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Dix C, Moloney M, Tran HA, McFadyen JD. Venous Thromboembolism and Estrogen-Containing Gender-Affirming Hormone Therapy. Thromb Haemost 2024; 124:387-398. [PMID: 37816389 DOI: 10.1055/a-2188-8898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
Gender-affirming therapy involves the use of hormones to develop the physical characteristics of the identified gender and suppressing endogenous sex hormone production. Venous thromboembolism (VTE) is a known risk of exogenous estrogen therapy, and while evidence of VTE risk among transgender women using modern gender-affirming hormone therapy (GAHT) is still emerging, it is thought to affect up to 5% of transgender women. Historically, GAHT was associated with a high risk of VTE; however, modern preparations are less thrombogenic mainly due to significantly lower doses used as well as different preparations. This review presents the available literature regarding the following four topics: (1) risk of VTE among transgender women receiving estradiol GAHT, (2) how the route of administration of estradiol affects the VTE risk, (3) perioperative management of GAHT, (4) VTE risk among adolescents on GAHT. There is a need for large, longitudinal studies of transgender women using GAHT to further characterize VTE risk and how this is affected by factors such as patient age, duration of GAHT use, tobacco use, body mass index, and comorbidities. Future studies in these areas could inform the development of clinical guidelines to improve the care of transgender people.
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Affiliation(s)
- Caroline Dix
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Australia
| | - Mollie Moloney
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
| | - Huyen A Tran
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Australia
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
| | - James D McFadyen
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Australia
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
- Atherothrombosis and Vascular Biology Program, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
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2
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Yokota N, Inoue R, Kawamura K, Egashira K, Kuma H, Kato K. The effects of dienogest and combined oral contraceptives on protein S-specific activity in endometriosis patients. Eur J Obstet Gynecol Reprod Biol 2024; 295:67-74. [PMID: 38340593 DOI: 10.1016/j.ejogrb.2024.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 01/15/2024] [Accepted: 01/21/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE One serious side effect of combined oral contraceptives (COCs) is venous thromboembolism. Reduced activity in activated protein C-related coagulation pathways is attributable to low protein S activity in one-third of Japanese patients with deep vein thrombosis. Herer, we quantified the behavior of protein S-specific activity in response to dienogest (DNG) and COCs using the protein S-specific activity assay system to explore its potential utility as a thrombosis marker. STUDY DESIGN This was a prospective cohort study. Female patients aged 20 - 49 years who were starting drug treatment for endometriosis using DNG or COCs were enrolled. Blood samples were taken before treatment and at the first, third, and sixth months of treatment. To analyze the primary endpoints, changes in total protein S antigen levels, total protein S activity, and protein S-specific activity from baseline to each time point were estimated using a linear mixed-effects model. All statistical analyses were performed in the SAS software version 9.4 (SAS Institute, Cary, NC). A two-sided P < 0.05 was considered statistically significant. RESULTS 64 patients took DNG and 34 patients took COCs. Protein S-specific activity did not change significantly from baseline in the six months after treatment started in either group. In the DNG group, total protein S activity and total protein S antigen levels increased slightly from baseline levels after the treatment. The means for total protein S activity and total protein S antigen levels in the COC group remained within reference limits, but they both decreased markedly in the first month and stayed low. Protein S-specific activity in four women remaind below the reference limit throughout the whole study period, suggesting they may have potential protein S deficiencies. CONCLUSION The effects of DNG on protein S were negligible, though both total protein S activity and antigen levels decreased soon after COC treatment began and remained low. As there was no VTE event during the study, further studies with larger numbers of patients will be needed to confirm that protein S-specific activity can be a surrogate maker of VTE risk.
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Affiliation(s)
- Natsuko Yokota
- Department of Obstetrics and Gynecology, School of Medical Sciences, Kyushu University. 3-1-1 Maidashi, Higashi-ku, Fukuoka city, Fukuoka, Japan.
| | - Reiko Inoue
- Department of Obstetrics and Gynecology, School of Medical Sciences, Kyushu University. 3-1-1 Maidashi, Higashi-ku, Fukuoka city, Fukuoka, Japan.
| | - Keiko Kawamura
- Department of Obstetrics and Gynecology, School of Medical Sciences, Kyushu University. 3-1-1 Maidashi, Higashi-ku, Fukuoka city, Fukuoka, Japan.
| | - Katsuko Egashira
- Department of Obstetrics and Gynecology, School of Medical Sciences, Kyushu University. 3-1-1 Maidashi, Higashi-ku, Fukuoka city, Fukuoka, Japan.
| | - Hiroyuki Kuma
- Faculty of Pharmaceutical Sciences, Nagasaki International University. 2825-7 Hausutenbosu-cho, Sasebo-shi, Nagasaki, Japan.
| | - Kiyoko Kato
- Department of Obstetrics and Gynecology, School of Medical Sciences, Kyushu University. 3-1-1 Maidashi, Higashi-ku, Fukuoka city, Fukuoka, Japan.
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Arafat A, Gennari P, Ignatov A, Tchaikovski S. Role of tissue factor pathway inhibitor in hormone-induced venous thromboembolism. Blood Coagul Fibrinolysis 2023; 34:233-238. [PMID: 37115963 DOI: 10.1097/mbc.0000000000001198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
ABSTRACT Exposure to higher levels of steroid hormones, like that in pregnancy or during combined hormonal contraception, increases the risk of venous thromboembolism. Development of resistance to activated protein C (APC) thought to be the underlying pathomechanism of this prothrombotic state. This coagulation phenomena is largely to be explained by the hormone-induced impairment of the protein S/ tissue factor pathway inhibitor (TFPI) leading to a less efficient inactivation of factor Va and factor VIIIa by APC. APC resistance and decreased protein S/TFPI function were associated with the risk of first as well as recurrent venous thromboembolism. Preexisting disturbances in these pathways are likely to predispose to thrombosis during hormone exposure and can persist over years after the thrombosis event.Further studies are necessary to investigate the predictive value of forgoing APC resistance and decreased protein S/TFPI function or an excessive alteration in these parameters during hormone intake on the development of hormone-induced venous thromboembolism.
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Affiliation(s)
- Amina Arafat
- Department of Obstetrics and Gynecology, Otto von Guericke University Clinic, Magdeburg, Germany
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Gérard C, Foidart JM. Estetrol: From Preclinical to Clinical Pharmacology and Advances in the Understanding of the Molecular Mechanism of Action. Drugs R D 2023:10.1007/s40268-023-00419-5. [PMID: 37133685 DOI: 10.1007/s40268-023-00419-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 05/04/2023] Open
Abstract
Estetrol (E4) is the most recently described natural estrogen. It is produced by the human fetal liver during pregnancy and its physiological function remains unclear. E4 is the estrogenic component of a recently approved combined oral contraceptive. It is also in development for use as menopausal hormone therapy. In the context of these developments, the pharmacological activity of E4, alone or in combination with a progestin, has been extensively characterized in preclinical models as well as in clinical studies in women of reproductive age and postmenopausal women. Despite the clinical benefits, the use of oral estrogens for contraception or menopause is also associated with unwanted effects, such as an increased risk of breast cancer and thromboembolic events, due to their impact on non-target tissues. Preclinical and clinical data for E4 point to a tissue-specific activity and a more selective pharmacological profile compared with other estrogens, including a low impact on the liver and hemostasis balance. This review summarizes the characterization of the pharmacological properties of E4 as well as recent advances made in the understanding of the molecular mechanisms of action driving its activity. How the unique mode of action and the different metabolism of E4 might support its favorable benefit-risk ratio is also discussed.
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Affiliation(s)
- Céline Gérard
- Estetra SRL (an affiliate company of Mithra Pharmaceuticals), Rue Saint Georges 5, 4000, Liège, Belgium.
| | - Jean-Michel Foidart
- Estetra SRL (an affiliate company of Mithra Pharmaceuticals), Rue Saint Georges 5, 4000, Liège, Belgium
- Department of Obstetrics and Gynecology, University of Liège, 4000, Liège, Belgium
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Haverinen AH, Luiro KM, Szanto T, Kangasniemi MH, Hiltunen L, Sainio S, Piltonen TT, Lassila R, Tapanainen JS, Heikinheimo O. Combined oral contraceptives containing estradiol valerate vs ethinylestradiol on coagulation: A randomized clinical trial. Acta Obstet Gynecol Scand 2022; 101:1102-1111. [PMID: 35909329 PMCID: PMC9812067 DOI: 10.1111/aogs.14428] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/09/2022] [Accepted: 07/03/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Contraceptives containing ethinylestradiol (EE) induce changes in the coagulation system and are associated with a risk of venous thromboembolism. However, studies comparing the effects of combined oral contraceptives containing EE and low-potency estrogens (ie, estradiol [E2 ] and estradiol valerate [EV]) on coagulation biomarkers are limited. This study represents secondary outcomes of a randomized trial comparing combined oral contraceptives containing EV + dienogest (DNG), EE + DNG, and DNG alone on selected coagulation biomarkers. We could compare the specific effects of the different estrogen components owing to the inclusion of preparations containing the same progestin. MATERIAL AND METHODS We enrolled 59 healthy, 18- to 35-year-old, non-smoking women, of whom three discontinued. The participants were randomly allocated to 9 weeks of continuous treatment with EV 2 mg + DNG 2-3 mg (n = 20), EE 0.03 mg + DNG 2 mg (n = 20), or DNG 2 mg (n = 19). Blood samples were collected at baseline and after 9 weeks. We assessed coagulation in vitro by thrombin generation using the Calibrated Automated Thrombogram. Thrombin generation was evaluated by lag time, time to thrombin peak, thrombin peak, and endogenous thrombin potential in response to tissue factor (1 pm). In vivo coagulation assessment was based on levels of prothrombin fragment 1 + 2 (F1 + 2) (thrombin generation) and D-dimer (fibrin turnover). CLINICAL TRIAL REGISTRATION NCT02352090. RESULTS Lag time and time to thrombin peak remained unaltered after exposure to EV + DNG, whereas EE + DNG shortened both lag time (mean percentage change -24%, 95% confidence interval [CI] -32% to -15%; p < 0.01) and time to thrombin peak (-26%, 95% CI -37% to -16%; p < 0.01). EV + DNG induced lower thrombin peak and endogenous thrombin potential than EE + DNG (peak; +45%, 95% CI 22%-67% vs +147%,95% CI 96%-198%; p < 0.01, and endogenous thrombin potential; +26%, 95% CI 15%-38% vs +64%, 95% CI 51%-76%; p < 0.01). Median F1 + 2 levels remained unchanged with EV + DNG (p = 0.22) but increased within normal ranges with EE + DNG (from 152 pmol/L, 95% CI 127-206] pmol/L to 194 pmol/L, 95% CI 149-250 pmol/L, p = 0.04). The within-group change in D-dimer levels was not significant in any of the groups. DNG alone did not affect these biomarkers. CONCLUSIONS Both in vitro and in vivo thrombin generation was lower after exposure to EV + DNG compared with EE + DNG. The lower thrombin generation measures after treatment with EV + DNG indicate less enhancement of coagulation potential and suggest that EV may be favorable to EE as a component of combined oral contraceptives.
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Affiliation(s)
- Annina H. Haverinen
- Department of Obstetrics and GynecologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Kaisu M. Luiro
- Department of Obstetrics and GynecologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Timea Szanto
- Department of Hematology and Comprehensive Cancer CenterUnit of Coagulation Disorders, Helsinki University HospitalHelsinkiFinland,Research Program in Systems Oncology, Faculty of MedicineUniversity of HelsinkiHelsinkiFinland
| | - Marika H. Kangasniemi
- Department of Obstetrics and GynecologyUniversity of Oulu, Oulu University Hospital and Medical Research Center PEDEGO Research UnitOuluFinland
| | - Leena Hiltunen
- Department of HemostasisFinnish Red Cross Blood ServiceHelsinkiFinland,Hemostasis and Platelet LaboratoryFimlab Laboratoriot Oy LtdVantaaFinland
| | - Susanna Sainio
- Department of HemostasisFinnish Red Cross Blood ServiceHelsinkiFinland
| | - Terhi T. Piltonen
- Department of Obstetrics and GynecologyUniversity of Oulu, Oulu University Hospital and Medical Research Center PEDEGO Research UnitOuluFinland
| | - Riitta Lassila
- Department of Hematology and Comprehensive Cancer CenterUnit of Coagulation Disorders, Helsinki University HospitalHelsinkiFinland,Research Program in Systems Oncology, Faculty of MedicineUniversity of HelsinkiHelsinkiFinland
| | - Juha S. Tapanainen
- Department of Obstetrics and GynecologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland,Department of Obstetrics and GynecologyUniversity of Oulu, Oulu University Hospital and Medical Research Center PEDEGO Research UnitOuluFinland
| | - Oskari Heikinheimo
- Department of Obstetrics and GynecologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
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Morimont L, Leclercq C, Didembourg M, De Gottal É, Carlo A, Gaspard U, Dogné J, Douxfils J. Analytical performance of the endogenous thrombin potential–based activated protein C resistance assay on the automated ST Genesia system. Res Pract Thromb Haemost 2022; 6:e12684. [PMID: 35425874 PMCID: PMC8988860 DOI: 10.1002/rth2.12684] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/14/2022] [Accepted: 02/18/2022] [Indexed: 11/07/2022] Open
Abstract
Background Objectives Method Results Conclusion
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Affiliation(s)
- Laure Morimont
- Qualiblood saNamurBelgium
- Department of PharmacyFaculty of MedicineNamur Research Institute for Life Sciences (NARILIS)Namur Thrombosis and Hemostasis Center (NTHC)University of NamurNamurBelgium
| | - Charline Leclercq
- Department of GynecologyCentre Hospitalier Régional de HuyLiègeBelgium
| | - Marie Didembourg
- Department of PharmacyFaculty of MedicineNamur Research Institute for Life Sciences (NARILIS)Namur Thrombosis and Hemostasis Center (NTHC)University of NamurNamurBelgium
| | - Émilie De Gottal
- Department of GynecologyCentre Hospitalier Régional de HuyLiègeBelgium
| | | | - Ulysse Gaspard
- Department of Obstetrics and GynecologyUniversity of LiègeLiègeBelgium
| | - Jean‐Michel Dogné
- Department of PharmacyFaculty of MedicineNamur Research Institute for Life Sciences (NARILIS)Namur Thrombosis and Hemostasis Center (NTHC)University of NamurNamurBelgium
| | - Jonathan Douxfils
- Qualiblood saNamurBelgium
- Department of PharmacyFaculty of MedicineNamur Research Institute for Life Sciences (NARILIS)Namur Thrombosis and Hemostasis Center (NTHC)University of NamurNamurBelgium
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7
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Morimont L, Didembourg M, Haguet H, Modaffari É, Tillier M, Bouvy C, Lebreton A, Dogné J, Douxfils J. Interlaboratory variability of activated protein C resistance using the ETP-based APC resistance assay. Res Pract Thromb Haemost 2021; 5:e12612. [PMID: 34761157 PMCID: PMC8563922 DOI: 10.1002/rth2.12612] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/09/2021] [Accepted: 09/24/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Although the endogenous thrombin potential (ETP)-based activated protein C (APC) resistance is recommended for the development of steroid contraceptive agents, one of the main limitations of this technique was its lack of standardization, which hampered study-to-study comparison. A validated methodology that meets all the regulatory requirements in terms of analytical performances has been developed recently. To ensure a wide implementation of this test, the assessment of the interlaboratory variability was needed. METHOD The assay was implemented in three testing laboratories. First, dose-response curves were performed to locally define APC concentration leading to 90% of ETP inhibition on healthy donors. Intra- and inter-run repeatability were assessed on a reference plasma and three quality controls. To investigate the variability in results among the different testing units, 60 donor samples were analyzed at each site. RESULTS The APC concentration leading to 90% of ETP inhibition was defined at 1.21 µg/ml and 1.14 µg/ml in the two receiving units. Intra- and inter-run repeatability showed standard deviation below 3%. Analyses of the 60 donor samples showed no statistically significant difference. The sensitivity of the test in the different laboratories was maintained and subgroup analyses still reported significant differences depending on hormonal status of donors. CONCLUSION This study is the first reporting the interlaboratory variability of the ETP-based APC resistance assay. Data revealed excellent intra- and interlaboratory reproducibility. These results support the concept that this blood coagulation test provides an appropriate sensitivity irrespective of the laboratory in which analyses are performed.
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Affiliation(s)
- Laure Morimont
- Qualiblood saNamurBelgium
- Faculty of MedicineDepartment of PharmacyNamur Research Institute for Life Sciences (NARILIS)Namur Thrombosis and Hemostasis Center (NTHC)University of NamurNamurBelgium
| | - Marie Didembourg
- Faculty of MedicineDepartment of PharmacyNamur Research Institute for Life Sciences (NARILIS)Namur Thrombosis and Hemostasis Center (NTHC)University of NamurNamurBelgium
| | - Hélène Haguet
- Qualiblood saNamurBelgium
- Faculty of MedicineDepartment of PharmacyNamur Research Institute for Life Sciences (NARILIS)Namur Thrombosis and Hemostasis Center (NTHC)University of NamurNamurBelgium
| | | | - Maxence Tillier
- Service d'hématologie BiologiqueCHU Clermont‐FerrandClermont‐FerrandFrance
| | | | - Aurélien Lebreton
- Service d'hématologie BiologiqueCHU Clermont‐FerrandClermont‐FerrandFrance
| | - Jean‐Michel Dogné
- Faculty of MedicineDepartment of PharmacyNamur Research Institute for Life Sciences (NARILIS)Namur Thrombosis and Hemostasis Center (NTHC)University of NamurNamurBelgium
| | - Jonathan Douxfils
- Qualiblood saNamurBelgium
- Faculty of MedicineDepartment of PharmacyNamur Research Institute for Life Sciences (NARILIS)Namur Thrombosis and Hemostasis Center (NTHC)University of NamurNamurBelgium
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Wan J, Konings J, de Laat B, Hackeng TM, Roest M. Added Value of Blood Cells in Thrombin Generation Testing. Thromb Haemost 2021; 121:1574-1587. [PMID: 33742437 DOI: 10.1055/a-1450-8300] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The capacity of blood to form thrombin is a critical determinant of coagulability. Plasma thrombin generation (TG), a test that probes the capacity of plasma to form thrombin, has improved our knowledge of the coagulation system and shows promising utility in coagulation management. Although plasma TG gives comprehensive insights into the function of pro- and anticoagulation drivers, it does not measure the role of blood cells in TG. In this literature review, we discuss currently available continuous TG tests that can reflect the involvement of blood cells in coagulation, in particular the fluorogenic assays that allow continuous measurement in platelet-rich plasma and whole blood. We also provide an overview about the influence of blood cells on blood coagulation, with emphasis on the direct influence of blood cells on TG. Platelets accelerate the initiation and velocity of TG by phosphatidylserine exposure, granule content release and surface receptor interaction with coagulation proteins. Erythrocytes are also major providers of phosphatidylserine, and erythrocyte membranes trigger contact activation. Furthermore, leukocytes and cancer cells may be important players in cell-mediated coagulation because, under certain conditions, they express tissue factor, release procoagulant components and can induce platelet activation. We argue that testing TG in the presence of blood cells may be useful to distinguish blood cell-related coagulation disorders. However, it should also be noted that these blood cell-dependent TG assays are not clinically validated. Further standardization and validation studies are needed to explore their clinical usefulness.
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Affiliation(s)
- Jun Wan
- Synapse Research Institute, Maastricht, The Netherlands.,Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Joke Konings
- Synapse Research Institute, Maastricht, The Netherlands.,Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Bas de Laat
- Synapse Research Institute, Maastricht, The Netherlands.,Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Tilman M Hackeng
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Mark Roest
- Synapse Research Institute, Maastricht, The Netherlands.,Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
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Evrard J, Morimont L, Didembourg M, Haguet H, Siriez R, Dogné JM, Douxfils J. Assessment of acquired activated protein C resistance with the FibWave and comparison with the ETP-based APC resistance. Int J Lab Hematol 2020; 43:802-812. [PMID: 33314736 DOI: 10.1111/ijlh.13427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/22/2020] [Accepted: 11/23/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Activated protein C (APC) resistance is a major risk factor of venous thrombosis which may be acquired by hormonal therapy or other causes. The FibWave, a sensitive global clot-based assay design to analyze the coagulation kinetics in plasma, may be a good candidate to assess this prothrombotic state. This study aims to assess the suitability of the FibWave to differentiate the coagulation kinetics of women on oral contraceptives. MATERIALS AND METHODS Fifty-four healthy volunteers were divided into 5 groups: men [n = 13], women not using hormonal contraception [n = 12], women using second [n = 12] or third generation [n = 12] combined oral contraceptives, and women using progestin only contraceptive [n = 5]. Patients with coagulation abnormalities were also assessed [n = 8]. The APC resistance was assessed on the FibWave using exogenous APC or Protac, and on the Calibrated Automated Thrombogram using the ETP-based APC resistance assay. RESULTS Either in presence or in absence of APC or Protac, the FibWave was able to detect a hypercoagulable state in plasma samples. All combined oral contraceptives showed a lower FW-Max1 , FW-Max2, and FW-Min2 percentage of inhibition and a lower FW-Ttpeak ratio than the other groups. The sensitivity of the FibWave was similar to the one of the ETP-based APC resistance assay. CONCLUSION The FibWave is able to differentiate APC resistance levels observed in women on combined oral contraceptive. The FW-Max1 , FW-Max2, and to a lesser degree FW-Min2 were identified as the most sensitive parameters with a similar performance to the ETP-based APC resistance assay.
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Affiliation(s)
- Jonathan Evrard
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Laure Morimont
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium.,Qualiblood s.a, Namur, Belgium
| | - Marie Didembourg
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Hélène Haguet
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Romain Siriez
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium.,Namur Biobank-eXchange (NAB-X), University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium.,Qualiblood s.a, Namur, Belgium
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10
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Evaluation of the effect of a new oral contraceptive containing estetrol and drospirenone on hemostasis parameters. Contraception 2020; 102:396-402. [DOI: 10.1016/j.contraception.2020.08.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 08/19/2020] [Accepted: 08/30/2020] [Indexed: 12/21/2022]
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11
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Douxfils J, Morimont L, Bouvy C. Oral Contraceptives and Venous Thromboembolism: Focus on Testing that May Enable Prediction and Assessment of the Risk. Semin Thromb Hemost 2020; 46:872-886. [DOI: 10.1055/s-0040-1714140] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AbstractCombined oral contraceptives (COCs) induce several changes in the levels of coagulation factors. The levels of procoagulant factors are often increased, while levels of anticoagulant factors are decreased. Fibrinolysis is also affected, even if the effect seems to be more counterbalanced by opposite regulation of profibrinolytic and antifibrinolytic factors. These effects on hemostasis are more pronounced with third- or fourth-generation COC compared with second-generation COC. Venous thromboembolism (VTE) risk increases when multiple risk factors, including genetic and environmental, are present simultaneously. COC use causes changes in coagulation that modify the prothrombotic state induced by preexisting hemostatic alterations in a supra-additive manner. Therefore, testing appears to be of importance not only before implementing COC but also to monitor any potential thrombogenicity induced by COC therapy. Inherited genetic factors, such as factor V Leiden, G20210A prothrombin mutation, antithrombin, protein C or protein S deficiencies, non-O blood group, as well as CYP2C9*2 and the rs4379368 mutations, have all been identified as genetic predictive risk factors of VTE in women. Nevertheless, the screening of these genetic biomarkers is not capable of assessing the phenotypic expression of the risk. This review will focus on the different options for screening the thrombogenic status in this population. Specific attention will be given to the endogenous thrombin potential-based activated protein C resistance, a test aiming at assessing the thrombogenicity induced by hormonal therapies and inherited or acquired thrombophilia.
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Affiliation(s)
- Jonathan Douxfils
- QUALIblood s.a., Namur, Belgium
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Faculty of Medicine, University of Namur, Namur, Belgium
| | - Laure Morimont
- QUALIblood s.a., Namur, Belgium
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Faculty of Medicine, University of Namur, Namur, Belgium
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Abou-Ismail MY, Citla Sridhar D, Nayak L. Estrogen and thrombosis: A bench to bedside review. Thromb Res 2020; 192:40-51. [PMID: 32450447 DOI: 10.1016/j.thromres.2020.05.008] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/12/2020] [Accepted: 05/07/2020] [Indexed: 02/07/2023]
Abstract
Estrogen, in the clinical setting is used primarily for contraception and hormone replacement therapy. It has been well established that estrogen increases the risk of both arterial and venous thrombosis. While estrogen is known to induce a prothrombotic milieu through various effects on the hemostatic pathways, the exact molecular mechanism leading to those effects is not known. The most common clinical presentation of estrogen-related thrombosis is venous thromboembolism (VTE) of the deep veins of the legs or pulmonary vessels, usually within the first few months of use. Estrogen has also been associated with increased risk of "unusual site" thromboses, as well as arterial thrombosis. Women at high-risk of thrombosis need careful evaluation and counseling for contraception, pregnancy, menopausal hormonal therapy and other estrogen-related conditions or treatments in order to lower the risk of thromboses. We review the most recent evidence on management of high-estrogen states in women at high-risk of thrombosis, as well as emerging data on unique populations such as transgender women. More studies are needed to better understand the pathophysiology of hormone-related thrombosis, as well as more comprehensive techniques to stratify risks for thrombosis so as to enable tailoring of recommendations for each individual.
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Affiliation(s)
- Mouhamed Yazan Abou-Ismail
- Case Western Reserve University, Cleveland, OH, United States of America; University Hospitals Cleveland Medical Center, Cleveland, OH, United States of America
| | - Divyaswathi Citla Sridhar
- Case Western Reserve University, Cleveland, OH, United States of America; Rainbow Babies & Children's Hospital, Cleveland, OH, United States of America
| | - Lalitha Nayak
- Case Western Reserve University, Cleveland, OH, United States of America; University Hospitals Cleveland Medical Center, Cleveland, OH, United States of America.
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Morimont L, Bouvy C, Delvigne AS, Dogné JM, Douxfils J. Proof of concept of a new scale for the harmonization and the standardization of the ETP-based APC resistance. J Thromb Haemost 2020; 18:895-904. [PMID: 31984653 DOI: 10.1111/jth.14745] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/23/2019] [Accepted: 01/13/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The evaluation of the activated protein C resistance (APCr) based on the endogenous thrombin potential (ETP) is recommended during the development of steroid contraceptives. Results are usually expressed as "normalized APC sensitivity ratio" (nAPCsr) using a reference plasma that should achieve an ETP ratio of 0.1 in presence of exogenous APC. Because of the interassay variability, achieving exactly an ETP ratio of 0.1 in each run is almost impossible, which significantly affects the theoretical 0-10 scale of nAPCsr. OBJECTIVES To compare the nAPCsr to the nAPCsr10 , a newly proposed method to express the degree of APC resistance. METHODS Individual plasma samples (n = 854) were analyzed to compare nAPCsr and nAPCsr10 . These values were obtained using the validated ETP-based APCr assay. RESULTS The Spearman correlation between nAPCsr and nAPCsr10 had a coefficient of 0.99. Linear regression showed the following equation y = 0.9315*x + 0.03942 (r2 = .97). When differences (nAPCsr10 - nAPCsr) were plotted against nAPCsr10 , the mean difference equaled 0.16% or 4.95%. The correction obtained with the use of the nAPCsr10 showed that the results of the nAPCsr were statistically different (P < .0001). CONCLUSIONS This new scale provides a harmonization and normalization of the nAPCsr. Results show a better reproducibility with the nAPCsr10 . It avoids the additional variability and the unharmonized scale introduced by the use of a reference plasma. This adapted method for the calculation of the APC resistance could provide the regulatory and scientific bodies with more reproducible and harmonized evaluations.
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Affiliation(s)
- Laure Morimont
- Qualiblood sa, Namur, Belgium
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences, University of Namur, Namur, Belgium
| | | | | | - Jean-Michel Dogné
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences, University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- Qualiblood sa, Namur, Belgium
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences, University of Namur, Namur, Belgium
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Connors JM, Middeldorp S. Transgender patients and the role of the coagulation clinician. J Thromb Haemost 2019; 17:1790-1797. [PMID: 31465627 DOI: 10.1111/jth.14626] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 08/26/2019] [Indexed: 11/29/2022]
Abstract
The medical care of transgender patients relies on the use of sex hormones to develop and maintain the physical characteristics consistent with gender identity as the first step in transitioning. Hormonal therapy is usually continued indefinitely, even following gender-affirming surgeries. The use of hormonal treatments is associated with a multitude of positive effects as well as complications and side effects. The risk of venous thromboembolism (VTE) is a major concern. Transgender patients are often referred to coagulation specialists for advice regarding an individual patient's risk for VTE, especially if there is a personal or family history of VTE. Coagulation specialists need to be familiar with endocrine therapy including the goals of treatment and the VTE risks associated with currently used hormone regimens. We will review common referral questions and the available data and their limitations for the use of hormonal therapy in transgender patients focusing on the risk of VTE.
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Affiliation(s)
- Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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15
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Swanepoel AC, Roberts HC, Soma P, Lindeque BG, Bester J. Hemorheological mechanisms for increased thrombosis in subjects using gestodene. Microsc Res Tech 2018; 81:1489-1500. [PMID: 30365192 DOI: 10.1002/jemt.23149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 09/05/2018] [Accepted: 09/07/2018] [Indexed: 11/07/2022]
Abstract
There are several possible mechanisms by which combined oral contraceptives (COC) use increase venous thromboembolism (VTE) risk. Melodene® is a monophasic COC containing the third-generation progestin Gestodene (GSD), which is associated with increased risk of VTE. Therefore, the aim of this study was to investigate the possible alterations in viscoelastic parameters of whole blood and plasma clots along with the biophysical characteristics of erythrocytes and specifically fibrin fibers in females using a COC containing GSD. GSD appeared to have a significant impact on the biophysical characteristics of fibrin fiber networks. When GSD is combined with ethinylestradiol the viscoelastic properties of whole blood clots tend to become more prothrombotic. The alterations to and aggregation of erythrocytes accompanied with spontaneous formation of a fibrin "blanket" provides a possible mechanism for the increased occurrence of "red" clots, which can lead to occlusions in the vascular system. Thus, the increased risk of VTE associated with these COCs can be attributed to these erythrocyte-and-fibrin-rich-clots occluding venous vessels. However, our findings also propose that these changes to the biophysical properties of both erythrocytes and fibrin, specifically spontaneous expansion of deformed fibrin networks, can also occlude vessels in the microcirculation, which could have lasting, subclinical complications for female users. We recommend that a thorough risk assessment, with specific focus on coagulation and other factors affecting fibrin formation, be done for each female before prescribing a GSD-containing COC. Females that "qualify" then need to be monitored on a regular basis to lower the risk of thrombotic events. RESEARCH HIGHLIGHTS: Gestodene in combination with ethinyl estradiol significantly impacts the biophysical characteristics of erythrocytes and fibrin fiber networks. These changes, specifically spontaneous expansion of deformed fibrin networks, can occlude vessels in the microcirculation, which could have lasting, subclinical complications for the female user. The changes observed for specifically erythrocytes and fibrin show that the hormone formulation investigated contribute to a thrombogenic profile for female users.
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Affiliation(s)
- Albe Carina Swanepoel
- Department of Physiology, School of Medicine, Faculty of Health Sciences, University of Pretoria, Arcadia, South Africa
| | - Hildegarde Cecilia Roberts
- Department of Physiology, School of Medicine, Faculty of Health Sciences, University of Pretoria, Arcadia, South Africa
| | - Prashilla Soma
- Department of Physiology, School of Medicine, Faculty of Health Sciences, University of Pretoria, Arcadia, South Africa
| | - Barend Gerhardus Lindeque
- Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, University of Pretoria, Arcadia, South Africa
| | - Janette Bester
- Department of Physiology, School of Medicine, Faculty of Health Sciences, University of Pretoria, Arcadia, South Africa
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Mohamed ABO, Kelchtermans H, Konings J, van Daal J, Al Marzouki A, Harakeh S, de Laat B. The effects of oral contraceptive usage on thrombin generation and activated protein C resistance in Saudi women, with a possible impact of the body mass index. PLoS One 2018; 13:e0206376. [PMID: 30359453 PMCID: PMC6201944 DOI: 10.1371/journal.pone.0206376] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 10/11/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The effect of oral contraceptive (OC) usage on coagulation has been studied worldwide. However, no such studies have been conducted in Saudi Arabia on Saudi women using OCs. The aim of this study was to investigate the effects of OC-induced changes of thrombin generation (TG) in the absence and presence of activated protein C (APC) or thrombomodulin (TM) in Saudi women. METHODS A total of 115 adult women, 47 on oral contraception (OC users) and 68 controls (not using OCs) were recruited from the obstetrics-gynecology outpatient clinic in Saudi Arabia. OCs that were used in this study include the following: Marvelon, Gynera, Cerrazetem, Yasmine, Microlut, Gracial and Diane. The plasma calibrated automated thrombinography (CAT) was used to determine TG which was expressed as endogenous thrombin potential (ETP; nM/min), lag time (min), peak (nM) and time-to-peak (ttpeak; min). In the presence of TM or APC, TG parameters were expressed relative to the parameters in the absence of TM or APC. RESULTS AND CONCLUSION As in other populations, our study demonstrated that OC usage induced prothrombotic changes in plasma of Saudi women, including resistance to the inhibitory actions of TM and APC. More specifically, OC usage in our population predominantly influenced TG and APC/TM sensitivity in overweight and obese individuals, a finding that needs confirmation in large cohort studies. The effects of APC and TM on TG parameters showed a positive association, and the correlation coefficients were higher in OC users for both ETP and peak values.
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Affiliation(s)
- Abdulrahman B. O. Mohamed
- Department of Pharmacology, King Abdul-Aziz University, Jeddah, Saudi Arabia
- Synapse Research Institute, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Hilde Kelchtermans
- Synapse Research Institute, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Joke Konings
- Synapse Research Institute, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Jamilla van Daal
- Synapse Research Institute, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Anas Al Marzouki
- Department of Obstetrics Gynecology, King Abdul-Aziz University, Jeddah, Saudi Arabia
| | - Steve Harakeh
- Special Infectious Agents Unit, King Fahd Medical Research Center, King Abdul-Aziz University, Jeddah, Saudi Arabia
| | - Bas de Laat
- Synapse Research Institute, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
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17
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Tripodi A. Detection of procoagulant imbalance. Thromb Haemost 2017; 117:830-836. [DOI: 10.1160/th16-10-0806] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/25/2017] [Indexed: 01/14/2023]
Abstract
SummaryEach individual possesses his/her own endogenous-thrombin-potential (ETP) (i. e. the ability to generate thrombin) which depends on the relative strength of the pro- and anticoagulant drivers operating in plasma. This ability depends in turn on the clinical conditions in which the balance between the two drivers is variably affected. One of the major determinants of this balance is the factor (F)VIII-protein C(PC) axis and its effect can be conveniently explored by the thrombin generation procedures with results expressed as ETP ratio with/without thrombomodulin (TM) (ETP-TM ratio). Furthermore, owing to the many feedback mechanisms mediated by thrombin (e. g. activation of PC, FXI, FV, FVIII, platelets etc.) it is also possible that any perturbation of the balance between pro- and anticoagulants that may occur in plasma even outside the FVIII-PC axis could result in an increased ETPTM ratio and therefore may suggest a procoagulant imbalance. Indeed, other non-coagulation moieties (e. g. microparticles, neutrophil extracellular traps, pro-inflammatory cytokines and others) circulating in blood of patients with various clinical conditions may also contribute to the procoagulant imbalance even when FVIII and/or PC are apparently normal. It can be postulated that dual ETP measurements performed in the presence and absence of TM with results expressed as their ratio may be the candidate procedure to detect subtle procoagulant imbalance in many clinical conditions characterised by an increased risk of thromboembolism. This article aimed at reviewing the clinical conditions in which evidence for the value of the ETP-TM ratio has been provided.
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18
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Tanratana P, Ellery P, Westmark P, Mast AE, Sheehan JP. Elevated Plasma Factor IXa Activity in Premenopausal Women on Hormonal Contraception. Arterioscler Thromb Vasc Biol 2017; 38:266-274. [PMID: 29097362 DOI: 10.1161/atvbaha.117.309919] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 10/12/2017] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Combined oral contraceptives induce a reversible hypercoagulable state with an enhanced risk of venous thromboembolism, but the underlying mechanism(s) remain unclear. Subjects on combined oral contraceptives also demonstrate a characteristic resistance to APC (activated protein C) in the thrombin generation assay. Here, we report the potential role of plasma factor IXa (FIXa) as a mechanism for hormone-induced systemic hypercoagulability. APPROACH AND RESULTS A novel assay was used to determine FIXa activity in plasma samples from volunteer blood donors. Plasma from 36 premenopausal females on hormonal contraception and 35 not on hormonal contraception, 35 postmenopausal females, and 10 males were analyzed for FIXa activity, total PS (protein S), total tissue factor pathway inhibitor (TFPI), and TFPI-α antigen. Premenopausal females on hormonal contraception demonstrated significantly increased FIXa activity and decreased TFPI-α compared with the other groups. Remarkably, FIXa values were not normally distributed in the hormonal contraception group, but skewed toward the high end. Plasma FIXa activity inversely correlated with both TFPI-α and total PS antigen. Ex vivo determination of TF-dependent FIX activation in FV-deficient plasma demonstrated that inhibitory anti-TFPI antibodies enhanced FIXa generation by 2- to 3-fold, whereas addition of 75 nmol/L PS reduced FIXa generation by ≈2-fold. Further, increasing FIXa concentration enhanced APC resistance during TF-triggered plasma thrombin generation. CONCLUSIONS Elevation of plasma FIXa activity in association with reductions in TFPI-α and PS is a potential mechanism for systemic hypercoagulability and resistance to APC in premenopausal females on hormonal contraception.
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Affiliation(s)
- Pansakorn Tanratana
- From the Department of Pathology and Laboratory Medicine (P.T.), Department of Medicine/Hematology-Oncology (P.W., J.P.S.), University of Wisconsin School of Medicine and Public Health, Madison; Department of Pharmacology, Faculty of Science, Mahidol University, Bangkok, Thailand (P.T.); Blood Research Institute, Blood Center of Wisconsin, Milwaukee (P.E., A.E.M.); and School of Biomedical Sciences, Curtin University, Perth, Western Australia, Australia (P.E.)
| | - Paul Ellery
- From the Department of Pathology and Laboratory Medicine (P.T.), Department of Medicine/Hematology-Oncology (P.W., J.P.S.), University of Wisconsin School of Medicine and Public Health, Madison; Department of Pharmacology, Faculty of Science, Mahidol University, Bangkok, Thailand (P.T.); Blood Research Institute, Blood Center of Wisconsin, Milwaukee (P.E., A.E.M.); and School of Biomedical Sciences, Curtin University, Perth, Western Australia, Australia (P.E.)
| | - Pamela Westmark
- From the Department of Pathology and Laboratory Medicine (P.T.), Department of Medicine/Hematology-Oncology (P.W., J.P.S.), University of Wisconsin School of Medicine and Public Health, Madison; Department of Pharmacology, Faculty of Science, Mahidol University, Bangkok, Thailand (P.T.); Blood Research Institute, Blood Center of Wisconsin, Milwaukee (P.E., A.E.M.); and School of Biomedical Sciences, Curtin University, Perth, Western Australia, Australia (P.E.)
| | - Alan E Mast
- From the Department of Pathology and Laboratory Medicine (P.T.), Department of Medicine/Hematology-Oncology (P.W., J.P.S.), University of Wisconsin School of Medicine and Public Health, Madison; Department of Pharmacology, Faculty of Science, Mahidol University, Bangkok, Thailand (P.T.); Blood Research Institute, Blood Center of Wisconsin, Milwaukee (P.E., A.E.M.); and School of Biomedical Sciences, Curtin University, Perth, Western Australia, Australia (P.E.)
| | - John P Sheehan
- From the Department of Pathology and Laboratory Medicine (P.T.), Department of Medicine/Hematology-Oncology (P.W., J.P.S.), University of Wisconsin School of Medicine and Public Health, Madison; Department of Pharmacology, Faculty of Science, Mahidol University, Bangkok, Thailand (P.T.); Blood Research Institute, Blood Center of Wisconsin, Milwaukee (P.E., A.E.M.); and School of Biomedical Sciences, Curtin University, Perth, Western Australia, Australia (P.E.).
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19
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Westhoff CL, Pike MC, Cremers S, Eisenberger A, Thomassen S, Rosing J. Endogenous thrombin potential changes during the first cycle of oral contraceptive use. Contraception 2017; 95:456-463. [PMID: 28088496 DOI: 10.1016/j.contraception.2017.01.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 01/03/2017] [Accepted: 01/04/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Venous thromboembolism (VTE) risk increases within months of combination oral contraceptive (COC) initiation. Because elevated endogenous thrombin potential (ETP) has been found in several studies to be a VTE risk factor, we evaluated the extent of ETP changes during the initial cycle of an ethinyl estradiol (EE) and levonorgestrel (LNG) COC. We also assessed the relationship between ETP changes and systemic EE and LNG concentrations. STUDY DESIGN Participants provided multiple blood samples during a first 21-day cycle of a 30-mcg EE/150-mcg LNG COC and after a further 7 days without an active COC. Thrombin generation measured with and without addition of activated protein C (APC) yielded ETP+APC and ETP-APC and the normalized APC sensitivity ratio (nAPCsr). EE and LNG pharmacokinetic analyses were conducted over 24 h after the first COC tablet and again at steady state. RESULTS Thrombin generation was determined in 16 of the 17 women who completed the study. Mean ETP-APC increased steadily to 21% above baseline at 24 h after the 6th COC tablet (COC624; p<.001) and to 28% above baseline at steady state (COC21; p<.001). The percentage increase in mean ETP+APC was considerably more - 54% at COC624 and 79% at steady state. Mean nAPCsr increased by 28% at COC624 and by 41% at steady state. Higher concentrations of EE or LNG were not correlated with greater increases in ETP. CONCLUSIONS ETP increases during the first COC cycle were substantial. IMPLICATIONS The early increases in ETP may provide biological support for the rapid increase in VTE risk during initial COC use. The lack of association between this clotting system perturbation and the systemic EE concentration is surprising and deserves further study.
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Affiliation(s)
- Carolyn L Westhoff
- Department of Obstetrics & Gynecology, Columbia University Medical Center, New York, NY 10032, USA; Department of Epidemiology, Columbia University Medical Center, New York, NY 10032, USA.
| | - Malcolm C Pike
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10017, USA
| | - Serge Cremers
- Department of Pathology & Cell Biology, Columbia University Medical Center, New York, NY 10032, USA
| | - Andrew Eisenberger
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, USA
| | - Stella Thomassen
- Department of Biochemistry, Maastricht University, Maastricht, The Netherlands
| | - Jan Rosing
- Department of Biochemistry, Maastricht University, Maastricht, The Netherlands
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20
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Procoagulant imbalance in patients with non-alcoholic fatty liver disease. J Hepatol 2017; 66:248-250. [PMID: 27769731 DOI: 10.1016/j.jhep.2016.09.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 09/26/2016] [Accepted: 09/28/2016] [Indexed: 12/29/2022]
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21
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Bick RL, Kaplan H. Syndromes of Thrombosis and Hypercoagulability: Congenital and Acquired Thrombophilias. Clin Appl Thromb Hemost 2016. [DOI: 10.1177/107602969800400106] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This article stresses the common hereditary and acquired blood protein defects associated with thrombosis. The most common of the hereditary defects apear to be APC-R, SPS, antithrombin, protein C, and protein S deficiency, and the most common acquired defects are anticardiolipin antibodies and the lupus anticoagulant (antiphospholipid antibodies). Therefore, these are the defects that should first be looked for in an individual with unexplained thrombosis. If these more common defects are not found, then the rarer defects including HC II, plasminogen or TPA deficiency, dysfibrinogenemia, el evated PAI-1 and hyperhomocysteinemia should be sought. The importance of finding these defects has significant impli cations for therapy of the individual patient and for institutions of family studies to identify, inform, and possibly treat others at risk. It is expected that as knowledge of hemostasis expands, more hereditary and acquired defects, such as elevated lipopro tein (a) or defects of extrinsic (tissue factor) pathway inhibitor (EPI, TFPI), may be associated with enhanced risks of throm bosis. Finally, it must be recalled that a diagnosis of thrombo sis, like that of anemia, is only a generic and partial diagnosis; just as in the anemic patient, the etiology must be clearly de fined. Only in this manner can cost-effective and appropriate therapy for both primary treatment and secondary prevention be designed. In addition, the demonstration of a hereditary defect will allow primary prevention in afflicted family mem bers by allowing the choice of appropriate therapy.
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Affiliation(s)
- Rodger L. Bick
- Department of Medicine (HematologylOncology) and Pathology, University of Texas Southwestern Medical Center, Dallas Thrombosis Hemostasis & Difficult Hematology Clinical Center, Presbyterian Hospital of Dallas
| | - Harold Kaplan
- Special Coagulation Laboratories, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
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Zia A, Callaghan MU, Callaghan JH, Sawni A, Bartlett H, Backos A, Marshall S, Chitlur M, Rajpurkar M. Hypercoagulability in adolescent girls on oral contraceptives-global coagulation profile and estrogen receptor polymorphisms. Am J Hematol 2015; 90:725-31. [PMID: 26014094 DOI: 10.1002/ajh.24064] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 05/06/2015] [Accepted: 05/13/2015] [Indexed: 11/07/2022]
Abstract
Oral contraceptive (OCP) induced changes on coagulation are complex with high inter-individual variability. The precise reason for differences in this variability is unknown. We hypothesized that global coagulation assays better delineate these changes and variability in hypercoagulability may be the result of differences in estrogen metabolism and thrombophilia. Fifty-two adolescents initiating OCPs were prospectively enrolled; 33 subjects completed the study. Samples were analyzed prior to and after OCPs for procoagulant and anticoagulant factor activities and thrombin generation (TG) +/-thrombomodulin. Participants were genotyped for common thrombophilia and estrogen receptor-α (ESR-α) single nucleotide polymorphisms (SNPs). SNP genotypes were compared to coagulation parameters; TG parameters and differences pre and post OCPs were examined. At baseline, a striking finding was elevated FVIII levels. FVL was absent in all and F2 G20210A was present in one participant. The ESR-α polymorphism was present in heterozygous state in 59% and homozygous state in 21% participants. There were no differences in VWF levels and FVIII C after being on OCPs. Protein S levels decreased with OCPs. Sixty percent of participants showed evidence of hypercoagulability on TG testing on OCPs. Higher thrombin peak and endogenous thrombin potential (ETP) were seen on TG after OCPs. With thrombomodulin, ETP and thrombin peak did not decrease after OCPs, signifying 'thrombomodulin resistance'. We demonstrated that OCPs induce a state of "variable" hypercoagulability in adolescents, predominantly through the protein S pathway. Genetic and nongenetic factors may account for the variable increase in hypercoagulability. Further research is needed to understand this.
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Affiliation(s)
- Ayesha Zia
- Department of Pediatrics, Division of Hematology Oncology; The University of Texas Southwestern Medical Center; Dallas Texas
| | - Michael U. Callaghan
- Division of Hematology/Oncology, the Carman Ann Adams Department of Pediatrics; Wayne State University School of Medicine; Detroit Michigan
| | - Joseph H. Callaghan
- Department of Accounting and Finance, School of Business Administration; Oakland University; Rochester Michigan
| | - Anju Sawni
- Department of Pediatrics; Michigan State University of Human Medicine; Flint Michigan
| | - Heather Bartlett
- Division of Adolescent Medicine, Department of Pediatrics, The Carman Ann Adams; Wayne State University School of Medicine; Detroit Michigan
| | - Alcesa Backos
- Division of Adolescent Medicine, Department of Pediatrics, The Carman Ann Adams; Wayne State University School of Medicine; Detroit Michigan
| | - Sharon Marshall
- Division of Adolescent Medicine, Department of Pediatrics, The Carman Ann Adams; Wayne State University School of Medicine; Detroit Michigan
| | - Meera Chitlur
- Division of Hematology/Oncology, the Carman Ann Adams Department of Pediatrics; Wayne State University School of Medicine; Detroit Michigan
| | - Madhvi Rajpurkar
- Division of Hematology/Oncology, the Carman Ann Adams Department of Pediatrics; Wayne State University School of Medicine; Detroit Michigan
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23
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Amoozegar F, Ronksley PE, Sauve R, Menon BK. Hormonal contraceptives and cerebral venous thrombosis risk: a systematic review and meta-analysis. Front Neurol 2015; 6:7. [PMID: 25699010 PMCID: PMC4313700 DOI: 10.3389/fneur.2015.00007] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 01/11/2015] [Indexed: 11/13/2022] Open
Abstract
Objectives: Use of oral contraceptive pills (OCP) increases the risk of cerebral venous sinus thrombosis (CVST). Whether this risk varies by type, duration, and other forms of hormonal contraceptives is largely unknown. This systematic review and meta-analysis update the current state of knowledge. Methods: We performed a search to identify all published studies on the association between hormonal contraceptive use and risk of CVST in women aged 15–50 years. Results: Of 861 studies reviewed, 11 were included. The pooled odds of developing CVST in women aged 15–50 years taking OCPs was 7.59 times higher compared to women not taking OCPs (OR = 7.59, 95% CI 3.82–15.09). Data are insufficient to make conclusions about duration of use and other forms of hormonal contraceptives. Conclusion: Oral contraceptive pills use increases the risk of developing CVST in women of reproductive age. Future studies are required to determine if duration and type of hormonal contraceptives modify this risk.
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Affiliation(s)
- Farnaz Amoozegar
- Department of Clinical Neurosciences, University of Calgary , Calgary, AB , Canada
| | - Paul E Ronksley
- Department of Clinical Epidemiology, Ottawa Hospital Research Institute , Ottawa, ON , Canada
| | - Reg Sauve
- Department of Pediatrics and Community Health Sciences, University of Calgary , Calgary, AB , Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences, University of Calgary , Calgary, AB , Canada ; Department of Radiology, University of Calgary , Calgary, AB , Canada ; Hotchkiss Brain Institute , Calgary, AB , Canada
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Comparison of the hemostatic effects of a levonorgestrel-releasing intrauterine system and leuprolide acetate in women with endometriosis: A randomized clinical trial. Thromb Res 2014; 134:1193-7. [DOI: 10.1016/j.thromres.2014.09.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 09/03/2014] [Accepted: 09/09/2014] [Indexed: 11/27/2022]
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Rühl H, Schröder L, Müller J, Sukhitashvili S, Welz J, Kuhn WC, Oldenburg J, Rudlowski C, Pötzsch B. Impact of hormone-associated resistance to activated protein C on the thrombotic potential of oral contraceptives: a prospective observational study. PLoS One 2014; 9:e105007. [PMID: 25121606 PMCID: PMC4133351 DOI: 10.1371/journal.pone.0105007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 07/15/2014] [Indexed: 11/18/2022] Open
Abstract
Introduction The increased thrombotic risk of oral contraceptives (OC) has been attributed to various alterations of the hemostatic system, including acquired resistance to activated protein C (APC). To evaluate to what extent OC-associated APC resistance induces a prothrombotic state we monitored plasma levels of thrombin and molecular markers specific for thrombin formation in women starting OC use. Elevated plasma levels of thrombin have been reported to characterize situations of high thrombotic risk such as trauma-induced hypercoagulability, but have not yet been studied during OC use. Patients and Methods Blood samples were collected prospectively from healthy women (n = 21) before and during three menstruation cycles after start of OC. APC resistance was evaluated using a thrombin generation-based assay. Plasma levels of thrombin and APC were directly measured using highly sensitive oligonucleotide-based enzyme capture assay (OECA) technology. Thrombin generation markers and other hemostasis parameters were measured additionally. Results All women developed APC resistance as indicated by an increased APC sensitivity ratio compared with baseline after start of OC (p = 0.0003). Simultaneously, plasma levels of thrombin, prothrombin fragment 1+2, and of thrombin-antithrombin complexes did not change, ruling out increased thrombin formation. APC plasma levels were also not influenced by OC use, giving further evidence that increased thrombin formation did not occur. Conclusions In the majority of OC users no enhanced thrombin formation occurs despite the development of APC resistance. It cannot be ruled out, however, that thrombin formation might occur to a greater extent in the presence of additional risk factors. If this were the case, endogenous thrombin levels might be a potential biomarker candidate to identify women at high thrombotic risk during OC treatment. Large-scale studies are required to assess the value of plasma levels of thrombin as predictors of OC-associated thrombotic risk.
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Affiliation(s)
- Heiko Rühl
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
- * E-mail:
| | - Lars Schröder
- Department of Gynecology and Obstetrics, Center for Integrated Oncology (CIO) Köln/Bonn, University Hospital Bonn, Bonn, Germany
| | - Jens Müller
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Shorena Sukhitashvili
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Julia Welz
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
- Department of Gynecology and Obstetrics, Center for Integrated Oncology (CIO) Köln/Bonn, University Hospital Bonn, Bonn, Germany
| | - Walther C. Kuhn
- Department of Gynecology and Obstetrics, Center for Integrated Oncology (CIO) Köln/Bonn, University Hospital Bonn, Bonn, Germany
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Christian Rudlowski
- Department of Gynecology and Obstetrics, Center for Integrated Oncology (CIO) Köln/Bonn, University Hospital Bonn, Bonn, Germany
| | - Bernd Pötzsch
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
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Tan JJ, Hassoun A, Elmalem VI. Cerebral venous sinus thrombosis with ophthalmic manifestations in 18-year-olds on oral contraceptives. Clin Pediatr (Phila) 2014; 53:826-30. [PMID: 24803635 DOI: 10.1177/0009922814533405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cerebral venous sinus thrombosis (CVST) is a rare and potentially life-threatening cause of stroke. In the past few decades, the incidence and patient demographics have changed because of many factors, including the widespread use of oral contraceptives, improved detection of prothrombotic conditions, and advancement of imaging technology. The presentation of CVST is varied and can include ocular signs and symptoms. We present 2 cases of oral contraceptive-induced CVST in 18-year-old women, whose main presenting findings were ophthalmologic.
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Bleker SM, Coppens M, Middeldorp S. Sex, thrombosis and inherited thrombophilia. Blood Rev 2014; 28:123-33. [DOI: 10.1016/j.blre.2014.03.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 03/11/2014] [Indexed: 10/25/2022]
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Rühl H, Schröder L, Müller J, Fimmers R, Sukhitashvili S, Welz J, Kuhn WC, Oldenburg J, Rudlowski C, Pötzsch B. Tamoxifen induces resistance to activated protein C. Thromb Res 2014; 133:886-91. [DOI: 10.1016/j.thromres.2014.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 12/21/2013] [Accepted: 02/04/2014] [Indexed: 11/28/2022]
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Investigation of the hemostatic effect of a transdermal patch containing 0.55 mg ethinyl estradiol and 2.1 mg gestodene compared with a monophasic oral contraceptive containing 0.03 mg ethinyl estradiol and 0.15 mg levonorgestrel: an open-label, randomized, crossover study. Drugs R D 2014; 13:223-33. [PMID: 24043457 PMCID: PMC3784047 DOI: 10.1007/s40268-013-0028-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Transdermal delivery of contraceptives offers several advantages over combined oral contraceptives (COCs), including effective absorption and the provision of relatively constant serum concentrations. Ethinyl estradiol (EE) and the progestin gestodene are well-absorbed through the skin and, therefore, well-suited for use in a transdermal contraceptive patch. Objective The objective of this study was to investigate the impact of a once-weekly transparent, transdermal patch delivering low doses of EE and gestodene equivalent to a COC containing 0.02 mg EE and 0.06 mg gestodene on hemostasis parameters compared with a monophasic COC containing 0.03 mg EE and 0.15 mg levonorgestrel. Methods In this single-center, open-label, randomized, crossover study, 30 women (aged 18–35 years) received three cycles of each treatment, separated by a two-cycle washout period. The primary outcome measure was the absolute change from baseline in prothrombin fragments 1 + 2 and d-dimer. Results For both treatments, prothrombin fragments 1 + 2 remained stable during the first treatment period, and increased only slightly in the second period (mean absolute change 0.025 and 0.028 nmol/L in the novel Bayer patch and COC groups, respectively). Increases in d-dimer were observed in both periods (mean absolute change 107.0 ± 147.2 ng/L for the novel Bayer patch and 113.7 ± 159.0 ng/L for the COC). There were no statistically significant treatment differences in prothrombin 1 + 2 or d-dimer (p = 0.667 and p = 0.884, respectively) and no statistically significant treatment sequence or period effects. Conclusion A COC containing 0.03 mg EE and 0.15 mg levonorgestrel and the novel Bayer patch have comparable influence on hemostatic endpoints. Both treatments were well-tolerated by subjects.
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Smith NL, Blondon M, Wiggins KL, Harrington LB, van Hylckama Vlieg A, Floyd JS, Hwang M, Bis JC, McKnight B, Rice KM, Lumley T, Rosendaal FR, Heckbert SR, Psaty BM. Lower risk of cardiovascular events in postmenopausal women taking oral estradiol compared with oral conjugated equine estrogens. JAMA Intern Med 2014; 174:25-31. [PMID: 24081194 PMCID: PMC4636198 DOI: 10.1001/jamainternmed.2013.11074] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE Little is known about the comparative cardiovascular safety of oral hormone therapy products, which impedes women from making informed safety decisions about hormone therapy to treat menopausal symptoms. OBJECTIVE To compare the relative clinical cardiovascular safety of 2 commonly used oral estrogen drugs-conjugated equine estrogens (CEEs) and estradiol. DESIGN, SETTING, AND PARTICIPANTS Population-based, case-control study from January 1, 2003, to December 31, 2009, comparing cardiovascular event risk associated with current CEEs and estradiol use in a large health maintenance organization in which the preferred formulary estrogen changed from CEEs to estradiol during the course of data collection. Participants were 384 postmenopausal women aged 30 to 79 years using oral hormone therapy. MAIN OUTCOMES AND MEASURES Incident venous thrombosis was the primary clinical outcome, and incident myocardial infarction and ischemic stroke were secondary outcomes. As validation, an intermediate clotting phenotype, the endogenous thrombin potential-based normalized activated protein C sensitivity ratio, was measured in plasma of controls. RESULTS We studied 68 venous thrombosis, 67 myocardial infarction, and 48 ischemic stroke cases, with 201 matched controls; all participants were current users of oral CEEs or estradiol. In adjusted analyses, current oral CEEs use compared with current oral estradiol use was associated with an increased venous thrombosis risk (odds ratio, 2.08; 95% CI, 1.02-4.27; P = .045) and an increased myocardial infarction risk that did not reach statistical significance (odds ratio, 1.87; 95% CI, 0.91-3.84; P = .09) and was not associated with ischemic stroke risk (odds ratio, 1.13; 95% CI, 0.55-2.31; P = .74). Among 140 controls, CEEs users compared with estradiol users had higher endogenous thrombin potential-based normalized activated protein C sensitivity ratios (P < .001), indicating a stronger clotting propensity. CONCLUSIONS AND RELEVANCE In an observational study of oral hormone therapy users, CEEs use was associated with a higher risk of incident venous thrombosis and possibly myocardial infarction than estradiol use. This risk differential was supported by biologic data. These findings need replication and suggest that various oral estrogen drugs may be associated with different levels of cardiovascular risk.
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Affiliation(s)
- Nicholas L Smith
- Department of Epidemiology, University of Washington, Seattle2Group Health Research Institute, Group Health Cooperative, Seattle, Washington3Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Devel
| | - Marc Blondon
- Department of Epidemiology, University of Washington, Seattle4Department of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | | | | | | | - James S Floyd
- Department of Medicine, University of Washington, Seattle
| | - Melody Hwang
- Department of Epidemiology, University of Washington, Seattle
| | - Joshua C Bis
- Department of Medicine, University of Washington, Seattle
| | | | - Kenneth M Rice
- Department of Biostatistics, University of Washington, Seattle
| | - Thomas Lumley
- Department of Biostatistics, University of Washington, Seattle8Department of Statistics, University of Auckland, Auckland, New Zealand
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands9Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Susan R Heckbert
- Department of Epidemiology, University of Washington, Seattle2Group Health Research Institute, Group Health Cooperative, Seattle, Washington
| | - Bruce M Psaty
- Department of Epidemiology, University of Washington, Seattle2Group Health Research Institute, Group Health Cooperative, Seattle, Washington5Department of Medicine, University of Washington, Seattle10Department of Health Services, University of Washington
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Abstract
There is now compelling evidence that use of oral contraceptives and postmenopausal hormonal therapies containing various estrogens is associated with a weak, but clinically relevant risk of both arterial and venous thrombosis. The increased risk is related to type and dose of both estrogen and combined progestagen and mode of delivery. Treatment induces mainly subtle changes in individual components of the coagulation and fibrinolytic systems, but the overall effect is the induction of a prothrombotic phenotype. This brief review summarizes some of the mechanisms responsible the prothrombotic effects of such treatment.
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Affiliation(s)
- Per Morten Sandset
- Oslo University Hospital Rikshospitalet, Department of Haematology and Research Institute of Internal Medicine, University of Oslo, Oslo, Norway.
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Raps M, Helmerhorst FM, Fleischer K, Dahm AEA, Rosendaal FR, Rosing J, Reitsma P, Sandset PM, van Vliet HAAM. The effect of different hormonal contraceptives on plasma levels of free protein S and free TFPI. Thromb Haemost 2013; 109:606-13. [PMID: 23407778 DOI: 10.1160/th12-10-0771] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 12/14/2012] [Indexed: 11/05/2022]
Abstract
Use of combined oral contraceptives is associated with a three- to six-fold increased risk of venous thrombosis. Hormonal contraceptives induce acquired resistance to activated protein C (APC), which predicts the risk of venous thrombosis. The biological basis of the acquired APC resistance is unknown. Free protein S (PS) and free tissue factor pathway inhibitor (TFPI) are the two main determinants of APC. Our objective was to assess the effect of both hormonal and non-hormonal contraceptives with different routes of administration on free TFPI and free PS levels. We conducted an observational study in 243 users of different contraceptives and measured APC sensitivity ratios (nAPCsr), free TFPI and free PS levels. Users of contraceptives with the highest risk of venous thrombosis as reported in recent literature, had the lowest free TFPI and free PS levels, and vice versa, women who used contraceptives with the lowest risk of venous thrombosis had the highest free TFPI and free PS levels. An association was observed between levels of free TFPI and nAPCsr, and between free PS and nAPCsr. The effect of oral contraceptives on TFPI and PS is a possible explanation for the increased risk of venous thrombosis associated with oral contraceptives.
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Affiliation(s)
- Marjolein Raps
- Marjolein Raps, Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.
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Green L, Safa O, Machin SJ, Mackie IJ, Ryland K, Cohen H, Lawrie AS. Development and application of an automated chromogenic thrombin generation assay that is sensitive to defects in the protein C pathway. Thromb Res 2012; 130:780-4. [DOI: 10.1016/j.thromres.2011.12.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 12/21/2011] [Accepted: 12/22/2011] [Indexed: 10/14/2022]
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Tchaikovski S, Tans G, Rosing J. Venous thrombosis and oral contraceptives: current status. WOMENS HEALTH 2012; 2:761-72. [PMID: 19803829 DOI: 10.2217/17455057.2.5.761] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The use of oral contraceptives is associated with an increased risk of venous thrombosis. It is now generally accepted that women who use oral contraceptives that contain so-called third-generation progestins (desogestrel or gestodene) are exposed to a twofold higher risk of venous thrombosis than women who use oral contraceptives that contain the second-generation progestin levonorgestrel. Coagulation studies demonstrated that oral contraceptives increase the plasma level of prothrombin, decrease the level of protein S and induce acquired activated protein C resistance. The changes in hemostatic parameters can explain why women who use oral contraceptives are exposed to an increased risk of venous thrombosis and why the risk is further increased in third-generation oral contraceptive users.
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Affiliation(s)
- Svetlana Tchaikovski
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands.
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35
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The APC-PCI concentration as an early marker of activation of blood coagulation. Thromb Res 2012; 130:636-9. [DOI: 10.1016/j.thromres.2011.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 11/03/2011] [Accepted: 11/07/2011] [Indexed: 11/21/2022]
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36
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Effects of the etonogestrel-releasing contraceptive implant inserted immediately postpartum on maternal hemostasis: A randomized controlled trial. Thromb Res 2012; 130:355-60. [DOI: 10.1016/j.thromres.2012.03.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 03/23/2012] [Accepted: 03/29/2012] [Indexed: 11/22/2022]
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Jordan SW, Corriere MA, Vossen CY, Rosendaal FR, Chaikof EL. Flow-simulated thrombin generation profiles as a predictor of thrombotic risk among pre-menopausal women. Thromb Haemost 2012; 108:258-65. [PMID: 22688389 PMCID: PMC3482384 DOI: 10.1160/th12-02-0098] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2012] [Accepted: 04/25/2012] [Indexed: 11/05/2022]
Abstract
A large number of individuals are at risk for deep venous thrombosis (DVT) due to alterations in multiple coagulation factors and inhibitors secondary to malignancy, drug interactions, or other general medical conditions. Traditional metrics of haemostasis such as prothrombin time, partial thromboplastin time, and bleeding time, generally estimate anticoagulation status and bleeding risk rather than thrombosis risk. The objective of this study was to correlate a novel, systems-based metric of clotting potential to risk of DVT from a database derived from the Leiden Thrombophilia Study (LETS). We utilised a computational model of blood coagulation, which addresses the interplay between biochemical factors, blood flow, and physiologic surface initiation of coagulation, to calculate an individualised, systems-based metric of clotting potential, termed the flow-simulated thrombin generation (FSTG), for 210 pre-menopausal women in LETS. Both DVT and oral contraceptive (OC) use were associated with higher values of FSTG. We demonstrated a nearly three-fold increased risk of DVT for each standard deviation increase above the mean in FSTG determined under venous flow conditions, which remained highly predictive after adjustment for age and OC status (adjusted odds ratio 2.66; 95% confidence interval 1.69-4.19; p<0.0001). In conclusion, a systems-based screening approach that integrates biochemical factors and flow haemodynamics identifies small subgroups of patients at risk of thrombosis that may benefit from oral anticoagulants.
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Affiliation(s)
- Sumanas W Jordan
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA
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Klipping C, Duijkers I, Parke S, Mellinger U, Serrani M, Junge W. Hemostatic effects of a novel estradiol-based oral contraceptive: an open-label, randomized, crossover study of estradiol valerate/dienogest versus ethinylestradiol/levonorgestrel. Drugs R D 2012; 11:159-70. [PMID: 21679006 PMCID: PMC3585947 DOI: 10.2165/11591200-000000000-00000] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background: A novel estradiol-based combined oral contraceptive (COC) is currently available in many countries worldwide, including Europe and the US. Based on previous studies, it is expected that this estradiol-based COC will have a reduced hepatic effect compared with COCs containing ethinylestradiol with regard to proteins controlling the hemostatic balance. Objective: The aim of this study was to compare the hemostatic effects of the estradiol valerate/dienogest COC with a monophasic low-estrogen dose COC containing ethinylestradiol/levonorgestrel. Study Design: Healthy women aged 18–50 years were randomized to receive a COC containing estradiol valerate/dienogest (2 days estradiol valerate 3 mg, 5 days estradiol valerate 2mg/dienogest 2 mg, 17 days estradiol valerate 2mg/dienogest 3 mg, 2 days estradiol valerate 1 mg, 2 days placebo) or ethinylestradiol 0.03mg/levonorgestrel 0.15mg in a crossover study design. Women received each treatment for three cycles, with two washout cycles between treatments. The primary efficacy variables were the intra-individual absolute changes in prothrombin fragment 1 + 2 and D-dimer from baseline to cycle three. Results: Data from 29 women were assessed. Intra-individual absolute changes in prothrombin fragment 1 + 2 and D-dimer from baseline to cycle three were less pronounced with estradiol valerate/dienogest than with ethinylestradiol/ levonorgestrel. Conclusion: The novel COC containing estradiol valerate/dienogest had similar or less pronounced effects on hemostatic parameters than ethinylestradiol/ levonorgestrel.
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Elmer J, Wittels KA. Emergency reversal of pentasaccharide anticoagulants: a systematic review of the literature. Transfus Med 2011; 22:108-15. [DOI: 10.1111/j.1365-3148.2011.01125.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Ågren UM, Anttila M, Mäenpää-Liukko K, Rantala ML, Rautiainen H, Sommer WF, Mommers E. Effects of a monophasic combined oral contraceptive containing nomegestrol acetate and 17β-oestradiol compared with one containing levonorgestrel and ethinylestradiol on haemostasis, lipids and carbohydrate metabolism. EUR J CONTRACEP REPR 2011; 16:444-57. [PMID: 22066891 PMCID: PMC3233272 DOI: 10.3109/13625187.2011.604450] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare the effects of a combined oral contraceptive (COC) containing nomegestrol acetate and 17β-oestradiol (NOMAC/E2) on haemostasis, lipids, carbohydrate metabolism, C-reactive protein (CRP) and sex hormone-binding globulin (SHBG) with those of a COC containing levonorgestrel and ethinylestradiol (LNG/EE). METHODS In a randomised, open-label study, 121 healthy women, 18-50 years of age, were randomly assigned to receive NOMAC/E2 (2.5 mg/1.5 mg) in a 24/4-day regimen (n=60) or LNG/EE (150 μg/30 μg) in a 21/7-day regimen (n=61) for six cycles. The primary outcome was the change from baseline to cycle 6 for all indices. RESULTS All parameters were similar at baseline between the two groups. Over six cycles, NOMAC/E2 had less effect on most haemostatic indices than LNG/EE. Lipids were essentially unchanged with NOMAC/E2, whereas with LNG/EE high-density lipoprotein cholesterol decreased and low-density lipoprotein cholesterol and triglycerides slightly increased. NOMAC/E2 induced negligible changes in glucose and insulin parameters, in contrast to LNG/EE. A much smaller increase in CRP was observed with NOMAC/E2 than with LNG/EE. NOMAC/E2 was associated with a greater increase in SHBG. CONCLUSIONS The monophasic COC NOMAC/E2 had less influence on haemostasis, lipids and carbohydrate metabolism than the COC LNG/EE.
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Tchaikovski SN, Thomassen MCLGD, Costa SD, Peeters LLH, Rosing J. Role of protein S and tissue factor pathway inhibitor in the development of activated protein C resistance early in pregnancy in women with a history of preeclampsia. Thromb Haemost 2011; 106:914-21. [PMID: 21979881 DOI: 10.1160/th11-04-0244] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2011] [Accepted: 08/09/2011] [Indexed: 11/05/2022]
Abstract
Pregnancy increases the risk of venous thromboembolism. Particularly in early pregnancy, the thrombosis risk can be attributed to the changes in coagulation. Elevated thrombin generation and resistance to activated protein C (APC) are likely to contribute to the increased thrombosis risk during pregnancy. We studied changes and the determinants of thrombin generation and APC resistance in the first 16 weeks of gestation in women with history of preeclampsia. Additionally, we investigated the influence of pregnancy-induced haemodilution on the coagulation system. We measured thrombin generation, APC resistance and plasma levels of prothrombin, factor V, factor X, protein S and tissue factor pathway inhibitor (TFPI) in 30 non-pregnant and 21 pregnant women at 8, 12 and 16 weeks of gestation. All participants shared a history of a hypertensive complication in the preceding pregnancy. Thrombin generation and APC resistance were higher at eight weeks of pregnancy than in the non-pregnant state, and progressively increased between eight and 16 weeks of gestation. Changes in the TFPI and protein S levels accounted for ~70% of pregnancy-induced APC resistance. Interestingly, a significant correlation (slope 2.23; 95%CI: 1.56 to 2.91; r= 0.58) was observed between protein Stotal or protein Sfree levels and haematocrit. In conclusion, pregnancy induces a decrease of TFPIfree and protein Sfree levels that attenuates the function of the TFPI and protein C systems and results in elevated thrombin generation and increased APC resistance. Besides, our data suggest that pregnancy-dependent haemodilution may contribute to the decreased peripheral protein S levels.
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Affiliation(s)
- S N Tchaikovski
- University Women´s Hospital, Otto-von-Guericke University, Gerhard-Hauptmann Straße 35, Magdeburg, Germany.
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Winkler UH, Daume E, Sudik R, Oberhoff C, Bier U, Hallmann C, Andreas JO, Schindler AE. A comparative study of the hemostatic effects of two monophasic oral contraceptives containing 30 μg ethinylestradiol and either 2 mg chlormadinone acetate or 150 μg desogestrel. EUR J CONTRACEP REPR 2011. [DOI: 10.1080/13625189909040809] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Exogenous hormones, the risk of venous thromboembolism, and activated protein C resistance. Menopause 2011; 17:1099-103. [PMID: 20975607 DOI: 10.1097/gme.0b013e3181fa264c] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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van Hylckama Vlieg A, Middeldorp S. Hormone therapies and venous thromboembolism: where are we now? J Thromb Haemost 2011; 9:257-66. [PMID: 21114755 DOI: 10.1111/j.1538-7836.2010.04148.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- A van Hylckama Vlieg
- Leiden University Medical Center, Department of Clinical Epidemiology, Leiden, The Netherlands.
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Contraception hormonale. Contraception 2011. [DOI: 10.1016/b978-2-294-70921-0.00006-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Magnetic resonance venography and genetics of a female patient with pelvic venous thrombosis. J Thromb Thrombolysis 2010; 30:233-9. [DOI: 10.1007/s11239-010-0443-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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48
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Abstract
Proteolytic inactivation of factors Va (FVa) and VIIIa (FVIIIa) by activated protein C (APC) and its cofactors protein S and factor V (FV) is a key process in the physiological down-regulation of blood coagulation. Functional abnormalities of this pathway, which manifest themselves in vitro as a poor anticoagulant response of plasma to added APC (APC resistance), are prevalent in the general population and are associated with an increased risk of venous thrombosis. APC resistance was originally discovered in thrombophilic families and later shown to be associated with the common FV Arg506Gln (FV(Leiden)) mutation, which abolishes one of the APC-cleavage sites in FV. Although FV(Leiden) is the major cause of hereditary APC resistance, it is becoming increasingly clear that several other genetic and acquired conditions contribute to APC resistance and thereby increase the risk of venous thrombosis. This paper reviews the multifactorial etiology of APC resistance and discusses its clinical implications.
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Affiliation(s)
- E Castoldi
- Department of Biochemistry, Maastricht University, Maastricht, the Netherlands
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Tchaikovski SN, Rosing J. Mechanisms of estrogen-induced venous thromboembolism. Thromb Res 2010; 126:5-11. [PMID: 20163835 DOI: 10.1016/j.thromres.2010.01.045] [Citation(s) in RCA: 143] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Revised: 01/21/2010] [Accepted: 01/24/2010] [Indexed: 12/14/2022]
Abstract
The use of oral contraceptives (OC) is a well established risk factor for venous thrombosis. It has been known for many years that almost all haemostatic parameters i.e. plasma levels of coagulation factors, anticoagulant proteins and proteins involved in the fibrinolytic pathway change during OC use. The discovery of several risk factors of venous thrombosis in the 1990s shed new light on the association between the effects of OC on the haemostatic system and the increased risk of venous thrombosis. In this review, we summarize the current knowledge on the effects of different kinds of hormonal contraceptives (OC, transdermal contraceptives, vaginal ring and levonorgestrel-releasing intrauterine device) on haemostatic variables and the relationship between the changes of these variables and the risk of venous thrombosis.
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Affiliation(s)
- Svetlana N Tchaikovski
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
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50
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Pötzsch B, Madlener K. Thrombingenerierung und endogens Thrombinbildungs-potenzial. Hamostaseologie 2010. [DOI: 10.1007/978-3-642-01544-1_65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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