Does the type of hormone replacement therapy influence the risk of deep vein thrombosis? A prospective case-control study

The Role of Vitamin D in the Relationship Between Gender and Deep Vein Thrombosis Among Stroke Patients

Introduction: Accumulating evidence had demonstrated that females had a higher risk of deep vein thrombosis (DVT) than males, but the mechanism was still unknown. Vitamin D was found to play an essential role in DVT, and gender may influence the serum vitamin D levels. This study aimed to explore whether vitamin D played a role in the gender difference in DVT.

Materials and Methods: A total of 444 patients with acute stroke were recruited, which were divided into the DVT group (n = 222) and the non-DVT group (n = 222). Serum vitamin D levels were measured after admission and were split into three categories, including deficiency (<50 nmol/L), insufficiency (52.5–72.5 nmol/L), and sufficiency (more than 75 nmol/L). Hierarchical regression analysis was adopted to analyze the relationship between gender and DVT, controlling the confounding factors.

Results: Females showed a higher proportion of DVT than males (60.7 vs. 42.5%, p < 0.001), and lower serum vitamin D levels than males (53.44 ± 16.45 vs. 69.43 ± 23.14, p < 0.001). Moreover, serum vitamin D levels were lower in the DVT group than in the non-DVT group (59.44 ± 19.61 vs. 66.24 ± 23.86, p < 0.001). Besides, the DVT group showed a lower proportion of vitamin D sufficiency than the non-DVT group (21.2 vs. 32.9%, p < 0.05). Hierarchical regression analysis showed that females had 2.083-fold (p < 0.001, unadjusted model) and 1.413-fold (p = 0.155, adjusted model) risk to develop DVT. In addition, the sufficiency status of vitamin D showed an independent protective effect on DVT (unadjusted model OR, 0.504, p = 0.004; adjusted model OR, 0.686, p = 0.011).

Conclusion: Females had a higher risk of DVT than males, and vitamin D may play an essential role in this relationship. Further studies are needed to explore whether vitamin D supplementation could reduce DVT risk in stroke patients, especially females.

[Menopause and risk of thromboembolic events. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]

The incidence of venous thromboembolism (VTE) increases with age with an annual incidence of 1.25/1000 women in the 40-59 age group. Menopausal hormone therapy (MHT) may also increase the risk of VTE. This risk must be assessed during the first consultation before initiating MHT and assess each renewal of the MHT. MHT with oral estrogen combined (or not) with progestin increases the risk of VTE by about 70%. Using transdermal estrogen does not appear to increase the risk of VTE in women. VTE risk appears to be modulated by the type of progestin combined in MHT. The risk of VTE associated with MHT with transdermal estradiol appears to be safe in women using micronised progesterone and pregnane derivatives and higher in women using norpregnane derivatives . To limit the risk of VTE associated with MHT, transdermal estradiol use is recommended. In women at risk of VTE, MHT with oral estrogen is contraindicated. MHT with transdermal estradiol associated (or not) with micronised progesterone or dydrogesterone may be used in women with low or moderate risk of VTE.

Pathophysiology, Biomarkers, and Therapeutic Modalities Associated with Skeletal Muscle Loss Following Spinal Cord Injury

A spinal cord injury (SCI) may lead to loss of strength, sensation, locomotion and other body functions distal to the lesion site. Individuals with SCI also develop secondary conditions due to the lack of skeletal muscle activity. As SCI case numbers increase, recent studies have attempted to determine the best options to salvage affected musculature before it is lost. These approaches include pharmacotherapeutic options, immunosuppressants, physical activity or a combination thereof. Associated biomarkers are increasingly used to determine if these treatments aid in the protection and reconstruction of affected musculature.

Venous thromboembolism in women: new challenges for an old disease

In countries that have controlled classic causes of maternal death, such as eclampsia and hemorrhage, venous thromboembolism (VTE) has become the major concern. Prevention of VTE during pregnancy and postpartum by applying guidelines and implementing pharmacoprophylaxis is still the best strategy to reduce occurrence of this complication. Hormonal contraceptives and hormone replacement therapy also increase the risk of VTE, but women cannot be deprived of their benefits, which increase their freedom at childbearing age and reduce their symptoms at menopause. Both indiscriminate use and unmotivated prohibition are inappropriate. Contraceptive and hormone replacement methods should be chosen with care, evaluating the patients’ contraindications, eligibility criteria, and autonomy. This article presents a nonsystematic review of recent literature with the aim of evaluating and summarizing the associations between VTE and clinical situations peculiar to women.

Cardiovascular Risk/Benefit Profile of MHT

Background and Objectives: Data emerging from the Women’s Health Initiative (WHI) study point toward an association between menopausal hormone therapy (MHT) and cardiovascular (CV) risk. However, post hoc subgroup analyses stratifying participants according to their age and time since menopause, have opened the way to a better understanding of the relationship between estrogen and CV risk. The aim of this review was to revise the current literature and evaluate the CV risk or benefit following administration of MHT considering several factors such as MHT timing, dose, route of administration, and formulation. Materials and Methods: An electronic databases search of MEDLINE (PubMed), Cochrane Central Register of Controlled Trials, Web of Science, SCOPUS, congress abstracts, and Grey literature (Google Scholar; British Library) was performed, with the date range from each database’s inception until June 2019. All the studies evaluating MHT and cardiovascular risk, including thromboembolism or stroke, were selected. Results: Timing of MHT initiation was shown to be a critical factor in CV risk assessment. In concordance with the “timing hypothesis”, healthy symptomatic women who initiated MHT when aged younger than 60 years, or who were within 10 years of menopause onset, have demonstrated a reduction in both coronary heart disease (CHD) risk and all-cause mortality. In particular, MHT therapy was associated with improvement of subclinical signs of atherosclerosis. Venous thromboembolism (VTE) risk is reduced when low doses of oral estrogen are used. Moreover, transdermal hormonal application significantly reduces CV risk compared with oral administration. MHT impact on the CV system is influenced by either factors inherent to the specific regimen, or factors inherent to the specific patient. Hence, individualization of care is necessary. Conclusion: CV risk calculation should be considered by clinicians in order to exclude patients with high CV risk, in whom MHT is contraindicated. Assessing risks and benefits in a patient-centered approach according to individual’s features, health status, and personal preferences is important in order to realize a safe and effective treatment.

The Prophylaxis of Venous Thromboembolism

BACKGROUND

Venous thromboembolism (VTE) is the third most common cardiovascular condition, after myocardial infarction and stroke. Prophylactic measures in accordance with current guidelines can significantly reduce the risk of VTE and the associated morbidity and mortality. Until now, the German interdisciplinary, evidence- and consensus-based (S3) clinical practice guideline on VTE prophylaxis was based on a complete review of all pertinent literature available in MEDLINE up to January 2008. More recent publications and drug approvals have made a thorough revision necessary.

METHODS

A systematic search was carried out in the MEDLINE and Embase databases for publications that appeared from 1 January 2008 to 7 August 2013. Updates of 5 national and international reference guidelines and 2 new Health Technology Assessment (HTA) reports were considered as well. A structured consensus-finding process was carried out with delegates from 27 scientific medical societies and from the Union of Medical Specialist Associations.

RESULTS

46 randomized controlled trials (RCTs) were included for critical appraisal. New findings led to re-evaluation of the value of compression stockings in combination with pharmacological prophylaxis (open recommendation), and suggest equal value of non-vitamin K antagonist oral anticoagulants (NOACs) and low molecular weight heparins (LMWH) or fondaparinux in elective hip and knee replacement (strong recommendation). For patients undergoing hip fracture surgery, we recommend LMWH or fondaparinux.

CONCLUSION

Further research is needed to assess the value of NOACs for pharmacological prophylaxis in orthopedic/trauma patients undergoing surgical procedures other than the ones mentioned above, and into the benefit and harm of new devices available for mechanical prophylaxis. The stringent implementation of basic measures such as early mobilization, movement exercises, and patient instruction is a key point to prevent venous thrombo - embolism.

How do you decide on hormone replacement therapy in women with risk of venous thromboembolism?

Women are increasingly encouraged to participate in making decisions about hormone replacement therapy (HRT). In postmenopausal women with severe vasomotor symptoms, HRT can significantly improve the quality of life. However, the use of HRT may also increase the risk of venous thromboembolism (VTE), the risk which depends of both treatment-related and patient-related factors. This review summarizes some important points about the selection of the safest hormonal replacement modality in women with a history of VTE and management of VTE risks in postmenopausal women wishing to take HRT.

Update on the Cardiovascular Risks of Hormone Replacement Therapy

Systematic reviews of randomized, controlled trials have shown that use of hormone replacement therapy in women increases the risk of total cardiovascular disease (venous thromboembolism, stroke and coronary heart disease; there may also be an increased risk of peripheral arterial disease). The relative increase in risk is similar to that for use of combined oral contraceptives, but the absolute increase in risk is higher owing to the higher age of hormone replacement therapy users. The increased risk appears confined to current users, increases with age and obesity, and may differ with type of preparation. Transdermal hormone replacement therapy may carry a lower risk of venous thromboembolism compared with oral hormone replacement therapy. The mechanism for the increased risk is probably activated blood coagulation. The risk of venous thromboembolism is higher in women with thrombophilias; however, the value of screening for thrombophilias is not established. Further research is required to establish the risks of cardiovascular (and other) diseases in different groups of women for different types of hormone replacement therapy, including an individual participant meta-analysis of reported randomized, controlled trials.

Ascites in the Puerperium in the Context of a Woman with Turner Syndrome Who Conceived through Assisted Reproductive Technology

The case is about a young female who delivered twins by caesarean section (CS). On the 4th postoperative day, she presented with ascites which was resistant to empirical antibiotic and diuretic treatment. The woman was affected by Turner syndrome (TS); she had a medical background of chronic use of hormonal medication since puberty and conceived through ART- (assisted reproduction techniques-) IVF-oocyte donation. It is important to exhibit high suspicion for clot formation in the hepatic vasculature during the puerperium, especially in the case of history of chronic hormone treatment. Ascites albumin gradient and Doppler values lead to the diagnosis of thrombosis and the administration of high doses of anticoagulants is considered to be fundamental.

Deep venous thrombosis in a patient undergoing In-vitro fertilization with oocyte donation

Deep venous thrombosis (DVT) has been reported extensively following ovarian hyperstimulation syndrome during in-vitro fertilization (IVF). Pregnancy per se increases the risk of DVT due to a hypercoagulable state. The long-term use of hormone replacement therapy (HRT) is another critical factor associated with DVT in women. However, an association between the short-term use of HRT in oocyte donation (OD) cycles and DVT has not yet been reported. We present a case of 43-year-old woman who developed DVT after IVF-OD. DVT was diagnosed at 7 weeks of pregnancy and was managed with low-molecular-weight heparin. We suggest that even a short-term use of HRT should be considered a risk factor for DVT especially in the presence of additional risk factors such as obesity. The patient had an uneventful recovery and delivered three healthy though preterm babies.

Deep vein thrombosis due to continuous prone positioning after retinal detachment surgery

In March 2014, a 56-year-old woman without previous underlying disease underwent encircling scleral buckling, 20-gauge pars plana vitrectomy, cryotherapy around a retinal tear, and gas-fluid exchange with 15% perfluoropropane flush for upper rhegmatogenous retinal detachment of the left eye. However, she developed progressive left leg swelling, pain, warmth, and redness, associated with difficulty in elevating her left leg after continuously maintaining a prone head position when either lying down or sitting for 2 days. When she arrived at the emergency room, she had an elevated D-dimer level. After undergoing Doppler ultrasound imaging, she was diagnosed as having deep vein thrombosis of the left leg. She received anticoagulation therapy with enoxaparin and warfarin overlapping for 7 days. The edema, pain, and paresthesia of her left leg were relieved. However, because of the risk of bleeding with anti-coagulation drug usage, the patient needed to be monitored for 6 months. Prone positioning for gas tamponade is important for anatomic and functional success in retinal detachment surgery; however, timely walking and rest between periods of continuous prone positioning should be encouraged to prevent deep vein thrombosis and other impaired circulation-related complications.

Hormone therapy and risk of venous thromboembolism among postmenopausal women

Despite a decrease in the use of postmenopausal hormone therapy (HT) over the last decade, many women are still prescribed this treatment, as it remains the most effective means of counteracting climacteric symptoms. Its use declined when it was shown that HT increases the risk of breast cancer, stroke and venous thromboembolism (VTE). Nevertheless, that benefit/risk ratio was established among women using oral estrogens alone or combined with a specific progestogen and it cannot necessarily be extrapolated to other HTs. Oral estrogens increase the risk of VTE especially during the first year of treatment and past users revert to a similar risk as women who have never used them. There is now growing evidence that VTE risk among HT users strongly depends on the route of administration. Indeed, transdermal estrogens, unlike oral estrogens, are not associated with an increased VTE risk and biological data support this difference between oral and transdermal estrogens. In addition, transdermal estrogens may not confer additional risk in women at high risk of VTE. Significant differences in thrombotic risk between HT preparations also relate to the concomitant progestogen. Studies have consistently shown that VTE risk is higher among users of combined estrogens plus progestogens than among users of estrogens alone. With respect to the different pharmacological classes of progestogens, two observational studies found that norpregnane derivatives are associated with an increased VTE risk, whereas micronized progesterone may be safe with respect to thrombotic risk. In conclusion, transdermal estrogens alone or combined with micronized progesterone may represent the safest alternative for women who require HT.

Menopausal hormone therapy and venous thromboembolism

Menopausal hormone therapy (MHT) is the most effective method of treating vasomotor symptoms and other climacteric symptoms related to estrogen deficiency in peri- and postmenopausal period. In addition to estrogen replacement, women with preserved uterus require the addition of progestagen in order to ensure endometrial safety. One of rare but severe complications of MHT is venous thromboembolism (VTE). The incidence of VTE rises in parallel to women's age and body weight. The condition is also linked to hereditary and acquired risk factors. Oral estrogens increase the risk of venous thromboembolic complications to varying extents, probably depending on their type and dose used. Observational studies have not found an association between an increased risk of VTE and transdermal estrogen treatment regardless of women's age and body mass index (BMI). Micronized progesterone and pregnanes, including dydrogesterone, have no effect on the risk of VTE, whereas norpregnane progestagens cause an additional increase in risk. Among hormonal preparations which are commercially available in Poland, the combination of transdermal estradiol with oral dydrogesterone appears to be the optimum choice, as it does not elevate the risk of VTE (compared to patients not using MHT), and dydrogesterone seems to be the progestagen of choice.

Hormone replacement therapy and venous thromboembolism

Hormone replacement therapy (HRT) for post-menopausal women is known to promote venous thromboembolism (VTE), i.e., deep venous thrombosis and pulmonary embolism, though the absolute risk for a given patient is very small. The risk of VTE appears to be greatest soon after the initiation of HRT and returns to the baseline level of risk of non-HRT users after discontinuation. There is inconsistent data about whether estrogen-only or combined estrogen-progestin HRT are associated with similar VTE risk. Retrospective analyses suggest that transdermal HRT is not as prothrombotic as oral HRT, though this has not been evaluated in randomized clinical trials. Increasing age and weight further promote HRT's VTE risk. Some studies have investigated whether prothrombotic combinations may increase HRT's VTE risk and there is evidence that Factor V Leiden may do this. However, no benefit to screening prospective HRT users has been described, yet. Advanced proteomic and genomic studies may hold promise in the future for better elucidating which HRT users are at highest risk for VTE. Presently, physicians and prospective HRT users should discuss the potential risks and benefits for the individual patient, acknowledging there is no way to fully mitigate the risk of VTE. This article is part of a Special Issue entitled 'Menopause'.

The risk of venous thrombosis in women over 50 years old using oral contraception or postmenopausal hormone therapy

BACKGROUND

Oral contraception (OC) and postmenopausal hormone therapy (HT) can be used to alleviate menopausal symptoms. However, the risk of venous thrombosis (VT) associated with OC use in women over 50 years old has never been assessed and the two preparations have not been directly compared.

OBJECTIVES

To determine and compare the risk of VT associated with OC and HT use.

METHODS

From a large case-control study, 2550 women aged over 50 years old, 1082 patients with a first VT and 1468 controls, were included. Odds ratios (ORs) and 95% confidence intervals for VT were calculated for OC-users (164 patients and 54 controls) and HT-users (88 patients and 102 controls) compared with non-hormone users (823 patients and 1304 controls).

RESULTS

OC-users had a 6.3-fold (4.6-9.8) increased risk of VT. This ranged from 5.4 (3.3-8.9) for preparations containing levonorgestrel to 10.2 (4.8-21.7) for desogestrel. The VT-risk associated with oral HT use was 4.0 (1.8-8.2) for conjugated equine estrogen combined with medroxyprogesterone acetate and 3.9 (1.5-10.7) for micronized estradiol combined with norethisterone acetate. Non-oral HT did not increase the risk of VT: OR 1.1 (0.6-1.8). Relative risk estimates were further increased in hormone users with factor V Leiden, prothrombin G20210A or blood group non-O and hormone users with a family history of VT.

CONCLUSIONS

In this study, non-oral HT seemed to be the safest hormonal preparation in women over 50 years old. OC use increased the VT risk the most, especially in women with inherited thrombophilia or a family history of VT.

Venous thromboembolism risk in relation to use of different types of postmenopausal hormone therapy in a large prospective study

BACKGROUND

Current use of menopausal hormone therapy (HT) increases the risk of venous thromboembolism (VTE) and the formulations used may affect risk.

METHODS

A total of 1,058,259 postmenopausal UK women were followed by record linkage to routinely collected National Health Service hospital admission and death records. HT use and risk of VTE was examined using Cox regression to estimate relative risks (RRs) and 95% confidence intervals (CIs).

RESULTS

During 3.3 million years of follow-up, 2200 women had an incident VTE, diagnosed, on average, 1.5 years after last reporting HT use. RRs in current vs. never users at last reporting varied by HT formulation: the risk was significantly greater for oral estrogen-progestin than oral estrogen-only therapy (RR = 2.07 [95%CI, 1.86-2.31] vs. 1.42 [1.21-1.66]), with no increased risk with transdermal estrogen-only therapy (0.82 [0.64-1.06]). Among users of oral estrogen-progestin, the risk from HT varied by progestin type, with significantly greater risks for preparations containing medroxyprogesterone acetate than other progestins (2.67 [2.25-3.17] vs. 1.91 [1.69-2.17]; Pheterogeneity = 0.0007). Current users of oral HT at last reporting had twice the risk of VTE in the first 2 years after starting HT than later (Pheterogeneity = 0.0006). Associations were similar for deep vein thrombosis with and without pulmonary embolism. Over 5 years, 1 in 660 who had never used HT were admitted to hospital for (or died from) pulmonary embolism, compared with 1 in 475 current users of oral estrogen-only HT,1 in 390 users of estrogen-progestin HT containing norethisterone/norgestrel, and 1 in 250 users of estrogen-progestin HT containing medroxyprogesterone acetate.

CONCLUSIONS

The risk of VTE varied considerably by HT formulation, being greatest in users of oral estrogen-progestin HT, especially formulations containing medroxyprogesterone acetate.

[Comparison of two different types of hormone therapy effects on haemostatic parameters in early postmenopausal women]

INTRODUCTION

Most postmenopausal women have some of menopausal symptoms due to oestrogen deprivation. Many therapeutic options are available for managing menopausal problems. However, hormone therapy is associated with a heightened risk for thromboembolic events.

OBJECTIVE

To investigate the effects of different types of hormone therapy on some haemostatic parameters.

METHODS

This randomized, controlled study included 56 healthy, early postmenopausal women aged 46-58 years on different types of hormone therapy (tibolone 2.5 mg/day, 25 women, or CCHT 2 mg estradiol plus 1 mg norethisteron acetate, 31 women) and 20 healthy postmenopausal women of the same age receiving placebo. Effects of these 2 medicaments on some haemostasis parameters were measured 3 and 6 months after the onset of treatment.

RESULTS

Short-term use (3 months) of both tibolone and CCHT had a detrimental effect on antithrombin, protein C and protein S levels (decreased), and even more so in the group treated with CCHT. Plasminogen-activator inhibitor type 1 levels were decreased by both tibolone and CCHT, but more so by CCHT; thrombin-antithrombin complex were increased in both groups. There were no changes in haemostatic parameters between 3-month and 6-month treatment in any group.

CONCLUSION

Both therapeutic options are associated with an activation of thrombogenic and fibrinolytic markers within 3 months of use. Tibolone appears to produce a better balance between thrombogenesis and fibrinolysis. Since our results show a lower incidence of thrombotic events, further studies are required.

The effect of prothrombotic blood abnormalities on risk of deep vein thrombosis in users of hormone replacement therapy: a prospective case-control study

BACKGROUND

Few studies have assessed the effect of prothrombotic blood abnormalities on the risk of deep vein thrombosis (DVT) with hormone replacement therapy (HRT).

METHODS

We studied postmenopausal women with suspected DVT in whom HRT use and prothrombotic blood abnormalities were sought. Cases had unprovoked DVT and controls had no DVT and without DVT risk factors. The risk of DVT was determined in women with and without prothrombotic abnormalities.

RESULTS

A total of 510 postmenopausal women with suspected DVT were assessed; 57 cases and 283 controls were identified. Compared to HRT, nonusers without the factor V Leiden mutation, the risk of DVT was increased in estrogen-progestin HRT users (odds ratio [OR], 3.2; 95% confidence interval [CI]: 1.2-8.6) and in nonusers with the factor V Leiden mutation (OR, 5.3; 1.9-15.4) and appears multiplied in users of estrogen-progestin HRT with the factor V Leiden mutation (OR, 17.1; 3.7-78). Compared to HRT, nonusers with normal factor VIII, the risk of DVT was increased in estrogen-progestin HRT users with normal factor VIII (OR, 2.8; 1.0-7.9) and in HRT nonusers with the highest factor VIII quartile (OR, 6.0; 2.1-17), and appears to be multiplied in women who are users of estrogen-progestin HRT with the highest factor VIII quartile (OR, 17.0; 3.6-80).

CONCLUSIONS

In postmenopausal women who are estrogen-progestin HRT users, the presence of the factor V Leiden mutation or an elevated factor VIII level appears to have a multiplicative effect on their overall risk of DVT, increasing it 17-fold compared to women without these blood abnormalities who are HRT nonusers.

Is progestin an independent risk factor for incident venous thromboembolism? A population-based case-control study

INTRODUCTION

Because the risk of venous thromboembolism (VTE) associated with progestin is uncertain, we tested oral contraceptives, estrogen and progestin as independent VTE risk factors.

MATERIALS AND METHODS

Using longitudinal, population-based Rochester Epidemiology Project resources, we identified all Olmsted County, MN women with objectively-diagnosed incident VTE over the 13-year period, 1988-2000 (n=726) and one to two Olmsted County women per case matched on age, event year and duration of prior medical history (n=830), and reviewed their complete medical history in the community for previously-identified VTE risk factors (i.e., hospitalization with or without surgery, nursing home confinement, trauma/fracture, leg paresis, active cancer, varicose veins and pregnancy/postpartum), and oral contraceptive, oral estrogen, and oral or injectable progestin exposure. Using conditional logistic regression we tested these hormone exposures as VTE risk factors, both unadjusted and after adjusting for previously-identified VTE risk factors.

RESULTS

In unadjusted models, oral contraceptives, progestin alone, and estrogen plus progestin were significantly associated with VTE. Individually adjusting for body mass index (BMI) and previously-identified VTE risk factors, these effects remained essentially unchanged except that progestin alone was not associated with VTE after adjusting for active cancer. Considering only case-control pairs without active cancer, progestin alone was positively but non-significantly associated with VTE (OR=2.49; p=0.16). Adjusting for BMI and previously-identified VTE risk factors including active cancer, oral contraceptives, estrogen alone, and progestin with or without estrogen were significantly associated with VTE.

CONCLUSIONS

Oral contraceptives, estrogen alone, estrogen plus progestin, and progestin with or without estrogen are independent VTE risk factors.

Hormone replacement therapy and the risk of venous thromboembolism: a population-based study

SUMMARY BACKGROUND

Hormone replacement therapy (HRT) using oral estrogen alone or combined with a progestogen is associated with an increased risk of venous thromboembolism (VTE) in postmenopausal women. This risk may differ for tibolone and transdermal HRT.

METHODS

Among the United Kingdom's General Practice Research Database, we identified the cohort of all women aged 50-79 between 1 January 1987 and 1 March 2008. Using a nested case-control approach, all incident cases of VTE occurring during the study period were identified and matched with up to 10 controls selected from the cohort members. Rate ratios (RR) of VTE with current use of tibolone, transdermal and oral HRT were estimated using conditional logistic regression.

RESULTS

The cohort of 955 582 postmenopausal women included 23 505 cases of VTE matched with 231 562 controls. The risk of VTE was not increased with current use of transdermal estrogen alone (RR 1.01; 95% CI, 0.89-1.16) or combined with a progestogen (RR 0.96; 95% CI, 0.77-1.20), or with current use of tibolone (RR 0.92; 95% CI: 0.77-1.10), relative to non-use. On the other hand, the risk was increased with current use of oral estrogen (RR 1.49; 95% CI, 1.37-1.63) and oral estrogen-progestogen (RR 1.54; 95% CI, 1.44-1.65), and increased with estrogen dosage. The risks with oral formulations were particularly elevated during the first year of use but disappeared 4 months after discontinuation.

CONCLUSION

Transdermal HRT and tibolone were not associated with an increased risk of VTE in postmenopausal women.

Postmenopausal Hormone Therapy and Risk of Idiopathic Venous Thromboembolism

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.

The pickwickian syndrome-obesity hypoventilation syndrome

Obesity-hypoventilation syndrome (OHS), also historically described as the Pickwickian syndrome, consists of the triad of obesity, sleep disordered breathing, and chronic hypercapnia during wakefulness in the absence of other known causes of hypercapnia. Its exact prevalence is unknown, but it has been estimated that 10% to 20% of obese patients with obstructive sleep apnea have hypercapnia. OHS often remains undiagnosed until late in the course of the disease. Early recognition is important because these patients have significant morbidity and mortality. Effective treatment can lead to significant improvement in patient outcomes, underscoring the importance of early diagnosis. The authors review the definition and epidemiology of OHS, in addition to the current multifaceted understanding of the pathophysiology, and provide useful clinical approaches to diagnosis and treatment.

Risk factors for deep vein thrombosis in women aged 18 to 50: a retrospective analysis

BACKGROUND

Deep vein thrombosis (DVT) occurs in one of every 1,000 individuals per year. Various inherited and acquired risk factors are known. We investigated the importance of oral contraceptives (OCs) as a risk factor in women of child-bearing age.

OBJECTIVES

To evaluate the risk factors for DVT in a female patient collective.

METHODS

We analyzed the records of 99 women aged 18 to 50 with DVT. We documented age, identifiable risk factor of DVT, location of the thrombus, use of OCs, and thrombophilia.

RESULTS

52.5% of patients suffering from DVT were aged between 40-50 years. Forty-six patients had an unprovoked DVT; the most common risk factor was immobilization in 41. Thrombophilia was found in 18 cases. Twenty-nine patients used OCs; no influence of OCs on any of the other risk factors was found.

CONCLUSIONS

In our patient group, the most important risk factors were older age and immobilization. DVT is typically idiopathic and may be caused by subtle nondetectable thrombophilic disorders. The use of OCs was distributed in DVT patients just as in the general Austrian community and seems not to be a severe additional risk factor. Examining the whole lower extremity during ultrasonography is important so as not to overlook a DVT of the lower leg.

Could transdermal estradiol + progesterone be a safer postmenopausal HRT? A review

Hormone replacement therapy (HRT) in young postmenopausal women is a safe and effective tool to counteract climacteric symptoms and to prevent long-term degenerative diseases, such as osteoporotic fractures, cardiovascular disease, diabetes mellitus and possibly cognitive impairment. The different types of HRT offer to many extent comparable efficacies on symptoms control; however, the expert selection of specific compounds, doses or routes of administration can provide significant clinical advantages. This paper reviews the role of the non-oral route of administration of sex steroids in the clinical management of postmenopausal women. Non-orally administered estrogens, minimizing the hepatic induction of clotting factors and others proteins associated with the first-pass effect, are associated with potential advantages on the cardiovascular system. In particular, the risk of developing deep vein thrombosis or pulmonary thromboembolism is negligible in comparison to that associated with oral estrogens. In addition, recent indications suggest potential advantages for blood pressure control with non-oral estrogens. To the same extent, a growing literature suggests that the progestins used in association with estrogens may not be equivalent. Recent evidence indeed shows that natural progesterone displays a favorable action on the vessels and on the brain, while this might not be true for some synthetic progestins. Compelling indications also exist that differences might also be present for the risk of developing breast cancer, with recent trials indicating that the association of natural progesterone with estrogens confers less or even no risk of breast cancer as opposed to the use of other synthetic progestins. In conclusion, while all types of hormone replacement therapies are safe and effective and confer significant benefits in the long-term when initiated in young postmenopausal women, in specific clinical settings the choice of the transdermal route of administration of estrogens and the use of natural progesterone might offer significant benefits and added safety.

Assessment and management of patients with obesity hypoventilation syndrome

Obesity hypoventilation syndrome (OHS) is characterized by obesity, daytime hypercapnia, and sleep-disordered breathing in the absence of significant lung or respiratory muscle disease. Compared with eucapnic morbidly obese patients and eucapnic patients with sleep-disordered breathing, patients with OHS have increased health care expenses and are at higher risk of developing serious cardiovascular disease leading to early mortality. Despite the significant morbidity and mortality associated with this syndrome, diagnosis and institution of effective treatment occur late in the course of the syndrome. Given that the prevalence of extreme obesity has increased considerably, it is likely that clinicians will encounter patients with OHS in their clinical practice. Therefore maintaining a high index of suspicion can lead to early recognition and treatment reducing the high burden of morbidity and mortality and related health care expenditure associated with undiagnosed and untreated OHS. In this review we define the clinical characteristics of the syndrome and review the pathophysiology, morbidity, and mortality associated with it. Last, we discuss currently available treatment modalities.

Hormone therapy and thromboembolic disease

PURPOSE OF REVIEW

Hormone therapy increases the risk of venous thromboembolism (VTE). To reduce this risk, changes in dosage, composition and route of administration have been made over the years. This review provides a summary of the available evidence and an update on the most recent findings on the issue.

RECENT FINDINGS

Contraceptives containing third-generation progestagens confer a higher risk of VTE than second-generation compounds. Little data are available on preparations containing less than 30 micarog of estrogen, new progestagens or levonorgestrel-releasing intrauterine devices. Hormone replacement therapy increases the risk of VTE by 2 to 3-fold. Transdermal administration may be less thrombogenic than oral administration, while different estrogens and progestagens may carry a different risk. VTE risk is further increased in carriers of inherited thrombophilia. Despite a similar increase in relative risk of thrombosis associated with hormone therapy, absolute risk is lower in fertile women and higher in postmenopausal ones. Universal screening for thrombophilia before prescribing hormone replacement therapy might be cost-effective.

SUMMARY

Careful evaluation of individual risk factor is warranted before prescribing hormone therapy. Further investigations are needed to establish whether or not newer compounds are safer than older ones with respect to the risk of thrombosis.

Sex hormones and thrombosis

There is compelling evidence that use of oral formulations of female hormone replacement and of the combined oral contraceptive induces a prothrombotic state. This translates to an increased thrombotic risk. Within the individual, the absolute risk is determined by the interaction between that induced by hormone use and heritable and acquired risk factors for thrombosis. Knowledge of the accumulating epidemiologic and clinical trial-derived data on this topic is essential for the delivery of evidence-based counseling in the clinical environment and is the subject of this review.

A comparative study of the effect of continuous combined conjugated equine estrogen plus medroxyprogesterone acetate and tibolone on blood coagulability

BACKGROUND

Hormone therapy (HT) after the menopause is associated with increased risk of venous thromboembolism (VTE). Tibolone has pharmacodynamic properties different from other hormone preparations. We compared the effect of a combined HT and tibolone on the inhibition of haemostasis.

METHODS

Thirty-eight post-menopausal women were randomly assigned to 1.25 or 2.5 mg per day of tibolone or oral continuous combined conjugated equine estrogen plus medroxyprogesterone acetate (CEE/MPA). Inhibitors of haemostasis were measured at baseline and after 12 months.

RESULTS

Results from the two groups of women receiving tibolone were not significantly different and, to improve the power of the study, the two groups were merged. Higher concentration of protein S (1.16 versus 1.00 IU ml(-1); P = 0.005) and higher activated protein C resistance ratio (APC-R) (4.2 versus 3.65; P = 0.04) were observed in the tibolone group than in the CEE/MPA group. Both doses of tibolone increased APC-R significantly (P < 0.01). Tissue factor pathway inhibitor (TFPI) was lower in the CEE/MPA group than in the tibolone group (67.8 versus 79.9 ng ml(-1); P = 0.03). CEE/MPA reduced the concentration of antithrombin (P = 0.002), protein S (P < 0.001) and TFPI (P < 0.001). Both preparations reduced the concentration of plasminogen activator inhibitor 1 (P < 0.05).

CONCLUSIONS

Tibolone induces fewer pharmacological alterations on blood coagulability than CEE/MPA and has a potentially favourable effect on APC-R. This may translate into a corresponding low risk of VTE, as also indicated from the existing clinical data.

Estrogen receptor alpha polymorphism and venous thromboembolism in male and female: Data from the EDITH study

BACKGROUND

Association between estrogen receptor (ER) alpha polymorphism c.454-397 T>C and venous thromboembolism (VTE) has been reported in postmenopausal women. Comprehensive data are lacking. We herein evaluated the risk for VTE related to c.454-397 T>C ER alpha gene polymorphism in both men and women.

PATIENTS/METHODS

The EDITH Study enrolled consecutive patients, aged over 18 years, hospitalized between May 2000 and December 2004 in Brest University Hospital with an objectively proven symptomatic VTE. For each case, one control who matched the case for age within a five-year age band, gender and major acquired risk factors, was selected. The present analysis was restricted to 677 cases with a VTE event not related to major acquired risk factors and their matched controls.

RESULTS AND CONCLUSIONS

The relationship between VTE and c.454-397 T>C ER alpha polymorphism was consistent with a dominant model in women and a recessive model in men. Adjusted conditional odds ratios (95% CI) were 1.37 (1.05-1.78) and 1.29 (0.85-1.94) for CT/CC genotypes in women and CC genotype in men respectively compared to TT genotype. Among women hormone use did not substantially modify effect-measure estimate. Our results further extend results from previous studies. Other investigations are required to precise underlying mechanisms.

Tratamiento hormonal sustitutivo y enfermedades cardiovasculares

Despite biologically plausible mechanisms for cardiac protection and compelling evidence from observational studies suggesting that menopausal hormone therapy confers cardiovascular benefit, results of well-designed and conducted randomized clinical trials in healthy women and in women with established coronary heart disease displayed that menopausal hormone therapy failed to prevent clinical cardiovascular events and rather was associated with harms. Clinical trial of the SERM raloxifene also did not demonstrate a decrease in coronary events. It is unknown whether the earlier initiation of such therapies, i.e., at menopause, would result in favorable outcomes; or whether different hormonal preparations, lower doses, or alternate routes of administration would confer benefit. At present, proved coronary risk reduction strategies are requisite (albeit underutilized) for menopausal women; these include lifestyle and pharmacologic coronary preventive interventions. The baseline characteristics of menopausal women with coronary heart disease who were participants in cardiovascular outcome trials of menopausal hormone therapy or raloxifene were remarkably similar; globally, cardiovascular risk factors were not optimally controlled at entry into these trials, suggesting that more aggressive cardiovascular risk interventions are appropriate to achieve optimal target goals for menopausal women with documented coronary heart disease.

Conventional-dose hormone therapy (HT) and tibolone, but not low-dose HT and raloxifene, increase markers of activated coagulation

OBJECTIVES

Hormone therapy (HT) is associated with a modest, but significantly increased risk for arterial and venous thromboembolism. We have compared the effects of estrogen, tibolone, and raloxifene on relevant markers of coagulation activation and investigated whether there is a dose-response relationship of oral HT.

METHODS

Randomized, open-label, comparative study of 202 healthy women who were assigned to receive treatment for 12 weeks with either low-dose hormone therapy containing 1 mg 17beta-estradiol + 0.5 mg norethisterone acetate (NETA) (n=50), conventional-dose HT containing 2 mg 17beta-estradiol and 1 mg NETA (n=50), 2.5 mg tibolone (n=51), or 60 mg raloxifene (n=51).

RESULTS

The groups were comparable with regard to demographic characteristics and laboratory variables at baseline. D-dimer increased markedly in the conventional-dose HT group, but remained unchanged in the low-dose HT group. Tibolone was associated with a medium increase, whereas raloxifene was associated with a decrease in D-dimer levels. Changes in prothrombin fragment 1 + 2 showed a similar pattern for all four groups, whereas no significant differences in changes of thrombin-antithrombin complex were observed.

CONCLUSIONS

Our data suggest that low-dose HT is associated with less activation of coagulation than conventional-dose HT. This finding may be of clinical importance since randomized clinical trials showing increased risk of thrombosis have utilized conventional-dose HT.

Postmenopausal hormone replacement therapy and venous thromboembolism

BACKGROUND

Women taking hormone replacement therapy (HRT) have a 2- to 5-fold increased risk of venous thrombosis compared with nonusers. Increasingly, evidence has suggested that the size of the risk increase varies according to related factors, such as the type of estrogen used, the mode of delivery, and the presence of other predisposing factors.

OBJECTIVE

The aim of this study was to examine the current literature to assess the varying risk of venous thrombosis among women taking HRT.

METHODS

An extensive search was carried out on all major electronic databases including MEDLINE 1995 to October 2005 and BIS (EMBASE) 1980 to October 2005. Relevant keywords relating to thrombosis (venous thromboembolism, venous thrombosis, deep vein thrombosis, and pulmonary embolism) combined with hormones (hormone replacement therapy and estrogen) were used to capture all potentially relevant studies.

RESULTS

The increased risk of a first episode of venous thrombosis in women currently taking HRT compared with nonusers ranged from 1.22 (95% CI, 0.76-1.94) to 4.50 (95% CI, 1.30-15.10). Similar increases in risks for deep vein thrombosis and pulmonary embolism were found. The risk of venous thrombosis is the highest in the first year of therapy, durich which as much as a greater than 6-fold increase was found. Women taking estrogen-progestin HRT had a significantly greater risk of venous thrombosis than those using estrogen-only preparations (odds ratio [OR], 1.60; 95% CI, 1.13-2.26). Studies have also suggested a dose-related effect, suggesting high-dose estrogen therapy is associated with a greater increased risk of venous thrombosis than low-dose preparations. Comparisons between oral and transdermal HRT have shown a significant difference in the relative risk of venous thrombosis (OR, 4.0; 95% CI, 1.9-8.3) favoring the use of transdermal preparations. The presence of thrombophilia, particularly factor V Leiden, further amplifies the risk of venous thrombosis in women using HRT (OR, 13.16; 95% CI, 4.28-40.47). The presence of other risk factors, such as increasing age and being overweight, were all shown to be associated with a further increase in the risk of venous thrombosis.

CONCLUSIONS

Recent studies have confirmed that current users of HRT are at increased risk of venous thrombosis. The increase in risk has been shown to vary according to duration of use, with the risk being greatest during the first year of use. Moreover, the increased risk varies according to the type of preparation and presence of additional risk factors such as increasing age, obesity, cancer, and recent surgery. Few studies have examined the relationship between thrombophilia, HRT and venous thrombosis; thus, more research is required in this area before accurate estimates of the risk can be made.