PCOS & Venous thrombosis: Can PCO women continue to ingest Cyproterone containg Pills if so how long??

Oestrogens & VTE:-- Estrogen cause slight increase in fibrinogen and by that promotes slightly increased prevalence of venous thrombosis  in prolonged use . But this is peculiar for EE (Ethinyl oestradiol)  which is a very potent oestrogen Though 20 mcg EE containg Pill (Loette) / 15 mcg(Minesse)  and even 10 mcg have been used still some amount of risk remains. That is why many women are switching over to COC with natural orstrogens which will regularize the cycle with no added risk of VTE . I have mentioned many  a times on CC with natural oestrogens  .

Of the contraceptive steroids we should remember that it is the estrogen which causes hypercoagulable state and is primarily attributed for DVT and allied thrombosis during OCP intake. The risk of VTE is directly related to dose of E but the OCP induced risk of VTE  in pregnancy is lower than the risk associated with even low-dose coc.

Inherited Thrombophilia:-  But as we know in some countries factor Leiden mutation, Protein-C /S synthesis disorders (DEFICIENT PRODUCTION) or prothrombin mutation disorders are to the extent of 0.5 to 5% of general population .. In such countries it will be prudent to screen women who candidates for inherited thrombophilias and refrain from prescribing OCP if screen +ve or family is +ve/ or she herself has already suffered from DVT in the recent past.  Fortunately such inherited thrombophilia is uncommon in India  and so we don’t screen women aspiring for COC . Inherited Thrombophilia is very very  uncommon  for our country.

 

Increased APC resistance can invite thrombosis: No OCP for them .  Lack of a response to activated protein C (APC), Acquired APC resistance:-  APC resistance :- APC resistance is characterized by a reduced anticoagulant response of patient.  Activated protein C resistance (APCR) is  hypercoagulability (an increased tendency of the blood to clot) characterized by a lack of a response to activated protein C (APC), which normally helps prevent blood from clotting excessively. This results in an increased risk of venous thrombosis (blood clots in veins), which resulting in medical conditions such as deep vein thrombosis (usually in the leg) and pulmonary embolism . APC naturally down regulates the thrombin formation. APC therefore is a naturally occurring  anticoagulant and if resistance is there there will be tendency to clot formation .  In acquired APC resistance the prevalence of  spontaneous DVT is 6/10,000 women in reproductive years(without OCP) . But if one uses OCP then the prevalence f DVT goes up-

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PCOS & Venous thrombosis: Can PCO women continue to ingest Cyproterone containg Pills if so how long?? This kind of Pills conatins 35 mcg of EE ?? – No. I think such PCO women with evidence of acne and hirsute  can take at best 4 yrs of My Pill.Ginete-35/.Dianette 35 which contain 35 mcg E> Later if symprecurs we can supplement with Metformin, Androcure (Schering ) 50 /100 mg cyproterone acetate or say Aldactone which counteracts enzymes at hair follicles and prevents androgens to act there ,using Thrombosis can occur at varying sites including legs, thigh veins, lungs, LFT & Lipid profile are within normal limits then A)Mirena is the first choice which should be preceded by EB B) Next choice will be MPA- in high dose. e.g. Orgemed/Deviry/Meprate/Modus/Farlutal at least 40 mg OD for 2-3 months. communicated to us that she is a case of PCOS. PCOS women, admittedly not all ,do suffer from lifelong Hyperestrogenic state which itself can promote VTE. However there is no contraindication to use MPA tab in this case . Moreover, MPA may prevent Endo hyperplasia as well and will ,hopefully take care of irregular bleeding. MPA is not an androgenic progesterone. Therefore MPA enjoys great safety profile on metabolic, homeostatic and lipid parameters, not to speak acceleration of thrombotic mechanism.. By contrast other commonly used progesterones particularly synthetic androgenic progesterones like norgestrel, Desogestrel, Norgestimate, gestodene DRSP which are derivatives of 19-Nortestosterone or 17-alpha acetoxy-P do have some lipid / atherogenic potentiality and ill effects on SHBG,APC Most of them decrease TG,HDL and cause rise of LDL. These side effects are predominant on estrane derivatives of 19-Nor testosterone but not so much with gonane derivatives. But MPA is a separate class of Progesterone. The only caution is that it is not a contraceptive and never has been used as contraceptive progesterone.