Estradiol-17beta reduces blood pressure and restores the normal amplitude of the circadian blood pressure rhythm in postmenopausal hypertension

Influence of 17beta-oestradiol on blood pressure of postmenopausal women at high vascular risk

OBJECTIVES

It remains an unsolved issue whether hormone replacement therapy (HRT) lowers blood pressure. This randomized trial examined the effect of 17beta-oestradiol combined cyclically with gestodene on blood pressure of postmenopausal women who were not on antihypertensive medication. All subjects had an increased risk for adverse vascular events as indicated by intima-media thickness of carotid arteries and standard risk factors.

DESIGN AND SETTING

Two hundred and twenty-six postmenopausal women were randomized to oral treatment for 48 weeks with 1 mg of 17beta-oestradiol per day continuously, plus 0.025 mg gestodene on days 17-28 of each 4-week cycle (HRT 1), or plus gestodene in each third cycle only (HRT 2), or no HRT. According to predefined criteria, four subjects in HRT 1, 12 in HRT 2 and 13 in no HRT who were started on antihypertensive medication were excluded from the analysis. Thirty subjects ended participation prematurely for other reasons. Resting blood pressure was measured at baseline and after 12, 22 and 48 weeks.

RESULTS

During treatment diastolic blood pressure changed significantly in both HRT groups compared to no HRT, by -3.7 +/- 9.8 mmHg, -3.0 +/- 8.8 mmHg and 1.0 +/- 9.9 mmHg at week 48 in groups HRT 2, HRT 1 and no HRT, respectively (P = 0.008 for HRT 2 versus no HRT, P = 0.027 for HRT 1 versus no HRT). The higher the diastolic blood pressure was at beginning the greater was the decrease. The decrease of systolic blood pressure was not significantly different between groups.

CONCLUSIONS

For postmenopausal women with high cardiovascular risk but without antihypertensive medication, long-term treatment with 17beta-oestradiol combined with gestodene lowers diastolic blood pressure.

Effects of hormonal replacement therapy in postmenopausal hypertensive patients

OBJECTIVE

To evaluate the effect of hormonal replacement therapy (HRT) on blood pressure (BP) in postmenopausal hypertensive women.

METHODS

Sixty women affected by hypertension were enrolled and randomized in two groups of treatment: transdermal continuous HRT in a sequential regimen (group A) and placebo (group P). At baseline, after 3 and 6 months of treatment, the BP with standard sphygmomanometer and with 24-h ambulatory recording method was evaluated in two periods (from day 10 through day 16 of the cycle and from day 20 through day 27 of the cycle). At the same time, we also evaluated total cholesterol, LDL-c, HDL-c, triglycerides, and fibrinogen levels.

RESULTS

After 3 and 6 months of treatment, no significant variations of systolic and diastolic BP measured with standard sphygmomanometer were detected in both groups. On the contrary, in group A in comparison with basal values and group P, and without difference between the two phases of treatment, the 24-h recording showed a significant (P<0.05) decrease in BP. No significant variations were detected in group P versus baseline. In particular, we observed in group A at 3 months of treatment a significant (P<0.05) decrease only in daytime BP in comparison with basal values and group P, without difference between the two phases of treatment. Indeed, the decrease in daytime BP was significant (P<0.05) for both systolic and diastolic BP. At 3 and 6 months a significant (P<0.05) decrease in total cholesterol, LDL-c and fibrinogen levels was detected in group A versus baseline and group P. HDL-c and triglyceride concentrations showed no significant variations.

CONCLUSIONS

The transdermal HRT induces a significant reduction of BP values and a favorable metabolic action in postmenopausal hypertensive patients.

Blunted nighttime blood pressure dipping in postmenopausal women

Blunting of the normal drop in blood pressure (BP) from day to night is emerging as a strong prognostic indicator of cardiovascular morbidity and mortality. This study evaluated the effects of natural menopause on BP dipping in African American and white women. A total of 112 women (62 premenopausal and 50 postmenopausal) took part in the study. Pre- and postmenopausal groups were comparable in terms of clinic BP, body mass index, and ethnic composition. Ambulatory BP was recorded over 24 h during a typical workday, with measurements programmed to be taken every 15 min during waking hours and every 30-minutes during sleeping hours. Nocturnal BP dipping was defined as the difference between waking and sleep BP. Waking BP did not differ by menopausal status. However, nocturnal systolic BP (SBP) and diastolic BP (DBP) dipping were attenuated in postmenopausal women, with both SBP (P < .05) and DBP (P < .05) higher during nighttime sleep in postmenopausal than in premenopausal women. Ethnicity was also related to BP dipping, with African American women tending to show blunted SBP dipping (P = .055) compared with white women; BP dipping was most blunted in postmenopausal African American women. These observations suggest that blunted nighttime BP dipping may contribute to increased cardiovascular disease risk in postmenopausal women.

Transdermal estrogen replacement therapy decreases sympathetic activity in postmenopausal women

BACKGROUND

Menopause heralds a dramatic increase in incident hypertension, suggesting a protective effect of estrogen on blood pressure (BP). In female rats, estrogen has been shown to decrease sympathetic nerve discharge (SND) and BP. SND, however, has not been recorded during estrogen replacement therapy (ERT) in humans. Methods and Results-In 12 normotensive postmenopausal women, we conducted a randomized crossover placebo-controlled study to test whether chronic ERT caused a sustained decrease in SND and BP. Twenty-four-hour ambulatory BP, SND, and arterial baroreflex sensitivity were measured before and after 8 weeks of transdermal estradiol (200 microgram/d), oral conjugated estrogens (0.625 mg/d), or placebo. To test the acute effects of estrogen on SND, additional studies were performed in the same women receiving intravenous conjugated estrogens or sublingual estradiol. After 8 weeks of transdermal ERT, the basal rate of SND decreased by 30% (from 40+/-4 to 27+/-4 bursts per minute, P=0.0001) and ambulatory diastolic BP fell by 5+/-2 mm Hg (P=0.0003). In contrast, SND and BP were unaffected either by 8 weeks of oral ERT or by acute estrogen administration. Neither transdermal nor oral ERT had any effects on baroreflex sensitivity.

CONCLUSIONS

In normotensive postmenopausal women, chronic transdermal ERT decreases SND without augmenting arterial baroreflexes and causes a small but statistically significant decrease in ambulatory BP. Sympathetic inhibition is evident only with chronic rather than acute estrogen administration, implying a genomic mechanism of action. Because the effects of transdermal ERT are larger than those of oral ERT, the route of administration may be an important consideration in optimizing the beneficial effects of ERT on BP and overall cardiovascular health.

The use of hormone replacement therapy in postmenopausal women with type 2 diabetes

In healthy postmenopausal women, estrogen or hormone replacement therapy (ERT or HRT) can alleviate menopausal symptoms and prevent osteoporosis and may also protect against cardiovascular disease (CVD). In addition to improving lipid metabolism, there are reports that estrogen also improves parameters regulating carbohydrate metabolism, including insulin resistance, in healthy women. Therefore, it is likely that ERT or HRT would also benefit women with type 2 diabetes, not only in relieving menopausal symptoms but also in improving the metabolic abnormalities associated with diabetes and in preventing cardiovascular disease.

[Hormone replacement therapy in ischemic heart disease prevention in women. Arguments in favor]

Numerous evidence have suggested a physiologic action of sexual steroids upon the cardiovascular system and the coherence of epidemiological studies have raised the possibility of a positive action of estradiol in preventing cardiovascular disease, specially through atheroma inhibition and other vascular wall-related mechanisms. From an experimental point of view, some clinical trials have demonstrated an improvement in some intermediate clinical variables, such as hypercholesterolemia and hypertension, after the administration of estradiol. Nonetheless, the HERS study, the first secondary prevention trial of estrogen and cardiovascular disease, failed to demonstrate these positive actions suggested by epidemiological studies and the efficacy of estradiol in the treatment of postmenopausal women with cardiovascular disease has been questioned. In spite of this, the HERS study has also been questioned because of different pitfalls in its development and, for some authors, it is inconclusive. Therefore, at present, it is not possible to make an evidence based clinical decision regarding the key question about the real actions of estradiol in the prevention of cardiovascular disease in postmenopausal women.

The nature of the effect of female gonadal hormone replacement therapy on cognitive function in post-menopausal women: a meta-analysis

We reviewed epidemiological and experimental studies of female gonadal hormone replacement therapy (HRT) on cognitive function in post-menopausal women and carried out meta-analyses. In healthy ageing women, HRT has small and inconsistent effects that include enhancement of verbal memory, abstract reasoning and information processing. Epidemiological studies show larger effects than experimental studies, which is not related to sample size. Important confounds may be that women who start using HRT are healthier than women who do not. Also, controlling for socio-economic status diminishes the effect of HRT. The effects of HRT may depend on the age and type of menopause and the therapeutic intervention used, with the most widely used drug, Premarin, having least effect. However, the effects are independent of mood and climacteric symptom alleviation. There is a paucity of experimental studies that include healthy elderly women. The evidence for an estrogen deficiency in women with dementia and cognitive dysfunction is inconsistent. Nevertheless, epidemiological studies suggest that HRT protects against the development of clinically diagnosed Alzheimer's disease. However, poor recall of HRT use by patients and altered physician behaviour may have confounded the effects. Surprisingly, both healthy and demented women with low education seem to benefit most from HRT. Three recent controlled experimental studies using Premarin showed no effects of HRT in preventing further cognitive decline in women who already have Alzheimer's disease. Duration of treatment seems to play an important role, with beneficial effects declining-and even reversing-with longer treatment in women with Alzheimer's disease.Future research should further investigate the cognitive effect of different HRT preparations, serum estrogen levels, and the interactions of HRT with age, menopausal status and existing protective (e.g. education) and risk factors (e.g. smoking and apolipoprotein E genotype) for cognitive decline and Alzheimer's disease.

The pharmacokinetics and efficacy of different estrogens are not equivalent

In the next decade many women will turn to the medical community for advice on maintaining or improving health after menopause. Estrogen replacement therapy, with or without progestins, alleviates menopausal symptoms, prevents or manages osteoporosis, and reduces the increased cardiovascular disease risk that results from estrogen deficiency caused by ovarian decline. Although several estrogen replacement products are available, the pharmacokinetics and efficacy of these products may vary depending on either the estrogen formulation or the route of administration, or both. For example, oral estrogens, which elicit a marked hepatic response, induce greater beneficial effects on serum lipoproteins than transdermal estrogens, which circumvent first-pass liver metabolism. Oral conjugated estrogens and transdermal estradiol increase bone density and prevent bone loss. This article summarizes the studies comparing estrogen formulations and discusses the differential effects of various estrogen products that promote postmenopausal health.

Do we need clinical trials to test the ability of transdermal HRT to prevent coronary heart disease?

Postmenopausal hormone replacement therapy (HRT) with oral oestrogen was predicted to reduce coronary heart disease (CHD) risk by 50%. Randomized controlled trials show no such benefit, however, pointing instead to an initial increase in CHD events. Although the cardiovascular effects of transdermal HRT are largely unknown, improvements in arterial function are maintained when oestrogen is administered transdermally. Transdermal HRT also avoids the increased plasma levels of C-reactive protein (CRP) that are seen with oral HRT. However, the clinical significance of this general reduction in hepatic over-synthesis of plasma proteins is difficult to assess. Nevertheless, the available evidence on transdermal HRT appears to justify a formal clinical trial.

Female steroid hormones modulate receptors for nerve growth factor in rat dorsal root ganglia

Calcitonin gene-related peptide (CGRP) is a vasodilatory peptide, and it is primarily synthesized in dorsal root ganglia (DRG). Plasma CGRP levels increase during pregnancy and with steroid hormones, and nerve growth factor (NGF) stimulates calcitonin/CGRP promoter and CGRP synthesis in DRG. We previously showed that CGRP levels in DRG were stimulated with steroid hormone treatments in vivo but not in vitro. Thus, the stimulation of CGRP by these hormones may be indirect through the upregulation of NGF effects. We hypothesized that the female sex steroid hormones upregulate NGF receptors, trkA and p75(NTR), in DRG. We examined the effects of 17 beta-estradiol (E(2)) and progesterone (P(4)) on NGF receptors in DRG obtained from ovariectomized (ovx) rats. Groups of 4 ovx rats were injected s.c. with 5 microg E(2), 4 mg P(4), or 5 microg E(2) + 4 mg P(4) in 0.2 ml sesame oil or injected with oil only and were killed at 6, 24, and 48 h. In addition, ovx rats were also injected s.c. with varying doses (0.2, 1.0, 5.0, 25 microg) of E(2) (0.5, 1.5, 4, 10 mg) P(4), and (5 microg) E(2) + (0.5, 1.5, 4.0, 10 mg) P(4) in 0.2 ml sesame oil, or vehicle, and killed at 6 (for E(2)) or 24 (for P(4) and E(2) + P(4)) h. Furthermore, groups of ovx rats were also killed at 12 and 24 h; 3 and 7 days; 2, 4, and 6 wk after ovariectomy. The DRGs were collected from all groups and then processed for Western immunoblotting to examine both trkA and p75(NTR) levels. Estradiol increased trkA at 6 h but not p75(NTR). Progesterone caused upregulation of trkA and p75(NTR) at 6 and 24 h. 17 beta-Estradiol + P(4) increased trkA at 6 and 24 h and p75(NTR) at all time points examined. One microgram of E(2) increased trkA but did not affect p75(NTR) levels. Progesterone at 4 and 10 mg upregulated trkA but only 10 mg P(4) increased p75(NTR). Five micrograms of E(2) coinjected with P(4) at 1.5 and 4 mg increased trkA, while p75(NTR) receptor was upregulated when coinjected with P(4) at 1.5 to 10 mg. The ovariectomy caused a decrease in trkA receptors compared to proestrus rats, and these decreases were significant by 6 wk, but surprisingly p75(NTR) increased at 2 wk after ovariectomy. 17 beta-Estradiol increased trkA but not p75(NTR) receptors in DRG, whereas P(4) caused increases in both trkA and p75(NTR) in DRG. In addition, the combination of these steroid hormones had more effect on both receptors than either hormone alone. Thus, we concluded that high levels of female steroid hormones such as those due to pregnancy or hormonal replacement therapy could increase NGF receptor expression in DRG that carry more NGF to elevate the CGRP synthesis in these groups. We suggested that the regulation of NGF receptors by ovarian steroids may underlie steroidal regulation of other factors such as CGRP.

Hormone replacement therapy and 24-hour blood pressure profile of postmenopausal women

Menopause is associated with an increase in blood pressure (BP) and a decrease in physiologic nocturnal BP fall. These factors may play a role in the increased risk of cardiovascular events after menopause. Some studies indicate that transdermal estrogen replacement therapy may help restore the 24-h BP profile, but data on the effect of oral conjugated estrogens are lacking. We compared 24-h ambulatory BP profiles of 42 postmenopausal women not receiving hormone replacement therapy (HRT) and 20 women receiving HRT. HRT was associated with a significant increase in the proportion of dippers (50% in women not receiving HRT and 80% in women receiving HRT, P = .048). Increase in nocturnal dipping may account, in part, for the beneficial cardiovascular effects of HRT.

Inability to induce hypertension in normotensive rat expressing AT(1) receptor antisense

Our previous studies have shown that neonatal delivery of angiotensin type 1 receptor antisense (AT(1)R-AS) in a retroviral vector prevents spontaneously hypertensive rats from developing hypertension for life but has no effect on blood pressure (BP) in normotensive animals. Based on these results, we hypothesized that AT(1)R-AS transduction in normotensive rats would protect them from developing experimental hypertension. The present study was designed to evaluate this hypothesis. A single intracardiac administration of AT(1)R-AS by a retroviral-mediated delivery system (LNSV-AT(1)R-AS) in 5-day-old normotensive Sprague-Dawley rats resulted in long-term expression of the AT(1)R-AS without an effect on basal BP. However, angiotensin II (Ang II)-induced BP, dipsogenic responses, and renovascular contractility were significantly attenuated in the LNSV-AT(1)R-AS-treated rats. Chronic infusion of low-dose Ang II (55 ng. kg(-)(1). min(-)(1)) in LNSV-alone-treated rats caused a modest increase in BP, profound increase in cardiac hypertrophy, and increased vascular contractility. In contrast, the LNSV-AT(1)R-AS-treated rats were protected from developing these changes after Ang II infusion. These data establish that LNSV-AT(1)R-AS pretreatment protects healthy rats from developing Ang II-dependent hypertension.

17beta-estradiol modulates baroreflex sensitivity and autonomic tone of female rats

The following experiments examine the role of estrogen as a central modulator of autonomic tone and baroreflex sensitivity in the female rat. Female Sprague-Dawley rats were ovariectomized and then supplemented daily for 7 days with a fixed dose of estrogen (5 microg/kg; sc) to produce a stable level of estrogen similar to that present at proestrous (17 pg/ml). The rats were then anaesthetized with sodium thiobutabarbital (100 mg/kg) and instrumented to record blood pressure, heart rate and both vagal and renal efferent nerve activities. The sensitivity of the cardiac baroreflex was tested using intravenous injection of multiple doses of either phenylephrine hydrochloride or sodium nitroprusside. Estrogen-supplemented female rats exhibited a significantly enhanced BRS as compared to male rats from a previous study (0.78 vs. 0.5). Furthermore, bolus injection of estrogen (1x10(-2) mg/kg; iv) in estrogen-supplemented female rats produced a significant increase in vagal nerve activity and a significant decrease in renal nerve activity which together resulted in a further enhancement of the BRS (0.78 vs. 2.4). Injection of the selective estrogen receptor antagonist, ICI 182,780, into nucleus ambiguus and the intrathecal space of the spinal cord blocked the respective changes in parasympathetic and sympathetic nerve activities indicating that intravenously administered estrogen modulates baseline autonomic tone via the activation of central estrogen receptors.

Postmenopausal hypertension

Cardiovascular disease is the leading cause of death in women and claims the lives of more than half a million women every year. Hypertension is one of the most prevalent and powerful contributors to atherosclerotic cardiovascular disease. Hypertension affects more men than women until 55 years of age, but after age 55, the percentage of women is higher. Estrogen deficiency has been linked to the rapid increase in cardiovascular disease in women who have undergone natural or surgical menopause. Hormone replacement therapy (HRT) has been shown to decrease the incidence of cardiovascular disease and, in some studies, to reduce blood pressure in postmenopausal women. However, little information is available on the effects of HRT on blood pressure in hypertensive postmenopausal patients. The cardioprotective effects of estrogens are not completely understood but may involve direct effects on blood vessels through modulation of endogenous vasoconstrictors and vasodilators and through reductions in serum lipoprotein and cholesterol levels. Experimental evidence suggests that estrogen increases the biological actions of nitric oxide and decreases the actions of angiotensin. After menopause, loss of the vascular protective effects of estrogens may unmask a population of women particularly prone to hypertension who would be at higher risk for cardiovascular disease.