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Douxfils J, Gaspard U, Taziaux M, Jost M, Bouvy C, Lobo RA, Utian WH, Foidart JM. Impact of estetrol (E4) on hemostasis, metabolism and bone turnover in postmenopausal women. Climacteric 2023; 26:55-63. [PMID: 36399023 DOI: 10.1080/13697137.2022.2139599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This study aimed to determine the effects of estetrol (E4) on hemostasis, lipids, carbohydrate metabolism and bone turnover in postmenopausal women. METHODS This study was a multicenter, randomized, double-blind placebo-controlled phase 2 trial. Participants (n = 180, age 43-64 years) received E4 2.5 mg, 5 mg, 10 mg and 15 mg or placebo once daily for 12 weeks. Changes from baseline at week 12 were evaluated versus placebo for hemostasis parameters, sex hormone binding globulin (SHBG), lipids, carbohydrate metabolism and bone markers. RESULTS Changes for hemostasis parameters were minimal with a small increase only in the normalized activated protein C sensitivity ratio in the E4 15 mg group versus placebo. SHBG increased in the E4 5 mg, 10 mg and 15 mg groups versus placebo. High-density lipoprotein cholesterol increased in all E4 groups; changes were not consistent for other lipids. Significant decreases versus placebo were seen for insulin resistance (E4 10 mg group), hemoglobin A1c (E4 15 mg group) and type 1 collagen C-terminal telopeptide (E4 10 mg and 15 mg groups). Small decreases in osteocalcin in the E4 5 mg, 10 mg and 15 mg groups were significant versus the increase observed in placebo. CONCLUSION E4 had limited impact on hemostasis and potentially beneficial effects on lipids, carbohydrate metabolism and bone turnover.
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Affiliation(s)
- J Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, University of Namur, Namur, Belgium.,QUALIblood s.a, Namur, Belgium
| | - U Gaspard
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - M Taziaux
- Estetra SRL, an affiliate company of Mithra Pharmaceuticals, Liège, Belgium
| | - M Jost
- Estetra SRL, an affiliate company of Mithra Pharmaceuticals, Liège, Belgium
| | - C Bouvy
- QUALIblood s.a, Namur, Belgium
| | - R A Lobo
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - W H Utian
- Case Western Reserve Medical School, Cleveland, OH, USA
| | - J-M Foidart
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium.,Estetra SRL, an affiliate company of Mithra Pharmaceuticals, Liège, Belgium
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Helkkula P, Hassan S, Saarentaus E, Vartiainen E, Ruotsalainen S, Leinonen JT, Palotie A, Karjalainen J, Kurki M, Ripatti S, Tukiainen T. Genome-wide association study of varicose veins identifies a protective missense variant in GJD3 enriched in the Finnish population. Commun Biol 2023; 6:71. [PMID: 36653477 PMCID: PMC9849365 DOI: 10.1038/s42003-022-04285-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 11/21/2022] [Indexed: 01/19/2023] Open
Abstract
Varicose veins is the most common manifestation of chronic venous disease that displays female-biased incidence. To identify protein-inactivating variants that could guide identification of drug target genes for varicose veins and genetic evidence for the disease prevalence difference between the sexes, we conducted a genome-wide association study of varicose veins in Finns using the FinnGen dataset with 17,027 cases and 190,028 controls. We identified 50 associated genetic loci (P < 5.0 × 10-8) of which 29 were novel including one near ERG with female-specificity (rs2836405-G, OR[95% CI] = 1.09[1.05-1.13], P = 3.1 × 10-8). These also include two X-chromosomal (ARHGAP6 and SRPX) and two autosomal novel loci (TGFB2 and GJD3) with protein-coding lead variants enriched above 56-fold in Finns over non-Finnish non-Estonian Europeans. A low-frequency missense variant in GJD3 (p.Pro59Thr) is exclusively associated with a lower risk for varicose veins (OR = 0.62 [0.55-0.70], P = 1.0 × 10-14) in a phenome-wide scan of the FinnGen data. The absence of observed pleiotropy and its membership of the connexin gene family underlines GJD3 as a potential connexin-modulating therapeutic strategy for varicose veins. Our results provide insights into varicose veins etiopathology and highlight the power of isolated populations, including Finns, to discover genetic variants that inform therapeutic development.
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Grants
- MC_PC_17228 Medical Research Council
- Academy of Finland (Suomen Akatemia)
- Sydäntutkimussäätiö (Finnish Foundation for Cardiovascular Research)
- Academy of Finland Center of Excellence in Complex Disease Genetics (Grant No 312062), Sigrid Juselius Foundation (S.Ri. and T.T.), University of Helsinki HiLIFE Fellow and Grand Challenge grants (S.Ri.), University of Helsinki three-year research project grant (T.T.), FIMM-EMBL PhD program doctoral funding (S.H.), Nylands Nation, University of Helsinki (P.H.) The FinnGen project is funded by two grants from Business Finland (HUS 4685/31/2016 and UH 4386/31/2016) and the following industry partners: AbbVie Inc., AstraZeneca UK Ltd, Biogen MA Inc., Bristol Myers Squibb (and Celgene Corporation & Celgene International II Sàrl), Genentech Inc., Merck Sharp & Dohme Corp, Pfizer Inc., GlaxoSmithKline Intellectual Property Development Ltd., Sanofi US Services Inc., Maze Therapeutics Inc., Janssen Biotech Inc, Novartis AG, and Boehringer Ingelheim. Following biobanks are acknowledged for delivering biobank samples to FinnGen: Auria Biobank (www.auria.fi/biopankki), THL Biobank (www.thl.fi/biobank), Helsinki Biobank (www.helsinginbiopankki.fi), Biobank Borealis of Northern Finland (https://www.ppshp.fi/Tutkimus-ja-opetus/Biopankki/Pages/Biobank-Borealis-briefly-in-English.aspx), Finnish Clinical Biobank Tampere (www.tays.fi/en-US/Research_and_development/Finnish_Clinical_Biobank_Tampere), Biobank of Eastern Finland (www.ita-suomenbiopankki.fi/en), Central Finland Biobank (www.ksshp.fi/fi-FI/Potilaalle/Biopankki), Finnish Red Cross Blood Service Biobank (www.veripalvelu.fi/verenluovutus/biopankkitoiminta) and Terveystalo Biobank (www.terveystalo.com/fi/Yritystietoa/Terveystalo-Biopankki/Biopankki/).
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Affiliation(s)
- Pyry Helkkula
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki, Finland
| | - Shabbeer Hassan
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki, Finland
| | - Elmo Saarentaus
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki, Finland
| | - Emilia Vartiainen
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki, Finland
| | - Sanni Ruotsalainen
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki, Finland
| | - Jaakko T Leinonen
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki, Finland
| | - Aarno Palotie
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki, Finland
- Program in Medical and Population Genetics and Stanley Center for Psychiatric Research, Broad Institute of Harvard and MIT, Cambridge, MA, USA
- Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Juha Karjalainen
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki, Finland
- Broad Institute of the Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA
| | - Mitja Kurki
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki, Finland
- Broad Institute of the Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA
| | - Samuli Ripatti
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki, Finland
- Broad Institute of the Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA
- Department of Public Health, Clinicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Taru Tukiainen
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki, Finland.
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Haverinen A, Luiro K, Kangasniemi MH, Piltonen TT, Hustad S, Heikinheimo O, Tapanainen JS. Estradiol Valerate vs Ethinylestradiol in Combined Oral Contraceptives: Effects on the Pituitary-Ovarian Axis. J Clin Endocrinol Metab 2022; 107:e3008-e3017. [PMID: 35279718 DOI: 10.1210/clinem/dgac150] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Indexed: 12/27/2022]
Abstract
CONTEXT Limited studies have compared the effects of combined oral contraceptives (COCs) containing natural estrogens and synthetic ethinylestradiol (EE) on reproductive hormones. OBJECTIVE To compare estradiol valerate (EV) + dienogest (DNG), EE + DNG, and DNG alone (active control) on levels of follicle stimulating hormone (FSH), luteinizing hormone, anti-Müllerian hormone (AMH), ovarian steroids, sex hormone binding globulin (SHBG), and the free androgen index (FAI). METHODS This spin-off study from a randomized trial enrolled 59 healthy, 18 to 35-year-old ovulatory women, outpatients at Helsinki and Oulu University Hospitals, Finland, who were randomized to EV 2 mg + DNG 2-3 mg (n = 20); EE 0.03 mg + DNG 2 mg (n = 20); and DNG 2 mg (n = 19) for 9 weeks. Blood samples were drawn at baseline, and at 5 and 9 weeks. Age and BMI were comparable between groups; 3 women discontinued. RESULTS EV + DNG suppressed FSH by -27% (-51% to -3%) (median [95% CI]) vs EE + DNG, -64% (-78 to -51), P = 0.04, but AMH levels decreased similarly by -9% (-18 to -0.1) vs -13% (-28 to 0.2), P = 0.38, respectively. EV + DNG increased SHBG levels by 56% (30% to 82%) and EE + DNG by 385% (313% to 423%), P < 0.001. Total testosterone decreased by 16% (-27% to -5%) in the EV + DNG group but it did not decrease in the EE + DNG group, whereas the FAI decreased by -39% (-54% to -25%) vs -72% (-78% to -67%), P < 0.001. DNG alone did not induce changes in any of these parameters. CONCLUSION Compared with EE + DNG, treatment with EV + DNG resulted in milder pituitary downregulation and reduced induction of hepatic SHBG synthesis-potentially carrying more beneficial health effects.
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Affiliation(s)
- Annina Haverinen
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, PO Box 140, 00029 Helsinki, Finland
| | - Kaisu Luiro
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, PO Box 140, 00029 Helsinki, Finland
| | - Marika H Kangasniemi
- Department of Obstetrics and Gynecology, University of Oulu, Oulu University Hospital and Medical Research Centre PEDEGO Research Unit, PO Box 5000, 90014 Oulu, Finland
| | - Terhi T Piltonen
- Department of Obstetrics and Gynecology, University of Oulu, Oulu University Hospital and Medical Research Centre PEDEGO Research Unit, PO Box 5000, 90014 Oulu, Finland
| | - Steinar Hustad
- Department of Clinical Science and Core Facility for Metabolomics, University of Bergen, NO-5020 Bergen, Norway
| | - Oskari Heikinheimo
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, PO Box 140, 00029 Helsinki, Finland
| | - Juha S Tapanainen
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, PO Box 140, 00029 Helsinki, Finland
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Morimont L, Haguet H, Dogné JM, Gaspard U, Douxfils J. Combined Oral Contraceptives and Venous Thromboembolism: Review and Perspective to Mitigate the Risk. Front Endocrinol (Lausanne) 2021; 12:769187. [PMID: 34956081 PMCID: PMC8697849 DOI: 10.3389/fendo.2021.769187] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/08/2021] [Indexed: 12/02/2022] Open
Abstract
Many factors must be considered and discussed with women when initiating a contraceptive method and the risk of venous thromboembolism (VTE) is one of them. In this review, we discuss the numerous strategies that have been implemented to reduce the thrombotic risk associated with combined oral contraceptives (COCs) from their arrival on the market until today. Evidences suggesting that COCs were associated with an increased risk of VTE appeared rapidly after their marketing. Identified as the main contributor of this risk, the dosage of the estrogen, i.e., ethinylestradiol (EE), was significantly reduced. New progestins were also synthetized (e.g., desogestrel or gestodene) but their weak androgenic activity did not permit to counterbalance the effect of EE as did the initial progestins such as levonorgestrel. Numerous studies assessed the impact of estroprogestative combinations on hemostasis and demonstrated that women under COC suffered from resistance towards activated protein C (APC). Subsequently, the European Medicines Agency updated its guidelines on clinical investigation of steroid contraceptives in which they recommended to assess this biological marker. In 2009, estradiol-containing COCs were marketed and the use of this natural form of estrogen was found to exert a weaker effect on the synthesis of hepatic proteins compared to EE. In this year 2021, a novel COC based on a native estrogen, i.e., estetrol, will be introduced on the market. Associated with drospirenone, this preparation demonstrated minor effects on coagulation proteins as compared with other drospirenone-containing COCs. At the present time, the standard of care when starting a contraception, consists of identifying the presence of hereditary thrombophilia solely on the basis of familial history of VTE. This strategy has however been reported as poorly predictive of hereditary thrombophilia. One rationale and affordable perspective which has already been considered in the past could be the implementation of a baseline screening of the prothrombotic state to provide health care professionals with objective data to support the prescription of the more appropriate contraceptive method. While this strategy was judged too expensive due to limited laboratory solutions, the endogenous thrombin potential-based APC resistance assay could now represent an interesting alternative.
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Affiliation(s)
- Laure Morimont
- Research Department, Qualiblood s.a., Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
| | - Hélène Haguet
- Research Department, Qualiblood s.a., Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
| | | | - Ulysse Gaspard
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - Jonathan Douxfils
- Research Department, Qualiblood s.a., Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
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Kirakosyan EV, Sosnova EA. The Effect Of Combined Oral Contraceptives And Hormone Therapy During Assisted Reproductive Technologies On The Function Of The Hemostatic System In Non-Pregnant And Pregnant Women. RUSSIAN OPEN MEDICAL JOURNAL 2021. [DOI: 10.15275/rusomj.2021.0210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
A review of world literature was conducted in the databases Scopus, Web of Science, MedLine, Cochrane CENTRAL, Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effectiveness (DARE), EMBASE, Global Health, CyberLeninka, RSCI on the problem of the effect of combined oral contraceptives (COCs) and hormone therapy during assisted reproductive technologies on the function of the hemostatic system in non-pregnant and pregnant women. The scientific concept of this work is different in that we have summarized and analyzed information on the effect of sex hormones entering the woman’s body from the outside on individual links and the hemostatic system as a whole, determined the relationship between drug administration and thrombotic complications, optimized the sequence of diagnosis of conditions predisposing to thrombosis. The scientific novelty of this work is that we have compared the effects of COCs and hormonal changes during pregnancy on the hemostatic system and found that changes in the hemostatic system in women taking COCs are similar to those that occur during pregnancy.
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Affiliation(s)
- Evgeniya V. Kirakosyan
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Elena A. Sosnova
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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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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Khialani D, Rosendaal F, Vlieg AVH. Hormonal Contraceptives and the Risk of Venous Thrombosis. Semin Thromb Hemost 2020; 46:865-871. [DOI: 10.1055/s-0040-1715793] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AbstractThe risk of venous thrombosis (VT) varies according to the type of progestogen that is found in combined oral contraceptives (COCs). When combined with the estrogen component ethinylestradiol (EE), the androgenic progestogens are better able to counteract the EE-induced stimulation of liver proteins and hence are associated with a twofold decreased risk of VT compared with non- or antiandrogenic progestogens, which exert limited counteraction of EE. Because EE is responsible for the increased risk, novel estrogens such as estradiol were developed and seem to have a lower risk of VT than EE. Besides COCs, there are other methods of hormonal contraceptives, such as progestogen-only contraceptives, which do not increase VT risk, except for injectables. Other nonoral contraceptives are combined vaginal rings and patches. There is insufficient evidence regarding the risk of VT associated with these two methods compared with COCs. The increased risk associated with COCs is more pronounced in women with inherited thrombophilia. In these women, the progestogen levonorgestrel seems to be associated with the lowest risk of VT. Currently, there are no studies that have investigated the risk of VT in women who switch COCs. We hypothesize that switching COCs, even when switching from a high- to a low-risk COC, increases the risk of VT. Finally, risk prediction models in women who use COCs are lacking. Since there is a large number of VT cases associated with COC use, it is important to identify women at risk of VT and advise them on alternative contraception methods.
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Affiliation(s)
- Deeksha Khialani
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frits Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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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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Bai XF, Wu ZX, Zhao CH, Wu Y, Fei CS, Zhang LQ, Chen ZH. Maternal oral contraceptive pill use and the risk of atopic diseases in the offspring: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e19607. [PMID: 32311929 PMCID: PMC7220114 DOI: 10.1097/md.0000000000019607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Studies of maternal oral contraceptive pill (OCP) exposure and the offspring's risk of atopic diseases are of current interest due to concerns about widespread use of OCP before or during pregnancy.We evaluated whether maternal OCP exposure is associated with an increased risk of atopic diseases by reviewing the literature and performing a meta-analysis. The PubMed and Embase databases were searched to identify potential studies for inclusion. Three common atopic outcomes were included: asthma, eczema, and rhinitis.We found 693 titles, abstracts, and citations, and 6 studies were included in this analysis. A meta-analysis revealed that maternal OCP exposure was associated with higher odds of asthma (odds ratio [OR] 1.1; 95% confidence interval [CI] 1.02-1.19; P = .014), rhinitis (OR 1.34; 95% CI 1.07-1.68; P = .011) during childhood, whereas there was no association with eczema (OR 1.17; 95% CI 0.81-1.68; P = .383). This analysis was limited by the small number of studies included and the limited adjustments for the possible confounders in the studies.Current evidence suggests that maternal OCP exposure increases the risk for respiratory allergic diseases (asthma and rhinitis) in the offspring, but not for eczema. Given the few studies included, future larger, prospective studies that control for important confounders are needed to verify our findings.
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Affiliation(s)
- Xue-Feng Bai
- Otolaryngology Head Neck Surgery, Tongxiang First People's Hospital
| | - Zheng-Xiang Wu
- Department of Pediatrics, Tongxiang Second People's Hospital, Tongxiang
| | - Chun-Hong Zhao
- Otolaryngology Head Neck Surgery, Tongxiang First People's Hospital
| | - Yong Wu
- Otolaryngology Head Neck Surgery, Tongxiang First People's Hospital
| | - Chang-Shun Fei
- Otolaryngology Head Neck Surgery, Tongxiang First People's Hospital
| | - Li-Qin Zhang
- Otolaryngology Head Neck Surgery, Tongxiang First People's Hospital
| | - Zhao-Hui Chen
- Department of Otolaryngology Head and Neck Surgery, Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang, China
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Scheres LJJ, van Hylckama Vlieg A, Ballieux BEPB, Fauser BCJM, Rosendaal FR, Middeldorp S, Cannegieter SC. Endogenous sex hormones and risk of venous thromboembolism in young women. J Thromb Haemost 2019; 17:1297-1304. [PMID: 31054196 PMCID: PMC6852478 DOI: 10.1111/jth.14474] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 04/24/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND The risk of venous thromboembolism (VTE) in young women can predominantly be attributed to exogenous hormone use. The influence of (abnormalities in) endogenous sex hormones, as in polycystic ovary syndrome (PCOS) or primary ovarian insufficiency (POI), on VTE risk is uncertain. OBJECTIVES Th assess the association between endogenous sex hormone levels and VTE risk. METHODS Women aged ≤45 years from the MEGA case-control study who provided a blood sample in the absence of exogenous hormone exposure or pregnancy were included. Sex hormone-binding globulin (SHBG), estradiol, follicle-stimulating hormone (FSH) and testosterone were measured. The free androgen index (FAI) and estradiol to testosterone ratio (E:T) were calculated. VTE risk was assessed according to quartiles (Qs) of levels and clinical cut-offs as proxies for PCOS (FAI > 4.5) and POI (FSH > 40 U/L). Logistic regression models were used to estimate adjusted odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS Six hundred and sixty-five women (369 cases; 296 controls) were eligible for the analyses. Testosterone and FSH levels, E:T and POI (FSH > 40 U/L vs FSH ≤ 40 U/L) were not associated with VTE risk. For estradiol, VTE risk was increased with levels in Q4 vs Q1 (OR 1.6; 95% CI 1.0-2.5). There was a dose-response relationship between SHBG levels and VTE risk, with the highest OR at Q4 vs Q1: 2.0 (95% CI 1.2-3.3). FAI > 4.5 (PCOS proxy) vs FAI ≤ 4.5 was associated with increased VTE risk (OR 3.3; 95% CI 0.9-11.8). CONCLUSIONS Estradiol, SHBG and FAI were associated with VTE risk, suggesting a role for endogenous sex hormones in the pathophysiology of VTE in young women.
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Affiliation(s)
- Luuk J. J. Scheres
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | | | - Bart E. P. B. Ballieux
- Department of Clinical Chemistry and Laboratory MedicineLeiden University Medical CenterLeidenthe Netherlands
| | - Bart C. J. M. Fauser
- Department of Reproductive Medicine & GynecologyUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Frits R. Rosendaal
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Saskia Middeldorp
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Department of Internal MedicineSection of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
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11
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Relationship between sex hormone binding globulin and blood coagulation in women on postmenopausal hormone treatment. Blood Coagul Fibrinolysis 2019; 30:17-23. [DOI: 10.1097/mbc.0000000000000784] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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12
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Roetker NS, MacLehose RF, Hoogeveen RC, Ballantyne CM, Basu S, Cushman M, Folsom AR. Prospective Study of Endogenous Hormones and Incidence of Venous Thromboembolism: The Atherosclerosis Risk in Communities Study. Thromb Haemost 2018; 118:1940-1950. [PMID: 30296818 PMCID: PMC6289254 DOI: 10.1055/s-0038-1673613] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Exogenous hormone treatments in women (oral contraceptives and hormone replacement therapy [HRT]) are established risk factors for venous thromboembolism (VTE), but less is known about associations between plasma levels of endogenous hormones and VTE risk. We examined the association of baseline dehydroepiandrosterone sulphate (DHEAS), testosterone and sex hormone-binding globulin (SHBG) with risk of future VTE in men and post-menopausal women in the Atherosclerosis Risk in Communities Study. Testosterone, DHEAS and SHBG were measured in plasma samples collected in 1996 to 1998. Cox proportional hazards models were used to estimate hazard ratios for incident VTE adjusting for age, race/ethnicity, body mass index, height, smoking, estimated glomerular filtration rate and C-reactive protein. All analyses were stratified by sex and by current HRT use in women. Among 3,051 non-HRT-using women, 1,414 HRT-using women and 3,925 men at risk at baseline, 184, 62 and 206 experienced incident VTE after a median follow-up of 17.6 years. Plasma hormones were not associated with incidence of VTE among men and non-HRT-using women, although lower plasma DHEAS, when modelled using quartiles or restricted cubic splines, was associated with higher risk of VTE among HRT-using women. This study does not support the existence of an important association between plasma concentrations of endogenous testosterone, DHEAS or SHBG with risk of VTE in middle-aged to older men or post-menopausal women not using HRT.
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Affiliation(s)
- Nicholas S Roetker
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, United States
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States
| | - Richard F MacLehose
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States
| | - Ron C Hoogeveen
- Section of Atherosclerosis and Vascular Medicine, Baylor College of Medicine, The Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas, United States
| | - Christie M Ballantyne
- Section of Atherosclerosis and Vascular Medicine, Baylor College of Medicine, The Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas, United States
| | - Saonli Basu
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States
| | - Mary Cushman
- Division of Hematology/Oncology, Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, United States
| | - Aaron R Folsom
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States
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13
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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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14
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Hormonal contraception and thrombosis. Fertil Steril 2016; 106:1289-1294. [DOI: 10.1016/j.fertnstert.2016.08.039] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 08/17/2016] [Accepted: 08/18/2016] [Indexed: 11/21/2022]
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15
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Hugon-Rodin J, Alhenc-Gelas M, Hemker HC, Brailly-Tabard S, Guiochon-Mantel A, Plu-Bureau G, Scarabin PY. Sex hormone-binding globulin and thrombin generation in women using hormonal contraception. Biomarkers 2016; 22:81-85. [DOI: 10.1080/1354750x.2016.1204010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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16
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Archer D, Thomas M, Conard J, Merkatz R, Creasy G, Roberts K, Plagianos M, Blithe D, Sitruk-Ware R. Impact on hepatic estrogen-sensitive proteins by a 1-year contraceptive vaginal ring delivering Nestorone® and ethinyl estradiol. Contraception 2016; 93:58-64. [DOI: 10.1016/j.contraception.2015.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 09/18/2015] [Accepted: 09/21/2015] [Indexed: 10/23/2022]
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17
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Lete I, Chabbert-Buffet N, Jamin C, Lello S, Lobo P, Nappi RE, Pintiaux A. Haemostatic and metabolic impact of estradiol pills and drospirenone-containing ethinylestradiol pills vs. levonorgestrel-containing ethinylestradiol pills: A literature review. EUR J CONTRACEP REPR 2015; 20:329-43. [DOI: 10.3109/13625187.2015.1050091] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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18
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Hugon-Rodin J, Gompel A, Plu-Bureau G. Epidemiology of hormonal contraceptives-related venous thromboembolism. Eur J Endocrinol 2014; 171:R221-30. [PMID: 25012200 DOI: 10.1530/eje-14-0527] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
For many years, it has been well documented that combined hormonal contraceptives increase the risk of venous thromboembolism (VTE). The third-generation pill use (desogestrel or gestodene (GSD)) is associated with an increased VTE risk as compared with second-generation (levonorgestrel) pill use. Other progestins such as drospirenone or cyproterone acetate combined with ethinyl-estradiol (EE) have been investigated. Most studies have reported a significant increased VTE risk among users of these combined oral contraceptives (COCs) when compared with users of second-generation pills. Non-oral combined hormonal contraception, such as the transdermal patch and the vaginal ring, is also available. Current data support that these routes of administration are more thrombogenic than second-generation pills. These results are consistent with the biological evidence of coagulation activation. Overall, the estrogenic potency of each hormonal contraceptive depending on both EE doses and progestin molecule explains the level of thrombotic risk. Some studies have shown a similar increased VTE risk among users of COCs containing norgestimate (NGM) as compared with users of second-generation pill. However, for this combination, biological data, based on quantitative assessment of sex hormone-binding globulin or haemostasis parameters, are not in agreement with these epidemiological results. Similarly, the VTE risk associated with low doses of EE and GSD is not biologically plausible. In conclusion, newer generation formulations of hormonal contraceptives as well as non-oral hormonal contraceptives seem to be more thrombogenic than second-generation hormonal contraceptives. Further studies are needed to conclude on the combinations containing NGM or low doses of EE associated with GSD.
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Affiliation(s)
- Justine Hugon-Rodin
- Department of Gynecology and EndocrinologyHôpitaux Universitaires Paris Centre, Paris-Descartes University, Paris, France
| | - Anne Gompel
- Department of Gynecology and EndocrinologyHôpitaux Universitaires Paris Centre, Paris-Descartes University, Paris, France
| | - Geneviève Plu-Bureau
- Department of Gynecology and EndocrinologyHôpitaux Universitaires Paris Centre, Paris-Descartes University, Paris, France
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19
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Maxwell WD, Jacob M, Spiryda LB, Bennett CL. Selection of Contraceptive Therapy for Patients with Thrombophilia: A Review of the Evidence. J Womens Health (Larchmt) 2014; 23:318-26. [DOI: 10.1089/jwh.2013.4479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Whitney D. Maxwell
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, University of South Carolina, Columbia, South Carolina
| | - Merna Jacob
- South Carolina College of Pharmacy, University of South Carolina, Columbia, South Carolina
| | - Lisa B. Spiryda
- Department of Obstetrics and Gynecology, University of Florida, College of Medicine, Gainesville, Florida
| | - Charles L. Bennett
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, University of South Carolina, Columbia, South Carolina
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20
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Thyroid function, activated protein C resistance and the risk of venous thrombosis in users of hormonal contraceptives. Thromb Res 2014; 133:640-4. [DOI: 10.1016/j.thromres.2013.12.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 12/27/2013] [Accepted: 12/30/2013] [Indexed: 11/24/2022]
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21
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Effects of oral contraceptives on selected parameters of the homeostatic control system in young women having a sudden disorder of the auditory and/or balance system. Eur Arch Otorhinolaryngol 2013; 272:321-6. [PMID: 24337825 PMCID: PMC4293499 DOI: 10.1007/s00405-013-2853-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 11/30/2013] [Indexed: 11/17/2022]
Abstract
The purpose of the paper was to assess the effects of oral contraceptives on selected parameters of the homeostatic control system in women having a sudden disorder of the auditory and/or balance system. The study included 105 young women divided into two groups: Group I—52 women with the disorder of the auditory and/or balance system using hormonal contraceptives for at least 2 months, aged 20–49; and Group II—53 women without any disorder of the auditory and/or balance system using hormonal contraceptives for at least 2 months, aged 18–40. The patients included in the study underwent a full otoneurological evaluation, detailed laryngological diagnostics and an evaluation of selected parameters of the homeostatic control system—fibrinogen level, D-dimer level, evaluation of APTT and PT indicator, plasma estradiol and progesterone with the Roche Cobas analyser by means of chemiluminescence. The vertigo occurring in the study group was most often central (59.6 % of cases), mixed with compensation in 36.6 % of cases, and peripheral only in 3.8 % of cases, indicating labyrinth damage in 40.4 % of cases. An analysis of the progesterone level, considering the menstrual cycle phase in the group, showed that its value was abnormal in 51.0 % of women in the study group and 47.1 % in the control group. In their own studies, the authors observed that the estradiol level in the plasma, considering the menstrual cycle phase in the study group, was abnormal in 41.2 % of women and that the differences in its concentration were statistically significant in the study and control groups (p = 0.005), which may have a negative impact on the possibility of a thromboembolic episode.
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22
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Chabbert-Buffet N, Gerris J, Jamin C, Lello S, Lete I, Lobo P, Nappi RE, Pintiaux A. Toward a new concept of "natural balance" in oral estroprogestin contraception. Gynecol Endocrinol 2013; 29:891-6. [PMID: 23931030 DOI: 10.3109/09513590.2013.824963] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The Pill has undergone many changes since its first appearance some 50 years ago. Key developments included the reduction of ethinylestradiol doses and the synthesis of new progestins in order to increase safety, compliance and efficiency. Low-dose combined oral contraceptives (COCs) are currently the preferred option for millions of women. Due to this widespread use, it has been argued that the safety of COCs should be even better, raising the threshold for excellence. Yet in spite of major improvements, there is still an associated risk of venous thromboembolism (VTE). The next step in COCs' evolution should take total estrogenicity and hepatic estro-androgenic balance into account. The focus on the estrogen component--which has not changed in 50 years--has yielded a new class of natural estrogen pills. Following the introduction of a first quadriphasic pill, a monophasic estradiol pill based on the concept of "natural balance" was subsequently made available. These recent achievements could represent a step forward in the evolution of COCs and pave the way for better safety.
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Affiliation(s)
- Nathalie Chabbert-Buffet
- Department of Obstetrics and Gynecology, APHP Tenon Hospital, University Pierre and Marie Curie Paris 06, Paris, France
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23
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Stegeman BH, de Bastos M, Rosendaal FR, van Hylckama Vlieg A, Helmerhorst FM, Stijnen T, Dekkers OM. Different combined oral contraceptives and the risk of venous thrombosis: systematic review and network meta-analysis. BMJ 2013; 347:f5298. [PMID: 24030561 PMCID: PMC3771677 DOI: 10.1136/bmj.f5298] [Citation(s) in RCA: 231] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2013] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To provide a comprehensive overview of the risk of venous thrombosis in women using different combined oral contraceptives. DESIGN Systematic review and network meta-analysis. DATA SOURCES PubMed, Embase, Web of Science, Cochrane, Cumulative Index to Nursing and Allied Health Literature, Academic Search Premier, and ScienceDirect up to 22 April 2013. REVIEW METHODS Observational studies that assessed the effect of combined oral contraceptives on venous thrombosis in healthy women. The primary outcome of interest was a fatal or non-fatal first event of venous thrombosis with the main focus on deep venous thrombosis or pulmonary embolism. Publications with at least 10 events in total were eligible. The network meta-analysis was performed using an extension of frequentist random effects models for mixed multiple treatment comparisons. Unadjusted relative risks with 95% confidence intervals were reported. The requirement for crude numbers did not allow adjustment for potential confounding variables. RESULTS 3110 publications were retrieved through a search strategy; 25 publications reporting on 26 studies were included. Incidence of venous thrombosis in non-users from two included cohorts was 1.9 and 3.7 per 10,000 woman years, in line with previously reported incidences of 1-6 per 10,000 woman years. Use of combined oral contraceptives increased the risk of venous thrombosis compared with non-use (relative risk 3.5, 95% confidence interval 2.9 to 4.3). The relative risk of venous thrombosis for combined oral contraceptives with 30-35 µg ethinylestradiol and gestodene, desogestrel, cyproterone acetate, or drospirenone were similar and about 50-80% higher than for combined oral contraceptives with levonorgestrel. A dose related effect of ethinylestradiol was observed for gestodene, desogestrel, and levonorgestrel, with higher doses being associated with higher thrombosis risk. CONCLUSION All combined oral contraceptives investigated in this analysis were associated with an increased risk of venous thrombosis. The effect size depended both on the progestogen used and the dose of ethinylestradiol.
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MESH Headings
- Adult
- Case-Control Studies
- Confounding Factors, Epidemiologic
- Contraceptives, Oral, Combined/administration & dosage
- Contraceptives, Oral, Combined/adverse effects
- Contraceptives, Oral, Hormonal/administration & dosage
- Contraceptives, Oral, Hormonal/adverse effects
- Dose-Response Relationship, Drug
- Ethinyl Estradiol/administration & dosage
- Ethinyl Estradiol/adverse effects
- Female
- Humans
- Medication Adherence/statistics & numerical data
- Progestins/administration & dosage
- Progestins/adverse effects
- Risk Assessment
- Risk Factors
- Venous Thrombosis/chemically induced
- Venous Thrombosis/epidemiology
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24
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Chabbert-Buffet N, Guigues B, Trillot N, Biron C, Morange P, Pernod G, Scheffler M, Brugere S, Hedon B. [DVT and combined oral contraceptives: update of the pluridisciplinary CNGOF-FNCGM-GEHT-SFMV group]. J Gynecol Obstet Hum Reprod 2013; 42:309-315. [PMID: 23642503 DOI: 10.1016/j.jgyn.2013.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Revised: 03/25/2013] [Accepted: 03/26/2013] [Indexed: 06/02/2023]
Abstract
Thrombotic risk among combined oral contraceptives (COC) users has recently been debated following a court action initiated by a patient. Recent epidemiological data, as well as accumulating biological data underlying these data, have led French Health authorities to modify COC prescription and reimbursement modalities. A short synthesis is proposed by a multidisciplinary group of experts from four French societies (CGOF, FNCGM, GHT, and SFMV).
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Affiliation(s)
- N Chabbert-Buffet
- Collège national des gynécologues-obstétriciens français (CNGOF), 91, boulevard de Sébastopol, 75002 Paris, France.
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25
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Raps M, Rosendaal F, Ballieux B, Rosing J, Thomassen S, Helmerhorst F, van Vliet H. Resistance to APC and SHBG levels during use of a four-phasic oral contraceptive containing dienogest and estradiol valerate: a randomized controlled trial. J Thromb Haemost 2013; 11:855-61. [PMID: 23410231 DOI: 10.1111/jth.12172] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 01/17/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of combined oral contraceptives is associated with a 3- to 6-fold increased risk of venous thrombosis. This increased risk depends on the estrogen dose as well as the progestogen type of combined oral contraceptives. Thrombin generation-based activated protein C resistance (APC resistance) and sex hormone-binding globulin (SHBG) levels predict the thrombotic risk of a combined hormonal contraceptive. Recently, a four-phasic oral contraceptive containing dienogest (DNG) and estradiol valerate (E2V) has been marketed. The aim of this study was to evaluate the thrombotic risk of the DNG/E2V oral contraceptive by comparing APC resistance by measuring normalized APC sensitivity ratios (nAPCsr) and SHBG levels in users of oral contraceptives containing dienogest and estradiol valerate (DNG/E2V) and oral contraceptives containing levonorgestrel and ethinyl estradiol (LNG/EE). METHODS We conducted a single-center, randomized, open label, parallel-group study in 74 women using DNG/E2V or LNG/EE, and measured nAPCsr and SHBG levels in every phase of the regimen of DNG/E2V. RESULTS During the pill cycle SHBG levels did not differ between DNG/E2V users and LNG/EE users. nAPCsr levels were overall slightly lower in DNG/E2V users than in LNG/EE users, mean difference -0.44 (95% CI, -1.04 to 0.17) for day 2, -0.20 (95% CI, -0.76 to 0.37) for day 7, -0.27 (95% CI, -0.81 to 0.28) for day 24 and -0.34 (95% CI, -0.91 to 0.24) for day 26. CONCLUSION No statistical significant differences in nAPCsr and SHBG levels were found between users of the oral contraceptive containing DNG/E2V and LNG/EE, suggesting a comparable thrombotic risk.
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Affiliation(s)
- M Raps
- Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.
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26
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Raps M, Helmerhorst FM, Fleischer K, van Hylckama Vlieg A, Van Hylckama VA, Stegeman BH, Thomassen S, Rosendaal FR, Rosing J, Ballieux BEPB, Van Vliet HAAM. Sex hormone-binding globulin as a marker for the thrombotic risk of hormonal contraceptives: reply to a rebuttal. J Thromb Haemost 2013; 11:396-7. [PMID: 23176323 DOI: 10.1111/jth.12080] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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27
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Kluft C, Skouby SO, Jespersen J, Burggraaf J. Sex hormone-binding globulin as a marker for the thrombotic risk of hormonal contraceptives: a rebuttal. J Thromb Haemost 2013; 11:394-5. [PMID: 23140257 DOI: 10.1111/jth.12067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Stegeman BH, Raps M, Helmerhorst FM, Vos HL, van Vliet HAAM, Rosendaal FR, van Hylckama Vlieg A. Effect of ethinylestradiol dose and progestagen in combined oral contraceptives on plasma sex hormone-binding globulin levels in premenopausal women. J Thromb Haemost 2013; 11:203-5. [PMID: 23122048 DOI: 10.1111/jth.12054] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
MESH Headings
- Adolescent
- Adult
- Biomarkers/blood
- Contraceptives, Oral, Combined/administration & dosage
- Contraceptives, Oral, Combined/adverse effects
- Contraceptives, Oral, Combined/blood
- Contraceptives, Oral, Hormonal/administration & dosage
- Contraceptives, Oral, Hormonal/adverse effects
- Contraceptives, Oral, Hormonal/blood
- Ethinyl Estradiol/administration & dosage
- Ethinyl Estradiol/adverse effects
- Ethinyl Estradiol/blood
- Female
- Humans
- Middle Aged
- Odds Ratio
- Premenopause/blood
- Progestins/administration & dosage
- Progestins/adverse effects
- Progestins/blood
- Risk Factors
- Sex Hormone-Binding Globulin/metabolism
- Venous Thrombosis/blood
- Venous Thrombosis/chemically induced
- Young Adult
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Affiliation(s)
- B H Stegeman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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29
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Gourdy P, Bachelot A, Catteau-Jonard S, Chabbert-Buffet N, Christin-Maître S, Conard J, Fredenrich A, Gompel A, Lamiche-Lorenzini F, Moreau C, Plu-Bureau G, Vambergue A, Vergès B, Kerlan V. Hormonal contraception in women at risk of vascular and metabolic disorders: Guidelines of the French Society of Endocrinology. ANNALES D'ENDOCRINOLOGIE 2012; 73:469-87. [DOI: 10.1016/j.ando.2012.09.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Oslakovic S, Zadro R. Comparison of the impact of four generations of progestins on hemostatic variables. Clin Appl Thromb Hemost 2012; 20:448-55. [PMID: 23091282 DOI: 10.1177/1076029612463426] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This study was undertaken to evaluate the impact of progestins as part of low-estrogen (ethinyl estradiol [EE2] ≤35 μg) combined oral contraceptives (COCs) on hemostatic variables. One hundred ninety-five healthy women took oral contraceptives with following formulations: 35 EE2/norgestimate (NGM), 35 EE2/cyproterone acetate, 35 EE2/norethisterone, 30 EE2/levonorgestrel, 30 EE2/drospirenone (DRSP), 20 EE2/gestodene, and 20 EE2/DRSP, for 6 months. Hemostatic assays (prothrombin time, activated partial thromboplastin time, fibrinogen, resistance to activated protein C ratio, protein C, protein S, factor VIII [FVIII], antithrombin, plasminogen, α2-antiplasmin, inhibitor of plasminogen activator type 1 [PAI-1] and d-dimers) were performed in 3 time points: at baseline, after 3, and 6 cycles. For each formulation, results were compared according to baseline values, intergroup analysis, and the amount of estrogen or progestin component. Most of the variables were changed except FVIII. Significant difference between oral contraceptives was found in antithrombin, protein C, protein S activities, and PAI-1 values, but changes were mostly within reference range.
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Affiliation(s)
- Sandra Oslakovic
- 1Department of Transfusion Medicine, Cakovec County Hospital, Cakovec, Croatia
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31
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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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32
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Stegeman BH, Helmerhorst FM, Vos HL, Rosendaal FR, Van Hylckama Vlieg A. Sex hormone-binding globulin levels are not causally related to venous thrombosis risk in women not using hormonal contraceptives. J Thromb Haemost 2012; 10:2061-7. [PMID: 22882730 DOI: 10.1111/j.1538-7836.2012.04878.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Oral contraceptive use increases the risk of venous thrombosis as well as sex hormone-binding globulin (SHBG) levels. Furthermore, increased SHBG levels are positively associated with activated protein C (APC) resistance and thrombotic risk in oral contraceptive users. OBJECTIVES To determine whether increased SHBG levels are causally related to venous thrombosis in women not using hormonal contraceptives. METHODS Premenopausal women were selected from a case-control study on venous thrombosis, the Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis (MEGA) study (23 patients; 258 controls). Women using hormonal contraceptives were excluded. First, the risk of venous thrombosis with SHBG levels above the normal reference range (70 nm) was determined. Second, because multiple regulatory factors affect SHBG levels and residual confounding may remain, we determined six single-nucleotide polymorphisms (SNPs) in the SHBG gene and assessed the risk of venous thrombosis in a different case-control study, the Leiden Thrombophilia Study (LETS) (20 patients; 74 controls), and in the MEGA study. Finally, the association between SHBG levels and the normalized activated partial thromboplastin time-based APC resistance (an intermediate endpoint for venous thrombosis) was determined. RESULTS Elevated SHBG levels (> 70.0 nm) were associated with venous thrombosis (odds ratio 1.92; 95% confidence interval [CI] 0.74-5.00). However, this finding can be explained by residual confounding. Two SNPs in the SHBG gene affected SHBG levels, but not venous thrombosis risk. Furthermore, SHBG levels in controls were not associated with APC resistance (SHBG level, > 70.0 vs. ≤ 70.0 nm: mean difference in normalized APC sensitivity ratio, 0.03; 95% CI -0.05 to 0.10). Exclusion of women with FV Leiden did not materially change these results. CONCLUSIONS Increased SHBG levels are not causally related to the risk of venous thrombosis.
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Affiliation(s)
- B H Stegeman
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands
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33
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Rad M, Burggraaf J, de Kam ML, Cohen AF, Kluft C. Discriminant analysis of the metabolic effects of a new combined contraceptive vaginal ring containing Nestorone/EE vs. a second-generation oral contraceptive containing levonorgestrel/EE. Contraception 2012; 86:231-7. [DOI: 10.1016/j.contraception.2011.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Revised: 10/31/2011] [Accepted: 12/28/2011] [Indexed: 11/29/2022]
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34
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Martínez F, Ramírez I, Pérez-Campos E, Latorre K, Lete I. Venous and pulmonary thromboembolism and combined hormonal contraceptives. Systematic review and meta-analysis. EUR J CONTRACEP REPR 2012; 17:7-29. [DOI: 10.3109/13625187.2011.643836] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kolacki C, Rocco V. The combined vaginal contraceptive ring, nuvaring, and cerebral venous sinus thrombosis: a case report and review of the literature. J Emerg Med 2011; 42:413-6. [PMID: 21945504 DOI: 10.1016/j.jemermed.2011.06.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 02/07/2011] [Accepted: 06/01/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Combined oral contraceptives are known to confer a risk of venous thromboembolism, including cerebral venous sinus thrombosis (CVST), to otherwise healthy women. NuvaRing (Organon USA, Inc., Roseland, NJ) is a contraceptive vaginal ring that delivers 120 μg of etonogestrel and 15 μg of ethinyl estradiol per day. Its use has been associated with rare venous thromboembolic events, but few cases of CVST associated with NuvaRing have been reported. OBJECTIVE To describe a case that illustrates the increased risk of CVST associated with use of NuvaRing. We describe the case of a NuvaRing user who presented to our emergency department with a headache, who was diagnosed with CVST. CONCLUSION Evidence suggests that NuvaRing has at least as much prothrombotic potential as combined oral contraceptives. Thus, emergency physicians should suspect serious venous thromboembolic events, including CVST, deep venous thrombosis, and pulmonary embolism, in NuvaRing users in the proper clinical setting.
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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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Christiansen SC, Lijfering WM, Helmerhorst FM, Rosendaal FR, Cannegieter SC. Sex difference in risk of recurrent venous thrombosis and the risk profile for a second event. J Thromb Haemost 2010; 8:2159-68. [PMID: 20738758 DOI: 10.1111/j.1538-7836.2010.03994.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED BACKGROUND The risk of recurrent venous thrombosis is higher in men than in women, and this is so far unexplained. We set out to determine the influence of age, time between first and second event, type of first event, oral contraception, pregnancy and surgery. METHODS We performed a prospective follow-up study of 474 patients with a first objective diagnosis of deep vein thrombosis, aged 18-70 years (Leiden Thrombophilia Study cohort). RESULTS During 3477 person-years of follow-up, 90 recurrences occurred. The overall incidence rates of recurrence (IRs) were 40.9 per 1000 person-years in men and 15.8 per 1000 person-years in women. Men with an unprovoked first event had the highest risk of recurrence, with almost one-third experiencing a second unprovoked event within 8 years (IR 41.2 per 1000 person-years). This risk was three-fold lower in women [IR 14.2 per 1000 person-years; hazard ratio 2.8 (95% confidence interval 1.4-5.7)]. Age at diagnosis had little effect on recurrence rate, and nor had time elapsed since the first event. In women, almost half of the recurrences were provoked and were mainly related to oral contraceptive use or pregnancy. CONCLUSIONS The higher recurrence rate in men than in women is not the result of differences in the environmental or transient risk factors that we studied. The risk profile for a second thrombotic event is clearly different from that of a first.
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Affiliation(s)
- S C Christiansen
- Department of Clinical Epidemiology, Leiden University Medical Centre, the Netherlands
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38
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van Hylckama Vlieg A, Helmerhorst FM, Rosendaal FR. The risk of deep venous thrombosis associated with injectable depot-medroxyprogesterone acetate contraceptives or a levonorgestrel intrauterine device. Arterioscler Thromb Vasc Biol 2010; 30:2297-300. [PMID: 20798377 DOI: 10.1161/atvbaha.110.211482] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To assess the risk of venous thrombosis associated with nonoral contraceptives (ie, injectable depot-medroxyprogesterone acetate contraceptives, hormone [levonorgestrel]-releasing intrauterine devices, a contraceptive patch, or a contraceptive implant). METHODS AND RESULTS Analyses were performed in the Multiple Environmental and Genetic Assessment study, a large case-control study on risk factors for venous thrombosis. For the current analyses, we selected premenopausal women, aged 18 to 50 years, who were not pregnant nor within 4 weeks postpartum and were not using oral contraceptives; 446 patients and 1146 controls were included. Injectable depot-medroxyprogesterone acetate contraceptives were associated with a 3.6-fold (95% CI, 1.8- to 7.1-fold) increased risk of venous thrombosis compared with nonusers of hormonal contraceptives. The use of a levonorgestrel intrauterine device was not associated with an increased risk (odds ratio, 0.3; 95% CI, 0.1 to 1.1). Unfortunately, the few women using a contraceptive patch or an implant prevented a reliable estimate of the risk of thrombosis. CONCLUSIONS The risk of venous thrombosis was increased for injectable depot-medroxyprogesterone acetate contraceptive users, while we were able to reliably exclude an increased risk associated with levonorgestrel intrauterine device use. Therefore, the latter seems to be the safest option regarding the risk of venous thrombosis.
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Affiliation(s)
- Astrid van Hylckama Vlieg
- Department of Clinical Epidemiology, Leiden University Medical Center, C7-P, PO Box 9600, NL-2300 RC Leiden, 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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40
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van Vliet HA, Rosendaal FR, Fleischer K, Rosing J, Helmerhorst FM. Effects of the contraceptive vaginal ring, the contraceptive transdermal patch and combined oral contraceptives on markers of hemostasis. Contraception 2010; 81:88-9; author reply 89-90. [DOI: 10.1016/j.contraception.2009.05.131] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Accepted: 05/31/2009] [Indexed: 11/26/2022]
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Maitrot-Mantelet L, Agopian A, Gompel A. Antigonadotropic progestogens as contraceptive agents in women with contraindication to combined pill. Horm Mol Biol Clin Investig 2010; 3:441-7. [DOI: 10.1515/hmbci.2010.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Accepted: 11/03/2010] [Indexed: 11/15/2022]
Abstract
AbstractSynthetic progestogens belong to different pharmacological classes and are mixed steroids. They display different properties due to their various affinities to the different steroid receptors. In addition, the dosage used can modify their side effects. Normethyltestosterone used at minimal doses, also called progestogen only pill (POP), constitute the standard recommended hormonal contraception for women with vascular and metabolic contraindications to combined pill (COC). However, POP efficacy and gynecological tolerance are limited. We have developed for more than 20 years in France the use of two pregnane derivatives as contraceptive agents in women with contraindication to COC. Chlormadinone acetate and cyproterone acetate have different antigonadotropic potencies but remain neutral on vascular risk. We have analyzed the efficacy, vascular and gynecological tolerances in 187 women with systemic lupus erythematous with or without antiphospholipids. Venous thrombosis and arterial events rates were lower than those reported in the literature. The current experience in women with thrombophilia is similar as reported in a series of 150 patients. In addition, we have also used antigonadotropic progestins in women with hereditary angioedema (HAE) types I, II or III. HAE symptoms can be induced or worsened by COC. We could demonstrate a significant improvement of the symptoms in most women with HAE under antigonadotropic progestins. Gynecological and general tolerances were satisfactory. In conclusion, antigonadotropic progestins could have clinical positive benefits as contraceptive agents in women with contraindication to COC.
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van Hylckama Vlieg A, Helmerhorst FM, Vandenbroucke JP, Doggen CJM, Rosendaal FR. The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and progestogen type: results of the MEGA case-control study. BMJ 2009; 339:b2921. [PMID: 19679614 PMCID: PMC2726929 DOI: 10.1136/bmj.b2921] [Citation(s) in RCA: 374] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/29/2009] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess the thrombotic risk associated with oral contraceptive use with a focus on dose of oestrogen and type of progestogen of oral contraceptives available in the Netherlands. DESIGN Population based case-control study. SETTING Six participating anticoagulation clinics in the Netherlands (Amersfoort, Amsterdam, The Hague, Leiden, Rotterdam, and Utrecht). PARTICIPANTS Premenopausal women <50 years old who were not pregnant, not within four weeks postpartum, and not using a hormone excreting intrauterine device or depot contraceptive. Analysis included 1524 patients and 1760 controls. MAIN OUTCOME MEASURES First objectively diagnosed episodes of deep venous thrombosis of the leg or pulmonary embolism. Odds ratios calculated by cross-tabulation with a 95% confidence interval according to Woolf's method; adjusted odds ratios estimated by unconditional logistic regression, standard errors derived from the model. RESULTS Currently available oral contraceptives increased the risk of venous thrombosis fivefold compared with non-use (odds ratio 5.0, 95% CI 4.2 to 5.8). The risk clearly differed by type of progestogen and dose of oestrogen. The use of oral contraceptives containing levonorgestrel was associated with an almost fourfold increased risk of venous thrombosis (odds ratio 3.6, 2.9 to 4.6) relative to non-users, whereas the risk of venous thrombosis compared with non-use was increased 5.6-fold for gestodene (5.6, 3.7 to 8.4), 7.3-fold for desogestrel (7.3, 5.3 to 10.0), 6.8-fold for cyproterone acetate (6.8, 4.7 to 10.0), and 6.3-fold for drospirenone (6.3, 2.9 to 13.7). The risk of venous thrombosis was positively associated with oestrogen dose. We confirmed a high risk of venous thrombosis during the first months of oral contraceptive use irrespective of the type of oral contraceptives. CONCLUSIONS Currently available oral contraceptives still have a major impact on thrombosis occurrence and many women do not use the safest brands with regard to risk of venous thrombosis.
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Affiliation(s)
- A van Hylckama Vlieg
- Department of Clinical Epidemiology, Leiden University Medical Center, C7-P, PO Box 9600, NL-2300 RC Leiden, Netherlands
| | - F M Helmerhorst
- Department of Clinical Epidemiology, Leiden University Medical Center, C7-P, PO Box 9600, NL-2300 RC Leiden, Netherlands
- Department of Gynaecology and Reproductive Medicine, Leiden University Medical Center
| | - J P Vandenbroucke
- Department of Clinical Epidemiology, Leiden University Medical Center, C7-P, PO Box 9600, NL-2300 RC Leiden, Netherlands
| | - C J M Doggen
- Department of Clinical Epidemiology, Leiden University Medical Center, C7-P, PO Box 9600, NL-2300 RC Leiden, Netherlands
| | - F R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, C7-P, PO Box 9600, NL-2300 RC Leiden, Netherlands
- Department of Thrombosis and Haemostasis, Leiden University Medical Center
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center
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Abstract
This review provides an update of knowledge regarding venous thromboembolism (VTE) and combined hormonal contraceptives (CHCs) in the light of new progestins and new administration routes for CHCs. Practical recommendations are also offered. The association between the use of combined oral contraceptives (COCs) and an increased risk of VTE has been known about for many years, it being related mainly to the dose of oestrogen; however, recent research has also shown the influence of the type of progestin. When compared to COCs containing levonorgestrel or norethisterone, those containing desogestrel or gestodene present a two-fold greater risk of VTE; for COCs containing cyproterone acetate, the risk is four-fold greater, while there are no or insufficient data for those containing norgestimate, chlormadinone acetate or drospirenone. With regard to the contraceptive patch, the available data suggest that the risk of VTE is similar to that observed with COCs. There are no data concerning vaginal rings. The greatest risk of COC-associated VTE occurs during the first year of use, thus suggesting the existence of a predisposing condition, such as being a carrier of a thrombogenic mutation with which the COCs would exert a synergistic effect. Routine screening for such conditions is not justified. Changes in haemostatic variables produced by COCs, for example, acquired resistance to protein C, could be linked to VTE, although it has yet to be demonstrated that such alterations are related to a clinical risk of VTE among COC users. At present there are no laboratory tests able to detect an increased risk of VTE in asymptomatic women. The key procedures in terms of ensuring the safe use of this contraceptive method are a full clinical, personal and family history, in order to evaluate risk factors for VTE and cardiovascular disease, along with the recording of blood pressure and body mass index prior to the prescription of COCs.
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Kapur R, Stramrood CAI, Schutgens REG, van Asbeck BS. Cyproterone acetate- and ethinyloestradiol-containing oral contraceptive as a risk factor for upper extremity deep venous thrombosis-a case report. EUR J CONTRACEP REPR 2009; 14:160-3. [PMID: 19340712 DOI: 10.1080/13625180902741451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Deep venous thrombosis of the upper extremity (UEDVT) is a rare variety of deep venous thrombosis. Compared to lower-extremity deep venous thrombosis, less is known about the risk factors for primary UEDVT. We report on a 27-year-old woman with UEDVT extending from the jugular and subclavian veins to the elbow. The thrombosis was possibly provoked by a shoulder trauma, in combination with heterozygosity for the prothrombin G20210A mutation and a protein S-deficiency, which may have been induced by the use of a cyproterone acetate- and ethinyloestradiol (CPA/EE)-containing oral contraceptive.
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Affiliation(s)
- Rick Kapur
- Selective Utrecht Medical Master (SUMMA), University Medical Center Utrecht, Utrecht, The Netherlands.
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45
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Sex hormone-binding globulin: an adequate surrogate marker for venous thromboembolism in women using new hormonal contraceptives. Contraception 2009; 79:328-9; author reply 329-30. [DOI: 10.1016/j.contraception.2008.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Accepted: 11/04/2008] [Indexed: 11/22/2022]
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Fleischer K, van Vliet H, Rosendaal F, Rosing J, Tchaikovski S, Helmerhorst F. Effects of the contraceptive patch, the vaginal ring and an oral contraceptive on APC resistance and SHBG: A cross-over study. Thromb Res 2009; 123:429-35. [DOI: 10.1016/j.thromres.2008.04.022] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2007] [Revised: 04/25/2008] [Accepted: 04/28/2008] [Indexed: 10/21/2022]
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Soares GM, Vieira CS, de Paula Martins W, Dos Reis RM, de Sá MFS, Ferriani RA. Metabolic and cardiovascular impact of oral contraceptives in polycystic ovary syndrome. Int J Clin Pract 2009; 63:160-9. [PMID: 18795969 DOI: 10.1111/j.1742-1241.2008.01877.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Chronic anovulation, polycystic ovarian morphology and hyperandrogenism are the diagnostic criteria for polycystic ovary syndrome (PCOS). Metabolic disturbances are more common in PCOS women who are prone to develop metabolic syndrome and to present higher levels of some cardiovascular disease risk marker. Oral contraceptives are widely used in PCOS, but conflicting data have been reported regarding their impact on carbohydrate and lipid metabolism on PCOS women. This paper presents a critical evaluation of combined oral contraceptives (COCs) metabolic effect - carbohydrate metabolism and insulin sensitivity, lipid metabolism, haemostasis, body weight, arterial pressure and cardiovascular impact - on PCOS women. Because of the paucity of data on the impact of COCs on cardiovascular and metabolic parameters in PCOS patients, most of there commendations are based on studies involving ovulatory women. The use of low-dose COCs is preferable in PCOS, especially among patients with glucose intolerance, insulin resistance and uncomplicated diabetes mellitus. Although reported as a side effect of COCs, marked weight gain has not been confirmed among users. However, when arterial hypertension or elevated risk for thromboembolism is present, progestogen-only hormonal contraceptives should be used instead of COCs. Regarding dyslipidaemia, COCs reduce low-density lipoprotein and total cholesterol and elevate high-density lipoprotein and triglycerides, and therefore are not recommended for women with high triglycerides levels. The choice of a COC, which alleviates the PCOS-induced hyperandrogenism without significant negative impact on cardiovascular risk, is one of the greatest challenges faced by gynaecologists nowadays.
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Affiliation(s)
- G M Soares
- Department of Gynecology and Obstetrics at the University of São Paulo, Ribeirão Preto School of Medicine, Ribeirão Preto, Brazil
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L'hermite M, Simoncini T, Fuller S, Genazzani AR. Could transdermal estradiol + progesterone be a safer postmenopausal HRT? A review. Maturitas 2008; 60:185-201. [PMID: 18775609 DOI: 10.1016/j.maturitas.2008.07.007] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2008] [Revised: 07/10/2008] [Accepted: 07/21/2008] [Indexed: 12/26/2022]
Abstract
Hormone replacement therapy (HRT) in young postmenopausal women is a safe and effective tool to counteract climacteric symptoms and to prevent long-term degenerative diseases, such as osteoporotic fractures, cardiovascular disease, diabetes mellitus and possibly cognitive impairment. The different types of HRT offer to many extent comparable efficacies on symptoms control; however, the expert selection of specific compounds, doses or routes of administration can provide significant clinical advantages. This paper reviews the role of the non-oral route of administration of sex steroids in the clinical management of postmenopausal women. Non-orally administered estrogens, minimizing the hepatic induction of clotting factors and others proteins associated with the first-pass effect, are associated with potential advantages on the cardiovascular system. In particular, the risk of developing deep vein thrombosis or pulmonary thromboembolism is negligible in comparison to that associated with oral estrogens. In addition, recent indications suggest potential advantages for blood pressure control with non-oral estrogens. To the same extent, a growing literature suggests that the progestins used in association with estrogens may not be equivalent. Recent evidence indeed shows that natural progesterone displays a favorable action on the vessels and on the brain, while this might not be true for some synthetic progestins. Compelling indications also exist that differences might also be present for the risk of developing breast cancer, with recent trials indicating that the association of natural progesterone with estrogens confers less or even no risk of breast cancer as opposed to the use of other synthetic progestins. In conclusion, while all types of hormone replacement therapies are safe and effective and confer significant benefits in the long-term when initiated in young postmenopausal women, in specific clinical settings the choice of the transdermal route of administration of estrogens and the use of natural progesterone might offer significant benefits and added safety.
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Affiliation(s)
- Marc L'hermite
- Department of Gynecology and Obstetrics, Université Libre de Bruxelles, Bruxelles, Belgium.
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Stanczyk FZ, Grimes DA. Sex hormone-binding globulin: not a surrogate marker for venous thromboembolism in women using oral contraceptives. Contraception 2008; 78:201-3. [DOI: 10.1016/j.contraception.2008.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Accepted: 04/18/2008] [Indexed: 11/30/2022]
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Plu-Bureau G, Horellou MH, Gompel A, Conard J. Contraception hormonale et risque thromboembolique veineux : quand demander une étude de l’hémostase ? Et laquelle ? ACTA ACUST UNITED AC 2008; 36:448-54. [DOI: 10.1016/j.gyobfe.2008.02.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2007] [Accepted: 02/12/2008] [Indexed: 11/28/2022]
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