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      Portomesenteric venous thrombosis in a postmenopausal female with testosterone implant: a case report

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          Abstract

          Background

          Acute portal vein thrombosis is a rare medical event usually seen in liver disease, but it can also occur due to any inherited or acquired procoagulable state that triggers venous occlusion. Hormonal therapies have been associated with an increased risk of prothrombotic states. This case report documents a portomesenteric venous thrombosis in a postmenopausal woman with testosterone implant for the treatment of hypoactive sexual desire and discusses the importance of identifying hypercoagulable risk factors before initiating hormone replacement therapy. We want to improve the awareness of an unusual medical complication associated with hormone replacement therapy and shed light on how testosterone implants could facilitate a thrombotic event related to other risk factors such as obesity and chronic hypoxic states, as well as the importance of differential diagnosis in the evaluation of postmenopausal women on testosterone replacement therapy presenting with acute abdominal pain.

          Case presentation

          A 55-year-old obese postmenopausal Hispanic female with medical history of chronic obstructive pulmonary disease presents with intractable abdominal pain, is found to have elevated hemoglobin and hematocrit, and an abdominopelvic computed tomography scan revealing portal and superior mesenteric vein thrombosis. Further evaluation excluded inherited and acquired thrombophilia but revealed elevated testosterone levels. The patient was treated with anticoagulation, which resulted in recanalization of the portal and superior mesenteric veins.

          Conclusion

          Supraphysiologic levels of testosterone caused by testosterone implants as a treatment of hypoactive sexual desire in postmenopausal women can contribute to thrombotic events in the presence of additional prothrombotic risk factors. Therefore, testosterone therapy should include a thorough risk assessment for prothrombotic states, be tailored to patients’ physiologic testosterone levels, and have close follow-up with testosterone level monitoring.

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          Most cited references13

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          Recent portal or mesenteric venous thrombosis: increased recognition and frequent recanalization on anticoagulant therapy.

          D Valla, B Condat, M H Denninger … (2000)
          Characteristics and outcomes of recent portal or mesenteric venous thrombosis are ill-known. We intended to compare these features with those of patients with portal cavernoma, and also to assess the incidence of recanalization of recent thrombosis on anticoagulation therapy. All patients seen between 1983 and 1999 were enrolled into this retrospective study if recent portal or mesenteric venous thrombosis or portal cavernoma had been documented, and if cancer of the liver, pancreas, or bile duct, intrahepatic block including cirrhosis, and obstruction of the hepatic veins had been ruled out. The proportion of recent thrombosis was 7% in patients seen before 1990 and 56% after 1994 (P <.05). Patients with recent thrombosis (n = 33) or cavernoma (n = 108) did not differ with regard to age, sex ratio, or prevalence of prothrombotic states and of previous thrombotic events. In patients with recent thrombosis, septic pylephlebitis was more common and the incidence of gastrointestinal bleeding was lower (2.4 vs. 12.7/100 patient-years). Recanalization occurred in 25 of 27 patients given anticoagulation and 0 of 2 patients not given anticoagulation. The probability of recanalization was related to the extent of thrombosis (P =.003). In conclusion, mesenteric or portal venous thrombosis is increasingly recognized at an early stage. The features differentiating recent thrombosis and cavernoma are related to silent onset precluding early recognition and therapy in the latter. Frequent association with prothrombotic states and frequent recanalization on anticoagulation support the recommendation of early anticoagulation therapy in all patients with recent portal vein thrombosis.
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            The benefits and risks of testosterone replacement therapy: a review

            Nazem Bassil, Saad Alkaade, John E. Morley (2009)
            Increased longevity and population aging will increase the number of men with late onset hypogonadism. It is a common condition, but often underdiagnosed and undertreated. The indication of testosterone-replacement therapy (TRT) treatment requires the presence of low testosterone level, and symptoms and signs of hypogonadism. Although controversy remains regarding indications for testosterone supplementation in aging men due to lack of large-scale, long-term studies assessing the benefits and risks of testosterone-replacement therapy in men, reports indicate that TRT may produce a wide range of benefits for men with hypogonadism that include improvement in libido and sexual function, bone density, muscle mass, body composition, mood, erythropoiesis, cognition, quality of life and cardiovascular disease. Perhaps the most controversial area is the issue of risk, especially possible stimulation of prostate cancer by testosterone, even though no evidence to support this risk exists. Other possible risks include worsening symptoms of benign prostatic hypertrophy, liver toxicity, hyperviscosity, erythrocytosis, worsening untreated sleep apnea or severe heart failure. Despite this controversy, testosterone supplementation in the United States has increased substantially over the past several years. The physician should discuss with the patient the potential benefits and risks of TRT. The purpose of this review is to discuss what is known and not known regarding the benefits and risks of TRT.
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              Testosterone treatment and risk of venous thromboembolism: population based case-control study

              Carlos Martinez, Samy Suissa, Stephan Rietbrock … (2016)
              Objective To determine the risk of venous thromboembolism associated with use of testosterone treatment in men, focusing particularly on the timing of the risk. Design Population based case-control study Setting 370 general practices in UK primary care with linked hospital discharge diagnoses and in-hospital procedures and information on all cause mortality. Participants 19 215 patients with confirmed venous thromboembolism (comprising deep venous thrombosis and pulmonary embolism) and 909 530 age matched controls from source population including more than 2.22 million men between January 2001 and May 2013. Exposure of interest Three mutually exclusive testosterone exposure groups were identified: current treatment, recent (but not current) treatment, and no treatment in the previous two years. Current treatment was subdivided into duration of more or less than six months. Main outcome measure Rate ratios of venous thromboembolism in association with current testosterone treatment compared with no treatment were estimated using conditional logistic regression and adjusted for comorbidities and all matching factors. Results The adjusted rate ratio of venous thromboembolism was 1.25 (95% confidence interval 0.94 to 1.66) for current versus no testosterone treatment. In the first six months of testosterone treatment, the rate ratio of venous thromboembolism was 1.63 (1.12 to 2.37), corresponding to 10.0 (1.9 to 21.6) additional venous thromboembolisms above the base rate of 15.8 per 10 000 person years. The rate ratio after more than six months’ treatment was 1.00 (0.68 to 1.47), and after treatment cessation it was 0.68 (0.43 to 1.07). Increased rate ratios within the first six months of treatment were observed in all strata: the rate ratio was 1.52 (0.94 to 2.46) for patients with pathological hypogonadism and 1.88 (1.02 to 3.45) for those without it, and 1.41 (0.82 to 2.41) for those with a known risk factor for venous thromboembolism and 1.91 (1.13 to 3.23) for those without one. Conclusions Starting testosterone treatment was associated with an increased risk of venous thromboembolism, which peaked within six months and declined thereafter.
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                Author and article information

                Contributors
                Monica Zanconato Campitruz:
                ORCID: http://orcid.org/0000-0002-9655-415X
                monicazanconatomd@gmail.com
                Journal
                Journal ID (nlm-ta): J Med Case Rep
                Journal ID (iso-abbrev): J Med Case Rep
                Title: Journal of Medical Case Reports
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1752-1947
                Publication date (Electronic): 19 May 2021
                Publication date PMC-release: 19 May 2021
                Publication date Collection: 2021
                Volume: 15
                Electronic Location Identifier: 280
                Affiliations
                [1 ]Hoboken University Medical Center, 308 Willow Avenue, Hoboken, NJ 07030 USA
                [2 ]GRID grid.240473.6, ISNI 0000 0004 0543 9901, Penn State Health Milton S. Hershey Medical Center, ; 500 University Drive, Hershey, PA 17033 USA
                [3 ]GRID grid.267034.4, ISNI 0000 0001 0153 191X, University of Puerto Rico Medical Sciences Campus, ; Paseo Dr. José Celso Barbosa, San Juan, PR 00921 USA
                [4 ]West New York, USA
                Author information
                http://orcid.org/0000-0002-9655-415X
                Article
                Publisher ID: 2805
                DOI: 10.1186/s13256-021-02805-6
                PMC ID: 8132368
                SO-VID: 48777bc9-8456-4566-902a-da6b23e02182
                Copyright © © The Author(s) 2021
                License:

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                Date received : 16 January 2021
                Date accepted : 18 March 2021
                Categories
                Subject: Case Report
                Custom metadata
                issue-copyright-statement © The Author(s) 2021

                ScienceOpen disciplines: Medicine
                Keywords: portal vein thrombosis,superior mesenteric vein thrombosis,prothrombotic states,testosterone implant,hormone replacement therapy
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: portal vein thrombosis, superior mesenteric vein thrombosis, prothrombotic states, testosterone implant, hormone replacement therapy

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