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Morris G, Talaulikar V. Hormone replacement therapy in women with history of thrombosis or a thrombophilia. Post Reprod Health 2023; 29:33-41. [PMID: 36573625 DOI: 10.1177/20533691221148036] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Findings from the Women's Health Initiative (WHI) randomised placebo-controlled trial (RCT) were published at the beginning of this century. They suggested that hormone replacement therapy (HRT) use increased the risk of cardiovascular disease and venous thromboembolism including pulmonary embolism and deep vein thrombosis The findings led to a decline in HRT prescriptions and negative publicity about the use of HRT for women with significant menopausal symptoms. Subsequent studies have shown that the risk of thrombosis with HRT relates to whether estrogen is combined with a progestogen and the route of administration of estrogen. In healthy women with no background medical problems, transdermal hormone replacement is not associated with an increased risk of thrombosis. However, much less is known about the safety of various HRT preparations in women with a high background risk of thrombosis. These cases can often be challenging for clinicians with uncertainties around testing for thrombophilia, use of anticoagulation and striking a balance between the risks and benefits of prescribing HRT. This article will review the mechanism of thrombosis with differing types of HRT and present the evidence from the relevant trials. The article will also present the evidence that specifically relates to women with a personal history of thrombosis or thrombophilia (heritable and acquired) to enable clinicians to better individualise the risk assessment for each woman requesting HRT and understand the role of thrombophilia screening or concomitant anticoagulation in such situations.
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Affiliation(s)
- Guy Morris
- Subspecialty Trainee in Reproductive Medicine and Surgery, St Michael's Hospital, 1984University Hospitals Bristol, and Weston NHS Foundation Trust, Bristol, UK
| | - Vikram Talaulikar
- Reproductive Medicine Unit, EGA Wing, 8964University College London Hospital, London, UK
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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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Abstract
PURPOSE To determine whether testosterone supplementation is associated with retinal artery occlusion (RAO) or retinal vein occlusion (RVO). METHODS Retrospective matched cohort study using data from a large national U.S. insurance database. The testosterone cohort consisted of all male patients who filled a prescription for testosterone from 2000 to 2013. Five controls were matched on age (±3 years), sex, race, and similar time in plan (±3 months) for every exposed patient. Exclusion occurred for <2 years in the plan, <1 eye care visit, medications known to affect androgen levels, and systemic diseases associated with occlusions or increased testosterone. Cox proportional hazard regression assessed the hazard of a new diagnosis of RAO or RVO while controlling for age, race, diabetes mellitus, and hypertension. RESULTS A total of 35,784 incident testosterone users were compared with 178,860 matched controls. Ninety-three (0.3%) RAOs and 50 (0.1%) RVOs were found in the testosterone cohort and contrasted with 316 (0.2%) RAOs and 232 (0.1%) RVOs in the control group. After multivariate analysis, testosterone supplementation significantly increased the hazard of RAO (hazard ratio: 1.43, 95% confidence interval: 1.12-1.81, P = 0.004), but not of RVO (hazard ratio: 1.03, 95% confidence interval: 0.74-1.42, P = 0.86). CONCLUSION Although the incidence of RAO and RVO is low in users of testosterone, supplementation therapy is associated with an increased hazard of RAO, but apparently not of RVO.
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Testosterone Therapy, Thrombophilia, Venous Thromboembolism, and Thrombotic Events. J Clin Med 2018; 8:jcm8010011. [PMID: 30577621 PMCID: PMC6352146 DOI: 10.3390/jcm8010011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 12/11/2018] [Accepted: 12/18/2018] [Indexed: 01/24/2023] Open
Abstract
In our sequential studies of 67 and 21 patients, testosterone therapy (TT) interacted with thrombophilia⁻hypofibrinolysis, leading to venous thromboembolism (VTE). Compared to 111 VTE controls not taking TT (VTE-no TT), the 67 and 21 cases were more likely (p < 0.05 for all) to have Factor V Leiden (FVL) heterogeneity (24% and 33% vs. 12%), the lupus anticoagulant (14% and 33% vs. 4%), and high lipoprotein(a) (33% vs. 13%, n = 21). After a first VTE and continuing TT, 11 thrombophilic cases had a second VTE despite adequate anticoagulation, 6 of whom, still anticoagulated, had a third VTE. The greatest density of thrombotic events was at three months after starting TT, with a rapid decline by 10 months. From <1 to 8 months after starting TT, 65% of VTE occurred, which may reflect TT-induced depletion of susceptible thrombophilic patients, leaving a winnowed residual group with fewer VTE events despite the continuation of TT. Before starting TT, we suggest screening for FVL, lipoprotein(a), and the lupus anticoagulant to identify patients at increased VTE risk, with an adverse risk-to-benefit ratio for TT. We suggest that TT should not be started in patients with known thrombophilia⁻hypofibrinolysis, and should not be continued after a first VTE. When TT is given to patients with thrombophilia⁻hypofibrinolysis, VTE may occur and then recur despite adequate anticoagulation.
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Goldman A, Basaria S. Adverse health effects of androgen use. Mol Cell Endocrinol 2018; 464:46-55. [PMID: 28606866 DOI: 10.1016/j.mce.2017.06.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 06/08/2017] [Indexed: 01/21/2023]
Abstract
Anabolic androgenic steroids (AAS) are performance enhancing drugs commonly used by athletes and bodybuilders to improve appearance and athletic capability. Unfortunately, these testosterone derivatives can be associated with serious and potentially irreversible side effects, and can impact multiple organ systems. It is important that physicians be familiar with these adverse consequences so that they can appropriately counsel patients whom they suspect of AAS-abuse. In this chapter, we will review the negative effects of these compounds on various organ systems in men using AAS.
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Affiliation(s)
- Anna Goldman
- Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shehzad Basaria
- Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Shatzel JJ, Connelly KJ, DeLoughery TG. Thrombotic issues in transgender medicine: A review. Am J Hematol 2017; 92:204-208. [PMID: 27779767 DOI: 10.1002/ajh.24593] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 10/15/2016] [Accepted: 10/23/2016] [Indexed: 01/14/2023]
Abstract
Clinicians, including hematologists, are more frequently encountering transgender individuals in practice; however, most lack training on the management and complications of transgender medicine. Hormonal therapy forms the backbone of medical interventions for patients undergoing gender transition. While supplementing an individual's intrinsic sex hormone is associated with a variety of hematologic complications including increased rates of venous thrombosis, cardiovascular events, erthyrocytosis, and malignancy, the risks of supplementing with opposing sex hormones are not well understood. Data on the hematologic complications of these therapies are accumulating but remain limited, and clinicians have little experience with their management. This review highlights the current interventions available in transgender medicine and related potential hematologic complications, and it suggests simple, evidence-based management going forward. Am. J. Hematol. 92:204-208, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Joseph J. Shatzel
- Division of Hematology/Medical Oncology; Knight Cancer Institute; Portland Oregon
| | - Kara J. Connelly
- Department of Pediatrics; Oregon Health & Science University; Portland Oregon
| | - Thomas G. DeLoughery
- Division of Hematology/Medical Oncology; Knight Cancer Institute; Portland Oregon
- Department of Pediatrics; Oregon Health & Science University; Portland Oregon
- Department of Pathology; Oregon Health & Science University; Portland Oregon
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Glueck CJ, Lee K, Prince M, Jetty V, Shah P, Wang P. Four Thrombotic Events Over 5 Years, Two Pulmonary Emboli and Two Deep Venous Thrombosis, When Testosterone-HCG Therapy Was Continued Despite Concurrent Anticoagulation in a 55-Year-Old Man With Lupus Anticoagulant. J Investig Med High Impact Case Rep 2016; 4:2324709616661833. [PMID: 27536705 PMCID: PMC4971595 DOI: 10.1177/2324709616661833] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 06/29/2016] [Accepted: 07/02/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND When exogenous testosterone or treatments to elevate testosterone (human chorionic gonadotropin [HCG] or Clomid) are prescribed for men who have antecedent thrombophilia, deep venous thrombosis and pulmonary embolism often occur and may recur despite adequate anticoagulation if testosterone therapy is continued. CASE PRESENTATION A 55-year-old white male was referred to us because of 4 thrombotic events, 3 despite adequate anticoagulation over a 5-year period. We assessed interactions between thrombophilia, exogenous testosterone therapy, and recurrent thrombosis. In 2009, despite low-normal serum testosterone 334 ng/dL (lower normal limit [LNL] 300 ng/dL), he was given testosterone (TT) cypionate (50 mg/week) and human chorionic gonadotropin (HCG; 500 units/week) for presumed hypogonadism. Ten months later, with supranormal serum T (1385 ng/dL, upper normal limit [UNL] 827 ng/dL) and estradiol (E2) 45 pg/mL (UNL 41 pg/mL), he had a pulmonary embolus (PE) and was then anticoagulated for 2 years (enoxaparin, then warfarin). Four years later, on TT-HCG, he had his first deep venous thrombosis (DVT). TT was stopped and HCG continued; he was anticoagulated (enoxaparin, then warfarin, then apixaban, then fondaparinux). One year after his first DVT, on HCG, still on fondaparinux, he had a second DVT (5/315), was anticoagulated (enoxaparin + warfarin), with a Greenfield filter placed, but 8 days later had a second PE. Thrombophilia testing revealed the lupus anticoagulant. After stopping HCG, and maintained on warfarin, he has been free of further DVT-PE for 9 months. CONCLUSION When DVT-PE occur on TT or HCG, in the presence of thrombophilia, TT-HCG should be stopped, lest DVT-PE reoccur despite concurrent anticoagulation.
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Affiliation(s)
| | - Kevin Lee
- Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | | | - Vybhav Jetty
- Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Parth Shah
- Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Ping Wang
- Jewish Hospital of Cincinnati, Cincinnati, OH, USA
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Association Between Testosterone Replacement Therapy and the Incidence of DVT and Pulmonary Embolism: A Retrospective Cohort Study of the Veterans Administration Database. Chest 2016; 150:563-71. [PMID: 27179907 DOI: 10.1016/j.chest.2016.05.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 03/07/2016] [Accepted: 05/02/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Testosterone replacement therapy (TRT) prescriptions have increased several-fold in the last decade. There have been concerns regarding a possible increased incidence of DVT and pulmonary embolism (PE) with TRT. Few data support the association between TRT and DVT/PE. We evaluated the incidence of DVT and PE in men who were prescribed TRT for low serum total testosterone (sTT) levels. METHODS This is a retrospective cohort study, conducted using data obtained from the Veterans Affairs Informatics and Computing Infrastructure. We compared the incidence of DVT/PE between those who received TRT and subsequently had normal on-treatment sTT levels (Gp1), those who received TRT but continued to have low on-treatment sTT (Gp2), and those who did not receive TRT (Gp3). Those with prior history of DVT/PE, cancer, hypercoagulable state, and chronic anticoagulation were excluded. RESULTS The final cohort consisted of 71,407 subjects with low baseline sTT. Of these, 10,854 did not receive TRT (Gp3) and 60,553 received TRT. Of those who received TRT, 38,362 achieved normal sTT (Gp1) while 22,191 continued to have low sTT (Gp2). The incidence of DVT/PE was 0.5%, 0.4%, and 0.4% in Gp1, Gp2, and Gp3, respectively. Univariate, multivariate, and stabilized inverse probability of treatment weights analyses showed no statistically significant difference in DVT/PE-free survival between the various groups. CONCLUSIONS This study did not detect a significant association between testosterone replacement therapy and risk of DVT/PE in adult men with low sTT who were at low to moderate baseline risk of DVT/PE.
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Prince M, Glueck CJ, Shah P, Kumar A, Goldenberg M, Rothschild M, Motayar N, Jetty V, Lee K, Wang P. Hospitalization for pulmonary embolism associated with antecedent testosterone or estrogen therapy in patients found to have familial and acquired thrombophilia. BMC HEMATOLOGY 2016; 16:6. [PMID: 26958344 PMCID: PMC4782383 DOI: 10.1186/s12878-016-0045-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 02/27/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND In patients hospitalized over a 4 year period for pulmonary embolism (PE), we assessed relationships of testosterone (TT) and estrogen therapy (ET) anteceding PE in patients found to have familial-acquired thrombophilia. METHODS From 2011 through 2014, 347 patients were hospitalized in Cincinnati Mercy Hospitals with PE. Retrospective chart review was used to identify patients receiving TT or ET before PE; coagulation studies were done prospectively if necessary. RESULTS Preceding hospitalization for PE, 8 of 154 men (5 %) used TT, and 24 of 193 women (12 %) used ET. The median number of months from the initiation of TT or ET to development of PE was 7 months in men and 18 months in women. Of the 6 men having coagulation measures, all had ≥ 1 thrombophilia, and of the 18 women having measures of coagulation, 16 had ≥ 1 thrombophilia. The sensitivity of a previous history of thrombosis to predict PE was low, 25 % (2/8 men), 4 % (1/24 women). CONCLUSIONS Of 154 men hospitalized for PE, 8 (5 %) used TT, and of 193 women, 24 (12 %) used ET. Our data suggests that PE is an important complication of TT in men and ET in women, in part reflecting an interaction between familial and acquired thrombophilia and exogenous hormone use.
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Affiliation(s)
- Marloe Prince
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
| | - Charles J. Glueck
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
| | - Parth Shah
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
| | - Ashwin Kumar
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
| | - Michael Goldenberg
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
| | - Matan Rothschild
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
| | - Nasim Motayar
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
| | - Vybhav Jetty
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
| | - Kevin Lee
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
| | - Ping Wang
- From the Internal Medicine Residency Program, Cholesterol, Metabolism, and Thrombosis Center of the Jewish Hospital of Cincinnati, 2135 Dana Avenue, Suite 430, Cincinnati, OH 45207 USA
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Glueck CJ, Riaz R, Prince M, Freiberg RA, Wang P. Testosterone Therapy Can Interact With Thrombophilia, Leading to Osteonecrosis. Orthopedics 2015; 38:e1073-8. [PMID: 26652327 DOI: 10.3928/01477447-20151120-03] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 04/08/2015] [Indexed: 02/03/2023]
Abstract
Although this effect is not widely recognized, testosterone therapy can interact with thrombophilia, causing osteonecrosis. In 12 men and 4 women who had idiopathic osteonecrosis a median of 6 months after the onset of testosterone therapy, the authors examined the interaction between testosterone therapy and previously undiagnosed thrombophilia. The authors hypothesized that patients who had osteonecrosis after starting testosterone therapy were more likely than 110 normal control subjects or 48 patients who had osteonecrosis and were not receiving testosterone therapy to have thrombophilia. Measures of thrombophilia included Factor V Leiden, prothrombin, PAI-1 gene mutations, Factor VIII, Factor XI, anticardiolipin antibody immunoglobulin G or immunoglobulin M, and homocysteine values. In 10 cases, osteonecrosis occurred 6 months or less after the onset of testosterone therapy, and in all 16 cases, it occurred after a median of 6 months of testosterone therapy. Of the 16 cases, 5 (31%) were Factor V Leiden heterozygotes vs 2 of 109 (2%) healthy control subjects (P=.0003) and 4 of 48 patients who had osteonecrosis and were not receiving testosterone therapy (P=.04). Of the 16 cases, 4 (25%) had high (>150%) Factor VIII levels vs 7 of 103 (7%) healthy control subjects (P=.04), and 3 (19%) had high (>150%) Factor XI levels vs 3 of 101 (3%) healthy control subjects (P=.03). Of the 16 patients with osteonecrosis, 14 (88%) had at least 1 abnormal procoagulant value (of the 8 measured) vs 47 of 110 (43%) healthy control subjects (P=.0009). Of the 5 men whose serum estradiol level was measured while they were receiving testosterone therapy, this level was high (≥42.6 pg/mL) in 4. When testosterone therapy is given to patients with thrombophilia, they are at increased risk for osteonecrosis.
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Glueck CJ, Prince M, Patel N, Patel J, Shah P, Mehta N, Wang P. Thrombophilia in 67 Patients With Thrombotic Events After Starting Testosterone Therapy. Clin Appl Thromb Hemost 2015; 22:548-53. [PMID: 26620418 DOI: 10.1177/1076029615619486] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We compared thrombophilia in 67 cases (59 men and 8 women) with thrombotic events after starting testosterone therapy (TT) versus 111 patient controls having unprovoked venous thrombotic events without TT. In the 67 patients, thrombosis (47 deep venous thrombosis-pulmonary embolism, 16 osteonecrosis, and 4 ocular thrombosis) occurred 6 months (median) after starting TT. Cases differed from controls for factor V Leiden heterozygosity (16 of the 67 [24%] vs 13 [12%] of the 111, P = .038) and for lupus anticoagulant (9 [14%] of the 64 vs 4 [4%] of the 106, P = .019). After a first thrombotic event and continuing TT, 11 cases had a second thrombotic event, despite adequate anticoagulation, 6 of whom, still anticoagulated, had a third thrombosis. Screening for thrombophilia before starting TT should identify men and women at high risk for thrombotic events with an adverse risk-benefit ratio for TT. When TT is given to patients with familial and acquired thrombophilia, thrombosis may occur and recur in thrombophilic men despite anticoagulation.
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Affiliation(s)
- Charles J Glueck
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Marloe Prince
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Niravkumar Patel
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Jaykumar Patel
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Parth Shah
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Nishi Mehta
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Ping Wang
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
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Baillargeon J, Urban RJ, Morgentaler A, Glueck CJ, Baillargeon G, Sharma G, Kuo YF. Risk of Venous Thromboembolism in Men Receiving Testosterone Therapy. Mayo Clin Proc 2015. [PMID: 26205547 DOI: 10.1016/j.mayocp.2015.05.012] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine the risk of venous thromboembolism (VTE) associated with exposure to testosterone therapy in middle-aged and older men. PATIENTS AND METHODS We conducted a case-control study of 30,572 men 40 years and older who were enrolled in one of the nation's largest commercial insurance programs between January 1, 2007, and December 31, 2012. Cases were defined as men who had a primary diagnosis of VTE and received an anticoagulant drug in the 60 days after their diagnoses. Cases were matched with 3 controls on event/index month, age, geographic region, diagnosis of hypogonadism, and diagnosis of any underlying prothrombotic condition. Conditional logistic regression analysis was used to calculate adjusted odds ratios (aORs) and 95% CIs for the risk of VTE associated with previous exposure to testosterone therapy. RESULTS Exposure to testosterone therapy in the 15 days before the event/index date was not associated with an increased risk of VTE (aOR, 0.90; 95% CI, 0.73-1.12). None of the specific routes of administration examined were associated with an increased risk of VTE (topical [aOR, 0.80; 95% CI, 0.61-10.41], transdermal [aOR, 0.91; 95% CI, 0.38-2.16], and intramuscular [aOR, 1.15; 95% CI, 0.80-1.64]). These findings persisted using exposure windows that extended to 30 and 60 days before the event/index date. CONCLUSION Having filled a prescription for testosterone therapy was not associated with an increased risk of VTE in commercially insured middle-aged and older men. These findings may provide clinically relevant information about the benefit-risk assessment for men with testosterone deficiency considering treatment.
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Affiliation(s)
- Jacques Baillargeon
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX; Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX; Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX.
| | - Randall J Urban
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | | | | | - Gwen Baillargeon
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
| | - Gulshan Sharma
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX; Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX; Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX; Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX
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Freedman J, Glueck CJ, Prince M, Riaz R, Wang P. Testosterone, thrombophilia, thrombosis. Transl Res 2015; 165:537-48. [PMID: 25639953 DOI: 10.1016/j.trsl.2014.12.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 12/16/2014] [Accepted: 12/17/2014] [Indexed: 10/24/2022]
Abstract
We screened previously undiagnosed thrombophilia (V Leiden-prothrombin mutations, Factors VIII and XI, homocysteine, and antiphospholipid antibody [APL] syndrome) in 15 men and 2 women with venous thromboembolism (VTE) or osteonecrosis 7 months (median) after starting testosterone therapy (TT), gel (30-50 mg/d), intramuscular (100-400 mg/wk), or human chorionic gonadotropin (HCG) (6000 IU/wk). Thrombophilia was studied in 2 healthy control groups without thrombosis (97 normal controls, 31 subjects on TT) and in a third control group (n = 22) with VTE, not on TT. Of the 17 cases, 76% had ≥1 thrombophilia vs 19% of 97 normal controls (P < 0.0001), vs 29% of 31 TT controls (P = 0.002). Cases differed from normal controls by Factor V Leiden (12% vs 0%, P = 0.021), by high Factor VIII (>150%) (24% vs 7%, P = 0.058), by high homocysteine (29% vs 5%, P = 0.007), and from both normal and TT controls for APL syndrome (18% vs 2%, P = 0.023, vs 0%, P = 0.04). Despite adequate anticoagulation with TT continued after the first deep venous thrombosis-pulmonary embolus (DVT-PE), 1 man sustained 3 DVT-PEs 5, 8, and 11 months later and a second man had 2 DVT-PEs 1 and 2 months later. Of the 10 cases with serum T measured on TT, 6 (60%) had supranormal T (>800 ng/dL) and of 9 with estradiol measured on TT, 7 (78%) had supranormal levels (>42.6 pg/mL). TT interacts with thrombophilia leading to thrombosis. TT continuation in thrombophilic men is contraindicated because of recurrent thrombi despite anticoagulation. Screening for thrombophilia before starting TT should identify subjects at high risk for VTE with an adverse the risk to benefit ratio for TT.
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Affiliation(s)
- Joel Freedman
- Jewish Hospital Internal Medicine Residency Program, Cincinnati, Ohio
| | - Charles J Glueck
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, Ohio.
| | - Marloe Prince
- Jewish Hospital Internal Medicine Residency Program, Cincinnati, Ohio
| | - Rashid Riaz
- Jewish Hospital Internal Medicine Residency Program, Cincinnati, Ohio
| | - Ping Wang
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, Ohio
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Rao A, Steels E, Beccaria G, Inder WJ, Vitetta L. Influence of a Specialized Trigonella foenum-graecum Seed Extract (Libifem), on Testosterone, Estradiol and Sexual Function in Healthy Menstruating Women, a Randomised Placebo Controlled Study. Phytother Res 2015; 29:1123-30. [PMID: 25914334 DOI: 10.1002/ptr.5355] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Revised: 03/17/2015] [Accepted: 03/23/2015] [Indexed: 11/09/2022]
Abstract
The aim of the study was to evaluate the effect of Trigonella foenum-graecum (fenugreek) seed extract on sex hormones and sexual function in healthy menstruating women who reported low sexual drive. This short term, single site, double blind, randomised, placebo-controlled study was conducted on 80 women, aged 20 to 49 years. Participants were randomised to either an oral dose of a standardised T. foenum-graecum seed extract (libifem) at a dose of 600 mg/day or placebo over two menstrual cycles. Dehydroepiandrosterone sulfate, progesterone, androstenedione, total and free testosterone, estradiol (E2), luteinizing hormone, follicle stimulating hormone, sex hormone binding globulin and cholesterol were measured at baseline and 8 weeks. The individual aspects of sexual function were measured using the Derogatis interview for sexual functioning and female sexual function index self-administered questionnaires. Stress, fatigue and quality of the relationship with partner were also measured using the PSS (Perceived Stress Scale), MFI-20 (Multidimensional Fatigue Inventory) and DAS (Dyadic Adjustment Scale) quality of life measures, respectively. There was a significant increase in free testosterone and E2 in the active group as well as sexual desire and arousal compared with the placebo group. The results indicate that this extract of T. foenum-graecum may be a useful treatment for increasing sexual arousal and desire in women.
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Affiliation(s)
- Amanda Rao
- Sydney Medical School, The University of Sydney, Edward Ford Building A27, Sydney, NSW, 2006, Australia
| | - Elizabeth Steels
- Integrated Health Group Pty Ltd, 188 James St, New Farm, Qld, 4005, Australia
| | - Gavin Beccaria
- University of Southern Queensland, 487/521-535 West Street, Darling Heights, QLD, 4350, Australia
| | - Warrick J Inder
- School of Medicine, the University of Queensland and Department of Diabetes and Endocrinology, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD, 4102, Australia
| | - Luis Vitetta
- Sydney Medical School, The University of Sydney, Edward Ford Building A27, Sydney, NSW, 2006, Australia.,Medlab Pty Ltd, 66 McCauley Street, Alexandria, 2015, Sydney, Australia
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Glueck CJ, Friedman J, Hafeez A, Hassan A, Wang P. Testosterone therapy, thrombophilia, and hospitalization for deep venous thrombosis–pulmonary embolus, an exploratory, hypothesis-generating study. Med Hypotheses 2015; 84:341-3. [DOI: 10.1016/j.mehy.2015.01.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 01/15/2015] [Indexed: 11/26/2022]
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17
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Glueck CJ, Wang P. Testosterone therapy, thrombosis, thrombophilia, cardiovascular events. Metabolism 2014; 63:989-94. [PMID: 24930993 DOI: 10.1016/j.metabol.2014.05.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 05/06/2014] [Accepted: 05/11/2014] [Indexed: 12/13/2022]
Abstract
There are similar time intervals between starting testosterone therapy (TT) and development of thrombotic (~4.5 months) or cardiovascular (CVD) events (~3 months) which may, speculatively, reflect a shared pathophysiology. We have described thrombotic events 5 months (median) after starting TT in 38 men and 4 women, including 27 with deep venous thrombosis-pulmonary embolism, 12 with osteonecrosis, 1 with central retinal vein thrombosis, 1 with amaurosis fugax, and 1 with spinal cord infarction. In 8 men whose TT was continued, second thrombotic events occurred despite adequate anticoagulation with Coumadin in 8 men, 3 of whom had a third thrombotic event. Of these 42 cases, 40 had measures of thrombophilia-hypofibrinolysis, and 39 were found to have previously undiagnosed thrombophilia-hypofibrinolysis. Before beginning TT, especially in men with previous history of thrombotic events, we suggest that, at a minimum, measurements be made for the Factor V Leiden and Prothrombin mutations, Factors VIII and XI, and homocysteine, to identify men who should not receive TT. We need prospective data focused on whether there should be pre-TT screening based on history of previous venous thromboembolism or for all subjects for major gene thrombophilias. To better resolve questions about TT and all cause and cardiovascular morbidity and mortality and thrombosis, a long term, prospective, randomized, blinded study following the example of the Women's Health Initiative is needed. While we wait for prospective placebo-controlled TT outcome data, TT should be restricted to men with well-defined androgen deficiency syndromes.
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Affiliation(s)
- Charles J Glueck
- Jewish Hospital Cholesterol, Metabolism, Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA.
| | - Ping Wang
- Jewish Hospital Cholesterol, Metabolism, Thrombosis Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
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18
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Testosterone, anastrozole, factor V Leiden heterozygosity and osteonecrosis of the jaws. Blood Coagul Fibrinolysis 2014; 25:286-8. [DOI: 10.1097/mbc.0000000000000047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Glueck CJ, Richardson-Royer C, Schultz R, Burger T, Bowe D, Padda J, Wang P. Testosterone Therapy, Thrombophilia–Hypofibrinolysis, and Hospitalization for Deep Venous Thrombosis-Pulmonary Embolus. Clin Appl Thromb Hemost 2013; 20:244-9. [DOI: 10.1177/1076029613499819] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In our study of 596 men hospitalized in the last 3 years for deep venous thrombosis-pulmonary emboli (DVT-PE), we determined the prevalence of exogenous testosterone (T) use with subsequent development of DVT-PE. Of the 596 men, 110 were now dead, 97 had cancer thought to cause DVT-PE, 250 could not be contacted, leaving 139, of whom 7 had taken T before and at the time of their admissions, 1.2% of the total cohort, a conservative estimate of the prevalence of T-associated DVT-PE. In all, 5 of the 7 DVT-PE events occurred within 3 months of initiation of T, with mean and median intervals between initiation of T and hospitalization with DVT-PE 6.7 and 2 months. Of the 7 men treated with exogenous T, all 5 men who had evaluation of thrombophilia–hypofibrinolysis were found to have previously undiagnosed familial or acquired thrombophilia or hypofibrinolysis, suggesting a thrombotic interaction between exogenous T and thrombophilia–hypofibrinolysis.
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Affiliation(s)
- Charles J. Glueck
- Jewish Hospital Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Caitlin Richardson-Royer
- Jewish Hospital Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
- Internal Medicine Residency Program, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Reiker Schultz
- Jewish Hospital Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
- Internal Medicine Residency Program, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Tim Burger
- Jewish Hospital Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
- Internal Medicine Residency Program, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Dedrick Bowe
- Jewish Hospital Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
- Internal Medicine Residency Program, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Jagjit Padda
- Jewish Hospital Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
- Internal Medicine Residency Program, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Ping Wang
- Jewish Hospital Cholesterol Center, Jewish Hospital of Cincinnati, Cincinnati, OH, USA
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