrogate marker for venous thromboembolism in women using new hormonal contraceptives. Contraception 2009; 79:328-9; author reply 329-30. [DOI: 10.1016/j.contraception.2008.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Accepted: 11/04/2008] [Indexed: 11/22/2022]
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Soares GM, Vieira CS, de Paula Martins W, Dos Reis RM, de Sá MFS, Ferriani RA. Metabolic and cardiovascular impact of oral contraceptives in polycystic ovary syndrome. Int J Clin Pract 2009; 63:160-9. [PMID: 18795969 DOI: 10.1111/j.1742-1241.2008.01877.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Chronic anovulation, polycystic ovarian morphology and hyperandrogenism are the diagnostic criteria for polycystic ovary syndrome (PCOS). Metabolic disturbances are more common in PCOS women who are prone to develop metabolic syndrome and to present higher levels of some cardiovascular disease risk marker. Oral contraceptives are widely used in PCOS, but conflicting data have been reported regarding their impact on carbohydrate and lipid metabolism on PCOS women. This paper presents a critical evaluation of combined oral contraceptives (COCs) metabolic effect - carbohydrate metabolism and insulin sensitivity, lipid metabolism, haemostasis, body weight, arterial pressure and cardiovascular impact - on PCOS women. Because of the paucity of data on the impact of COCs on cardiovascular and metabolic parameters in PCOS patients, most of there commendations are based on studies involving ovulatory women. The use of low-dose COCs is preferable in PCOS, especially among patients with glucose intolerance, insulin resistance and uncomplicated diabetes mellitus. Although reported as a side effect of COCs, marked weight gain has not been confirmed among users. However, when arterial hypertension or elevated risk for thromboembolism is present, progestogen-only hormonal contraceptives should be used instead of COCs. Regarding dyslipidaemia, COCs reduce low-density lipoprotein and total cholesterol and elevate high-density lipoprotein and triglycerides, and therefore are not recommended for women with high triglycerides levels. The choice of a COC, which alleviates the PCOS-induced hyperandrogenism without significant negative impact on cardiovascular risk, is one of the greatest challenges faced by gynaecologists nowadays.
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Affiliation(s)
- G M Soares
- Department of Gynecology and Obstetrics at the University of São Paulo, Ribeirão Preto School of Medicine, Ribeirão Preto, Brazil
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34
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Mise au point sur la contraception progestative. ACTA ACUST UNITED AC 2008; 37:637-60. [DOI: 10.1016/j.jgyn.2008.06.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2008] [Revised: 05/30/2008] [Accepted: 06/17/2008] [Indexed: 11/23/2022]
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Abstract
Abstract The risk of venous thromboembolism (VTE) varies throughout a woman’s life and is associated primarily with underlying hormonal exposure. Alteration in hemostatic mechanisms, including resistance to activated protein C, may explain this altered risk. Initially, development of VTE with the use of contraception in young adulthood may reveal inherited thrombophilia. Pregnancy, and particularly the post-partum period, likely confer the greatest risk of VTE, but the absolute risk is small. Guidelines for prevention of VTE during pregnancy are based on personal or family history of VTE, and known inherited thrombophilia. Use of hormone replacement therapy later in life is associated with increased risk of VTE, and may be safest if given as an estrogen-only preparation to young postmenopausal women for less than 5 years. Universal screening for thrombophilia prior to pregnancy or initiating hormonal therapy is not recommended; however, selected testing in high-risk groups may be warranted. The lack of firm recommendations for the prevention of VTE in women highlights the need for future investigation aimed at identifying high-risk groups and evaluating the efficacy of prophylactic measures.
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Affiliation(s)
- Suman Rathbun
- Non-invasive Vascular Laboratories, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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36
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Plu-Bureau G, Horellou MH, Gompel A, Conard J. Contraception hormonale et risque thromboembolique veineux : quand demander une étude de l’hémostase ? Et laquelle ? ACTA ACUST UNITED AC 2008; 36:448-54. [DOI: 10.1016/j.gyobfe.2008.02.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2007] [Accepted: 02/12/2008] [Indexed: 11/28/2022]
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van Vliet HAAM, Bertina RM, Dahm AEA, Rosendaal FR, Rosing J, Sandset PM, Helmerhorst FM. Different effects of oral contraceptives containing different progestogens on protein S and tissue factor pathway inhibitor. J Thromb Haemost 2008; 6:346-51. [PMID: 18067603 DOI: 10.1111/j.1538-7836.2008.02863.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Oral contraceptives (OC) containing different types of progestogens induce different sensitivities to activated protein C (APC) measured with the thrombin generation-based APC-resistance test. These differences in APC resistance may be the biological explanation for the differences in thrombotic risk of the various pills. The mechanistic basis of APC resistance observed in OC users is unknown. Our objective was to study the effect of OC on the two main determinants of the APC-resistance test, free protein S and free tissue factor pathway inhibitor (TFPI). PATIENTS/METHODS We measured free protein S and free TFPI in 156 users of various types of OC. RESULTS Users of desogestrel-containing OC, known to double the risk of thrombosis compared with levonorgestrel-containing OC, had lower free protein S (24 vs. 33 U dL(-1)) and TFPI free antigen (2.9 vs. 3.6 ng mL(-1)) levels than users of OC containing levonorgestrel. Women using cyproterone acetate-containing OC, known to confer a high thrombotic risk, had the lowest free protein S (19 U dL(-1)) and free TPFI antigen (2.5 ng mL(-1)) levels. Users of OC containing drospirenone had lower free protein S (23 U dL(-1)) and TFPI antigen levels (3.2 ng mL(-1)) than users of levonorgestrel-containing OC. Low free protein S and low free TFPI antigen levels were associated with an increased resistance to APC, an established risk factor for thrombosis. CONCLUSIONS This study observed that the differences in APC resistance induced by OC containing different progestogens can at least in part be explained by different effects of OC on free protein S and TFPI.
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MESH Headings
- Activated Protein C Resistance/blood
- Activated Protein C Resistance/chemically induced
- Adolescent
- Adult
- Androstenes/adverse effects
- Androstenes/pharmacology
- Contraceptives, Oral, Combined/adverse effects
- Contraceptives, Oral, Combined/pharmacology
- Contraceptives, Oral, Hormonal/adverse effects
- Contraceptives, Oral, Hormonal/pharmacology
- Contraceptives, Oral, Synthetic/adverse effects
- Contraceptives, Oral, Synthetic/pharmacology
- Cyproterone Acetate/adverse effects
- Cyproterone Acetate/pharmacology
- Desogestrel/adverse effects
- Desogestrel/pharmacology
- Ethinyl Estradiol-Norgestrel Combination/adverse effects
- Ethinyl Estradiol-Norgestrel Combination/pharmacology
- Female
- Humans
- Levonorgestrel/pharmacology
- Lipoproteins/analysis
- Middle Aged
- Protein S/analysis
- Thrombophilia/chemically induced
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Affiliation(s)
- H A A M van Vliet
- Department of Gynaecology and Reproductive Medicine, Leiden University Medical Center, Leiden, The Netherlands.
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Lapecorella M, Orecchioni A, Dell'Orso L, Mariani G. Upper extremity deep vein thrombosis after suspension of progesterone-only oral treatment. Blood Coagul Fibrinolysis 2007; 18:513-7. [PMID: 17581329 DOI: 10.1097/mbc.0b013e3281a3bed8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The intake of steroid hormone contraceptives is a strong and independent risk factor for venous thromboembolism. Several studies have assessed an increased risk of venous thromboembolism in women using oral contraceptives who are carriers of the G20210A mutation in the prothrombin gene. Most trials evaluating the thrombotic risk of oral contraceptives are based on combined oral preparations, but only a few focus on progestogen-only oral preparations. Results from such studies are conflicting and globally assess the thrombotic risk, ranging from modest to slightly increased. Furthermore, little is known about the relationship between the C677T mutation in the methylenetetrahydrofolate reductase gene and the progestogen-based preparations. Herewith we report the case of a 49-year-old woman with a complex genetic thrombosis risk factor who had taken oral progesterone for 15 months without any complication, but then experienced severe left upper extremity deep vein thrombosis 2 months after the drug suspension.
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Affiliation(s)
- Mario Lapecorella
- Centro Emofilia e Trombosi, Unità Operativa Medicina Interna 2, Ematologia, Università de L'Aquila, Ospedale San Salvatore, L'Aquila, Italy.
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Canonico M, Oger E, Plu-Bureau G, Conard J, Meyer G, Lévesque H, Trillot N, Barrellier MT, Wahl D, Emmerich J, Scarabin PY. Hormone therapy and venous thromboembolism among postmenopausal women: impact of the route of estrogen administration and progestogens: the ESTHER study. Circulation 2007; 115:840-5. [PMID: 17309934 DOI: 10.1161/circulationaha.106.642280] [Citation(s) in RCA: 464] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Oral estrogen therapy increases the risk of venous thromboembolism (VTE) in postmenopausal women. Transdermal estrogen may be safer. However, currently available data have limited the ability to investigate the wide variety of types of progestogen. METHODS AND RESULTS We performed a multicenter case-control study of VTE among postmenopausal women 45 to 70 years of age between 1999 and 2005 in France. We recruited 271 consecutive cases with a first documented episode of idiopathic VTE (208 hospital cases, 63 outpatient cases) and 610 controls (426 hospital controls, 184 community controls) matched for center, age, and admission date. After adjustment for potential confounding factors, odds ratios (ORs) for VTE in current users of oral and transdermal estrogen compared with nonusers were 4.2 (95% CI, 1.5 to 11.6) and 0.9 (95% CI, 0.4 to 2.1), respectively. There was no significant association of VTE with micronized progesterone and pregnane derivatives (OR, 0.7; 95% CI, 0.3 to 1.9 and OR, 0.9; 95% CI, 0.4 to 2.3, respectively). In contrast, norpregnane derivatives were associated with a 4-fold-increased VTE risk (OR, 3.9; 95% CI, 1.5 to 10.0). CONCLUSIONS Oral but not transdermal estrogen is associated with an increased VTE risk. In addition, our data suggest that norpregnane derivatives may be thrombogenic, whereas micronized progesterone and pregnane derivatives appear safe with respect to thrombotic risk. If confirmed, these findings could benefit women in the management of their menopausal symptoms with respect to the VTE risk associated with oral estrogen and use of progestogens.
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Affiliation(s)
- Marianne Canonico
- Inserm Unit 780, Cardiovascular Epidemiology Section, 16 Avenue Paul Vaillant Couturier, 94807 Villejuif Cedex, France
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Turgeon JL, Carr MC, Maki PM, Mendelsohn ME, Wise PM. Complex actions of sex steroids in adipose tissue, the cardiovascular system, and brain: Insights from basic science and clinical studies. Endocr Rev 2006; 27:575-605. [PMID: 16763155 DOI: 10.1210/er.2005-0020] [Citation(s) in RCA: 188] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Recent publications describing the results of the Women's Health Initiative (WHI) and other studies reporting the impact of hormone therapy on aging women have spurred reexamination of the broad use of estrogens and progestins during the postmenopausal years. Here, we review the complex pharmacology of these hormones, the diverse and sometimes opposite effects that result from the use of different estrogenic and progestinic compounds, given via different delivery routes in different concentrations and treatment sequence, and to women of different ages and health status. We examine our new and growing appreciation of the role of estrogens in the immune system and the inflammatory response, and we pose the concept that estrogen's interface with this system may be at the core of some of the effects on multiple physiological systems, such as the adipose/metabolic system, the cardiovascular system, and the central nervous system. We compare and contrast clinical and basic science studies as we focus on the actions of estrogens in these systems because the untoward effects of hormone therapy reported in the WHI were not expected. The broad interpretation and publicity of the results of the WHI have resulted in a general condemnation of all hormone replacement in postmenopausal women. In fact, careful review of the extensive literature suggests that data resulting from the WHI and other recent studies should be interpreted within the narrow context of the study design. We argue that these results should encourage us to perform new studies that take advantage of a dialogue between basic scientists and clinician scientists to ensure appropriate design, incorporation of current knowledge, and proper interpretation of results. Only then will we have a better understanding of what hormonal compounds should be used in which populations of women and at what stages of menopausal/postmenopausal life.
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Affiliation(s)
- Judith L Turgeon
- Department of Internal Medicine, Division of Endocrinology, Clinical Nutrition, and Vascular Medicine, University of California Davis, Davis, California 95616, USA.
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Rad M, Kluft C, Ménard J, Burggraaf J, de Kam ML, Meijer P, Sivin I, Sitruk-Ware RL. Comparative effects of a contraceptive vaginal ring delivering a nonandrogenic progestin and continuous ethinyl estradiol and a combined oral contraceptive containing levonorgestrel on hemostasis variables. Am J Obstet Gynecol 2006; 195:72-7. [PMID: 16545330 DOI: 10.1016/j.ajog.2005.12.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2005] [Revised: 11/04/2005] [Accepted: 12/05/2005] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed to compare the effects on hemostasis variables of a contraceptive vaginal ring with those of an oral contraceptive. STUDY DESIGN Twenty-three and 22 healthy premenopausal women were randomized to the contraceptive vaginal ring (150 microg Nestorone and 15 microg ethinyl estradiol) or Stediril 30 during 3 cycles. Analysis of covariance was performed with baseline values as covariate. RESULTS The contraceptive vaginal ring changed most hemostasis variables similarly but raised (95% confidence intervals of percent treatment differences) Factor VIIt (28% to 49%), extrinsic activated protein C resistance (14% to 65%), and sex hormone-binding globulin (117% to 210%) and lowered Protein S (-32% to -16%) and the global activated partial thromboplastin time-based activated protein C resistance (-12% to -2%) more than the oral contraceptive. CONCLUSION The contraceptive vaginal ring affected some measured hemostasis variables and sex hormone-binding globulin differently from the oral contraceptive, most likely because of difference in androgenicity of the progestins. The results suggest that the contraindications for oral contraceptive use would also apply to the tested contraceptive vaginal ring.
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Affiliation(s)
- Mandana Rad
- Centre for Human Drug Research, Leiden, The Netherlands.
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Hézard N, Bouaziz-Borgi L, Remy MG, Nguyen P. Utility of Thrombin-Generation Assay in the Screening of Factor V G1691A (Leiden) and Prothrombin G20210A Mutations and Protein S Deficiency. Clin Chem 2006; 52:665-70. [PMID: 16469858 DOI: 10.1373/clinchem.2005.063339] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Background: The thrombin-generation assay has a variety of clinical uses, including diagnosis of thromboembolism-related disease, and particular profiles are associated with thrombophilic risk factors. The aim of this study was to evaluate the use of this assay in screening and identifying patients who require specific thrombophilic testing.
Methods: We used a 2-step approach to perform specific thrombophilic testing and thrombin-generation assays on 169 consecutive patients. The first step was to identify particular profiles of thrombin generation corresponding to each type of thrombophilic risk factor and to determine the pertinent variables related to thrombin generation. We then performed ROC curve analysis for each predefined variable to determine the relevant cutoffs for identification of patients in need of further testing (negative predictive value, 100%).
Results: Suggestive profiles were seen in factor V Leiden (n = 49) and prothrombin (n = 12) mutations and in protein S deficiency (n = 12). ROC curves showed that factor V Leiden may be excluded when the difference between lag times obtained in the absence and presence of activated protein C (APC) is >1.5 min and that prothrombin G20210A may also be excluded when the peak thrombin concentration is ≤426 nmol/L. In addition, protein S deficiency may be excluded when the percentage of APC-induced endogenous thrombin potential inhibition is >63%.
Conclusion: The thrombin-generation assay represents a promising tool for screening thrombophilic risk factors, particularly in patients who are carriers of factor V Leiden or prothrombin G20210A mutations and patients with protein S deficiency.
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Affiliation(s)
- Nathalie Hézard
- Laboratoire d'Hématologie, Centre Hospitalaire et Régional, CHU, Robert Debré, Reims, France
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Hedenmalm K, Samuelsson E. Fatal Venous Thromboembolism Associated with Different Combined Oral Contraceptives. Drug Saf 2005; 28:907-16. [PMID: 16180940 DOI: 10.2165/00002018-200528100-00007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Fatal venous thromboembolism (VTE) is a rare complication of combined oral contraceptive (COC) treatment. This study aims to determine incidences of fatal VTE in relation to the type of COC and the percentage of cases reported to the Swedish Adverse Drug Reactions Advisory Committee (SADRAC). A further aim is to compare the characteristics of reported and not reported cases. METHODS This retrospective study is a separate analysis using data from a larger study that included women aged 15-44 years between 1990 and 1999 with VTE coded as the underlying or contributory cause of death in the Swedish Cause of Death Register. COC use within 2 months of the date of symptom onset or death was identified in 28 cases. Sales data were obtained from the National Corporation of Swedish Pharmacies. Reported cases were identified in the SADRAC database. RESULTS After excluding two cases where the type of COC was unknown, the crude incidences of fatal VTE were 5.1 (95% CI 2.3, 9.6), 8.6 (95% CI 4.3, 15.4) and 9.1 (95% CI 3.3, 19.8) cases per million women per year for levonorgestrel-, desogestrel- and norethisterone-containing COCs, respectively. Age-adjusted incidences were approximately twice as high for desogestrel- and norethisterone-containing COCs compared with levonorgestrel-containing COCs, although differences were not statistically significant. Thirty-six percent of cases were reported. Reporting was positively associated with information in medical records relevant to the VTE diagnosis that the patient was a COC user and was significantly higher in northern Sweden. CONCLUSION Results from this study support a higher incidence of fatal VTE with desogestrel-containing COCs than with levonorgestrel-containing COCs.
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Affiliation(s)
- Karin Hedenmalm
- Pharmacovigilance Unit and Clinical Trial Unit, Medical Products Agency, Uppsala, Sweden.
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