Issues of aging in preventive medicine and the example of osteoporosis

Aging introduces a unique dimension into the theory and practice of preventive medicine. Preserving functional status and quality of life assume particular importance in old age. Effective preventive care can serve these goals by compressing the morbidity of old age into a shorter period prior to death and by increasing longevity towards its biological potential. The prevalence of osteoporosis and many other chronic diseases increases steadily with age, as does the clinical significance of these conditions. The pathophysiology of osteoporosis, options for its early detection and treatment and the importance of falls as a precipitant of osteoporotic fractures among the elderly are discussed in detail.

Hormone replacement therapy and cancer

The benefits of hormone replacement therapy in alleviating climacteric symptoms, preventing osteoporosis and reducing the incidence of cardiovascular disease and stroke are now generally agreed. Nonetheless, perhaps only 5% of postmenopausal women currently receive adequate treatment often because of patient or clinician fears that such treatment may be associated with harmful side effects.

Patients at high risk of cardiovascular complications in oestrogen treatment of prostatic cancer

The aim of this study was to predict cardiovascular complications in patients with prostatic cancer treated with oestrogen. A randomised prospective study of oestrogen therapy versus orchiectomy was performed. Patients with pre-existing cardiovascular morbidity were excluded (16%). Prior to the initiation of therapy, patients were subjected to exercise stress tests, physiological evaluation of peripheral circulation, blood volume estimation, chest X-ray, blood test, including hormones, lipoproteins, and antithrombin III, and a physical examination and history by a cardiologist. The oestrogen treatment and the orchiectomy group did not differ with regard to these pretreatment variables; 25% of the patients given oestrogen therapy had cardiovascular complications during the initial treatment year compared with none in the orchiectomy group. Three statistical discriminating techniques were employed and they allowed us to identify 2 strong discriminating variables for cardiovascular complications if oestrogen therapy is instituted in patients with prostatic cancer but without overt clinical cardiovascular disease. These 2 discriminators were luteinising hormone (LH) and ST-segment depression during exercise. This means that a patient with ST-segment depression during an exercise test and/or a high luteinising hormone concentration should not be treated with oestrogen.

Bacterial vaginosis is not a simple ecological disorder

Eighty-four patients with bacterial vaginosis were examined in an open randomized trial, the aim of which was to define clinical results and the microbiological panorama after topical treatment for 1 week with either an acetic acid jelly (A), an estrogen cream (B), a fermented milk product (C) or metronidazole (D). After exclusion because of chlamydia infection (15 cases) or for other reasons, 61 cases remained for complete evaluation 4 weeks after the start of treatment. Clinical cure was obtained in 3 cases out of 17 on regimen A, in 1 out of 16 on regimen B, in 1 of 14 on regimen C, and in 13 out of 14 on regimen D. The patients were conclusively either symptomless or symptomatic when examined on 113 occasions. Statistically significant reduction after treatment resulting in relief of symptoms was observed in the numbers of corynebacteria and anaerobic cocci, whereas lactobacilli increased in numbers. The instillation of high numbers of Lactobacillus acidophilus (C) into the vagina cured only 1 patient and did not influence the predominance of lactobacilli in the vagina at the follow-up examination. The difference in microbiological profile of women in symptomatic and asymptomatic conditions becomes still more apparent when the results of the present and previously published studies on the subject by the present group of investigators are combined. The symptomatic woman is significantly more often harboring corynebacteria, Gardnerella vaginalis, peptostreptococci, peptococci, eubacteria and Bacteroides species. Lactobacilli are significantly reduced in numbers. However, only 51% of our previously symptomatic, but now symptomless women show predominant growth of lactobacilli, which is less than expected for healthy women.(ABSTRACT TRUNCATED AT 250 WORDS)

Estrogen-progesterone treatment of Osler-Weber-Rendu disease

A 56-year-old woman with Osler-Weber-Rendu disease had longstanding iron deficiency anemia from recurrent melena. Since neither laser photocoagulation nor surgery were successful in stopping the increasing transfusion need, combined estrogen-progesterone therapy was started. Except for slight bleeding from a temporary ileostomy, the bleeding and need for transfusion terminated promptly. This experience confirms that estrogen-progesterone therapy may promote cessation of bleeding gastrointestinal telangiectasias and indicates the need for controlled investigations.

[Prevention of atherosclerosis by estrogen substitution?]

Epidemiological, experimental and clinical data verify that the risk of cardiovascular diseases is increased by a long-term estrogen deficiency. This is, among other things, caused by alterations of lipid metabolism (e.g., rise in total cholesterol and LDL-cholesterol, decrease in HDL-cholesterol) due to the estrogen dificit which are involved in an accelerated development of atherosclerosis. If there is an estrogen deficiency, an elevated serum level of cholesterol or LDL-cholesterol can be reduced and the HDL-cholesterol level can be increased by an adequate estrogen replacement therapy, i.e., treatment with an estrogen and progestogen the type and dose of which are adjusted to the clinical picture. When the present knowledge about the physiological and pathological pathways is weighed and the epidemiological data are critically valued - whereby the extent and duration of the stage of estrogen deficit has to be regarded as an important criterion -, it can be assumed that an estrogen therapy prevents a premature atherosclerosis and coronary heart disease provided that they are related to an estrogen deficiency. The differences in the degree of estrogen deficit and the symptoms as well as in the pharmacological and pharmacodynamic peculiarities if the individual women render it necessary to adjust individually the estrogen therapy, to avoid overdosing and to pay attention to risk factors. Therefore, an undifferentiated treatment with estrogens (e.g. estrogen for every woman) does not appear to be appropriate.

Estrogens and phenylpropanolamine in combination for stress urinary incontinence in postmenopausal women

Thirty-six postmenopausal women with objectively verified stress incontinence were treated with oral estriol (Triovex, 2 mg x 1) and phenylpropanolamine (Kontexin, 50 mg x 2) alone and in combination. After an initial four-week single-blind period with phenylpropanolamine (PPA), either estriol or estriol and PPA were given randomly in four-week periods, in a crossover design. PPA and estriol in combination as well as PPA alone, raised the intraurethral pressure and significantly reduced the urinary loss by 35 per cent in a standardized physical strain test. In women with an initial low urethral pressure estriol also induced pressure increase. The leakage episodes and the assessed leakage amounts were significantly reduced by both estriol and PPA given separately as single treatment (28%) or when given as combined therapy (40%). Most of the women preferred the combined treatment to either drug alone. Additive but no synergistic effects are indicated.

[Drug therapy of osteoporosis]

It has proved worthwhile to treat osteoporosis simultaneously in two ways. For symptomatic treatment of the pain, passive and active physiotherapy is important, backed up by treatment with analgesic and antirheumatic agents and calcitonin, while any other drugs are given mainly for treatment of the osteoporosis itself. For women in high-risk categories for osteoporosis long-term (10-12 years) preventative treatment with estrogens (plus progesterone) is indicated. When osteoporosis is already apparent on radiological examination, fluoride (+ calcium) is generally given over 3-4 years, while calcitonin therapy is appropriate in acute painful and rapidly progressive osteoporosis with fresh vertebral fractures. In this case both the antiosteoclastic and the analgesic effect of the hormone come into play. Calcium can be used for pre- and postmenopausal prophylaxis and as a supplement to fluoride therapy.

Medical castration using megestrol acetate and minidose estrogen

Sixty-two men who presented with previously untreated metastatic carcinoma of the prostate (D0: 10 patients; D1: 29 patients; D2: 23 patients) received oral megestrol acetate (80 mg twice daily) and minidose estrogen (diethylstibestrol 0.1 mg or ethinyl estradiol 0.05 mg once daily) as a means of achieving total androgen ablation (testicular and adrenal). A high incidence of feminizing side effects (70-74%), a higher than expected rate of cardiovascular complications (18%), an unexpected need for cortisone replacement (13%), and failure of patients with Stage D2 disease to obtain results better than those of standard therapy during the first year of observation suggest this regimen offers no advantage over other more conventional therapy.

Bromine-80m-labeled estrogens: Auger electron-emitting, estrogen receptor-directed ligands with potential for therapy of estrogen receptor-positive cancers

To assess their possible use for estrogen receptor (ER)-directed radiotherapy of estrogen receptor-containing cancers, two estrogens were synthesized with the Auger electron-emitting nuclide bromine-80m and administered to immature female rats. Both the triphenylethylene-based estrogen, [80mBr]-2-bromo-1,1-bis(4-hydroxyphenyl)phenylethylene (Br-BHPE) and the steroidal estrogen [80mBr]17 alpha-bromovinylestradiol, showed substantial diethylstilbestrol-inhibitable localization only in the estrogen target tissues, the uterus, pituitary, ovaries, and vagina and, except for the liver and intestines, generally lower concentrations in all other tissues at both 0.5 and 2 h. The [80mBr]Br-BHPE (specific activity, 8700 Ci/mmol), was shown to bind specifically to the low salt extractable ER of the rat uterus. Comparing i.p., i.v., and s.c. administration of [80mBr]BHPE the i.p. route was found to be particularly advantageous to effect maximum, DES-inhibitable concentrations of radiobromine in the ER-rich target organs in the peritoneal cavity. When the tissue distribution of the [80mBr]Br-BHPE was compared with that of sodium bromide-80m, it was apparent that no substantial amounts of radiobromine were released from the bromoestrogen prior to its target tissue localization. The substantial concentration of these bromine-80m-labeled estrogens in ER-rich tissues, combined with previously reported evidence for the effective radiotoxicity of Auger electron-emitting nuclides within cell nuclei suggest a good potential for such ligands for therapy of ER positive cancers.

Changes in blood coagulation and fibrinolysis in patients on different treatment regimens for prostatic cancer. Predictors for cardiovascular complications?

An analysis of haemostatic variables was done in 31 prostate cancer patients treated with oestrogens (13 pts), estramustine phosphate (7 pts) or orchidectomy (11 pts) before, at about 7 weeks and 6 months of treatment. Six patients treated with either of the drugs developed venous thromboembolism or ischemic vascular disease. Already before treatment there were changes indicating some activation of blood coagulation, fibrinolysis and kallikrein systems. The drug treated group showed significant changes in several variables: i.e. increase in factor VII, plasminogen and prekallikrein but also a decrease in antithrombin and in inhibitors to the fibrinolytic and kallikrein system. Significant difference between the drug treated groups was found in circulating platelet aggregates and in kallikrein inhibiting activity. Tissue plasminogen activator capacity was significantly lower in the drug treated patients with complications than in those without. The study also showed that in addition to the assay of the tissue plasminogen activator capacity during the first weeks of therapy it might be helpful in predicting cardiovascular complications to investigate platelet aggregates, prothrombin complex, factor X, von Willebrand factor antigen, fibrinogen, antithrombin, fibrino-peptide A, and the inhibitors of fibrinolysis as well as C1-esterase inhibitor.

Comparison of endocrine and radiation therapy in locally advanced prostatic cancer

151 patients with locally advanced prostatic cancer (T3-4 M0), representing 38% of the 404 cancer patients in a Finnish multicenter study, were randomly assigned to one of three treatment arms: orchiectomy, estrogens or radiotherapy. During the 4-year follow-up period there were no significant differences in the progression rates (appearance of metastases in bone scan) between the therapy groups. The frequency of thromboembolic and other cardiovascular complications was highest in the estrogen group (13/50 patients). In the radiotherapy group, 19 of 45 patients had bowel or bladder complications. On the other hand, orchiectomy has few, if any, complications. The high risk of complications associated with estrogens and radiotherapy has to be taken into consideration in the selection of treatment.

Aspects on reference values for tumor markers in human prostatic carcinoma

The efficiency of the tumor markers prostatic acid phosphatase (PAP), prostate-specific antigen (PSA), neopterin, and osteocalcin was tested with regard to their ability to predict cancer death within 2 years plus survival beyond 2 years in a series of patients with newly diagnosed prostate cancer. For all markers, an elevated level suggested a tumor with a worse prognosis. Moreover, the extent to which the level was increased carried additional information. The prognostic efficiency was routinely improved by selecting cutoff levels higher than the standards suggested by the radioimmunoassay (RIA) kit manufacturers. Seventy-four percent of the patients with elevated levels of neopterin were still alive after 2 years when 8 nmol/L was selected as the upper normal value compared to only 43% at 12 nmol/L. At a cut-off value of 3 micrograms/L for osteocalcin, 79% of the patients with elevated levels were still alive after 2 years compared with only 20% when 7 micrograms/L was selected. Such adjustments to higher cutoff levels could be made without increasing the number of "false-negatives." The efficiency of PAP to predict short-term prognosis was poor at the standard cutoff level of 1.9 microgram/L. Not until 20 micrograms/L was selected did the efficiency exceed 80%. PSA was highly sensitive but little specific at any of the cutoff levels tested with regard to ability to indicate prognosis.

Cardiovascular follow-up of patients with prostatic cancer treated with single-drug polyestradiol phosphate

Thirty-eight patients with cancer of the prostate were treated with strict parenteral estrogen in the form of monthly polyestradiol phosphate injections--160 mg, 240 mg, and 320 mg--in this nonrandomized study. In contrast to studies with oral estrogens, there have been no cardiovascular complications at a mean follow-up of 12.9 +/- 0.7 months (SEM). Twenty-nine of the 38 patients (76%) have responded to therapy.

Pretreatment plasma levels of testosterone and sex hormone binding globulin binding capacity in relation to clinical staging and survival in prostatic cancer patients

Pretreatment plasma concentrations of total testosterone (T), sex hormone binding globulin binding capacity (SHBG). T/SHBG ratio, and free testosterone (fT) were measured in 123 patients with prostatic cancer categorized into groups according to the UICC classification. The patients were randomized to orchiectomy or estrogen therapy and the mean follow-up time was 48 months. The mean plasma levels of T were higher in patients without metastases and with intracapsular cancer, but the differences were not statistically significant. The calculated ratio of T/SHBG was noticed to be significantly higher (p less than 0.05) in the M0 category. The prognostic significance of pretreatment T and, more impressively, T/SHBG ratio and fT was confirmed. Low pretreatment values indicated poorer prognosis. This study supports the view that there are differences in the pretreatment T and fT levels in prostatic cancer patients in relation to the stage of tumor and that these hormone assays could be used as prognostic factors.

Relationship between serum lipoproteins and hemostatic parameters in men with prostatic cancer

Serum lipoprotein concentrations were related to hemostatic parameters in a group of 31 men before and during three different hormone treatment regimens for prostate cancer in an attempt to analyse to what extent the changes in these two systems correlate. In a correlation matrix the number of significant relationships at the 5% and 1% level corresponded to what could be expected by chance. The study thus failed to demonstrate any consistent relationship between any lipoprotein lipid concentration and the hemostatic parameters in men treated for prostate cancer. Most significant relationships were found for HDL-TG versus plasminogen, but the clinical significance of this observation is not clear.

The influence of exogenous estrogen use on survival after diagnosis of endometrial cancer

For examination of the effect of prior exogenous estrogen use on survival after diagnosis of endometrial cancer, 244 endometrial cancer cases newly diagnosed at North Carolina Memorial Hospital, Chapel Hill, North Carolina, between 1970 and 1976 were followed until 1982. Estrogen users (n = 46) were younger, had less advanced disease, and were more likely to be nonobese and white than were nonusers (n = 198). The estimated probability of surviving (Kaplan-Meier) five years after diagnosis was 0.89 for users and 0.53 for nonusers. When adjusted for age, grade, stage, obesity, race, and treatment (using the Cox proportional hazards regression model), the survival probabilities throughout the period of observation for estrogen users continued to be higher. The adjusted hazard rate for a nonuser was 2.05 (95% confidence interval (Cl) 0.96-4.39) times that for an estrogen user. The adjusted hazard rate from endometrial cancer only was 4.01 (95% Cl 1.22-13.21) times greater among estrogen nonusers. The more frequent occurrence of endometrial cancer in an earlier stage and grade among estrogen users may not be the sole cause of their lower hazard rate from this disease.

Hormonal management of stage D carcinoma of the prostate

A variety of new agents is available for the hormonal treatment of prostatic cancer. None of these agents has shown itself to be superior to bilateral orchiectomy, but their individual side effects profiles may make one more appealing than another. Total androgen ablation may offer a slight survival advantage over partial androgen ablation, but this must be weighed in terms of increased side effects and overall cost. Hormonal therapy remains an effective palliative but not curative means of treating advanced prostatic cancer.

[Estrogens in contraception]

Ehtinylestradiol (EE) and Mestranol (ME) are oral highly effective estrogens. They inhibit pituitary FSH and LH and thus cause inhibition of ovulation. This effect is synergistically increased by progestogens. 50 micrograms EE or ME per day are the minimal dose for inhibition of ovulation for a duration of 8 days. The metabolism of EE and ME is different from that of natural estrogens. They are very little metabolized and have a longer half life. Oral hormonal contraceptives with an estrogen contain either EE or ME. Their doses have been lowered in the last years. The possibilities of contraception with one-phase-, two-phase-, and step-up-preparations and especially the estrogen part of their effects and some side effects are discussed.

[Principles of differential pathogenesis-oriented therapy of various forms of osteopenia]

From the demonstration of etiopathogenetic mechanisms of osteopenia 7 different histologically and histomorphometrically defined pictures of the state (diseases) of the skeleton are derived. From this 4 different possibilities of the influence on the permanent transformation of the skeleton--the remodeling are the result. The medicamentous support of the blockade or stimulation of osteoclasts and the optimization of the mineralization are the basis of therapeutic considerations. In the light of these pathogenetically orientated treatment strategies the real and at present practicable therapy regimes of the various clinical manifestations of the osteopenia and new beginnings especially also of the therapy of osteoporosis are discussed.