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Abstract

Our hypothesis was that thrombosis occurring in postmenopausal women given testosterone (T) or testosterone–estradiol (TE) to improve libido was associated with a prothrombotic interaction between T or TE with underlying inherited procoagulants. In three previously healthy, postmenopausal, Caucasian women with no antecedent thrombosis and previously undiagnosed G20210A prothrombin gene heterozygosity, hyperhomocysteinemia and 4G4G homozygosity of the PAI-1 gene, we describe central retinal vein thrombosis and osteonecrosis that developed at 16 days, 2 months and 11 months in the three cases, respectively, after T or TE therapy was started. Exogenous T or TE in postmenopausal women may be associated with thrombosis, speculatively when it is superimposed on underlying procoagulants. This small observational case series can serve as a starting point for a larger observational study with greater detail on patient history, serum T and estradiol levels, and detailed PCR and serologic assessment of thrombophilia and hypofibrinolysis.

Keywords

central retinal vein thrombosis G20210A prothrombin gene mutation hyperhomocysteinemia osteonecrosis testosterone testosterone–estradiol thrombosis

We have recently described deep venous thrombosis [1], pulmonary embolism, amaurosis fugax and osteonecrosis (ON) of the hips after exogenous testosterone (T) was given to six previously healthy men with no antecedent thrombosis, five of whom were found to have previously undiagnosed factor V Leiden heterozygosity and one who had high factor VIII [1]. ON may be caused, in part, by thrombophilia and hypofibrinolysis-induced thrombus of the major efferent veins of the head of the femur leading to increased intracortical pressure and reduced arterial inflow, with subsequent bone hypoxia and bone death [1,2].

The major source of estradiol (E2) in men comes from the aromatization of T (endogenous or exogenous) to E2 [3]. We speculated [1] that when exogenous T is aromatized to E2 [3 –6], and E2-induced thrombophilia is superimposed on underlying familial thrombophilia, thrombosis occurs [1]. Estrogen use in postmenopausal women is associated with increased risk of venous thrombosis [7,8] and ischemic stroke [9]. We have recently reported two previously healthy women who developed ON [10] and central retinal vein occlusion thrombosis (CRVO) [8] after starting T therapy for libido (patch 300 μg and T–E2 (TE) pellet [75–75 mg]) and were found to have previously undiagnosed familial thrombophilia (high homocysteine and high factor XI, respectively).

In postmenopausal women and in women with surgical oophorectomy, the roles played by androgens or estrogens in women's libido remain uncertain [11,12]. The relationship between androgen deficiency and loss of libido in women remains unclear [13]. T transdermal patches have been reported to safely improve libido in 24-week blind trials of estrogen-using postmenopausal women who have had bilateral oophorectomy [14 –16], and to improve sexual function in some women with natural menopause not taking estrogen [13,17,18]. Despite these significant short-term studies, in 2004, the US FDA advisory committee unanimously rejected a fast-track application for Intrinsa® (Procter and Gamble Co., OH, USA; transdermal T patch) approval, citing concerns about off-label use. However, T, usually administered subcutaneously as pellets, is increasingly given off-label to improve libido and sexual function in women.

Our hypothesis in the current case series is that thrombosis occurring in postmenopausal women given T or TE to improve libido is associated with an interaction between T or TE with underlying inherited procoagulants.

Patients & methods

Study design

Informed consent was obtained after the nature of the procedures (blood drawing, measures of coagulation and medical history) had been fully explained. The procedures followed were in accordance with the ethical standards of the institutional review board of the Jewish Hospital (OH, USA), which approved the research protocol.

In the sequential order of their referral for evaluation of CRVO or ON, patient information was obtained by history and physical examination. Some of the data for one of the three women in the current report (case one) ( Table 1 ) are also included in another paper [10]. None of the data for the other two women have been previously reported [1,8,19].

Table 1.

Coagulation measures in three postmenopausal women who sustained thrombi after exogenous testosterone or testosterone–estradiol adminitration.

Age (years), race, sex	FV	PTG	MTHFR C677T/A1298C	PAIG	RAPC	Prot C (%)	Prot S/free S (%)	ATIII (%)	Homo (μmol/l)	FVIII (%)	FXI (%)	APTT (s)	Lupus anticoag	ACLA		Lp(a) (mg/dl)
														IgG (GPL)	IgM (MPL)
Normal range	NN	NN	C677T: NN or PN/NN	5G5G 4G5G	≥2.2	≥60	≥60/≥62	≥72	<15	<150	<150	<36.4	Negative	<15	<13	<31
53, white, female	NN	NN	PN/NN	4G4G	4.0	131	96/–	101	8.6	42	110	20.1	Negative	6	5	28
54, white, female	NN	NN	PN/PN†	4G4G†	2.5	87	93/96	80	22.1†	128	86	31.0	Negative	5	5	17
45, white, female	NN	PN†	NN/PP	4G5G	2.3	98	128/102	110	7.0	112	119	31.3	Negative	9	16†	1

†

Abnormal findings.

ACLA: Anticardiolipin antibody; Anticoag: Anticoagulant; APTT: Activated partial thromboplastin time; ATIII: Antigenic antithrombin III; Free S: Antigenic free protein S; FV: Factor V Leiden; FVIII: Factor VIII; FXI: Factor XI; Homo: Homocysteine; Lp(a): Lipoprotein (a); NN: Heterozygous wild-type normal; PN: Heterozygous mutant allele; PP: Homozygous mutant allele; Prot C: Antigenic protein C; Prot S: Antigenic protein S; RAPC: Resistance to activated protein C.

After an overnight fast, blood was drawn in the seated position for assessment of thrombophilia and hypofibrinolysis [20].

Laboratory assessment of coagulation factors

PCR assays

PCR measures of G1691A factor V Leiden, G20210A prothrombin, MTHFR C677T–A1298C and 4G5G plasminogen activator inhibitor activity (PAI-1) mutations were performed in all cases using previously published methods by laboratory staff who were blinded to the subjects’ status (diagnosis and severity of disease) [21 –23].

Serologic measures

Serologic measures included anticardiolipin antibodies (IgG and IgM), antigenic protein C, total and free antigenic protein S, antigenic antithrombin III, resistance to activated protein C (RAPC), activated partial thromboplastin time (APTT), lupus anticoagulant, factors VIII, factor XI and homocysteine. Established, previously published methods were used [21,24]. Serologic measures of Lp(a) and plasminogen activator inhibitor activity were carried out using established, previously published methods [22,25].

Results

Interaction of T-supplementation therapy in postmenopausal women with previously undiagnosed procoagulants led to thrombotic events, including CRVO thrombosis and ON.

The temporal associations of exogenous T or TE with subsequent, otherwise unprovoked, thrombotic events, led us to evaluate for underlying previously undiagnosed procoagulants in three postmenopausal women ( Table 1 ).

Before our evaluation, which was triggered by thrombotic events, none of the previously healthy women had a history of thrombosis and none had any previous coagulation testing. They had no antecedent history of trauma, surgery, overt cancer or immobilization. None of the three women had taken long-term, high-dose corticosteroids, none were alcoholic and all three were nonsmokers. Cases one and two were naturally postmenopausal, and case three was surgically postmenopausal, having had hysterectomy–oophorectomy 8 years before treatment with subcutaneous TE pellets.

After their thrombotic events on T or TE therapy given to improve libido, one woman (case three) was found to be heterozygous for the G20210A prothrombin gene mutation, one woman (case two) had hyperhomocysteinemia with accompanying MTHFR C677T–A1298C compound heterozygosity and PAI-1 gene 4G4G homozygosity, and one woman (case one) had PAI-1 4G4G homozygosity ( Table 1 ).

Case one

To improve libido, this 53-year-old post-menopausal Caucasian woman was given a T patch that delivered 300 μg/day. Bilateral hip ON was diagnosed by MRI and x-ray 11 months after starting T. Coagulation tests revealed 4G4G homozygosity of the PAI-1 gene ( Table 1 ).

Case two

To improve libido, this 54-year-old post-menopausal Caucasian woman was given a T–E (75–75 mg) subcutaneous implant, and 16 days after the implant, she developed CRVO. Coagulation tests revealed compound heterozygosity for the MTHFR C677T and A1298C mutations, with accompanying thrombophilic high homocysteine, as well as 4G4G homozygosity of the PAI-1 gene ( Table 1 ).

Case three

To improve libido, this 45-year-old Caucasian woman, 8 years after oophorectomy, was given a T–E (75–75 mg) subcutaneous implant. Bilateral hip pain occured 1 month later; 2 months after the implant, bilateral ON of both hips was diagnosed by x-ray and MRI. Coagulation studies revealed thrombophilic heterozygosity for the G20210A mutation of the prothrombin gene ( Table 1 ).

When taking the TE subcutaneous implant, serum T in case three was high (76 ng/dl) and E2 was high (260 pg/ml) for a postmenopausal woman ( Table 2 ). A total of 3 weeks after stopping the T–E2 implant, T fell to a very low level (<3 ng/dl), and E2 fell into the normal postmenopausal range (31.1 pg/ml) ( Table 2 ).

Table 2.

Lipids, testosterone and estradiol in the three women.

Age (years), race, sex	BMI (kg/m²)	LDLC/HDLC/TG (mg/dl)	Total T (ng/dl)	Estradiol (pg/ml)
Normal range	<25.0 normal (25.0 to <30.0 overweight and >30.0 obese)	<130/≥50/<150	<48	<54.7
53, white, female	20.4	–	–	–
54, white, female	26.9†	121/75/70	–	–
45, white, female	29.4†	118/55/136	On T supplement: 76	On T supplement: 260
			Off T: <3	Off T: 31.1

†

Abnormal findings.

HDLC: High-density lipid cholesterol; LDLC: Low-density lipid cholesterol; T: Testosterone; TG: Trigylceride.

Discussion

The novel finding of the current study was that in three previously healthy postmenopausal women without previous thrombotic events, and without previously known prothrombotic factors, thrombotic events (CRVO and ON) occurred at 16 days, 2 months and 11 months in the three cases, respectively, after T or TE were given to improve libido. The data of the current study confirms and expands the association between thrombosis and T treatment in our initial report on six men [1], our second report on 13 men and one woman [19], and our third report in one woman with CRVO [8]. Congruent with our previous reports, which were predominantly in men (19 out of 21 cases) [1,8,19], the thrombotic events in the three women of the current study were associated with previously undiagnosed heterozygosity for the G20210A prothrombin gene mutation, MTHFR C677T and A1298C compound heterozygosity with accompanying high homocysteine, and with the 4G4G mutation of the PAI-1 gene. High homocysteine is a risk factor for CRVO [8]. ON is associated with the G20210A prothrombin gene mutation [26] and with the 4G4G mutation of the PAI-1 gene [2,27,28]. Given an estimated population prevalence of heterozygosity for the factor V Leiden mutation in 5% of women, [29] and prevalence of thrombophilias (factor V Leiden, prothrombin, MTHFR mutations, high homocysteine, and high factors VIII and XI) in 18–28% of women [7,30,31], there is considerable opportunity for women given T or TE to also have an increased likelihood of thrombosis.

We speculate that the increasing and off-label frequency of T prescription to improve women's libido may be associated with a parallel and largely preventable increase in thrombotic events [1,8,19] and, possibly, cardiovascular adverse events [32].

We speculate that as exogenous T is aromatized to E2 [1,33], thrombophilic E2 interacts with previously undiagnosed procoagulants, such as high homocysteine and the G20210A prothrombin mutation, to produce thrombotic events, as in the current study, and in our recent reports in men [1] and in both men and women [8,19] who were receiving T. As recently reported in women, given a 100-mg T implant for symptoms of androgen deficiency [34], 4 weeks after implantation and when androgen deficiency symptoms returned later, serum T levels were several-fold higher than endogenous T. Glaser et al. concluded that “pharmacologic dosing of subcutaneous T, as evidenced by serum levels on therapy, is needed to produce a physiologic effect in female patients” [34]. Congruent with this report by Glaser et al., in one woman in our current study where T and E2 were measured on and off TE therapy, T and E2 were both high on TE (76 ng/dl and 260 pg/ml, respectively), and off TE, T fell to very low levels (<3 ng/dl) and E2 fell to normal postmenopausal levels (31.1 pg/ml) [34]. We speculate that in women given 75–100-mg T pellet implantation, as in two women in the current report, supraphysiologic serum T will be aromatized to supraphysiologic high E2 [34], increasing the risk of thrombosis in women with underlying, and previously undiagnosed, thrombophilia [1,8,19]. When 75-mg T is combined with 75-mg E2, as in two women in the current study, we speculate that thrombophilic high serum E2 levels may be even more supraphysiologic.

As reported by Svartborg et al., in age-adjusted analyses, endogenous sex hormone levels in men are not associated with risk of venous thromboembolism [35]. In our previous report of 13 men and one woman with thrombotic events after T therapy [19], endogenous male sex hormones were not associated with venous thromboembolism. Endogenous E2 in women is not related to thrombophilic resistance to activated protein C [36]. However, there are case reports of deep vein thrombosis pulmonary embolus in men after exogenous testosterone–nandrolone [37], and cerebral sinus thrombosis after exogenous nandrolone [38]. Exogenous androgenic hormone regimens increase risk of breast cancer in women [39]; however, to the best of our knowledge, the current report and our two other recent studies are the first to document thrombotic events associated with T or TE therapy in women [8,19].

Conclusion

Exogenous T or TE therapy in postmenopausal women may be associated with thrombosis, speculatively when it is superimposed on underlying thrombophilia, such as hyperhomocysteinemia and G20210A prothrombin gene heterozygosity, as in the current report. Our small observational case series can serve as a starting point for a larger observational study with greater detail on patient history, serum T and E2 levels, and detailed PCR and serologic assessment of thrombophilia and hypofibrinolysis.

Future perspective

In 5–10 years, the cost of serologic and PCR measures of major mutations that promote thrombosis should fall sharply, thus allowing economically feasible screening of women for procoagulants before prescription of exogenous T or TE. This will facilitate better assessment of benefit-to-risk ratios relative to T and TE treatment in women.

Financial & competing interests disclosure

Funding was received from the Lipoprotein Research Fund, the Metabolic Research Fund and the Jewish Hospital of Cincinnati. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Informed consent disclosure

The authors state that they have obtained verbal and written informed consent from the patients for the inclusion of their medical and treatment history within this case series.

Executive summary

The novel finding of the current study was that in three previously healthy postmenopausal woman without previous thrombotic events, and without previously known procoagulants, thrombotic events (central retinal vein occlusion and osteonecrosis) occurred at 16 days, 2 months and 11 months, in the three cases respectively, after testosterone or testosterone–estradiol therapy.

Our small observational case series can serve as a starting point for a larger observational study with greater detail on patient history, serum testosterone and estradiol levels, and detailed PCR and serologic assessment of thrombophilia and hypofibrinolysis.

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Thrombosis in Three Postmenopausal Women Receiving Testosterone Therapy for Low Libido

Abstract

Keywords

Patients & methods

Study design

Laboratory assessment of coagulation factors

PCR assays

Serologic measures

Results

Case one

Case two

Case three

Discussion

Conclusion

Future perspective

Financial & competing interests disclosure

Informed consent disclosure

References