Estrogen receptor 1 haplotype does not regulate oral contraceptive-induced changes in haemostasis and inflammation risk factors for venous and arterial thrombosis

BACKGROUND

Administration of oral contraceptives (OCs) has profound effects on the plasma levels of haemostasis and inflammation variables, resulting in an increased thrombosis risk. Individuals show large differences in the response of these variables to OCs. Polymorphism in the estrogen receptor-1 (ER1) gene may explain part of this inter-individual response.

METHODS

We investigated the relationship between variants (c.454-397T>C and c.454-351A>G polymorphisms and the combined haplotype) in the ER1 gene in relation to changes in haemostasis and inflammation variables that are known risk factors for thrombosis in 507 healthy, nonsmoking, nulliparous women receiving six cycles of monophasic OCs with 20, 30 or 50 microg/day estrogen.

RESULTS

A significant relationship was observed between the ER1 haplotype and changes in tissue-type plasminogen activator activity (P = 0.006), but no clear interaction pattern between the genotypes or between the estrogen doses was seen. No relationships were observed for the other variables, neither in the haplotype nor in the single polymorphism analysis.

CONCLUSION

The ER1 haplotype does not have a strong effect on the estrogen-induced changes in haemostasis and inflammation risk markers for arterial and venous thrombosis.

Cycle control, quality of life and acne with two low-dose oral contraceptives containing 20 microg ethinylestradiol

OBJECTIVES

Poor cycle control and tolerability can be reasons for irregular pill intake. This study compared the tolerability of two low-dose oral contraceptives and their effect on cycle control.

METHODS

In this open, group-comparative, randomized multicenter trial in Germany and the Netherlands, women received either 20 microg ethinylestradiol plus 150 microg desogestrel (20EE/DSG; n = 500) or 20 microg ethinylestradiol plus 100 microg levonorgestrel (20EE/LNG; n = 498) for six treatment cycles. Cycle control, dysmenorrhea and premenstrual syndrome (PMS) were assessed using diary cards. Tolerability was assessed using the self-administered questionnaires Psychological General Well-Being Index (PGWBI) and the Profile of Mood States (POMS). Acne was assessed by objective (acne counts) and subjective (no, moderate, mild, severe) acne scoring of the facial area at baseline and treatment cycles 1, 3 and 6.

RESULTS

A total of 404 (78.1%) and 384 (75.3%) women in the 20EE/DSG and 20EE/LNG groups, respectively, completed the trial. The occurrence rate of irregular bleeding and spotting was statistically significantly higher with 20EE/LNG than with 20EE/DSG (0.18 vs. 0.13; p < 0.05). The mean number of bleeding-spotting days per cycle was statistically significantly higher with 20EE/LNG than with 20EE/DSG (0.63 vs. 0.48; p < 0.05). Early withdrawal bleeding was more frequent with 20EE/LNG (0.15 vs. 0.08; p < 0.005), whereas continued withdrawal bleeding was more frequent with 20EE/DSG (0.32 vs. 0.45; p < 0.001); absence of withdrawal bleeding was comparable (0.06 vs. 0.04, respectively). Thirteen subjects in the 20EE/LNG group and three in the 20EE/DSG group discontinued due to unacceptable bleeding (p < 0.05). Dysmenorrhea and PMS decreased comparably in both groups. There were no differences between groups for the mean total scores of PGWBI or POMS at all time-points. Fewer acne lesions were counted with 20EE/DSG vs. 20EE/LNG after six cycles (p < 0.05). The subjective acne scores supported this finding.

CONCLUSIONS

20EE/DSG provided better cycle control than 20EE/LNG with less treatment discontinuation due to unacceptable bleeding. There were no apparent differences between the two groups regarding tolerability and quality of life. There was less acne with 20EE/DSG.

Effect of four oral contraceptives on hemostatic parameters

This is the first double-blind, controlled, randomized study comparing the effect of different estrogen components in oral contraceptives (OCs) on hemostasis variables. Four groups of 25 women each were treated for six cycles with monophasic combinations containing 21 tablets with either 30 microg ethinylestradiol (EE) + 2 mg dienogest (DNG) (30EE/DNG), 20 microg EE + 2 mg DNG (20EE/DNG), 10 microg EE + 2 mg estradiol valerate (EV) + 2 mg DNG (EE/EV/DNG) or 20 microg EE + 100 microg levonorgestrel (LNG) (EE/LNG). Blood samples were taken on Days 21-26 of the control cycle and on Days 18-21 of the first, third and sixth treatment cycle. Treatment with all four OCs caused an increase in levels of fibrinogen, prothrombin fragment 1+2, D-dimer, plasminogen, plasmin-antiplasmin complex and an increase in protein C activity, a decrease in antithrombin activity, tissue-plasminogen activator (t-PA) and plasminogen activator inhibitor (PAI), and a slight decrease in the sensitivity to activated protein C, but no significant change in that of the thrombin-antithrombin complex. In users of the DNG-containing OCs, the reduction in total and free protein S, and in t-PA and PAI was dependent on the EE dose, while factor VII activity was elevated, but not significantly different from EE/LNG. The results are in agreement with those of previous studies. The effects of EE/EV/DNG on total and free protein S and on t-PA and PAI were lower than those of 20EE/DNG, suggesting that the impact of 2 mg EV on several hemostasis variables is less than that of 10 microg EE. The results show an antagonistic effect of LNG on the EE-induced rise of factor VII activity and fragment 1+2 and on the EE-dependent reduction of total and free protein S.

Effect of four oral contraceptives on thyroid hormones, adrenal and blood pressure parameters

In a double-blind, controlled, randomized, four-arm, bicentric clinical study, the effect of four oral contraceptives (OCs) on thyroid hormone parameters, cortisol, aldosterone, endothelin-1 and angiotensin II was investigated. Four groups composed of 25 volunteers each (ages between 18 and 35 years) were treated for six cycles with monophasic combinations containing 21 tablets with either 30 microg ethinylestradiol (EE) + 2 mg dienogest (DNG) (30EE/DNG), 20 microg EE + 2 mg DNG (20EE/DNG), 10 microg EE + 2 mg estradiol valerate (EV) + 2 mg DNG (EE/EV/DNG) or 20 microg EE + 100 microg levonorgestrel (LNG) (EE/LNG). The study was completed by 91 subjects. Blood samples were taken by venipuncture after at least 12 h fasting on Day 21-26 of the control cycle and on Day 18-21 of the first, third and sixth treatment cycle. There was a significant increase in triiodothyronine (T3) and thyroxine (T4) by 20-40% in all treatment cycles, while thyroid-stimulating hormone was significantly increased only with EE/EV/DNG. Treatment with the DNG-containing OCs caused no change in free T4 (FT4) and a transitory reduction in free T3 (FT3) levels during the first cycle. During intake of EE/LNG, FT4 rose slightly, while FT3 was not altered. The pronounced rise in the serum concentrations of cortisol appeared to be related to the EE dose. During the first three cycles of treatment, no effect on angiotensin II levels was observed, while in the sixth cycle a significant decrease was measured in all treatment groups. The four OCs did not influence the serum concentrations of endothelin-1 and no consistent effects were found concerning those of aldosterone. The results suggest that the three DNG-containing and the LNG-containing low-dose OCs may increase T3, T4 and cortisol due to an elevated binding to serum globulins, while the free proportion of the hormones is not or only slightly changed. Therefore, these OCs have only minor effects on thyroid function, adrenal and blood pressure serum parameters.

Effect of four different oral contraceptives on various sex hormones and serum-binding globulins

In a double-blind, controlled, randomized, four-arm, bicentric clinical study, the effect of four oral contraceptives (OCs) on various hormone parameters and serum-binding globulins was investigated. Four groups with 25 volunteers each (18-35 years of age) were treated for six cycles with monophasic combinations containing 21 tablets with either 30 microg ethinylestradiol (EE) + 2 mg dienogest (DNG) (30EE/DNG), 20 microg EE + 2 mg DNG (20EE/DNG), 10 microg EE + 2 mg estradiol valerate (EV) + 2 mg DNG (EE/EV/DNG) or 20 microg EE + 100 microg levonorgestrel (LNG) (EE/LNG). The study was completed by 91 subjects. Blood samples were taken after at least 12 h of fasting on Day 21-26 of the preceding control cycle and on Day 18-21 of the first, third and sixth treatment cycle. The serum concentrations of free testosterone were significantly decreased by about 40-60% in all four groups, while those of dehydroepiandrosterone sulfate (DHEAS) showed a time-dependent decrease during treatment. Except for EE/EV/DNG, which increased prolactin significantly during the third and sixth cycles, no change was observed with the EE-containing preparations. There was a significant increase in the levels of serum-binding globulins during treatment, which differed according to the composition of the OCs used. The rise in sex hormone-binding globulin (SHBG) was highest during intake of 30EE/DNG (+320%) and lowest with EE/LNG (+80%), while the effect of 20EE/DNG and EE/EV/DNG was similar (+270%). The thyroxine-binding globulin (TBG) levels increased significantly, by 50-60%, during treatment with the DNG-containing formulations, while the effect of EE/LNG was less significant (+30%). The rise in corticosteroid-binding globulin (CBG), which occurred in all groups, was most pronounced in women treated with 30EE/DNG (+90%) and least with EE/EV/DNG (+55%), indicating a strong influence of EE and no effect of the progestogen component. In all treatment groups, the frequency of intracyclic bleeding rose in the first treatment cycle and decreased thereafter. Cycle control was significantly better with 30EE/DNG or EE/LNG than with 20EE/DNG or EE/EV/DNG. There was no significant change in blood pressure, body mass index or pulse rate throughout the study. In conclusion, the DNG-containing OCs caused a higher rise in SHBG and TBG levels than the LNG-containing preparation. The effects on CBG suggest a lesser hepatic effect of 2 mg EV as compared to 20 or 30 microg EE. In contrast to EE, the use of estradiol in OCs appeared to increase prolactin release, while the cycle control was better with the OC containing 30 microg EE.

Effect of dienogest-containing oral contraceptives on lipid metabolism

In a double-blind, controlled, randomized, four-arm, bicentric clinical study, the effect of four oral contraceptives (OCs) on lipid metabolism was investigated. Four groups composed of 25 volunteers each (mean age 26.1 +/- 4.5 years; body mass index 21.9 +/- 2.8 kg/m(2)) were treated for six cycles with monophasic combinations containing 21 tablets with either 30 microg ethinyl estradiol (EE) + 2 mg dienogest (DNG) (30 EE/DNG), 20 microg EE + 2 mg DNG (20 EE/DNG), 10 microg EE + 2 mg estradiol valerate (EV) + 2 mg DNG (EE/EV/DNG), or 20 microg EE + 100 microg levonorgestrel (LNG; EE/LNG). The study was completed by 91 women. Blood samples were taken by venipuncture after at least 12 h fasting on Days 21-26 of the control cycle and Days 18-21 of the first, third, and sixth treatment cycle. There were clear differences between the effects of EE/LNG and the formulations containing estrogens and DNG. Although EE/LNG did not change the triglycerides levels, a significant increase was observed during treatment with the DNG-containing preparations. Although EE/LNG significantly reduced HDL-CH and HDL(2)-CH, there was a nonsignificant increase with the DNG-containing OCs. No change was observed in the levels of HDL(3)-CH. A significant rise in apolipoprotein A1 occurred during intake with the three DNG-containing formulations, but not with EE/LNG. In contrast to the women treated with combinations of estrogens and DNG, apolipoprotein B rose significantly in the women in the EE/LNG group. Lipoprotein (a) was significantly reduced by 30 EE/DNG and EE/LNG and remained unaltered with 20 EE/DNG and EE/EV/DNG. Altogether, the changes in lipid metabolism caused by the DNG-containing formulations appeared to be more favorable than those observed with EE/LNG. In OCs with DNG, the EE dose does not seem to play a major role with respect to the effect on lipids.

Cyclic progestin therapy for the management of mastopathy and mastodynia

The management of benign diseases of the breast aims to halt the progression of fibrocystic transformation and to eliminate the symptoms of pain and breast tenderness. Progestins can be used for this purpose. In a controlled, randomized, double-blind, parallel-group study we treated 31 women with mastopathy/mastodynia with the progestins medrogestone (10 mg/day) or dydrogesterone (10 mg/day) from day 14 to day 25 for six cycles. Before, during and at the end of therapy the following parameters were evaluated: subjective symptoms (pain, tenderness, impairment of daily activities), palpatory findings, sonographic diagnosis and sex hormone profiles. Cyclic administration of the low-dose progestins medrogestone and dydrogesterone proved to be an effective and safe treatment of mastodynia and mastopathy. The objective parameters palpatory findings and sonographic imaging of breast nodules and cysts improved in more than 50% of patients. Improvement was particularly marked in women with low progesterone levels in the second half of the cycle. After six treatment cycles, 75% of the patients treated with dydrogesterone and 86% of the patients treated with medrogestone were completely pain-free.

The effect of tranexamic acid on the quality of life of women with heavy menstrual bleeding

OBJECTIVE

To investigate whether medical treatment with tranexamic acid would increase the quality of life of women with heavy menstrual bleeding.

STUDY DESIGN

This open, uncontrolled usage study included 849 women diagnosed with heavy menstrual bleeding and considered eligible for tranexamic-acid treatment. The condition of the women was investigated at baseline and after the first and the third treated menstruation. Quality of life and subjectively experienced state of health were assessed with the aid of a questionnaire. Satisfaction with the treatment was registered.

RESULTS

After the third menstruation, 80% of the women were satisfied with the treatment. Impairment of social activities and impairment at work were greatly reduced by the treatment. Substantial improvements were also recorded with regard to alertness, productivity, cleanliness, spirits, action radius and overall well-being. Adverse reactions to the drug used for the treatment were few and non-serious.

CONCLUSIONS

Medical treatment with tranexamic acid increases quality of life for women with heavy menstrual bleeding.

Hemostatic effects of high-dose megestrol acetate therapy in patients with advanced gynecological cancer

Effects of high-dose megestrol acetate on blood coagulation and fibrinolysis were investigated in patients with gynecological (n = 13) and breast (n = 10) cancer. Patients received either 160 mg or 320 mg/day megestrol acetate orally. Blood sampling was performed prior to and after months 1, 3 and 6 of treatment. Pretreatment values of global clotting times, fibrinogen, factor VII, thrombin-antithrombin III complex, anticoagulation, fibrinolysis and antifibrinolysis were found to be within the reference range. Elevated plasma levels were demonstrated for prothrombin fragments 1 and 2, fibrin degradation products and the plasmin-antiplasmin complex. We demonstrated a significant 20-30% reduction of factor VII until the 3rd month of therapy. No further effects were seen within the remaining 3 months of treatment. For the other analyzed parameters of hemostasis, no significant influence of high-dose progestin treatment was found. Furthermore, we observed no clinically relevant differences between the two dosages. Our results do not provide any evidence that there is a thrombogenic effect of high-dosage megestrol acetate with 160 mg or 320 mg per day amongst patients with advanced gynecological malignancies. The observed incidence of thrombosis might be the consequence of other risk factors such as tumor-induced hypercoagulability, simultaneous chemotherapy or other individual thrombosis risk factors.

Perioperative development of a thrombogenic risk profile in patients with carcinomas of the breast: a cause of increased thrombosis

Within the context of a prospective study we investigated the influence of malignant and benign breast disease on the coagulation systems both prior to and after surgery. In addition we also investigated to what extent individual risk factors aid the formation of a thrombophiliac risk profile. Altogether 50 patients with carcinomas of the breast and 12 patients with benign breast disease were included in the study. The coagulation investigations took place prior to surgery and on the 1st, 3rd, 7th and 10th day following the operation. The results have already revealed that prior to surgery a clear activation of the haemostasis takes place among patients with a carcinoma of the breast. When compared to patients with benign breast conditions there was a far greater plasma level of factor VIII vWF, fibrinogen, thrombin-antithrombin III complex, D-dimer fibrin degradation products, tissue-type plasminogen activator and the activity and the antigen of plasminogen activator inhibitor 1. Also during the postoperative period the malignant tumour was a stimulus for additional increased activity of blood coagulation and fibrinolysis. Individual risk factors such as age, menopausal status, obesity and smoking lead to a thrombogenic risk profile which could provide a possible explanation for the observed increased incidence of thrombosis in breast cancer patients. For the clinical work there is a need for intensive pre- and postoperative monitoring in the cases of patients with malignant tumours including angiological examinations, intensive physiotherapy and a risk-adapted prophylactic anticoagulation.

[Liposuction for "body contouring" in gynecology]

OBJECTIVES

The aim of this study was to describe the possible use of the ultrasound-assisted liposuction and liposuction with the tumescent technique for the contouring and remodelling of superficial fat areas of women in the field of gynaecology.

PATIENTS AND METHODS

Between 1997 and 1999 85 healthy female patients underwent a liposuction in the department of gynaecology of the university of Essen. The patients were divided into two groups. Thirty patients (group 1) underwent an ultrasound-assisted liposuction whereas the remaining 55 patients (group 2) were operated using only the tumescent technique.

RESULTS

From the operated 582 body areas a large volume liposuction with the aspiration of more than 1,000 cc fat was performed in 48.2% of the cases. In the remaining 51.8% of the cases aspiration volumes between 300 and 1,000 cc fat were obtained. No statistically significant differences could be observed when comparing the aspirat volumes between both treatment groups (p > 0.05). Serious complications were not observed.

DISCUSSION

Our data could show, that liposuction is an extremely safe method for eliminating surperficial fat depots in the sense of body contouring in gynaecology, but that it should not be used for the reduction of obese body volumes. If ultrasound-assisted liposuction is really superior to liposuction with the tumescent technique remaining uncertain, no time gain could be observed due to this technique.

Adjuvant CMF-chemotherapy and haemostasis. Effect of "classical" and "modified" adjuvant CMF-chemotherapy on blood coagulation fibrinolysis in patients with breast cancer

Effects of "classical" and "modified" adjuvant CMF-chemotherapy on haemostasis were studied in 22 patients with breast cancer receiving cyclophosphamide (100 mg/m2 p.o.; days 1-14 or 600 mg/m2 i.v.; days 1,8), methotrexate (40 mg/m2 i.v.; days 1,8) and 5-fluorouracil (600 mg/m2 i.v.; days 1,8). Blood collection was done prior to chemotherapy on day 1 and 8. A significant decrease of protein C antigen and activity associated with cumulative effects was observed from day 1 to 8. This effect was similar with "classical" and "modified" CMF-chemotherapy but the reduction of protein C was more pronounced with the oral application of cyclophosphamide. In absence of any significant cumulative decrease of other vitamin K-dependent blood coagulation proteins (factor VII, protein S), the simultaneous decrease of protein C activity and antigen indicates a specific influence of CMF-chemotherapy on vitamin K-dependent protein C-synthesis in the liver.

Hemostatic effects of third- and second-generation oral contraceptives: absence of a causal mechanism for a difference in risk of venous thromboembolism

Some observational studies have found a difference in the risk of nonfatal venous thromboembolism (VTE) with low-dose, oral contraceptives (OCs) containing desogestrel (DSG) or gestodene (GSD) and those containing levonorgestrel (LNG). However, this does not agree with current pathophysiological concepts. This review compares all 17 comparative studies on the hemostatic effects of DSG/GSD- and LNG- or norgestimate (NGM)-containing OCs, and comments on two recent cross-sectional studies on the effects of third- and second-generation OCs on activated protein C (APC) sensitivity. In the comparative studies, the only difference in hemostatic parameters between DSG/GSD- and LNG- or NGM-containing OC users was a tendency towards higher factor VII (FVII) levels with DSG/GSD OCs. Differential effects on APC sensitivity were observed with the endogenous thrombin generation potential (ETP) assay, but not with the classical APC resistance test. FVII is not a risk marker for VTE, but is affected by dietary fat, estrogens and androgens and may interfere with the ETP assay. As no differences in established VTE risk markers were observed, there is no plausible reason for a differential risk of VTE with DSG/GSD- and LNG-containing OCs. In fact, the lack of differences with regard to established risk markers of VTE gives further support to the findings of the most recent epidemiological studies, which have not found any difference in the risk of VTE between third- and second-generation OCs.

Effects of tibolone and continuous combined hormone replacement therapy on parameters in the clotting cascade: a multicenter, double-blind, randomized study

OBJECTIVE

To determine the effects of tibolone and continuous combined HRT (ccHRT) on parameters in the clotting cascade.

DESIGN

Randomized, double-blind study.

SETTING

Hemostasis unit of a university hospital clinic in Germany.

PATIENT(S)

Sixty healthy postmenopausal women.

INTERVENTION(S)

Twenty-nine subjects were treated with tibolone (2.5 mg/d) and 31 with oral ccHRT containing estradiol (2 mg/d) + estriol (1 mg/d) + norethindrone acetate (1 mg/d).

MAIN OUTCOME MEASURE(S)

Effects on parameters in the clotting cascade at baseline and after 12 and 24 weeks of treatment.

RESULT(S)

Tibolone increased fibrinolysis parameters without significantly altering coagulation parameters. Treatment with ccHRT resulted in a stimulating effect on parameters of both fibrinolysis and coagulation. Tibolone showed a stronger reduction of factor VII activity; less reduction of AT-III, protein C activity, and protein S activity; stronger increase of the activated partial thromboplastin time, plasminogen and plasminogen-antiplasminogen complexes; and less increase of D-Dimer than ccHRT. Both preparations similarly reduced climacteric complaints, whereas tibolone showed less breast complaints than ccHRT.

CONCLUSION(S)

This study confirms that tibolone, and to a lesser extent also ccHRT, changes hemostasis parameters toward a more fibrinolytic profile, which may diminish the risk of venous thrombosis.

[Non-contraceptive benefits of the pill--an often neglected fact]

While rare cardiovascular risks of oral contraceptives (OCs) caused a lot of concern among OC-using women in the recent past, little attention has been paid in the public to the non-contraceptive benefits of OCs. Short, medium and long term non-contraceptive benefits have to be considered. The early Anglo-American cohort and case-control studies demonstrated a reduction of menstrual complaints, iron-deficiency anaemia, ectopic pregnancies, and a partly drastic reduction of some benign and malignant tumours such as endometrial and ovarian cancer. A risk reduction of rheumatoid arthritis is discussed controversially. The present paper gives an overview of the state of knowledge. For newer OCs with different composition, comparable studies are lacking. Therefore, a cohort study was initiated in Germany in April 1998 to investigate these associations as well for newer OCs, which is presented. The described non-contraceptive benefits should be considered in the benefit-risk assessment when prescribing OCs.

[German Cohort Study of Women's Health--benefits of oral contraceptives. Study protocol]

This publication is about the study protocol of the German Cohort Study on Women's Health. The main objective is to investigate medical benefits of a long-term oral contraceptive use. The design is an analytical cohort study based on inquiries. Additional cases will be recruited to analyse rare events in separate case-control studies. Voluntary participants who signed to participate in a long-term study are included. An annual drop-out rate of 15% is expected. Study variables encompass personal characteristics, lifetime history of diseases, but also disturbances of the state of health, and quality of life. It is anticipated to achieve 400,000 women-years of observation by 2001 (historic and concurrent follow-up). The study started April 1, 1998 and the current financial phase finishes December 31, 2001. 6000 participants were recruited until December 1998 equivalent to about 190,000 observation-years. Until the end of 1999, an additional 70,000 women-years should be included. There have been many suggestions from participants' to include additional issues of women's health into the study.

A comparative study of the hemostatic effects of two monophasic oral contraceptives containing 30 mu(g) ethinylestradiol and either 2 mg chlormadinone acetate or 150 mu(g) desogestrel

OBJECTIVES

To determine the effect of two low-dose monophasic oral contraceptives containing either 2 mg chlormadinone acetate or 150 microg desogestrel on blood clotting and fibrinolysis.

METHODS

In vivo markers of intravascular coagulatory and fibrinolytic activity were measured in 45 volunteers randomly assigned to a 6-month treatment with one of the two study preparations.

RESULTS

During oral contraceptive use, the procoagulatory activity increased (increased prothrombin fragment 1+2), the anticoagulatory capacity changed (increased protein C activity, decreased activated protein C sensitivity, decreased protein S activity and decreased antithrombin III activity) and the fibrinolytic system was activated (increased concentrations of plasmin-antiplasmin complexes and D-dimer as well as total fibrin degradation products). There were no relevant differences between the two medication groups.

CONCLUSION

Our results demonstrate that both oral contraceptive preparations have comparable effects on the hemostatic system. There was a shift towards a new equilibrium of hemostatic activities, both coagulatory and fibrinolytic, at a higher turnover rate. Changes did not exceed the range of normal variation and were comparable to the published effects of other low-dose oral contraceptives. There was no evidence ofa differential risk of deep vein thrombosis between the two preparations.

[Pregnancy in mothers with congenital heart defects. An overview]

The improved pediatric-cardiological diagnostics and cardio-surgical therapy result in a numerical increase of women reaching reproductive age. Pregnancy considerably strains heart and circulation, which is countered by various cardiorespiratory mechanisms. Today mothers are not endangered vitally (exception: Eisenmenger-syndrome), but congestive heart failure, thromboembolic complications and rhythm disturbances may occur. Spontaneous abortion rate is 20-25%, prematurity and underweight are obligatory in cyanotic mothers. On the basis of an extensive review of literature the specific risks during pregnancy are discussed taking into account the hemodynamic situations in different heart defects. Anticoagulation of valve prosthesis depends upon the model and location of the prosthesis. Contraceptive counselling is deficient; it has to consider the risk of thromboembolic complications. Regarding the genetic risk we have to differentiate between each single defect and between the sex of the parents.

Effects of progestins on cardiovascular diseases: the haemostatic system

The effect of progestin-only therapy on the haemostatic system has mainly been studied in premenopausal women. Although these studies are difficult to compare, most authors agree that there is no consistent pattern of effects on haemostasis. Oestrogen-progestin combinations have been extensively studied in pre- (combined oral contraceptives) and postmenopausal women (sequential and continuous combined hormone replacement therapy), but mostly with emphasis on the effects of oestrogens. Comparative studies into the differential effects of progestins in combined preparations are scarce. Based on these studies, there is evidence for modifying effects of progestins on oestrogen-induced changes, particularly on fibrinogen, factor VII and the fibrinolytic system. The modifying effects appear to vary among certain progestins, the variation being most likely due to differential effects on lipid metabolism. The clinical interpretation of steroid-induced effects on the haemostatic system is difficult. Retrospective analyses linking certain patterns of haemostatic regulation to the risk of venous or arterial vascular diseases are subject to bias, and no interventional studies are yet available. In the absence of such prospective studies and well-designed comparative studies, the available data do not support the notion of a superiority of certain progestins with regard to cardiovascular risks of combined preparations.

Outcome of pregnancy in women with congenital heart disease

Improvements in diagnosis and surgical technique for correction have led to an increasing number of women with congenital heart disease reaching the child-bearing age. Pregnancy places considerable strain on the heart and circulation and necessitates marked cardiorespiratory adaptation. Today, with the exception of the Eisenmenger syndrome, there is no increased mortality associated with pregnancy in congenital heart disease. In contrast, there is still considerable morbidity, due to congestive heart failure, thromboembolic complications and disturbances of rhythm. Fetal outcome is complicated by a high rate of spontaneous abortions (20-25%), retardation of fetal growth, and premature delivery (almost 100% in cyanotic mothers). Based on an extensive review of the literature, we discuss the specific risks in pregnancy depending on the hemodynamic situations produced by different heart defects. We also discuss the risks and advantages of different regimens for anticoagulation. Counselling concerning contraception is frequently inadequate. The most important problems are thromboembolic complications with the use of hormonal contraception, and hyper- and dysmenorrhea in those using intrauterine devices. Finally, the genetic risks must be considered, differentiating between single gene defects and the sex of the parents suffering from congenital heart diseases.

Effects on hemostatic variables of desogestrel- and gestodene-containing oral contraceptives in comparison with levonorgestrel-containing oral contraceptives: a review

In some studies third-generation oral contraceptives have been reported to be associated with a higher risk of venous thromboembolism than are second-generation oral contraceptives, whereas recent, more refined studies have not confirmed this. The reasons for the alleged differences are under discussion, and differential effects on hemostasis have been proposed. Eighteen studies comparing second- and third-generation oral contraceptives with respect to their effects on hemostasis were analyzed. Significant changes from baseline were reported for many variables with both second- and third-generation oral contraceptives without significant between-group differences. Also, in a combined analysis of nonsignificant changes, no consistent pattern of change emerged for any marker, with the exception of higher factor VII levels associated with third-generation oral contraceptives. However, factor VII is not related to venous thromboembolism risk. In addition, 1 cross-sectional study with an unvalidated assay reported a higher ratio of activated protein C sensitivity with third-generation oral contraceptives. Only 2 components of the hemostatic system (factor VII and activated protein C sensitivity ratio) emerged as potentially differentially affected by second- and third-generation oral contraceptives; the association with venous thromboembolism risk is questionable in the former case and unknown in the latter.

Adjuvant antiestrogen treatment with tamoxifen in postmenopausal women with breast cancer: a longitudinal study of blood coagulation and fibrinolysis

Potential effects of tamoxifen therapy on blood coagulation and fibrinolysis were investigated in women with breast cancer. We studied 14 parameters of hemostasis in 19 postmenopausal women receiving 20 mg tamoxifen/day as an adjuvant treatment. Blood sampling was done before and after the 1st, 3rd, and 6th month of treatment. Pretreatment values of procoagulation, anticoagulation, plasminogen, and plasminogen activator inhibitor were found within the reference range, whereas tissue-plasminogen activator, fibrin degradation products, and prothrombin-fragment 1+2 were elevated. On therapy an initial decrease of all measured parameters was observed. The effect was pronounced in coagulation inhibitors (antithrombin III, protein C and S). No pathological values (below 60%) were observed. No further effects were found during the 3rd and 6th month of treatment. Our data indicate that the decrease of hemostatic parameters during the initial phase of tamoxifen treatment is due to the timing of blood collection, which took place no more than 14 days after surgery. The reduction of coagulation inhibitors was not associated with pathological values. No cumulative effects were seen during tamoxifen therapy. The decrease was not associated with a concomittant increase of in vivo coagulation markers (prothrombin-fragment 1+2, thrombin-antithrombin-complex, fibrin degradation products). Therefore our results are likely to reflect only the resolution of postoperative activation and do not translate into a drug related thrombogenic effect.

[Obesity and thrombotic vascular diseases]

Obesity may either be unspecific as indicated by an increased body mass index (BMI) or due to an abnormal fat-distribution as indicated by an increased waist-to-hip ratio (WHR). The latter is frequently associated with deteriorations of glucose tolerance, hypertriglyceridaemia and hypertension (the metabolic syndrome), a syndrome which is among the strongest risk factors of ischemic heart disease. It is important to note that visceral obesity is a frequent feature of the polycystic ovary syndrome. Also, weight gain after menopause is often associated with a particular increase of the WHR. Obesity as indicated by an increased BMI (> 30 kg/m2) is a weak but easily detectable risk marker of venous thrombotic disease. This risk needs to be considered in clinical practice since obesity was shown to enhance the power of precipitating risk factors of venous disease such as pregnancy, surgery or estrogen treatment.

A randomized controlled double-blind study of the effects on hemostasis of two progestogen-only pills containing 75 microgram desogestrel or 30 microgram levonorgestrel

The effects of two progestogen-only pills containing either 75 microgram desogestrel (DSG) or 30 microgram levonorgestrel (LNG) on hemostasis were investigated in a double-blind, randomized, controlled study of seven treatment cycles in 78 healthy women. DSG reduced factor VII activity (p < 0.05) and prothrombin fragment 1+2 (p < 0.05) and increased protein S (p < 0.001). LNG reduced factor VII activity (p < 0.01) and plasminogen activity (p < 0.01) and increased tissue-plasminogen activator (t-PA) (p < 0.05). At the end of the post-treatment cycle with DSG, protein S (p < 0.01) and t-PA (p < 0.05) were increased and plasminogen activity was decreased (p < 0.05), whereas with LNG, t-PA was increased (p < 0.001) and prothrombin fragment 1+2 (p < 0.05) and plasminogen activity (p < 0.001) were decreased. Between-group comparisons revealed higher values for DSG regarding the anticoagulatory parameter protein S at cycle 7 (p < 0.01) and post-treatment assessments (p < 0.05), and the fibrinolytic parameter plasmin-antiplasmin complex was higher with DSG at cycle 7 (p < 0.05) and at post-treatment (p < 0.05). Both preparations had comparable and potentially favorable effects of hemostasis, and may offer suitable hormonal contraception to women with a personal or family history of venous thromboembolic diseases.

Activated protein C resistance and deficiencies of antithrombin III, protein C or protein S and the risk of thromboembolic disease in users of oral contraceptives

The objective of this paper was to assess the risk of thrombosis in users of oral contraceptives. Furthermore, the sensitivity, specificity and predictive values of potential screening tests for the prediction of thromboembolic complications in users of oral contraceptives were calculated for the approximately six million German pill users. Despite high specificity, the predictive values of a positive family history, or evidence of either antithrombin III, protein C or protein S deficiency or resistance to activated protein C, are low due to the very low absolute risk of thrombosis among pill users. More than half of the 840 annual cases would pass the screening protocol undetected. A two-step screening protocol is suggested using family history as a selection criterion (thus reducing the need for laboratory screening by 85%) for laboratory investigation of activated protein C sensitivity and deficiencies of antithrombin III, protein C or protein S. Genotyping for factor V Leiden mutation is useful in cases with equivocal activated protein C sensitivities or to confirm a homozygous genotype.

[The effect of cyclic administration of progestagens on blood coagulation factors]

The relationship between thromboembolism and oral contraceptives has been discussed for 30 years. Recently, a new actuality for this problem has grown up. The estrogen component of the preparations seems to be the cause, but some authors also think of the progestogens as responsible for drug-related thromboembolic disorders. In 31 patients with mastopathy or mastodynia, who had been treated with 10 mg medrogeston of dydrogesteron for six cycles, there were no significant changes in the parameters of hemostasis and fibrinolysis. Especially, we did not find any indications to an activation of the coagulation system. There is no evidence for a thrombogenetic effect caused by the cyclic therapy with these progestogens.

[Effect of ethinyl estradiol-dienogest combination on serum androgen concentrations]

Antiandrogens or progestins with an antiandrogenic component usually have only a weak antigonadotropic activity. It is thus possible that the antiandrogenic effect on the cellular level is cancelled or at least reduced by an increased ovarian androgen production. The aim of the four submitted clinical studies of the progestin and antiandrogen dienogest alone (0.5-2 mg/day) or of a combined regimen of ethinylestradiol (0.03 mg) plus dienogest (2 mg) (EE/DNG) was to examine the influence on the serum androgen and SHBG concentrations as well as on the serum FSH, LH, progesterone and 17 beta-estradiol concentrations in young women. Like the progesterone derivatives, dienogest has a relatively low antigonadotropic activity. Inhibition of ovulation is mainly produced by peripheral mechanisms such as the reduction of preovulatory 17 beta-estradiol secretion. Dienogest alone has no significant effects on the serum SHBG and androgen concentrations. Unlike this, the combination of EE plus DNG markedly increases SHBG concentrations (to 2.1-3.7 fold the basal levels). The decrease in serum androgens with total testosterone (by 17 and 40%), free testosterone (by 48 and 54%) and dehydroepiandrosterone sulfate (by 51%) corresponds to the values shown in the literature for other oral contraceptives with modern progestins. EE/DNG does not affect the serum concentrations of 5 alpha-dihydrotestosterone (DHT), although the marker of the peripheral transformation from T to DHT, androstanediol glucuronide, is distinctly reduced (by 38%). In a double-blind comparison no differences are found between EE/DNG and a regimen combining 0.02 mg of ethinylestradiol and 0.150 mg of desogestrel. Solely the SHBG concentrations, with EE/DNG, as expected, are significantly higher. In a sequential regimen, dienogest, chlormadinone acetate and desogestrel (progestins without binding to SHBG) enhance the inhibitory effect of ethinylestradiol sulfonate on free testosterone, whereas norethindrone acetate and levonorgestrel (progestins with a strong binding to SHBG) reduce this effect of the estrogen significantly. These results exclude the possibility that the very distinct antiandrogenic effect of dienogest on a cellular level is neutralised or reduced by an increased systemic supply of androgen.

Blood coagulation and oral contraceptives. A critical review

The use of oral contraceptives is associated with altered plasma concentrations of many components of the coagulation and fibrinolysis system, increased plasma levels of markers indicating in vivo coagulation and fibrinolysis, and a modified response to challenge tests both in vivo and in vitro. None of these effects seems to be specific for users of oral contraceptives and none was found uniformly in all users. The predictive value of each of these effects, or even of certain combinations of tests, for the prediction of venous thrombosis is low. There is no established way to assess the "thrombogenicity" of particular pills. The individual susceptibility, however, to develop venous thrombosis varies considerably. Recently, several congenital abnormalities of the hemostatic system have been found that are associated with an increased risk of venous thrombosis in general. The risk associated with the use of oral contraceptives appears to act synergistically with some of these thrombophilic conditions. Although the prevalence of these congenital predispositions varies among different populations, screening for these conditions is not feasible: negative results would not exclude the occurrence of about two-thirds of oral contraceptives-associated thromboses and positive results are likely to be disregarded because of their poor predictive value. Future research has to evaluate the role of a more targeted screening strategy aiming at women with risk factors such as a positive personal or family history of venous thromboembolism.

[Activation of blood coagulation and fibrinolysis after angiocardiography with ionic and non-ionic contrast media]

PURPOSE

To study the effects of a ionic (amidotrizoate) and a non-ionic x-ray contrast medium (iopromid) during routine levocardiography and coronary angiography, we employed assays that detect reaction products of thrombin and plasmin to assess the activation of the haemostatic system.

METHODS

Subsequent to informed consent, 20 patients were randomly assigned to receive either amidotrizoate or iopromid during standard levocardiography and coronary angiography in a double-blind comparative study. Groups were comparable in respect of age, weight, sex and severity of the disease. No anticoagulation was provided. Coronary angiography was performed according to a standardised protocol. Consumption of contrast media and duration of the examination were comparable in both groups.

RESULTS

Thrombin generation (F.1+2) and thrombin activity (TAT) were higher with the ionic contrast medium but did not attain statistical significance. Fibrin generation and degradation as expressed by D-dimer fibrin split products was significantly increased in patients who had been receiving amidotrizoate (p < 0.05, U-Test).

CONCLUSION

The non-ionic x-ray contrast medium induced significantly less haemostatic activation in vivo than did the ionic medium amidotrizoate. These data suggest that earlier in vitro observations of more pronounced anticoagulant effects of ionic x-ray contrast media are of limited significance for the evaluation of in vivo effects of x-ray contrast media on haemostatic function.

[Adjuvant CMF chemotherapy in patients with breast cancer--results on blood coagulation and fibrinolysis]

Breast cancer disease and as well as CMF-chemotherapy are associated with an increased risk for thromboembolic complications. There is evidence that effects on the hemostatic system may play an important role. To minimize the impact of tumor associated hypercoagulability, we choose to study CMF-associated effects on the hemostatic system within an adjuvant setting. Blood coagulation and fibrinolysis were examined before and 24 hours after intravenous application of CMF-therapy at 17 patients with breast cancer. 16 parameters of coagulation and fibrinolysis were studied. In a longitudinal analysis covering the complete 6 month treatment period we found a decrease of thromboplastin time (TPZ) factor VII (FVII) and protein C antigen (PC Ag) and activity (PC Act). Clinically relevant pathological results and cumulative effects were observed only for PC Ag and Act, while the mean values of TPZ and FVII returned to pre-treatment levels after each course of treatment. These data suggest a potential impact of CMF-chemotherapy on synthesis and activation of vitamin-K-dependent coagulation factors thus providing a possible explanation for the increased risk for thrombosis during CMF-chemotherapy.

A multicenter European survey of the attitudes to contraception in women at high risk or with established cardiovascular disease

OBJECTIVES

The survey was designed to study the attitudes of gynecologists from 11 European centers providing guidance in contraception to women at high risk and women with cardiovascular disease.

METHODS

Attitudes were registered by means of a standard questionnaire.

RESULTS

Most contributors reported that, in women with venous thrombosis (10/11), deep venous thrombosis (10/11), coagulation disorders (11/11) and stroke (8/11), they prefer to prescribe methods other than combined oral contraceptives (COCs). A history of myocardial infarction was considered a relative contraindication and some experts suggested that, in some cases, the use of third-generation COCs may be possible. COCs were not recommended in women with severe cardiovascular disease and in those over 35 years of age with light or moderate cardiovascular disease, heavy smokers (over 20 cigarettes per day), or those presenting with severe hyperlipidemia.

CONCLUSION

The pill is not considered appropriate for women with clinically established cardiovascular diseases or in cases where more than two coronary risk factors exist. COCs may safely be given to women with elevated blood pressure as long as it is lower than 160/100 mmHg, in cases of light and moderate cardiovascular disease as long as the patient is less than 35 years of age, in women who are not heavy smokers, in the presence of a light or moderate degree of hyperlipidemia, and in uncomplicated diabetes mellitus provided that there are no additional risk factors. In these cases, third-generation COCs are preferred. The co-operation of the cardiologist is desirable in order to classify cardiovascular disease and for patient follow-up.

Ethinylestradiol 20 versus 30 micrograms combined with 150 micrograms desogestrel: a large comparative study of the effects of two low-dose oral contraceptives on the hemostatic system

In a 6-month, randomized, double-blind study the effects of two combined oral contraceptives containing 150 micrograms desogestrel and either 20 or 30 micrograms ethinylestradiol on hemostatic parameters were investigated in 1633 healthy women. Compared with baseline, the 30 micrograms ethinylestradiol formulation increased prothrombin fragment 1 + 2 (+72.2%), D-dimer (+42.4%) and protein C activity (+6.1%), whereas antithrombin-III activity (-6.3%) and protein S activity (-19.7%) were decreased. The use of the 20 micrograms ethinylestradiol formulation was associated with the same pattern of changes, but with lower magnitude (F1+2 + 61.1%, D-dimer +36.0%, antithrombin III -5.3%, protein C +4.6% and protein S-16.0%). The changes from baseline were significantly smaller in the 20 micrograms ethinylestradiol group for D-dimer, antithrombin III and protein S than in the 30 micrograms ethinylestradiol group (p = 0.019, p = 0.038 and p = 0.001, respectively). One woman with a combined deficiency of proteins C and S developed deep venous thrombosis while using the 20 micrograms ethinylestradiol formulation. Use of both formulations was associated with a shift of the coagulation-fibrinolysis balance to an enhanced fibrin-generating and fibrin-degradating activity. The less-pronounced effect on hemostasis with the 20 micrograms ethinylestradiol preparation is reassuring with regard to thromboembolic risk in general. However, women with coagulation inhibitor deficiency should be advised not to use oral contraceptives.

Effects of androgens on haemostasis

Androgen deficiency is associated with an increased incidence of cardiovascular disease. There is evidence that thromboembolic disease as well as myocardial ifarction in hypogonadic males are mediated by low baseline fibrinolytic activity. Hypogonadism in males is associated with an enhancement of fibrinolytic inhibition via increased synthesis of the plasminogen activator inhibitor PAI 1. On the other hand, stanozolol and danazol reduce PAI 1 and are associated with increased fibrinolytic activity. However, in male abusers of anabolic steroids the net effect on the haemostatic system may change from anti- to prothrombotic; there appears to be an individual threshold dose above which thrombogenic effects on platelets and vasomotion may overcome the profibrinolytic effects on PAI 1. There are numerous reports on weight-lifters dying of atherothrombotic ischemic heart disease while abusing anabolic steroids. Androgens are known to have profound effects on carbohydrate and lipid metabolism. In fact, much of the individual inconsistency of the effects of androgens on fibrinolytic and haemostatic activity appears to be based on the close interrelationship of these metabolic systems. Androgens may have unfavourable effects on the HDL/LDL cholesterol ratio, on triglyceride levels and on the insulin/insulin-like growth factor 1 (IGF 1) system. Hypertriglyceridemia as well as insulin resistance are both associated with low fibrinolytic activity and increased PAI 1 levels. On the other hand, lipoprotein(a), a recently acknowledged independent risk factor of CVD was shown to respond favourable to androgen treatment, in men as well as in women. In women, agonistic as well as antagonistic effects of estrogens and progestins need to be taken into account. In fact, estradiol may modulate testosterone effects on haemostasis. Androgen medication in premenopausal women, such as danazol, was found to reduce PAI 1 suggesting an improvement of the fibrinolytic activity. Also, in hormone replacement therapy (HRT) androgenic progestins or complex compounds with androgenic effects are associated with a marked reduction of PAI 1 and an improvement of fibrinolytic activity. Further improvement of fibrinolytic activity may be associated with the marked decrease of lipoprotein (a) (Lp(a)) in women on androgenic HRT. However, little is known on the interrelationship of estrogens, 19-nortestosterone or progesterone derivatives and testosterone. an interrelationship that may have substantial impact on the metabolic and particularly haemostatic net effects of a preparation. In summary, information on the effects of androgens on haemostasis is limited and may be particularly incomplete due to the fact that interaction with other sex steroids appears to be an important confounder. In any case, there are numerous effects of synthetic androgens on the synthesis and release of haemostatic factors, namely an increase of the inhibitors of coagulation and a decrease of the inhibitor of the fibrinolytic system. However, the use of androgens in patients with congenital deficiencies of these coagulation factors or previous events of cardiovascular disease has yielded disappointing results. On the other hand, particularly the reduction of fibrinolytic inhibition (PAI 1) and Lp(a) were considered favourable effects of androgens with regard to the risk of cardiovascular disease. Differences between preparations with pronounced androgenic versus antiandrogenic effects and the effect of combined preparations need to be studied in much more detail. The profibrinolytic effects of androgens may be of particular interest with regard to favourable effects of HRT on cardiovascular disease.

Hormone replacement therapy and hemostasis: principles of a complex interaction

Postmenopausal women on hormone replacement therapy (HRT) have been shown to be at reduced risk of arterial thrombotic disease. The risk of venous thrombosis appears not to be increased in HRT users in the absence of specific risk factors. However, while these data refer predominantly to women using conjugated equine estrogens, it is less clear whether the favourable impact on cardiovascular diseases may also be achieved by other preparations. Dose, as well as route of application and, particularly, the combination of steroids have been shown to affect both the clinical and the metabolic profile. With regard to cardiovascular diseases, differential effects on the hemostatic system are of particular interest. The principles of the interaction of steroids with the hemostatic system are reviewed. Also, the principal limitations of the assessment of the hemostatic system, as well as its interpretation, with regard to cardiovascular diseases are discussed. It is proposed to view the hemostatic system predominantly as a monitor of endothelial function rather than as a mediator of potential harmful effects on the cardiovascular system.

[Prevention and treatment of thrombosis in pregnancy]

Pregnancy and especially delivery and the puerperium are associated with an increased risk of thromboembolic disease. Intravenous high dose heparin is the therapy of choice for manifest thromboembolic disease in pregnancy. However, high-dose heparin fails to prevent postthrombotic chronic venous insufficiency in more than one-third of the cases. Low-dose heparin may be used for antithrombotic prophylaxis during pregnancy. However, low-dose heparin may induce a substantial loss of bone density in up to 30% of cases and may be complicated by heparin-associated thrombopenia in up to 2%. This review discusses strategies to reduce these considerable risks. Prospective studies suggest that the risk of recurrence after prior deep vein thrombosis may be somewhat overestimated. These data suggest new therapeutic options in women with no risk factors other than a personal history of thrombosis. Improved diagnostic techniques may contribute to a better evaluation of the individual risk by assessing possible underlying problems such as resistance to activated protein C or deficiencies of coagulation inhibitors. Also, duration of prophylactic anticoagulation may be reduced by targeting treatment to periods of increased risk such as immobilisation, dehydration, surgery, delivery and the puerperium. Recently, evidence has been provided indicating that the use of low molecular weight heparins may be associated with reduced loss of bone density and a significantly attenuated risk of heparin-associated thrombopenia.

Routine screening for coagulation inhibitors prior to prescribing the pill: prevalence data from a large cohort of German pill starters

A total of 2674 women were recruited to participate in a multicenter oral contraceptive (OC) study on hemostasis. At baseline, protein S activity less than 60% of normal values was found in two volunteers (0.75 per 1000) and the antithrombin III activity was less than 60% of normal values in three volunteers (1.1 per 1000). All measurements were confirmed by a second assessment. In contrast, of the 28 women presenting with protein C levels less than 60% of normal values, only six were confirmed (2.3 per 1000). Of these, one was also protein S-deficient. Seven women could not be studied twice and 15 were false-low according to their normal control values. These data suggest that routine screening of the hemostatic system may reveal findings suggestive of inhibitor deficiencies in as many as 3.75 per 1000 of apparently healthy candidates for OCs. However, our data also demonstrate that unselected screening is compromised by a considerable rate of false-positive results and cannot generally be recommended. However, screening of coagulation inhibitors is feasible in women with a family history of thromboembolic disease.

A comparative study of the effects of the hemostatic system of two monophasic gestodene oral contraceptives containing 20 micrograms and 30 micrograms ethinylestradiol

The effects of two oral contraceptives, containing gestodene and either 20 micrograms or 30 micrograms ethinylestradiol, on hemostatic parameters was investigated in a six-month randomized study involving a total of 40 healthy women between the ages of 18 and 30 years. A large number of hemostatic parameters were measured, which were categorized as either pro-coagulatory, anti-coagulatory, profibrinolytic, anti-fibrinolytic or indicative of fibrin turnover. Additionally, tissue plasminogen activator (t-PA) and plasminogen activator inhibitor (PAI-1) were measured before and after venous occlusion and delta and ratio values calculated. Pro-coagulatory factors as well as reaction products reflecting in vivo coagulatory activity (thrombin-antithrombin III complex, prothrombin fragment 1 + 2) were found to increase. Among the anti-coagulatory parameters, only protein S concentration and protein S activity decreased, most notably in the 30 micrograms EE group. There was a corresponding increase in fibrinolytic activity reflected by reaction products of in vivo fibrinolysis (plasmin-antiplasmin 2-complex, fibrin-degradation products). Measurement of t-PA and PAI-1, before and after venous occlusion, revealed that the fibrinolytic response was more pronounced in the 20 micrograms EE group. There was also an increase in the threshold of fibrinolytic inhibition (ratio PAI-1) in both groups, which was less pronounced in the 20 micrograms EE group. Apart from isolated measurements, all parameters remained within their normal ranges and values returned to baseline in the follow-up cycle. It is concluded that both preparations had a balanced effect on the hemostatic system stimulating both pro-coagulant and fibrinolytic activity. No statistically significant differences were observed between the two groups; however, there was a trend towards greater fibrinolytic capacity in the 20 micrograms EE group.

Hemostatic effects of two oral contraceptives containing low doses of ethinyl estradiol and either gestodene or norgestimate: an open, randomized, parallel-group study

OBJECTIVE

To determine effects on blood clotting of two modern low-dose monophasic oral contraceptives.

SUBJECTS AND METHODS

We measured in vivo markers of intravascular coagulatory and fibrinolytic activity in 40 volunteers randomly assigned to one of two low-dose oral contraceptives (OCs) for 6 months; one contained 35 micrograms of ethinyl estradiol (EE) plus 250 micrograms of norgestimate and the other, 30 micrograms of EE plus 75 micrograms of gestodene.

RESULTS

Both formulations increased coagulatory as well as fibrinolytic activity over baseline: circulating reactive products of thrombin increased by 40%, and plasmin activity by 60%, after 3 months of treatment. Six months of OC use increased hemostatic activity substantially over that with 3 months of use. Differences between both OC formulations were marginal and clinically insignificant.

CONCLUSION

The data suggest an EE-dose-dependent, balanced activation of in vivo coagulation and fibrinolysis in users of currently available, combined OCs. However, there is considerable consumption of coagulation inhibiting factors, suggesting that women with congenital deficiencies of antithrombin III and protein C should not use combined OCs.

[Hormone replacement therapy and the cardiovascular system: on the role of hemostasis]

Postmenopausal women using hormone replacement therapy are likely to experience the first signs of cardiovascular disease at a higher age than women with a comparable risk-profile who choose not to use hormone replacement therapy. Epidemiologic as well as clinical evidence suggest that this benefit prevails even in risk groups such as hypercholsterinemic, hypertensive or diabetic women. Thus, hormone replacement therapy exerts its clinical benefit via steroidal effects on various metabolic pathways. We have reviewed these metabolic effects with particular reference to the differential impact of oral versus transdermal therapy. We have focused on the endothelial function as the common final pathway of all pathomechanisms associated with cardiovascular disease. Endothelial dysfunction may be assessed by analysis of the hemostatic system. Analysis of the available data on hemostatic effects reveals only minor differences between oral and transdermal therapy and gives no support to the notion that only oral hormone replacement therapy provides benefits with regard to cardiovascular disease.

Influence of gestodene and desogestrel as components of low-dose oral contraceptives on the pharmacokinetics of ethinyl estradiol (EE2), on serum CBG and on urinary cortisol and 6 beta-hydroxycortisol

A randomized controlled clinical trial was undertaken over a 6-month treatment period with two low-dose combined oral contraceptives (OC) to investigate whether the metabolism and elimination of ethinyl estradiol (EE2) is differently influenced by the two progestational components gestodene (G) and desogestrel (D), an issue which has been very controversial recently. The two formulations contained 30 micrograms EE2 each, together with either 75 micrograms G or 150 micrograms D. Of the 40 young women recruited for each formulation, 31 of each group were available for statistical evaluation. The pharmacokinetics of serum EE2 were studied on day 1, 10 and 21 of cycle 1, 3 and 6. There were no significant differences between the two groups in any cycle with respect to parameters measured. This was true for the distinct intracyclical rise in the mean EE2 serum levels from day 1 to day 10 and the smaller further increase between day 10 and day 21, with no change in this respect between the cycles studied. Respective changes were seen with regard to the area under the EE2 serum concentration curve up to 4 and 24 hours (AUC0-4 and AUC0-24), cmax and tmax of serum EE2. The estrogen-dependent corticoid-binding globulin (CBG) increased similarly in the two groups intracyclically and slightly also intercyclically at all times tested. Except for the first treatment cycle, urinary excretion of cortisol and 6 beta-hydroxycortisol displayed a tendency to lower values intracyclically as well as intercyclically, again with no differences between the two groups. Also, the 6 beta-hydroxycortisol-to-cortisol ratio was not different between the groups, showing a slight tendency to rise from about 4 at the beginning of the medication to around 5.5 at the end of the 6th treatment cycle in both groups. It is concluded that G and D as components of low-dose OCs exert comparable effects on the metabolism and elimination of EE2.

Lack of coagulation defects after the intraamniotic instillation of ethacridine (Rivanol) for second trimester abortion

Second trimester abortion was induced by the intraamniotic infusion of ethacridine. Coagulation studies revealed no change in 10 cases. It is felt that the intraamniotic use of ethacridine is probably safe.