Skip to main content Accessibility help

The Impact of Two Combined Oral Contraceptives Containing Ethinyl Estradiol and Drospirenone on Whole Blood Clot Viscoelasticity and the Biophysical and Biochemical Characteristics of Erythrocytes

  • Odette Emmerson (a1), Janette Bester (a1), Barend G. Lindeque (a2) and Albe C. Swanepoel (a1)


Venous thrombosis is associated with combined oral contraceptive (COC) use. We investigated the impact of two ethinyl estradiol (EE) and drospirenone (DRSP) containing COCs (3 mg DRSP/20 µg EE and 3 µg DRSP/30 µg EE) on the viscoelasticity of whole blood clots along with the biophysical and biochemical characteristics of erythrocytes. Thromboelastography (TEG) analysis showed a tendency toward a hypercoagulable state in the COCs groups that was more pronounced with higher EE concentrations. Light microscopy and scanning electron microscopy (SEM) showed rouleaux formation of erythrocytes and alterations to the erythrocyte shape for both COC groups, which was attributed to membrane damage. SEM analysis showed spontaneous activation of fibrin and platelets in the COC groups, along with interactions between erythrocytes and platelets and/or fibrin. Confocal microscopy confirmed compromised membrane integrity in the COC groups compared to controls. Global thrombosis test analysis showed increased platelet activation and low thrombolysis in both COC groups when compared to controls. In conclusion, DRSP/EE formulations impact erythrocytes’ biophysical and biochemical properties to cause a shift in hemostasis to a prothrombotic state. Although these effects are mostly subclinical the long-term effects and risks involved with the use of these hormones should be considered carefully for each individual.


Corresponding author

*Author for correspondence: Albe C. Swanepoel, E-mail:


Hide All

Cite this article: Emmerson O, Bester J, Lindeque BG and Swanepoel AC (2018) The Impact of Two Combined Oral Contraceptives Containing Ethinyl Estradiol and Drospirenone on Whole Blood Clot Viscoelasticity and the Biophysical and Biochemical Characteristics of Erythrocytes. Microsc Microanal24(6), 713–728. doi: 10.1017/S1431927618015453



Hide All
Aleman, MM, Walton, BL, Byrnes, JR, Wang, J-G, Heisler, MJ, Machlus, KR, Cooley, BC Wolberg, AS (2013) Elevated prothrombin promotes venous, but not arterial, thrombosis in micesignificance. Arterioscler Thromb Vasc Biol 33(8), 18291836.
Aleman, MM, Walton, BL, Byrnes, JR Wolberg, AS (2014) Fibrinogen and red blood cells in venous thrombosis. Thromb Res 133, S38S40.
Ami, RB, Barshtein, G, Zeltser, D, Goldberg, Y, Shapira, I, Roth, A, Keren, G, Miller, H, Prochorov, V Eldor, A (2001) Parameters of red blood cell aggregation as correlates of the inflammatory state. Am J Physiol-Heart Circ Physiol 280(5), H1982H1988.
Barshtein, G, Wajnblum, D Yedgar, S (2000) Kinetics of linear rouleaux formation studied by visual monitoring of red cell dynamic organization. Biophys J 78(5), 24702474.
Baskurt, O, Neu, B Meiselman, HJ (2011) Red Blood Cell Aggregation. Boca Raton, Florida, USA: CRC Press.
Baskurt, OK Meiselman, HJ (2003) Blood rheology and hemodynamics. Semin Thromb Hemost, 29(5), 435–450.
Bonnar, J (1987) Coagulation effects of oral contraception. Am J Obstet Gynecol 157(4), 10421048.
Borgo, M, Claudio, E, Silva, F, Romero, W, Gouvea, S, Moysés, M, Santos, R, Almeida, S, Podratz, P Graceli, J (2016) Hormonal therapywith estradiol and drospirenone improves endothelium-dependent vasodilation in the coronary bed of ovariectomized spontaneously hypertensive rats. Braz J Med Biol Res 49(1), e4655.
Brynhildsen, J (2014) Combined hormonal contraceptives: Prescribing patterns, compliance, and benefits versus risks. Ther Adv Drug Saf 5(5), 201213.
Burkman, R (2002) The evolution of oral contraceptives: 40 years of continuous improvement. Clinician 20, 330.
Buys, AV, Lipinski, B, Van Papendorp, D, Pretorius, E, Van Rooy, M-J Soma, P (2013) Changes in red blood cell membrane structure in type 2 diabetes: A scanning electron and atomic force microscopy study. Cardiovasc Diabetol 12(1), 25.
Crowl, LM Fogelson, AL (2010) Computational model of whole blood exhibiting lateral platelet motion induced by red blood cells. Int J Numer Method Biomed Eng 26(3–4), 471487.
Davie, EW (1995) Biochemical and molecular aspects of the coagulation cascade. Thromb Haemost 74(1), 1.
Dayan, N, Holcroft, CA Tagalakis, V (2011) The risk of venous thrombosis, including cerebral vein thrombosis, among women with thrombophilia and oral contraceptive use: A meta-analysis. Clin Appl Thromb Hemost 17(6), E141152.
Dinger, J, Do Minh, T, Buttmann, N Bardenheuer, K (2011) Effectiveness of oral contraceptive pills in a large US cohort comparing progestogen and regimen. Obstet Gynecol 117(1), 3340.
Du, VX, Huskens, D, Maas, C, Al Dieri, R, de Groot, PG de Laat, B (2014) New insights into the role of erythrocytes in thrombus formation. Semin Thromb Hemost, 40(1), 72–80.
Engelen, C, Moritz, A, Barthel, F Bauer, N (2017) Preliminary reference intervals and the impact of citrate storage time for thrombelastography in cats including delta and the velocity curve. BMC Vet Res 13(1), 366.
Fan, X, Chen, X, Wang, C, Dai, J, Lu, Y, Wang, K, Liu, J, Zhang, J Wu, X (2015) Drospirenone enhances GPIb‐IX‐V‐mediated platelet activation. J Thromb Haemost 13(10), 19181924.
Furukawa, S, Fujita, T, Shimabukuro, M, Iwaki, M, Yamada, Y, Nakajima, Y, Nakayama, O, Makishima, M, Matsuda, M Shimomura, I (2017) Increased oxidative stress in obesity and its impact on metabolic syndrome. J Clin Invest 114(12), 17521761.
Furuyama, A, Hirano, S, Koike, E Kobayashi, T (2006) Induction of oxidative stress and inhibition of plasminogen activator inhibitor-1 production in endothelial cells following exposure to organic extracts of diesel exhaust particles and urban fine particles. Arch Toxicol 80(3), 154162.
Gronich, N, Lavi, I Rennert, G (2011) Higher risk of venous thrombosis associated with drospirenone-containing oral contraceptives: A population-based cohort study. CMAJ 183(18), E1319E1325.
H, Kuhl (2005) Pharmacology of estrogens and progestogens: Influence of different routes of administration. Climacteric 8(1), 363.
Ibáñez, L de Zegher, F (2004) Ethinylestradiol-drospirenone, flutamide-metformin, or both for adolescents and women with hyperinsulinemic hyperandrogenism: Opposite effects on adipocytokines and body adiposity. J Clin Endocrinol Metabol 89(4), 15921597.
Idota, N, Kobayashi, M, Miyamori, D, Kakiuchi, Y Ikegaya, H (2015) Drospirenone detected in postmortem blood of a young woman with pulmonary thromboembolism: A case report and review of the literature. Legal Med 17(2), 109115.
Josefsson, A, Wiréhn, A-B, Lindberg, M, Foldemo, A Brynhildsen, J (2013) Continuation rates of oral hormonal contraceptives in a cohort of first-time users: A population-based registry study, Sweden 2005–2010. BMJ Open 3(10), e003401.
Kaestner, L Bogdanova, A (2014) Regulation of Red Cell Life-Span, Erythropoiesis, Senescence and Clearance. Lausanne, Switzerland: Frontiers E-books.
Kieler, H, Persson, I Odlind, V (2003) Venous thromboembolism and combined oral contraceptives. Reported adverse reactions indicate at least similar risk with the most recent contraceptive pills. Lakartidningen 100(39), 30503052.
Klipping, C, Duijkers, I, Fortier, MP, Marr, J, Trummer, D Elliesen, J (2012 a) Contraceptive efficacy and tolerability of ethinylestradiol 20 µg/drospirenone 3 mg in a flexible extended regimen: An open-label, multicentre, randomised, controlled study. J Fam Plann Reprod Health Care 38(2), 7383.
Klipping, C, Duijkers, I, Fortier, MP, Marr, J, Trummer, D Elliesen, J (2012 b) Long-term tolerability of ethinylestradiol 20 µg/drospirenone 3 mg in a flexible extended regimen: Results from a randomised, controlled, multicentre study. J Fam Plann Reprod Health Care 38(2), 8493.
Kluft, C, Endrikat, J, Mulder, SM, Gerlinger, C Heithecker, R (2006) A prospective study on the effects on hemostasis of two oral contraceptives containing drospirenone in combination with either 30 or 20 μg ethinyl estradiol and a reference containing desogestrel and 30 μg ethinyl estradiol. Contraception 73(4), 336343.
Mankelow, T, Satchwell, T Burton, N (2012) Refined views of multi-protein complexes in the erythrocyte membrane. Blood Cells Mol Dis 49(1), 110.
Mathur, R, Levin, O Azziz, R (2008) Use of ethinylestradiol/drospirenone combination in patients with the polycystic ovary syndrome. Ther Clin Risk Manag 4(2), 487492.
Mohandas, N Gallagher, PG (2008) Red cell membrane: Past, present, and future. Blood 112(10), 39393948.
Muhn, P, Fuhrmann, U, Fritzemeier, KH, Krattenmacher, R Schillinger, E (1995) Drospirenone: A novel progestogen with antimineralocorticoid and antiandrogenic activity. Ann N Y Acad Sci 761(1), 311335.
Nans, A, Mohandas, N Stokes, DL (2011) Native ultrastructure of the red cell cytoskeleton by cryo-electron tomography. Biophys J 101(10), 23412350.
Norris, LA (2003) Blood coagulation. Best Pract Res Clin Obstet Gynaecol 17(3), 369383.
Pearce, HM, Layton, D, Wilton, LV Shakir, SA (2005) Deep vein thrombosis and pulmonary embolism reported in the Prescription Event Monitoring Study of Yasmin®. Br J Clin Pharmacol 60(1), 98102.
Pérez-López, FR (2008) Clinical experiences with drospirenone: From reproductive to postmenopausal years. Maturitas 60(2), 7891.
Pretorius, E, du Plooy, JN Bester, J (2016) A comprehensive review on eryptosis. Cell Physiol Biochem 39(5), 19772000.
Pretorius, E Kell, DB (2014) Diagnostic morphology: Biophysical indicators for iron-driven inflammatory diseases. Integr Biol 6(5), 486510.
Reid, R (2009) Oral contraceptives and venous thromboembolism, consensus opinion from an international workshop held in Berlin, Germany. December.
Seeger, JD, Loughlin, J, Eng, PM, Clifford, CR, Cutone, J Walker, AM (2007) Risk of thromboembolism in women taking ethinylestradiol/drospirenone and other oral contraceptives. Obstet Gynecol 110(3), 587593.
Sheldon, T (2002) Dutch GPs warned against new contraceptive pill. BMJ 324(7342), 869.
Shin, S, Ku, Y, Babu, N Singh, M (2007) Erythrocyte deformability and its variation in diabetes mellitus. Indian J Exp Biol 45(1), 121–128.
Shulman, LP (2002) Safety and efficacy of a new oral contraceptive containing drospirenone. J Reprod Med 47(11 Suppl), 981984.
Sitruk-Ware, R (2005) Pharmacology of different progestogens: The special case of drospirenone. Climacteric 8(Suppl 3), 412.
Sitruk-Ware, R Nath, A (2011) Metabolic effects of contraceptive steroids. Rev Endocr Metab Disord 12(2), 63.
Stegeman, BHB (2013) Hormonal contraceptives and venous thrombosis. Department of Thrombosis and Hemostasis, Faculty of Medicine, Leiden University Library (LUMC), Leiden University, Leiden, Netherlands.
Stocco, B, Fumagalli, HF, Franceschini, SA, Martinez, EZ, Marzocchi-Machado, CM, de Sá, M Toloi, M (2015 a) Comparative study of the effects of combined oral contraceptives in hemostatic variables: An observational preliminary study. Medicine 94(4), e385e385.
Straat, M, van Bruggen, R, de Korte, D Juffermans, NP (2012) Red blood cell clearance in inflammation. Transfus Med Hemother 39(5), 353360.
Strowitzki, T, Kirsch, B Elliesen, J (2012) Efficacy of ethinylestradiol 20 µg/drospirenone 3 mg in a flexible extended regimen in women with moderate-to-severe primary dysmenorrhoea: An open-label, multicentre, randomised, controlled study. J Fam Plann Reprod Health Care 38(2), 94101.
Subramanian, S, Matejuk, A, Zamora, A, Vandenbark, AA Offner, H (2003) Oral feeding with ethinyl estradiol suppresses and treats experimental autoimmune encephalomyelitis in SJL mice and inhibits the recruitment of inflammatory cells into the central nervous system. J Immunol 170(3), 15481555.
Swanepoel, AC, Emmerson, O Pretorius, E (2017 a) The effect of endogenous and synthetic estrogens on whole blood clot formation and erythrocyte structure. Microsc Microanal 23(3), 599606.
Swanepoel, AC, Emmerson, O Pretorius, E (2017 b) Effect of progesterone and synthetic progestins on whole blood clot formation and erythrocyte structure. Microsc Microanal 23(3), 607617.
Swanepoel, AC, Nielsen, VG Pretorius, E (2015) Viscoelasticity and ultrastructure in coagulation and inflammation: Two diverse techniques, one conclusion. Inflammation 38(4), 17071726.
Swanepoel, AC, Visagie, A, de Lange, Z, Emmerson, O, Nielsen, VG Pretorius, E (2016 a) The clinical relevance of altered fibrinogen packaging in the presence of 17β-estradiol and progesterone. Thromb Res 146, 2334.
Swanepoel, AC, Visagie, A Pretorius, E (2016b) Synthetic hormones and clot formation. Microsc Microanal 22(4), 878886.
Trenor, CC, Chung, RJ, Michelson, AD, Neufeld, EJ, Gordon, CM, Laufer, MR Emans, SJ (2011) Hormonal contraception and thrombotic risk: A multidisciplinary approach. Pediatrics 127(2), 347357.
US Food and Drug Administration (2015) FDA monograph on physician labelling for Yasmin 28 tablets (drospirenone and ethinyl estradiol). Physician labelling.
VARGA‐SZABO, D, Braun, A Nieswandt, B (2009) Calcium signaling in platelets. J Thromb Haemost 7(7), 10571066.
Wagner, DD Burger, PC (2003) Platelets in inflammation and thrombosis. Arterioscler Thromb Vas Biol 23(12), 21312137.
Wang, Q-Y, Song, Y, Huang, W, Xiao, L, Wang, Q-S Feng, G-M (2016) Comparison of drospirenone-with cyproterone acetate-containing oral contraceptives, combined with metformin and lifestyle modifications in women with polycystic ovary syndrome and metabolic disorders: A prospective randomized control trial. Chin Med J 129(8), 883.
Wiegratz, I, Elliesen, J, Paoletti, AM, Walzer, A Kirsch, B (2015) Adherence with ethinylestradiol 20 μg/drospirenone 3 mg in a flexible extended regimen supported by the use of a digital tablet dispenser with or without acoustic alarm: an open-label, randomized, multicenter study. Int J Womens Health 7, 19.
Wiegratz, I Thaler, CJ (2011) Hormonal contraception—what kind, when, and for whom? Dtsch Ärztebl Int 108(28–29), 495506.
Willis, SA, Kuehl, TJ, Spiekerman, AM Sulak, PJ (2006) Greater inhibition of the pituitary–ovarian axis in oral contraceptive regimens with a shortened hormone-free interval. Contraception 74(2), 100103.
Wolberg, AS, Monroe, DM, Roberts, HR Hoffman, M (2003) Elevated prothrombin results in clots with an altered fiber structure: A possible mechanism of the increased thrombotic risk. Blood 101(8), 30083013.
Yamamoto, J, Inoue, N, Otsui, K, Ishii, H Gorog, D (2014) Global thrombosis test (GTT) can detect major determinants of haemostasis including platelet reactivity, endogenous fibrinolytic and thrombin generating potential. Thromb Res 133(5), 919926.
Yamamoto, J, Yamashita, T, Ikarugi, H, Taka, T, Hashimoto, M, Ishii, H, Watanabe, S Kovacs, IB (2003) Görög thrombosis test: a global in-vitro test of platelet function and thrombolysis. Blood Coagul Fibrinolysis 14(1), 3139.



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed