1
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Laing A, Thomas L, Hillard T, Panay N, Briggs P. Exploring the potential for a set of UK hormone replacement therapy eligibility guidelines: A suggested proposal on the topic of venous thromboembolism. Post Reprod Health 2024; 30:39-54. [PMID: 38149845 DOI: 10.1177/20533691231223682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
OBJECTIVE To explore the feasibility for a set of hormone replacement therapy (HRT) eligibility guidelines that follow a similar structure and appearance to the UKMEC guidance for contraception. To enable non-specialists to feel confident in safely prescribing HRT and to aid selection of the most appropriate first line treatment. METHODS A literature review was undertaken with evidence summarised on the topic of venous thromboembolism (VTE) which is an area frequently considered a barrier to prescribing. Medical eligibility tables which separated HRT by type were then produced for a set of VTE-related topics. RESULTS The literature search confirmed the importance of distinguishing between different types and routes of administration when considering the suitability of HRT. Much of the evidence has been based on older synthetic types of HRT and whilst they still have a role in management, these medications carry different risks to the now more accepted use of body identical types. The search also highlighted the nuances involved, increasing the complexity of forming guidelines, with the need for consideration to be given to an individual's own perception of risks and benefits. CONCLUSION The demand for HRT has risen in recent years and there is a need for this to be managed effectively, particularly for patients in primary care. The production of this type of guidance will enable the non-specialist to feel confident in safe and evidence-based prescribing. The guidelines are also designed to demonstrate to prescribers which complex patients should be referred onto menopause specialists.
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Affiliation(s)
- Abbie Laing
- Poole Menopause Centre University Hospitals Dorset, Poole, UK
| | - Lindsey Thomas
- Leeds Menopause Service, Meanwood Health Centre, Leeds, UK
| | - Tim Hillard
- Poole Menopause Centre University Hospitals Dorset, Poole, UK
| | - Nick Panay
- Imperial College Healthcare NHS Trust, UK
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2
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Abouharb ALZ, Mehta S, Rathnayake H, Pandit H. Withholding of Hormone Replacement Therapy Prior to Total Joint Arthroplasty Surgery to Reduce the Risk of Postoperative Thromboembolic Events: Is It Justified?-A Systematic Review of Clinical Practice Guidelines. J Arthroplasty 2024; 39:541-548.e24. [PMID: 37634878 DOI: 10.1016/j.arth.2023.08.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Hormone replacement therapy (HRT), menopausal hormone therapy (MHT), and estrogen-containing medications are frequently withheld before elective lower limb arthroplasty, based on a perceived risk of venous thromboembolism (VTE). However, evidence linking HRT, MHT, and an increased VTE risk is equivocal. This systematic review evaluated the concordance of international clinical practice guidelines (CPGs) on the withholding of HRT or MHT. METHODS The PubMed, Google Scholar, Cochrane, and Ovid databases were searched for CPGs for the preoperative, perioperative, and postoperative management of patients on HRT and MHT undergoing elective lower limb arthroplasty. This was supplemented by an internet search. There were 7 international CPGs in English, from Europe and North America, published between January 2000 and February 2023 reviewed against the Appraisal of Guidelines for Research & Evaluation Instrument (AGREE-II) criteria, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. RESULTS The guidelines reviewed revealed a mixed picture on HRT or MHT withdrawal and use in arthroplasty, with some featuring detailed advice on the preoperative and postoperative management of HRT or MHT (Scottish Intercollegiate Guidelines Network), while others featured no guidance (American College of Chest Physicians). The evidence referenced in these guidelines highlighted studies showing HRT or MHT to play a limited role in increasing VTE risk, with most studies from the 1990s and 2000s. CONCLUSIONS Based on current evidence, non-estrogen-containing transdermal HRT or MHT should not be withheld in patients undergoing elective joint arthroplasty, though further evidence is required to justify withholding estrogen-containing forms.
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Affiliation(s)
- Alexander L Z Abouharb
- Leeds Teaching Hospitals NHS Trust, St. James's University Hospital, Leeds, West Yorkshire, United Kingdom; Imperial College London, Faculty of Medicine, St Mary's Hospital, London, United Kingdom
| | - Sachit Mehta
- Imperial College London, Faculty of Medicine, St Mary's Hospital, London, United Kingdom
| | - Hasithe Rathnayake
- Imperial College London, Faculty of Medicine, St Mary's Hospital, London, United Kingdom
| | - Hemant Pandit
- Leeds Teaching Hospitals NHS Trust, St. James's University Hospital, Leeds, West Yorkshire, United Kingdom; Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Chapel Allerton Hospital, Leeds, United Kingdom
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3
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Porterfield L, Davis JW, Weller SC, Chen L, Wilkinson G. Does hormone therapy exacerbate other venous thromboembolism risk factors? Menopause 2024; 31:123-129. [PMID: 38270903 DOI: 10.1097/gme.0000000000002305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
OBJECTIVE Postmenopausal symptoms in women at higher risk for venous thromboembolism (VTE) due to comorbidities are often undertreated because of concerns that hormone therapy (HT) may increase VTE risk; however, it is unclear how much HT impacts risk of VTE when compared with other risk factors. METHODS This is a case-control study in a commercial claims database from 2007 to 2019. Women aged 50 to 64 years (n = 223,949) were classified as cases if they had an International Classification of Diseases code indicating an acute VTE plus a filled prescription for an anticoagulant, placement of intravascular vena cava filter, or death within 30 days of diagnosis. Controls were matched 10:1 to each case by index date and age. Risk factors and comorbidities present within the year before index were examined. Exposure was defined as a HT prescription within 60 days before index. RESULTS There were 20,359 VTE cases and 203,590 matched controls. A conditional logistic regression indicated that the greatest risks for VTE were from metastatic cancer (odds ratio [OR], 13.66; 95% CI, 12.64-14.75), hospitalization/surgery (OR, 8.51; 95% CI, 8.09-8.96), trauma (OR, 3.52; 95% CI, 3.32-3.73), comorbidity burden (OR, 3.51; 95% CI, 3.34-3.69), history of hypercoagulable condition (OR, 3.10; 95% CI, 2.87-3.36), and varicose veins (OR, 2.87; 95% CI, 2.56-3.22). Regarding hormone exposure, we observed ORs of 1.51 (95% CI, 1.43-1.60) for any recent hormone exposure; 1.13 (95% CI, 1.04-1.23; number needed to harm, 4,274) for unopposed estrogen menopausal HT; 1.23 (95% CI, 1.10-1.38; number needed to harm, 2,440) for combined menopausal HT; and 5.22 (95% CI, 4.67-5.84) for combined hormonal contraceptives compared with no recent HT exposure. CONCLUSIONS Hormone therapy exposure did not appear to adversely influence other risk factors, and exposure generally played a minor role in VTE risk. Contraceptives, however, were a strong risk factor.
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Affiliation(s)
| | - John W Davis
- Department of Population Health Science, School of Public and Population Health, University of Texas Medical Branch, Galveston, TX
| | - Susan C Weller
- Department of Population Health Science, School of Public and Population Health, University of Texas Medical Branch, Galveston, TX
| | - Lu Chen
- Department of Population Health Science, School of Public and Population Health, University of Texas Medical Branch, Galveston, TX
| | - Gregg Wilkinson
- Department of Population Health Science, School of Public and Population Health, University of Texas Medical Branch, Galveston, TX
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Garland K, Mullins E, Bercovitz RS, Rodriguez V, Connors J, Sokkary N. Hemostatic considerations for gender affirming care. Thromb Res 2023; 230:126-132. [PMID: 37717369 DOI: 10.1016/j.thromres.2023.09.002] [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: 07/14/2023] [Revised: 08/24/2023] [Accepted: 09/08/2023] [Indexed: 09/19/2023]
Abstract
Gender dysphoria or gender incongruence is defined as "persons that are not satisfied with their designated gender" [1]. The awareness and evidence-based treatment options available to this population have grown immensely over the last two decades. Protocols now include an Endocrine Society Clinical Practice Guideline [1] as well as the World Professional Association of Transgender Health Standards of Care (WPATH SOC) [2]. Hematologic manifestations, most notably thrombosis, are one of the most recognized adverse reactions to the hormones used for gender-affirming care. Therefore, hematologists are frequently consulted prior to initiation of hormonal therapy to help guide safe treatment. This review will focus on the scientific evidence related to hemostatic considerations for various gender-affirming therapies and serve as a resource to assist in medical decision-making among providers and patients.
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Affiliation(s)
- Kathleen Garland
- Children's Minnesota, Minneapolis, MN 55404, United States of America.
| | - Eric Mullins
- Cincinnati Children's Hospital Medical Center and University of Cincinnati-College of Medicine, Cincinnati, OH 45229, United States of America
| | - Rachel S Bercovitz
- Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States of America
| | - Vilmarie Rodriguez
- Nationwide Children's Hospital, The Ohio State University, Columbus, OH 43205, United States of America
| | - Jean Connors
- Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA 02115, United States of America
| | - Nancy Sokkary
- Children's Healthcare of Atlanta, Atlanta, GA 30308, United States of America
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Fabunmi OA, Dludla PV, Nkambule BB. Investigating cardiovascular risk in premenopausal women on oral contraceptives: Systematic review with meta-analysis. Front Cardiovasc Med 2023; 10:1127104. [PMID: 37180788 PMCID: PMC10167286 DOI: 10.3389/fcvm.2023.1127104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/09/2023] [Indexed: 05/16/2023] Open
Abstract
Background The use of oral contraceptives (OCs) is associated with an increased risk of cardiovascular events such as arterial and venous thrombosis (VTE). Cardiovascular diseases (CVDs) are the leading cause of death worldwide, with low- and middle-income nations accounting for over three-quarter of CVD deaths. The aim of this systematic review is to provide a comprehensive synthesis of the available evidence on the link between OC use and CVD risk in premenopausal women and to further assess the role of geographic disparities in the reported prevalence of CVD risk in women on OCs. Methods A comprehensive search of databases such as MEDLINE, Academic Search Complete, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Health Source: Nursing/Academic Edition was conducted, right from the inception to the present, by using the EBSCOhost search engine. The Cochrane Central Register of Clinical trials (CENTRAL) was also searched to augment relevant sources of information. OpenGrey, which is a repository of information providing open access to bibliographical references, was searched and the reference list of the selected studies was also scanned. The potential risk of bias of the included studies was assessed using the modified Downs and Black checklist. Data analysis was performed using the Review Manager (RevMan) version 5.3. Results We included 25 studies that comprised 3,245 participants, of which 1,605 (49.5%) are OC users, while 1,640 (50.5%) are non-OC users. A total of 15 studies were included for meta-analysis, and the overall pooled estimates suggested a significant increase in the traditional cardiovascular risk variables [standardized mean difference (SMD) = 0.73, (0.46, 0.99) (Z = 5.41, p < 0.001)] and little to no difference in endothelial activation among OC users when compared with non-OC users [SMD = -0.11, (-0.81, 0.60) (Z = 0.30, p = 0.76)]. Europe [SMD = 0.03, (-0.21, 0.27), (Z = 0.25 p = 0.88)] had the least effect size, while North America had the highest effect size [SMD = 1.86, (-0.31, 4.04), (Z = 1.68 p = 0.09)] for CVD risk in OC users when compared with non-OC users. Conclusion The use of OCs suggests a significant increase in the prevalence of traditional cardiovascular risk variables with little to no difference in the risk of endothelial dysfunction when compared with non-OC users, and the magnitude of CVD risks varies across different geographical regions. Registration and protocol This systematic review was registered in the international prospective register of systematic reviews (PROSPERO) under the registration number: CRD42020216169.
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Affiliation(s)
- Oyesanmi A. Fabunmi
- School of Laboratory Medicine and Medical Sciences (SLMMS), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- Department of Physiology, Ekiti State University, Ado-Ekiti, Nigeria
| | - Phiwayinkosi V. Dludla
- Biomedical Research and Innovation Platform, South African Medical Research Council, Tygerberg, South Africa
| | - Bongani B. Nkambule
- School of Laboratory Medicine and Medical Sciences (SLMMS), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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6
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Sundell M, Spetz Holm AC, Fredrikson M, Hammar M, Hoffmann M, Brynhildsen J. Pulmonary embolism in menopausal hormone therapy: a population-based register study. Climacteric 2022; 25:615-621. [PMID: 36218141 DOI: 10.1080/13697137.2022.2127352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Oral but not transdermal menopausal hormone therapy (MHT) increases the risk of venous thromboembolism. There is no evidence regarding the risk of the serious complication pulmonary embolism (PE). The aim was to investigate the risk of PE in women using MHT depending on administration route, type of progestin and treatment duration. METHOD The population-based case-control study covered 1,771,253 women aged 40-69 years, during 2006-2015. Diagnoses of PE (n = 13,974) and drug dispensations were received from national validated registers. RESULTS Current MHT users had a higher risk of PE than non-users (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.05-1.26). First ever users had the highest risk (OR 2.07, 95% CI 1.23-3.50). Transdermal administration was not associated with increased risk of PE. The OR was slightly but non-significantly higher with estrogen combined with medroxyprogesterone acetate than with norethisterone acetate. DISCUSSION The risk of PE was significantly increased in users of oral but not transdermal MHT, with the highest risk in first ever users of oral estrogen combined with medroxyprogesterone acetate. The risk was considerably lower in women with recurrent treatment, probably because of the healthy user effect. CONCLUSION PE was most common close to initiation of oral treatment. Transdermal MHT did not increase the risk of PE.
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Affiliation(s)
- Micaela Sundell
- Department of Obstetrics and Gynecology, Kalmar County Hospital, Kalmar, Sweden.,Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Anna-Clara Spetz Holm
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Obstetrics and Gynecology, Linköping University Hospital, Sweden
| | - Mats Fredrikson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Mats Hammar
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Mikael Hoffmann
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Jan Brynhildsen
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Obstetrics and Gynecology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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7
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Linnemann B, Rott H, Zotz R, Hart C. Venous Thromboembolism Issues in Women. Hamostaseologie 2022; 42:290-299. [DOI: 10.1055/a-1919-9558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
AbstractThe lifetime risk of venous thromboembolism (VTE) is slightly higher in women than in men. There are several issues related to VTE that are unique to women. Combined hormonal contraceptives and pregnancy increase the risk of VTE in women of childbearing age, whereas hormone replacement therapy increases the VTE risk of postmenopausal women. Hereditary thrombophilia and risk factors such as older age, obesity, or smoking contribute to the risk increase. In women diagnosed with acute hormone-related VTE who are treated with oral anticoagulants, adequate contraception is mandatory to avoid unwanted pregnancies. According to current knowledge, hormonal contraception may be continued during anticoagulant therapy but must be switched to an estrogen-free contraception method at least 6 weeks before the termination of anticoagulation. VTE is also a major cause of maternal morbidity and mortality during pregnancy and the postpartum period. Currently, assisted reproduction technologies such as in vitro fertilization are widely used to treat couples affected by infertility. Complications of fertility treatment comprise VTE cases, especially in women with ovarian hyperstimulation syndrome. With this review, we intended to focus on VTE issues in women and summarize current evidence and guideline recommendations.
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Affiliation(s)
- Birgit Linnemann
- Division of Angiology, University Center of Vascular Medicine, University Hospital Regensburg, Regensburg, Germany
| | | | - Rainer Zotz
- Centrum für Blutgerinnungsstörungen und Transfusionsmedizin, Düsseldorf, Germany
| | - Christina Hart
- Department of Haematology and Oncology, Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
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8
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LaVasseur C, Neukam S, Kartika T, Samuelson Bannow B, Shatzel J, DeLoughery TG. Hormonal therapies and venous thrombosis: Considerations for prevention and management. Res Pract Thromb Haemost 2022; 6:e12763. [PMID: 36032216 PMCID: PMC9399360 DOI: 10.1002/rth2.12763] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 04/12/2022] [Accepted: 05/21/2022] [Indexed: 11/18/2022] Open
Abstract
Background Venous thromboses are well‐established complications of hormonal therapy. Thrombosis risk is seen with both hormonal contraceptive agents and with hormone replacement therapy for menopause and gender transition. Over the past several decades, large epidemiological studies have helped better define these risks. Objectives To review and discuss the differences in thrombosis risk of the many of hormonal preparations available as well as their interaction with patient‐specific factors. Methods We conducted a narrative review of the available literature regarding venous thrombosis and hormonal therapies including for contraception, menopausal symptoms, and gender transition. Results Thrombosis risk with estrogen‐containing compounds increases with increasing systemic dose of estrogen. While progesterone‐only–containing products are not associated with thrombosis, when paired with estrogen in combined oral contraceptives, the formulation of progesterone does impact the risk. These components, along with patient‐specific factors, may influence the choice of hormonal preparation. For patients who develop thrombosis on hormonal treatment, anticoagulation is protective against future thrombosis. Duration of anticoagulation is dependent on ongoing and future hormone therapy choice. Finally, the optimal management of hormone therapy for individuals diagnosed with prothrombotic illnesses such as COVID‐19 remains unclear. Conclusions When contemplating hormonal contraception or hormone replacement therapy, clinicians must consider a variety of factors including hormone type, dose, route, personal and family history of thrombosis, and other prothrombotic risk factors to make informed, personalized decisions regarding the risk of venous thrombosis.
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Affiliation(s)
- Corinne LaVasseur
- Department of Medicine Oregon Health and Sciences University Portland Oregon USA
| | - Suvi Neukam
- Department of Medicine Oregon Health and Sciences University Portland Oregon USA.,Division of Internal Medicine Oregon Health and Sciences University Portland Oregon USA
| | - Thomas Kartika
- Division of Hematology-Oncology Oregon Health and Sciences University Portland Oregon USA
| | - Bethany Samuelson Bannow
- Department of Medicine Oregon Health and Sciences University Portland Oregon USA.,Division of Hematology-Oncology Oregon Health and Sciences University Portland Oregon USA.,The Hemophilia Center Oregon Health and Sciences University Portland Oregon USA
| | - Joseph Shatzel
- Department of Medicine Oregon Health and Sciences University Portland Oregon USA.,Division of Hematology-Oncology Oregon Health and Sciences University Portland Oregon USA
| | - Thomas G DeLoughery
- Department of Medicine Oregon Health and Sciences University Portland Oregon USA.,Division of Hematology-Oncology Oregon Health and Sciences University Portland Oregon USA.,Division of Laboratory Medicine, Department of Pathology Oregon Health and Sciences University Portland Oregon USA
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9
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Kerrebrouck M, Vantilborgh A, Collet S, T’Sjoen G. Thrombophilia and hormonal therapy in transgender persons: A literature review and case series. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 23:377-391. [PMID: 36324880 PMCID: PMC9621226 DOI: 10.1080/26895269.2022.2025551] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Background: Venous thromboembolism (VTE) is a rare side effect of hormonal therapy in transgender persons. Prothrombotic genetic variants can increase this risk. For this reason, previous VTE and/or genetic thrombophilia may be considered by some as contraindications to hormonal treatment. Aim: To formulate directions for clinical practice about the indications for thrombophilia screening and when to consider combination therapy of therapeutic anticoagulation and hormonal treatment as a safe alternative to withholding hormonal treatment. Methods: We conducted a literature search and describe a case series. All adult patients with gender dysphoria and a known prothrombotic genetic variant or history of VTE were invited by letter to participate in this study. Results: In our center, thrombophilia screening before start of hormonal treatment was restricted to those with a personal or family history of VTE. Sixteen individuals with a history of VTE and/or an underlying prothrombogenic condition were described. The time of follow up varied from 4 months to 20 years. Seven trans women had a positive thrombophilia screening (2 Factor V Leiden (FVL), 1 FVL + anticardiolipin antibodies, 1 FVL + high Factor VIII coagulant activity, 1 protein C deficiency, 1 prothrombin mutation, 1 positive lupus anticoagulant). Three trans women experienced an unprovoked VTE after start of hormonal therapy of which one lead to a positive thrombophilia screening. One VTE event in a trans woman was assumed to be provoked by surgery. Five trans men were identified with a prothrombogenic mutation (3 FVL, 1 protein C deficiency, 1 prothrombin mutation). One trans man, with a negative thrombophilia screen, experienced multiple provoked VTE events before start of hormonal therapy. Conclusion: Based on our literature review and case series we offer guidance when confronted with patients with previous VTE and/or genetic thrombophilia requesting hormonal interventions.
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Affiliation(s)
| | - Anna Vantilborgh
- Department of Hematology, Ghent University Hospital, Ghent, Belgium
| | - Sarah Collet
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Guy T’Sjoen
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
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10
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Oral postmenopausal hormone therapy and genetic risk on venous thromboembolism: gene-hormone interaction results from a large prospective cohort study. Menopause 2022; 29:293-303. [PMID: 35013060 PMCID: PMC8881382 DOI: 10.1097/gme.0000000000001924] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Oral postmenopausal hormone therapy (HT) has been shown to be associated with venous thromboembolism (VTE), but whether this association is modified by VTE-associated genetic susceptibility is unknown. We examined interactions between oral HT use and a genetic risk score (GRS) of VTE. METHOD Eligible women were postmenopausal women who had data on oral HT use, VTE incidence between 1990 and 2012, and genetic data in the Nurses' Health Study. We built a GRS aggregating 16 VTE-related genetic variants. We used Cox regression to estimate associations of HT use with incident VTE and assessed interactions between HT use and VTE GRS. We also estimated incidence of VTE between age 50 and 79 years for groups of women defined by HT use and VTE GRS. RESULTS We identified 432 incident VTE cases. Current HT users were at higher risk of VTE than never users (HR: 1.9, 95% CI: 1.5-2.6), with slightly higher risk for estrogen plus progestin HT than estrogen only (HR: 2.4 vs 1.9). The GRS was associated with VTE risk (HR comparing 4th quartile to 1st: 2.0, 95% CI: 1.2-3.4). We did not observe significant multiplicative interactions between HT use and GRS. The estimated VTE risk difference (per 10,000 person-years) comparing 50-year-old current HT users to never users was 22.5 for women in the highest GRS quartile and 9.8 for women in the lowest GRS quartile. CONCLUSION The VTE GRS might inform clinical guidance regarding the balance of risks and benefits of HT use, especially among younger women.
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Pellikaan K, Ben Brahim Y, Rosenberg AGW, Davidse K, Poitou C, Coupaye M, Goldstone AP, Høybye C, Markovic TP, Grugni G, Crinò A, Caixàs A, Eldar-Geva T, Hirsch HJ, Gross-Tsur V, Butler MG, Miller JL, van der Kuy PHM, van den Berg SAA, Visser JA, van der Lely AJ, de Graaff LCG. Hypogonadism in Women with Prader-Willi Syndrome-Clinical Recommendations Based on a Dutch Cohort Study, Review of the Literature and an International Expert Panel Discussion. J Clin Med 2021; 10:jcm10245781. [PMID: 34945077 PMCID: PMC8707541 DOI: 10.3390/jcm10245781] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/23/2021] [Accepted: 11/28/2021] [Indexed: 12/27/2022] Open
Abstract
Prader-Willi syndrome (PWS) is a rare neuroendocrine genetic syndrome. Characteristics of PWS include hyperphagia, hypotonia, and intellectual disability. Pituitary hormone deficiencies, caused by hypothalamic dysfunction, are common and hypogonadism is the most prevalent. Untreated hypogonadism can cause osteoporosis, which is already an important issue in PWS. Therefore, timely detection and treatment of hypogonadism is crucial. To increase understanding and prevent undertreatment, we (1) performed a cohort study in the Dutch PWS population, (2) thoroughly reviewed the literature on female hypogonadism in PWS and (3) provide clinical recommendations on behalf of an international expert panel. For the cohort study, we retrospectively collected results of a systematic health screening in 64 female adults with PWS, which included a medical questionnaire, medical file search, medical interview, physical examination and biochemical measurements. Our data show that hypogonadism is frequent in females with PWS (94%), but is often undiagnosed and untreated. This could be related to unfamiliarity with the syndrome, fear of behavioral changes, hygienic concerns, or drug interactions. To prevent underdiagnosis and undertreatment, we provide practical recommendations for the screening and treatment of hypogonadism in females with PWS.
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Affiliation(s)
- Karlijn Pellikaan
- Department of Internal Medicine, Division of Endocrinology, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands; (K.P.); (Y.B.B.); (A.G.W.R.); (K.D.); (S.A.A.v.d.B.); (J.A.V.); (A.J.v.d.L.)
- Center for Adults with Rare Genetic Syndromes, Department of Internal Medicine, Division of Endocrinology, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
- Dutch Center of Reference for Prader-Willi Syndrome, 3015 GD Rotterdam, The Netherlands
- Academic Centre for Growth Disorders, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Yassine Ben Brahim
- Department of Internal Medicine, Division of Endocrinology, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands; (K.P.); (Y.B.B.); (A.G.W.R.); (K.D.); (S.A.A.v.d.B.); (J.A.V.); (A.J.v.d.L.)
- Center for Adults with Rare Genetic Syndromes, Department of Internal Medicine, Division of Endocrinology, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
- Dutch Center of Reference for Prader-Willi Syndrome, 3015 GD Rotterdam, The Netherlands
- Academic Centre for Growth Disorders, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Anna G. W. Rosenberg
- Department of Internal Medicine, Division of Endocrinology, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands; (K.P.); (Y.B.B.); (A.G.W.R.); (K.D.); (S.A.A.v.d.B.); (J.A.V.); (A.J.v.d.L.)
- Center for Adults with Rare Genetic Syndromes, Department of Internal Medicine, Division of Endocrinology, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
- Dutch Center of Reference for Prader-Willi Syndrome, 3015 GD Rotterdam, The Netherlands
- Academic Centre for Growth Disorders, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Kirsten Davidse
- Department of Internal Medicine, Division of Endocrinology, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands; (K.P.); (Y.B.B.); (A.G.W.R.); (K.D.); (S.A.A.v.d.B.); (J.A.V.); (A.J.v.d.L.)
- Center for Adults with Rare Genetic Syndromes, Department of Internal Medicine, Division of Endocrinology, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
- Dutch Center of Reference for Prader-Willi Syndrome, 3015 GD Rotterdam, The Netherlands
- Academic Centre for Growth Disorders, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Christine Poitou
- Rare Diseases Center of Reference ‘Prader-Willi Syndrome and Obesity with Eating Disorders’ (PRADORT), Nutrition Department, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, F-75013 Paris, France; (C.P.); (M.C.)
- International Network for Research, Management & Education on adults with PWS (INfoRMEd-PWS); (A.P.G.); (C.H.); (T.P.M.); (G.G.); (A.C.)
- ENDO-ERN (European Reference Network)
| | - Muriel Coupaye
- Rare Diseases Center of Reference ‘Prader-Willi Syndrome and Obesity with Eating Disorders’ (PRADORT), Nutrition Department, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, F-75013 Paris, France; (C.P.); (M.C.)
- International Network for Research, Management & Education on adults with PWS (INfoRMEd-PWS); (A.P.G.); (C.H.); (T.P.M.); (G.G.); (A.C.)
- ENDO-ERN (European Reference Network)
| | - Anthony P. Goldstone
- International Network for Research, Management & Education on adults with PWS (INfoRMEd-PWS); (A.P.G.); (C.H.); (T.P.M.); (G.G.); (A.C.)
- PsychoNeuroEndocrinology Research Group, Centre for Neuropsychopharmacology, Division of Psychiatry, and Computational, Cognitive and Clinical Neuroimaging Laboratory, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, London W12 0NN, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Charlotte Høybye
- International Network for Research, Management & Education on adults with PWS (INfoRMEd-PWS); (A.P.G.); (C.H.); (T.P.M.); (G.G.); (A.C.)
- ENDO-ERN (European Reference Network)
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 17176 Stockholm, Sweden
- Center for Adults with Rare Genetic Syndromes, Department of Internal Medicine, Division of Department of Endocrinology, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Tania P. Markovic
- International Network for Research, Management & Education on adults with PWS (INfoRMEd-PWS); (A.P.G.); (C.H.); (T.P.M.); (G.G.); (A.C.)
- Metabolism & Obesity Services, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
- Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia
| | - Graziano Grugni
- International Network for Research, Management & Education on adults with PWS (INfoRMEd-PWS); (A.P.G.); (C.H.); (T.P.M.); (G.G.); (A.C.)
- ENDO-ERN (European Reference Network)
- Divison of Auxology, Istituto Auxologico Italiano, IRCCS, 28824 Piancavallo, Italy
| | - Antonino Crinò
- International Network for Research, Management & Education on adults with PWS (INfoRMEd-PWS); (A.P.G.); (C.H.); (T.P.M.); (G.G.); (A.C.)
- Reference Center for Prader-Willi Syndrome, Bambino Gesù Hospital, Research Institute, 00050 Palidoro, Italy
| | - Assumpta Caixàs
- International Network for Research, Management & Education on adults with PWS (INfoRMEd-PWS); (A.P.G.); (C.H.); (T.P.M.); (G.G.); (A.C.)
- Endocrinology and Nutrition Department, Institut d’Investigació I Innovació Parc Taulí I3PT, Parc Taulí Hospital Universitari, Department of Medicine, Universitat Autònoma de Barcelona, 08208 Sabadell, Spain
- Correspondence: (A.C.); (L.C.G.d.G.)
| | - Talia Eldar-Geva
- The Israel Multidisciplinary Prader-Willi Syndrome Clinic, Jerusalem 9103102, Israel; (T.E.-G.); (H.J.H.); (V.G.-T.)
- Reproductive Endocrinology and Genetics Unit, Department of Obstetrics and Gynecology, Shaare-Zedek Medical Center, Jerusalem 9103102, Israel
- Hebrew University School of Medicine, Jerusalem 9112102, Israel
| | - Harry J. Hirsch
- The Israel Multidisciplinary Prader-Willi Syndrome Clinic, Jerusalem 9103102, Israel; (T.E.-G.); (H.J.H.); (V.G.-T.)
- Department of Pediatrics, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
| | - Varda Gross-Tsur
- The Israel Multidisciplinary Prader-Willi Syndrome Clinic, Jerusalem 9103102, Israel; (T.E.-G.); (H.J.H.); (V.G.-T.)
- Hebrew University School of Medicine, Jerusalem 9112102, Israel
- Neuropediatrics Unit, Department of Pediatrics, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
| | - Merlin G. Butler
- Departments of Psychiatry, Behavioral Sciences and Pediatrics, University of Kansas Medical Center, Kansas City, KS 66160, USA;
| | - Jennifer L. Miller
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL 32610, USA;
| | - Paul-Hugo M. van der Kuy
- Department of Hospital Pharmacy, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands;
| | - Sjoerd A. A. van den Berg
- Department of Internal Medicine, Division of Endocrinology, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands; (K.P.); (Y.B.B.); (A.G.W.R.); (K.D.); (S.A.A.v.d.B.); (J.A.V.); (A.J.v.d.L.)
- Department of Clinical Chemistry, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Jenny A. Visser
- Department of Internal Medicine, Division of Endocrinology, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands; (K.P.); (Y.B.B.); (A.G.W.R.); (K.D.); (S.A.A.v.d.B.); (J.A.V.); (A.J.v.d.L.)
| | - Aart J. van der Lely
- Department of Internal Medicine, Division of Endocrinology, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands; (K.P.); (Y.B.B.); (A.G.W.R.); (K.D.); (S.A.A.v.d.B.); (J.A.V.); (A.J.v.d.L.)
| | - Laura C. G. de Graaff
- Department of Internal Medicine, Division of Endocrinology, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands; (K.P.); (Y.B.B.); (A.G.W.R.); (K.D.); (S.A.A.v.d.B.); (J.A.V.); (A.J.v.d.L.)
- Center for Adults with Rare Genetic Syndromes, Department of Internal Medicine, Division of Endocrinology, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
- Dutch Center of Reference for Prader-Willi Syndrome, 3015 GD Rotterdam, The Netherlands
- Academic Centre for Growth Disorders, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
- International Network for Research, Management & Education on adults with PWS (INfoRMEd-PWS); (A.P.G.); (C.H.); (T.P.M.); (G.G.); (A.C.)
- ENDO-ERN (European Reference Network)
- Correspondence: (A.C.); (L.C.G.d.G.)
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12
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Fluorometric Quantification of Human Platelet Polyphosphate Using 4',6-Diamidine-2-phenylindole Dihydrochloride: Applications in the Japanese Population. Int J Mol Sci 2021; 22:ijms22147257. [PMID: 34298874 PMCID: PMC8307652 DOI: 10.3390/ijms22147257] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/29/2021] [Accepted: 07/01/2021] [Indexed: 02/07/2023] Open
Abstract
Polyphosphate (polyP), a biopolymer of inorganic phosphate, is widely distributed in living organisms. In platelets, polyP is released upon activation and plays important roles in coagulation and tissue regeneration. However, the lack of a specific quantification method has delayed the in-depth study of polyP. The fluorescent dye 4′,6-diamidine-2-phenylindole dihydrochloride (DAPI) has recently received attention as a promising probe for the visualization and quantification of cellular polyP levels. In this study, we further optimized quantification conditions and applied this protocol in quantification of platelet polyP levels in a Japanese population. Blood samples were collected from non-smoking, healthy Japanese subjects (23 males, 23 females). Washed platelets were fixed and probed with DAPI for fluorometric determination. PolyP levels per platelet count were significantly higher in women than that in men. A moderate negative correlation between age and polyP levels was found in women. Responsiveness to CaCl2 stimulation was also significantly higher in women than that in men. Overall, our optimized protocol requires neither purification nor degradation steps, reducing both the time and bias for reproducible quantification. Thus, we suggest that despite its low specificity, this DAPI-based protocol would be useful in routine laboratory testing to quantify platelet polyP levels efficiently and economically.
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13
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Lindner LH. [Deep vein thrombosis - diagnostics and clarification]. Dtsch Med Wochenschr 2021; 146:832-836. [PMID: 34130326 DOI: 10.1055/a-1226-5288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Deep vein thrombosis usually manifests as leg or pelvic vein thrombosis (DVT). The causes are either acquired or inherited and can also occur in combination. Early diagnosis and treatment of DVT can reduce the risk of pulmonary embolism and postthrombotic syndrome. The estimation of the clinical probability, if necessary in combination with the D-dimer test, points the way to further imaging diagnostics. After diagnosis, risk factors that led to the occurrence of thrombosis can be identified in many cases. In more than half of the cases, genetic causes play a role. If the cause is not clear, tumor screening should be performed, since up to 20 % of thromboses are due to tumor disease.
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14
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Hugon-Rodin J, Perol S, Plu-Bureau G. [Menopause and risk of thromboembolic events. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2021; 49:455-461. [PMID: 33757918 DOI: 10.1016/j.gofs.2021.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The incidence of venous thromboembolism (VTE) increases with age with an annual incidence of 1.25/1000 women in the 40-59 age group. Menopausal hormone therapy (MHT) may also increase the risk of VTE. This risk must be assessed during the first consultation before initiating MHT and assess each renewal of the MHT. MHT with oral estrogen combined (or not) with progestin increases the risk of VTE by about 70%. Using transdermal estrogen does not appear to increase the risk of VTE in women. VTE risk appears to be modulated by the type of progestin combined in MHT. The risk of VTE associated with MHT with transdermal estradiol appears to be safe in women using micronised progesterone and pregnane derivatives and higher in women using norpregnane derivatives . To limit the risk of VTE associated with MHT, transdermal estradiol use is recommended. In women at risk of VTE, MHT with oral estrogen is contraindicated. MHT with transdermal estradiol associated (or not) with micronised progesterone or dydrogesterone may be used in women with low or moderate risk of VTE.
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Affiliation(s)
- J Hugon-Rodin
- Service de gynécologie, groupe hospitalier Paris Saint-Joseph, Paris, France; Inserm U 1153, Épidémiologie obstétricale, périnatale et pédiatrique, Centre de recherche en épidémiologie et statistiques, Paris, France
| | - S Perol
- Service de gynécologie obstétrique, unité de gynécologie médicale, hôpital Port-Royal-Cochin, Paris, France; Université de Paris, Paris, France
| | - G Plu-Bureau
- Service de gynécologie obstétrique, unité de gynécologie médicale, hôpital Port-Royal-Cochin, Paris, France; Université de Paris, Paris, France; Inserm U 1153, Épidémiologie obstétricale, périnatale et pédiatrique, Centre de recherche en épidémiologie et statistiques, Paris, France.
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15
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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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16
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Mullins ES, Geer R, Metcalf M, Piccola J, Lane A, Conard LAE, Mullins TLK. Thrombosis Risk in Transgender Adolescents Receiving Gender-Affirming Hormone Therapy. Pediatrics 2021; 147:peds.2020-023549. [PMID: 33753543 DOI: 10.1542/peds.2020-023549] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Many transgender youth experience gender dysphoria, a risk factor for suicide. Gender-affirming hormone therapy (GAHT) ameliorates this risk but may increase the risk for thrombosis, as seen from studies in adults. The aim with this study was to examine thrombosis and thrombosis risk factors among an exclusively adolescent and young adult transgender population. METHODS This retrospective chart review was conducted at a pediatric hospital-associated transgender health clinic. The primary outcome was incidence of arterial or venous thrombosis during GAHT. Secondary measures included the prevalence of thrombosis risk factors. RESULTS Among 611 participants, 28.8% were transgender women and 68.1% were transgender men. Median age was 17 years at GAHT initiation. Median follow-up time was 554 and 577 days for estrogen and testosterone users, respectively. Individuals starting GAHT had estradiol and testosterone levels titrated to physiologic normal. Multiple thrombotic risk factors were noted among the cohort, including obesity, tobacco use, and personal and family history of thrombosis. Seventeen youth with risk factors for thrombosis were referred for hematologic evaluation. Five individuals were treated with anticoagulation during GAHT: 2 with a previous thrombosis and 3 for thromboprophylaxis. No participant developed thrombosis while on GAHT. CONCLUSIONS In this study, we examined thrombosis and thrombosis risk factors in an exclusively adolescent and young adult population of transgender people receiving GAHT. These data suggest that GAHT in youth, titrated within physiologic range, does not carry a significant risk of thrombosis in the short-term, even with the presence of preexisting thrombosis risk factors.
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Affiliation(s)
- Eric S Mullins
- Divisions of Hematology and.,College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | | | | | - Adam Lane
- Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Diseases Institute, and.,College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Lee Ann E Conard
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and.,College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Tanya L Kowalczyk Mullins
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and .,College of Medicine, University of Cincinnati, Cincinnati, Ohio
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Huvinen E, Holopainen E, Heikinheimo O. Norethisterone and its acetate - what's so special about them? BMJ SEXUAL & REPRODUCTIVE HEALTH 2021; 47:102-109. [PMID: 32398290 DOI: 10.1136/bmjsrh-2020-200619] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/06/2020] [Accepted: 04/13/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Progestogens (progestins) are widely used for contraception, in postmenopausal hormone therapy, and in treatment of abnormal uterine bleeding and endometriosis. Norethisterone (NET) and its acetate (NETA) differ from other progestogens by their partial conversion to ethinylestradiol (EE). We review their special characteristics and focus on the clinically relevant risk factors associated with estrogen action, such as migraine with aura and risk of thrombosis. METHODS Narrative review based on a medical literature (OvidMedline and PubMed) search. RESULTS NET converts to significant amounts of EE; 10-20 mg NET corresponds to 20-30 µg EE. The effects of NET on the endometrium are pronounced, making it a good choice for treating abnormal uterine bleeding, endometriosis, and endometrial hyperplasia. NET also has beneficial effects on bone mineral density and positive or neutral effects on cardiovascular health. Conversely, long-term use of NET is associated with a slightly increased breast cancer risk, and the risk of venous thromboembolism is moderately increased. This risk seems to be dose-dependent; contraceptive use carries no risk, but therapeutic doses might be associated with an increased risk. Studies suggest an association between combinations of EE and progestogens and ischaemic stroke, which in particular concerns women with migraine. No studies have, however, assessed this risk related to the therapeutic use of NET. CONCLUSIONS NET is a potent progestogen, especially when considering the endometrium. Its partial conversion to EE, however, is important to remember. Clinical consideration is required with women at high risk for either breast cancer or thromboembolism, or experiencing migraine with aura.
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Affiliation(s)
- Emilia Huvinen
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki 00029, Finland
| | - Elina Holopainen
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki 00029, Finland
| | - Oskari Heikinheimo
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki 00029, Finland
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18
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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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19
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Sugiura K, Kobayashi T, Ojima T. The epidemiological characteristics of thromboembolism related to oral contraceptives in Japan: Results of a national survey. J Obstet Gynaecol Res 2020; 47:198-207. [PMID: 32885566 DOI: 10.1111/jog.14452] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 07/03/2020] [Accepted: 08/08/2020] [Indexed: 11/28/2022]
Abstract
AIM The aim of this study was to reveal the epidemiological characteristics of thromboembolism related to combined oral contraceptives (COCs) in Japan. METHODS A survey of confirmed thromboembolism patients among Japanese COC users was conducted at randomly selected hospitals from across Japan. The survey examined six types of venous thromboembolism (VTE) and arterial thromboembolism (ATE) in all COC users: pulmonary embolism, deep vein thrombosis, other venous thrombosis, cerebral infarction, myocardial infarction, and other arterial thrombosis. The survey covered 5 years from 2009 to 2013. This study was approved in an ethical review by Hamamatsu University School of Medicine. RESULTS Four hundred and twenty-five cases clearly related to COCs were analyzed. The annual estimated incidence rates per 10 000 person-years of VTE, ATE and all thromboembolisms in all COC users were 1.17, 0.33 and 1.50, respectively. The incidence of thromboembolism was 35.2% within 30 days from the start of COCs, 53.8% within 90 days, 66.9% within 180 days and 78.2% within 360 days regardless of progestin type. Age adjusted odds ratios in the obese and underweight groups were 2.33 and 0.98 for overall thromboembolism, 2.59 and 0.77 for VTE, and 1.11 and 1.28 for ATE compared with the standard group, respectively. Odds ratios for thromboembolism in non-O blood groups were 1.89 for overall thromboembolism, 2.16 for VTE, and 1.35 for ATE, when compared with the O blood group. CONCLUSION The epidemiological characteristics of COC-related thromboembolisms were revealed in this national survey covering the years from 2009 to 2013.
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Affiliation(s)
- Kazuko Sugiura
- Department of Reproductive Health Nursing/Midwifery, Nagoya City University Graduate School of Nursing, Nagoya, Japan
| | - Takao Kobayashi
- Department of Obstetrics and Gynecology, Hamamatsu Medical Center, Hamamatsu, Japan
| | - Toshiyuki Ojima
- Department of Community Health and Preventive Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
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20
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de Oliveira ALML, Paschôa AF, Marques MA. Venous thromboembolism in women: new challenges for an old disease. J Vasc Bras 2020; 19:e20190148. [PMID: 34178071 PMCID: PMC8202191 DOI: 10.1590/1677-5449.190148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In countries that have controlled classic causes of maternal death, such as eclampsia
and hemorrhage, venous thromboembolism (VTE) has become the major concern. Prevention
of VTE during pregnancy and postpartum by applying guidelines and implementing
pharmacoprophylaxis is still the best strategy to reduce occurrence of this
complication. Hormonal contraceptives and hormone replacement therapy also increase
the risk of VTE, but women cannot be deprived of their benefits, which increase their
freedom at childbearing age and reduce their symptoms at menopause. Both
indiscriminate use and unmotivated prohibition are inappropriate. Contraceptive and
hormone replacement methods should be chosen with care, evaluating the patients’
contraindications, eligibility criteria, and autonomy. This article presents a
nonsystematic review of recent literature with the aim of evaluating and summarizing
the associations between VTE and clinical situations peculiar to women.
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Affiliation(s)
| | - Adilson Ferraz Paschôa
- Hospital da Beneficência Portuguesa de São Paulo, Cirurgia Vascular, São Paulo, SP, Brasil
| | - Marcos Arêas Marques
- Universidade do Estado do Rio de Janeiro - UERJ, Hospital Universitário Pedro Ernesto, Unidade Docente Assistencial de Angiologia, Rio de Janeiro, RJ, Brasil.,Universidade Federal do Estado do Rio de Janeiro - UNIRIO, Hospital Universitário Gafrée e Guinle, Serviço de Cirurgia Vascular, Rio de Janeiro, RJ, Brasil
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21
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Sugiura K, Kobayashi T, Ojima T. National survey of confirmed thromboembolism related to female hormones in Japan. J Obstet Gynaecol Res 2020; 46:1173-1182. [DOI: 10.1111/jog.14303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 04/25/2020] [Accepted: 04/30/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Kazuko Sugiura
- Department of Reproductive Health Nursing/Midwifery Nagoya City University Graduate School of Nursing Nagoya Japan
| | - Takao Kobayashi
- Department of Obstetrics and Gynecology Hamamatsu Medical Center Hamamatsu Japan
| | - Toshiyuki Ojima
- Department of Community Health and Preventive Medicine Hamamatsu University School of Medicine Hamamatsu Japan
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22
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Farge D, Le Maignan C, Doucet L, Frere C. Women, thrombosis, and cancer. Thromb Res 2019; 181 Suppl 1:S47-S53. [DOI: 10.1016/s0049-3848(19)30367-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/12/2022]
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Abstract
Because clinical trial data assessing more than 10 years of hormone therapy (HT) use are not available, providing guidance to menopausal women regarding duration of systemic HT is controversial. However, clinicians routinely encounter this issue in practice. Using available evidence and clinical experience, this chapter provides guidance for clinicians who care for patients who may be candidates for extended use of systemic HT.
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Abstract
For women at elevated risk of thrombosis, clinicians are challenged to relieve menopausal symptoms without increasing the risk of thrombosis. Oral menopausal hormone therapy increases the risk of venous thromboembolism by 2-fold to 3-fold. Observational studies suggest less thrombotic risk with transdermal therapies and with progesterone over synthetic progestogens (progestins), but the data are limited. Beneficial nonpharmacologic therapies include cognitive behavioral therapy and clinical hypnosis, whereas beneficial nonhormonal pharmacologic therapies include selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. For treatment of the genitourinary syndrome of menopause, vaginal lubricants and moisturizers, low-dose vaginal estrogen, and intravaginal dehydroepiandrosterone are options.
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Farge D, Le Maignan C, Doucet L, Frere C. WITHDRAWN: Women, thrombosis, and cancer. Thromb Res 2019. [DOI: 10.1016/j.thromres.2019.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Speed V, Roberts LN, Patel JP, Arya R. Venous thromboembolism and women's health. Br J Haematol 2018; 183:346-363. [DOI: 10.1111/bjh.15608] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Victoria Speed
- King's Thrombosis Centre; Department of Haematological Medicine; King's College Hospital NHS Foundation Trust; London UK
- Institute of Pharmaceutical Sciences; King's College London; London UK
| | - Lara N. Roberts
- King's Thrombosis Centre; Department of Haematological Medicine; King's College Hospital NHS Foundation Trust; London UK
| | - Jignesh P. Patel
- King's Thrombosis Centre; Department of Haematological Medicine; King's College Hospital NHS Foundation Trust; London UK
- Institute of Pharmaceutical Sciences; King's College London; London UK
| | - Roopen Arya
- King's Thrombosis Centre; Department of Haematological Medicine; King's College Hospital NHS Foundation Trust; London UK
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Getahun D, Nash R, Flanders WD, Baird TC, Becerra-Culqui TA, Cromwell L, Hunkeler E, Lash TL, Millman A, Quinn VP, Robinson B, Roblin D, Silverberg MJ, Safer J, Slovis J, Tangpricha V, Goodman M. Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons: A Cohort Study. Ann Intern Med 2018; 169:205-213. [PMID: 29987313 PMCID: PMC6636681 DOI: 10.7326/m17-2785] [Citation(s) in RCA: 254] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE), ischemic stroke, and myocardial infarction in transgender persons may be related to hormone use. OBJECTIVE To examine the incidence of these events in a cohort of transgender persons. DESIGN Electronic medical record-based cohort study of transgender members of integrated health care systems who had an index date (first evidence of transgender status) from 2006 through 2014. Ten male and 10 female cisgender enrollees were matched to each transgender participant by year of birth, race/ethnicity, study site, and index date enrollment. SETTING Kaiser Permanente in Georgia and northern and southern California. PATIENTS 2842 transfeminine and 2118 transmasculine members with a mean follow-up of 4.0 and 3.6 years, respectively, matched to 48 686 cisgender men and 48 775 cisgender women. MEASUREMENTS VTE, ischemic stroke, and myocardial infarction events ascertained from diagnostic codes through the end of 2016 in transgender and reference cohorts. RESULTS Transfeminine participants had a higher incidence of VTE, with 2- and 8-year risk differences of 4.1 (95% CI, 1.6 to 6.7) and 16.7 (CI, 6.4 to 27.5) per 1000 persons relative to cisgender men and 3.4 (CI, 1.1 to 5.6) and 13.7 (CI, 4.1 to 22.7) relative to cisgender women. The overall analyses for ischemic stroke and myocardial infarction demonstrated similar incidence across groups. More pronounced differences for VTE and ischemic stroke were observed among transfeminine participants who initiated hormone therapy during follow-up. The evidence was insufficient to allow conclusions regarding risk among transmasculine participants. LIMITATION Inability to determine which transgender members received hormones elsewhere. CONCLUSION The patterns of increases in VTE and ischemic stroke rates among transfeminine persons are not consistent with those observed in cisgender women. These results may indicate the need for long-term vigilance in identifying vascular side effects of cross-sex estrogen. PRIMARY FUNDING SOURCE Patient-Centered Outcomes Research Institute and Eunice Kennedy Shriver National Institute of Child Health and Human Development.
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Affiliation(s)
- Darios Getahun
- Kaiser Permanente Southern California, Pasadena, California (D.G., T.A.B., V.P.Q.)
| | - Rebecca Nash
- Emory University, Atlanta, Georgia (R.N., W.D.F., T.L.L., M.G.)
| | - W Dana Flanders
- Emory University, Atlanta, Georgia (R.N., W.D.F., T.L.L., M.G.)
| | - Tisha C Baird
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California (T.C.B.)
| | | | - Lee Cromwell
- Kaiser Permanente Georgia, Atlanta, Georgia (L.C., B.R.)
| | - Enid Hunkeler
- Kaiser Permanente Northern California, Oakland, California (E.H., A.M., M.J.S., J.S.)
| | - Timothy L Lash
- Emory University, Atlanta, Georgia (R.N., W.D.F., T.L.L., M.G.)
| | - Andrea Millman
- Kaiser Permanente Northern California, Oakland, California (E.H., A.M., M.J.S., J.S.)
| | - Virginia P Quinn
- Kaiser Permanente Southern California, Pasadena, California (D.G., T.A.B., V.P.Q.)
| | | | - Douglas Roblin
- Kaiser Permanente Mid-Atlantic States, Rockville, Maryland (D.R.)
| | - Michael J Silverberg
- Kaiser Permanente Northern California, Oakland, California (E.H., A.M., M.J.S., J.S.)
| | - Joshua Safer
- Icahn School of Medicine at Mount Sinai, New York, New York (J.S.)
| | - Jennifer Slovis
- Kaiser Permanente Northern California, Oakland, California (E.H., A.M., M.J.S., J.S.)
| | - Vin Tangpricha
- Emory University School of Medicine and Atlanta VA Medical Center, Atlanta, Georgia (V.T.)
| | - Michael Goodman
- Emory University, Atlanta, Georgia (R.N., W.D.F., T.L.L., M.G.)
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Risk of venous thromboembolism events in postmenopausal women using oral versus non-oral hormone therapy: A systematic review and meta-analysis. Thromb Res 2018; 168:83-95. [DOI: 10.1016/j.thromres.2018.06.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 05/22/2018] [Accepted: 06/16/2018] [Indexed: 11/19/2022]
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Beyer-Westendorf J, Bauersachs R, Hach-Wunderle V, Zotz RB, Rott H. Sex hormones and venous thromboembolism - from contraception to hormone replacement therapy. VASA 2018; 47:441-450. [PMID: 30008249 DOI: 10.1024/0301-1526/a000726] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The use of sex hormones such as combined oral contraceptives (COC) or hormone replacement therapy (HRT) increases the risk for venous thromboembolism (VTE) considerably, especially in patients with an increased intrinsic risk for thromboembolic complications. Despite public and media attention and increasing scientific evidence, prescription patterns seem to be hard to change. It is well recognized that the patient's baseline risk is the most relevant factor in the absolute risk for developing VTE. The relative risk increase associated with sex hormones, depends on the type and dosage of hormones, the route of application (oral, vaginal, transdermal), and for COC, on the specific combination of oestrogen and gestagen components. Consequently, a careful decision for or against any specific type of hormone treatment needs to be based on an assessment of the patient's risk profile (disposition) as well as on the treatment-associated risks and benefits (exposition). This review discusses the most common sex hormone treatments in contraception and HRT, the relevance for VTE risk patients, and strategies to counsel patients with regard to hormone use according to their risk profiles. Keywords: Oral contraceptives, hormonal contraception, hormone replacement therapy, venous thromboembolism.
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Affiliation(s)
- Jan Beyer-Westendorf
- 1 Thrombosis Research Unit, Department of Medicine I, Division Hematology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany.,2 Kings Thrombosis Service, Department of Hematology, Kings College London, UK
| | | | | | - Rainer B Zotz
- 5 Institute for Laboratory Medicine, Blood Coagulation and Transfusion Medicine (LBT), Düsseldorf, Germany.,6 Department of Haemostasis, Haemotherapy and Transfusion Medicine, Heinrich Heine University Medical Centre, Düsseldorf, Germany
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Sugiura K, Ojima T, Urano T, Kobayashi T. The incidence and prognosis of thromboembolism associated with oral contraceptives: Age-dependent difference in Japanese population. J Obstet Gynaecol Res 2018; 44:1766-1772. [PMID: 29998477 PMCID: PMC6175086 DOI: 10.1111/jog.13706] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 05/20/2018] [Indexed: 12/01/2022]
Abstract
Aim We analyzed the incidence and prognosis of thromboembolism associated with combined oral contraceptives (COCs) by age groups in Japan. Methods A total of 581 events of venous thromboembolism (VTE) and arterial thromboembolism (ATE) associated with COCs were analyzed from the Pharmaceuticals and Medical Devices Agency database from 2004 to 2013. In a statistical analysis, a good‐prognosis group included recovery cases and a poor‐prognosis group involved unrecovered cases with some sequela and fatal cases. The significant difference between these two groups was calculated by Pearson's chi‐square test, and the age‐specific tendency and the trend of differences in prognosis according to different hormonal contraceptives were examined by Cochran–Armitage trend test. Results A total of 543 events were analyzed except 38 events due to unknown age, in which DVT only was the most frequent, followed by cerebral infarction, PE with DVT, PE only, cerebral vein thromboses. ATE ratio for overall thromboembolism tended to increase with advancing age (P = 0.0041). Good‐prognosis group was common (291 cases in VTE and 83 cases in ATE), followed by poor‐prognosis group (46 cases in VTE and 34 cases in ATE). All ATE cases had a significantly poorer prognosis in comparison with all VTE cases (P < 0.0001). Types of progestin and age difference, however, showed no trend in the differences between good‐prognosis group and poor‐prognosis group (P = 0.3548 and P = 0.6097). Conclusion Thromboembolic events were the most frequent in the 40s. The ATE ratio for overall thromboembolism tended to increase with advancing age. All ATE cases had a significantly poorer prognosis in comparison with all VTE cases.
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Affiliation(s)
- Kazuko Sugiura
- Department of Reproductive Health Nursing/Midwifery, Nagoya City University Graduate School of Nursing, Nagoya, Japan
| | - Toshiyuki Ojima
- Department of Community Health and Preventive Medicine, Shizuoka, Japan
| | - Tetsumei Urano
- Department of Medical Physiology, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Takao Kobayashi
- Department of Obstetrics and Gynecology, Hamamatsu Medical Center, Shizuoka, Japan
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Ospemifene's effects on lipids and coagulation factors: a post hoc analysis of phase 2 and 3 clinical trial data. Menopause 2018; 24:1167-1174. [PMID: 28509812 PMCID: PMC5617371 DOI: 10.1097/gme.0000000000000900] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: To evaluate the effect of ospemifene 60 mg on the lipid and coagulation parameters of postmenopausal women using data from five phase 2 and 3 clinical trials. Methods: Data for lipids and coagulation factors for 2,166 postmenopausal women were pooled from five randomized, placebo-controlled studies. Lipid and coagulation parameters included in this analysis were total cholesterol, high-density lipoproteins (HDL), low-density lipoproteins (LDL), triglycerides, activated partial thromboplastin time (aPTT), fibrinogen, antithrombin antigen, protein C Ag, and protein S Ag free. Results: Mean percent changes in HDL and LDL were significantly greater with ospemifene versus placebo at month 3 (HDL: 4.4% vs 0.2%; LDL: −5.2% vs 2.4%), month 6 (HDL: 5.1% vs 1.5%; LDL: −6.7% vs 2.4%), and month 12 (HDL: 2.3% vs −1.9%; LDL: −7.0% vs −2.1%; P < 0.05, for all comparisons). Ospemifene significantly reduced total cholesterol at 6 months (−1.8% vs 1.6%; P = 0.0345 versus placebo), and changes in triglycerides with ospemifene were similar to placebo at all three time points. In subgroup analyses based on age, body mass index, and baseline triglyceride level, ospemifene increased HDL and decreased LDL, but had no significant effect on total cholesterol and triglycerides relative to placebo. Ospemifene significantly improved fibrinogen and protein C antigen levels relative to placebo at months 3 (−8.7% vs −0.8% and −2.7% vs 0.5%, respectively), 6 (−6.0% vs 6.7% and −3.6 vs 8.0%), and 12 (−8.7% vs 7.3% and −4.5% vs 6.6%; P < 0.01, for all). The levels of all coagulation factors remained within the normal range throughout the studies. Conclusion: Ospemifene 60 mg does not have a detrimental effect on lipid and coagulation parameters of postmenopausal women with up to 12 months of use.
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Berglund A, Johannsen TH, Stochholm K, Viuff MH, Fedder J, Main KM, Gravholt CH. Morbidity, Mortality, and Socioeconomics in Females With 46,XY Disorders of Sex Development: A Nationwide Study. J Clin Endocrinol Metab 2018; 103:1418-1428. [PMID: 29165629 DOI: 10.1210/jc.2017-01888] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 11/15/2017] [Indexed: 12/29/2022]
Abstract
CONTEXT Little is known about long-term health outcomes in phenotypic females with 46,XY disorders of sex development (XY females), and the socioeconomic profile has not been described in detail. OBJECTIVE To describe morbidity, mortality, and socioeconomic status in XY females in a comparison to the general population. DESIGN Nationwide registry study with complete follow-up. SETTING Uniform public health care system. PARTICIPANTS A total of 123 XY females karyotyped in Denmark during 1960 to 2012 and a randomly selected age-matched control cohort of 12,300 females and 12,300 males from the general population. MAIN OUTCOME MEASURES Overall mortality and morbidity as well as cause-specific morbidity; medicine use and socioeconomics (education, income, cohabitation, motherhood, and retirement). RESULTS Compared with female controls, overall morbidity was increased in XY females [hazard ratio (HR), 1.72; 95% confidence interval (CI), 1.43 to 2.08] but not when excluding diagnoses associated with the specific disorder of sex development (DSD) diagnosis or pregnancy and birth (HR, 1.13; CI, 0.93 to 1.37). Mortality was similar to controls (HR, 0.79; CI, 0.35 to 1.77). Cohabitation (HR, 0.44; CI, 0.33 to 0.58) and motherhood (HR, 0.10; CI, 0.05 to 0.18) were reduced in XY females but education (HR, 0.92; CI, 0.61 to 1.37) was similar to controls. Income was higher than among controls in the older years. CONCLUSIONS Morbidity was not increased in XY females when excluding diagnoses associated to the DSD condition per se. Judged on education and income, XY females perform well in the labor market. However, DSD seems to impact on the prospects of family life.
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MESH Headings
- Adolescent
- Adult
- Case-Control Studies
- Castration/methods
- Child
- Child, Preschool
- Denmark/epidemiology
- Female
- Gonadal Dysgenesis, 46,XY/drug therapy
- Gonadal Dysgenesis, 46,XY/epidemiology
- Gonadal Dysgenesis, 46,XY/genetics
- Gonadal Dysgenesis, 46,XY/surgery
- Humans
- Infant
- Infant, Newborn
- Male
- Morbidity
- Neoplasms/epidemiology
- Neoplasms/genetics
- Retirement
- Socioeconomic Factors
- Young Adult
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Affiliation(s)
- Agnethe Berglund
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus C, Denmark
| | - Trine H Johannsen
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kirstine Stochholm
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus C, Denmark
- Center of Rare Diseases, Department of Pediatrics, Aarhus University Hospital, Aarhus N, Denmark
| | - Mette H Viuff
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus C, Denmark
| | - Jens Fedder
- Center of Andrology and Fertility Clinic, Odense University Hospital, Odense C, Denmark
| | - Katharina M Main
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Claus H Gravholt
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus C, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus N, Denmark
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Scarabin PY. Progestogens and venous thromboembolism in menopausal women: an updated oral versus transdermal estrogen meta-analysis. Climacteric 2018; 21:341-345. [PMID: 29570359 DOI: 10.1080/13697137.2018.1446931] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Postmenopausal hormone therapy (HT) is a modifiable risk factor for venous thromboembolism (VTE). While the route of estrogen administration is now well recognized as an important determinant of VTE risk, there is also increasing evidence that progestogens may modulate the estrogen-related VTE risk. This review updates previous meta-analyses of VTE risk in HT users, focusing on the route of estrogen administration, hormonal regimen and progestogen type. Among women using estrogen-only preparations, oral but not transdermal preparations increased VTE risk (relative risk (RR) 1.48, 95% confidence interval (CI) 1.39-1.58; RR 0.97, 95% CI 0.87-1.09, respectively). In women using opposed estrogen, results were highly heterogeneous due to important differences between the molecules of progestogen. In transdermal estrogen users, there was no change in VTE risk in women using micronized progesterone (RR 0.93, 95% CI 0.65-1.33), whereas norpregnane derivatives were associated with increased VTE risk (RR 2.42, 95% CI 1.84-3.18). Among women using opposed oral estrogen, there was higher VTE risk in women using medroxyprogesterone acetate (RR 2.77, 95% CI 2.33-3.30) than in those using other progestins. These clinical findings, together with consistent biological data, emphasize the safety advantage of transdermal estrogen combined with progesterone and support the current evidence-based recommendations on HT, especially in women at high VTE risk.
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Affiliation(s)
- P-Y Scarabin
- a Université Paris-Saclay, Université Paris-Sud, UVSQ, Centre de Recherche en Epidémiologie et Santé des Populations , INSERM UMRS1018 Villejuif , France
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Abstract
Major advances in menopause hormone therapy (MHT) hold promise in the future of better and safer care for women at and after the menopause. The principal advances are: (1) the critical window or 'window of opportunity' in the 10 years or so after the menopause, during which the benefits of MHT in healthy women exceed any risks; (2) use of transdermal instead of oral administration of estrogen to reduce the risk of venous thromboembolism; (c) investigation of the use of oral micronized progesterone (MP) and vaginal MP to prevent endometrial hyperplasia and carcinoma without any increased risk of breast cancer and venous thromboembolism in postmenopausal women receiving estrogens; vaginal MP prevents endometrial proliferation in the short term but the long-term effects in MHT remain to be established; (4) investigation into the use of intrauterine levonorgestrel-releasing devices (LNG-IUDs), which are an attractive form of MHT in perimenopausal women, providing contraception and reducing uterine bleeding, although the risk of breast cancer with LNG-IUDs requires clarification. Women in the future can look forward to a symptom-free menopause and to safer and more beneficial MHT.
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Affiliation(s)
- D A Davey
- a Faculty of Health Sciences , University of Cape Town , Western Cape , South Africa
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Oral versus transdermal estrogens and venous thromboembolism in postmenopausal women: what is new since 2003? Menopause 2018; 23:587-8. [PMID: 27116463 DOI: 10.1097/gme.0000000000000665] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Risk of venous thromboembolism associated with local and systemic use of hormone therapy in peri- and postmenopausal women and in relation to type and route of administration. Menopause 2018; 23:593-9. [PMID: 27023862 DOI: 10.1097/gme.0000000000000611] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to assess the risk of venous thromboembolism (VTE) associated with systemic hormone therapy according to type and to route of administration and the risk of VTE associated with locally administered estrogen. METHODS In this case-control study, conducted in Sweden between 2003 and 2009, we included 838 cases of VTE and 891 controls with a mean age of 55 years. Controls were matched by age to the cases and randomly selected from the population. We used logistic regression to calculate odds ratios (ORs) with 95% CIs and adjusted for smoking, body mass index, and immobilization. RESULTS Current use of any hormone therapy was associated with an increased risk of VTE (OR 1.72, 95% CI 1.34-2.20). For estrogen in combination with progestogen the OR was 2.85 (95% CI 2.08-3.90), and for estrogen only the OR was 1.31 (95% CI 0.78-2.21). In orally administered estrogen combined with progestogen, the OR was slightly, but not significantly, higher among users of medroxyprogesterone acetate (OR 2.94, 95% CI 1.67-5.36) than among norethisterone acetate users (OR 2.55, 95% CI 1.50-3.40). Transdermal estrogen combined with progestogen was not associated with VTE risk (crude and imprecise ORs ranging from 0.87 to 1.16). For local effect of estrogen, there was no association with VTE risk (OR 0.69, 95% CI 0.43-1.10). CONCLUSIONS The risk of VTE risk is higher in users of systemic combined estrogen-progestogen treatment than in users of estrogen only. Furthermore, the risk of VTE was lower for women who used local estrogen than among those using oral estrogen only. Transdermal estrogen only treatment and estrogen for local effect seem not to be related to an increased risk of VTE.
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Li X, Ohlsson H, Ji J, Sundquist J, Sundquist K, Zöller B. Family history of venous thromboembolism as a risk factor and genetic research tool. Thromb Haemost 2017; 114:890-900. [DOI: 10.1160/th15-04-0306] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 07/03/2015] [Indexed: 12/25/2022]
Abstract
SummaryFamilial clustering of venous thromboembolism (VTE) was described as far back as 1905 by Briggs. Although Egeberg discovered inherited deficiency of antithrombin in 1965, it was not until Dahlback discovered resistance to activated protein C in 1993 that it became clear that genetic factors are common risk factors of VTE. Several genes have been linked to familial aggregation of VTE and genome-wide association studies have found several novel gene loci. Still, it has been estimated that much of the heritability for VTE remains to be discovered. Family history (FH) of VTE is therefore still important to determine whether a patient has an increased genetic risk of VTE. FH has the potential to represent the sum of effects and interactions between environmental and genetic factors. In this article the design, methodology, results, clinical and genetic implications of FH studies of VTE are reviewed. FH in first-degree relatives (siblings and/or parents) is associated with a 2–3 times increased familial relative risk (FRR). However, the FRR is dependent on age, number of affected relatives, and presentation of VTE (provoked/unprovoked). Especially high familial risks are observed in individuals with two or more affected siblings (FFR> 50). However, the familial risk for recurrent VTE is much lower or non-significant. Moreover, FH of VTE appears mainly to be important for venous diseases (i. e. VTE and varicose veins). The familial associations with other diseases are weaker. In conclusion, FH of VTE is an important research tool and a clinically potential useful risk factor for VTE.
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Crandall CJ, Hovey KM, Andrews C, Cauley JA, Stefanick M, Shufelt C, Prentice RL, Kaunitz AM, Eaton C, Wactawski-Wende J, Manson JE. Comparison of clinical outcomes among users of oral and transdermal estrogen therapy in the Women's Health Initiative Observational Study. Menopause 2017; 24:1145-1153. [PMID: 28697036 PMCID: PMC5607093 DOI: 10.1097/gme.0000000000000899] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine associations of estrogen preparations with an index of health risks versus benefits. METHODS Using data from 45,112 participants of the Women's Health Initiative Observational Study (average follow-up 5.5 years), we examined associations of estrogen type and oral conjugated equine estrogen (CEE) dose with time to first global index event (GIE), defined as coronary heart disease, breast cancer, stroke, pulmonary embolism, hip fracture, colorectal cancer, endometrial cancer, or death. RESULTS Oral CEE less than 0.625 mg/d + progestogen (P) users had a lower risk of a GIE (adjusted hazard ratio 0.74, 95% confidence interval 0.56-0.97) than oral CEE 0.625 mg/d + P users. GIE risk in oral CEE 0.625 mg/d + P users was greater with at least 5-year use (adjusted hazard ratio 1.22, 95% confidence interval 1.06-1.41) than with less than 5-year use. In women with prior hysterectomy, compared with women taking oral CEE 0.625 mg/d for less than 5 years, GIE risk was similar with oral CEE below 0.625 mg/d, oral estradiol (E2), and transdermal E2, whether used for less than 5 years or for at least 5 years. There was no difference in GIE risk between users of the following: oral CEE + P versus oral E2 + P; oral CEE + P versus transdermal E2 + P; oral E2 + P versus transdermal E2 + P. Findings were similar among women with hysterectomy taking estrogen alone. CONCLUSIONS The summary index of risks versus benefits was similar for oral CEE versus oral or transdermal E2-containing regimens. CEE + P containing less than 0.625 mg/d of CEE (vs 0.625 mg/d) for less than 5 years appeared safer.
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Affiliation(s)
- Carolyn J Crandall
- 1Department of Medicine, University of California, Los Angeles, Los Angeles, CA 2Dept of Epidemiology and Environmental Health, University at Buffalo, The State University of New York, Buffalo, NY 3Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 4Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 5Department of Medicine, Stanford University School of Medicine, Stanford, CA 6Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA 7Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA 8Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL 9Department of Family Medicine and Epidemiology, Brown University Warren Alpert Medical School and School of Public Health, Pawtucket, RI 10Department of Epidemiology and Environmental Health, University at Buffalo, State University of New York, Buffalo, NY 11Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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39
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Kobayashi T, Sugiura K, Ojima T. Risks of thromboembolism associated with hormone contraceptives in Japanese compared with Western women. J Obstet Gynaecol Res 2017; 43:789-797. [PMID: 28422361 DOI: 10.1111/jog.13304] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 01/09/2017] [Indexed: 11/27/2022]
Abstract
We extracted 581 thromboembolic events associated with combined oral contraceptives (COC) that occurred between 2004 and 2013 in Japan, from the Pharmaceuticals and Medical Devices Agency database. The most common thromboembolic events associated with COC were deep vein thrombosis, pulmonary embolism and their combination. The reported thromboembolic events increased year by year, in association with an increase in the quantity of prescribed low-dose estrogen progestin after approval for health insurance coverage for dysmenorrhea in 2008 in Japan. The incidence of venous thromboembolism (VTE) in Japanese COC users is estimated to be lower compared with their Western counterparts. In contrast, the frequency of all thromboembolic events peaked at 90 days from the start of COC, as in Western studies. The risk of VTE in the overweight group (body mass index ≥ 25 kg/m2 ) was more than twofold higher than in the standard group, and age-specific incidence rate rose sharply after the age of 40. There were different VTE risks according to progestin type in Japan as in Western countries, but a definite conclusion about risk according to progestin type was not able to be reached at present. As for the risk of arterial embolism and thrombosis, the difference by progestin type was small, but it became higher at ≥50 years of age. Last, mortality rate caused by thromboembolism is extremely low among COC users.
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Affiliation(s)
- Takao Kobayashi
- Department of Obstetrics and Gynecology, Hamamatsu Medical Center, Hamamatsu, Japan
| | - Kazuko Sugiura
- Department of Reproductive Health Nursing/Midwifery, Nagoya City University Graduate School of Nursing, Nagoya, Japan
| | - Toshiyuki Ojima
- Department of Community Health and Preventive Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
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40
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Lekovic D, Miljic P, Dmitrovic A, Thachil J. How do you decide on hormone replacement therapy in women with risk of venous thromboembolism? Blood Rev 2016; 31:151-157. [PMID: 27998619 DOI: 10.1016/j.blre.2016.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 10/30/2016] [Accepted: 12/09/2016] [Indexed: 01/26/2023]
Abstract
Women are increasingly encouraged to participate in making decisions about hormone replacement therapy (HRT). In postmenopausal women with severe vasomotor symptoms, HRT can significantly improve the quality of life. However, the use of HRT may also increase the risk of venous thromboembolism (VTE), the risk which depends of both treatment-related and patient-related factors. This review summarizes some important points about the selection of the safest hormonal replacement modality in women with a history of VTE and management of VTE risks in postmenopausal women wishing to take HRT.
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Affiliation(s)
- Danijela Lekovic
- Clinic for Hematology, Clinical Center of Serbia, Belgrade, Serbia; Medical Faculty, University of Belgrade, Belgrade, Serbia.
| | - Predrag Miljic
- Clinic for Hematology, Clinical Center of Serbia, Belgrade, Serbia; Medical Faculty, University of Belgrade, Belgrade, Serbia.
| | | | - Jecko Thachil
- Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom.
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41
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Tepper NK, Whiteman MK, Marchbanks PA, James AH, Curtis KM. Progestin-only contraception and thromboembolism: A systematic review. Contraception 2016; 94:678-700. [PMID: 27153743 PMCID: PMC11034842 DOI: 10.1016/j.contraception.2016.04.014] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 04/25/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Women with medical conditions associated with increased risk for thrombosis generally should not use estrogen-containing contraceptives; however, less is known about progestin-only contraceptives (POCs) and thrombosis risk. OBJECTIVES The objective was to identify evidence regarding the risk of venous thromboembolism (VTE) or arterial thromboembolism [stroke or acute myocardial infarction (AMI)] among women using POCs. METHODS We searched the PubMed database for all articles published from database inception through January 2016 for studies examining thrombosis among women using POCs. We included studies which examined women with medical conditions associated with thrombosis risk, as well as studies of women in the general population (either without these conditions or who were not specified to have these conditions). Hormonal contraceptives of interest included progestin-only pills (POPs), injectables, implants and levonorgestrel-releasing intrauterine devices (LNG-IUDs). Outcomes of interest included VTE, stroke and AMI. RESULTS There were 26 articles of good to poor quality that met inclusion criteria; 9 studies examined women with medical conditions and 20 examined women in the general population. Two studies found that, among smokers and women with certain thrombogenic mutations, use of depot medroxyprogesterone acetate (DMPA) had elevated odds of VTE compared with nonsmokers or those without mutations, although confidence intervals were wide and overlapped with odds among nonusers. One study found that, among women with previous VTE, use of POCs (including DMPA) was associated with a nonsignificant increased odds of recurrent VTE (all of which were among DMPA users); two other studies that examined POCs other than DMPA did not observe an association with recurrent VTE. Two studies found that use of DMPA among healthy women was also associated with increased odds of VTE. Two studies found that use of POCs for therapeutic indications was associated with increased odds of VTE. Studies did not find increased odds of VTE with POPs for contraceptive purposes, implants or LNG-IUDs nor were there increased odds of stroke or AMI with any POCs. CONCLUSION The majority of evidence identified by this systematic review did not suggest an increase in odds for venous or arterial events with use of most POCs. Limited evidence suggested increased odds of VTE with use of injectables (three studies) and use of POCs for therapeutic indications (two studies, one with POCs unspecified and the other with POPs). Any increase in risk likely translates to a small increase in absolute numbers of thrombotic events at the population level.
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Affiliation(s)
- Naomi K Tepper
- Division of Reproductive Health, US Centers for Disease Control and Prevention, Atlanta, GA, 30341, USA.
| | - Maura K Whiteman
- Division of Reproductive Health, US Centers for Disease Control and Prevention, Atlanta, GA, 30341, USA
| | - Polly A Marchbanks
- Division of Reproductive Health, US Centers for Disease Control and Prevention, Atlanta, GA, 30341, USA
| | - Andra H James
- Duke University School of Medicine, Durham, NC, 27710, USA
| | - Kathryn M Curtis
- Division of Reproductive Health, US Centers for Disease Control and Prevention, Atlanta, GA, 30341, USA
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42
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Gawlik A, Hankus M, Such K, Drosdzol-Cop A, Madej P, Borkowska M, Zachurzok A, Malecka-Tendera E. Hypogonadism and Sex Steroid Replacement Therapy in Girls with Turner Syndrome. J Pediatr Adolesc Gynecol 2016; 29:542-550. [PMID: 27018757 DOI: 10.1016/j.jpag.2016.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 03/06/2016] [Accepted: 03/09/2016] [Indexed: 12/28/2022]
Abstract
Turner syndrome is the most common example of hypergonadotropic hypogonadism resulting from gonadal dysgenesis. Most patients present delayed, or even absent, puberty. Premature ovarian failure can be expected even if spontaneous menarche occurs. Laboratory markers of gonadal dysgenesis are well known. The choice of optimal hormone replacement therapy in children and adolescents remains controversial, particularly regarding the age at which therapy should be initiated, and the dose and route of estrogen administration. On the basis of a review of the literature, we present the most acceptable schedule of sex steroid replacement therapy in younger patients with Turner syndrome.
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Affiliation(s)
- Aneta Gawlik
- Department of Pediatrics and Pediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland; Department of Pediatrics, Pediatric Endocrinology and Diabetes, Upper-Silesian Pediatric Health Center, Katowice, Poland.
| | - Magdalena Hankus
- Department of Pediatrics, Pediatric Endocrinology and Diabetes, Upper-Silesian Pediatric Health Center, Katowice, Poland
| | - Kamila Such
- Medical Students' Scientific Association, Katowice, Poland
| | | | - Paweł Madej
- Department of Endocrinological Gynecology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | | | - Agnieszka Zachurzok
- Department of Pediatrics and Pediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland; Department of Pediatrics, Pediatric Endocrinology and Diabetes, Upper-Silesian Pediatric Health Center, Katowice, Poland
| | - Ewa Malecka-Tendera
- Department of Pediatrics and Pediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland; Department of Pediatrics, Pediatric Endocrinology and Diabetes, Upper-Silesian Pediatric Health Center, Katowice, Poland
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van Vlijmen EFW, Wiewel-Verschueren S, Monster TBM, Meijer K. Combined oral contraceptives, thrombophilia and the risk of venous thromboembolism: a systematic review and meta-analysis. J Thromb Haemost 2016; 14:1393-403. [PMID: 27121914 DOI: 10.1111/jth.13349] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 04/17/2016] [Indexed: 11/29/2022]
Abstract
UNLABELLED Essentials We performed a meta-analysis on thrombosis risk in thrombophilic oral contraceptive (COC)-users. The results support discouraging COC-use in women with a natural anticoagulant deficiency. Contrary, additive risk of factor V Leiden (FVL) or prothrombin-G20210A (PT) mutation is modest. Women with a FVL/PT-mutation as single risk factor can use COCs if alternatives are not tolerated. SUMMARY Background Combined oral contraceptives (COCs) are associated with an increased risk of venous thromboembolism (VTE), which is shown to be more pronounced in women with hereditary thrombophilia. Currently, WHO recommendations state that COC-use in women with hereditary thrombophilias (antithrombin deficiency, protein C deficiency, protein S deficiency, factor V Leiden and prothrombin-G20210A mutation) is associated with an unacceptable health risk. Objective To perform a meta-analysis evaluating the additional risk of VTE in COC-users with thrombophilia. Methods The MEDLINE and EMBASE databases were searched on 10 February 2015 for potential eligible studies. A distinction was made between 'mild' (factor V Leiden and prothrombin-G20210A mutation) and 'severe' thrombophilia (antithrombin deficiency, protein C deficiency, protein S deficiency, double heterozygosity or homozygosity of factor V Leiden and prothrombin-G20210A mutation). Results We identified 12 case-control and three cohort studies. In COC-users, mild and severe thrombophilia increased the risk of VTE almost 6-fold (rate ratio [RR], 5.89; 95% confidence interval [CI], 4.21-8.23) and 7-fold (RR, 7.15; 95% CI, 2.93-17.45), respectively. The cohort studies showed that absolute VTE risk was far higher in COC-users with severe thrombophilia than in those with mild thrombophilia (4.3 to 4.6 vs. 0.49 to 2.0 per 100 pill-years, respectively), and these differences in absolute risks were also noted in non-affected women (0.48 to 0.7 vs. 0.19 to 0.0), but with the caveat that absolute risks were estimated in relatives of thrombophilic patients with VTE (i.e. with a positive family history). Conclusion These results support discouraging COC-use in women with severe hereditary thrombophilia. By contrast, additive VTE risk of mild thrombophilia is modest. When no other risk factors are present, (e.g. family history) COCs can be offered to these women when reliable alternative contraceptives are not tolerated.
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Affiliation(s)
- E F W van Vlijmen
- Division of Haemostasis and Thrombosis, Department of Haematology, University of Groningen, University Medical Center, Groningen, the Netherlands
| | - S Wiewel-Verschueren
- Division of Haemostasis and Thrombosis, Department of Haematology, University of Groningen, University Medical Center, Groningen, the Netherlands
- Department of Obstetrics and Gynaecology, University of Groningen, University Medical Center, Groningen, the Netherlands
| | - T B M Monster
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center, Groningen, the Netherlands
| | - K Meijer
- Division of Haemostasis and Thrombosis, Department of Haematology, University of Groningen, University Medical Center, Groningen, the Netherlands
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Abstract
Over 50 million Americans have low bone mass. Poor bone quality is known to complicate spinal fusion surgery, which relies on strong bony purchase to be effective. Unfortunately, many spine surgeons do not perform routine workups for either osteoporosis or osteomalacia. Effective screening and risk factor assessment can allow for appropriate medical management of osteoporosis in the perioperative setting, improving outcomes. Medical management can be grouped into several different categories: vitamins and minerals, bisphosphonates, recombinant parathyroid hormone, estrogen replacement or modification, inhibitors of receptor activator of nuclear factor κ-B ligand (RANKL), and calcitonin. Calcium and vitamin D supplements are the least expensive to prescribe, with minimal side effects and promising animal studies, and thus should be provided to most osteoporotic patients. Recombinant parathyroid hormone can also be considered, as clinical studies have demonstrated impressive results in spine fusion patients. Bisphosphonates, estrogen therapy or selective estrogen receptor modulators, and calcitonin should all be avoided in this patient population given unproven benefit and potentially harmful side-effect profiles. Denosumab is potentially an option, but may not be first line given the general lack of supporting data for its use in perioperative management of spine surgery patients.
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45
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Incremental value of hormonal therapy for deep vein thrombosis prediction. Blood Coagul Fibrinolysis 2016; 27:328-33. [DOI: 10.1097/mbc.0000000000000426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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46
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Andonova S, Robeva R, Sirakov M, Mainhard K, Tomova A, Ledig S, Kumanov P, Savov A. A Novel SRY Gene Mutation p.F109L in a 46,XY Female with Complete Gonadal Dysgenesis. Sex Dev 2016; 9:333-7. [PMID: 26871559 DOI: 10.1159/000443807] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2015] [Indexed: 11/19/2022] Open
Abstract
46,XY complete gonadal dysgenesis (CGD) is a disorder of sexual development that can result from different mutations in genes associated with sex determination. Patients are phenotypically females, and the disease is often diagnosed in late adolescence because of delayed puberty. Here, we present the clinical and molecular data of a 46,XY female CGD patient with gonadoblastoma with dysgerminoma and incidentally found inherited thrombophilia. The clinical significance of the described de novo SRY gene mutation c.325T>C (p.F109L) is discussed. This case report supports the critical role of the HGM domain in the SRY gene and the need of a multidisciplinary approach for CGD patients.
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Affiliation(s)
- Silvia Andonova
- National Genetic Laboratory - UHOG x2018;Maichin dom', Sofia, Bulgaria
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47
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Risks of thromboembolism associated with hormonal contraceptives related to body mass index and aging in Japanese women. Thromb Res 2016; 137:11-16. [DOI: 10.1016/j.thromres.2015.11.038] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 11/18/2015] [Accepted: 11/27/2015] [Indexed: 11/19/2022]
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48
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Canonico M. Hormone therapy and risk of venous thromboembolism among postmenopausal women. Maturitas 2015; 82:304-7. [PMID: 26276103 DOI: 10.1016/j.maturitas.2015.06.040] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 06/28/2015] [Indexed: 11/29/2022]
Abstract
Despite a decrease in the use of postmenopausal hormone therapy (HT) over the last decade, many women are still prescribed this treatment, as it remains the most effective means of counteracting climacteric symptoms. Its use declined when it was shown that HT increases the risk of breast cancer, stroke and venous thromboembolism (VTE). Nevertheless, that benefit/risk ratio was established among women using oral estrogens alone or combined with a specific progestogen and it cannot necessarily be extrapolated to other HTs. Oral estrogens increase the risk of VTE especially during the first year of treatment and past users revert to a similar risk as women who have never used them. There is now growing evidence that VTE risk among HT users strongly depends on the route of administration. Indeed, transdermal estrogens, unlike oral estrogens, are not associated with an increased VTE risk and biological data support this difference between oral and transdermal estrogens. In addition, transdermal estrogens may not confer additional risk in women at high risk of VTE. Significant differences in thrombotic risk between HT preparations also relate to the concomitant progestogen. Studies have consistently shown that VTE risk is higher among users of combined estrogens plus progestogens than among users of estrogens alone. With respect to the different pharmacological classes of progestogens, two observational studies found that norpregnane derivatives are associated with an increased VTE risk, whereas micronized progesterone may be safe with respect to thrombotic risk. In conclusion, transdermal estrogens alone or combined with micronized progesterone may represent the safest alternative for women who require HT.
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Affiliation(s)
- Marianne Canonico
- Inserm U1018, "Epidemiology of Ageing and Age-Related Diseases" Team, Université Paris-Sud 11, Villejuif, France.
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49
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Abstract
Although providing guidance to patients regarding duration of hormone therapy represents a topic surrounded by controversy, clinicians often encounter this issue in practice. As pointed out in the NAMS 2012 Hormone Therapy (HT) Position Statement, determining the optimal duration of HT is challenging both for clinicians and for patients. This Practice Pearl addresses clinical situations for which long-term HT might be appropriate and provides practical guidance regarding prudent therapeutic choices for women using HT for an extended duration.
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Affiliation(s)
- Andrew M Kaunitz
- From the University of Florida College of Medicine-Jacksonville, Department of Obstetrics & Gynecology, Jacksonville, FL
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50
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Abstract
Abstract Venous thromboembolism (VTE) is a common and potentially fatal disease in postmenopausal women. VTE has emerged as the most prevalent adverse effect of oral estrogens in 50-60-year-old women. Obesity and VTE history can be easily used to identify women at high risk but genetic screening is not cost-effective. Based on consistent biological and epidemiological findings, transdermal estrogen is the safest option with respect to VTE, especially in women at high risk. There is strong evidence that VTE risk is greater in women using medroxyprogesterone acetate compared with those receiving other progestins. Based on observational data, progesterone appears safe with respect to VTE. More research and action are needed to avert the hepatic first-pass effect of oral estrogens and to increase awareness of hormone-related VTE. Improving individual risk stratification and a personalized approach to hormone therapy are major challenges for future work.
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Affiliation(s)
- P-Y Scarabin
- Inserm, CESP Centre for Research in Epidemiology and Population Health, U1018, Hormones and Cardiovascular Diseases Team, Villejuif, and Université Paris Sud , UMRS 1018, Villejuif , France
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