VEINS and SYNTHETIC ESTRO-PROGESTATIVES
1. Synthetic Estro-progestatives "SOP"
2. SOPs and signs of venous insufficiency
3. SOPs and varicose veins
4. SOPs and thrombo-embolism
VEINS and HORMONAL REPLACEMENT THERAPY
Risk of thrombo-embolism : Why and what can be done to minimise such a risk ?
VEINS and SYNTHETIC ESTRO-PROGESTATIVES
Prescribed since 1966, the contraceptive pill or SOP is known to pose a risk to the venous system as noticeable increases in venous insufficiencies and thrombo-embolic accidents have been reported
Over the years, the hormonal content of SOPs has come down regularly. As for progestatives, their nature has also changed markedly from one generation to another, the aim being to achieve maximum efficiency while reducing side effects and complications.
1. SOP
First generation SOP’s:
Called macro-doses, they are composed of
- a synthetic estrogen : ETHYNILESTRADIOL, 40 to 100 ug/cp
- a progestative of the "ESTRANES" class, 300 to 1 000 ug/cp
Secong generation SOP’s :
- ETHYNILESTRADIOL, 50 ug/cp on average
- a progestative : either NORGESTREL or LEVONORGESTREL, 125 to 500 ug/cp
Third generation SOP’s:
- ETHYNILESTRADIOL, 15 to 40 ug/cp
- a progestative of the "GONANES"class, 60 to 250 ug/cp
Below the dose of 50 ug of Ethynilestradiol, the pill is classified as mini-dose.
These modifications aim to reduce the number of cardio-vascular accidents. The arterial risk is more likely linked to the progestative content, whereas the risk to the venous system which we are considering here, is thought to be linked to the Ethynilestradiol.
2. SOP’s and venous symptoms :
The use of SOP’s may accentuate symptoms of venous insufficiency, i.e.
-Heaviness in the legs
- Painful legs at the end of the day
- A feeling of heat and pins and needles in the calf
- Oedema in the ankle.
Whilst these symptoms do not make the use of contraceptives inadvisable, it is nevertheless indicated that the patient be followed by a treatment of venotonics and/or the wearing of light support stockings.
3. SOP’s and Varicose veins :
Taking SOP’s may trigger the formation of new varicose veins but may also at the same time worsen existing varicose veins.
Regular controls by a phlebologist are therefore indicated.
After an examination and a duplex-scan evaluation, he can decide which treatment is most adapted to your case, i.e. medical treatment by sclerotherapy or surgical intervention.
4. SOP’s and thrombo-embolism
The pill leads to an important increase in the risk for venous thrombosis (VT), a risk multiplied, according to various studies, by 3 to 6, or 4 cases per 1 000 patients a year.
This risk is thought to be linked particularly to Ethynilestradiol, which explains the trend towards a reduction of this component. As a matter of fact, at a dose of 50 ug of Ethynilestradiol, the incident of VT is considerably reduced.
However, no matter which SOP’s is used, certain rules have to be respected, such as the enquiry into personal or family antecedents of VT and/or thrombophilia.
- Personal antecedents of VT :
The use of SOP’s is not advisable and other methods of contraception are therefore recommended.
- Personal antecedents of thrombophilia :
Thrombophily is a condition which favours accidents of VT and/or pulmonary embolism due to a hereditary anomaly of coagulation and fibrinolysis (joint reactions which permit the elimination of the blood clot).
The most frequent anomalies recognised are :
- The deficit of Antithrombine III
- The deficit of Protein C
- The deficit of Protein S
- The resistance to activated Protein C (linked to a genetic mutation of Factor V "Leiden", named after his discoverer). The latter in particular, in conjonction with the administration of an SOP, is know to multiply by 35 to 50 the risk of VT. The existence of any of these anomalies makes the administration of the pill unadvisable and a different method of contraception should in this case be recommended to the patient.
- Antecedents in the family of VT and/or Thrombophilia :
Research of coagulation anomalies is mainly recommended for patients whose first-degree relatives have suffered a confirmed VT.
The same applies to research on the resistance to activated protein C, the importance of which is not to be underestimated. If, on the other hand, there is a history of thrombophilia in the family, one should check medical records. If they are not available, one should carry out tests before the prescription of an estro-progestative treatment.
VEINS and HORMONAL REPLACEMENT THERAPY
Hormonal Replacement Therapy (HRT) consists in taking natural hormones, estrogens either orally or by patch associated with a progestative (unless one has had a hysterectomy), the aim being to minimise the effects of hormonal deficiency. It has a role in the prevention of osteoporosis and coronary disease and decreases the risk of colorectal cancer; it is said to reduce weight increase and the risk of age-related macular degeneration that can lead to blindness. However the prescription of HRT increases the risk of breast cancer and cancer of the womb.
What about its effects on the venous system?
First, it may sometimes increase the symptoms of venous insufficiency already mentioned, but above all, many studies seem to show a significant increase in thrombo-embolic accidents, mainly during the first year of treatment.
WHY ?
Venous thrombosis results from the haemostatic potent (entirety of phenomena of coagulation) within the vascular system. The failure of inhibitory systems, the excess of procoagulants (activators) as well as a modification in the fibrinolytic system (entirety of reactions allowing the elimination of a clot or fibrinolyse) can result in a thrombosis.
Not all modifications that may occur during menopause have yet been identified with certainty, whereas the various effects of HRT according to their mode of administration are well known. It is in fact recognised that:
- If HRT contains an estrogen applied by patch on the skin, this has little influence on the systems that are regulating coagulation and fibrinolysis ;
- If HRT contains an estrogen applies orally, one can note an increase in the concentration of the coagulation markers in the blood plasma, thus increasing the risk of venous thrombosis. (These findings do not appear to depend on the administration of a progestative).
CONCLUSION
During HRT, the risk of venous thrombosis is multiplied by 2 to 4 times. The risk is particularly pronounced during the first year of treatment and appears to stabilize around 2 to 4 cases a year per 1 000 patients.
It is of the utmost importance to consider all contra-indications and in particular all known antecedents of venous thrombosis and/or thrombophilia. A frank discussion with the patient should take place since the benefit to the woman concerned may be considered more important than the known risk, the incidence of which may be minor.
Medically termed Hyperhidrosis, excessive sweating is the result of over activity of sweat glands.
It is quoted as occurring for feet in 12% and 1% for palms of the population aged over 15 years.
It appears to be equal between the sexes. Though benign, hyperhidrosis presents the patient with
significant psychological and social concerns.
There are two classical types:
The first type, usually nocturnal, is secondary to some internal pathology.
This type of hyperhidrosis must be carefully ruled out prior to arriving at a diagnosis of primary hyperhidrosis because it is commonly associated with an underlying medical problem or use of certain medications.
While secondary hyperhidrosis may present as localized, it is often characterized by a more generalized pattern of sweating that occurs during both daytime and nighttime hours.
The second type, is more often primary and emotional.
This condition is the cause of much embracement both socially and professionally : in particular in those who daily handle sheets of paper (secretaries, schoolchildren, designers, architects...) or hold solid objects in their hands (gymnasts, tennis players...). Micro technical industries (watchmakers, precision instrument manipulators) are also concerned as the sweat from the workers can oxidize the metallic parts they handle.
These persons change their clothes several times a day because of large perspiration stains, or avoided shaking hands or touching their friends because their palms were always moist. They could also stop playing music because the excessive moisture on their hands damaged the strings of their instrument.
Furthermore, excess sweating of the feet is often associated with an unpleasant smell, maceration of the toes and web spaces, with, as a result, bacterial and fungus infections, plantar warts by sweat environment.
Angiologists are often presented with sweaty palm and feet problem.
Most patients have the hyperhidrosis localized to their hands and feet.
Although thoracoscopic sympathectic trunkotomy and botulinum toxin injections may be effective, they can produce serious side effects, some of which may be irreversible. Surgery is only rarely necessary, and there are numerous surgical pitfalls, which include recurrence of hyperhidrosis, almost certain impotence, compensatory sweating, permanent neurological damage from anoxia, and worst. Botulinum toxin, which is recommend requires 24-36 painful injections per foot or hand and can produce also serious effects as muscle weakness. Even this horrendous procedure gives only 11 months' relief, and antibody formation may reduce long term efficiency. The cost of BTX therapy is approximately $700 to $1,000 per course of treatment.
Iontophoresis is easy to perform, cheap, effective in many, free of hazardous side effects, and well accepted by almost all patients.
The equipment consists of batteries device that supplies the current, it allow variability in the intensity of the current from 0 to 20 mA, plastics trays in which are placed two electrodes covered by grids, also in plastic, to prevent direct contact of the skin with the electrodes. The hands or feet in the trays are partly submerged in warm water through which a mild electric current is run. The treatment can be carried out in two anatomical areas simultaneously. At the start the intensity is slowly increased. This intensity is applied for 20mn.
The patient is asked to remove all metallic objects (rings, chains, bracelets...) and to keep the treated parts still and submerged throughout the treatment; a sudden withdrawal from the water would beak the circuit resulting in a most unpleasant but harmless electrical discharge. The frequency of treatments, first week treatments on D1, D2 & D4 (D1= 1st treatment day), second week treatments on D7 & D10, third week treatment on D15, fourth week treatment on D22, in practice, an almost complete session of sweating can be achieved after the fourth treatment.
After the seventh treatment session, further sessions will only be needed if sweating restarts, as a form of maintenance therapy and therefore infrequently.
Contra-indications to this treatment are pregnancy, cardiac pacemakers, and metal orthopaedic implants.
Recommended resources about Iontophoresis devices and links :
i2m-labs.com
It is estimated that more than 800 million people worldwide travel by air each year. More than a billion and a half will do so by 2020.
Health problems linked to long airplane trips can therefore only increase, mainly deep or superficial venous thromboses of the lower limbs, and pulmonary embolisms.
Better prevention based on a better knowledge of patients at risk will certainly lead to a lower incidence of these accidents.
By the way, airplanes are not the only means of transportation involved. Similar problems can also occur during long trips by car, bus or train.
PHLEBITIS vs EMBOLISM
A decrease in blood fluidity can lead to the formation of clots (thrombosis) in the deep venous system or in the superficial venous system of the lower limbs. If these clots remain in the legs, the disease is called phlebitis (deep or superficial). If these clots break away and move towards the lungs, they can cause pulmonary embolisms.
FREQUENCY
Several thousand cases likely occur each year. Nobody knows exactly how frequently these problems occur during air travel because airlines only report incidents that occur during or immediately after the trip. However, most problems show up only several days later and are therefore not included in the statistics. It is very likely that less than 5% of long-haul travelers are affected.
WHAT ARE THE RISK FACTORS FOR THROMBOSES?
Age: Being over 50 increases risks. Patients are 63 on average.
Sex: 70% of patients are women.
Traveler’s Health:
- Personal history of deep or superficial phlebitis
- Family history of deep or superficial phlebitis
- Active cancer
- Reduced cardiac output
- Leg in cast or broken
- Recent femoral catheterization
- Pregnancy or estrogen treatment
- Blood diseases (excess levels of platelets or red cells)
Traveler’s behavior:
- Stress and fatigue
- Tobacco and alcoholic beverages, heavy meals
- Use of sleeping pills
- Prolonged sitting position. Sitting down with flexed or crossed legs pushing against the seat hampers the venous return flow and can lead to the formation of clots.
Factors linked to the plane:
- Flights over five hours
- Dry air leading to body and blood dehydration
- Cabin pressurization leading to reduced levels of oxygen, which increases the blood viscosity
- Sitting in the middle seat or close to windows, traveling in the economy class.
WHAT ARE THE WARNING SIGNS OF VENOUS THROMBOSIS AND PULMONARY EMBOLISM?
The first symptoms can occur either during the flight or shortly after landing, or, most frequently, several hours or days after the trip.
Superficial phlebitis appears typically as an indurated and painful cord along a superficial vein, normal or more often varicose.
Deep phlebitis may occur with no visible or painful symptom. More often, however, the leg becomes swollen, red, inflamed, tender with or without palpation.
Pulmonary embolism can be fatal as soon as symptoms first appear. It can also be associated with chest pain, impaired breathing, and bloody sputum.
ADVICE TO LONG-HAUL TRAVELERS
To all passengers:
- take a walk at regular intervals (every two hours)
- do not cross your legs
- drink regularly non-alcoholic beverages (ideally one liter of water for every 5 hours of flying)
- avoid long periods of sleep leading to immobility
- move around your ankles and the calf muscles while sitting
- wear loose and light clothes
To passengers with varicose veins:
It is recommended to wear special elastic socks, strength 2.
A venotonic medication, useful for its anti-edematous and/or anti-inflammatory effects, can help if the treatment starts 48 hours before the trip and continues for 48 hours after arrival.
To passengers at risk for thrombo-embolism:
An elastic contention must be worn (minimum strength 2).
Heparin injections should be planned on the day of the trip and the day after arrival. Ready-to--use syringes are available to travelers but a demonstration by a physician is advised beforehand. Heparin liquefies the blood and constitutes an excellent prevention of venous clots. One should note that there are contra-indications to the use of these products.