Differential effects of E and droloxifene on C-reactive protein and other markers of inflammation in healthy postmenopausal women

Hormone Replacement Therapy and Psoriasis Risk: A Nationwide Population-Based Cohort Study

BACKGROUND

Hormone replacement therapy (HRT) is used to relieve menopause symptoms, but has been reported to be associated with coronary heart disease and cancers in women. However, a link between HRT and psoriasis has yet to be established. The aim of this study was to determine the association between HRT and the risk of psoriasis.

METHODS

We executed a nationwide population-based study. A total of 1,130,741 post-menopause women were enrolled in the national health care insurance database based on the enrollment criteria. The study population was classified into four groups based on the duration of the HRT, and the risk of psoriasis was analyzed.

RESULTS

The incidence rates of psoriasis per 1,000 person-years were 3.36 and 4.09 in the no history of HRT and ≥ 5 years of HRT, respectively. After adjustment for age, smoking, alcohol intake, regular exercise, body mass index, diabetes mellitus, hypertension, and dyslipidemia, the most prolonged duration of the HRT group (≥ 5 years) exhibited significantly increased risk of developing psoriasis (hazard ratio, 1.22; 95% confidence interval, 1.16-1.29).

CONCLUSION

We propose that HRT in post-menopausal women is associated with an increased likelihood of psoriasis development.

Commercial Hormone Replacement Therapy Jeopardized Proinflammatory Factors in Experimental Rat Models

BACKGROUND: Hormonal contraceptive therapy is considered the easiest and most convenient contraceptive method. Commercially, available contraceptive combination differs in their composition and concentration of combined constituents. These variations make some of these products preferred over others by consumers based on their side effects profile. AIM: The objective of the current research was to ascertain the proinflammatory influences of commercially available products. METHODS: To do so, five groups of rats (ten rats in each group) were exposed to Microgynon, Depo-Provera, marvel on, and Yasmin compared to the control non-treated group. We measured proinflammatory markers including d-dimer, TNF-α (tumor necrosis factor-alpha), IL (interleukin)-6, IL (interleukin)-1B, and c-reactive protein. RESULTS: The results confirmed that Yasmin has induced the most deleterious effects on proinflammatory markers indicated by significant elevation of IL1B. CONCLUSION: Hormone replacement therapy should be critically indicated and precautions raised inpatient with subclinical diseases, especially cardiovascular ones.

The role of sex hormones in induced-systemic inflammation in female albino rats

Estrogen (E(2)) and progesterone (P) hormones have a pro-inflammatory and an anti-inflammatory role under different conditions. The current study explored this phenomenon in the context of septic inflammation.

MATERIALS AND METHODS

This study involved 48 female albino rats. E(2) (4 mg/100 g body weight (b.w.) and P (5 mg/kg b.w.) were administered to ovariectomized (OVX) rats after systemic inflammation (SI) induced by puncturing the caecum I cm from its end with a single hole by using a 21-gauge needle. Key indices of inflammation and apoptosis were evaluated.

RESULTS

OVX animals subjected to SI showed significantly increased levels of serum tumor necrosis factor-alpha (TNF-u), C reactive protein (CRP) and alanine aminotransferase (ALT). They also showed higher levels of expression of the enzyme inducible nitric oxide synthase (iN OS); 312 ± 43 mg/ml; in the liver, and the activity of both cyclooxygenase 2 (COX-2); 59.4 ± 3.2 U/ml; and caspase 3 enzymes; 6.3 ± 0.54 ng/ml; when compared to non-OVX animals subjected to (SI), (180 ± 3 mg/ml, 16.4 ± 1.69 U/ml, 0.98 ± 0.23 ng/ml respectively). Administration of E(2) resulted in a significant reduction of all serum and liver tissue parameters of inflammation (e.g.decreased iNOS; 193 ± 28 mg/ml and COX-2; 27.6 ± 3.91 U/ml) and decreased apoptosis (Caspase 3; 1.18 ± 0.21 ng/ml). In contrast, OVX animals injected with P before induction of SI showed a significant rise of all measured parameters.

CONCLUSIONS

E(2) and Pin physiological levels have contrasting though complementary roles in regulation of the immune system possibly allowing a limited inflammatory response while preventing excessive damage to the tissues.

Effects of raloxifene on serum macrophage colony-stimulating factor and interleukin-18 levels in postmenopausal women younger than 60 years

OBJECTIVE

Macrophage colony-stimulating factor (M-CSF) and interleukin-18 (IL-18) are cytokines expressed predominantly in atheromatous plaque, and overproduction of these has been found to be associated with coronary artery disease. The aim of this study was to investigate the effect of raloxifene, a selective estrogen receptor modulator, on serum M-CSF and IL-18 levels, cytokines that are presumably involved in the pathogenesis of atherosclerosis.

METHODS

A total of 70 postmenopausal women (age, 56.45 ± 1.52 y) without previously confirmed cardiovascular disease were enrolled in a 6-month prospective, randomized, controlled study. Women were randomly assigned to two groups: 35 women received oral administration of 60 mg/day raloxifene for 6 months and 35 were in the control group and received no medications. Serum lipid concentrations and high-sensitivity C-reactive protein (hs-CRP), M-CSF, and IL-18 levels were measured at baseline and at the sixth month in both groups.

RESULTS

Compared with the control group, the raloxifene group had a significant decrease in serum IL-18 concentrations and a 25.29% reduction in serum hs-CRP concentrations. M-CSF levels were reduced by 5.94% in the raloxifene group, but the difference was not statistically significant. At the sixth month, 60 mg/day of raloxifene significantly decreased the median serum total cholesterol and low-density lipoprotein cholesterol levels when compared with the baseline levels.

CONCLUSIONS

Raloxifene reduces serum total cholesterol, low-density lipoprotein cholesterol, hs-CRP, and IL-18 levels. According to the results of our study, it is suggested that raloxifene may have a favorable effect on the prevention of cardiovascular disease in healthy postmenopausal women younger than 60 years.

Effects of long-term hormone replacement therapy: results from a cohort study

The positive effects of hormonal replacement therapy (HRT) in protecting the cardiovascular system in women have been supported by several observational studies, while also being questioned by other randomized controlled trials. Today, it is unclear whether HRT plays a crucial role, or even whether there is any role at all, for this therapy in preventing or in lowering cardiovascular disease (CVD). In the present study, we have evaluated the effectiveness of long-term HRT in post-menopausal women on the incidence of cardiovascular events and arterial remodeling, as well as on some metabolic factors. Eighty-four post-menopausal women (mean age: 46.3 ± 5.2; age range: 42-66 yr) underwent HRT for 10.9 ± 1.2 yr (range: 8-12 yr). None of these subjects showed new cardiovascular events, and we found a reduction of the intima-media thickness (baseline: 1.39 ± 0.2, 1.35 ± 0.2, 1.31 ± 0.2 mm) and total cholesterol, LDL and antithrombin III levels were lower, while HDL and fibrinogen levels increased. The study highlights a number of positive effects both on vascular conditions and metabolic and coagulative markers that are usually considered as generic and crucial risk factors for CVD. The relatively low number of patients is perhaps a limitation of this study, however, the long-term period of followup should be considered an interesting and important factor. Furthermore, this study underlines the real-life clinical experience of a Menopause Center.

Atherosclerosis and sex hormones: current concepts

CVD (cardiovascular disease) is the leading cause of death for women. Considerable progress has been made in both our understanding of the complexities governing menopausal hormone therapy and our understanding of the cellular and molecular mechanisms underlying hormone and hormone receptor function. Understanding the interplay of atherosclerosis and sex steroid hormones and their cognate receptors at the level of the vessel wall has important ramifications for clinical practice. In the present review, we discuss the epidemiology of CVD in men and women, the clinical impact of sex hormones on CVD, and summarize our current understanding of the pathogenesis of atherosclerosis with a focus on gender differences in CVD, its clinical presentation and course, and pathobiology. The critical animal and human data that pertain to the role of oestrogens, androgens and progestins on the vessel wall is also reviewed, with particular attention to the actions of sex hormones on each of the three key cell types involved in atherogenesis: the endothelium, smooth muscle cells and macrophages. Where relevant, the systemic (metabolic) effects of sex hormones that influence atherogenesis, such as those involving vascular reactivity, inflammation and lipoprotein metabolism, are discussed. In addition, four key current concepts in the field are explored: (i) total hormone exposure time and coronary heart disease risk; (ii) the importance of tissue specificity of sex steroid hormones, critical timing and the stage of atherosclerosis in hormone action; (iii) biomarkers for atherosclerosis with regard to hormone therapy; and (iv) the complex role of sex steroids in inflammation. Future studies in this field will contribute to guiding clinical treatment recommendations for women and help define research priorities.

Effects of hormone therapyon C-reactive protein and IL-6 in postmenopausal women: a review article

The results of the Women's Health Initiative, showing an increase in coronary heart disease events in postmenopausal women on estrogen and medroxyprogesterone acetate, have created considerable interest in finding an underlying mechanism that may confer cardiovascular risk in women on hormone therapy (HT). Inflammation is thought to play a key role in the progression of atherosclerosis. C-reactive protein (CRP) is an inflammatory marker that has been studied as a predictor of future coronary risk. Interleukin 6 (IL-6) is felt to be an important cytokine in the inflammatory cascade and instrumental in CRP expression. The purpose of this article is to summarize the observational and randomized studies that examine the difference in IL-6 and CRP concentrations with respect to oral versus transdermal hormone therapy. We also review studies looking at differences in CRP levels based on the progestin component of HT and trials examining the effect of estrogen agonists on IL-6 and CRP. In our review, we found CRP levels to be elevated in the majority of postmenopausal women on oral HT. There was no correlation between IL-6 and CRP levels. Studies examining the effect of progestins produced varying results. Transdermal estrogen, in contrast, showed no elevation in levels of IL-6 or CRP alone or with the addition of progestins. Selective estrogen receptor agonists (SERMs) did not demonstrate an effect on CRP levels, although tibolone did increase CRP in one reviewed trial. Questions remain about the role of progestins and transdermal HT therapy in the inflammatory process and the underlying mechanism of CRP activation. More research is needed to understand how HT may be involved in the inflammatory process.

Effects of estrogen versus estrogen and progesterone on cortisol and interleukin-6

OBJECTIVES

The purpose of this study was to compare the effects of 3 months of estrogen replacement therapy, estrogen plus progesterone replacement therapy and a placebo, on the resting cortisol and interleukin-6 (IL-6) levels in post-menopausal women.

METHODS

Forty-three women were randomised to one of three treatment arms: estradiol 2mg/day (ERT), estradiol 2mg/day plus medroxyprogesterone acetate 5mg/day (HRT), or a placebo that was administered orally for 3 months.

RESULTS

Cortisol levels showed a significant condition by intervention interaction. Post hoc tests showed that ERT significantly increased cortisol levels after treatment compared to baseline, while in the HRT group a trend toward increased cortisol was found. No changes were observed in IL-6 levels.

CONCLUSIONS

Estrogen administration elevated cortisol levels, but this effect may be moderated by progestins. IL-6 was not altered by ERT or HRT, future studies should consider the interaction of cortisol increases on change in IL-6 expression.

Effects of hormone therapy on soluble cell adhesion molecules in postmenopausal women with coronary artery disease

OBJECTIVE

Although observational studies showed an apparent lower ischemic coronary disease risk in postmenopausal women receiving hormone therapy (HT), randomized clinical trials in postmenopausal women showed an increase in ischemic cardiovascular events. Soluble cell adhesion molecules have been associated with cardiovascular risk factors and events. HT reduces circulating levels of soluble cell adhesion molecules in healthy postmenopausal women, but its effects in postmenopausal women with coronary artery disease are less clear. We assessed the effect of HT on soluble cell adhesion molecules in the Estrogen Replacement and Atherosclerosis trial.

DESIGN

The Estrogen Replacement and Atherosclerosis trial was a double-blind, placebo-controlled study that randomized 309 postmenopausal women (mean age, 65.8 y) to daily unopposed estrogen (conjugated estrogens 0.625 mg), estrogen plus 2.5 mg of medroxyprogesterone acetate, or placebo, with a mean follow-up period of 3.2 years. Soluble intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and E-selectin were measured in serum obtained from participants at baseline and after 12 months of follow-up.

RESULTS

Of the 265 women with complete data, 87 women were assigned to unopposed estrogen, 88 women to estrogen plus medroxyprogesterone acetate, and 90 women to placebo. Compared with placebo, 12 months of HT (n = 175) was associated with reductions in soluble intercellular adhesion molecule-1 (25.6 +/- 4.7 vs 10.6 +/- 6.4 ng/mL, P = 0.06), soluble vascular cell adhesion molecule-1 (80.2+/- 10.6 vs 28.8 +/- 14.7 ng/mL, P = 0.005), and E-selectin (8.8 +/- 0.9 vs -1.1 +/- 1.2 ng/mL, P < 0.001).

CONCLUSIONS

Twelve months of HT in postmenopausal women with established coronary artery disease was associated with reductions in serum markers of endothelial cell activation/injury such as soluble intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and E-selectin.

Epidemiology of cytokines: the Women On the Move through Activity and Nutrition (WOMAN) Study

Using multiplex technology, the authors investigated the laboratory and biologic variation of a panel of cytokines (interleukin (IL)-1a, IL-1 receptor antagonist, IL-4, IL-6, IL-8, IL-10, interferon-inducible protein-10, monocyte chemoattractant protein-1, and tumor necrosis factor-alpha) over 18 months and their relations to cardiovascular disease risk factors, hormone therapy, and weight loss. Data were obtained from the Woman On the Move through Activity and Nutrition (WOMAN) Study, a randomized clinical trial investigating the effect of nonpharmacologic interventions on subclinical atherosclerosis among overweight, postmenopausal women in Pennsylvania. The present analysis (February 2002-August 2005) comprised 290 women aged 52-62 years (mean age = 57 years). Most of the cytokines were detectable in a majority of the samples, and the between-individual biologic variation was greater than the within-individual biologic and laboratory variation. There was little association between use of hormone therapy at baseline or change in hormone therapy by 18 months and cytokine levels. Weight loss was associated with a decrease in levels of IL-1 receptor antagonist, IL-6, and C-reactive protein. The results suggest that a wide panel of cytokines may be measured simultaneously from one sample. There is large unexplained variability in cytokine levels that is probably due to genetic-environmental associations.

Selective estrogen receptor modulators: an update on recent clinical findings

Recent clinical data on selective estrogen receptor modulators (SERMs) have provided the basis for reassessment of the SERM concept. The molecular basis of SERM activity involves binding of the ligand SERM to the estrogen receptor (ER), causing conformational changes which facilitate interactions with coactivator or corepressor proteins, and subsequently initiate or suppress transcription of target genes. SERM activity is intrinsic to each ER ligand, which accomplishes its unique profile by specific interactions in the target cell, leading to tissue selective actions. We discuss the estrogenic and anti-estrogenic effects of early SERMs, such as clomiphene citrate, used for treatment of ovulation induction, and the triphenylethylene, tamoxifen, which has ER antagonist activity in the breast, and is used for prevention and treatment of ER-positive breast cancer. Since the development of tamoxifen, other triphenylethylene SERMs have been studied for breast cancer prevention, including droloxifene, idoxifene, toremifene, and ospemifene. Other SERMs have entered clinical development more recently, including benzothiophenes (raloxifene and arzoxifene), benzopyrans (ormeloxifene, levormeloxifene, and EM-800), lasofoxifene, pipendoxifene, bazedoxifene, HMR-3339, and fulvestrant, an anti-estrogen which is approved for breast cancer treatment. SERMs have effects on tissues containing ER, such as the breast, bone, uterine and genitourinary tissues, and brain, and on markers of cardiovascular risk. Current evidence indicates that each SERM has a unique array of clinical activities. Differences in the patterns of action of SERMs suggest that each clinical end point must be evaluated individually, and conclusions about any particular SERM can only be established through appropriate clinical trials.

The complex role of estrogens in inflammation

There is still an unresolved paradox with respect to the immunomodulating role of estrogens. On one side, we recognize inhibition of bone resorption and suppression of inflammation in several animal models of chronic inflammatory diseases. On the other hand, we realize the immunosupportive role of estrogens in trauma/sepsis and the proinflammatory effects in some chronic autoimmune diseases in humans. This review examines possible causes for this paradox. This review delineates how the effects of estrogens are dependent on criteria such as: 1) the immune stimulus (foreign antigens or autoantigens) and subsequent antigen-specific immune responses (e.g., T cell inhibited by estrogens vs. activation of B cell); 2) the cell types involved during different phases of the disease; 3) the target organ with its specific microenvironment; 4) timing of 17beta-estradiol administration in relation to the disease course (and the reproductive status of a woman); 5) the concentration of estrogens; 6) the variability in expression of estrogen receptor alpha and beta depending on the microenvironment and the cell type; and 7) intracellular metabolism of estrogens leading to important biologically active metabolites with quite different anti- and proinflammatory function. Also mentioned are systemic supersystems such as the hypothalamic-pituitary-adrenal axis, the sensory nervous system, and the sympathetic nervous system and how they are influenced by estrogens. This review reinforces the concept that estrogens have antiinflammatory but also proinflammatory roles depending on above-mentioned criteria. It also explains that a uniform concept as to the action of estrogens cannot be found for all inflammatory diseases due to the enormous variable responses of immune and repair systems.

Selective estrogen receptor modulators and risk for coronary heart disease

Coronary heart disease (CHD) is the leading cause of death in women in most countries. Atherosclerosis is the main biological process determining CHD. Clinical data support the notion that CHD is sensitive to estrogens, but debate exists concerning the effects of the hormone on atherosclerosis and its complications. Selective estrogen receptor modulators (SERMs) are compounds capable of binding the estrogen receptor to induce a functional profile distinct from estrogens. The possibility that SERMs may shift the estrogenic balance on cardiovascular risk towards a more beneficial profile has generated interest in recent years. There is considerable information on the effects of SERMs on distinct areas that are crucial in atherogenesis. The complexity derived from the diversity of variables affecting their mechanism of action plus the differences between compounds make it difficult to delineate one uniform trend for SERMs. The present picture, nonetheless, is one where SERMs seem less powerful than estrogens in atherosclerosis protection, but more gentle with advanced forms of the disease. The recent publication of the Raloxifene Use for The Heart (RUTH) study has confirmed a neutral effect for raloxifene. Prothrombotic states may favor occlusive thrombi at sites occupied by atheromatous plaques. Platelet activation has received attention as an important determinant of arterial thrombogenesis. Although still sparse, available evidence globally suggests neutral or beneficial effects for SERMs.

Critical appraisal of C-reactive protein throughout the spectrum of cardiovascular disease

Clinicians involved in the care of patients with cardiovascular conditions have recently been confronted with an important body of literature linking inflammation and cardiovascular disease. Indeed, the level of systemic inflammation as measured by circulating levels of C-reactive protein (CRP) has been linked to prognosis in patients with atherosclerotic disease, congestive heart failure, atrial fibrillation, myocarditis, aortic valve disease and heart transplantation. In addition, a number of basic science reports suggest an active role for CRP in the pathophysiology of cardiovascular diseases. This article explores the potential role of CRP in disease initiation, progression, and clinical manifestations and reviews its role in the prediction of future events in clinical practice. Therapeutic interventions to decrease circulating levels of CRP are also reviewed.

Effects of low-dose continuous combined hormone replacement therapy on glucose homeostasis and markers of cardiovascular risk in women with type 2 diabetes

BACKGROUND

Low-dose hormone replacement therapy (HRT) has attracted interest for the treatment of postmenopausal symptoms in diabetes because of concerns about increased risk of coronary heart disease (CHD) and stroke with conventional HRT containing conjugated equine oestrogens (CEEs) and medroxyprogesterone acetate (MPA).

OBJECTIVES

We assessed the effects on glucose homeostasis and cardiovascular risk factors of continuous oral 17beta oestradiol (1 mg) and norethisterone (0.5 mg) in postmenopausal women with type 2 diabetes.

DESIGN

Double-blind, randomized placebo-controlled trial.

ASSESSMENTS

Hyperinsulinaemic isoglycaemic clamp and cardiovascular risk factors were assessed before and after 3 months of treatment.

RESULTS

Twenty-eight women completed the study. HRT decreased fasting glucose compared with placebo [-9.4% with HRT vs.+2.3% for placebo, 95% confidence interval (CI) -23.2 to -0.3] and total cholesterol (-13.7 vs.+1.0%, 95% CI -22.4 to -3.1%) No significant effect was seen on metabolic clearance rate of glucose, glycated haemoglobin (HbA1c), triglycerides, high density lipoprotein (HDL)-cholesterol or C-reactive protein (CRP).

CONCLUSIONS

In women with type 2 diabetes, low-dose HRT decreased fasting glucose and total cholesterol without detectable adverse effects on glucose clearance, triglycerides and CRP as reported with conventional HRT.

Progestins affect mechanism of estrogen-induced C-reactive protein stimulation

PURPOSE

To determine whether the mechanisms of C-reactive protein production differ depending on the presence or absence of a progestin in the regimen.

SUBJECTS AND METHODS

We examined data from the Postmenopausal Estrogen Progestin Intervention (PEPI) study, a 5-group (3 different combined estrogen-progestin regimens, conjugated equine estrogen-only, and placebo) randomized clinical trial. This substudy included 221 postmenopausal women assigned to active treatment groups who took at least 80% of pills and had stored plasma specimens available to assess 12-month changes in estrone, sex hormone binding globulin, interleukin (IL)-6, and C-reactive protein levels.

RESULTS

All treatments resulted in increases in estrone, sex hormone binding globulin, and C-reactive protein at 12 months compared with baseline values. In all progestin-containing groups, 12-month change in IL-6 was positively correlated with 12-month change in C-reactive protein (r between 0.34 and 0.65, each P <.010). By contrast, in the conjugated equine estrogen-only group, 12-month change in IL-6 was negatively correlated with 12-month change in C-reactive protein (r value -0.31, P = .055). In adjusted models predicting 12-month C-reactive protein change, an interaction between change in IL-6 and treatment group was highly significant (P=.0008-P <.0001) for each of the progestin-containing groups compared with the conjugated equine estrogen-only group. In the conjugated equine estrogen-only group, the change in C-reactive protein per unit increase in IL-6 was -0.88, whereas in the progestin-containing groups it ranged from 1.46 to 2.85 (P <.0001 for each comparison with conjugated equine estrogen-only).

CONCLUSION

Progestins in combination with conjugated equine estrogen potentiate the IL-6 (inflammatory)-mediated stimulation of C-reactive protein. These findings support the hypothesis that progestins plus estrogen, not estrogen alone, generate C-reactive protein through an inflammatory mechanism.

Emerging Selective Estrogen Receptor Modulators

Menopause, regardless of age at onset, is associated with a marked increase in coronary heart disease (CHD) risk. On the basis of epidemiological studies that demonstrated mainly positive effects of postmenopausal hormone therapy on CHD as well as on risk markers of CHD, it has been suggested that CHD could be prevented in postmenopausal women with long-term hormone therapy. However, since the publications of the Heart and Estrogen/progestin Replacement Study and the Women's Health Initiative trial, prescription of hormone therapy for the prevention of CHD has become controversial. Major efforts have been made to identify alternatives for hormone therapy. Compounds suggested have included selective estrogen receptor modulators (SERMs), which represent a class with a growing number of compounds that act as either estrogen receptor agonists or antagonists in a tissue-specific manner. This pharmacological profile may offer the opportunity to dissociate favourable estrogenic effects on the bone and cardiovascular system from unfavourable stimulatory effects on the breast and endometrium. Two SERMs presently on the market are tamoxifen and raloxifene. The only data available regarding the effects of tamoxifen on cardiovascular events in postmenopausal women are from breast cancer trials. These trials found fewer fatal myocardial events in women randomly assigned to tamoxifen compared with women assigned to placebo. Raloxifene is a second-generation SERM that has been shown to prevent osteoporotic fractures, is safe for the endometrium and holds high promise for the prevention of breast cancer. The effect of raloxifene on CHD is still uncertain. On the basis of the MORE (Multiple Outcomes of Raloxifene Evaluation) trial, raloxifene may offer some protection to women with CHD or to those who are at high risk of CHD. Proof that raloxifene reduces the risk of CHD requires a clinical trial with hard clinical endpoints. Such a study is currently underway. Next-generation SERMs taken into clinical development include idoxifene, droloxifene, ospemifene, arzoxifene, acolbifene/EM-800, levormeloxifene, lasofoxifene, bazedoxifene and HMR 3339. The aim is to find a compound with the ideal profile, that is, alleviation of climacteric symptoms and prevention of osteoporotic fractures, but without an adverse effect on the breast and endometrium, and no negative effect or even a beneficial effect on the cardiovascular system and the brain. Currently, limited data are available with regard to these next-generation SERMs and CHD. Nevertheless, some of these novel agents provide arguments for continuing the search for an ideal SERM.

Association of Endogenous Hormones with C-reactive Protein, Fibrinogen, and White Blood Count in Post-menopausal Women

Oral exogenous estrogen raises C-reactive protein (CRP) concentrations, but the impact of endogenous hormones is unknown. We examined the cross-sectional relation of several serum hormones with CRP, fibrinogen, and white blood cell count - three inflammatory markers linked prospectively to coronary artery disease. Serum hormones were measured on a sample (n = 317) of postmenopausal female participants, with or without carotid intima-media thickening, in the Atherosclerosis Risk in Communities (ARIC) Study. Fibrinogen and white blood cell count were available on all and CRP in a subset (n = 57). Adjusted for age, race, and case-control status, mean CRP was 2-fold greater in the highest vs. lowest quartiles of estrone and androstenedione, and CRP was 2-fold less across quartiles of sex hormone binding globulin. These associations were not all statistically significant with this sample size. Fibrinogen and white blood cell count also were associated positively with estrone, androstenedione, and testosterone (and fibrinogen also with dehydroepiandrosterone sulfate). Adjustment for other risk factors and especially body mass index, a known determinant of endogenous hormone levels, attenuated most associations. In conclusion, several endogenous sex hormones may influence basal levels of inflammatory markers. Obesity appears to play a modulating role.

Effects of soy isoflavones and conjugated equine estrogens on inflammatory markers in atherosclerotic, ovariectomized monkeys

The effects of dietary soy isoflavones (IF) and conjugated equine estrogens (CEE) on circulating inflammatory markers were determined at the end of a 3-yr study of ovariectomized monkeys consuming a moderately atherogenic diet. Treatments were: 1) control, receiving alcohol-extracted soy-protein-based diet with low IF content (comparable to approximately 5 mg/d); 2) CEE, added to the control diet at a dose comparable to 0.625 mg/d; and 3) IF, consumed as a part of unextracted soy protein isolate at a dose comparable to 129 mg/d. Serum soluble vascular cell adhesion molecule-1 (sVCAM-1) was reduced by both IF (P < 0.006) and CEE (P < 0.0001) relative to controls. Serum monocyte chemoattractant protein (MCP)-1 was reduced by CEE (P < 0.0001) but not by IF (P = 1.00). Treatments did not affect serum IL-6 (P = 0.40), soluble E-selectin (P = 0.17), or C-reactive protein (P = 0.15). Serum MCP-1 and, to a lesser extent, IL-6 significantly correlated with atherosclerosis (plaque area) in the iliac and carotid arteries (all P < 0.05). Serum MCP-1 was also strongly associated with coronary artery atherosclerosis and with indices of plaque inflammation and matrix remodeling (matrix metalloproteinase-9) in the coronary artery intima (all P < 0.01). We conclude that, in this well-established nonhuman primate model of atherosclerosis, this dose of soy IF provided an antiinflammatory effect specific for sVCAM-1, whereas the effects of CEE extended to both sVCAM-1 and MCP1. It is possible that the atheroprotective effects of IF and CEE are mediated, at least in part, by effects on VCAM-1. The sites of IF inhibitory effects on sVCAM-1 production are not known, but likely candidates include the liver and/or the cardiovascular system.

Estrogen replacement raises rat CRP without evidence of complement activation

Given current controversies regarding anti- and pro-inflammatory effects of estrogen, there is a need to explore relationships between gonadal hormones and inflammation using appropriate animal models. It has been proposed that rats are not appropriate for such research since, contrary to the effect of estrogen in humans, earlier animal studies had reported that estrogen downregulates serum C-reactive protein (rCRP) levels in the rat. With these considerations in mind, we re-examined the effects of estrogen withdrawal and replacement on CRP expression and complement activation in the rat. F-344 rats underwent bilateral ovariectomy or sham surgery at 9-10 months of age. Four months later, ovariectomized rats were treated with traditional high-dose 17beta-estradiol (Hi-E2) capsules, lower-dose (Lo-E2) 17beta-estradiol capsules, or placebo capsules for 7 days prior to sacrifice. Levels of plasma rat C-reactive protein (rCRP) were significantly lower in ovariectomized vs. sham-operated animals (415.5 +/- 10.6 vs. 626.6 +/- 23.0 mg/L, p < 0.001). Estrogen replacement significantly raised rCRP levels in ovariectomized animals (690.0 +/- 28.0 mg/L in Lo-E2 and 735.5 +/- 35.8 mg/L in Hi-E2, respectively, p < 0.001). Plasma rCRP levels correlated significantly with both hepatic rCRP (r = 0.79, p < 0.001) and serum estradiol (r = 0.70, p < 0.001) levels. However, no significant differences were observed in indices of complement activation (C4b/c) or CRP-complement complex generation (rCRP-C3 complex). In the mature female rat, ovariectomy reduces and estrogen replacement raises rCRP. Effects of estrogen on plasma rCRP induction are mediated, at least in part, through hepatic mechanisms and do not appear to require or be associated with complement activation.

Should Progestins Be Blamed for the Failure of Hormone Replacement Therapy to Reduce Cardiovascular Events in Randomized Controlled Trials?

Many observational studies and experimental and animal studies have demonstrated that estrogen replacement therapy (ERT) or hormone replacement therapy (HRT) (estrogen plus progestin) significantly reduces the risk of coronary heart disease. Nonetheless, recent randomized controlled trials demonstrated some trends toward an increased risk of cardiovascular events rather than a reduction of risk. Recently, both the HRT and ERT arms of the Women’s Health Initiative (WHI) study were terminated early because of an increased/no incidence of invasive breast cancer, increased incidence of stroke, and increased trend/no protective effects of cardiovascular disease. We discuss the controversial effects of HRT and ERT on cardiovascular system and provide a hypothesis that the failure of HRT and ERT in reducing the risk of cardiovascular events in postmenopausal women might be because of the stage of their atherosclerosis at the time of initiation of HRT or ERT.

Tamoxifen improves endothelial function and reduces carotid intima-media thickness in postmenopausal women

BACKGROUND

Tamoxifen is a selective estrogen-receptor modulator shown to improve several cardiovascular risk factors in postmenopausal women with breast cancer. In animal studies tamoxifen inhibits the progression of atherosclerosis. Although the presence of a history with tamoxifen treatment is related to a lower intima-media thickness (IMT) of the common carotid artery, data from controlled follow-up studies are lacking to support this observation.

METHODS

We examined 14 postmenopausal women with early stage breast cancer with indication for tamoxifen treatment (20 mg/d) and 13 healthy postmenopausal women. Flow-mediated dilatation (FMD) of the brachial artery, combined carotid IMT, and aortic pulse wave were measured before and 6 months after treatment in the tamoxifen group and at the same times in the control group.

RESULTS

FMD and IMT were significantly increased and decreased, respectively, in the treatment group compared to the control group (FMD: +2.2% +/- 0.9% vs +0.085% +/- 1%, P =.012; IMT: -0.088 +/- 0.03 mm vs +0.04 +/- 0.03 mm, P =.018, mean +/- standard error of the mean, treatment vs control group). These differences remained significant even when adjusted for age, duration of menopause, and cardiovascular risk factors. Low-density lipoprotein cholesterol was also significantly reduced after tamoxifen treatment.

CONCLUSIONS

Tamoxifen treatment slows the progression of atherosclerosis in postmenopausal women with breast cancer as assessed by changes in carotid IMT. An improvement in endothelial function and blood lipid profile may be the reason for this beneficial effect.

The effect of hormone therapy and raloxifene on serum matrix metalloproteinase-2 and -9 in postmenopausal women

OBJECTIVE

The aim of the study was to investigate the effect of continuous-combined hormone therapy and raloxifene on the total and active forms of serum matrix metalloproteinase (MMP) -2 and -9.

DESIGN

The study was double-blinded, with a placebo run-in period of 28 to 50 days. Twenty-eight women received either 17beta-estradiol 2 mg + norethisterone acetate 1 mg (E2/NETA) or raloxifene HCL 60 mg for a period of 6 months. Total and active forms of MMP-2 and -9 were estimated at baseline and at month 6.

RESULTS

Total MMP-2 increased significantly in both E2/NETA and raloxifene groups (raloxifene baseline: 278.1 +/- 18.1 ng/mL; 6 months: 303.1 +/- 29.9 ng/mL, P = 0.008) (E2/NETA baseline: 281.9 +/- 27.5 ng/mL; 6 months: 298.8 +/- 12.7 ng/mL, P = 0.025). Similarly, both treatments increased the active MMP-2 fraction, although only the raloxifene-associated increase acquired significance (raloxifene baseline: 24.9 +/- 8.6 ng/mL; 6 months: 31.6 +/- 15.3 ng/mL, P = 0.045) (E2/NETA baseline: 21.7 +/- 5.7 ng/mL; 6 months: 27.4 +/- 5.8 ng/mL, P = 0.128). Total as well as active fractions of MMP-9 were not significantly affected by either treatment.

CONCLUSIONS

Both E2/NETA and raloxifene increased the total and active MMP-2 serum levels. MMP-9 was not significantly affected by either regimen. Larger, long-term clinical trials are needed to elucidate the effect of HT and raloxifene on MMPs and the possible clinical implications for cardiovascular health.

Effect of Lower Dosage of Oral Conjugated Equine Estrogen on Inflammatory Markers and Endothelial Function in Healthy Postmenopausal Women

Objective— Although oral estrogen replacement therapy (ERT) in postmenopausal women improves endothelial function, it also increases plasma C-reactive protein (CRP) and interleukin-6 (IL-6) concentration. The proinflammatory effect of oral ERT may explain the increased risk of coronary heart disease (CHD) associated with this treatment. Recent observational studies have demonstrated that a lower dose of oral estrogen reduces the risk for CHD. The purpose of the present study was to investigate the effects of low-dose oral estrogen on vascular inflammatory markers and endothelium-dependent vasodilation in postmenopausal women.

Methods and Results— Postmenopausal women were randomized into 3 groups to receive no treatment (n=14) or oral conjugated equine estrogen (CEE) at a dosage of 0.625 mg (n=15) or 0.3125 mg (n=15) daily for 3 months. CEE at a dosage of 0.625 mg resulted in significant increases in plasma concentrations of CRP from 690.9±749.5 to 1541.9±1608.0 ng/mL, serum amyloid A from 6.12±4.15 to 8.25±4.40 μg/mL, and IL-6 from 1.45±0.73 to 2.35±1.16 pg/mL. In contrast, CEE at a dosage of 0.3125 mg had no effect on these inflammatory markers. Both dosages of estrogen significantly decreased E-selectin concentration, whereas the concentrations of intercellular and vascular cell adhesion molecules remained unchanged. In both CEE groups, flow-mediated vasodilation in the brachial artery was increased significantly, whereas nitroglycerine-induced vasodilation was unaltered.

Conclusions— Oral CEE at a low dose of 0.3125 mg in postmenopausal women eliminated the adverse effects of high-dosage oral CEE on vascular inflammatory markers in addition to preserving the favorable effects of estrogen on cell adhesion molecules and endothelial function.

Effects of conjugated oestrogen and droloxifene on the renin-angiotensin system, blood pressure and renal blood flow in postmenopausal women

OBJECTIVE

The aim of this study was to evaluate the effect of conjugated equine oestrogen (CEE), and droloxifene, a selective oestrogen receptor modulator (SERM) on individual components of renin-angiotensin-aldosterone (RAAS) and blood pressure (BP) in postmenopausal women.

DESIGN AND PATIENTS

Twenty-one normotensive (NT) and 10 hypertensive (HT) postmenopausal women received either CEE (0.625 mg/day) or droloxifene (60 mg/day) for 6 weeks and, after a 4-week washout, were restudied on the alternate medication.

MEASUREMENTS

Hormones of the RAAS and supine BP were measured prior to and at the end of each drug treatment in all subjects. In a subgroup of the NT (n = 10), 24 h ambulatory BP was performed and renal blood flow was determined by PAH clearance both basally and in response to 45-min angiotensin II (Ang II) infusion (3 ng/kg/min).

RESULTS

CEE significantly increased angiotensinogen, decreased active renin and angiotensin-converting enzyme (ACE), and maintained plasma immunoreactive (ir) angiotensin I (Ang I) levels compared to baseline. With droloxifene, angiotensinogen, active renin and Ang I remained unchanged. Both CEE and droloxifene significantly increased plasma ir-Ang II levels (pmol/l) in NT (baseline: 25.7 +/- 2.5, CEE: 36.6 +/- 3.4, droloxifene: 33.3 +/- 3.1, P < 0.002) and HT women (baseline: 17.9 +/- 2.3, CEE: 27.9 +/- 3.2, droloxifene: 25.9 +/- 4.9, P < 0.005). Renal blood flow was lower on CEE (P = 0.02) compared with baseline. Systemic BP (supine and 24-h ambulatory) was unchanged during both treatments.

CONCLUSION

This study demonstrates higher circulating levels of ir-Ang II with CEE and droloxifene.

Effect of simvastatin on serum C-reactive protein during hormone replacement therapy

Because statins seem to attenuate the early, increased cardiovascular hazard induced by hormone replacement therapy (HRT), we treated 16 postmenopausal hypercholesterolemic women with coronary artery disease with combined HRT, simvastatin, and the combination of HRT and simvastatin in a double-blind, crossover, placebo-controlled study; we also evaluated C-reactive protein (CRP) levels at the end of each treatment period. We found that only HRT significantly increased CRP compared with placebo, whereas the combination of HRT with simvastatin did not. We concluded that statins may reduce the inflammatory adverse effects associated with the CRP increase induced by HRT.

Dietary fish oil decreases C-reactive protein, interleukin-6, and triacylglycerol to HDL-cholesterol ratio in postmenopausal women on HRT

BACKGROUND

Atherogenesis is a complex process involving both a low-grade inflammation and a disturbed lipid profile. Although dietary fish and fish oil improve the latter of these two risk factors, their impact on the former is less clear.

OBJECTIVE

This study addressed the effect of supplementation with fish oil in doses achievable with diet on serum C-reactive protein (CRP), interleukin-6 (IL-6), and the lipid profile.

METHODS AND RESULTS

Thirty healthy subjects taking HRT were randomly divided into three groups and supplemented for five weeks with 14 g/day safflower oil (SO), 7 g/day of both safflower oil and fish oil (LFO), or 14 g/day fish oil (HFO). Measurements included serum high-sensitivity CRP, IL-6 in plasma and in cell culture supernatant collected from 24-hr lipopolysaccharide (LPS)-stimulated whole blood, and lipid profile markers. CRP and IL-6 were adjusted for body mass index (BMI). Fish oil supplementation significantly decreased CRP and IL-6 compared to SO, with a greater effect in the LFO than HFO groups. Plasma triacylglycerol (TG) and the TG/HDL-C ratio were significantly lower in the HFO compared to the SO group.

CONCLUSIONS

These results suggest that dietary fish oil may decrease the risk for cardiovascular disease through the modulation of both plasma lipids and inflammatory markers in healthy postmenopausal women.

Preanalytic and analytic sources of variations in C-reactive protein measurement: implications for cardiovascular disease risk assessment

BACKGROUND

C-reactive protein (CRP) is a widely recognized indicator of inflammation and is known to play an important role in atherogenesis. Recent prospective studies have demonstrated that increased CRP concentrations within the reference interval are a strong predictor of myocardial infarction, stroke, sudden cardiac death, and peripheral vascular disease in apparently healthy adults. On the basis of available evidence, the American Heart Association and the CDC have issued guidelines for the utility of CRP in the primary prevention of coronary heart disease and in patients with stable coronary disease or acute coronary syndromes. Nevertheless, there remains considerable work to optimize the utility of this marker for risk assessment.

ISSUES

Most traditional CRP tests designed to monitor acute and chronic inflammation have inadequate sensitivity for risk stratification of coronary disease. Thus, manufacturers have had to develop tests with higher sensitivity. Because an individual's CRP concentration will be interpreted according to fixed cut-points, issues related to the preanalytic and analytic components of CRP measurement must be considered and standardized where possible to avoid potential misclassification of cardiovascular risk.

CONCLUSIONS

Efforts to define performance criteria for high-sensitivity CRP applications coupled with growing awareness of the physiologic aspects of CRP most likely will lead to refinements in standardization, improved performance in quality-assessment schemes, and enhanced risk prediction.

Estrogen increases inducible nitric oxide synthase gene expression

OBJECTIVE

The goal of this study was to determine whether estrogen increases the expression of the inducible nitric oxide synthase gene.

STUDY DESIGN

An inducible nitric oxide synthase fusion gene was created with its promoter and the reporter gene, luciferase. COS cells were transfected transiently with the fusion gene and cotransfected with an estrogen receptor-alpha expression plasmid to ensure the presence of an estrogen receptor. Cells were then exposed to estradiol (1 nmol/L and 10 nmol/L) or a cytokine mix that consisting of tumor necrosis factor-alpha, interleukin-1beta, and interferon gamma. Gene expression was measured in relative light units.

RESULTS

Estradiol increased the expression of inducible nitric oxide synthase by an average of 31.2% in the COS cells that were cotransfected with estrogen receptor compared with -10.4% in cells without estrogen receptor (P =.006).

CONCLUSION

Inducible nitric oxide synthase expression was increased with the addition of estrogen. These data support previous studies that demonstrated the inflammatory effects of estrogen and provides further insight into the mechanism by which estrogen might have an impact on the cardiovascular system.

Postmenopausal hormone replacement therapy and atherosclerosis

The role of postmenopausal hormone replacement therapy (HRT) in the prevention of cardiovascular disease (CVD) has evolved since estrogen was first proposed to be vasoprotective. The discovery of novel molecular signaling pathways involving the estrogen receptor in vascular cells and the elucidation of numerous biologic mechanisms have suggested that HRT may exert its potentially beneficial or adverse cardiovascular effects through multiple mechanisms. Estrogen has genomic, as well as rapid nongenomic, effects that alter vasodilation, coagulation, inflammation, and the vascular injury response, some of which may have potentially beneficial or adverse cardiovascular consequences. Current guidelines do not support the use of HRT in the secondary prevention of CVD, and recent results of primary prevention trials show evidence of increased early cardiovascular risk and no overall health benefit with combination estrogen-progestin treatment. The role of estrogen alone in the primary prevention of CVD awaits the results of ongoing trials. The key to the use of estrogen replacement therapy for the prevention of CVD may be to target therapy before atherosclerosis is evident, and to identify women with genetic susceptibility who may be at increased risk for an adverse outcome associated with therapy.

Common estrogen receptor polymorphism augments effects of hormone replacement therapy on E-selectin but not C-reactive protein

BACKGROUND

The estrogen receptor-alpha (ER-alpha) IVS1-401 polymorphism identifies a group of women (approximately 20%) who have augmented effects of hormone replacement therapy (HRT) on levels of HDL cholesterol. This study sought to determine if this augmentation extends to HRT regulation of E-selectin and C-reactive protein (CRP) and to explore possible mechanisms by which this polymorphism might influence estrogen action.

METHODS AND RESULTS

Serum levels of soluble E-selectin and CRP were measured at baseline and 1 year in 264 postmenopausal women randomized to treatment with oral conjugated equine estrogen (0.625 mg/d), estrogen plus progestin (medroxyprogesterone acetate 2.5 mg/d), or placebo. Women with the ER-alpha IVS1-401 C/C genotype receiving HRT had nearly a 2-fold greater reduction in E-selectin compared with C/T or T/T women (P for interaction=0.02). In contrast, there was no augmentation of the HRT-associated increase in CRP among the C/C women compared with C/T or T/T women (P for interaction=0.54). Of luciferase reporter constructs containing sequences spanning the IVS1-401 T/C polymorphism, expression of the construct containing the C allele was enhanced >10-fold, with cotransfection of a constitutively expressed B-myb vector. In contrast, B-myb resulted in only a 2.5-fold increase in expression of the T allele construct.

CONCLUSIONS

Women with the ER-alpha IVS1-401 C/C genotype have greater reductions in E-selectin but no further increases in CRP with HRT. The C allele produces a functional binding site for the transcription factor B-myb. The impact of this polymorphism on ER-alpha transcription and other estrogen-sensitive intermediate and clinical end points has not yet been established.

Statin attenuates increase in C-reactive protein during estrogen replacement therapy in postmenopausal women

BACKGROUND

HMG-CoA reductase inhibitor (statin) therapy reduces cardiovascular risk, mechanisms of which may include diminished arterial inflammation, as suggested by reduction in levels of C-reactive protein (CRP). Because oral estrogens increase CRP in postmenopausal women, with potential inflammatory and thrombotic consequences that could compromise any benefit to cardiovascular risk, we determined whether the coadministration of a statin might modify the estrogenic effect on CRP.

METHODS AND RESULTS

In a double-blind, 3-period crossover study, 28 postmenopausal women (average LDL cholesterol 163+/-36 mg/dL) were randomly assigned to daily conjugated equine estrogens (CEEs) 0.625 mg, simvastatin 10 mg, or their combination for 6 weeks, with each treatment period separated by 6 weeks. CEEs increased median CRP levels from 0.27 to 0.46 mg/dL, simvastatin decreased CRP from 0.29 to 0.28 mg/dL, and the therapies combined increased CRP from 0.28 to 0.36 mg/dL (all P< or =0.02 versus respective baseline values). Post hoc testing showed that the 29% increase in CRP on the combination of CEEs with simvastatin was significantly less than the 70% increase in CRP on CEEs alone (P<0.05). The effect of combination therapy on CRP levels did not correlate with baseline CRP or with baseline or treatment-induced changes in levels of interleukin-6, lipoproteins, or flow-mediated dilation of the brachial artery as a measure of nitric oxide bioactivity.

CONCLUSIONS

The combination of statin with estrogen may attenuate the potential harmful effects of estrogen therapy in postmenopausal women and maximize any benefit to cardiovascular risk.