Reversal by medical treatment of endometrial hyperplasia caused by estrogen replacement therapy

OBJECTIVE

Endometrial hyperplasia, an entity considered a precursor to endometrial carcinoma, frequently develops in women receiving unopposed estrogens. Progestins used concomitantly with estrogens can largely prevent endometrial hyperplasia and carcinoma. However, the ability of progestins to reverse endometrial hyperplasia induced by estrogens is less well recognized. The purpose of this study was to assess the medical reversal rate of endometrial hyperplasia that develops in women receiving unopposed estrogen replacement therapy (ERT).

DESIGN

Review of recent literature (1990-2000).

RESULTS

Based on four large series, more than 90% of endometrial hyperplasia caused by ERT can be reversed by medical treatment. Discontinuation of estrogen and oral administration of 10 mg/day of medroxyprogesterone acetate continuously for 6 weeks or cyclically for 3 months (2 weeks of each month) are the two regimens most widely used. Other progestins also have been shown to be effective.

CONCLUSIONS

Progestins are highly successful in reversing endometrial hyperplasia caused by ERT.

Reversal of gonadotropin-releasing hormone agonist induced reductions in mammographic densities on stopping treatment

Previously, we described the reduction in mammographic densities that occurred in premenopausal women after 12 months on a hormonal regimen designed to be chemopreventive for breast (and ovarian) cancer consisting of a gonadotropin-releasing hormone agonist (GnRHA) plus low-dose add-back estrogen-progestin. We sought to determine whether the density reduction persisted with continuation of the regimen for 24 months, and, if so, whether the densities would return to baseline after the regimen was discontinued. Twenty-one women, 27-40 years of age, with a 5-fold greater than normal risk of breast cancer, were randomly assigned in a 2:1 ratio to the treatment group (14 women) and to a control group (7 women). The percentage of mammographic densities, calculated as the proportion of the breast area on the mammogram containing densities, were assessed blindly using a computer-based threshold method at baseline, after 12 and 24 months of treatment, and at between 6 and 12 months after treatment was stopped. The previously described percentage of mammographic density reductions of 9.7% (P = 0.012) after 12 months of treatment were increased slightly to 11.4% (P = 0.010) after 24 months of treatment, but the additional change was not statistically significant. Ten of 11 treated women assessed at 24 months had reduced percentages of mammographic densities compared with baseline. Six to 12 months after completion of treatment, the mean percentage of mammographic density in the treated group was no different from that at baseline (mean decline of 2.0%; P = 0.73). The women in the control group had no statistically significant changes in densities over the period of the study. Reductions in mammographic densities engendered by the GnRHA plus a low-dose add-back estrogen-progestin regimen persist as long as the women receive treatment. The densities return to baseline when the women resume normal menstrual cycles. These results confirm that mammographic densities are influenced by ovarian function. Improved efficacy of mammographic screening is to be expected as long as a woman continues on such a regimen. Whether such a regimen is chemopreventive for breast cancer remains to be established, but the recent report on a randomized trial of use of GnRHA alone in premenopausal breast cancer cases showing a marked reduction in incidence of contralateral disease provides strong support for the hypothesis.

Temporary discontinuation: a compliance issue in injectable users

This study examined compliance in injectable users and followed women post-discontinuation to document their contraceptive practices. A cohort of 189 predominantly new users of depot-medroxyprogesterone acetate and norethisterone oenanthate were recruited and followed for 2 years regardless of whether or not they continued the method. Continuation rates were 42% at 1 year and 21% at 2 years. Of the 78 women who discontinued the method, 31 reported that they were "taking a break." For 20 of these women, this break (nonuse segment) occurred within the 2-year period, and 15 of them returned to the injection before the end of study period. The other five switched methods after the nonuse segment. The mean length of the nonuse segment was 7 months (range 2-13 months). In all 20 women, no other contraceptive method was used, they remained sexually active, and started the break within 6 months of commencing use of the injectable. In addition, 11 women were in a self-reported nonuse segment at the end of the study and stated their intention to return to the method at a later date. Menstrual disturbances were cited as the main reason for the break. Strengthened counseling at method acceptance was identified as a strategy to decrease the frequency of breaks in injectable method use.

Effects of oral and transdermal hormone replacement therapy on internal carotid artery pulsatility indices in postmenopausal women. A prospective, randomized, comparative study

OBJECTIVE

To compare the effects of oral and transdermal hormone replacement therapy on the internal carotid artery pulsatility index in postmenopausal women.

STUDY DESIGN

Thirty-seven women were randomized to six months of treatment with oral (n = 19) or transdermal (n = 18) sequential combined hormone replacement therapy. The internal carotid artery pulsatility index was assessed by color Doppler ultrasound at baseline and after six months of treatment.

RESULTS

Carotid artery pulsatility indices were significantly lower than the mean of 0.939 +/- 0.139 at 0.860 +/- 0.084 in the oral hormone replacement group and significantly lower than the mean of 0.928 +/- 0.092 at 0.891 +/- 0.046 in the transdermal hormone replacement therapy group (P = .042) after six months of treatment. The mean changes in the carotid artery pulsatility index between the oral and transdermal hormone replacement groups were nonsignificant (-0.078 +/- 0.131 and -0.037 +/- 0.067, respectively; P = .53). There was a significant negative correlation between the change in pulsatility index during treatment and baseline values in the carotid artery (r = -.81, P = .001), but no correlation was found with time since menopause and serum estradiol level.

CONCLUSION

Oral and transdermal sequential hormone replacement therapy are similarly effective at six months in reducing impedance to flow in the internal carotid artery.

New options in contraception for adolescents

There have been several recent advances in the contraceptive methods available to adolescents in the United States. A new monthly injectable method combines efficacy and ease of compliance with excellent menstrual cycle control. Very low-dose oral contraceptive pills containing gonane progestins decrease the incidence of estrogen-related side effects, and are associated with low rates of breakthrough bleeding. Oral contraceptive pills prescribed in continuous cycles can provide relief from menstrual-related symptoms, and may improve contraceptive effectiveness. Noncontraceptive benefits of oral contraceptive pills, such as improvement in dysmenorrhea and acne, may motivate more consistent pill-taking, and should be identified as additional reasons for pill continuation. Maximizing the prescribing time limit of emergency contraception to 120 hours after unprotected intercourse may improve access. Emergency contraception is more effective the sooner it is used, and should be provided in advance to adolescents for immediate use in the event a postcoital method becomes necessary.

Restoration of menstruation after chemotherapy-induced amenorrhoea in a patient with ovarian immature teratoma

We described a rare case of a 20-year-old woman with an ovarian immature teratoma who resumed regular spontaneous menses after more than 5 years of chemotherapy-induced amenorrhoea. Efforts to reverse chemotherapy-induced ovarian failure can be continued even after persistent menstrual dysfunction of 5 or more years.

Anaylsis of birefringence during wound healing and remodeling following alkali burns in rabbit cornea

The use of synthetic inhibitors of metalloproteinases (SIMP) or medroxyprogesterone (MP) can prevent or significantly delay the ulceration of alkali-injured corneas by influencing collagen degradation. We have examined the remodeling of rabbit corneal stroma following alkali injury and have assessed the effect of SIMP and MP treatment. Following a defined alkali injury to the rabbit cornea, animals were divided into three subgroups, one group treated with topical beta-mercaptomethyl tripeptide (SIMP), one treated by subconjunctival injection of MP and one treated with a control solution. The corneal tissue was taken at 3 days, 1, 2, 3, 4, 9 and 26 weeks after alkali injury and prepared for light microscopy and transmission electron microscopy (TEM). A quantitative measurement of birefringence, in terms of the optical path difference (OPD), was made using a modified polarized microscopy technique based on the analysis of interference colours. The results showed that SIMP effectively prevented deep corneal ulceration. MP could delay the ulceration and the corneas treated with MP appeared to have better transparency than the other groups. There was a significant difference of the OPD between the anterior (5.8 +/-0.3 nm) and posterior (7.8 +/-0.4 nm) stroma of the normal cornea (P<0.001). The OPD values from the central corneas from alkali-injured eyes were generally lower than normal during the first 4 weeks and then gradually recovered to the normal level or above, except for the posterior stroma of the MP-treated eyes. We found that the OPD changes were very dependent on the presence of corneal lesions. The stroma near corneal ulceration, scar tissue, calcified stroma and the retro-corneal collagen layer showed a significant reduction of birefringence (lower OPD values). These OPD values remained much lower than normal up to the end of the experiment. TEM showed disrupted corneal stroma in all three groups, with thinner scar tissue in the MP group. The fibril diameters did not change significantly 3 days and 1 week after the alkali burns (27.1+/-2.3 nm in the control group, 27.3+/-2.2 nm in the SIMP group and 27.7+/-2.1 nm in the MP group) and there were no differences compared with 29.7+/-1.7 nm of the normal cornea (P>0.05). After 2 weeks of tissue remodeling, the fibril diameters in alkali-injured corneas showed a large variation (the range was between 11.5 and 80 nm) with a bimodal distribution, especially in the control group. The technique presented here for birefringence evaluation can provide an alternative way to monitor wound healing and tissue remodeling, both visually and quantitatively.

Anti-ischemic effect of chronic oestrogen replacement therapy alone or in combination with medroxyprogesterone acetate in different replacement schemes

BACKGROUND

Oestrogen replacement therapy in postmenopausal women has a protective effect upon the cardiovascular system and improves exercise-induced myocardial ischemia. Although in hormone replacement schemes progestins are required to reduce the likelihood of uterine malignancies, little is known on the cardiovascular effect of progestins. The purpose of this study was to evaluate the effect of oestrogen replacement alone and two different estrogen-progestin replacement therapy schemes upon exercise induced myocardial ischemia.

MATERIAL AND METHOD

The study population included 18 female menopausal patients with coronary artery disease. After a baseline exercise test patients received conjugated equine estrogens (CEE) 0.625 mg alone for 30 days when they underwent a second exercise test and were randomized to receive in a cross-over design medroxyprogesterone acetate (MPA) either in continuous combined therapy (2.5 mg/daily) for 28 days or in cyclical therapy (10 mg o.d. from day 16 to day 28).

RESULTS

After CEE alone two patients with a previously positive exercise test showed a negative exercise test. CEE increased time to 1 mm ST compared to baseline (352+/-185 vs 265+/-133 s, P<0.01). In the 2 pts in whom the exercise test was negative after CEE the test remained negative during continuous combined MPA therapy while become positive during cyclical MPA. CEE+continuous combined MPA increased both time to 1 mm ST and exercise time compared to baseline (386+/-165 vs 265+/-133 s, P<0.01 and 545+/-198 vs 465+/-186 s, P<0.05, respectively). No difference was found between baseline and CEE+cyclical MPA in either time to 1 mm ST or exercise time (268+/-164 vs 265+/-133 s, P=NS and 455+/-223 vs 465+/-186 s, P=NS, respectively).

CONCLUSION

Continuous combined therapy with CEE+MPA improves exercise-induced myocardial ischemia in female patients with coronary artery disease while the beneficial effect of CEE is reduced by cyclical therapy.

[Hormonal contraception for adolescents]

The new hormonal contraceptives are safe, effective and with fewer side effects than the older formulations. Their incidence of serious complications is low, particularly as compared to the health risk related to pregnancy. Adolescents must be screened for contra-indications before giving them a hormonal contraceptive. Because pills do not prevent sexually transmitted diseases, teenagers should be counselled to use a barrier methods together with COCs. Young girls need frequent follow-up and close monitoring to minimise side effects and to increase compliance and continuation in use. Long-term contraception by implants represents a valid alternative option with an increasing popularity among adolescents.

Influence of postmenopausal hormone replacement therapy on platelet serotonin uptake site and serotonin 2A receptor binding

OBJECTIVE

To examine whether binding of [3H]paroxetine to the platelet serotonin transporter or binding of [3H]lysergic acid diethylamide (LSD) to the platelet 5-HT(2A) receptor are influenced by postmenopausal estrogen/progestogen treatment.

METHODS

Twenty-three postmenopausal women with climacteric symptoms completed this double-blind, randomized, crossover study. The women received 2 mg of estradiol continuously during four 28-day cycles. In the last 14 days of each cycle, 10 mg of medroxyprogesterone acetate, 1 mg of norethindrone acetate, or placebo was given. Before treatment, as well as once during the last week of each treatment, blood samples were collected for analysis of [3H]LSD and [3H]paroxetine binding. The power of the study setup was 81%. The study had an effect size of 0.36, corresponding to the ability to detect a 15% difference in [3H]paroxetine and [3H]LSD binding between treatments with alpha =.05 and beta =.20, based on a previously reported standard deviation within cells of 20% of the mean binding values.

RESULTS

The number of platelet receptors (B(max)), or the affinity of the radioligand to the receptor (K(d)), for [3H]paroxetine binding did not change during estrogen or estrogen-progestogen treatment, nor did B(max) or K(d) for [3H]LSD binding change during the different treatments. However, in a subgroup of depressed patients, the decrease in B(max) for [3H]LSD binding during treatment was significantly more pronounced than in the nondepressed subgroup (P <.05).

CONCLUSION

Estrogen treatment with or without the addition of progestogen does not affect binding to the serotonin transporter or to the serotonergic 5-HT(2A) receptor in healthy postmenopausal women.

The effect of low-dose combined oral contraceptive pills versus injectable contraceptive (Depot Provera) on liver function tests of women with compensated bilharzial liver fibrosis

This was an open comparative trial of two types of hormonal contraceptives, a low-dose combined oral contraceptive and the injectable depot-medroxyprogerone acetate, with a control group using an intrauterine device (copper T-380). Clients were recruited from bilharzial patients attending the maternal-child health and family centers affiliated with the National Liver Institute. Clients with compensated bilharzial liver disease were chosen and were divided into three subgroups according to their own preference for the method of contraception. Baseline, 2-, and 4-months liver function tests were compared, and abdominal ultrasound scanning of the liver was done. There was a nonsignificant change in liver function tests, and the portal vein diameter measured by ultrasound scanning was not changed with steroidal contraceptives. The use of combined oral contraceptive containing low-dose estrogen or using depot medroxyprogertone acetate injectables are safe and can be prescribed in cases with compensated bilharzial hepatic fibrosis with normal function.

Contraceptive dispensing and selection in school-based health centers

PURPOSE

To determine whether initiation of on-site dispensing of hormonal contraceptives (oral contraceptive pill, Depo-provera, and Norplant) in six urban school-based health centers reduced time to initial selection, and increased their consistent use among sexually active females.

METHODS

Participants were sexually active females who received family planning care in a school year before (1994-1995 cohort) or after (1996-1997 cohort) the initiation of on-site dispensing. Data on contraception and sexual behavior were collected at each family planning visit. Cohorts were compared using Student's t-tests and Chi-square tests, analysis of covariance, and logistic regression.

RESULTS

About 59% of the 1994-1995 cohort selected hormonal contraceptives at the first or second visit; this increased to 72% of the 1996-1997 cohort (chi(2) = 11.3; p <.001). After adjustment for cohort differences, the 1996-1997 cohort consistently selected hormonal contraceptives a longer period of time, although the difference did not reach statistical significance (adjusted means: 1994-1995 cohort = 73 days, 1996-1997 cohort = 81 days; t = 1.6, p <.10).

CONCLUSION

Sexually active females receiving family planning care select methods of hormonal contraception sooner and somewhat more consistently when the clinics in their high schools can dispense contraceptives on-site.

Postmenopausal hormonal support: discontinuation of raloxifene versus estrogen

OBJECTIVE

To determine possible differences in continuation among women initiating treatment with the selective estrogen receptor modulator raloxifene, versus those initiating treatment with estrogen-containing regimens.

DESIGN

A pharmacy prescription database search for refill patterns. The study subjects were members of Kaiser Foundation Health Plan, a large health maintenance organization; 1,394 women age >or=60 years who filled index prescriptions for either raloxifene (n = 331) or systemic estrogens (n = 1,063) between April 1998 and March 1999. The main outcome measure was discontinuation based on prescription refill patterns through December 2000.

RESULTS

At 24 months, the probabilities of discontinuing were 56% for women starting raloxifene compared to 72% for women starting estrogens. The likelihood of discontinuation was significantly less among women starting raloxifene than among those starting estrogen (hazard ratio = 0.75; 95% confidence interval = 0.64-0.88). Adjustments for age and prescriber specialty did not affect the risk.

CONCLUSIONS

We conclude that discontinuation of estrogen by women well beyond the age of menopause is high; more than two-thirds discontinue within 2 years of starting. Women starting therapy with raloxifene are 25% percent less likely to discontinue their medication than those starting estrogen, providing some promise that long-term benefits of raloxifene may be more easily achieved than those of estrogen.

Effect of high-dose progestogen on hemostatic properties of blood in patients with endometrial cancer

Fifteen cases of endometrial cancer were administered daily doses of 600 mg of MPA after surgery to prevent the recurrence of cancer. The initiation times of coagulation (time necessary for fibrin network formation) were measured with a highly sensitive damped oscillation rheometer and compared with those of 15 control patients who were not administered MPA. Biochemical studies of blood coagulation and fibrinolysis were also done. The initiation times of coagulation were 19.0+/-1.8 minutes (min mean +/- standard deviation) after 3-6 months and 16.0+/-2.0 min after 9-12 months of MPA administration, both times being significantly shorter compared with the controls (24.0+/-2.5 min). Hematocrit values, platelet counts and fibrinogen levels were similar between the two groups. Activated partial thromboplastin time (APTT) was significantly decreased and antithrombin III activity (AT III), thrombin-antithrombin complex (TAT), plasminogen level, plasmin-alpha(2) plasmin inhibitor complex level (PIC) and the fibrin degradation product level (FDP) were significantly increased in the MPA group compared with the control group. Accelerated coagulation of blood was definitely induced by high-dose MPA but antithrombin and fibrinolytic activities were also induced, and, thus, thromboembolic complications were prevented.

Apoptosis inhibition mediated by medroxyprogesterone acetate treatment of breast cancer cell lines

Several reports suggested that steroidogenic hormones could be directly involved in the regulation of apoptosis in vitro, but whether this is due to blocking or promoting mechanism of these hormones remains controversial. However, it was shown that progesterone exhibited a protective effect against the apoptotic process during mouse mammary gland involution in vivo. In this study, we analyzed the effect of medroxyprogesterone acetate (MPA) treatment, an agonist of progesterone, on serum starvation induced apoptosis on breast cancer cell lines. Positive and negative progesterone receptor (PgR+ and PgR-) breast cancer cell lines were treated with MPA (10 nM), either in standard culture conditions or in serum-free medium to induce apoptosis. Cell survival, proliferation and apoptosis were simultaneously analyzed with the expression of apoptosis-related genes measured by a real time quantitative RT-PCR. At non cytotoxic doses, MPA protected PgR+ T47-D, MCF-7 and H466-B cell lines against serum depletion-induced apoptosis, while MPA did not protect PgR-MDA-MB-231 cells against serum depletion induced apoptosis. In PgR+ cell lines and in concordance with the protective effect, the pro-apoptotic HRK and BAK1 mRNAs were up-regulated after apoptosis induction, while they were no more induced in condition of protection against apoptosis after MPA treatment. We also observed, specifically in PgR+ cells, an up-regulation of BCLX-L and BCLX-S and a down-regulation of BCL2 mRNAs, which are specific to the MPA response and unrelated to apoptotic process. Involvement of these genes with regard to the MPA-mediated protection against apoptosis is discussed.

The relation of oxidized LDL autoantibodies and long-term hormone replacement therapy to ultrasonographically assessed atherosclerotic plaque quantity and severity in postmenopausal women

BACKGROUND

In epidemiologic studies, the incidence of atherosclerosis rises soon after menopause in women, and hormone replacement therapy (HRT) has proved to be useful in preventing onset of clinical manifestations of the disease. However, it is not known how HRT affects sonographically determined atherosclerotic severity (AS) and number of atherosclerotic plaques (NAP) in large arteries. Furthermore, it is not clear how HRT affects oxidation of low density lipoproteins (LDL), which obviously has an important role in the pathogenesis of atherosclerosis.

OBJECTIVES

The purpose of the study was to determine whether HRT has a beneficial effect on sonographically determined AS and NAP in large arteries of 101 postmenopausal women compared to 40 controls without HRT. We also studied the interaction of HRT and antibodies against oxidized LDL on AS and NAP progression.

RESULTS

Estradiol valerate alone, combined estradiol valerate-levonorgestrel and combined estradiol valerate-medroxyprogesterone acetate therapy are each associated with lower NAP and AS as compared to controls without HRT. In a multiple regression model explaining NAP in the whole study population, the strongest predictors were HRT (P=0.0006) and copper-oxidized LDL cholesterol autoantibodies (P=0.0491).

DISCUSSION

Our findings indicate that postmenopausal HRT is associated with a lower total number of atherosclerotic plaques and less severe atherosclerotic lesions, as compared to controls without HRT, and that this outcome may be associated with the effect of HRT on LDL cholesterol oxidation.

Combination treatment with estrogen and calcitriol in the prevention of age-related bone loss

Estrogen deficiency and declining calcium absorption due to reduced calcitriol levels or intestinal resistance to calcitriol, are important factors in the pathogenesis of age-related bone loss. The main objective of this study was to examine the effect of estrogen and 1,25-dihydroxyvitamin D therapy given individually or in combination on bone loss in elderly women. Four hundred eighty-nine elderly women with normal bone density for their age, aged 65-77 yr, were entered into a randomized double blind, placebo-controlled trial. Women were randomized to one of four groups: conjugated estrogens (0.625 mg, daily) to women without a uterus (estrogen replacement therapy) plus medroxyprogesterone acetate (2.5 mg, daily) to women with a uterus (hormone replacement therapy), calcitriol (0.25 microg twice daily), a combination of hormone replacement therapy/estrogen replacement therapy plus calcitriol, or placebos for 3 yr. The primary outcome was the change in bone mineral density of the femoral neck and spine. In the intent to treat analysis, hormone therapy (hormone replacement therapy/estrogen replacement therapy) produced a mean (+/-1 SD) increase in bone mineral density of 2.98% (+/-5.45%) at the femoral neck (P < 0.0001) and 4.36% (+/-6.42%) at the spine (P < 0.0001). There were parallel increases in total hip and trochanter bone mineral density. Calcitriol increased bone mineral density 0.10% (+/- 4.27%) at the femoral neck (P = 0.57) and 1.65% (+/- 4.83%) at the spine (P < 0.0124). The combination of hormone replacement therapy/estrogen replacement therapy + calcitriol increased bone mineral density 3.80% (+/-4.95%) at the femoral neck (P < 0.001), 4.91% (+/-6.0%) at the spine (P < 0.0001), and parallel changes at the total hip and trochanter. All three treatment groups differed significantly from placebo at the spine and for the hormone replacement therapy/estrogen replacement therapy groups at the femoral neck, spine, total hip and trochanter. There were no significant differences between combination therapy and hormone replacement therapy/estrogen replacement therapy alone on bone mineral density at any site in the intent to treat analysis. In a secondary analysis of the effect in women who were adherent to treatment, calcitriol had a more significant effect on spine (P = 0.003) and total hip (P = 0.004). The increase in bone mineral density in the adherent groups of women was always higher compared with the intent to treat groups. Combination therapy compared with hormone replacement therapy/estrogen replacement therapy alone produced a significantly greater response in trochanter (P = 0.007) and total hip bone mineral density (P = 0.0017). In summary, hormone replacement therapy/estrogen replacement therapy alone and in combination with calcitriol therapy was highly effective in reducing bone resorption and increasing bone mineral density at the hip and other clinically relevant sites in a group of elderly women, with normal bone density for their age. Calcitriol was effective in increasing spine bone mineral density. In the adherent women, combination therapy with hormone replacement therapy/estrogen replacement therapy and calcitriol increased bone mineral density significantly more in the total hip and trochanter than did hormone replacement therapy/estrogen replacement therapy alone.

[Minimally invasive treatment of gynecologic cancers]

This article describes the minimally invasive treatment of cervical, endometrial, and ovarian cancers, from the point of view of fertility conservation. It is hoped that the treatment fulfills the quality of life needs of female patients.

Effects of androgen supplementation of hormone replacement therapy on the vascular reactivity of cerebral arteries

OBJECTIVE

To determine the effect of the androgen supplementation of hormone replacement therapy (HRT) on the vascular reactivity of cerebral arteries.

DESIGN

Open randomized study.

SETTING

Healthy volunteers in an academic research environment.

PATIENT(S)

Forty postmenopausal women who were treated with sequential HRT (transdermal E2 50 microg/d + medroxyprogesterone acetate 10 mg/d for 12 days every other month) for > or =1 year and < or =5 years.

INTERVENTION(S)

Testosterone undecanoate (40 mg/d, p.o.) was randomly administered to 20 patients during ongoing HRT; the other 20 served as controls. Doppler evaluations of the internal carotid and middle cerebral arteries were performed together with lipid levels assessments. A visual analogue scale (VAS) was used to evaluate various parameters relating to sexual life and well-being.

MAIN OUTCOME MEASURE(S)

Pulsatility index (PI) of the arteries, VAS assessment of psychophysical well-being.

RESULT(S)

The administration of testosterone undecanoate during HRT induced an increase in the PI of the middle cerebral artery and a reduction of high-density lipoprotein cholesterol. Sexual desire and satisfaction were greatly improved.

CONCLUSION(S)

In postmenopausal women, androgen supplementation during HRT can partially counteract the beneficial effects of estrogens on cerebral vascular reactivity and lipid profiles, but sexual desire and satisfaction are greatly improved.

Quality of life and costs associated with micronized progesterone and medroxyprogesterone acetate in hormone replacement therapy for nonhysterectomized, postmenopausal women

BACKGROUND

Because natural progesterone is poorly absorbed and rapidly metabolized, synthetic derivatives of progesterone, such as medroxyprogesterone acetate (MPA), are used in combination with estrogen in hormone replacement therapy. A micronized form of natural progesterone is available that is readily absorbed and reaches peak serum concentrations from 1 to 4 hours after administration.

OBJECTIVE

The purpose of this study was to compare the quality of life (QOL), menopausal symptoms, and costs associated with a natural micronized progesterone (MP) formulation versus MPA as add-on therapy to estrogen in hormone replacement for post-menopausal women.

METHODS

This prospective, multicenter, randomized, fixed-dose, open-label, parallel-group study enrolled postmenopausal, otherwise healthy, nonhysterectomized women 45 to 65 years of age who had been amenorrheic for > or =6 months and exhibited symptoms of estrogen deficiency. All women received 0.625 mg conjugated equine estrogens on days 1 to 25 of a 30-day cycle; on days 12 to 25, women were randomized to receive either MP 200 mg or MPA 5 mg; patients were followed for 9 months. QOL, the primary end point, was measured at baseline and months 3, 6, and 9 using the 36-Item Short-Form Health Survey (SF-36), the Nottingham Health Profile (NHP), and the condition-specific Women's Health Questionnaire (WHQ). Bleeding pattern, compliance, menopausal symptoms, and cost were evaluated as secondary end points. Costs (in 1997 Canadian dollars) were assessed from the societal perspective and included costs of study medication, hormone therapy monitoring, concomitant medication, outpatient resources, out-of-pocket expenses, and patient and caregiver time loss.

RESULTS

A total of 182 women were enrolled; 89 received MP and 93 received MPA. Improvements in climacteric symptoms were observed from baseline to month 9 for both treatments. Mean scores on all domains of the SF-36 at month 9 were greater than scores at baseline in both treatment groups but the increases were not statistically significant. All domains within the NHP and WHQ improved significantly over this period for both groups (P < or = 0.008). Only patients receiving MP showed specific improvements in the menstrual problems and cognitive domains of the WHQ. The difference in average 9-month cost per patient was not statistically significant, at Can 367 dollars +/- 120 dollars and Can 360 dollars +/- 369 dollars for patients receiving MP and MPA, respectively.

CONCLUSIONS

MP is a clinically effective, well-tolerated, and cost-comparable alternative to MPA.

Hormone replacement therapy shortens QT dispersion in healthy postmenopausal women

BACKGROUND

The aim of the study was to investigate the effects of hormone replacement therapy (HRT) on myocardial repolarization characteristics in postmenopausal women without coronary artery disease.

METHODS

Fifty-one consecutive healthy postmenopausal women (age 48 +/- 5) with negative exercise stress testing were prospectively enrolled into the study. Standard 12-lead electrocardiograms were obtained to evaluate the effects of 6 months of HRT on QT intervals, corrected QT intervals (QTcmax and QTcmin), QT dispersion (QTd), and corrected QTd (QTcd). Hormone regimens were continuous 0.625 mg/day conjugated equine estrogen (CEE) plus 2.5 mg/day medroxyprogesterone acetate (MPA) or 0.625 mg/day CEE alone depending on the hysterectomy status.

RESULTS

Although not statistically significant, CEE alone or in combination with MPA increased QTmax and QTmin values. However, the increase in QTmin was greater than the increase in QTmax, which resulted in statistically significant shortening of QTd (P = 0.007 in CEE and P < 0.001 in CEE + MPA groups). There was a significant prolongation of QTcmin values after 6 months in patients assigned to the CEE group (P = 0.001). The QTcd values were significantly shortened by HRT with both regimens (for CEE group 49 +/- 13 ms vs 38 +/- 13 ms, P = 0.01; for CEE + MPA group 49 +/- 14 ms vs 36 +/- 13, P < 0.001).

CONCLUSION

HRT significantly decreased the QTd and QTcd in postmenopausal women without coronary artery disease, independent of the addition of MPA to the regimen. This improvement in myocardial repolarization may be one of the mechanisms of the favorable effects of HRT on cardiovascular system. However, the clinical implications of the shortening of QTd in postmenopausal women with HRT must be clarified.

Changes in quality of life after hormonal treatment of endometriosis

BACKGROUND

To assess whether hormonal treatment of endometriosis improves quality of life for women with endometriosis.

METHODS

In a prospective, randomized, double-blind, double-dummy study on 48 women with verified endometriosis, the pain pattern and quality of life were registered before, during and after treatment with nafarelin or medroxyprogesterone acetate. The distribution of the studied parameters were tested by means of a Skewness test. ANOVA analysis was used for normally distributed variables and Friedman's analysis and Mann-Whitney U-test for non normally distributed variables.

RESULTS

There was a difference between the 30 women who participated all through the study and the 18 who dropped out. It was noticeable that anxiety-depression and sleep disturbances were significantly more common among the drop outs. There was a significant reduction in symptom score during the study, without any significant difference between the treatment groups. The sleep disturbances and anxiety-depression score improved significantly from before treatment to the end of the follow-up, but the anxiety-depression score increased during the nafarelin treatment period. There was a statistically significant improvement of paid working life in the nafarelin treated group. All the other psycho-social parameters as well as emotional balance improved during the study period without difference between groups.

CONCLUSION

When hormonal treatment is planned it is very important to take into consideration previous psychosocial experiences of the patient. Factors of importance for quality of life such as sleep disturbances and anxiety-depression improved significantly after treatment with nafarelin or medroxyprogesterone acetate.

Endometrial effects of lower doses of conjugated equine estrogens and medroxyprogesterone acetate

OBJECTIVE

To determine the endometrial safety of lower doses of continuous combined conjugated equine estrogens (CEE) and medroxyprogesterone acetate (MPA).

DESIGN

Randomized, double-blind, placebo-controlled study (the Women's Health, Osteoporosis, Progestin, Estrogen study).

SETTING

Study centers across the United States.

PATIENT(S)

Healthy, postmenopausal women (n = 2,673) with an intact uterus.

INTERVENTION(S)

Patients received CEE 0.625 mg/day, CEE 0.625/MPA 2.5 mg/day, CEE 0.45 mg/day, CEE 0.45/MPA 2.5 mg/day, CEE 0.45/MPA 1.5 mg/day, CEE 0.3 mg/day, CEE 0.3/MPA 1.5 mg/day, or placebo for 1 year. Endometrial biopsies were evaluated at baseline, cycle 6, and year 1 using a centralized protocol.

MAIN OUTCOME MEASURE(S)

Efficacy of lower doses of CEE/MPA in reducing the incidence of endometrial hyperplasia rates associated with unopposed CEE.

RESULT(S)

Endometrial hyperplasia rates ranged from 0 to 0.37% for all CEE/MPA doses. Twenty-nine of the 32 cases of endometrial hyperplasia developed in women who were administered CEE 0.625 mg or CEE 0.45 mg. The incidence of endometrial hyperplasia increased with age for patients administered CEE alone. As expected, there were some inconsistencies among pathologists' ratings in the numbers of hyperplasias and incidence rates for the CEE-alone regimens. There were too few cases of hyperplasia in the combination groups to evaluate consistency among pathologists.

CONCLUSION(S)

One year of treatment with lower doses of CEE/MPA provides endometrial protection comparable to commonly prescribed doses. These regimens may be used by clinicians to individualize hormone replacement therapy in postmenopausal women.