Enhanced generation and resolution of fibrin in women above the age of 30 years using oral contraceptives low in estrogen

Changes in blood coagulation and fibrinolysis associated with maximal exercise and physical conditioning in women taking low dose oral contraceptives

Blood coagulation parameters (thromboplastin time. PT; activated partial thromboplastin time, aPTT; fibrinogen; antithrombin III, ATIII; von Willebrand factor-concentration, vWF; factor VIII-activity, FVIII) and fibrinolytic parameters (plasminogen; (alpha-antiplasmin; euglobulin-lysis-time, Elt; tissue plasminogenactivator-antigen, tPA-antigen; plasminogenactivator-1-antigen, PAI-1-antigen) were evaluated in 34 women on low-dose oral contraceptives (OC) twice at intervals of 12 weeks each time before and after maximal exercise. During the 12 weeks, 24 women took part in an aerobic conditioning program and 10 women were requested to avoid any kind of sports activity for this period. Blood samples were taken before training and before and after maximal treadmill exercise. This procedure was repeated after the training program. After maximal exercise we found a significant reduction of aPTT and PT (increase in %), a decrease in ATIII, vWF, fibrinogen, plasminogen and alpha2-antiplasmin but an increase in fibrinolytic activity (all p<0.05). Maximal exercise is associated with an increase in blood coagulation and fibrinolysis also in women taking OC. After the physical conditioning program an increase in fibrinolytic activity at rest was noted in the training group. Opposed to that the fibrinolytic activity at rest decreased in the control group after abstinence of sports activity over this period (p<0.05, MANOVA).

The effects of a low-dose monophasic preparation of levonorgestrel and ethinyl estradiol on coagulation and other hemostatic factors

OBJECTIVE

This study was undertaken to evaluate the effects on hemostatic factors of a low-dose preparation of levonorgestrel and ethinyl estradiol in a 12-cycle study.

STUDY DESIGN

Thirty healthy women began taking 100 microg levonorgestrel and 20 microg ethinyl estradiol on the first day of the menstrual cycle, continued to take the preparation for the next 21 days, and then took placebo for 7 days. Mean changes in prothrombin time, partial thromboplastin time, and levels of factors VII and X, antithrombin, plasminogen, fibrinogen, protein S, thrombin-antithrombin complexes, and D-dimer were analyzed at baseline and at cycles 3, 6, and 12 with paired Student t tests.

RESULTS

Factor X, plasminogen antigen and activity, and D-dimer levels were significantly increased (P </=.01) during all 3 cycle periods. Antithrombin antigen and protein S total antigen levels were significantly (P </=.001 ) decreased at cycles 3, 6, and 12, whereas factor VII and protein S activity levels were significantly (P </=.05) decreased at cycle 3 and at cycles 3 and 6, respectively.

CONCLUSION

The effects on hemostatic factors in healthy women of a monophasic preparation of 100 microg levonorgestrel and 20 microg ethinyl estradiol were similar to those of other low-dose oral contraceptives.

Haemostatic changes and the oral contraceptive pill

Oral contraceptives have been linked to an increased incidence of thrombovascular disease. This may be mediated by their effects on the haemostatic system. An increase in the activity of coagulation Factors VII, X and fibrinogen occur with pill usage. Increased Factor VII levels are dependent on both the oestrogen and progestogen component of the oral contraceptive. A reduction in antithrombin III levels has also been observed in some but not all studies. Increased fibrinolysis has also been shown in oral contraceptive users which should balance the changes in the coagulation pathway. The increase in fibrinolytic potential is thought to be due to a decrease in the levels of plasminogen activator inhibitor I combined with an increase in the levels of plasminogen; tissue plasminogen activator antigen is decreased in most studies. The increased levels of endpoints of coagulation and fibrinolysis in pill users indicate that enhanced activity of both systems is occurring in vivo. The increased coagulation activity appears to be balanced by the rise in fibrinolytic activity, so preserving haemostatic balance. Enhanced platelet activity has also been shown in women taking oral contraceptives. Thrombus formation can result, however, when local vascular wall damage exists, or when other risk factors for thrombo-embolism, such as older age and smoking, coexist and create a local activation resulting in a thrombus. In these situations, the small differences in levels of coagulation factors in women taking different oral contraceptive formulations may be important. Pills containing the lowest doses of oestrogen (20 micrograms ethinyloestradiol) have shown the least changes in haemostatic factors. The progestogen component of the pill modifies the effect of oestrogen on the haemostatic system.

No influence of proinsulin and insulin on plasma levels of plasminogen activator inhibitor type 1 and tissue plasminogen activator in young women before and during intake of contraceptive steroids

Clinical observations in patients predisposed to cardiovascular disorders and recent experimental observations suggest that proinsulin and insulin participate in the regulation of fibrinolysis in vivo. In the present study, we examined if proinsulin and insulin affect the constitutive (fasting) secretion of plasminogen activator inhibitor type 1 (PAI-1) and tissue plasminogen activator (t-PA) in young healthy women (N = 17). We also measured the antigen concentrations of PAI-1 and t-PA during slow and fast changes in proinsulin and insulin levels induced by oral (OGTT) and intravenous (IVGTT) glucose tolerance tests. The assessments were performed before and after 6 months of treatment with contraceptive steroids, which have a well-defined influence on the fibrinolytic variables. We observed no consistent correlations between fasting values of proinsulin, insulin, PAI-1, and t-PA either before or during hormonal treatment. Before hormonal treatment, PAI-1 and t-PA antigen levels decreased (P < .05) during the hyperproinsulinemia and hyperinsulinemia induced by the OGTT and IVGTT. After hormonal intake for 6 months, a decrease only in t-PA concentrations during the OGTT was observed despite similar proinsulin and insulin responses to the glucose loads. Our findings suggest that proinsulin and insulin have no influence on the regulation of plasma levels of PAI-1 and t-PA in young healthy women, irrespective of intake of contraceptive steroids.

The effect of oestrogen dose and progestogen type on haemostatic changes in women taking low dose oral contraceptives

OBJECTIVE

To determine the effect of oestrogen dose and progestogen type on the coagulation and fibrinolytic systems of a group of normal healthy women taking three different oral contraceptive combinations.

DESIGN

Plasma levels of factor VII, X, antithrombin III, protein C, fibrinogen, tissue plasminogen activator activity, plasminogen activator inhibitor I antigen and fibrin (D-dimer) degradation products were measured at pretreatment, 6, 14, 22 weeks of treatment and at 6 weeks post-treatment in a group of 67 women taking either 30 micrograms ethinyloestradiol/150 micrograms desogestrel (n = 21), 20 micrograms ethinyloestradiol/150 micrograms desogestrel (n = 24), 30 micrograms ethinyloestradiol/75 micrograms gestodene (n = 22).

PARTICIPANTS

Sixty-seven healthy normal women, 18 to 34 years, smoking fewer than 15 cigarettes per day. The subjects were within 10% of their normal body weight and had no history of thromboembolic disease.

SETTING

Coombe Women's Hospital and St James's Hospital, Dublin, Ireland.

RESULTS

Factor VII and X levels were significantly raised on treatment with both the 30 micrograms ethinyloestradiol/desogestrel and gestodene combinations. Higher levels of factor VII activity were observed in the 30 micrograms ethinyloestradiol/desogestrel combination compared with the gestodene combination. Factor VII and X were not significantly affected by the 20 micrograms ethinyloestradiol combination. Increased plasminogen, fibrinogen and D-dimer levels and decreased plasminogen activator inhibitor I antigen levels were observed during the treatment phases in all three groups. Antithrombin III and protein C activity did not change during treatment with any of the oral contraceptives studied.

CONCLUSIONS

Low dose oral contraceptives cause an activation of the coagulation system which is balanced by an activation of the fibrinolytic system. Reducing the dose of ethinyloestradiol from 30 micrograms to 20 micrograms reduces the effect on factor VII and X. This effect can be modified by the progestogen. The lesser effect of the 20 micrograms combination may make this a safer option for some women than pills containing a higher dose of oestrogen.

Large increase in plasmatic 11-dehydro-TxB2 levels due to oral contraceptives

Coagulation factors, 11-dehydro-TxB2 (metabolite of TxA2) and 6-keto-PGF1 alpha (metabolite of PGI2) levels in 87 women who were treated for 9 months with oral contraceptives (OC) containing low doses of oestrogens and progestogens (Triquilar, Trinovum or Cilest) were investigated. In plasma, increases in F I, II, VII, VIII-c and 11-dehydro-TxB2 levels, but no modification of 6-keto-PGF1 alpha were observed. In urine, FPA concentration rose, but no change occurred in 11-dehydro-TxB2 and 6-keto-PGF1 alpha levels. No marked difference between the 3 OC preparations were noted. These data, and particularly the large increase of 11-dehydro-TxB2 (p < 0.01) suggest that a hypercoagulable state persists in low dosage OC users.

Assessment of endothelial function during oral contraception in women with insulin-dependent diabetes mellitus

The effects of contraceptive steroids on the expression of endothelial homeostasis were examined by direct and indirect measures in women with insulin-dependent diabetes mellitus (IDDM) in a prospective nonrandomized controlled study. Study subjects were 13 women with uncomplicated IDDM treated with a monophasic combination of 30 micrograms ethinyl estradiol and 75 micrograms gestodene for 12 consecutive cycles and 13 women of comparable diabetic status as control. During the study period, none of the participants developed increased renal albumin excretion, which was used as a direct measure of endothelial function. In the indirect assessment of endothelial function, we found a proportionate increase in plasma levels of thrombin-antithrombin III (TAT) complexes and D-dimer during treatment. Hormonal intake was followed by decreased antigen concentrations of tissue plasminogen activator (t-PA) and plasminogen activator inhibitor (type 1 [PAI-1]), whereas the activities of t-PA and PAI-1 were unchanged. Plasma levels of plasminogen and histidine-rich glycoprotein (HRG) increased and decreased, respectively, whereas an increase in von Willebrand factor was observed in the treatment group. No significant changes in direct or indirect measures were observed in the control group during the observation period of 12 months. In conclusion, no adverse effect on endothelial function was demonstrated by direct measures, but our findings suggest that a procoagulant state, compensated by enhanced activity of the fibrinolytic system, is induced by hormonal treatment. Clinical and metabolic monitoring is recommended if the use of oral contraceptives in women with IDDM is extended.

Studies on oral contraceptive-induced changes in blood coagulation and fibrinolysis and the estrogen effect on endothelial cells

Blood coagulation (fibrinogen, thrombin-antithrombin III complexes, TAT, and prothrombin fragment F1 + 2) and fibrinolytic parameters [fibrin split-product D-dimer, tissue plasminogen activator (t-PA) activity, plasminogen activator inhibitor-1 activity (PAI-1), and plasmin-antiplasmin-complexes (PAP)] were evaluated in 16 women on low estrogen (EE) oral contraceptive (OC) therapy. Blood samples were taken before and between days 18 and 22 of the first, third, and sixth treatment cycle. Fibrinogen levels were found significantly elevated during OC treatment compared with pretreatment values, while TAT and also F1 + 2 levels remained unchanged. Treatment-induced activation of fibrinolysis was documented by elevated D-dimer [pretreatment (pt): 172 ng/ml (range: 65-640 ng/ml), cycle 6 (c.6): 351 ng/ml (range: 93-960 ng/ml), p < 0.05)] and PAP [(pt: 46.6 ng/ml (13-220 ng/ml), c.6: 66.4 ng/ml (21-200 ng/ml), p < 0.05] plasma levels. Among the fibrinolytic components a decrease in PAI-1 [pt: 10.8 ng/ml (2-56 ng/ml), c.6: 5.3 ng/ml (2.2-14.4 ng/ml), p < 0.05] and an increase in t-PA activity [pt: 0.23 U/ml (0.17-0.45 U/ml), c.6: 0.33 U/ml (0.2-0.9 U/ml), p < 0.05] were detected. Experiments with cultured human endothelial cells (EC) showed that EE influenced neither EC hemostatic regulatory activities (tissue factor, thrombomodulin) nor the secretion of the fibrinolytic components t-PA and PAI-1.

Contraception in older woman

Oral contraception (OC) in the premenopause has been recently proposed as treatment for control and prevention of the putative symptoms typical of this period of life. Indeed, menstrual cycle disturbances and climacteric symptoms frequently occur at this age. The major aim of normal contraception is resultant maintenance of normal sexual activity. The effects of one OC containing 20 mcg ethinylestradiol and 150 mcg desogestrel (EE/DOG) were studied. Treatment did not significantly modify both lipid metabolism (triglycerides, total cholesterol, HDL, LDL, Apo A, Apo B) and clotting system (fibrinogen, PT, PTT, antithrombin III, fibrinopeptide A). No significant modifications of oral glucose tolerance test (OGGT) occurred after EE/DOG treatment. Also, bone density was not modified during estro-progestinic administration. From our experience, if there are no risk factors such as smoking, obesity or hypertension, the OCs could be used until menopause for absolute contraceptive efficacy, good tolerance and lack of side effects.

Effects of monophasic low-dose oral contraceptives on fibrin formation and resolution in young women

OBJECTIVE

The purpose of this study was to examine key variables in the regulation of coagulation and fibrinolysis during intake of low-dose oral contraceptives containing newly developed progestogens.

STUDY DESIGN

Thirty-four healthy young women were allocated to 12 consecutive cycles of treatment with monophasic combinations of 20 micrograms ethinyl estradiol and 150 micrograms desogestrel (n = 15) or 30 micrograms ethinyl estradiol and 75 micrograms gestodene (n = 19). Nonparametric analysis of variance was used for statistical evaluation.

RESULTS

In both groups plasma levels of fibrinogen and Factor VIIc increased, and the capacity of coagulation inhibition was affected by increased protein C and decreased protein S levels. Increased fibrinolytic capacity was indicated by elevated activity and reduced antigen levels of tissue plasminogen activator and by reduced activity and concentration of plasminogen activator inhibitor. Thrombin-antithrombin III complexes and fibrin degradation products were unchanged, signifying no effect of hormonal intake on the degree of activation of the coagulation system or the efficacy of fibrinolysis.

CONCLUSION

The overall dynamic balance between generation and resolution of fibrin was maintained during treatment with both hormonal compounds. Our findings suggest that the risk of thrombosis in normal women should not be increased.

Norgestimate: a clinical overview of a new progestin

The efficacy and safety of a new monophasic oral contraceptive, norgestimate/ethinyl estradiol, containing the third-generation progestin, norgestimate (250 micrograms), and ethinyl estradiol (35 micrograms), are reviewed. Norgestimate/ethinyl estradiol demonstrates excellent contraceptive efficacy, with a Pearl index of 0.25. Cycle control is reliable, with a low incidence of breakthrough bleeding and spotting. Because of the minimal androgenicity of norgestimate, norgestimate/ethinyl estradiol has a low impact on carbohydrate and lipid metabolism. It neither reduces the vasodilatory and antiaggregatory prostacyclin nor increases its endogenous antagonist, thromboxane. Norgestimate/ethinyl estradiol has no significant effect on blood coagulation factors. All these characteristics suggest that norgestimate/ethinyl estradiol may be associated with a lower risk of cardiovascular disease than other oral contraceptives currently available. Epidemiologic data, however, are not available, and physicians should be reluctant to prescribe it or any oral contraceptive to patients who have a history of vascular or thrombotic disorders.