title: Four Thrombotic Events Over 5 Years, Two Pulmonary Emboli and Two Deep Venous Thrombosis, When Testosterone-HCG Therapy Was Continued Despite Concurrent Anticoagulation in a 55-Year-Old Man With Lupus Anticoagulant.
abstract: BACKGROUND
  When exogenous testosterone or treatments to elevate testosterone (human chorionic gonadotropin [HCG] or Clomid) are prescribed for men who have antecedent thrombophilia, deep venous thrombosis and pulmonary embolism often occur and may recur despite adequate anticoagulation if testosterone therapy is continued.
  
  
  METHODS
  A 55-year-old white male was referred to us because of 4 thrombotic events, 3 despite adequate anticoagulation over a 5-year period. We assessed interactions between thrombophilia, exogenous testosterone therapy, and recurrent thrombosis. In 2009, despite low-normal serum testosterone 334 ng/dL (lower normal limit [LNL] 300 ng/dL), he was given testosterone (TT) cypionate (50 mg/week) and human chorionic gonadotropin (HCG; 500 units/week) for presumed hypogonadism. Ten months later, with supranormal serum T (1385 ng/dL, upper normal limit [UNL] 827 ng/dL) and estradiol (E2) 45 pg/mL (UNL 41 pg/mL), he had a pulmonary embolus (PE) and was then anticoagulated for 2 years (enoxaparin, then warfarin). Four years later, on TT-HCG, he had his first deep venous thrombosis (DVT). TT was stopped and HCG continued; he was anticoagulated (enoxaparin, then warfarin, then apixaban, then fondaparinux). One year after his first DVT, on HCG, still on fondaparinux, he had a second DVT (5/315), was anticoagulated (enoxaparin + warfarin), with a Greenfield filter placed, but 8 days later had a second PE. Thrombophilia testing revealed the lupus anticoagulant. After stopping HCG, and maintained on warfarin, he has been free of further DVT-PE for 9 months.
  
  
  CONCLUSIONS
  When DVT-PE occur on TT or HCG, in the presence of thrombophilia, TT-HCG should be stopped, lest DVT-PE reoccur despite concurrent anticoagulation.
authors.affiliation: Jewish Hospital of Cincinnati, Cincinnati, OH, USA.
authors.forename: Charles J
authors.initials: CJ
authors.lastname: Glueck
authors.affiliation: Jewish Hospital of Cincinnati, Cincinnati, OH, USA.
authors.forename: Kevin
authors.initials: K
authors.lastname: Lee
authors.affiliation: Jewish Hospital of Cincinnati, Cincinnati, OH, USA.
authors.forename: Marloe
authors.initials: M
authors.lastname: Prince
authors.affiliation: Jewish Hospital of Cincinnati, Cincinnati, OH, USA.
authors.forename: Vybhav
authors.initials: V
authors.lastname: Jetty
authors.affiliation: Jewish Hospital of Cincinnati, Cincinnati, OH, USA.
authors.forename: Parth
authors.initials: P
authors.lastname: Shah
authors.affiliation: Jewish Hospital of Cincinnati, Cincinnati, OH, USA.
authors.forename: Ping
authors.initials: P
authors.lastname: Wang
keywords: Clomid; anticoagulation; deep venous thrombosis; human chorionic gonadotropin; pulmonary embolus; testosterone