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Xie H, Qian T, Liu L, Sun R, Che W, Zhao M, Hou X, Pan H, Su Y, Li J, Dong X, Liu P. Effect of progestin on thyroid function in female Wistar rats. Front Endocrinol (Lausanne) 2024; 15:1362774. [PMID: 38904035 PMCID: PMC11188309 DOI: 10.3389/fendo.2024.1362774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 05/22/2024] [Indexed: 06/22/2024] Open
Abstract
Introduction To characterize the influence of female-specific hormones on women's thyroid function, the study investigated the influence of extra progestin from oral contraceptives on inducing thyroid dysfunction. Methods Sixty female Wistar rats were divided into six groups based on levonorgestrel or desogestrel administration as the main active agents: control, low (0.0039 mg*20-fold), medium (0.0039 mg*100-fold), high (0.0318 mg*100-fold) levonorgestrel (pure product); and low (0.0083 mg*20-fold) and high (0.0083 mg*100-fold) desogestrel (pure product). Progestin was administered by gavage every 4 days for 1 month. Statistical analysis was performed using one-way analysis of variance and the Kruskal-Wallis test. Results Following levonorgestrel gavage, serum free T4 and thyroidstimulating hormone levels were significantly lower in the experimental group than that in the control group (p=0.013 and 0.043). After desogestrel gavage, the serum free T4 and free T3 levels were lower in the experimental group than that in the control group (p=0.019 and 0.030). Thyroid hormone antibody concentrations were lower in rats administered levonorgestrel and desogestrel than that in control rats. Moreover, exposure to progestin upregulated the expression of the thyroid-stimulating hormone receptor and sodium iodide symporter in thyroid. Discussion Progestin stimulation enhanced the proliferation of follicular epithelial cells in rat thyroid tissues. Progestin exposure could cause thyroid dysfunction by upregulating the transcription of thyroid-stimulating hormone receptor and sodium iodide symporter in thyroid, thus inducing pathomorphological changes in rats' thyroid.
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Affiliation(s)
- Honglei Xie
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, Harbin, China
| | - Tingting Qian
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, Harbin, China
- Endemic Disease Control Section, Yun nan Institute of Endemic Diseases Control and Prevention, Dali, China
| | - Lanchun Liu
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, Harbin, China
| | - Rong Sun
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, Harbin, China
| | - Wenjing Che
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, Harbin, China
| | - Meng Zhao
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, Harbin, China
| | - Xin Hou
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, Harbin, China
| | - Haowen Pan
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, Harbin, China
| | - Yue Su
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, Harbin, China
| | - Jia Li
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, Harbin, China
| | - Xiaoqiu Dong
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, Harbin, China
- Ultrasound Department, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Peng Liu
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, Harbin, China
- Key Lab of Etiology and Epidemiology, Education Bureau of Heilongjiang Province and Ministry of Health, Heilongjiang Provincial Key Laboratory of Trace Elements and Human Health, Harbin, China
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2
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Saadedine M, Faubion SS. Hormonal Contraception and Sexual Function: A Review, Clinical Insights, and Management Considerations. Obstet Gynecol Clin North Am 2024; 51:381-395. [PMID: 38777490 DOI: 10.1016/j.ogc.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Most sexually active women of reproductive age have used contraception, with hormonal methods constituting approximately 40% of contraceptive choices. Among these hormonal options, combined oral contraceptives stand out as the most selected. Within this same demographic, sexual issues are prevalent. Although specific hormonal contraceptives have been implicated in sexual dysfunction among these women, the correlation lacks consistency across studies and varies between different types of hormonal contraception. This article assesses the available literature on the associations between various hormonal contraceptive methods and sexual function and provides practical management insights.
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Affiliation(s)
- Mariam Saadedine
- Division of General Internal Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA; Center for Women's Health, Mayo Clinic, Rochester, MN, USA
| | - Stephanie S Faubion
- Division of General Internal Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA; Center for Women's Health, Mayo Clinic, Rochester, MN, USA.
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Özcan Ö, den Elzen WPJ, Hillebrand JJ, den Heijer M, van Loendersloot LL, Fischer J, Hamer H, de Jonge R, Heijboer AC. The effect of hormonal contraceptive therapy on clinical laboratory parameters: a literature review. Clin Chem Lab Med 2024; 62:18-40. [PMID: 37419659 DOI: 10.1515/cclm-2023-0384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/14/2023] [Indexed: 07/09/2023]
Abstract
Hormonal contraceptives (HC) are widely used among women in reproductive ages. In this review, the effects of HCs on 91 routine chemistry tests, metabolic tests, and tests for liver function, hemostatic system, renal function, hormones, vitamins and minerals were evaluated. Test parameters were differently affected by the dosage, duration, composition of HCs and route of administration. Most studies concerned the effects of combined oral contraceptives (COC) on the metabolic, hemostatic and (sex) steroids test results. Although the majority of the effects were minor, a major increase was seen in angiotensinogen levels (90-375 %) and the concentrations of the binding proteins (SHBG [∼200 %], CBG [∼100 %], TBG [∼90 %], VDBP [∼30 %], and IGFBPs [∼40 %]). Also, there were significant changes in levels of their bound molecules (testosterone, T3, T4, cortisol, vitamin D, IGF1 and GH). Data about the effects of all kinds of HCs on all test results are limited and sometimes inconclusive due to the large variety in HC, administration routes and dosages. Still, it can be concluded that HC use in women mainly stimulates the liver production of binding proteins. All biochemical test results of women using HC should be assessed carefully and unexpected test results should be further evaluated for both methodological and pre-analytical reasons. As HCs change over time, future studies are needed to learn more about the effects of other types, routes and combinations of HCs on clinical chemistry tests.
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Affiliation(s)
- Ömer Özcan
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
| | - Wendy P J den Elzen
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Jacquelien J Hillebrand
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
| | - Martin den Heijer
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Laura L van Loendersloot
- Department of Reproductive Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Johan Fischer
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Henrike Hamer
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Robert de Jonge
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Laboratory Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Annemieke C Heijboer
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
- Department of Laboratory Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
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Hugon-Rodin J, Fontana P, Poncet A, Streuli I, Casini A, Blondon M. Longitudinal profile of estrogen-related thrombotic biomarkers after cessation of combined hormonal contraceptives. Blood 2024; 143:70-78. [PMID: 37939264 DOI: 10.1182/blood.2023021717] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/28/2023] [Accepted: 09/13/2023] [Indexed: 11/10/2023] Open
Abstract
ABSTRACT The persistence of risk of venous thromboembolism (VTE) due to combined hormonal contraceptives (CHCs), after their cessation, is unknown but important to guide clinical practice. The objective of this prospective cohort study was to define the time until normalization of estrogen-related thrombotic biomarkers after CHC cessation. We enrolled women aged 18 to 50 years who had decided to stop their CHC, excluding those with a personal history of VTE, anticoagulation, or pregnancy. The study started before cessation of CHC, with 6 visits afterwards (at 1, 2, 4, 6, and 12 weeks after cessation). Primary outcomes were normalized sensitivity ratios to activated protein C (nAPCsr) and to thrombomodulin (nTMsr), with sex hormone-binding globulin (SHBG) as a secondary end point. We also included control women without CHC. Among 66 CHC users, from baseline until 12 weeks, average levels of nAPCsr, nTMsr, and SHBG decreased from 4.11 (standard deviation [SD], 2.06), 2.53 (SD, 1.03), and 167 nmol/L (SD, 103) to 1.27 (SD, 0.82), 1.11 (SD, 0.58), and 55.4 nmol/L (SD, 26.7), respectively. On a relative scale, 85.8%, 81.3%, and 76.2% of the decrease from baseline until 12 weeks was achieved at 2 weeks and 86.7%, 85.5%, and 87.8% at 4 weeks after CHC cessation, respectively. Levels were not meaningfully modified throughout the study period among 28 control women. In conclusion, CHC cessation is followed by a rapid decrease in estrogen-related thrombotic biomarkers. Two to 4 weeks of cessation before planned major surgery or withdrawal of anticoagulants in patients with VTE appears sufficient for the majority of women. The trial is registered at www.clinicaltrials.gov as #NCT03949985.
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Affiliation(s)
- Justine Hugon-Rodin
- Division of Gynecology, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
- Gynecology Department, Gynecological Endocrinology Unit, Hospital Saint Joseph, INSERM Unité Mixte de Recherche 1153, Équipe de Recherche en Épidémiologie Obstétricale Périnatale et Pédiatrique, Paris, France
| | - Pierre Fontana
- Division of Angiology and Hemostasis, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Antoine Poncet
- Center for Clinical Research, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Isabelle Streuli
- Division of Gynecology, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Alessandro Casini
- Division of Angiology and Hemostasis, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Marc Blondon
- Division of Angiology and Hemostasis, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
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5
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Fan Q, Meng Y, Nie Z, Xie S, Chen C. Sex hormone-binding globulin exerts sex-related causal effects on lower extremity varicose veins: evidence from gender-stratified Mendelian randomization. Front Endocrinol (Lausanne) 2023; 14:1230955. [PMID: 38152135 PMCID: PMC10752419 DOI: 10.3389/fendo.2023.1230955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 11/20/2023] [Indexed: 12/29/2023] Open
Abstract
Background The association between serum sex hormones and lower extremity varicose veins has been reported in observational studies. However, it is unclear whether the association reflects a causal relationship. Besides, serum sex hormone-binding globulin (SHBG) has been rarely studied in lower extremity varicose veins. Here, we aim to investigate the association between serum levels of SHBG, testosterone, and estradiol and the risk of lower extremity varicose veins using Mendelian randomization (MR). Methods We obtained genome-wide association study summary statistics for serum SHBG levels with 369,002 European participants, serum testosterone levels with 424,907 European participants, serum estradiol levels with 361,194 European participants, and lower extremity varicose veins with 207,055 European participants. First, a univariable MR was performed to identify the causality from SHBG and sex hormone levels to lower extremity varicose veins with several sensitivity analyses being performed. Then, a multivariable MR (MVMR) was performed to further assess whether the causal effects were independent. Finally, we performed a gender-stratified MR to understand the role of genders on lower extremity varicose veins. Results Genetically predicted higher serum SHBG levels significantly increased the risk of lower extremity varicose veins in the univariable MR analysis (OR=1.39; 95% CI: 1.13-1.70; P=1.58×10-3). Sensitivity analyses and MVMR (OR=1.50; 95% CI:1.13-1.99; P=5.61×10-3) verified the robustness of the causal relationships. Gender-stratified MR revealed that higher serum SHBG levels were associated with lower extremity varicose veins in both sexes. However, the OR of serum SHBG levels on lower extremity varicose veins risk in females (OR=1.51; 95% CI: 1.23-1.87; P=1.00×10-4) was greater than in males (OR=1.26; 95% CI: 1.04-1.54; P=1.86×10-2). Conclusions Serum SHBG levels are positively related to lower extremity varicose veins risk in both sexes, especially in females. This may partly explain the higher prevalence of varicose vines among females.
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Affiliation(s)
- Qinglu Fan
- Department of Thoracic Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yang Meng
- Department of Ophthalmology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhihao Nie
- Department of Thoracic Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Songping Xie
- Department of Thoracic Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Changzheng Chen
- Department of Ophthalmology, Renmin Hospital of Wuhan University, Wuhan, China
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Wang S, Wang Y, Bai M, Peng Y, Zhou D, Lei P, Zhou B, Zhang P, Zhang Z. Causal inference of sex hormone-binding globulin on venous thromboembolism: evidence from Mendelian randomisation. Thromb J 2023; 21:109. [PMID: 37880771 PMCID: PMC10599068 DOI: 10.1186/s12959-023-00553-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 10/11/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Previous cohort studies have shown that exogenous sex hormone use, such as testosterone replacement therapy and oestrogen-containing contraceptives, can increase the risk of venous thromboembolism (VTE). However, the relationship between endogenous sex hormone levels and VTE remains unclear. The goal of the present study was to explore the causal roles of endogenous sex hormones, including hormone-binding globulin (SHBG), bioactive testosterone (BT), and total testosterone (TT), in VTE and its two subgroups, deep vein thrombosis (DVT) and pulmonary embolism (PE). METHODS We used a genome-wide association study of sex hormones as exposure data and Finnish VTE data as the outcome. Inverse variance weighting, MR-Egger, and weighted median were used for two-sample Mendelian randomisation (MR). Sensitivity analyses included MR-Egger, MR-PRESSO, Cochrane Q test, MR Steiger, leave-one-out analysis, and funnel plot, combined with multivariate MR and replicated MR analyses using larger VTE data from the global biobank meta-analysis initiative. Linkage disequilibrium score regression (LDSC) was used to determine genetic associations and estimate sample overlap. RESULTS Our findings genetically predicted that an increase in serum SHBG levels by one standard deviation (SD) caused 25% higher odds for VTE (OR: 1.25, 95% CI: 1.01-1.55) and 58% higher odds for PE (OR: 1.58, 95% CI: 1.20-2.08). LDSC supported the genetic correlation between these two traits and replicated analyses confirm SHBG's genetic effect on VTE in both sexes (OR: 1.46, 95% CI: 1.20-1.78) and in females (OR: 1.49, 95% CI: 1.17-1.91). In addition, an increase in serum TT levels by one SD caused 32% higher odds for VTE (OR: 1.32, 95% CI: 1.08-1.62) and 31% higher odds for DVT (OR: 1.31, 95% CI: 1.01-1.69); however, LDSC and replicated analyses did not find a genetic correlation between TT and VTE or its subtypes. No significant correlation was observed between BT and all three outcome traits. CONCLUSION Our study provides evidence that elevated serum SHBG levels, as predicted by genetics, increase VTE risk. However, the causal effect of testosterone levels on VTE requires further investigation.
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Affiliation(s)
- Shuping Wang
- The First Clinical Medical School, Lanzhou University, Lanzhou, Gansu, China
- Heart Center, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Provincial Clinical Research Center for Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Yongxiang Wang
- Heart Center, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Provincial Clinical Research Center for Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Ming Bai
- The First Clinical Medical School, Lanzhou University, Lanzhou, Gansu, China
- Heart Center, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Provincial Clinical Research Center for Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Yu Peng
- Heart Center, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Provincial Clinical Research Center for Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Dan Zhou
- The First Clinical Medical School, Lanzhou University, Lanzhou, Gansu, China
- Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Peng Lei
- The First Clinical Medical School, Lanzhou University, Lanzhou, Gansu, China
- Heart Center, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Provincial Clinical Research Center for Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Binpeng Zhou
- Department of Emergency, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Piyi Zhang
- The First Clinical Medical School, Lanzhou University, Lanzhou, Gansu, China
- Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Zheng Zhang
- The First Clinical Medical School, Lanzhou University, Lanzhou, Gansu, China.
- Heart Center, The First Hospital of Lanzhou University, Lanzhou, Gansu, China.
- Gansu Provincial Clinical Research Center for Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China.
- Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China.
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Haverinen A, Luiro K, Kangasniemi MH, Piltonen TT, Hustad S, Heikinheimo O, Tapanainen JS. Estradiol Valerate vs Ethinylestradiol in Combined Oral Contraceptives: Effects on the Pituitary-Ovarian Axis. J Clin Endocrinol Metab 2022; 107:e3008-e3017. [PMID: 35279718 DOI: 10.1210/clinem/dgac150] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Indexed: 12/27/2022]
Abstract
CONTEXT Limited studies have compared the effects of combined oral contraceptives (COCs) containing natural estrogens and synthetic ethinylestradiol (EE) on reproductive hormones. OBJECTIVE To compare estradiol valerate (EV) + dienogest (DNG), EE + DNG, and DNG alone (active control) on levels of follicle stimulating hormone (FSH), luteinizing hormone, anti-Müllerian hormone (AMH), ovarian steroids, sex hormone binding globulin (SHBG), and the free androgen index (FAI). METHODS This spin-off study from a randomized trial enrolled 59 healthy, 18 to 35-year-old ovulatory women, outpatients at Helsinki and Oulu University Hospitals, Finland, who were randomized to EV 2 mg + DNG 2-3 mg (n = 20); EE 0.03 mg + DNG 2 mg (n = 20); and DNG 2 mg (n = 19) for 9 weeks. Blood samples were drawn at baseline, and at 5 and 9 weeks. Age and BMI were comparable between groups; 3 women discontinued. RESULTS EV + DNG suppressed FSH by -27% (-51% to -3%) (median [95% CI]) vs EE + DNG, -64% (-78 to -51), P = 0.04, but AMH levels decreased similarly by -9% (-18 to -0.1) vs -13% (-28 to 0.2), P = 0.38, respectively. EV + DNG increased SHBG levels by 56% (30% to 82%) and EE + DNG by 385% (313% to 423%), P < 0.001. Total testosterone decreased by 16% (-27% to -5%) in the EV + DNG group but it did not decrease in the EE + DNG group, whereas the FAI decreased by -39% (-54% to -25%) vs -72% (-78% to -67%), P < 0.001. DNG alone did not induce changes in any of these parameters. CONCLUSION Compared with EE + DNG, treatment with EV + DNG resulted in milder pituitary downregulation and reduced induction of hepatic SHBG synthesis-potentially carrying more beneficial health effects.
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Affiliation(s)
- Annina Haverinen
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, PO Box 140, 00029 Helsinki, Finland
| | - Kaisu Luiro
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, PO Box 140, 00029 Helsinki, Finland
| | - Marika H Kangasniemi
- Department of Obstetrics and Gynecology, University of Oulu, Oulu University Hospital and Medical Research Centre PEDEGO Research Unit, PO Box 5000, 90014 Oulu, Finland
| | - Terhi T Piltonen
- Department of Obstetrics and Gynecology, University of Oulu, Oulu University Hospital and Medical Research Centre PEDEGO Research Unit, PO Box 5000, 90014 Oulu, Finland
| | - Steinar Hustad
- Department of Clinical Science and Core Facility for Metabolomics, University of Bergen, NO-5020 Bergen, Norway
| | - Oskari Heikinheimo
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, PO Box 140, 00029 Helsinki, Finland
| | - Juha S Tapanainen
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, PO Box 140, 00029 Helsinki, Finland
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Morimont L, Haguet H, Dogné JM, Gaspard U, Douxfils J. Combined Oral Contraceptives and Venous Thromboembolism: Review and Perspective to Mitigate the Risk. Front Endocrinol (Lausanne) 2021; 12:769187. [PMID: 34956081 PMCID: PMC8697849 DOI: 10.3389/fendo.2021.769187] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/08/2021] [Indexed: 12/02/2022] Open
Abstract
Many factors must be considered and discussed with women when initiating a contraceptive method and the risk of venous thromboembolism (VTE) is one of them. In this review, we discuss the numerous strategies that have been implemented to reduce the thrombotic risk associated with combined oral contraceptives (COCs) from their arrival on the market until today. Evidences suggesting that COCs were associated with an increased risk of VTE appeared rapidly after their marketing. Identified as the main contributor of this risk, the dosage of the estrogen, i.e., ethinylestradiol (EE), was significantly reduced. New progestins were also synthetized (e.g., desogestrel or gestodene) but their weak androgenic activity did not permit to counterbalance the effect of EE as did the initial progestins such as levonorgestrel. Numerous studies assessed the impact of estroprogestative combinations on hemostasis and demonstrated that women under COC suffered from resistance towards activated protein C (APC). Subsequently, the European Medicines Agency updated its guidelines on clinical investigation of steroid contraceptives in which they recommended to assess this biological marker. In 2009, estradiol-containing COCs were marketed and the use of this natural form of estrogen was found to exert a weaker effect on the synthesis of hepatic proteins compared to EE. In this year 2021, a novel COC based on a native estrogen, i.e., estetrol, will be introduced on the market. Associated with drospirenone, this preparation demonstrated minor effects on coagulation proteins as compared with other drospirenone-containing COCs. At the present time, the standard of care when starting a contraception, consists of identifying the presence of hereditary thrombophilia solely on the basis of familial history of VTE. This strategy has however been reported as poorly predictive of hereditary thrombophilia. One rationale and affordable perspective which has already been considered in the past could be the implementation of a baseline screening of the prothrombotic state to provide health care professionals with objective data to support the prescription of the more appropriate contraceptive method. While this strategy was judged too expensive due to limited laboratory solutions, the endogenous thrombin potential-based APC resistance assay could now represent an interesting alternative.
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Affiliation(s)
- Laure Morimont
- Research Department, Qualiblood s.a., Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
| | - Hélène Haguet
- Research Department, Qualiblood s.a., Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
| | | | - Ulysse Gaspard
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - Jonathan Douxfils
- Research Department, Qualiblood s.a., Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
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Fruzzetti F, Fidecicchi T, Montt Guevara MM, Simoncini T. Estetrol: A New Choice for Contraception. J Clin Med 2021; 10:5625. [PMID: 34884326 PMCID: PMC8658652 DOI: 10.3390/jcm10235625] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/11/2021] [Accepted: 11/27/2021] [Indexed: 11/28/2022] Open
Abstract
Estetrol (E4) is a natural estrogenic steroid that is normally produced by human fetal liver. Recent research has demonstrated that it is a potent, orally bioavailable, natural selective estrogen receptor modulator; it has a moderate affinity for both human estrogen receptor alpha (ERα) and ERβ, with a preference for ERα. Clinical studies have demonstrated possible use as an estrogen in combined oral contraceptives (COC). COCs containing E4 and drospirenone (DRSP) showed a high acceptability, tolerability, and user satisfaction also when compared to COCs containing ethinylestradiol (EE). E4/DRSP effectively inhibits ovulation, with a similar effect on endometrium thickness than that of EE-containing COCs. Low doses (15 mg) of E4 with DRSP (3 mg) showed promising results in term of bleeding pattern and cycle control, also when compared to other COCs containing synthetic estrogens. Moreover, the association has limited effects on serum lipids, liver, SHBG levels, and carbohydrate metabolism. This combination also could drive a lower risk of venous thromboembolism than EE-containing COCs. In this review, we will summarize the actual knowledge about the new E4-containing contraceptive. Further large-scale studies in the full target population are needed to provide more insights into the cardiovascular safety profile and user satisfaction of E4/DRSP.
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Scheres LJ, Selier NL, Nota NM, van Diemen JJ, Cannegieter SC, den Heijer M. Effect of gender-affirming hormone use on coagulation profiles in transmen and transwomen. J Thromb Haemost 2021; 19:1029-1037. [PMID: 33527671 PMCID: PMC8048491 DOI: 10.1111/jth.15256] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/20/2021] [Accepted: 01/26/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND The transgender population that uses gender-affirming hormone therapy (GAHT) is rapidly growing. The (side) effects of GAHT are largely unknown. We examined the effect of GAHT on coagulation parameters associated with venous thromboembolism (VTE) risk. METHODS Factor (F)II, FIX, FXI, protein (p)C and free pS, fibrinogen, hematocrit, sex hormone-binding globulin, and normalized activated protein C ratio were measured in 98 transwomen (male sex at birth, female gender identity) and 100 transmen (female sex at birth, male gender identity) before and after 12 months of GAHT (oral or transdermal estradiol and anti-androgens in transwomen, transdermal or intramuscular testosterone in transmen). Mean paired differences in coagulation measurements were estimated with 95% confidence intervals (95% CI). Differences for route of administration and age were assessed with linear regression. RESULTS After GAHT, transwomen had more procoagulant profiles with a mean increase in FIX: 9.6 IU/dL (95% CI 3.1-16.0) and FXI: 13.5 IU/dL (95% CI 9.5-17.5), and a decrease in pC: -7.7 IU/dL (95% CI -10.1 to -5.2). Changes in measures of coagulation were influenced by route of administration (oral vs. transdermal) and age. A higher sex-hormone binding globulin level after 12 months was associated with a lower activated protein C resistance. In transmen, changes were not procoagulant overall and were influenced by age. Differences for route of administration (transdermal vs. intramuscular) were small. CONCLUSIONS GAHT in transmen was not associated with apparent procoagulant changes, which provides some reassurance regarding VTE risk. In transwomen, GAHT resulted in procoagulant changes, which likely contributes to the observed increased VTE risk.
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Affiliation(s)
- Luuk J.J. Scheres
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Department of Internal MedicineRadboud Institute for Health Sciences, Radboud University Medical CenterNijmegenthe Netherlands
| | - Nienke L.D. Selier
- Department of Internal MedicineDivision of EndocrinologyAmsterdam UMCVrije Universiteit AmsterdamAmsterdamthe Netherlands
- Center of Expertise on Gender DysphoriaAmsterdam UMCVrije Universiteit AmsterdamAmsterdamthe Netherlands
| | - Nienke M. Nota
- Department of Internal MedicineDivision of EndocrinologyAmsterdam UMCVrije Universiteit AmsterdamAmsterdamthe Netherlands
- Center of Expertise on Gender DysphoriaAmsterdam UMCVrije Universiteit AmsterdamAmsterdamthe Netherlands
| | - Jeske J.K. van Diemen
- Department of Internal MedicineDivision of Vascular MedicineAmsterdam UMCVrije Universiteit AmsterdamAmsterdamthe Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Department of Internal MedicineSection Thrombosis and HaemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Martin den Heijer
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Department of Internal MedicineDivision of EndocrinologyAmsterdam UMCVrije Universiteit AmsterdamAmsterdamthe Netherlands
- Center of Expertise on Gender DysphoriaAmsterdam UMCVrije Universiteit AmsterdamAmsterdamthe Netherlands
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11
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Skeith L, Le Gal G, Rodger MA. Oral contraceptives and hormone replacement therapy: How strong a risk factor for venous thromboembolism? Thromb Res 2021; 202:134-138. [PMID: 33836493 DOI: 10.1016/j.thromres.2021.03.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/14/2021] [Accepted: 03/15/2021] [Indexed: 10/21/2022]
Abstract
Exogenous hormone therapies, such as combined oral contraceptives (COC) and hormone replacement therapy (HRT), cause blood hypercoagulability and are a risk factor for venous thromboembolism (VTE). There is controversy on how strong this "provoking" risk factor is, and how other risk factors may synergise VTE risk. We aim to review the latest literature on the risk of initial and recurrent VTE with COC and HRT use to provide guidance for decision-making about duration of anticoagulation, and guide future research efforts.
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Affiliation(s)
- Leslie Skeith
- Division of Hematology and Hematological Malignancies, Department of Medicine, University of Calgary, Alberta, Canada.
| | - Grégoire Le Gal
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Marc A Rodger
- Department of Medicine, McGill University, Montreal, Quebec, Canada
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12
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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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13
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Khialani D, Rosendaal F, Vlieg AVH. Hormonal Contraceptives and the Risk of Venous Thrombosis. Semin Thromb Hemost 2020; 46:865-871. [DOI: 10.1055/s-0040-1715793] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AbstractThe risk of venous thrombosis (VT) varies according to the type of progestogen that is found in combined oral contraceptives (COCs). When combined with the estrogen component ethinylestradiol (EE), the androgenic progestogens are better able to counteract the EE-induced stimulation of liver proteins and hence are associated with a twofold decreased risk of VT compared with non- or antiandrogenic progestogens, which exert limited counteraction of EE. Because EE is responsible for the increased risk, novel estrogens such as estradiol were developed and seem to have a lower risk of VT than EE. Besides COCs, there are other methods of hormonal contraceptives, such as progestogen-only contraceptives, which do not increase VT risk, except for injectables. Other nonoral contraceptives are combined vaginal rings and patches. There is insufficient evidence regarding the risk of VT associated with these two methods compared with COCs. The increased risk associated with COCs is more pronounced in women with inherited thrombophilia. In these women, the progestogen levonorgestrel seems to be associated with the lowest risk of VT. Currently, there are no studies that have investigated the risk of VT in women who switch COCs. We hypothesize that switching COCs, even when switching from a high- to a low-risk COC, increases the risk of VT. Finally, risk prediction models in women who use COCs are lacking. Since there is a large number of VT cases associated with COC use, it is important to identify women at risk of VT and advise them on alternative contraception methods.
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Affiliation(s)
- Deeksha Khialani
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frits Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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14
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Ferreira-Filho ES, de Melo NR, Sorpreso ICE, Bahamondes L, Simões RDS, Soares-Júnior JM, Baracat EC. Contraception and reproductive planning during the COVID-19 pandemic. Expert Rev Clin Pharmacol 2020; 13:615-622. [DOI: 10.1080/17512433.2020.1782738] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Edson Santos Ferreira-Filho
- Gynecology Division, Hospital Das Clinicas HCFMUSP, Faculdade De Medicina, Universidade De Sao Paulo, Sao Paulo, Brazil
| | - Nilson Roberto de Melo
- Gynecology Division, Hospital Das Clinicas HCFMUSP, Faculdade De Medicina, Universidade De Sao Paulo, Sao Paulo, Brazil
| | | | - Luis Bahamondes
- Family Planning Clinic, Department of Obstetrics and Gynecology, Faculty of Medical Sciences, University of Campinas (Unicamp), Campinas, Brazil
| | - Ricardo Dos Santos Simões
- Gynecology Division, Hospital Das Clinicas HCFMUSP, Faculdade De Medicina, Universidade De Sao Paulo, Sao Paulo, Brazil
| | - José Maria Soares-Júnior
- Gynecology Division, Hospital Das Clinicas HCFMUSP, Faculdade De Medicina, Universidade De Sao Paulo, Sao Paulo, Brazil
| | - Edmund Chada Baracat
- Gynecology Division, Hospital Das Clinicas HCFMUSP, Faculdade De Medicina, Universidade De Sao Paulo, Sao Paulo, Brazil
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15
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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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16
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Ekman J, Skjeldestad FE. Do Norwegian providers comply with national recommendations when prescribing combined oral contraceptives to starters? A cohort study. BMJ Open 2019; 9:e027888. [PMID: 31772081 PMCID: PMC6886924 DOI: 10.1136/bmjopen-2018-027888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES To assess whether changes in patterns of combined oral contraceptive (COC) prescriptions to starters between 2008 and 2016 were in line with changes in national recommendations for use. DESIGN Historical prospective cohort study. SETTING The national Norwegian Prescription Database. PARTICIPANTS Women aged 10-49 years who started COCs between 1 January 2008 and 30 June 2016, in total 285 009 women. PRIMARY OUTCOME The proportion of levonorgestrel-containing COC prescriptions to starters. INTERVENTION The Norwegian Medical Agency recommended levonorgestrel-containing COCs to starters from 2010 onwards. RESULTS The proportion of levonorgestrel-containing COCs prescribed to starters increased from 41% in 2008 to 80% in 2016 with the greatest increase from 2011 to 2012. This prescription pattern comprised all age groups but was observed to a lower extent among older women. Public health nurses and midwifes had the highest compliance with recommendations and prescribed levonorgestrel-containing COCs to 96% of starters aged <20 years in 2016, compared with 75% and 86% among general practitioners and doctors with no specialty. CONCLUSION All professions have increased the proportion of levonorgestrel-containing COC prescriptions to starters. Public health nurses and midwives had the highest compliance with the new recommendations. Future studies will examine whether this shift in prescription pattern has prevented venous thromboembolism in women of reproductive age in Norway.
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Affiliation(s)
- Julie Ekman
- Research Group Epidemiology of Chronic Diseases, Universitetet i Tromso Institutt for Samfunnsmedisin ISM, Tromso, Norway
| | - Finn Egil Skjeldestad
- Research Group Epidemiology of Chronic Diseases, Universitetet i Tromso Institutt for Samfunnsmedisin ISM, Tromso, Norway
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17
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Connors JM, Middeldorp S. Transgender patients and the role of the coagulation clinician. J Thromb Haemost 2019; 17:1790-1797. [PMID: 31465627 DOI: 10.1111/jth.14626] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 08/26/2019] [Indexed: 11/29/2022]
Abstract
The medical care of transgender patients relies on the use of sex hormones to develop and maintain the physical characteristics consistent with gender identity as the first step in transitioning. Hormonal therapy is usually continued indefinitely, even following gender-affirming surgeries. The use of hormonal treatments is associated with a multitude of positive effects as well as complications and side effects. The risk of venous thromboembolism (VTE) is a major concern. Transgender patients are often referred to coagulation specialists for advice regarding an individual patient's risk for VTE, especially if there is a personal or family history of VTE. Coagulation specialists need to be familiar with endocrine therapy including the goals of treatment and the VTE risks associated with currently used hormone regimens. We will review common referral questions and the available data and their limitations for the use of hormonal therapy in transgender patients focusing on the risk of VTE.
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Affiliation(s)
- Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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18
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Douxfils J, Morimont L, Delvigne AS, Devel P, Masereel B, Haguet H, Bouvy C, Dogné JM. Validation and standardization of the ETP-based activated protein C resistance test for the clinical investigation of steroid contraceptives in women: an unmet clinical and regulatory need. ACTA ACUST UNITED AC 2019; 58:294-305. [DOI: 10.1515/cclm-2019-0471] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/30/2019] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Regulatory bodies recommend the use of an assay based on the assessment of the endogenous thrombin potential (ETP) for the investigation of the activated protein C resistance (APCr) in the development of steroid contraceptives in women. However, the assays described in the literature are home-made and not standardized regarding the method, the reagents, the reference plasma and the quality controls. In the absence of any commercially available method, we aimed at validating the ETP-based APCr assay.
Methods
The validation was performed according to regulatory standards. The method targets a 90% inhibition of the ETP in healthy donors in the presence of APC compared to the same condition in the absence of APC. As a large-scale production of a pool of plasma from well-selected healthy donors is impossible, algorithms were applied to a commercial reference plasma to correlate with the selected pool.
Results
Repeatability and intermediate precision passed the acceptance criteria. The assay demonstrated a curvilinear dose response to protein S and APC concentrations (R2 > 0.99). Analysis of plasma samples from 47 healthy individuals (22 women not taking combined hormonal contraceptives [CHC], and 25 men not Factor V Leiden carriers) confirmed the validity of the test, with a mean inhibition percentage of 90%. Investigations in 15 women taking different contraceptives and in two subjects with Factor V Leiden confirmed the good sensitivity and performance of the assay.
Conclusions
This validation provides the pharmaceutical industry, the regulatory bodies and physicians with a reproducible, sensitive and validated gold-standard ETP-based APCr assay.
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Affiliation(s)
- Jonathan Douxfils
- Qualiblood sa , Namur , Belgium
- University of Namur , Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences , Namur , Belgium
| | - Laure Morimont
- University of Namur , Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences , Namur , Belgium
| | | | - Philippe Devel
- University of Namur , Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences , Namur , Belgium
| | - Bernard Masereel
- Qualiblood sa , Namur , Belgium
- University of Namur , Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences , Namur , Belgium
| | - Hélène Haguet
- University of Namur , Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences , Namur , Belgium
| | | | - Jean-Michel Dogné
- University of Namur , Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences , Namur , Belgium
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19
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Scheres LJJ, van Hylckama Vlieg A, Ballieux BEPB, Fauser BCJM, Rosendaal FR, Middeldorp S, Cannegieter SC. Endogenous sex hormones and risk of venous thromboembolism in young women. J Thromb Haemost 2019; 17:1297-1304. [PMID: 31054196 PMCID: PMC6852478 DOI: 10.1111/jth.14474] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 04/24/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND The risk of venous thromboembolism (VTE) in young women can predominantly be attributed to exogenous hormone use. The influence of (abnormalities in) endogenous sex hormones, as in polycystic ovary syndrome (PCOS) or primary ovarian insufficiency (POI), on VTE risk is uncertain. OBJECTIVES Th assess the association between endogenous sex hormone levels and VTE risk. METHODS Women aged ≤45 years from the MEGA case-control study who provided a blood sample in the absence of exogenous hormone exposure or pregnancy were included. Sex hormone-binding globulin (SHBG), estradiol, follicle-stimulating hormone (FSH) and testosterone were measured. The free androgen index (FAI) and estradiol to testosterone ratio (E:T) were calculated. VTE risk was assessed according to quartiles (Qs) of levels and clinical cut-offs as proxies for PCOS (FAI > 4.5) and POI (FSH > 40 U/L). Logistic regression models were used to estimate adjusted odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS Six hundred and sixty-five women (369 cases; 296 controls) were eligible for the analyses. Testosterone and FSH levels, E:T and POI (FSH > 40 U/L vs FSH ≤ 40 U/L) were not associated with VTE risk. For estradiol, VTE risk was increased with levels in Q4 vs Q1 (OR 1.6; 95% CI 1.0-2.5). There was a dose-response relationship between SHBG levels and VTE risk, with the highest OR at Q4 vs Q1: 2.0 (95% CI 1.2-3.3). FAI > 4.5 (PCOS proxy) vs FAI ≤ 4.5 was associated with increased VTE risk (OR 3.3; 95% CI 0.9-11.8). CONCLUSIONS Estradiol, SHBG and FAI were associated with VTE risk, suggesting a role for endogenous sex hormones in the pathophysiology of VTE in young women.
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Affiliation(s)
- Luuk J. J. Scheres
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | | | - Bart E. P. B. Ballieux
- Department of Clinical Chemistry and Laboratory MedicineLeiden University Medical CenterLeidenthe Netherlands
| | - Bart C. J. M. Fauser
- Department of Reproductive Medicine & GynecologyUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Frits R. Rosendaal
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Saskia Middeldorp
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Department of Internal MedicineSection of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
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20
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Roetker NS, MacLehose RF, Hoogeveen RC, Ballantyne CM, Basu S, Cushman M, Folsom AR. Prospective Study of Endogenous Hormones and Incidence of Venous Thromboembolism: The Atherosclerosis Risk in Communities Study. Thromb Haemost 2018; 118:1940-1950. [PMID: 30296818 PMCID: PMC6289254 DOI: 10.1055/s-0038-1673613] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Exogenous hormone treatments in women (oral contraceptives and hormone replacement therapy [HRT]) are established risk factors for venous thromboembolism (VTE), but less is known about associations between plasma levels of endogenous hormones and VTE risk. We examined the association of baseline dehydroepiandrosterone sulphate (DHEAS), testosterone and sex hormone-binding globulin (SHBG) with risk of future VTE in men and post-menopausal women in the Atherosclerosis Risk in Communities Study. Testosterone, DHEAS and SHBG were measured in plasma samples collected in 1996 to 1998. Cox proportional hazards models were used to estimate hazard ratios for incident VTE adjusting for age, race/ethnicity, body mass index, height, smoking, estimated glomerular filtration rate and C-reactive protein. All analyses were stratified by sex and by current HRT use in women. Among 3,051 non-HRT-using women, 1,414 HRT-using women and 3,925 men at risk at baseline, 184, 62 and 206 experienced incident VTE after a median follow-up of 17.6 years. Plasma hormones were not associated with incidence of VTE among men and non-HRT-using women, although lower plasma DHEAS, when modelled using quartiles or restricted cubic splines, was associated with higher risk of VTE among HRT-using women. This study does not support the existence of an important association between plasma concentrations of endogenous testosterone, DHEAS or SHBG with risk of VTE in middle-aged to older men or post-menopausal women not using HRT.
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Affiliation(s)
- Nicholas S Roetker
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, United States
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States
| | - Richard F MacLehose
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States
| | - Ron C Hoogeveen
- Section of Atherosclerosis and Vascular Medicine, Baylor College of Medicine, The Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas, United States
| | - Christie M Ballantyne
- Section of Atherosclerosis and Vascular Medicine, Baylor College of Medicine, The Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas, United States
| | - Saonli Basu
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States
| | - Mary Cushman
- Division of Hematology/Oncology, Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, United States
| | - Aaron R Folsom
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States
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21
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Plu-Bureau G, Sabbagh E, Hugon-Rodin J. [Hormonal contraception and vascular risk: CNGOF Contraception Guidelines]. ACTA ACUST UNITED AC 2018; 46:823-833. [PMID: 30389542 DOI: 10.1016/j.gofs.2018.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Indexed: 12/15/2022]
Abstract
Venous thromboembolism and arterial ischemic events are the main deleterious diseases associated with the use of combined hormonal contraceptives (CHC). Even though their composition has been substantially improved, the vascular risk persists with the most recent CHCs use. If the vascular risk associated with CHCs containing 50μg EE is significantly higher than with those containing less than 50μg, there is no evidence that the CHCs containing either 30 or 20μg of EE induce different venous risks. CHC containing gestodene, desogestrel, drospirenone or cyproterone acetate are associated with a higher risk of venous thrombosis compared with levonorgestrel-containing CHCs. CHC containing norgestimate are associated with similar venous thrombosis risk than CHC containing levonorgestrel. Venous thrombosis risk of non-oral routes of administration of CHC appears to be equivalent to the risk of CHC containing gestodene or desogestrel, but this result is based on a small number of epidemiological studies. Before prescribing a CHC, it is important to determine all vascular risk factors. Family history of ischemic arterial event or venous thromboembolism disease should be routinely sought before any CHC prescription. All CHCs are contraindicated in women with biological thrombophilia, in women with combined vascular risk factors, in women with first-degree family history of arterial or venous event (under age 50) as well as in women suffering of migraine with aura. Progestin-only contraceptives are not associated with vascular risk (arterial or venous) outside of medroxyprogesterone acetate. In women with higher vascular risk, progestin-only contraceptives (administered by oral, sous-cutaneous or intra-uterine routes) can be prescribed.
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Affiliation(s)
- G Plu-Bureau
- Unité de gynécologie endocrinienne, hôpital Port-Royal, 53, avenue de l'Observatoire, 75679 Paris 14, France; Université Paris Descartes, 75005 Paris, France; Inserm UMR 1153, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), 75000 Paris, France.
| | - E Sabbagh
- Unité de gynécologie endocrinienne, hôpital Port-Royal, 53, avenue de l'Observatoire, 75679 Paris 14, France
| | - J Hugon-Rodin
- Unité de gynécologie endocrinienne, hôpital Port-Royal, 53, avenue de l'Observatoire, 75679 Paris 14, France; Université Paris Descartes, 75005 Paris, France; Inserm UMR 1153, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), 75000 Paris, France
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Affiliation(s)
- Angelo Cagnacci
- Department of Gynaecology and Obstetrics, University of Udine, Udine, Italy
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Matsui S, Yasui T, Kasai K, Keyama K, Yoshida K, Kato T, Uemura H, Kuwahara A, Matsuzaki T, Irahara M. Sex hormone-binding globulin and antithrombin III activity in women with oral ultra-low-dose estradiol. J OBSTET GYNAECOL 2017; 37:627-632. [DOI: 10.1080/01443615.2017.1285275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Sumika Matsui
- Department of Obstetrics and Gynecology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Toshiyuki Yasui
- Department of Reproductive and Menopausal Medicine, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Kana Kasai
- Department of Obstetrics and Gynecology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Kaoru Keyama
- Department of Obstetrics and Gynecology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Kanako Yoshida
- Department of Obstetrics and Gynecology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Takeshi Kato
- Department of Obstetrics and Gynecology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Hirokazu Uemura
- Department of Preventive Medicine, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Akira Kuwahara
- Department of Obstetrics and Gynecology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Toshiya Matsuzaki
- Department of Obstetrics and Gynecology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Minoru Irahara
- Department of Obstetrics and Gynecology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
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Gialeraki A, Valsami S, Pittaras T, Panayiotakopoulos G, Politou M. Oral Contraceptives and HRT Risk of Thrombosis. Clin Appl Thromb Hemost 2017; 24:217-225. [PMID: 28049361 DOI: 10.1177/1076029616683802] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Estrogen-containing medication, prescribed either for contraception in women of reproductive age or for prevention of cardiovascular events and osteoporosis as well as for alleviation of symptoms related to menopause, is associated with changes in the hemostatic balance and contributes to increased risk of development of venous thromboembolic complications. This risk is dose and medication dependent, increases with age, congenital and/or acquired predisposition to thrombosis, and mode of administration. This review attempts to summarize the current knowledge regarding the pathophysiology of oral contraceptive (OC) and hormone replacement therapy (HRT) -induced prothrombotic state in women, the risk of thrombosis associated with administration of various commercially available OCs and HRT, the additional risk in women with hereditary or acquired thrombophilia, and the currently available recommendations regarding massive screening of women for thrombophilia prior to initial prescription or continuation of treatment with OCs and HRT preparations.
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Affiliation(s)
- Argyri Gialeraki
- 1 Hematology Laboratory - Blood Bank, ATTIKON Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Serena Valsami
- 2 Hematology Laboratory - Blood Bank, ARETAIEION Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodoros Pittaras
- 2 Hematology Laboratory - Blood Bank, ARETAIEION Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Marianna Politou
- 2 Hematology Laboratory - Blood Bank, ARETAIEION Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Hugon-Rodin J, Alhenc-Gelas M, Hemker HC, Brailly-Tabard S, Guiochon-Mantel A, Plu-Bureau G, Scarabin PY. Sex hormone-binding globulin and thrombin generation in women using hormonal contraception. Biomarkers 2016; 22:81-85. [DOI: 10.1080/1354750x.2016.1204010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Grandi G, Napolitano A, Cagnacci A. Metabolic impact of combined hormonal contraceptives containing estradiol. Expert Opin Drug Metab Toxicol 2016; 12:779-87. [DOI: 10.1080/17425255.2016.1190832] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Giovanni Grandi
- Department of Obstetrics Gynecology and Pediatrics, Obstetrics and Gynecology Unit, Azienda Ospedaliero Universitaria Policlinico of Modena, Modena, Italy
| | - Antonella Napolitano
- Department of Obstetrics Gynecology and Pediatrics, Obstetrics and Gynecology Unit, Azienda Ospedaliero Universitaria Policlinico of Modena, Modena, Italy
| | - Angelo Cagnacci
- Department of Obstetrics Gynecology and Pediatrics, Obstetrics and Gynecology Unit, Azienda Ospedaliero Universitaria Policlinico of Modena, Modena, Italy
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Jiang J, Li W, Liang B, Xie R, Chen B, Huang H, Li Y, He Y, Lv J, He W, Chen L. A Novel Prioritization Method in Identifying Recurrent Venous Thromboembolism-Related Genes. PLoS One 2016; 11:e0153006. [PMID: 27050193 PMCID: PMC4822849 DOI: 10.1371/journal.pone.0153006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 03/21/2016] [Indexed: 12/13/2022] Open
Abstract
Identifying the genes involved in venous thromboembolism (VTE) recurrence is important not only for understanding the pathogenesis but also for discovering the therapeutic targets. We proposed a novel prioritization method called Function-Interaction-Pearson (FIP) by creating gene-disease similarity scores to prioritize candidate genes underling VTE. The scores were calculated by integrating and optimizing three types of resources including gene expression, gene ontology and protein-protein interaction. As a result, 124 out of top 200 prioritized candidate genes had been confirmed in literature, among which there were 34 antithrombotic drug targets. Compared with two well-known gene prioritization tools Endeavour and ToppNet, FIP was shown to have better performance. The approach provides a valuable alternative for drug targets discovery and disease therapy.
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Affiliation(s)
- Jing Jiang
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, Hei Longjiang Province, China, Postal code: 150081
| | - Wan Li
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, Hei Longjiang Province, China, Postal code: 150081
| | - Binhua Liang
- National Microbology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Ruiqiang Xie
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, Hei Longjiang Province, China, Postal code: 150081
| | - Binbin Chen
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, Hei Longjiang Province, China, Postal code: 150081
| | - Hao Huang
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, Hei Longjiang Province, China, Postal code: 150081
| | - Yiran Li
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, Hei Longjiang Province, China, Postal code: 150081
| | - Yuehan He
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, Hei Longjiang Province, China, Postal code: 150081
| | - Junjie Lv
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, Hei Longjiang Province, China, Postal code: 150081
| | - Weiming He
- Institute of Opto-electronics, Harbin Institute of Technology, Harbin, Hei Longjiang Province, China
- * E-mail: (LC); (WH)
| | - Lina Chen
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, Hei Longjiang Province, China, Postal code: 150081
- * E-mail: (LC); (WH)
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Westhoff CL, Eisenberger A, Tang R, Cremers S, Grossman LV, Pike MC. Clotting factor changes during the first cycle of oral contraceptive use. Contraception 2016; 93:70-6. [PMID: 26452328 PMCID: PMC5004596 DOI: 10.1016/j.contraception.2015.09.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/23/2015] [Accepted: 09/24/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The risk of venous thromboembolism (VTE) is highest during the initial months of oral contraceptive (OC) use. We sought to evaluate the extent of hemostatic variable changes during the initial OC cycle and if such changes are related to systemic ethinyl estradiol (EE2) exposure. STUDY DESIGN Participants provided multiple blood samples during a 21-day OC cycle (30mcg EE2; 150mcg levonorgestrel) and after a single dose following a washout period. Analytes included D-dimer, factor VIII activity, protein C total antigen and the hepatic proteins corticosteroid-binding globulin (CBG) and sex-hormone-binding globulin (SHBG). EE2 pharmacokinetic analyses related to the 24h after the first OC tablet (OC1) and at steady state (OC21). RESULTS Seventeen women completed the study. D-dimer more than doubled by OC6 (p=.013) and remained elevated at OC21 (p=.012). D-dimer levels within women varied widely from day to day. Factor VIII increased 27% by OC2 (p<.001) but declined to a 9% increase by OC21. Protein C increased only 6%. EE2 steady-state area-under-the-curve ranged from 488 to 1103pg∙h/mL; higher levels were not correlated with greater increases in clotting variables. CBG and SHBG increased significantly but were not significantly correlated with levels of EE2 or with the hemostatic variables. CONCLUSIONS D-dimer increases during the first OC cycle were at least as great as increases seen with longer OC use. These results provide support for the increased VTE risk during initial OC use. The extreme variability in D-dimer levels may be an important component of this risk. IMPLICATIONS This study showed that increases in D-dimer are clearly evident in the first cycle of OC use and may be larger than are seen after a longer duration of use and thus provide biological support for the increased VTE risk during initial OC use found in epidemiological studies.
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Affiliation(s)
- Carolyn L Westhoff
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY 10032, USA; Department of Epidemiology, Columbia University Medical Center, New York, NY 10032, USA.
| | - Andrew Eisenberger
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, USA
| | - Rosalind Tang
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY 10032, USA
| | - Serge Cremers
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY 10032, USA
| | - Lisa V Grossman
- Department of Epidemiology, Columbia University Medical Center, New York, NY 10032, USA
| | - Malcolm C Pike
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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Williams MS, Cushman M, Ouyang P, Heckbert SR, Kalyani RR, Vaidya D. Association of Serum Sex Hormones with Hemostatic Factors in Women On and Off Hormone Therapy: The Multiethnic Study of Atherosclerosis. J Womens Health (Larchmt) 2015; 25:166-72. [PMID: 26700933 DOI: 10.1089/jwh.2015.5465] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Hormone therapy (HT) is associated with increased risk of both venous and arterial thrombosis, which are multifactorial in origin. OBJECTIVES Our objectives were twofold: first, we sought to examine associations between endogenous serum sex hormone levels and biomarkers of thrombosis and/or coagulation in postmenopausal hormone nonusers. Second, we separately studied the associations between serum sex hormone levels and biomarkers of thrombosis and/or coagulation in postmenopausal hormone users considering the fact that pattern of circulating hormones is different in women taking exogenous hormones. PATIENTS/METHODS We performed a cross-sectional analysis of postmenopausal women enrolled in a large multiethnic community-based cohort study, The Multiethnic Study of Atherosclerosis. We hypothesized that higher levels of estrogen-related sex hormones would be associated with biomarkers of thrombosis, suggesting mechanisms for differences in thrombotic risk from HT. Women (n = 2878) were included if they were postmenopausal and had thrombotic biomarkers (homocysteine, fibrinogen, C-reactive protein [CRP], factor VIII, and d-dimer) and sex hormone levels (total testosterone [T], bioavailable testosterone, sex hormone binding globulin [SHBG], estradiol [E2], and dehydroepiandrosterone [DHEA]) measured. A smaller random sample of 491 women also had von Willebrand factor (vWF), plasminogen activator inhibitor (PAI-1), and tissue factor pathway inhibitor (TFPI) levels measured. RESULTS AND CONCLUSIONS We found that elevated levels of estradiol and SHBG in HT users were associated with elevated levels of CRP and lower levels of TFPI, both of which may be related to a prothrombotic milieu in HT users. HT nonusers had far more prothrombotic associations between elevated serum sex hormone levels and thrombotic biomarkers when compared with HT users.
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Affiliation(s)
- Marlene S Williams
- 1 Department of Medicine, Johns Hopkins University , Baltimore, Maryland
| | - Mary Cushman
- 2 Department of Medicine, The University of Vermont , Colchester, Vermont
| | - Pamela Ouyang
- 1 Department of Medicine, Johns Hopkins University , Baltimore, Maryland
| | - Susan R Heckbert
- 3 Department of Epidemiology, University of Washington , Seattle, Washington
| | | | - Dhanajay Vaidya
- 1 Department of Medicine, Johns Hopkins University , Baltimore, Maryland
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Abstract
INTRODUCTION This paper reviews the risk of thrombosis with use of different types of hormonal contraception in women of different ages. AREAS COVERED Combined hormonal contraceptives with desogestrel, gestodene, drospirenone or cyproterone acetate (high-risk products) confer a sixfold increased risk of venous thromboembolism as compared with nonusers, and about twice the risk as compared with users of products with norethisterone, levonorgestrel or norgestimate (low-risk products). Transdermal patches and vaginal ring belong to high-risk products. The risk of thrombotic stroke and myocardial infarction is increased 50 - 100% with use of combined products, with little difference in risk between different progestins. Progestin-only products do not confer any increased risk of venous or arterial thrombosis, except for progestin depot, which may double the risk of venous thrombosis. EXPERT OPINION First choice in women below 35 years should be a combined low-risk pill, that is, with a second-generation progestin, with the lowest compliable dose of estrogen. Young women with risk factors of thrombosis such as age above 35 years, genetic predispositions, adiposity, polycystic ovary syndrome, diabetes, smoking, hypertension or migraine with aura should not use high-risk products, but should primarily consider progestin-only products, and be careful to use low-risk combined products.
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Affiliation(s)
- Øjvind Lidegaard
- University of Copenhagen, Department of Obstetrics and Gynecology, Faculty of Health Science, 4232, Rigshospitalet , Copenhagen 2100 , Denmark
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Brache V, Merkatz R, Kumar N, Jesam C, Sussman H, Hoskin E, Roberts K, Alami M, Taylor D, Jorge A, Croxatto H, Lorange E, Mishell DR, Sitruk-Ware R. A dose-finding, cross-over study to evaluate the effect of a Nestorone®/Estradiol transdermal gel delivery on ovulation suppression in normal ovulating women. Contraception 2015; 92:289-97. [DOI: 10.1016/j.contraception.2015.05.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 04/24/2015] [Accepted: 05/13/2015] [Indexed: 11/29/2022]
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Mawet M, Maillard C, Klipping C, Zimmerman Y, Foidart JM, Coelingh Bennink HJT. Unique effects on hepatic function, lipid metabolism, bone and growth endocrine parameters of estetrol in combined oral contraceptives. EUR J CONTRACEP REPR 2015. [PMID: 26212489 PMCID: PMC4699469 DOI: 10.3109/13625187.2015.1068934] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Estetrol (E4) is a natural estrogen produced by the human fetal liver. In combination with drospirenone (DRSP) or levonorgestrel (LNG), E4 blocks ovulation and has less effect on haemostatic biomarkers in comparison with ethinylestradiol (EE) combined with DRSP. This study evaluates the impact of several doses of E4/DRSP and E4/LNG on safety parameters such as liver function, lipid metabolism, bone markers and growth endocrine parameters. METHODS This was a dose-finding, single-centre, controlled study performed in healthy women aged 18 to 35 years with a documented pretreatment ovulatory cycle. Participants received 5 mg or 10 mg E4/3 mg DRSP; 5 mg, 10 mg or 20 mg E4/150 μg LNG; or 20 μg EE/3 mg DRSP as a comparator for three consecutive cycles in a 24/4-day regimen. Changes from baseline to end of treatment in liver parameters, lipid metabolism, bone markers and growth endocrinology were evaluated. RESULTS A total of 109 women were included in the study. Carrier proteins were minimally affected in the E4/DRSP and E4/LNG groups, in comparison with the EE/DRSP group, where a significant increase in sex hormone-binding globulin was observed. Similarly, minor effects on lipoproteins were observed in the E4 groups, and the effects on triglycerides elicited by the E4 groups were significantly lower than those in the EE/DRSP group. No imbalances in bone markers were observed in any groups. No alterations in insulin-like growth factor were observed in the E4 groups. CONCLUSIONS E4-containing combinations have a limited effect on liver function, lipid metabolism, and bone and growth endocrine parameters.
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Hugon-Rodin J, Gompel A, Plu-Bureau G. Epidemiology of hormonal contraceptives-related venous thromboembolism. Eur J Endocrinol 2014; 171:R221-30. [PMID: 25012200 DOI: 10.1530/eje-14-0527] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
For many years, it has been well documented that combined hormonal contraceptives increase the risk of venous thromboembolism (VTE). The third-generation pill use (desogestrel or gestodene (GSD)) is associated with an increased VTE risk as compared with second-generation (levonorgestrel) pill use. Other progestins such as drospirenone or cyproterone acetate combined with ethinyl-estradiol (EE) have been investigated. Most studies have reported a significant increased VTE risk among users of these combined oral contraceptives (COCs) when compared with users of second-generation pills. Non-oral combined hormonal contraception, such as the transdermal patch and the vaginal ring, is also available. Current data support that these routes of administration are more thrombogenic than second-generation pills. These results are consistent with the biological evidence of coagulation activation. Overall, the estrogenic potency of each hormonal contraceptive depending on both EE doses and progestin molecule explains the level of thrombotic risk. Some studies have shown a similar increased VTE risk among users of COCs containing norgestimate (NGM) as compared with users of second-generation pill. However, for this combination, biological data, based on quantitative assessment of sex hormone-binding globulin or haemostasis parameters, are not in agreement with these epidemiological results. Similarly, the VTE risk associated with low doses of EE and GSD is not biologically plausible. In conclusion, newer generation formulations of hormonal contraceptives as well as non-oral hormonal contraceptives seem to be more thrombogenic than second-generation hormonal contraceptives. Further studies are needed to conclude on the combinations containing NGM or low doses of EE associated with GSD.
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Affiliation(s)
- Justine Hugon-Rodin
- Department of Gynecology and EndocrinologyHôpitaux Universitaires Paris Centre, Paris-Descartes University, Paris, France
| | - Anne Gompel
- Department of Gynecology and EndocrinologyHôpitaux Universitaires Paris Centre, Paris-Descartes University, Paris, France
| | - Geneviève Plu-Bureau
- Department of Gynecology and EndocrinologyHôpitaux Universitaires Paris Centre, Paris-Descartes University, Paris, France
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Ibáñez L, Ong KK, López-Bermejo A, Dunger DB, de Zegher F. Hyperinsulinaemic androgen excess in adolescent girls. Nat Rev Endocrinol 2014; 10:499-508. [PMID: 24776733 DOI: 10.1038/nrendo.2014.58] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Hyperinsulinaemic androgen excess is the most common cause of hirsutism, acne and menstrual irregularity in adolescent girls. Here, we propose that the disorder frequently originates from an absolute or relative excess of lipids in adipose tissue, and from associated changes in insulin sensitivity, gonadotropin secretion and ovarian androgen release. Girls from populations with genotypes attuned to nutritionally harsh conditions seem to be particularly vulnerable to the development of hyperinsulinaemic androgen excess in today's obesogenic environment. We propose that hirsutism, hyperandrogenaemia and menstrual irregularity (≥2 years after menarche) is used as a diagnostic triad for the disorder. No pharmacological therapy has been approved for girls with androgen excess; however, lifestyle intervention is essential to reduce adiposity. In girls without obesity who are not sexually active, insulin sensitization has more broadly normalizing effects than estradiol-progestogen combinations. The early recognition of girls at risk of developing hyperinsulinaemic androgen excess might enable prevention in childhood.
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Affiliation(s)
- Lourdes Ibáñez
- Endocrinology Unit, Hospital Sant Joan de Déu, University of Barcelona, Passeig de Sant Joan de Déu, 2, 08950 Esplugues de Llobregat, Barcelona, Spain
| | - Ken K Ong
- MRC Epidemiology Unit, Box 285, Institute of Metabolic Science, Cambridge Biomedical Campus, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Abel López-Bermejo
- Paediatric Endocrinology, Dr Josep Trueta Hospital and Girona Institute for Biomedical Research, Avenue de França s/n, 17007 Girona, Spain
| | - David B Dunger
- Department of Paediatrics, Box 116, Level 8, Addenbrooke's Hospital Hills Road, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Francis de Zegher
- Paediatric Endocrinology, University Hospital Gasthuisberg, University of Leuven, Herestraat 49, 3000 Leuven, Belgium
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Blondon M, van Hylckama Vlieg A, Wiggins KL, Harrington LB, McKnight B, Rice KM, Rosendaal FR, Heckbert SR, Psaty BM, Smith NL. Differential associations of oral estradiol and conjugated equine estrogen with hemostatic biomarkers. J Thromb Haemost 2014; 12:879-86. [PMID: 24628832 PMCID: PMC5371691 DOI: 10.1111/jth.12560] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND The risk of venous thrombosis (VT) associated with oral hormone therapy (HT) may differ by type of estrogen compound. OBJECTIVE To compare the thrombotic profile of women using oral conjugated equine estrogens (CEE) with that of women using oral estradiol (E2). METHODS In postmenopausal, female, health maintenance organization (HMO) members with no history of VT, we measured thrombin generation, levels of factor VII activity, antithrombin activity and total protein S antigen. Mean levels of hemostasis biomarkers were cross-sectionally compared by use and type of estrogen using multiple linear regressions. The type of estrogen used was determined primarily by the HMO formulary, which changed its preferred estrogen from CEE to E2 during the study period. RESULTS The sample included 92 E2 users and 48 CEE users, with a mean age of 64.1 years and mean BMI of 29.1 kg m(-2) . Twenty-seven per cent of HT contained medroxyprogesterone acetate. Compared with E2 users, CEE users had greater thrombin generation peak values and endogenous thrombin potential, and lower total protein S (multivariate adjusted differences of 49.8 nm (95% CI, 21.0, 78.6), 175.0 nm × Min (95% CI, 54.4, 295.7) and -13.4% (95% CI, -19.8, -6.9), respectively). Factor VII and antithrombin levels were not different between E2 and CEE users. Results were similar in subgroups of users of unopposed HT, opposed HT, low-dose estrogen and standard dose estrogen. CONCLUSION The hemostatic profile of women using CEE is more prothrombotic than that of women using E2. These findings provide further evidence for a different thrombotic risk for oral CEE and oral E2.
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Affiliation(s)
- M Blondon
- Department of Epidemiology, University of Washington, Seattle, WA, USA; Division of Angiology and Haemostasis, Geneva University Hospitals, Geneva, Switzerland
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Bleker SM, Coppens M, Middeldorp S. Sex, thrombosis and inherited thrombophilia. Blood Rev 2014; 28:123-33. [DOI: 10.1016/j.blre.2014.03.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 03/11/2014] [Indexed: 10/25/2022]
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Thyroid function, activated protein C resistance and the risk of venous thrombosis in users of hormonal contraceptives. Thromb Res 2014; 133:640-4. [DOI: 10.1016/j.thromres.2013.12.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 12/27/2013] [Accepted: 12/30/2013] [Indexed: 11/24/2022]
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Gronier H, Robin G. [Cardiovascular risks of combined oral contraceptives - beyond the French controversy]. ACTA ACUST UNITED AC 2014; 42:174-81. [PMID: 24582295 DOI: 10.1016/j.gyobfe.2014.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 01/24/2014] [Indexed: 11/19/2022]
Abstract
Combined hormonal contraceptive is the most used contraceptive method in France among childbearing-aged women. Following the temporary delisting of oral contraception containing a 3rd generation progestin and following the market withdrawal of oral pills containing cyproterone acetate in combination with ethynil-estradiol (35μg), the impact of these events on our prescribing practice remains to determine. We will especially discuss the cardiovascular risk associated with combined hormonal contraceptives in the light of the most recent publications either with epidemiological or biological data.
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Affiliation(s)
| | - G Robin
- Service de gynécologie endocrinienne et médecine de la reproduction, hôpital Jeanne-de-Flandre, centre hospitalier régional universitaire de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France; Service de gynécologie médicale, orthogénie et médecine du couple, hôpital Jeanne-de-Flandre, centre hospitalier régional universitaire de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France
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39
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Stegeman BH, de Bastos M, Rosendaal FR, van Hylckama Vlieg A, Helmerhorst FM, Stijnen T, Dekkers OM. Different combined oral contraceptives and the risk of venous thrombosis: systematic review and network meta-analysis. BMJ 2013; 347:f5298. [PMID: 24030561 PMCID: PMC3771677 DOI: 10.1136/bmj.f5298] [Citation(s) in RCA: 231] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2013] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To provide a comprehensive overview of the risk of venous thrombosis in women using different combined oral contraceptives. DESIGN Systematic review and network meta-analysis. DATA SOURCES PubMed, Embase, Web of Science, Cochrane, Cumulative Index to Nursing and Allied Health Literature, Academic Search Premier, and ScienceDirect up to 22 April 2013. REVIEW METHODS Observational studies that assessed the effect of combined oral contraceptives on venous thrombosis in healthy women. The primary outcome of interest was a fatal or non-fatal first event of venous thrombosis with the main focus on deep venous thrombosis or pulmonary embolism. Publications with at least 10 events in total were eligible. The network meta-analysis was performed using an extension of frequentist random effects models for mixed multiple treatment comparisons. Unadjusted relative risks with 95% confidence intervals were reported. The requirement for crude numbers did not allow adjustment for potential confounding variables. RESULTS 3110 publications were retrieved through a search strategy; 25 publications reporting on 26 studies were included. Incidence of venous thrombosis in non-users from two included cohorts was 1.9 and 3.7 per 10,000 woman years, in line with previously reported incidences of 1-6 per 10,000 woman years. Use of combined oral contraceptives increased the risk of venous thrombosis compared with non-use (relative risk 3.5, 95% confidence interval 2.9 to 4.3). The relative risk of venous thrombosis for combined oral contraceptives with 30-35 µg ethinylestradiol and gestodene, desogestrel, cyproterone acetate, or drospirenone were similar and about 50-80% higher than for combined oral contraceptives with levonorgestrel. A dose related effect of ethinylestradiol was observed for gestodene, desogestrel, and levonorgestrel, with higher doses being associated with higher thrombosis risk. CONCLUSION All combined oral contraceptives investigated in this analysis were associated with an increased risk of venous thrombosis. The effect size depended both on the progestogen used and the dose of ethinylestradiol.
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MESH Headings
- Adult
- Case-Control Studies
- Confounding Factors, Epidemiologic
- Contraceptives, Oral, Combined/administration & dosage
- Contraceptives, Oral, Combined/adverse effects
- Contraceptives, Oral, Hormonal/administration & dosage
- Contraceptives, Oral, Hormonal/adverse effects
- Dose-Response Relationship, Drug
- Ethinyl Estradiol/administration & dosage
- Ethinyl Estradiol/adverse effects
- Female
- Humans
- Medication Adherence/statistics & numerical data
- Progestins/administration & dosage
- Progestins/adverse effects
- Risk Assessment
- Risk Factors
- Venous Thrombosis/chemically induced
- Venous Thrombosis/epidemiology
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41
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Lévesque H, Hanslik T. Contraception œstroprogestative et risque thrombotique : des faits cliniques aux conséquences médiatiques. Rev Med Interne 2013; 34:453-5. [DOI: 10.1016/j.revmed.2013.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Accepted: 04/27/2013] [Indexed: 10/26/2022]
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42
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Chabbert-Buffet N, Guigues B, Trillot N, Biron C, Morange P, Pernod G, Scheffler M, Brugere S, Hedon B. [DVT and combined oral contraceptives: update of the pluridisciplinary CNGOF-FNCGM-GEHT-SFMV group]. J Gynecol Obstet Hum Reprod 2013; 42:309-315. [PMID: 23642503 DOI: 10.1016/j.jgyn.2013.03.015] [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] [Received: 03/23/2013] [Revised: 03/25/2013] [Accepted: 03/26/2013] [Indexed: 06/02/2023]
Abstract
Thrombotic risk among combined oral contraceptives (COC) users has recently been debated following a court action initiated by a patient. Recent epidemiological data, as well as accumulating biological data underlying these data, have led French Health authorities to modify COC prescription and reimbursement modalities. A short synthesis is proposed by a multidisciplinary group of experts from four French societies (CGOF, FNCGM, GHT, and SFMV).
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Affiliation(s)
- N Chabbert-Buffet
- Collège national des gynécologues-obstétriciens français (CNGOF), 91, boulevard de Sébastopol, 75002 Paris, France.
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43
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Raps M, Rosendaal F, Ballieux B, Rosing J, Thomassen S, Helmerhorst F, van Vliet H. Resistance to APC and SHBG levels during use of a four-phasic oral contraceptive containing dienogest and estradiol valerate: a randomized controlled trial. J Thromb Haemost 2013; 11:855-61. [PMID: 23410231 DOI: 10.1111/jth.12172] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 01/17/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of combined oral contraceptives is associated with a 3- to 6-fold increased risk of venous thrombosis. This increased risk depends on the estrogen dose as well as the progestogen type of combined oral contraceptives. Thrombin generation-based activated protein C resistance (APC resistance) and sex hormone-binding globulin (SHBG) levels predict the thrombotic risk of a combined hormonal contraceptive. Recently, a four-phasic oral contraceptive containing dienogest (DNG) and estradiol valerate (E2V) has been marketed. The aim of this study was to evaluate the thrombotic risk of the DNG/E2V oral contraceptive by comparing APC resistance by measuring normalized APC sensitivity ratios (nAPCsr) and SHBG levels in users of oral contraceptives containing dienogest and estradiol valerate (DNG/E2V) and oral contraceptives containing levonorgestrel and ethinyl estradiol (LNG/EE). METHODS We conducted a single-center, randomized, open label, parallel-group study in 74 women using DNG/E2V or LNG/EE, and measured nAPCsr and SHBG levels in every phase of the regimen of DNG/E2V. RESULTS During the pill cycle SHBG levels did not differ between DNG/E2V users and LNG/EE users. nAPCsr levels were overall slightly lower in DNG/E2V users than in LNG/EE users, mean difference -0.44 (95% CI, -1.04 to 0.17) for day 2, -0.20 (95% CI, -0.76 to 0.37) for day 7, -0.27 (95% CI, -0.81 to 0.28) for day 24 and -0.34 (95% CI, -0.91 to 0.24) for day 26. CONCLUSION No statistical significant differences in nAPCsr and SHBG levels were found between users of the oral contraceptive containing DNG/E2V and LNG/EE, suggesting a comparable thrombotic risk.
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Affiliation(s)
- M Raps
- Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.
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44
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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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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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Raps M, Helmerhorst FM, Fleischer K, van Hylckama Vlieg A, Van Hylckama VA, Stegeman BH, Thomassen S, Rosendaal FR, Rosing J, Ballieux BEPB, Van Vliet HAAM. Sex hormone-binding globulin as a marker for the thrombotic risk of hormonal contraceptives: reply to a rebuttal. J Thromb Haemost 2013; 11:396-7. [PMID: 23176323 DOI: 10.1111/jth.12080] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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48
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Kluft C, Skouby SO, Jespersen J, Burggraaf J. Sex hormone-binding globulin as a marker for the thrombotic risk of hormonal contraceptives: a rebuttal. J Thromb Haemost 2013; 11:394-5. [PMID: 23140257 DOI: 10.1111/jth.12067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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49
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Stegeman BH, Helmerhorst FM, Vos HL, Rosendaal FR, Van Hylckama Vlieg A. Sex hormone-binding globulin levels are not causally related to venous thrombosis risk in women not using hormonal contraceptives. J Thromb Haemost 2012; 10:2061-7. [PMID: 22882730 DOI: 10.1111/j.1538-7836.2012.04878.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Oral contraceptive use increases the risk of venous thrombosis as well as sex hormone-binding globulin (SHBG) levels. Furthermore, increased SHBG levels are positively associated with activated protein C (APC) resistance and thrombotic risk in oral contraceptive users. OBJECTIVES To determine whether increased SHBG levels are causally related to venous thrombosis in women not using hormonal contraceptives. METHODS Premenopausal women were selected from a case-control study on venous thrombosis, the Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis (MEGA) study (23 patients; 258 controls). Women using hormonal contraceptives were excluded. First, the risk of venous thrombosis with SHBG levels above the normal reference range (70 nm) was determined. Second, because multiple regulatory factors affect SHBG levels and residual confounding may remain, we determined six single-nucleotide polymorphisms (SNPs) in the SHBG gene and assessed the risk of venous thrombosis in a different case-control study, the Leiden Thrombophilia Study (LETS) (20 patients; 74 controls), and in the MEGA study. Finally, the association between SHBG levels and the normalized activated partial thromboplastin time-based APC resistance (an intermediate endpoint for venous thrombosis) was determined. RESULTS Elevated SHBG levels (> 70.0 nm) were associated with venous thrombosis (odds ratio 1.92; 95% confidence interval [CI] 0.74-5.00). However, this finding can be explained by residual confounding. Two SNPs in the SHBG gene affected SHBG levels, but not venous thrombosis risk. Furthermore, SHBG levels in controls were not associated with APC resistance (SHBG level, > 70.0 vs. ≤ 70.0 nm: mean difference in normalized APC sensitivity ratio, 0.03; 95% CI -0.05 to 0.10). Exclusion of women with FV Leiden did not materially change these results. CONCLUSIONS Increased SHBG levels are not causally related to the risk of venous thrombosis.
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Affiliation(s)
- B H Stegeman
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Lidegaard Ø, Milsom I, Geirsson RT, Skjeldestad FE. Hormonal contraception and venous thromboembolism. Acta Obstet Gynecol Scand 2012; 91:769-78. [PMID: 22568831 DOI: 10.1111/j.1600-0412.2012.01444.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND New studies about the influence of hormonal contraception on the risk of venous thromboembolism (VTE) have been published. AIM To evaluate new epidemiological data and to propose clinical consequences. DESIGN A literature survey. METHODS Studies assessing the risk of specific types of hormonal contraception were evaluated, compared and set into a clinical perspective. RESULTS The majority of newer studies have demonstrated a threefold increased risk of VTE in current users of medium- and low-dose combined oral contraceptives (COCs) with norethisterone, levonorgestrel (LNG) or norgestimate compared with non-users. The same studies have demonstrated a sixfold increased risk of VTE in users of combined pills with desogestrel, gestodene, drospirenone or cyproteroneacetate, and in users of the contraceptive vaginal ring, compared with non-users. The rate ratio of VTE between users of COCs with newer progestogens compared with users of COCs with LNG was 1.5-2.8 in seven studies and 1.0 in two studies. Progestogen-only contraception did not confer an increased risk of VTE in any study. The incidence rate of VTE in non-pregnant women aged 15-49 years using non-hormonal contraception is three per 10 000 years. CONCLUSIONS For women starting on hormonal contraception, we recommend medium- or low-dose combined pills with norethisterone, LNG or norgestimate as first-choice preparations. For the many women who are users of COCs with newer progestogens, although the absolute risk of VTE is low, a change to combined pills with norethisterone, LNG or norgestimate may halve their risk of VTE. Finally, we recommend COCs with 20 μg estrogen combined with the older progestogens to be launched in the Scandinavian countries. Women at an increased risk of VTE should consider progestogen-only contraception or non-hormonal contraception.
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Affiliation(s)
- Øjvind Lidegaard
- Gynaecological Clinic 4232, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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