The association between hypercoagulability and use of drospirenone (DRSP) and ethinylestradiol (EE) containing combined oral contraceptives (COCs) is an important clinical concern. We have previously reported that the two formulations of DRSP combined with EE (namely, DRSP/20EE and DRSP/30EE) bring about a prothrombotic state in hemostatic traits of female users. We report here the serum metabolomic changes in the same study cohort in relation to the attendant prothrombotic state induced by COC use, thus offering new insights on the underlying biochemical mechanisms contributing to the altered coagulatory profile with COC use. A total of 78 healthy women participated in this study and were grouped as follows: control group not using oral contraceptives (n = 25), DRSP/20EE group (n = 27), and DRSP/30EE group (n = 26). Untargeted metabolomics revealed changes in amino acid concentrations, particularly a decrease in glycine and an increase in both cysteine and lanthionine in the serum, accompanied by variations in oxidative stress markers in the COC users compared with the controls. Of importance, this study is the first to link specific amino acid variations, serum metabolites, and the oxidative metabolic profile with DRSP/EE use. These molecular changes could be linked to specific biophysical coagulatory alterations observed in the same individuals. These new findings lend evidence on the metabolomic substrates of the prothrombotic state associated with COC use in women and informs future personalized/precision medicine research. Moreover, we underscore the importance of an interdisciplinary approach to evaluate venous thrombotic risk associated with COC use.
Get full access to this article
View all access options for this article.
References
1.
AmatayakulK, LaokuldilokT, KoottathepS, et al. (1994). The effect of oral contraceptives on protein metabolism. J Med Assoc Thai, 77, 509–516.
2.
AnderssonA, LindgrenA, and HultbergB. (1995). Effect of thiol oxidation and thiol export from erythrocytes on determination of redox status of homocysteine and other thiols in plasma from healthy subjects and patients with cerebral infarction. Clin Chem, 41, 361–366.
3.
AndineP, OrwarO, JacobsonI, SandbergM, and HagbergH. (1991). Extracellular acidic sulfur-containing amino acids and gamma-glutamyl peptides in global ischemia: postischemic recovery of neuronal activity is paralleled by a tetrodotoxin-sensitive increase in cysteine sulfinate in the CA1 of the rat hippocampus. J Neurochem, 57, 230–236.
4.
ArakiA, SakoY, FukushimaY, et al. (1989). Plasma sulfhydryl-containing amino acids in patients with cerebral infarction and in hypertensive subjects. Atherosclerosis, 79, 139–146.
5.
AssemM, LandoM, GrissiM, et al. (2018). The impact of uremic toxins on cerebrovascular and cognitive disorders. Toxins (Basel), 10, 303.
6.
BialevichK, KostsinD, and SlobozhaninaE. (2014). Eryptosis is the programmed death of erythrocytes. Biol Bull Rev, 4, 477–483.
7.
BenjaminiY, and YekutieliD. (2001). The control of the false discovery rate in multiple testing under dependency. Annals of, Statistics, 1165–1188.
8.
BrynhildsenJ. (2014). Combined hormonal contraceptives: prescribing patterns, compliance, and benefits versus risks. Ther Adv Drug Saf, 5, 201–213.
9.
CampesiI, SannaM, ZinelluA, et al. (2012). Oral contraceptives modify DNA methylation and monocyte-derived macrophage function. Biol Sex Differ, 3, 4.
10.
CauciS, BuliganC, MarangoneM, and FrancescatoMP. (2016). Oxidative stress in female athletes using combined oral contraceptives. Sports Med Open, 2, 40.
11.
ChenJT, and KotaniK. (2012). Oral contraceptive therapy increases oxidative stress in pre-menopausal women. Int J Prev Med, 3, 893–896.
12.
ChikuT, PadovaniD, ZhuW, et al. (2009). H2S biogenesis by human cystathionine gamma-lyase leads to the novel sulfur metabolites lanthionine and homolanthionine and is responsive to the grade of hyperhomocysteinemia. J Biol Chem, 284, 11601–11612.
13.
CombrinkM, du PreezI, RonacherK, WalzlG, and LootsDT. (2019). Time-dependent changes in urinary metabolome before and after intensive phase tuberculosis therapy: a pharmacometabolomics study. OMICS, 23, 560–572.
14.
CraftIL, and PetersTJ. (1971). Quantitative changes in plasma amino acids induced by oral contraceptives. Clin Sci, 41, 301–307.
15.
De GrooteD, Perrier d'HauteriveS, PintiauxA, et al. (2009). Effects of oral contraception with ethinylestradiol and drospirenone on oxidative stress in women 18–35 years old. Contraception, 80, 187–193.
16.
DudmanNP, HicksC, WangJ, and WilckenDE. (1991). Human arterial endothelial cell detachment in vitro: its promotion by homocysteine and cysteine. Atherosclerosis, 91, 77–83.
17.
DurantonF, CohenG, De SmetR, et al. (2012). Normal and pathologic concentrations of uremic toxins. J Am Soc Nephrol, 23, 1258–1270.
18.
EmmersonO, BesterJ, LindequeBG, and SwanepoelAC. (2018). The impact of two combined oral contraceptives containing ethinyl estradiol and drospirenone on whole blood clot viscoelasticity and the biophysical and biochemical characteristics of erythrocytes. Microsc Microanal, 24, 713–728.
19.
EsmonCT. (2005). The interactions between inflammation and coagulation. Br J Haematol, 131, 417–430.
20.
FaustmannG, MeinitzerA, MagnesC, et al. (2018). Progesterone-associated arginine decline at luteal phase of menstrual cycle and associations with related amino acids and nuclear factor kB activation. PLoS One, 13, e0200489.
21.
GeampanaA. (2016). Pregnancy is more dangerous than the pill: a critical analysis of professional responses to the Yaz/Yasmin controversy. Soc Sci Med, 166, 9–16.
22.
GlassockRJ. (2008). Uremic toxins: what are they? An integrated overview of pathobiology and classification. J Ren Nutr, 18, 2–6.
23.
GronichN, LaviI, and RennertG. (2011). Higher risk of venous thrombosis associated with drospirenone-containing oral contraceptives: a population-based cohort study. CMAJ, 183, E1319–E1325.
HarisaGI, BadranMM, and AlanaziFK. (2017). Erythrocyte nanovesicles: biogenesis, biological roles and therapeutic approach: erythrocyte nanovesicles. Saudi Pharm J, 25, 8–17.
26.
HeineckeJW, RosenH, SuzukiLA, and ChaitA. (1987). The role of sulfur-containing amino acids in superoxide production and modification of low density lipoprotein by arterial smooth muscle cells. J Biol Chem, 262, 10098–10103.
27.
HimmelfarbJ, McMenaminE, and McMonagleE. (2002). Plasma aminothiol oxidation in chronic hemodialysis patients. Kidney Int, 61, 705–716.
28.
HoggN. (1999). The effect of cyst(e)ine on the auto-oxidation of homocysteine. Free Radic Biol Med, 27, 28–33.
29.
KielerH, PerssonI, and OdlindV. (2003). Venous thromboembolism and combined oral contraceptives. Reported adverse reactions indicate at least similar risk with the most recent contraceptive pills. Lakartidningen, 100, 3050–3052.
30.
KluftC, EndrikatJ, MulderSM, GerlingerC, and HeitheckerR. (2006). A prospective study on the effects on hemostasis of two oral contraceptives containing drospirenone in combination with either 30 or 20 microg ethinyl estradiol and a reference containing desogestrel and 30 microg ethinyl estradiol. Contraception, 73, 336–343.
31.
KrysiakR, GilowskaM, and OkopienB. (2017). The effect of oral contraception on cardiometabolic risk factors in women with elevated androgen levels. Pharmacol Rep, 69, 45–49.
32.
LangE, QadriSM, and LangF. (2012). Killing me softly—suicidal erythrocyte death. Int J Biochem Cell Biol, 44, 1236–1243.
33.
LangF, LangKS, LangPA, HuberSM, and WiederT. (2006). Mechanisms and significance of eryptosis. Antioxid Redox Signal, 8, 1183–1192.
34.
LangF, and QadriSM. (2012). Mechanisms and significance of eryptosis, the suicidal death of erythrocytes. Blood Purif, 33, 125–130.
35.
LecocqFR, BradleyEM, and GoldzieherJW. (1967). Metabolic balance studies with norethynodrel and chlormadinone acetate. Am J Obstet Gynecol, 99, 374–381.
36.
LehmannA, HagbergH, OrwarO, and SandbergM. (1993). Cysteine sulphinate and cysteate: mediators of cysteine toxicity in the neonatal rat brain?. Eur J Neurosci, 5, 1398–1412.
LhermusierT, ChapH, and PayrastreB. (2011). Platelet membrane phospholipid asymmetry: from the characterization of a scramblase activity to the identification of an essential protein mutated in Scott syndrome. J Thromb Haemost, 9, 1883–1891.
39.
LordRS, and BralleyJA. (2008). Clinical applications of urinary organic acids. Part I: detoxification markers. Altern Med Rev, 13, 205–215.
40.
MansoorMA, BergmarkC, SvardalAM, LonningPE, and UelandPM. (1995). Redox status and protein binding of plasma homocysteine and other aminothiols in patients with early-onset peripheral vascular disease. Homocysteine and peripheral vascular disease. Arterioscler Thromb Vasc Biol, 15, 232–240.
41.
MathurR, LevinO, and AzzizR. (2008). Use of ethinylestradiol/drospirenone combination in patients with the polycystic ovary syndrome. Ther Clin Risk Manag, 4, 487–492.
42.
MillsBJ, WeissMM, LangCA, LiuMC, and ZieglerC. (2000). Blood glutathione and cysteine changes in cardiovascular disease. J Lab Clin Med, 135, 396–401.
43.
MohantyJG, NagababuE, and RifkindJM. (2014). Red blood cell oxidative stress impairs oxygen delivery and induces red blood cell aging. Front Physiol, 5, 84.
44.
MollerSE, Maach-MollerB, OlesenM, et al. (1995). Tyrosine metabolism in users of oral contraceptives. Life Sci, 56, 687–695.
45.
MollerSE, MollerBM, OlesenM, and FjallandB. (1996). Effects of oral contraceptives on plasma neutral amino acids and cholesterol during a menstrual cycle. Eur J Clin Pharmacol, 50, 179–184.
46.
OzkanY, OzkanE, and SimsekB. (2002). Plasma total homocysteine and cysteine levels as cardiovascular risk factors in coronary heart disease. Int J Cardiol, 82, 269–277.
47.
ParthasarathyS. (1987). Oxidation of low-density lipoprotein by thiol compounds leads to its recognition by the acetyl LDL receptor. Biochim Biophys Acta, 917, 337–340.
48.
PedutoA, BaumgartnerMR, VerhoevenNM, et al. (2004). Hyperpipecolic acidaemia: a diagnostic tool for peroxisomal disorders. Mol Genet Metab, 82, 224–230.
49.
PernaAF, ZacchiaM, TrepiccioneF, and IngrossoD. (2017). The sulfur metabolite lanthionine: evidence for a role as a novel uremic toxin. Toxins, 9, 26.
50.
PincemailJ, VanbelleS, GaspardU, et al. (2007). Effect of different contraceptive methods on the oxidative stress status in women aged 40–48 years from the ELAN study in the province of Liège, Belgium. Hum Reprod, 22, 2335–2343.
51.
PoteraC, and RoseDP. (1978). Effect of oral alanine loads on plasma amino acids in oral contraceptive users and control women. Am J Clin Nutr, 31, 794–798.
52.
QadriSM, BissingerR, SolhZ, and OldenborgP-A. (2017). Eryptosis in health and disease: a paradigm shift towards understanding the (patho) physiological implications of programmed cell death of erythrocytes. Blood Rev, 31, 349–361.
53.
RapkinAJ, McDonaldM, and WinerSA. (2007). Ethinyl estradiol/drospirenone for the treatment of the emotional and physical symptoms of premenstrual dysphoric disorder. Womens Health (Lond), 3, 395–408.
54.
ReidRL, WesthoffC, MansourD, et al. (2010). Oral contraceptives and venous thromboembolism consensus opinion from an international workshop held in Berlin, Germany in December 2009. J Fam Plann Reprod Health Care, 36, 117–122.
55.
ReifS, SnelderN, and BlodeH. (2013). Characterisation of the pharmacokinetics of ethinylestradiol and drospirenone in extended-cycle regimens: population pharmacokinetic analysis from a randomised Phase III study. J Fam Plann Reprod Health Care, 39, e1–e13.
56.
RuoppoloM, CampesiI, ScolamieroE, et al. (2014). Serum metabolomic profiles suggest influence of sex and oral contraceptive use. Am J Transl Res, 6, 614–624.
57.
SaezG, ThornalleyPJ, HillHA, HemsR, and BannisterJV. (1982). The production of free radicals during the autoxidation of cysteine and their effect on isolated rat hepatocytes. Biochim Biophys Acta, 719, 24–31.
58.
SawaiA, TsuzukiK, YamauchiM, et al. (2018). The effects of estrogen and progesterone on plasma amino acids levels: evidence from change plasma amino acids levels during the menstrual cycle in women. Biol Rhythm Res, 51, 1–14.
SekharRV, PatelSG, GuthikondaAP, et al. (2011). Deficient synthesis of glutathione underlies oxidative stress in aging and can be corrected by dietary cysteine and glycine supplementation. Am J Clin Nutr, 94, 847–853.
61.
ShacterE, WilliamsJA, LimM, and LevineRL. (1994). Differential susceptibility of plasma proteins to oxidative modification: examination by western blot immunoassay. Free Radic Biol Med, 17, 429–437.
62.
ShefaU, KimM-S, JeongNY, and JungJ. (2018). Antioxidant and cell-signaling functions of hydrogen sulfide in the central nervous system. Oxid Med Cell Longev, 2018, 1873962.
63.
SheuFS, ZhuW, and FungPC. (2000). Direct observation of trapping and release of nitric oxide by glutathione and cysteine with electron paramagnetic resonance spectroscopy. Biophys J, 78, 1216–1226.
64.
Sitruk-WareR, and NathA. (2013). Characteristics and metabolic effects of estrogen and progestins contained in oral contraceptive pills. Best Pract Res Clin Endocrinol Metab, 27, 13–24.
65.
SmithGI, YoshinoJ, ReedsDN, et al. (2014). Testosterone and progesterone, but not estradiol, stimulate muscle protein synthesis in postmenopausal women. J Clin Endocrinol Metab, 99, 256–265.
66.
StarkebaumG, and HarlanJM. (1986). Endothelial cell injury due to copper-catalyzed hydrogen peroxide generation from homocysteine. J Clin Invest, 77, 1370–1376.
67.
StegemanBH, de BastosM, RosendaalFR, et al. (2013). Different combined oral contraceptives and the risk of venous thrombosis: systematic review and network meta-analysis. BMJ, 347, f5298.
68.
StipanukMH. (2004). Sulfur amino acid metabolism: pathways for production and removal of homocysteine and cysteine. Annu Rev Nutr, 24, 539–577.
69.
StipanukMH, DominyJEJr., Lee JI and ColosoRM. (2006). Mammalian cysteine metabolism: mew insights into regulation of cysteine metabolism. J Nutr, 136, 1652s–1659s.
70.
StipanukMH, UekiI, DominyJEJr., SimmonsCR, and HirschbergerLL. (2009). Cysteine dioxygenase: a robust system for regulation of cellular cysteine levels. Amino Acids, 37, 55–63.
71.
StoccoB, FumagalliHF, FranceschiniSA, et al. (2015). Comparative study of the effects of combined oral contraceptives in hemostatic variables: an observational preliminary study. Medicine (Baltimore), 94, e385.
72.
SwanepoelAC, EmmersonO, and PretoriusE. (2017). Effect of progesterone and synthetic progestins on whole blood clot formation and erythrocyte structure. Microsc Microanal, 23, 607–617.
73.
SwanepoelAC, LindequeBG, SwartPJ, AbdoolZ, and PretoriusE. (2014). Estrogen causes ultrastructural changes of fibrin networks during the menstrual cycle: a qualitative investigation. Microsc Res Tech, 77, 594–601.
74.
SwanepoelAC, NielsenVG, and PretoriusE. (2015). Viscoelasticity and ultrastructure in coagulation and inflammation: two diverse techniques, one conclusion. Inflammation, 38, 1707–1726.
75.
TsaiJC, PerrellaMA, YoshizumiM, et al. (1994). Promotion of vascular smooth muscle cell growth by homocysteine: a link to atherosclerosis. Proc Natl Acad Sci U S A, 91, 6369–6373.
76.
ValtonenP, PunnonenK, SaarelainenH, et al. (2010). ADMA concentration changes across the menstrual cycle and during oral contraceptive use: the Cardiovascular Risk in Young Finns Study. Eur J Endocrinol, 162, 259–265.
77.
van den BergRA, HoefslootHC, WesterhuisJA, SmildeAK, and van der WerfMJ. (2006). Centering, scaling, and transformations: improving the biological information content of metabolomics data. BMC Genomics, 7, 142.
78.
van der KloetFM, BobeldijkI, VerheijER, and JellemaRH. (2009). Analytical error reduction using single point calibration for accurate and precise metabolomic phenotyping. J Proteome Res, 8, 5132–5141.
79.
VerhoefP, StampferMJ, BuringJE, et al. (1996). Homocysteine metabolism and risk of myocardial infarction: relation with vitamins B6, B12, and folate. Am J Epidemiol, 143, 845–859.
80.
VigoritoC, AnishchenkoE, MeleL, et al. (2019). Uremic toxin lanthionine interferes with the transsulfuration pathway, angiogenetic signaling and increases intracellular calcium. Int J Mol Sci 20. pii:. E269.
81.
WangL, LiL, WangH, and LiuJ. (2016a). Study on the influence of oxidative stress on the fibrillization of fibrinogen. Biochem J, 473, 4373–4384.
82.
WangQ, WurtzP, AuroK, et al. (2016b). Effects of hormonal contraception on systemic metabolism: cross-sectional and longitudinal evidence. Int J Epidemiol, 45, 1445–1457.
83.
WangX, LiuL, ZhangW, et al. (2017). Serum metabolome biomarkers associate low-level environmental perfluorinated compound exposure with oxidative/nitrosative stress in humans. Environ Pollut, 229, 168–176.
84.
WelchGN, UpchurchGRJr., and LoscalzoJ. (1997). Homocysteine, oxidative stress, and vascular disease. Hosp Pract (1995) 32, 81, 82,, 85, 88–92.
85.
WhitemanM, and WinyardPG. (2011). Hydrogen sulfide and inflammation: the good, the bad, the ugly and the promising. Expert Rev Clin Pharmacol, 4, 13–32.
86.
WiegratzI, and ThalerCJ. (2011). Hormonal contraception—what kind, when, and for whom?. Dtsch Arztebl Int, 108, 495–506.
87.
WuG, FangYZ, YangS, LuptonJR, and TurnerND. (2004). Glutathione metabolism and its implications for health. J Nutr, 134, 489–492.
88.
ZimmermannKK, SpassovSG, StrosingKM, et al. (2018). Hydrogen sulfide exerts anti-oxidative and anti-inflammatory effects in acute lung injury. Inflammation, 41, 249–259.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
