Hypnotizability and opinions about hypnosis in a clinical trial for the hypnotic control of pain and anxiety during pregnancy termination

This descriptive study evaluates the hypnoanalgesic experience's effect on participants' hypnotizability and opinions about hypnosis and identifies factors associated with hypnotizability. Hypnotizability was assessed using the Stanford Hypnotic Susceptibility Scale: Form A in 290 women 1 month after their participation in a randomized clinical trial evaluating hypnotic intervention for pain/anxiety versus standard care during pregnancy termination. Opinions were collected before and after the intervention. The regression model describing hypnotizability (F = 13.55; p < .0001; R(2) = 0.20) retained 5 variables but not the intervention group. The variable explaining most of total variance (62.9%) was the level of perceived automaticity/involuntariness. Opinions about hypnosis were modified by the hypnotic experience compared to standard care but were not associated with hypnotizability. Exposure to hypnoanalgesia did not influence hypnotizability but modifies significantly the opinions about hypnosis. Consistent with previous findings, perceived automaticity appears to best predict hypnotizability.

Ethyl-eicosapentaenoic acid for the treatment of psychological distress and depressive symptoms in middle-aged women: a double-blind, placebo-controlled, randomized clinical trial

BACKGROUND

Psychological distress (PD) and depressive symptoms are commonly observed during menopausal transition. Studies suggest that omega-3 (n-3) fatty acids may help alleviate depression.

OBJECTIVE

The objective was to compare enriched ethyl-eicosapentaenoic acid (E-EPA) supplementation with placebo for the treatment of PD and depressive symptoms in middle-aged women.

DESIGN

Women with moderate-to-severe PD (n = 120) were randomly assigned to receive 1.05 g E-EPA/d plus 0.15 g ethyl-docosahexaenoic acid/d (n = 59) or placebo (n = 61) for 8 wk. The main outcomes were 8-wk changes in PD scores [Psychological General Well-Being Schedule (PGWB)] and depressive scales [20-item Hopkins Symptom Checklist Depression Scale (HSCL-D-20) and the 21-item Hamilton Depression Rating Scale (HAM-D-21)].

RESULTS

At baseline, women with PD were mildly to moderately depressed, and 24% met the major depressive episode (MDE) criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. After 8 wk, outcomes improved in both groups, but no significant differences were noted between them. Stratification analyses for MDE diagnosis at baseline indicated that differences in adjusted 8-wk changes between the E-EPA group without MDE (n = 46) and the placebo group (n = 45) were 8.0 (95% CI: 0.6, 15.3; P = 0.034) for the PGWB, -0.2 (95% CI: -0.01, -0.4; P = 0.040) for the HSCL-D-20, and -2.7 (95% CI: -0.3, -5.1; P = 0.030) for the HAM-D-21. Differences in adjusted 8-wk changes between the E-EPA group with MDE (n = 13) and the placebo group (n = 16) were not significant.

CONCLUSIONS

To our knowledge, this is the first trial of n-3 supplementation in the treatment of PD and depressive symptoms in middle-aged women. In women with PD without MDE at baseline, the 8-wk changes in PD and depressive scales improved significantly more with E-EPA than with placebo. This trial was registered at http://www.controlled-trials.com as ISRCTN69617477.

Patient decision aid on natural health products for menopausal symptoms: randomized controlled trial

Objective

To evaluate the impact of a patient decision aid (PDA) regarding the use of natural health products (NHPs) at menopause on decisional conflict, knowledge of NHPs, congruence between values and choice, persistence with an option, intention to disclose the use of NHPs to a physician or a pharmacist and intention to use decision support interventions in the future.

Study design

A randomized controlled trial in which 90 women, aged 45–64 years, facing a decision about using NHPs for menopausal symptoms, received a PDA (experimental group) or a general information brochure about menopause (control group).

Main outcome

Decisional conflict.

Measures

Women were evaluated at baseline and after a two-week period using the decisional conflict scale (DCS). Analysis of covariance was used to determine the differences between both groups on the DCS.

Results

Both groups experienced a statistically significant reduction on the DCS (−0.55 ± 0.59, P < 0.0001 versus −0.52 ± 0.73, P < 0.0001). However, there was no statistically significant difference between the groups ( P = 0.32). Both groups experienced a statistically significant improvement in knowledge of NHPs (0.86 ± 1.77, P = 0.002 versus 0.51 ± 1.47, P = 0.031). However, there was no statistically significant difference between the groups ( P = 0.162).

Conclusion

A PDA regarding the use of NHPs for menopausal symptoms impacted favourably on women's decisional conflict, but was not superior to a general information brochure on menopause.

Hypnotic induction and therapeutic suggestions in first-trimester pregnancy termination

Several papers of interest for researchers and clinicians have recently appeared in scientific medical literature evaluating hypnosis' efficacy in managing patients' distress and pain during surgical procedures. In this article, following a pilot study, the authors describe the context and standardized induction procedures that they are using in an ongoing clinical trial evaluating the effect of hypnosis on acute pain and anxiety during termination of pregnancy.

Synergistic cytotoxic effects of tamoxifen and black cohosh on MCF-7 and MDA-MB-231 human breast cancer cells: an in vitro study

Breast cancer cell cultures were exposed to different concentrations of black cohosh, estradiol (E2), and tamoxifen to examine the effect on cell proliferation; cytotoxicity was assessed by using sulforhodamine B (SRB) dye solution. E2 (10(-10) - 10(-8) mol/L) markedly stimulated the proliferation of MCF-7 cells (p < 0.01). Tamoxifen stimulated MCF-7 cell proliferation at 10(-6) mol/L and 10(-5) mol/L (p < 0.005) but inhibited in a dose-dependent fashion the proliferative effect of E2 (p < 0.001). Black cohosh alone did not show any stimulatory effect, but exhibited a cytotoxic effect, which was significant at 10(3) microg/mL (p < 0.001). Adding black cohosh at 10(0)-10(3) microg/mL to E2 at 10(-9) mol/L also resulted in a dose-dependent inhibition of E2 proliferative effect. Interestingly, the combination of black cohosh (10(0)-10(3) microg/mL) with increasing tamoxifen concentrations further inhibited MCF-7 cell growth. On MDA-MB-231 cells, neither E2 nor tamoxifen displayed any detectable effect. However, black cohosh inhibited MDA-MB-231 cell proliferation at 10(3) microg/mL (p < 0.05), and this inhibitory effect was enhanced by increasing tamoxifen concentrations. This study reveals a cytotoxic effect of black cohosh on both estrogen-sensitive and estrogen-insensitive breast cancer cells and a synergism with tamoxifen for inhibition of cancerous cell growth.

Intention to encourage complementary and alternative medicine among general practitioners and medical students

The authors' goal was to identify factors explaining intention to encourage a patient to follow complementary and alternative medicine (CAM) treatment among general practitioners (GPs), fourth-year medical students, and residents in family medicine. They surveyed 500 GPs and 904 medical students via a self-administered mailed questionnaire that they based on the Theory of Planned Behavior. Respondents expressed a neutral level of intention to encourage CAM approach. Variables explaining 75% of variance of intention of all participants were: moral norm, beta=0.34, p<.0001; perceived behavioral control, beta=0.29, p<.0001; attitude, beta=0.22, p<.0001; descriptive norm, beta=0.13, p<.0001; and professional status, (GPs, beta=-0.07, p<.0001; residents, beta=-0.07, p<.0001). Facilitating conditions and developing a better perception of control over perceived obstacles could help enhance health-care practitioners' intentions to use CAM. Also, a clear position on the part of the medical community would help to define a professional norm in line with the moral norm.

Plasma organochlorine concentrations and bone ultrasound measurements: a cross-sectional study in peri-and postmenopausal Inuit women from Greenland

BACKGROUND

Inuit women are highly exposed through their traditional seafood based diet to organochlorine compounds, some of them displaying endocrine disrupting properties. We hypothesized that this exposure might be related to bone characteristics that are altered in osteoporosis, because hormone deficiency is a known risk factor for the disease.

METHODS

We measured quantitative ultrasound parameters (QUS) at the right calcaneum of 153 peri- and postmenopausal Inuit women (49-64 year old) from Nuuk, Greenland, and investigated the relation between these parameters and plasma organochlorine concentrations. We used high-resolution gas chromatography with electron capture detection to analyze plasma samples for 14 polychlorinated biphenyls (PCB) congeners and 11 chlorinated pesticides and metabolites. We analysed morning urine samples for cadmium, a potential confounder, by atomic absorption spectrometry. We used a validated questionnaire to document dietary and lifestyle habits as well as reproductive and medical histories.

RESULTS

Concentrations of PCB 153, a surrogate of exposure to most organochlorines present in plasma samples, were inversely correlated to QUS parameters in univariate analyses (p < 0.001). However, PCB 153 concentrations were not associated with QUS values in multivariate analyses that comprised potential confounding factors such as age, body weight, former oral contraceptive use and current hormone replacement therapy (HRT) use, which were all significant predictors of bone stiffness (total R2 = 0.39; p < 0.001).

CONCLUSION

Overall we found little evidence that organochlorines exposure is related to osteoporosis in Greenlandic Inuit women, but the hypothesis that exposure to dioxin-like compounds might be linked to decreased bone quality and osteoporosis deserves further attention.

The use of hypnosis to improve pain management during voluntary interruption of pregnancy: an open randomized preliminary study

OBJECTIVE

This report describes an open randomized study that aims to determine whether a brief hypnotic intervention during first-trimester surgical abortion reduces requests for pain medication.

METHODS

Thirty women undergoing first-trimester surgical abortion at the family planning clinics of a large hospital in Quebec City were randomized into a control group that received standard care and a hypnosis group that received, in addition to standard care, an intervention of hypnosis, including analgesia suggestions 20 min before and throughout the surgical procedure. Patients in both groups were given the option to control their pain with nitrous oxide (N(2)O) sedation administered through a nose mask as often and for as long as they wanted during the procedure. N(2)O sedation as the primary outcome was assessed at each step of the procedure. The patient's self-reported anxiety and pain were also assessed during the procedure as secondary outcomes.

RESULTS

Thirty-six percent of patients in the hypnosis group requested N(2)O sedation during the procedure versus 87% in the control group (p<.01). No differences between the groups were found in reports of pain and anxiety during the procedure.

CONCLUSION

These results suggest that hypnosis can be integrated into standard care and reduces the need for N(2)O in patients undergoing first-trimester surgical abortion. This reduction in N(2)O consumption did not lead to significant changes in pain or anxiety, and a larger sample size is required to assess the possible effects of hypnosis on those variables.

Rosiglitazone and ethinyl estradiol/cyproterone acetate as single and combined treatment of overweight women with polycystic ovary syndrome and insulin resistance

BACKGROUND

Few studies have evaluated insulin sensitizers in comparison/association with oral contraceptives (OC) in women with polycystic ovary syndrome (PCOS) with insulin resistance (IR). This study assessed the effects of a thiazolidinedione versus an anti-androgenic estrogen-progestin followed by their sequential combinations in overweight PCOS women.

METHODS AND RESULTS

Twenty-eight candidates in whom elevated insulin was not normalized after 4 months of diet were randomly assigned to 6 months of rosiglitazone 4 mg/day or to ethinyl estradiol 35 mg/cyproterone acetate 2 mg (EE/CPA: 21/28 days cycle). Each group then received both medications for another 6 months. Rosiglitazone reduced insulin, IR indices [homeostasis model assessment (HOMA) and quantitative sensitivity check index (QUICKI)] and the insulin area under the curve in response to an oral glucose tolerance test (OGTT), but had limited effect on lipids, androgens and hirsutism. EE/CPA did not modify insulin and OGTT response but increased high-density lipoprotein cholesterol and triglycerides and decreased androgens and hirsutism. Similar changes occurred during combined treatments. End results were highly significant in combined groups without noticeable side-effects or changes in safety parameters.

CONCLUSIONS

In obese PCOS women with high insulin not corrected by diet, the combination of rosiglitazone and EE/CPA may be used to achieve complementary beneficial effects on endocrine-metabolic anomalies and clinical symptoms.

Variation in the psychosocial determinants of the intention to prescribe hormone therapy prior to the release of the Women's Health Initiative trial: a survey of general practitioners and gynaecologists in France and Quebec

BACKGROUND

Theory-based approaches are advocated to improve our understanding of prescription behaviour. This study is an application of the theory of planned behaviour (TPB) with additional variables. It was designed to assess which variables were associated with the intention to prescribe hormone therapy (HT). In addition, variations in the measures across medical specialities (GPs and gynaecologists) and across countries (France and Quebec) were investigated.

METHODS

A survey among 2,000 doctors from France and 1,044 doctors from Quebec was conducted. Data were collected by means of a self-administered questionnaire. A clinical vignette was used to elicit doctors' opinions. The following TPB variables were assessed: attitude, subjective norm, perceived behavioural control, attitudinal beliefs, normative beliefs and power of control beliefs. Additional variables (role belief, moral norm and practice pattern-related factors) were also assessed. A stepwise logistic regression was used to assess which variables were associated with the intention to prescribe HT. GPs and gynaecologists were compared to each other within countries and the two countries were compared within the specialties.

RESULTS

Overall, 1,085 doctors from France returned their questionnaire and 516 doctors from Quebec (response rate = 54% and 49%, respectively). In the overall regression model, power of control beliefs, moral norm and role belief were significantly associated with intention (all at p < 0.0001). The models by specialty and country were: for GPs in Quebec, power of control beliefs (p < 0.0001), moral norm (p < 0.01) and cytology and hormonal dosage (both at p < 0.05); for GPs in France, power of control beliefs and role belief (both at p < 0.0001) and perception of behavioural control (p < 0.05) and cessation of menses (p < 0.01); for gynaecologists in Quebec, moral norm and power of control beliefs (both at p = 0.01); and for gynaecologists in France, power of control beliefs (p < 0.0001), and moral norm, role belief and lipid profile (all at p < 0.05).

CONCLUSION

In both countries, compared with GPs, intention to prescribe HT was higher for gynaecologists. Psychosocial determinants of doctors' intention to prescribe HT varied according to the specialty and the country thus, suggesting an influence of contextual factors on these determinants.

A frequent regulatory variant of the estrogen-related receptor alpha gene associated with BMD in French-Canadian premenopausal women

Genes are important BMD determinants. We studied the association of an ESRRA gene functional variant with BMD in 1335 premenopausal women. The ESRRA genotype was an independent predictor of L2-L4 BMD, with an effect similar to smoking and equivalent to a 10-kg difference in weight.

INTRODUCTION

Several genetic polymorphisms have been associated with osteoporosis or osteoporosis fractures, but no functional effect has been shown for most of these gene variants. Because functional studies have implicated estrogen-related receptor alpha (ESRRA) in bone metabolism, we evaluated whether a recently described regulatory variant of the ESRRA gene is associated with lumbar and hip BMD as measured by DXA and with heel bone parameters as measured by quantitative ultrasound (QUS).

MATERIALS AND METHODS

Heel bone parameters were measured by right calcaneal QUS in 1335 healthy French-Canadian premenopausal women, and one-half of these women also had their BMD evaluated at two sites: femoral neck and lumbar spine (L2-L4) by DXA. All bone measures were tested separately for association with the ESRRA genotype by analysis of covariance. The significance of the ESRRA contribution to the model was also assessed by two different permutation tests.

RESULTS

A statistically significant association between ESRRA genotype and lumbar spine BMD was observed: women carrying the long ESRRA genotype had a 3.9% (0.045 g/cm2) higher lumbar spine BMD than those carrying the short ESRRA genotype (p = 0.004), independently of other risk factors measured. This effect of ESRRA genotype is similar to the effect of smoking and equivalent to a 10-kg difference in weight. This association was confirmed by permutation tests (p = 0.004). The same trend was observed for femoral neck BMD (2.6%, p = 0.07). However, no association was observed between ESRRA and QUS heel bone measures.

CONCLUSION

These results support the genetic influence of this ESRRA regulatory variant on BMD.

The effects of flaxseed dietary supplement on lipid profile, bone mineral density, and symptoms in menopausal women: a randomized, double-blind, wheat germ placebo-controlled clinical trial

Phytoestrogens are increasingly incorporated into the diet of menopausal women. However, there are limited data on the efficacy of flaxseed on the consequences of estrogen deficiency in menopausal women. The purpose of the study was to assess the effects of flaxseed incorporation into the diet of healthy menopausal women. One hundred and ninety-nine menopausal women were randomly assigned to consume 40 g flaxseed/d (n = 101) or wheat germ placebo (n = 98) for 12 months. At baseline and at month 12, serum levels of lipids, bone mineral density (BMD), and menopausal symptoms were evaluated. Statistical analysis was performed under the intention to treat principle. Flaxseed reduced serum total (-0.20 +/- 0.51 mmol/liter; P = 0.012) and high-density lipoprotein (-0.08 +/- 0.24 mmol/liter; P = 0.031) cholesterol concentrations compared with wheat germ placebo. BMD did not differ significantly between the two arms. Both flaxseed and wheat germ reduced (P < 0.0001) the severity scores of menopausal symptoms, but no statistical difference was found between the two arms. Our findings suggest that 1-yr incorporation of flaxseed into the diet produced a favorable, but not clinically significant, effect on blood cholesterol and caused no significant change in BMD or symptoms in healthy menopausal women.

Hormone therapy prescription among physicians in France and Quebec

OBJECTIVE

Our objective was to compare physician characteristics associated with high-frequency hormone therapy (HT) prescription between gynecologists and general practitioners (GPs) within and between France and Quebec, Canada.

DESIGN

A self-administered mail survey was sent to a representative sample of 2,000 physicians in France and 1,000 physicians in Quebec. High-frequency prescribers were those who reported prescribing HT to more than 70% of their postmenopausal patients. The following characteristics were included in the analysis: country, specialty, age, gender, characteristics of the practice (solo or group, private or public, rural or urban, number of patients seen daily, duration of practice, percentage of women 45 years or older), teaching or research activities, participation in education course on HT, and practice patterns relating to menopausal women (having patient education materials available, providing materials to patients, and discussing the possibility of HT).

RESULTS

The analysis covered 974 physicians in France (389 GPs and 585 gynecologists) and 452 physicians in Quebec, Canada (318 GPs and 134 gynecologists). Despite differences in health care, in both countries gynecologists were more likely to be high-frequency prescribers than were GPs, although this difference was smaller in Quebec. Canadian physicians were more likely to prescribe HT. The difference between countries was greatest among GPs. Except for nationality and practice patterns designed to provide women with information, none of the physician characteristics was associated with high-frequency prescription among GPs. Among gynecologists, only the number of patients per day and the provision of information were associated with high-frequency prescription.

CONCLUSIONS

Notwithstanding a common language, differences in the prescription pattern of HT between countries were greatest at the level of primary care than secondary care. In both countries, specialists were more likely to prescribe HT than were GPs. Implementation of clinical practice guidelines to set baseline standards in the field of menopausal health remains a challenge but will need to take into account cultural characteristics as well as level of medical care.

Ability of peripheral DXA measurement to diagnose osteoporosis as assessed by central DXA measurement

In order to evaluate the utility of peripheral measurement of bone mineral density (BMD) in the diagnosis of osteoporosis, we measured BMD at the spine and femoral neck with central dual-energy X-ray absorptiometry (DXA), at phalanx with AccuDXA (Schick) as well as proximal and distal forearm with pDXA (Norland) in 835 women ranging in age from 20 to 85 yr. In receiver operating characteristic (ROC) curves, where a positive case was defined as a T-score < or = -2.5 either on spine or femoral neck, the areas under the curve were not significantly different between sites. At a T-score of -2.5 as determined by each peripheral apparatus, sensitivity and specificity were, respectively, 0.39 and 0.95 for phalanx and 0.75 and 0.85 for proximal forearm whereas they were 0.42 and 0.96 for distal forearm. Using optimal absolute BMD cutoff values improved the results. Sensitivity and specificity were, respectively, 0.79 and 0.83 for phalanx at an absolute BMD value of 0.436 and 0.84 and 0.79 for proximal forearm at a value of 0.703, whereas they were 0.90 and 0.75 for distal forearm at a value of 0.208. Combining the two forearm measurements improves the results slightly. At cutoff values of 0.641 and 0.252, respectively for proximal and distal forearms, sensitivity was 0.83 and specificity was 0.84. Therefore, a peripheral measurement of BMD together with a good clinical evaluation of the osteoporosis risk profile of the patient, can be an interesting tool for the diagnosis of osteoporosis in areas where central DXA is not available.

Phytoœstrogènes chez la femme ménopausée

Many women seek alternatives to hormone replacement therapy (HRT). Phytoestrogens are nonsteroidal compounds with estrogenic or antiestrogenic properties. Six of the 16 clinical trials suggest a significant reduction in alleviating symptoms but to a lesser degree than HRT. A meta-analysis showed that phytoestrogens improve lipid profile. The 14 recent clinical trials led, however, to divergent findings. Small clinical trials suggested a protective effect of phytoestrogens on bone metabolism. High concentration of phytoestrogens was associated with a reduction in breast cancer risk in case-control studies.

Leisure physical activity is associated with quantitative ultrasound measurements independently of bone mineral density in postmenopausal women

The purpose of this study was to assess the magnitude of the relationship between leisure physical activity and bone status as measured either by an Achilles ultrasound bone densitometer (QUS) or dual-energy X-ray absorptiometry (DXA) in postmenopausal women. We studied 1162 French Canadian postmenopausal women, aged 33-84 years (mean age 58 years), for QUS parameters [broadband ultrasound attenuation (BUA), speed of sound (SOS), and stiffness index (SI)] measured at the right calcaneus, and bone mineral density (BMD) measured at the lumbar spine and femoral neck. Multivariate regression analyses revealed that leisure physical activity level was an independent predictor of the heel QUS parameters and of femoral neck BMD. No such association was observed for BMD of the lumbar spine. Heel QUS parameters (BUA, SOS, SI) and femoral neck BMD adjusted for interfering covariables showed a statistically significant difference between sedentary (less than three sessions/month) and active women (three or more sessions/week) (P < or = 0.001). Furthermore, after adjusting each heel QUS parameters for the mean lumbar spine BMD value, the association observed between leisure physical activity and QUS remained significant. These results suggest that regular leisure physical activity could influence QUS parameters, independently of BMD, and that quantitative ultrasound could be a suitable outcome measure in exercise studies in postmenopausal women.

Flaxseed dietary supplement versus hormone replacement therapy in hypercholesterolemic menopausal women

OBJECTIVE

To assess serum lipid changes by a phytoestrogen dietary supplement compared with oral estrogen-progesterone replacement in hypercholesterolemic menopausal women.

METHODS

Twenty-five menopausal patients with total cholesterol greater than 6.2 mmol/L (240 mg/dL), a cholesterol/high-density lipoprotein-cholesterol ratio greater than 4.5 and triglycerides less than 3.5 mmol/L (310 mg/dL) after a 4-month diet, were randomized to add 40 g/day of crushed flaxseed to their diet or to take daily 0.625 mg of conjugated equine estrogens alone (hysterectomy, n = 10) or combined with 100 mg of micronized progesterone (intact uterus, n = 15). After 2 months of treatment, both groups continued the diet alone during a 2-month washout period before crossing over to the alternate treatment for 2 more months.

RESULTS

Differences were found between hormone replacement therapy and flaxseed respectively for decrease of low-density lipoprotein cholesterol (3.8 +/- 0.2 versus 4.4 +/- 0.2 mmol/L) (148 +/- 8 versus 170 +/- 8 mg/dL) (P =.10), increase of high-density lipoprotein cholesterol (1.6 +/- 0.04 versus 1.3 +/- 0.03 mmol/L) (62 +/- 1 versus 50 +/- 1 mg/dL) (P =.001), and increase of apolipoprotein A-1 (1.71 +/- 0.07 versus 1.42 +/- 0.05 g/L) (P =.003). These changes were not related to modifications in diet, exercise, or anthropometric measurements evaluated in parallel. Both treatments produced similar decreases in menopausal symptoms and in glucose and insulin levels. Only hormone replacement therapy as compared with flaxseed induced an elevation of sex hormone binding globulin (P =.004), lowered fibrinogen (P =.08), and plasminogen activator inhibitor type 1 (P =.01).

CONCLUSION

Although 40 g of flaxseed is as effective as oral estrogen-progesterone to improve mild menopausal symptoms and to lower glucose and insulin levels, only hormone replacement therapy significantly improves cholesterol profile in hypercholesterolemic women and favorably modifies markers related to cardiovascular health.

Plasma concentrations of polychlorinated biphenyls and the risk of breast cancer: a congener-specific analysis

Some reports indicate that exposure to specific polychlorinated biphenyl (PCB) congeners is related to breast cancer risk. The authors recruited participants in a case-control study from October 1994 to March 1997 to assess the relation between breast cancer risk and concentrations of 14 PCB congeners measured in plasma lipids by high-resolution gas chromatography. Participants were incident cases of breast cancer (n = 314) and controls (n = 523) from the Quebec City region (Canada). Compared with controls, cases had significantly higher concentrations of PCB 99 (p = 0.02), PCB 118 (p = 0.03), and PCB 156 (p = 0.006). Associations were found between breast cancer risk and either PCB 118 (odds ratio (OR) = 1.60, 95% confidence interval (CI): 1.01, 2.53; fourth vs. first quartile) or PCB 156 (OR = 1.80, 95% CI: 1.11, 2.94; fourth vs. first quartile) concentration. Breast cancer risk was also associated with a total concentration of the three mono-ortho-substituted congeners 105, 118, and 156 expressed as 2,3,7,8-tetrachlorodibenzo-p-dioxin toxic equivalents (OR = 2.02, 95% CI: 1.24, 3.28; fourth vs. first quartile). These results suggest that exposure to dioxin-like PCBs increases breast cancer risk. Alternatively, the results may be explained by differences between cases and controls regarding metabolic pathways involved in the biotransformation of both mono-ortho PCBs and estrogens.

Association of physical activity and bone: influence of vitamin D receptor genotype

PURPOSE

The aim of the study was to investigate the interaction between leisure physical activity and a BsmI polymorphism at the vitamin D receptor (VDR) gene on the modulation of bone mineral density (BMD).

METHODS

We studied 575 unrelated healthy postmenopausal women. Lumbar spine and femoral neck BMD were measured by dual-energy x-ray absorptiometry (DXA), and results were expressed as age-and-weight-adjusted (Z-score). VDR BsmI genotype was determined by polymerase reaction chain on peripheral blood leukocytes.

RESULTS

Overall, no significant association was found between the level of leisure physical activity or VDR genotypes and adjusted BMD at both bone sites. However, in active women, there was a trend for an association between VDR genotypes and adjusted BMD at the lumbar spine. Active women, who exercised three times or more a week, carrying the "bb" genotype had a lower BMD at the lumbar spine than active women carrying "BB" genotype (ANOVA; P = 0.04). No significant difference in crude or adjusted BMD at both bone sites was found between VDR genotypes in sedentary or moderately active women. Furthermore, classification of women according to the median-age of the sample (63.1 yr) revealed a significant interaction between the level of leisure physical activity and VDR genotype on adjusted lumbar spine BMD in the older active postmenopausal women (N = 137). Older active women carrying the "bb" genotype showed a lower adjusted BMD at the lumbar spine compared with active women carrying the "BB" genotype (P = 0.007).

CONCLUSION

These results suggested that gene-environment interactions such as leisure physical activity and VDR genotype may play a role in maintaining the BMD at the lumbar spine in active postmenopausal women, especially in older active women.

Estrogen/progesterone replacement versus pravastatin and their sequential association in hypercholesterolemic postmenopausal women

OBJECTIVES

The objectives of this study were to assess serum lipid changes in response to an oral estrogen combined with progesterone (Group A) as compared with pravastatin (Group B) and to evaluate the additive effects of the sequential addition of statin to hormonal replacement therapy (HRT) and of HRT to statin.

METHODS

Thirty-seven of 63 hypercholesterolemic menopausal women initially submitted to a 4-month diet were randomised to oral conjugated estrogens (0.625 mg)/micronised progesterone (200 mg) or to pravastatin (40 mg). After 6 months, each group received both medications for another 6 months.

RESULTS

Nineteen percent of women corrected their lipids below decision levels with diet alone. Low density lipoprotein-cholesterol (LDL-C) decreased by 8+/-5% with HRT and by 26+/-3% (P<0.001) with the statin. These single medications increased high density lipoprotein-cholesterol (HDL-C) by 13+/-5% (P<0.01) and 11+/-7%, respectively. Combined interventions produced cumulative LDL-C reductions of 40+/-2 and 42+/-3% (P<0.001) and additive HDL-C augmentations of 16+/-4 and 23+/-5% (P<0.01) with proportional changes in apolipoprotein (Apo)B-100 and ApoA-1. These combined effects brought the atherogenic index (C/HDL-C) for Groups A and B, respectively, from a moderate (5.18+/-0.25 and 5.87+/-0.18) to a reduced (3.35+/-0.20 and 3.52+/-0.19) risk category. Triglycerides (TG) which were increased by HRT and decreased by the statin returned to baseline during combined treatments. No changes in diet, physical activity or anthropomorphometric measurements explained the lipid modifications.

CONCLUSIONS

In menopausal patients with elevated C not responding to diet, pravastatin was most effective to decrease LDL-C, and oral estrogen-micronised progesterone most effective to increase HDL-C. Marked reduction of the atherogenic index is achieved by sequential combinations of medications resulting from beneficial cumulative effects on both C-LDL and C-HDL.

[Making a decision about hormone replacement therapy. A randomized controlled trial]

OBJECTIVE

To compare the efficacy of a decision-making aid with an information document from the Society of Obstetricians and Gynaecologists of Canada (SOGC) with regard to decisions about hormone replacement therapy (HRT).

DESIGN

Randomized clinical trial.

SETTING

Quebec city region.

PARTICIPANTS

Menopausal Francophone women 45 to 69 years old.

INTERVENTIONS

Subjects were given a manual and an audiocassette describing a six-step approach to making a decision about HRT.

MAIN OUTCOME MEASURES

Amount of anxiety over the decision (main outcome), general knowledge of the risks and benefits of HRT, personal expectations and values concerning these risks and benefits, and women's views on HRT.

RESULTS

Anxiety levels were significantly reduced in both groups, but the difference between the effectiveness of the two interventions was not significant (P = .77). Percentages of women whose general knowledge increased and of women with realistic expectations were significantly higher in the experimental group (P < .003 and P < .0001, respectively). Congruence between personal values and decisions about HRT increased significantly more in the experimental group (P < or = .003).

CONCLUSION

The six-step approach to decision making was more helpful than the SOGC's information document in increasing subjects' knowledge of the risks and benefits of HRT, in creating more realistic expectations of HRT, and in increasing the congruence between subjects' personal values and their decisions on HRT.

Short polyglutamine tracts in the androgen receptor are protective against breast cancer in the general population

We studied the association of breast cancer with the polymorphic polyglutamine repeat of the androgen receptor (AR) in 255 incident cases of breast cancer and 461 matched controls from the Quebec City metropolitan area. Women for whom the sum of both of the AR (CAG)n-repeats alleles is 39 or less (short-allele AR genotypes) have one-half the risk of breast cancer compared with women for whom the sum of AR (CAG)n-repeats is 40 or more [odds ratio (OR), 0.5; 95% confidence interval (CI), 0.3-0.83; P = 0.007]. This association is stronger in postmenopausal women (180 cases, 297 controls; OR, 0.36; 95% CI, 0.19-0.7; P = 0.003). We also observed an interaction between the type of menopause (natural versus surgical) and the AR genotype on breast cancer risk. Alternately, when subjects were grouped according to their (CAG)n-repeat genotype [homozygous for short alleles (CAG)n < or = 20; other genotypes ("long allele")], results were similar (OR. 0.5; 95% CI, 0.27-0.82; P = 0.007). Thus, women with short-alleles AR genotypes appear to be protected against breast cancer. Short-alleles AR genotypes were observed in 16% of the general population as represented by the control group. Short polyglutamine repeats in the AR protein have been reported to be associated with an increase in the capacity of the receptor to activate transcription of reporter genes in vitro. Furthermore, androgens have been previously shown to inhibit in vitro the growth of breast cancer cell lines. This suggests that differences in the number of polyglutamines in the AR protein may influence individual risk of breast cancer, especially in postmenopausal women, and that this apparent protection could be the consequence of an increased response/sensitivity to androgens.

The association between heel ultrasound and hormone replacement therapy is modulated by a two-locus vitamin D and estrogen receptor genotype

Evidence supports the role of estrogen deprivation in the process of bone remodeling and increased risk of fracture in postmenopausal women but little is known about the genetic basis of individual differences in response to therapy. In a cross-sectional study, 425 ambulatory postmenopausal French-Canadian women from Quebec (age range, 42-85 years old) were genotyped for a common Bsm I polymorphism at the vitamin D receptor (VDR) gene as well as a Pvu II polymorphism in the estrogen receptor (ESR1) gene. Heel ultrasound was determined by right calcaneal quantitative ultrasound (QUS) and results were expressed as an age-and-weight-adjusted stiffness index (heel SI z score). Our aim was to investigate the interaction between hormone-replacement therapy (HRT) and receptor genotypes in an effect on heel SI. Notably, a two-locus genotype (VDR-bb/ESR-PP) present in 9.5% of women was responsible for over 30% of the total HRT-related heel SI difference in the whole sample. Women bearing this combined VDR/ESR1 genotype who received HRT for more than 5 years had a 21% (1.25 SD) greater heel SI (p = 0.002) than those bearing the same genotype but who received HRT for <5 years. This may translate into a 2- to 3-fold difference in the risk of fracture. Although follow-up studies are needed, our findings suggest that QUS of the heel in postmenopausal women taking HRT is affected by variation in VDR and ESR1 loci, jointly.

Determinants of the intention to adopt hormone replacement therapy among premenopausal women

OBJECTIVE

To identify the psychosocial factors that influence the intention to adopt hormone replacement therapy (HRT) at menopause.

METHODS

Random Digit Dialing was used to recruit 644 premenopausal non-hysterectomized women aged 45-54. Data were collected using a telephone questionnaire previously developed according to the theory of planned behaviour. Variables measured were: intention to adopt HRT (INT); attitude towards HRT (Aact); perceived social norm (SN); perceived behavioural control (PBC); and personal normative belief (PNB). Socio-demographic data were also obtained.

RESULTS

Stepwise multiple regression of INT on the theoretical variables yielded an R(2) of 0.70. The determinants were Aact (beta=0.39, P<0.001), PNB (beta=0.25, P<0.001), PBC (beta=0.23, P<0.001) and SN (beta=0.12, P<0.001). Women with a strong intention to adopt HRT represented 25% of the sample. These women were more likely to believe that adopting HRT would have the following positive consequences: an improvement in general well-being, the prevention of health problems, an improvement in interpersonal relationships, an increase in productivity, the regulation of mood swings and a reduction of hot flashes. They were also more likely to believe in the following negative consequences: side-effects, an increased risk of cancer, the likelihood of weight gain, and interference in the natural course of menopause (all at P<0.001).

CONCLUSION

Actions that target behaviourial beliefs regarding HRT and perceived barriers to its adoption are most likely to influence adoption of HRT.

Risk and aggressiveness of breast cancer in relation to plasma organochlorine concentrations

Several organochlorines identified as "hormone mimics" were proposed as possible risk factors for breast cancer. We conducted a case-control study to assess breast cancer risk and disease aggressiveness in relation to plasma concentrations of several organochlorine compounds. Plasma lipid concentrations of 11 chlorinated pesticides and 14 polychlorinated biphenyl congeners were measured in 315 women newly diagnosed with breast cancer, 219 hospital-based controls, and 307 population controls from the Quebec City area (Canada). Concentrations of hormonally active organochlorines or their surrogates were compared between cases and controls as well as between groups of cases defined according to tumor size and axillary-lymph-node involvement. We found similar levels of organochlorines in cases and controls and no relationship between the relative risk of breast cancer and organochlorine exposure. However, the probability of lymph-node invasion among cases increased with exposure to 1,1-dichloro-2,2-bis(4-chlorophenyl)ethylene [p,p'-DDE; odds ratio, 2.54; 95% confidence interval (CI), 1.20-5.35; between the highest and the lowest tertiles]. Furthermore, p,p'-DDE exposure was associated with a dose-related increased relative risk of exhibiting both lymph-node involvement and a large tumor. Indeed odds ratio raised to 2.33 (95% CI, 0.94-5.77) for the second tertile relative to the first tertile and reached 3.51 (95% CI, 1.41-8.73) for the third tertile relative to the first tertile. Similar associations were noted with beta-hexachlorocyclohexane, oxychlordane, and transnonachlor. We conclude that exposure to persistent, hormonally active organochlorines during adulthood is not associated with breast cancer risk. The possibility that some organochlorines and especially p,p'-DDE may increase breast cancer aggressiveness deserves further attention.

[Factors influencing the adoption of hormone replacement therapy]

OBJECTIVE

To develop and test the metrologic qualities of a questionnaire for a survey on determining factors in initiating hormone replacement therapy (HRT), using Ajzen's planned behaviour theory.

DESIGN

Semistructured interviews to collect the behavioural beliefs needed to develop the questionnaire and the test-retest.

SETTING

Family medicine practices and the community.

PARTICIPANTS

In two family medicine practices, 42 women completed semistructured interviews that yielded the beliefs needed to design the questionnaire for the core survey. Thirty other women from the community took part in the test-retest 2 weeks later.

MAIN OUTCOME MEASURES

The internal consistency of the constructs (tendency of answers within a group of questions) was determined using Cronbach's alpha coefficient. Stability of the global constructs (proportion of subjects who had an absolute difference in their scores of less than 1 between the two measurements) was determined using the adjusted agreement coefficient (adjusted Po).

RESULTS

Findings for 12 of the 14 global constructs were above the acceptance threshold of 0.60. In one case alpha could not be measured because there was only one question for measuring it. On the test-retest, 12 of the 14 adjusted Pos had a reliability rating at or above 80%.

CONCLUSION

The questionnaire developed using Ajzen's planned behaviour theory had the requisite metrologic qualities for integration into the core survey on determining factors for initiating HRT.

Organochlorine exposure and the risk of endometriosis

OBJECTIVE

To compare mean concentrations of organochlorine in women with a new diagnosis of endometriosis and in controls.

DESIGN

Case-control study.

SETTING

Women attending an institutional clinic of reproductive endocrinology.

PATIENT(S)

Cases and controls were selected among women who underwent laparoscopy for chronic pelvic pain, infertility, or tubal fulguration between January 1994 and December 1994. Eighty-six women with endometriosis and 70 controls, matched for the indication for laparoscopy, were recruited.

MAIN OUTCOME MEASURE(S)

Mean organochlorine plasma concentrations of 14 polychlorinated biphenyl congeners and 11 chlorinated pesticides were compared between the cases and controls. Analysis of covariance was used to adjust means for confounding variables, and odds ratios were estimated by logistic regression.

RESULT(S)

Crude geometric mean concentrations did not differ significantly between cases and controls for any of the organochlorine compounds. Similarly, crude or adjusted means of the sum of polychlorinated biphenyl congeners, the sum of chlordanes, or the sum of dichlorodiphenyltrichloroethanes did not differ between the groups. There was no significant linear trend in the adjusted odds ratios for endometriosis as organochlorine concentrations increased.

CONCLUSION(S)

These results suggest that exposure to polychlorinated biphenyls and chlorinated pesticides during adulthood is not associated with endometriosis in the general population.

Bone mineral density in French Canadian women

This cross-sectional study investigated bone mineral density (BMD) at the lumbar spine (L2-4) and femoral neck in French Canadian women residing in the Quebec city area. Data collection was initiated in 1988 and completed in 1994. A total of 747 French Canadian Caucasian women (16-79 years of age) with no metabolic bone disease were evaluated. BMD measurements were obtained using dual-photon absorptiometry (DPA) or dual-energy X-ray absorptiometry (DXA). Anthropometric measures such as weight, height and body mass index (BMI) were recorded. Medical files provided information on demographic characteristics, hormonal profile and lifestyle habits. Results show a curvilinear trend of BMD with aging. Furthermore, the peak BMD at the lumbar spine (L2-4) was reached at 29 years followed by a stable phase until 35 years, after which BMD started to decrease. The pattern of bone evolution at the femoral neck was different, peak BMD being achieved earlier, at 21 years, while after age 26 years a significant decrease was already observed. Women older than 60 years showed the lowest BMD. Regression analysis showed that age, weight and height are determinants of BMD at the lumbar spine and explained 33.9% of inter-individual variation. At the femoral neck, 29.1% of variation was explained by age and height only. In conclusion, our data suggest that French Canadian women have a different pattern of bone loss at the femoral neck compared with the lumbar spine, according to their mean BMD values.

Clinical efficacy and safety of low-dose flutamide alone and combined with an oral contraceptive for the treatment of idiopathic hirsutism

BACKGROUND AND OBJECTIVE

High doses of flutamide, which is the only antiandrogen that specifically blocks the androgen receptor, have recently been used with good clinical results in women with hirsutism. Since regression of hair growth requires long-term therapy, clinical and economic considerations are important. The use of the lowest efficacious dosage could reduce costs. This study was undertaken to compare safety and efficacy of a low dose of flutamide (125 mg twice daily) alone and in combination with a triphasic oral contraceptive (OC) in women with idiopathic hirsutism.

PATIENTS

Flutamide was administered orally in a low dose of 125 mg twice daily for 12 months alone in women with no risk of pregnancy or during the use of an oral contraceptive.

MEASUREMENTS

Women were seen every 3 months and were evaluated for hirsutism score, hormone and lipid measurements.

DESIGN

The study, which was conducted as a prospective open trial, was proposed to patients with idiopathic hirsutism, that is, with serum androgen levels in normal range and LH/FSH ratio less than 2.

RESULTS

A statistically significant decrease in hirsutism score as compared to baseline was observed after only 3 months with either treatment, flutamide alone (16.9 +/- 1.6 vs 14.2 +/- 1.7, P < 0.0001) or the combination of flutamide with OC (15.6 +/- 0.8 vs 11.9 +/- 0.8, P < 0.001). Three months after cessation of treatment a statistically significant decrease from baseline was observed in the two groups. Nevertheless, at 6 months post-treatment this decrease was still significant only in the group who took flutamide in combination with an oral contraceptive. Flutamide alone does not appear to modify the levels of lipoproteins. The association of flutamide with a triphasic formulation significantly increased the HDL-C levels.

CONCLUSIONS

This study shows beneficial effects of a low dose of flutamide in women with idiopathic hirsutism. The addition of an oral contraceptive is judicious to prevent pregnancy and reduce recurrence of hirsutism after cessation of flutamide. Peripheral androgenic blockage does not modify lipid profiles and it might reduce the negative effect of oral contraceptive on HDL-C levels. The addition of electrolysis delays the recurrence of hirsutism after cessation of flutamide.

Phasic serum lipid excursions occur during cyclical oral conjugated oestrogens but not during transdermal oestradiol sequentially combined with oral medroxyprogesterone acetate

BACKGROUND AND OBJECTIVE

Recent data indicate that oral medroxyprogesterone acetate (MPA) has limited unfavourable, neutral or even favourable effects on serum lipid fractions when added to oestrogen replacement therapy. The purpose of this study was to evaluate the serum lipid fractions at the beginning and at the end of each phase of a sequentially combined replacement cycle comparing the oral and the transdermal routes of oestrogen administration.

DESIGN

Randomized study with a matched control group. Oral conjugated oestrogens (OCE, 0.625 mg) or transdermal oestradiol (TE 50 micrograms) was taken from day 1 to day 25 and MPA (5 mg) added on days 14 to 25. Serum lipids were evaluated on days 1, 14 and 25 of monthly replacement cycles.

PATIENTS

The early post-menopausal women in the control group (n = 11) and in the treatment groups (OCE/MPA, n = 15; TE/MPA, n = 17) were evaluated every 3 months for 12 months and every 6 months for another 12 months.

MEASUREMENTS

Serum levels of triglycerides (TG), cholesterol (C) fractions and apolipoproteins (Apo) and their respective ratios were measured at months 1, 3, 6, 9, 12, 18, 24. Menopausal symptoms and uterine bleedings were evaluated in parallel and an endometrial biopsy was performed at the end of the 12th and 24th months of treatment.

RESULTS

After 14 days of OCE, C, LDL-C, and Apo B were decreased and TG, HDL-C and Apo A1 were increased. The sequential addition of MPA accentuated the reduction of LDL-C and Apo B but attenuated the elevation of TG, HDL-C and Apo A1. These changes tended to revert toward baseline during the period free of medication. By contrast, at the end of 14 days of TE there was a non-significant reduction in TG and LDL components and a limited increase in HDL-C and Apo A1. During the subsequent addition of MPA there was no significant decrease in TG, LDL-C or Apo B but an elimination of the increase in HDL components. These combined changes resulted in a significant reduction in the LDL-C/HDL-C ratio and a significant elevation in the Apo A1/Apo B ratio only in the OCE/MPA group.

CONCLUSION

Overall, oral conjugated oestrogens induced favourable intragroup changes in cholesterol fractions whereas transdermal oestradiol maintained serum lipids at levels not different from baseline. The sequential addition of oral medroxyprogesterone acetate attenuated the beneficial elevation of HDL, did not affect the beneficial effect of oestrogens on ratios of cholesterol fractions and attenuated the unfavourable effect of oral conjugated oestrogens on triglycerides. The partial loss of beneficial effects on lipoproteins during cyclical interruption of hormone therapy would be an argument in favour of the evaluation of continuous regimens of oestrogen/progestagen replacement.

Correlation between ovarian steroids and lipid fractions in relation to age in premenopausal women

OBJECTIVE

We evaluated the effect of sex steroids on the lipid fractions (cholesterol, triglycerides, LDL-C, HLD-C and subfractions HDL2-C and HDL3-C) and on the apolipoproteins (A-1 and B) in relation to age in women.

DESIGN

Twenty-eight normally cycling women belonging to three age groups (20-29, n = 11; 30-39, n = 10; 40-49, n = 7) had blood samples taken daily during one cycle.

MEASUREMENTS

Serum lipid fractions, apolipoproteins (Apo) and ovarian steroids were measured daily during the menstrual cycle. Diet and exercise were also evaluated.

RESULTS

Each age group had comparable profiles for daily serum concentrations of oestradiol, progesterone and testosterone. There were no significant variations of the lipid fractions or of the ApoA-I and ApoB during the menstrual cycle in each group. Using regression analysis, modifications of cholesterol, triglycerides, LDL-C and ApoB were partially but significantly correlated with age. These changes occurred in spite of similar serum concentrations of oestradiol, progesterone and testosterone in the three groups. Lipid fractions were also affected by the increase of body mass index with age, especially HDL-C and HDL2C. However, there were no differences in lipid and energy intake or in energy expenditure during physical leisure activities.

CONCLUSIONS

These results indicate that physiological fluctuations of ovarian steroids have no effects on lipids and Apo in normally cycling women of increasing age. In this study, the age related changes in the lipid fractions were partially correlated with body mass index but not with energy intake or exercise.