Influence of Pregnancy and Oral Contraceptives on Platelets in Relation to Coagulation ancl Aggregation

Occlusive vascular diseases in oral contraceptive users. Epidemiology, pathology and mechanisms

Despite being an unprecedented departure from normal physiology, the combined oral contraceptive is not only highly effective, but it also has a remarkably good safety record. Concerns over safety persist, though, particularly with regard to venous thromboembolism (VTE), stroke and myocardial infarction (MI). Epidemiological studies consistently show an increase in risk of VTE, but the results are more contentious with regard to arterial diseases. Despite 40 years of research, the mechanisms behind these adverse effects are not understood. In this review, we integrate information from published studies of the epidemiology and pathology of the occlusive vascular diseases and their risk factors to identify likely explanations for pathogenesis in oral contraceptive users. Oral contraceptives induce both prothrombotic and fibrinolytic changes in haemostatic factors and an imbalance in haemostasis is likely to be important in oral contraceptive-induced VTE. The complexity of the changes involved and the difficulty of ascribing clinical significance has meant that uncertainty persists. A seriously under-researched area concerns vascular changes in oral contraceptive users. Histologically, endothelial and intimal proliferation have been identified in women exposed to high plasma estrogen concentrations and these lesions are associated with thrombotic occlusion. Other structural changes may result in increased vascular permeability, loss of vascular tone and venous stasis. With regard to arterial disease risk, epidemiological information relating to dose effects and joint effects with other risk factors, and studies of pathology and changes in risk factors, suggests that oral contraceptive use per se does not cause arterial disease. It can, nevertheless, synergise very powerfully with subclinical endothelial damage to promote arterial occlusion. Accordingly, the prothrombotic effects of the oral contraceptive estrogen intervene in a cycle of endothelial damage and repair which would otherwise remain clinically silent or would ultimately progress - in, for example, the presence of cigarette smoking or hypertension - to atherosclerosis. Future work in this area should focus on modification of the effects of established risk factors by oral contraceptive use rather than modification of the supposed risk of oral contraceptive use by established risk factors. Attempts to understand vascular occlusion in oral contraceptive users in terms of the general features of VTE or with reference to atherosclerosis may be limiting, and future work needs to acknowledge that such occlusions may have unique features. Unequivocal identification of the mechanisms involved would contribute considerably to the alleviation of fears over vascular disease and to the development of even safer formulations.

Hormonal contraceptive increases plasma lipid peroxides in female rats. Relationship to platelet aggregation and lipid biosynthesis

We investigated whether changes in plasma oxidative properties could occur after oral (hormonal) contraceptive (OC) administration in female rats and whether such changes could be responsible for the platelet increase in aggregation and lipid biosynthesis observed with that treatment. Platelets and plasma (platelet-poor) from control and OC (ethinyl estradiol + lynestrenol)-treated rats were prepared separately. Thrombin-induced aggregation of control platelets was markedly enhanced after incubation for 4 (p less than 0.025) to 60 (p less than 0.001) minutes in OC as compared with control plasma. Under the same conditions, platelet lipid biosynthesis was increased also (p less than 0.05 to p less than 0.01), but after 3 hours incubation. The enhanced response of platelets to aggregation induced by OC plasma could be inhibited by adding either glutathione (p less than 0.025), vitamin E (p less than 0.025), catalase (p less than 0.05), or peroxidase + glutathione (p less than 0.005) to plasma or 2,6,di-bis(ter-butyl)p-cresol (p less than 0.05) to platelets before incubation. The peroxidized free fatty acids isolated from OC plasma added to normal platelets induced a 150% (p less than 0.001) increase in the response to thrombin as compared with the fatty acids from control plasma. In addition, the level of malondialdehyde and conjugated dienes was significantly (p less than 0.02 to p less than 0.001) increased in OC compared with control plasma. We conclude that the enhanced formation in plasma of lipid hydroperoxides seems to be the initial event stimulating platelets after OC treatment, at least in rats.

Human platelet alpha-adrenergic receptors and responses during pregnancy: no change except that with differing hematocrit

The possibility that platelet aggregation is altered during pregnancy is controversial. We tested for alterations of alpha-adrenergic receptor-induced platelet function during pregnancy compared to that in the early phase of the menstrual cycle. We found no change in alpha-adrenergic receptor concentration or in affinity of the receptor for epinephrine. The potency and sensitivity of epinephrine to inhibit adenylate cyclase, a response mediated by alpha 2-adrenergic receptors, was not different in platelets from the two groups of subjects. The ability of epinephrine to potentiate aggregation by adenosine diphosphate was significantly increased during pregnancy; however, this was an artifact introduced by lower hematocrits during pregnancy that resulted in an increased citrate concentration in the preparations of platelet-rich plasma from these women. The difference was eliminated by normalization of citrate concentration. Thus effects of alpha-adrenergic receptors on platelet function are not different during pregnancy. It is mandatory to recognize artifactual effects of differing hematocrits on platelet aggregation studied in vitro.

Oral contraceptives and blood coagulation: a critical review

Based on epidemiologic data, women who take oral contraceptives seem to have an increased risk of developing thromboembolic disease. In order to explain this association, some studies have been undertaken to find abnormalities in the hemostasis system. Many conflicting test results have been reported, probably reflecting in part the technical difficulties in use of reliable, reproducible, and specific assay systems. None of the data obtained seems to be specific for users of oral contraceptive drugs, and none was found uniformly in all takers of the drugs. Many findings are probably unimportant from the overall point of view of the physiology of hemostasis. Unfortunately, there seems to be no test procedure or even combination of tests that will reliably predict which patient might develop a thromboembolic episode in association with oral contraceptives or in association with any other condition recognized as being a risk factor. Even in most patients who do have a thrombosis, the test procedures fail to signal this event with reliability and predictability. At this time, it is not known whether oral contraceptives do or do not trigger the hemostasis system to develop a thrombosis or by which mechanism they could trigger the event. Fortunately, only a very small number of women develop thrombosis in association with oral contraceptives.