[What scientific and clinical findings will result from the controlled trial "Women's Health Initiative"?]

The Women's Health Initiative Study is the first large randomized controlled trial for primary prevention, comparing the beneficial or adverse effects of an oral continuous-combined regimen of conjugated estrogens + medroxyprogesterone acetate, vs placebo in late postmenopausal women. This study brings evidence for an absence of preventive cardiovascular effects of hormone replacement therapy (HRT), shows for the first time a small increase in risk for coronary disease, and confirms a small increased risk for invasive breast cancer from four-five years of treatment on, a reduction of risk of colorectal cancer and osteoporotic fractures, and a moderate increase in other already known cardiovascular risks during HRT, such as venous thromboembolism and stroke. Although this study has inherent limitations and may be criticised, and the observed risks are restricted, it forces the physician to better respect known contra-indications (a.o. vascular) to HRT, to carefully weigh the benefit/risk balance of the patients, shorten HRT administration (4-5 years?), use minimal effective hormone dosages, preferably by non-oral route, and change for new compounds with more selective estrogenic action, which are under development.

[Hormone replacement therapy one year after the results of the Women's Health Initiative]

The currently reported data concerning the large WHI randomized controlled trial compare the impact of continuous combined conjugated estrogens + medroxyprogesterone acetate vs placebo in postmenopausal women. These results appear largely pessimistic. After 5.2 years of hormone replacement, an excess of coronary heart disease, cerebrovascular disease, venous thromboembolism, breast cancer incidence and extension, mild cognitive impairment and dementia is recorded. By contrast, osteoporotic fracture risk and colorectal cancer are decreased during hormone replacement. Accordingly, this hormonal treatment can no longer be recommended on a long term basis, except after extensive risk-benefit balance evaluation. It should no longer be prescribed for prevention of chronic diseases. It remains indicated during 4-5 years for relief of vasomotor symptoms, genital atrophy and, potentially, for some aspects of quality of life. HRT should probably be prescribed in minimal-effective dosages; new regimens, routes of administration, new compounds and associations should be envisaged in order to avoid cardiovascular or breast problems. However these new approaches ask for thorough validation studies.

A randomized study over 13 cycles to assess the influence of oral contraceptives containing ethinylestradiol combined with drospirenone or desogestrel on carbohydrate metabolism

In this open-label, randomized study we compared the influence of a new oral contraceptive containing 30 microg ethinylestradiol and 3 mg drospirenone (Yasmin) with a reference preparation containing 30 microg ethinylestradiol and 150 microg desogestrel (Marvelon) on variables of carbohydrate metabolism by means of oral glucose tolerance tests at baseline and in the 6th and 13th treatment cycle. The mean levels of fasting glucose and insulin were similar at baseline and after 13 treatment cycles, whereas C-peptide and free fatty acid levels decreased slightly in both groups. All blood glucose and insulin values measured in the oral glucose tolerance tests were within normal ranges, despite a slight increase in the mean areas under the curves of 0-3 h [AUCs (0-3 h)] of both variables from baseline to treatment cycle 13. Differences between both treatments were not statistically significant. The mean AUCs (0-3 h) for C-peptide were not markedly changed in any treatment group. Free fatty acid levels decreased by 42% in the drospirenone group and increased by 48.9% in the desogestrel group, in terms of means of individual changes. Both preparations were well tolerated and equally efficacious regarding contraception and cycle control. The mean body weight was slightly decreased in most cycles during treatment with the drospirenone combination, as compared to baseline, while it was slightly increased versus baseline in all cycles during treatment with the desogestrel combination. The combination with drospirenone had less impact on blood pressure than the combination with desogestrel. In conclusion, Yasmin, a combined low-dose oral contraceptive with 30 microg ethinylestradiol and 3 mg of the novel progestogen drospirenone, as well as the reference Marvelon, containing 30 microg ethinylestradiol and 150 microg desogestrel had little impact on carbohydrate metabolism when used for 1 year. The observed changes were small and not suggestive of a clinically relevant deterioration of carbohydrate metabolism.

[Benefits and limitations of mammography]

The literature on screening mammography provides ample opportunity for doubt (the sceptics) and dogma (the screening zealots), and can be interpreted to prove both benefit and harm. The benefit of mammography screening, if any, is modest and the balance between beneficial (potentially, a 20% relative reduction in breast cancer mortality with no significant benefit on all-cause mortality) and harmful (physical and psychological morbidity related to the 15-40% missed cancers and the 80-90% false-positive diagnoses) effects is still delicate. The mammogram alone is a modest weapon. Concurrent clinical breast examination is mandatory. Women that are concerned about breast cancer should be fully informed of the potential benefits and risks of screening mammography. These women should benefit from mammography with concurrent clinical breast examination, and possible whole-breast ultrasound in heterogeneously dense and extremely dense breast patterns.

Breast cancer and serum organochlorine residues

BACKGROUND

Controversy still exists about the breast carcinogenic properties in humans of environmental xenoestrogens (organochlorines), justifying new investigations.

AIMS

To compare the blood levels of total dichlorodiphenyltrichloroethane (DDT) and hexachlorobenzene (HCB) in samples collected at the time of breast cancer discovery, in order to avoid the potential consequences of body weight change (after chemotherapy or radiotherapy) on the pesticide residue levels.

METHODS

Blood levels of HCB and total DDT (we calculated total DDT concentrations by adding all DDT and DDE isomers) were compared in 159 women with breast cancer and 250 presumably healthy controls. Risk of breast cancer associated with organochlorine concentration was evaluated.

RESULTS

Mean levels of total DDT and HCB were significantly higher for breast cancer patients than for controls. No differences in serum levels of total DDT or HCB were found between oestrogen receptor positive and oestrogen receptor negative patients with breast cancer.

CONCLUSIONS

These results add to the growing evidence that certain persistent pollutants may occur in higher concentrations in blood samples from breast cancer patients than controls.

[Postmenopausal hormone replacement therapy and breast cancer risk: an update]

Numerous studies have examined the risk of breast cancer in patients with postmenopausal hormone substitution. Most of these studies are retrospective, and a few recent studies are prospective. The observed results present with weak variations from baseline and major heterogeneity. Some studies highlight a slightly increased relative risk of breast cancer. A reanalysis of 51 studies demonstrates a relative risk of 1.35 for developing breast cancer during hormone substitution, with a 2.3% increased risk per year of use. Recently, the results of the WHI study have shown a slight increase of some risks of disease, including breast cancer (relative risk, 1.26). These results have induced the interruption of one of the 3 arms of the study (that of the patients treated with an estrogen-progestin combination), and have provoked a new discussion about the benefits and risks associated with hormone substitution. These facts have been largely related and commented in the general press. In this article, we review the important studies concerning this topic.

[Clinical study of the month. Benefit/risk balance of postmenopausal estrogen-progestin treatment in peril in the Women's Health Initiative study: practical attitude of the clinician]

The Women's Health Initiative (WHI) is sponsored by the NIH. The study focuses on risk and benefits of strategies that could potentially reduce the incidence of heart disease, breast and colon cancer, and fractures in postmenopausal women. One arm of the study, a double-blind, placebo-controlled trial, looking at the effects of continuous combined estrogen-progestin regimen was stopped prematurely based on health risks which exceeded health benefits. The main reason for this decision was the increase in risk of invasive breast cancer, as well as a slight increase in the rate of myocardial infarction and stroke. In this paper, we inform our colleagues of the detailed results of the study. We comment on its limitation and discuss the new original observations. Finally, we integrate the others to previous world literature data that are confirmed by the WHI study. It is important for the individual prescribing practitioner to issue practical conclusions and therapeutic recommendations. The department of Obstetrics and Gynaecologic of the University of Liege, in agreement with the European Menopause Society and the International Menopause Society, is convinced that there is no alternative to the hormone replacement therapy for menopausal symptoms. We should stick to the traditional indications for hormones, namely vasomotor symptoms and osteoporosis. We should continue to recommend hormones for symptomatic women. One should realize that the risk for breast cancer appears only after several years of use, and the risk for cardiovascular events below age 60 is very small (the age of the patients was 63 at inclusion in the WHI study). We should encourage women to take the necessary measures for routine, periodic breast examinations (both manual, echographic and radiographic). Women who use HRT for more than 5 years should discuss the latest data of the WHI study with their physician, in order to consider their individual benefit-risk equation. Those who feel good on hormones and are fully satisfied with this treatment should learn of possible harm after long-term use. It is important to take into account the importance of quality of life. We should leave to the patient the final decision whether or not to continue the treatment. It is presently impossible to decide whether other estroprogestin associations, other administration routes and other molecules such as estradiol, natural progesterone or other progestins, SERMS and Tibolone could have an impact very different from that of the estroprogestin combination used in the WHI study. It is the duty of every physician to decide, from the complex epidemiological data obtained in the aged women (63-68 years) with a high cardiovascular risk in the WHI study, if it is possible or not in each individual case to recommend the initiation or pursue of an hormone replacement therapy.

[Pharma-Clinics. Medication of the month. Totelle Cycle: new sequential estrogen/progesterone regimen for hormone replacement therapy in menopause]

Totelle Cycle is a sequential regimen containing 2 mg of oestradiol for 28 days associated with a new progestogen, trimegestone, from day 15 to 28. It is indicated for the treatment of climacteric symptoms and the prevention of post-menopausal bone loss. Trimegestone is a new 19-NOR progesterone derivative with an original activity profile, near to--but much more powerful than--progesterone itself, and devoid of androgenic, glucocorticoïd and oestrogenic activity. This particular profile confers to trimegestone its metabolic neutrality and concurs to the high degree of safety and tolerance observed in studies related to Totelle Cycle.

[Towards better investigation of abnormal uterine bleeding and uterine pathologies]

Exploration of menometrorrhagia needs perfect imaging of the uterus and pathologic analysis in order to diagnose the endometrial pathologies responsible for abnormal uterine bleeding. We present here a clinical case typical for difficulties in the exploration of abnormal uterine bleeding, and discuss the diagnostical steps.

[How I treat ... surgically benign uterine lesions in 2002]

For 20 years, pre-operative investigations have increasingly improved the gynaecological diagnosis, allowing to have an accurate idea on the size and the nature of the lesion to be treated when the matter is to carry out the surgical treatment. In the meantime, the gynaecological surgery has seen its endoscopic surgical techniques improved due to the development of these diagnostic techniques itself. The operative hysteroscopy allows to decrease considerably the amount of hysterectomies for benign lesions. The operative laparoscopy has become the first intended treatment for many pathologies. This latter allows performing either laparoscopic assisted vaginal hysterectomies or complete laparoscopic hysterectomies. On the other hand, even though these endoscopic techniques were developing, the vaginal hysterectomy strongly returned, in such a way that it became the dominating way, so that the rule is to perform abdominal hysterectomy only when it is impossible to carry out a low way hysterectomy. Consequently, the gynaecologist surgeon has to be capable, in 2002, to perform all these surgical techniques in order to offer to the patient the best treatment, matching as good as feasible according to the pathology to be treated and her anatomical status.

Relationship between bone mass density and tensile strength of the skin in women

BACKGROUND

Skin and bone may be affected similarly during the climacteric and during long-term corticotherapy. Little is known about the correlation between the respective alterations in bone mass density (BMD) and tensile strength of the skin.

MATERIALS AND METHODS

A total of 100 women aged 19-88 years, receiving, or not, hormone replenishment therapy or systemic corticosteroids, were enrolled in the study. Tensile strength of the inner forearm skin was measured using the suction method operated in both the steep and progressive-force application modes. BMD was measured by dual X-ray absorptiometry at the hip, femoral neck and lumbar spine.

RESULTS

Being heterogeneous, the population of volunteers yielded a wide range of BMD and cutaneous tensile strength values. However, significant correlations were found between BMD and tensile skin parameters. In particular, a positive correlation was yielded between the biological elasticity of skin and the BMD of the hip and femoral neck.

CONCLUSION

An overall correlation is shown between skin elasticity on a relatively sun-protected area and cortico-trabecular BMD.

[Multiple benefits of physical exercise in menopausal women]

In postmenopausal women, metabolic and cardiovascular risks are increased not only because of aging but also in relation to estrogen deprivation, decreased physical activity and dietary changes. Accordingly, an increase in total fat mass and its intra-abdominal component, a decrease in lean body mass, an atherogenic dyslipidemia, decreased glucose tolerance, insulin resistance and an increase in procoagulant factors are ensuing, in a manner similar to the metabolic syndrome X and its accompanying risk for cardiovascular disease. Physical exercise concurs with an appropriate diet to weight loss, increases lean body mass and altogether energy expenditure, decreases total body fat mass and visceral fat, improves insulin sensitivity, reduces fibrinogenemia and optimizes hemodynamic parameters. Additionally, physical exercise contributes to protecting bone mass and may be associated with a decreased risk of estrogen-dependent breast and endometrial carcinomas at the postmenopause. In association with a balanced diet, and estrogen administration, physical exercise significantly contributes to metabolic fitness and decreased cardiovascular risk in postmenopausal women.

A quantitative biometrological assessment of acne and hormonal evaluation in young women using a triphasic low-dose oral contraceptive containing gestodene

OBJECTIVE

To investigate the effect of a triphasic low-dose oral contraceptive pill containing gestodene on acne severity and hormone levels in young women over 13 menstrual cycles.

METHODS

A total of 33 subjects aged 16-25 years with moderate facial acne were enrolled in the study. The primary efficacy end-points used in the clinical assessment of acne were the overall severity and number of lesions, sebum secretion and superficial follicular biopsy. Both physicians and patients evaluated acne status. Blood levels of sex hormone binding globulin (SHBG), estradiol, progesterone and androgens were monitored.

RESULTS

By cycle 13, the total lesion count had been reduced by 80%. Physicians and patients assessed acne status in 90% and 95% of cases, respectively, as better or much better (p < 0.001). At the end of the study, SHBG levels had increased by 229% and total and free testosterone levels had decreased by 41% and 70%, respectively.

CONCLUSION

An oral contraceptive containing triphasic gestodene has a beneficial effect on the severity ofacne, decreases major circulating androgen levels and is well tolerated.

[New forms of hormonal contraception]

Among new forms of hormonal contraception, three interesting exemples are described with a high level of effectiveness and low dosage regimen that allow improved safety and tolerance: a very low-dose estrogen-progestogen combination of ethinylestradiol and gestodene for 24-day cyclical administration; a progestogen-alone subcutaneous implant containing etonogestrel; and a levonorgestrel-releasing intrauterine system. These preparations appear to be particularly interesting as they provide additional possibilities for individualizing contraceptive therapy.

[Change in sexual desire in the menopausal woman: a succinct evaluation]

Physicians or gynecologists, specifically in their general practice or in the setting of a menopause clinic, are more and more frequently confronted with sexual complaints of menopausal women. Among these, decline in sexual desire is probably the most usually reported. The first study to evaluate a potential relationship between sexual functioning and menopause was conducted by Hallström in 1977. Thereafter, a review of the literature was able to show that there is nearly a consensus regarding the role of estrogens in that condition. They effectively relieve vaginal atrophy and resulting dyspareunia. There is less agreement, however, regarding a direct effect of estrogens on more complex sexual behavior and motivation. When analyzing potential influence of sex hormones, estrogens may exert a positive effect on the quality of the sexual relationship whereas androgens can definitely increase sexual "motivation" including sexual desire. In spite of the potentially important part played by androgens as promoters of libido and in the maintenance of sexual functioning in men and women, the exact role of the hormonal treatment in releaving sexual complaints still remains controversial. In some women where decline of sexual desire can be reasonably attributed to menopause, androgens in non-masculinizing adequate dosages, can be effectively included in the postmenopausal hormone replacement regimen. However, etiology of diminished sexual motivation and desire is far from univocal particularly in the human being where psychological, social and cultural influences are endowed with a prominent importance. It is accordingly quite conspicuous that our sexual life is not reduced to hormonal fluctuations only. A short critical review of the literature devoted to the main aspects of changes of sexual desire associated with menopause is presented.

[Hormone replacement therapy: practical recommendations]

In addition to vasomotor symptoms, trophic and functional urogenital problems, postmenopause is characterized by an increased risk of osteoporosis, cardiovascular disease and cognitive problems. The goal of estrogen replacement therapy is to reduce these risks. Numerous therapeutic schemes are available and allow to reach a better acceptance of the treatment and, in some cases, to avoid uterine bleeding. The goal of this individual adaptation of the treatment is to obtain the best benefit/risk balance for each patient, with the best clinical tolerance, allowing to continue the treatment as long as possible. Moreover, new molecules proposed as monotherapies have been recently marketed. In this article, we will review the various modalities of hormone replacement therapy, their advantages and disadvantages, and contraindications.

[Inhibition of sexual desire associated with menopause]

Physicians or gynaecologists, specifically in their general practice or in the setting of a menopause clinic, are more and more frequently confronted to sexual complaints of menopausal women. Among these, decline in sexual desire is probably the most usually reported. The first study to evaluate a potential relationship between sexual functioning and menopause was conducted by Hallström in 1977. Thereafter, a review of the literature was able to show that there is nearly a consensus regarding the role of oestrogens in that condition. They effectively relieve vaginal atrophy and resulting dyspareunia. There is less agreement, however, regarding a direct effect of oestrogens on more complex sexual behaviour and motivation. When analyzing potential influence of sex hormones, oestrogens may exert a positive effect on the quality of the sexual relationship whereas androgens can definitely increase sexual "motivation" including sexual desire. In spite of the potentially important part played by androgens as promoters of libido and in the maintenance of sexual functioning in men and women, the exact role of the hormonal treatment in relieving sexual complaints still keeps controversial. In some women whose decline of sexual desire can be reasonably attributed to menopause, androgens in non-masculinizing adequate dosages, can be effectively included in the postmenopausal hormone replacement regimen. However, aetiology of diminished sexual motivation and desire is far from univocal particularly in the human being where psychological, social and cultural influences are endowed with a prominent importance. It is accordingly conspicuous that our sexual life is not reduced to hormonal fluctuations only. A short critical review of the literature devoted to the main aspects of changes of sexual desire associated with menopause is presented.

[Meno-metrorrhagia]

Menometrorrhagia is frequent. It consists in menorrhagia (excessive menstrual flow and duration) and metrorrhagia (irregular, excessive flow and duration). Three different types of aetiology occur: general extra-gynaecological causes, endocrine causes and organic causes. This last group is made of myomas, polyps, endometrial hyperplasia, adenomyosis and uterine cancers. Dysfunctional uterine bleedings do not find their cause in one of these three main causes. The diagnosis is based on three types of complementary investigations: endo-uterine cytological and histological samplings, medical imaging of which endovaginal echography is the most accurate, and diagnostic hysteroscopy. This triad allows to reach a very precise diagnosis in order to exclude a malignant lesion. Thanks to this precise diagnosis, the therapeutic decision is made according to the nature of the lesion to be treated, the desire to retain fertility, and age. Medical and surgical treatments are possible. In most cases of general extra-gynaecological and endocrine causes, medical treatment is efficient and etiological. When organic uterine lesions are present, several medical treatments are efficient by suppressing the cause of bleeding or by symptomatic action. Main medical treatments are: anti-fibrinolytic agents, nonsteroidal anti-inflammatory drugs, progestin, oral contraceptive pills, GnRH agonists and danazol. The surgical treatment consists in endoscopic techniques (operative hysteroscopy and laparoscopy) and hysterectomy performed by vaginal route with or without laparoscopic preparation, by laparoscopic approach only or by classical laparotomy. Currently, the classical D & C has become essentially a diagnostic method. Surgical treatment is necessary after failure of a medical treatment or in the presence of a lesion not directly accessible to medical therapy. The efficacy of conservative endoscopic techniques depends on the respect of the indications of these techniques. These allow to reduce the number of hysterectomies for benign lesions by up to 50%.

[Premenstrual tension syndrome or premenstrual dysphoria]

Premenstrual Tension Syndrome (PMS) has always existed: it has been first described by an endocrinologist from New York in 1931. It is responsible for significant and psychological disorders which justify the study of its pathogenesis. Hormonal dysfunction has been demonstrated among women who are at risk for PMS; nevertheless, it has been shown that neurological transducers are also affected, such as GABAergic, serotoninergic and endorphinic systems. Interactions between the two systems allow to raise the hypothesis of an inbalance between GABAergic and progesterone derived neurosteroids in a psychoneuroendocrinological model. Based on this hypothesis, psychological symptoms can be efficiently treated by anxiolytic or antidepressant treatment. On the other hand, progesterone derivatives and, sometimes, diuretics, are useful on physical symptoms. As far as we know there is so far no single treatment of demonstrated efficacy in the PMS.

[Hyperandrogenism: clinical aspects, investigation and treatment]

Androgen excess (AE) is one of the most common endocrine disorders, affecting 10% of adult women before the menopause. The clinical picture varies widely depending on the etiology of AE. Most of these women are suffering from hirsutism, acne, menstrual disturbances, anovulation and obesity. Virilization is unusual, except in patients with ovary or adrenal cancer. Polycystic ovary syndrome (PCOS) and idiopathic hirsutism (IH) are the most frequent causes of androgen excess, accounting for more than 90% of the cases. The pathogenesis of PCOS is still an unresolved problem. A hereditary predisposition has been suggested. Enzymatic deficiency is a less frequent cause of AE, the most common deficiency being the non classic 21-OH deficiency (NCAH). AE has been implicated as a side effect of many drugs. Ovary and adrenal tumours are unusual, however, they must be considered especially in case of severe hirsutism or virilization. Complementary investigations are selected based on the result of clinical examination. Pharmacologic therapy, usually with anti-androgens, is the most widely used treatment for PCOS, IH and NCAH. Surgical therapy should be considered only when there is a particular indication such as Cushing's syndrome, ovary or adrenal tumours.

[Surgical hysteroscopy or hysterectomy in the treatment of benign uterine lesions. What to choose in 1998?]

In the past, the treatment of benign uterine lesions required, in many instances, a hysterectomy. These days, most cases can be successfully treated by hysteroscopy. To be reliable, this technique must lead to a significant reduction in the number of hysterectomies performed for benign uterine lesions. The electroresection technique is preferred to that using the Nd-YAG laser because of its lower cost and its equivalent efficacy. By using the uterine perfusion pump device, the risk of resorption syndrome can be reduced to its minimum. Submucosal myomas < 1 cm, benign endometrial hyperplasia and adenomyosis are the commonest benign lesions treated. Dysfunctional uterine bleeding can also be treated by an endometrectomy. A preoperative workup includes a transvaginal ultrasound and a biopsy. This ensures that only benign lesions that are accessible to a hysteroscopy will be submitted to this technique and that no cases of endometrial cancer or atypical hyperplasia would be ignored. This study presents 270 cases of operative hysteroscopy with a follow-up to 4 years. 82.8% of myomatous lesions were treated with success. The results for patients with benign endometrial polyps or benign endometrial hyperplasia are also excellent with only 4.6% and 5.6% rate of secondary surgery respectively. Adenomyosis does not appear to be a good indication for hysteroscopy as only 37% of patients did not need a definitive hysterectomy. Rates of operative complications (post-operative bleeding, uterine perforation, resorption syndrome and difficulty of access) are acceptable and get less frequent as the surgeon experience increases.