Endogenous Sex Hormones and Incident Cardiovascular Disease in Post-Menopausal Women

Association of urinary metabolites of non-persistent pesticides with serum sex hormones among the US females: NHANES 2013-2014

BACKGROUND

Evidence indicated the possibility of non-persistent pesticides disrupting the homeostasis of sex hormones. However, few studies have focused on this relationship in females. We aimed to explore the relationship between non-persistent pesticide exposure and sex hormones among the US females from the National Health and Nutrition Examination Survey 2013-2014.

METHODS

A total of 790 females, including girls (6-11 years), female adolescents (12-19 years), and adult females (>19 years), were enrolled in this study. Age stratified associations of individual non-persistent pesticide metabolites and their mixtures with sex hormones were analyzed by weighted multiple linear regression and Bayesian kernel machine regression (BKMR) using spot urinary non-persistent pesticide measurement, including 2,4-dichlorophenoxyacetic acid (2,4-D), 3,5,6-trichloropyridinol (TCPY), para-nitrophenol (PNP) and 3-phenoxybenzoic acid (3-PBA), and three serum sex hormones [total testosterone (TT), estradiol (E2) and sex hormone binding globulin (SHBG)].

RESULTS

In girls, weighted multivariate linear regression indicated that both 2,4-D and PNP were negatively associated with TT, and TCPY was inversely associated with SHBG. In female adolescents, TCPY was negatively associated with TT and E2, and 3-PBA was negatively associated with SHBG; positive associations were detected both in 2,4-D with SHBG, and in PNP with TT. In adult females, a higher concentration of 3-PBA was associated with higher levels of TT. The BKMR model showed that in female adolescents, the concentrations of pesticide metabolite mixtures at or above the 55th percentile were negatively related to the levels of E2 compared with their mixtures at 50th percentile, and an inverse U-shaped exposure-response function between PNP and E2 was found.

CONCLUSIONS

Associations between the four non-persistent pesticide metabolites and serum sex hormones were identified in the US females from NHANES 2013-2014 and these associations were age dependent, especially in adolescents. Large-scale cohort studies are needed to confirm these findings and elucidate the potential biological mechanisms.

Per- and Polyfluoroalkyl Substances and Incident Hypertension in Multi-Racial/Ethnic Women: The Study of Women's Health Across the Nation

BACKGROUND

Perfluoroalkyl and polyfluoroalkyl substances (PFAS) are ubiquitous synthetic chemicals that may disrupt blood pressure controls; however, human evidence to support this hypothesis is scant. We examined the association between serum concentrations of PFAS and risks of developing hypertension.

METHODS

This study included 1058 midlife women initially free of hypertension from the multiracial and multiethnic SWAN (Study of Women's Health Across the Nation) with annual follow-up visits between 1999 and 2017. Hypertension was defined as blood pressure ≥140 mm Hg systolic or ≥90 mm Hg diastolic or receiving antihypertensive treatment. Cox proportional hazards models were utilized to calculate hazard ratios and 95% CIs. Quantile g-computation was implemented to evaluate the joint effect of PFAS mixtures.

RESULTS

During 11 722 person-years of follow-up, 470 participants developed incident hypertension (40.1 cases per 1000 person-years). Compared with the lowest tertile, women in the highest tertile of baseline serum concentrations had adjusted hazard ratios of 1.42 (95% CI, 1.19-1.68) for perfluorooctane sulfonate (P trend=0.01), 1.47 (95% CI, 1.24-1.75) for linear perfluorooctanoate (P trend=0.01), and 1.42 (95% CI, 1.19-1.70) for 2-(N-ethyl-perfluorooctane sulfonamido) acetate (P trend=0.01). No significant associations were observed for perfluorononanoate and perfluorohexane sulfonate. In the mixture analysis, women in the highest tertile of overall PFAS concentrations had a hazard ratio of 1.71 (95% CI, 1.15-2.54; P trend=0.008), compared with those in the lowest tertile.

CONCLUSIONS

Several PFAS showed positive associations with incident hypertension. These findings suggest that PFAS might be an underappreciated contributing factor to women's cardiovascular disease risk.

Endogenous Risk Factors of Cardiovascular Diseases (CVDs) in Military Professionals with a Special Emphasis on Military Pilots

Cardiovascular disease (CVD) risk factors can be categorized as non-modifiable and modifiable. Modifiable risk factors include some exogenous and behavioral factors that can be easily modified, whereas endogenous modifiable risk factors, such as hypertension, hyperlipidemia, diabetes, or obesity may be modified to a limited extend. An increased prevalence of CVDs as well as their risk factors have been observed in military personnel, as specific military-related stressors are highly correlated with acute cardiac disorders. Military pilots are a subpopulation with great CVD risk due to an accumulation of different psychological and physical stressors also considered to be CVD risk factors. This review presents data concerning CVD risk in military professionals, with a special emphasis on military pilots and crew members. We also discuss the usefulness of novel indicators related to oxidative stress, inflammation, or hormonal status as well as genetic factors as markers of CVD risk. For a correct and early estimation of CVD risk in asymptomatic soldiers, especially if no environmental risk factors coexist, the scope of performed tests should be increased with novel biomarkers. An indication of risk group among military professional, especially military pilots, enables the implementation the early preventive activities, which will prolong their state of health and military suitability.

Sex Differences in Molecular Mechanisms of Cardiovascular Aging

Cardiovascular disease (CVD) is still the leading cause of illness and death in the Western world. Cardiovascular aging is a progressive modification occurring in cardiac and vascular morphology and physiology where increased endothelial dysfunction and arterial stiffness are observed, generally accompanied by increased systolic blood pressure and augmented pulse pressure. The effects of biological sex on cardiovascular pathophysiology have long been known. The incidence of hypertension is higher in men, and it increases in postmenopausal women. Premenopausal women are protected from CVD compared with age-matched men and this protective effect is lost with menopause, suggesting that sex-hormones influence blood pressure regulation. In parallel, the heart progressively remodels over the course of life and the pattern of cardiac remodeling also differs between the sexes. Lower autonomic tone, reduced baroreceptor response, and greater vascular function are observed in premenopausal women than men of similar age. However, postmenopausal women have stiffer arteries than their male counterparts. The biological mechanisms responsible for sex-related differences observed in cardiovascular aging are being unraveled over the last several decades. This review focuses on molecular mechanisms underlying the sex-differences of CVD in aging.

The Hepatoprotective and Hepatotoxic Roles of Sex and Sex-Related Hormones

Most liver diseases, including acute liver injury, drug-induced liver injury, viral hepatitis, metabolic liver diseases, and end-stage liver diseases, are strongly linked with hormonal influences. Thus, delineating the clinical manifestation and underlying mechanisms of the “sexual dimorphism” is critical for providing hints for the prevention, management, and treatment of those diseases. Whether the sex hormones (androgen, estrogen, and progesterone) and sex-related hormones (gonadotrophin-releasing hormone, luteinizing hormone, follicle-stimulating hormone, and prolactin) play protective or toxic roles in the liver depends on the biological sex, disease stage, precipitating factor, and even the psychiatric status. Lifestyle factors, such as obesity, alcohol drinking, and smoking, also drastically affect the involving mechanisms of those hormones in liver diseases. Hormones deliver their hepatic regulatory signals primarily via classical and non-classical receptors in different liver cell types. Exogenous sex/sex-related hormone therapy may serve as a novel strategy for metabolic liver disease, cirrhosis, and liver cancer. However, the undesired hormone-induced liver injury should be carefully studied in pre-clinical models and monitored in clinical applications. This issue is particularly important for menopause females with hormone replacement therapy (HRT) and transgender populations who want to receive gender-affirming hormone therapy (GAHT). In conclusion, basic and clinical studies are warranted to depict the detailed hepatoprotective and hepatotoxic mechanisms of sex/sex-related hormones in liver disease. Prolactin holds a promising perspective in treating metabolic and advanced liver diseases.

Testosterone-to-estradiol ratio and platelet thromboxane release in ischemic heart disease: the EVA project

BACKGROUND

Data on the interplay between sexual hormones balance, platelet function and clinical outcomes of adults with ischemic heart disease (IHD) are still lacking.

OBJECTIVE

To assess the association between the Testosterone (T)-to-Estradiol (E2) Ratio (T/E2) and platelet activation biomarkers in IHD and its predictive value on adverse outcomes.

METHODS

The EVA study is a prospective observational study of consecutive hospitalized adults with IHD undergoing coronary angiography and/or percutaneous coronary interventions. Serum T/E2 ratios E2, levels of thromboxane B₂ (TxB₂) and nitrates (NO), were measured at admission and major adverse events, including all-cause mortality, were collected during a long-term follow-up.

RESULTS

Among 509 adults with IHD (mean age 67 ± 11 years, 30% females), males were older with a more adverse cluster of cardiovascular risk factors than females. Acute coronary syndrome and non-obstructive coronary artery disease were more prevalent in females versus males. The lower sex-specific T/E2 ratios identified adults with the highest level of serum TxB₂ and the lowest NO levels. During a median follow-up of 23.7 months, the lower sex-specific T/E2 was associated with higher all-cause mortality (HR 3.49; 95% CI 1.24-9.80; p = 0.018). In in vitro, platelets incubated with T/E2 ratios comparable to those measured in vivo in the lowest quartile showed increased platelet activation as indicated by higher levels of aggregation and TxB₂ production.

CONCLUSION

Among adults with IHD, higher T/E2 ratio was associated with a lower long-term risk of fatal events. The effect of sex hormones on the platelet thromboxane release may partially explain such finding.

Alisol B 23-acetate adjusts bile acid metabolisim via hepatic FXR-BSEP signaling activation to alleviate atherosclerosis

BACKGROUND

Postmenopausal women have a high incidence of atherosclerosis. Phytosterols have been shown to have cholesterol-lowering properties. Alisa B 23-acetate (AB23A) is a biologically active plant sterol isolated from Chinese herbal medicine Alisma. However, the atherosclerosis effect of AB23A after menopause and its possible mechanism have not been reported yet.

PURPOSE

To explore whether AB23A can prevent atherosclerosis by regulating farnesoid X receptor and subsequently increasing fecal bile acid and cholesterol excretion to reduce plasma cholesterol levels.

METHODS

Aortic samples from premenopausal and postmenopausal women with ascending aortic arteriosclerosis were analyzed, and bilateral ovariectomized (OVX) female LDLR^-/- mice and free fatty acid (FFA)-treated L02 cells were used to analyze the effect of AB23A supplementation therapy.

RESULTS

AB23A increased fecal cholesterol and bile acids (BAs) excretion dependent on activation of hepatic farnesoid X receptor (FXR) in ovariectomized mice. AB23A inhibited hepatic cholesterol 7α-hydroxylase (CYP7A1) and sterol 12α-hydroxylase (CYP8B1) via inducing small heterodimer partner (SHP) expression. On the other hand, AB23A increased the level of hepatic chenodeoxycholic acid (CDCA), and activated the hepatic BSEP signaling. The activation of hepatic FXR-BSEP signaling by AB23A in ovariectomized mice was accompanied by the reduction of liver cholesterol, hepatic lipolysis, and bile acids efflux, and reduced the damage of atherosclerosis. In vitro, AB23A fixed abnormal lipid metabolism in L02 cells and increased the expression of FXR, BSEP and SHP. Moreover, the inhibition and silencing of FXR canceled the regulation of BSEP by AB23A in L02 cells.

CONCLUSION

Our results shed light into the mechanisms behind the cholesterol-lowering of AB23A, and increasing FXR-BSEP signaling by AB23A may be a potential postmenopausal atherosclerosis therapy.

Sex Differences at Early Old Stage in Glycolipid Metabolism and Fatty Liver in Offspring Prenatally Exposed to Chinese Great Famine

Background

About 50 years ago, Chinese Great Famine (CGF) affected the entire population in China, and its long-term influence on the offspring has attracted significant attention for research. However, information on possible metabolic differences between sexes is limited. This study explored whether there might be sex differences in the risks of development of glucolipid metabolic dysfunction and fatty liver following prenatal exposure to CGF.

Materials and Methods

There were 11,417 subjects around 55 years of age (6,661 women and 4,756 men). They were divided as the exposed group in which the fetal stage was in CGF, and the unexposed group included those born after CGF. Analysis focused on comparisons between sexes.

Results

Compared to the unexposed group, the BMI and triglyceride (P < 0.05) in men were higher in exposed group, while waist circumference and blood sugar (P < 0.05) in the exposed women were significantly higher. With the ages being properly balanced, the risks of glycolipid metabolic dysfunction were significantly higher in both men and women in the exposed than in the unexposed group (P < 0.001). Prenatal exposure to CGF significantly increased risks of abnormal BMI (P < 0.001, 95% CI: 2.305–2.93), blood sugar (P < 0.05, 95% CI: 1.050–1.401), triglycerides (P < 0.05, 95% CI: 1.006–1.245), and fatty liver (P < 0.001, 95% CI: 1.121–1.390) in men, and increased risks of abnormal blood sugar (P < 0.05, 95% CI: 1.024–1.689) and positive urine sugar (P < 0.05, 95% CI: 1.062–6.211) in women. Height and body weight were either the same or higher in the exposed subjects compared with the unexposed ones, regardless of sexes.

Conclusion

This study is the first to identify sex differences in the long-term effects of CGF on metabolism and fatty liver. Importance of the findings include the benefits of prescribing medicine for the early prevention of certain diseases for each sex before aging based on the differences revealed. This study also shows “catch-up growth” in the offspring prenatally exposed to CGF as possible mechanisms underlying the long-term effects.

Relaxin-2 as a Potential Biomarker in Cardiovascular Diseases

The pleiotropic hormone relaxin-2 plays a pivotal role in the physiology and pathology of the cardiovascular system. Relaxin-2 exerts relevant regulatory functions in cardiovascular tissues through the specific receptor relaxin family peptide receptor 1 (RXFP1) in the regulation of cardiac metabolism; the induction of vasodilatation; the reversion of fibrosis and hypertrophy; the reduction of inflammation, oxidative stress, and apoptosis; and the stimulation of angiogenesis, with inotropic and chronotropic effects as well. Recent preclinical and clinical outcomes have encouraged the potential use of relaxin-2 (or its recombinant form, known as serelaxin) as a therapeutic strategy during cardiac injury and/or in patients suffering from different cardiovascular disarrangements, especially heart failure. Furthermore, relaxin-2 has been proposed as a promising biomarker of cardiovascular health and disease. In this review, we emphasize the relevance of the endogenous hormone relaxin-2 as a useful diagnostic biomarker in different backgrounds of cardiovascular pathology, such as heart failure, atrial fibrillation, myocardial infarction, ischemic heart disease, aortic valve disease, hypertension, and atherosclerosis, which could be relevant in daily clinical practice and could contribute to comprehending the specific role of relaxin-2 in cardiovascular diseases.

Melatonin Alleviates Ovariectomy-Induced Cardiovascular Inflammation in Sedentary or Exercised Rats by Upregulating SIRT1

We aimed to evaluate the impact of hormone replacement, melatonin, or exercise alone or their combination on oxidative damage and functional status of heart, brain, and aorta of ovariectomized (OVX) rats and to determine whether the signaling pathway is dependent on sirtuin-1 (SIRT1). Ovariectomized Sprague Dawley rats were orally given either a hormone replacement therapy (1 mg/kg/day,17β estradiol; HRT) or melatonin (4 mg/kg/day) or HRT + melatonin treatments or tap water, while each group was further divided into sedentary and exercise (30 min/5 days/week) groups. After the heart rate measurements and memory tests were performed, trunk blood was collected at the end of the 10th week to determine metabolic parameters in serum samples. Tissue samples of abdominal aorta, heart, and brain were taken for biochemical measurements and histopathological evaluation. Heart rates and memory performances of the OVX rats were not changed significantly by none of the applications. Melatonin treatment or its co-administration with HRT upregulated the expressions of IL-10 and SIRT1, reduced the expressions of IL-6 and TNF-α, and reduced DNA damage in the hearts and thoracic aortae of non-exercised rats. Co-administration of melatonin and HRT to exercised OVX rats reduced inflammatory response and upregulated SIRT1 expression in the aortic and cardiac tissues. The present study suggests that melatonin treatment, either alone or in combination with exercise and/or HRT, upregulates SIRT1 expression and alleviates oxidative injury and inflammation in the hearts and aortas of OVX rats. Melatonin should be considered in alleviating cardiovascular disease risk in postmenopausal women.

Exposure to disinfection by-products and reproductive hormones among women: Results from the Tongji Reproductive and Environmental (TREE) study

BACKGROUND

Disinfection by-products (DBPs) have been shown to impair female reproductive function. However, epidemiological evidence on reproductive hormones is scarce.

OBJECTIVE

To investigate the associations between DBP exposures and reproductive hormones among women undergoing assisted reproductive technology.

METHODS

We included 725 women from the Tongji Reproductive and Environmental (TREE) Study, an ongoing cohort conducted in Wuhan, China during December 2018 and January 2020. Urine samples collected at recruitment were quantified for dichloroacetic acid (DCAA) and trichloroacetic acid (TCAA) as biomarkers of DBP exposures. At day 2-5 of menstruation, serum reproductive hormones including luteinizing hormone (LH), estradiol (E₂), total testosterone (T), progesterone (PRGE), and prolactin (PRL) were determined. Multivariate linear regression models were performed to assess the associations of urinary DCAA and TCAA concentrations with reproductive hormone levels. Dose-response relationships were investigated using natural cubic spline (NCS) and restricted cubic spline (RCS) models.

RESULTS

After adjusting for relevant confounders, we observed that higher urinary DCAA levels were associated with increased serum PRGE (9.2%; 95% CI: -0.55%, 19.8% for the highest vs. lowest tertile; P for trend = 0.06). Based on NCS models, we observed U-shaped associations of urinary DCAA with serum PRGE and PRL; each ln-unit increment in urinary DCAA concentrations above 3.61 μg/L and 6.30 μg/L was associated with 18.9% (95% CI: 4.8%, 34.7%) and 23.3% (95% CI: -0.92%, 53.5%) increase in serum PRGE and PRL, respectively. The U-shaped associations were further confirmed in RCS models (P for overall association ≤0.01 and P for non-linear associations ≤0.04). We did not observe evidence of associations between urinary TCAA and reproductive hormones.

CONCLUSION

Urinary DCAA but not TCAA was associated with altered serum PRGE and PRL levels among women undergoing assisted reproductive technology.

Evaluation of the Interaction of Sex Hormones and Cardiovascular Function and Health

Purpose of Review

Sex hormones drive development and function of reproductive organs or the development of secondary sex characteristics but their effects on the cardiovascular system are poorly understood. In this review, we identify the gaps in our understanding of the interaction between sex hormones and the cardiovascular system.

Recent Findings

Studies are progressively elucidating molecular functions of sex hormones in specific cell types in parallel with the initiation of crucial large randomized controlled trials aimed at improving therapies for cardiovascular diseases (CVDs) associated with aberrant levels of sex hormones.

Summary

In contrast with historical assumptions, we now understand that men and women show different symptoms and progression of CVDs. Abnormal levels of sex hormones pose an independent risk for CVD, which is apparent in conditions like Klinefelter syndrome, androgen insensitivity syndrome, and menopause. Moreover, sex hormone–based therapies remain understudied and may not be beneficial for cardiovascular health.

Associations between endogenous sex hormones and FGF-23 among women and men in the Multi-Ethnic Study of Atherosclerosis

Elevated levels of testosterone and fibroblast growth factor 23 (FGF-23) are both independently associated with a higher risk of cardiovascular disease (CVD). However, the relationship between sex hormones and FGF-23 is not well established. We explored the association between sex hormones and FGF-23 among middle-aged to older men and women in MESA. We studied 3,052 men and 2,868 postmenopausal women free of CVD at the time of enrollment with baseline serum sex hormones [total testosterone (T), free T, estradiol (E2) and sex hormone binding globulin (SHBG)] and intact FGF-23. In sex-stratified analyses, we examined the cross-sectional associations between log-transformed sex hormones (per 1 SD) and log-transformed FGF-23 using multiple linear regression adjusted for socio-demographics, CVD risk factors, estimated glomerular filtration rate and mineral metabolites (25-hydroxyvitamin D, calcium, phosphorus and parathyroid hormone). The mean (SD) age of study participants was 64 (10) years. The median (IQR) of FGF-23 was similar in women and men [38 (30-46) vs 38 (31-47) pg/mL]. In adjusted analyses, among women, 1 SD increment in free T was associated with 3% higher FGF-23 while SHBG was associated with 2% lower FGF-23. In men, 1 SD increment in E2 was associated with 6% higher FGF-23 whereas total T/E2 ratio was associated with 7% lower FGF-23. In conclusion, this exploratory analysis found that a more androgenic sex hormone profile was directly associated with FGF-23 in women and inversely associated with FGF-23 in men. Longitudinal studies are required to determine whether FGF-23 mediates the relationship between sex hormones and CVD risk.

Androgenic steroids dysregulation and the risk of coronary artery disease

INTRODUCTION

Endogenous testosterone deficiency or excess anabolic-androgenic steroids (AAS) have been linked to alter the physiology of different organs in the body, more specifically, the vasculature of coronary arteries. Despite the health-related concerns of using synthetic testosterone derivatives, such as AAS, there has been a tremendous increase in the use of AAS among athletes and bodybuilders.

AREAS COVERED

We have highlighted the three main mechanisms that AAS increase the risk of coronary artery disease (CAD): altering the homeostasis of lipid metabolism which results in dyslipidemia and subsequently atherosclerosis, disturbing the function of platelet which results in platelet aggregation and subsequent thrombosis, and increasing the risk of coronary vasospasm by affecting the physiological function of vascular bed.

EXPERT OPINION

Despite the restriction of AAS in specific clinical conditions such as testosterone deficiency and cancer therapy, many amateurs' athletes misuse the AAS. Although there has been a strong association between the AAS misuse and risk of developing CAD, the more valued approach would be a randomized clinical double-blind trial. The suggested primary endpoint would be an occurrence of adverse cardiovascular events, such as myocardial infarction, cerebrovascular accidents, and death. Increasing awareness of the risk of missing AAS among high-risk groups is imperative.

Terapia Hormonal e Hipertensão em Mulheres na Pós-Menopausa: Resultados do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil)

Fundamento

A hipertensão arterial é considerada um importante fator de risco de morbidade e mortalidade cardiovascular em mulheres na pós-menopausa. Embora a terapia hormonal da menopausa (THM) seja um tratamento muito eficiente para sintomas vasomotores nesse período, a influência dessa terapia na pressão arterial ainda não está clara.

Objetivo

Avaliar a relação entre o uso de THM e a hipertensão em participantes do ELSA-Brasil.

Métodos

Um estudo transversal usando dados da linha de base da coorte ELSA-Brasil, com 2.138 mulheres que passaram por menopausa natural. Neste estudo, foi analisado a hipertensão, definida como pressão arterial ≥140/90 mmHg ou uso anterior de anti-hipertensivo, e o uso da THM, com participantes sendo classificadas em grupos daquelas que nunca usaram, que já usaram e que estavam em uso atual. As associações foram avaliadas usando-se um modelo de regressão logística multivariada com uma significância estatística definida em p<0,05.

Resultados

No total, 1.492 mulheres (69,8%) nunca tinham usado a THM, 457 (21,4%) tinham usado no passado, e 189 (8,8%) estavam em uso atual. O uso de THM foi mais comum em mulheres que tinham índice de massa corporal <25 kg/m² e níveis de triglicérides <150 mg/dl, que eram fisicamente menos inativas, não fumantes e não diabéticas. As mulheres em uso atual da THM apresentaram menores chances de ter hipertensão (OR=0,59; IC 95%: 0,41-0,85), em comparação com as que nunca a usaram. Na maioria dos casos, a THM foi iniciada com idade até 59 anos, com menos de 10 anos de menopausa e o uso durou até cinco anos.

Conclusão

O uso atual da THM não esteve relacionado à hipertensão, especialmente em mulheres saudáveis e que tinham menos de 60 anos de idade.

Infertility and Risk of Heart Failure in the Women's Health Initiative

BACKGROUND

There is growing recognition that reproductive factors are associated with increased risk of future cardiovascular disease. Infertility has been less well studied, although emerging data support its association with increased risk of cardiovascular disease. Whether infertility is associated with future risk of heart failure (HF) is not known.

OBJECTIVES

This study sought to examine the development of HF and HF subtypes in women with and without history of infertility.

METHODS

We followed postmenopausal women from the Women's Health Initiative prospectively for the development of HF. Infertility was self-reported at study baseline. Multivariable cause-specific Cox models were used to evaluate the association of infertility with incident overall HF and HF subtypes (heart failure with preserved ejection fraction [HFpEF]: left ventricular ejection fraction of ≥50% vs heart failure with reduced ejection fraction [HFrEF]: left ventricular ejection fraction of <50%]).

RESULTS

Among 38,528 postmenopausal women (mean age: 63 ± 7 years), 5,399 (14%) participants reported a history of infertility. Over a median follow-up of 15 years, 2,373 developed incident HF, including 807 with HFrEF and 1,133 with HFpEF. Infertility was independently associated with future risk of overall HF (HR: 1.16; 95% CI: 1.04-1.30; P = 0.006). Notably, when examining HF subtypes, infertility was associated with future risk of HFpEF (HR: 1.27; 95% CI: 1.09-1.48; P = 0.002) but not HFrEF (HR: 0.97; 95% CI: 0.80-1.18).

CONCLUSIONS

Infertility was significantly associated with incident HF. This was driven by increased risk of HFpEF, but not HFrEF, and appeared independent of traditional cardiovascular risk factors and other infertility-related conditions. Future research should investigate mechanisms that underlie the link between infertility and HFpEF.

Morbidity and mortality in PCOS: A prospective follow-up up to a mean age above 80 years

OBJECTIVE

Despite the clear evidence of increased cardiovascular disease (CVD) risk factors, the long-term effect on CVD and mortality is still uncertain in women with PCOS, especially in the elderly. Studies in elderly women with PCOS are lacking. The objective was to study morbidity/mortality in PCOS women compared with a reference group up to a mean age above 80 years.

STUDY DESIGN

A well-defined cohort of women with PCOS, examined in 1987 and 2008, was re-examined 32 years later in 2019 (age range 72-91 years), in parallel with an age-matched reference group. For deceased women register data was used, for women alive interviews were done, and medical records studied. Blood pressure and blood tests were analyzed. Morbidity and mortality data was available in 35/36 women with PCOS, and in 99/118 women in the reference group.

RESULTS

At mean age 81 years there was no difference in all-cause mortality (HR 1.1, ns), CVD-related mortality (HR 1.7, ns), all CVD (HR 1.2, ns), hypertension (HR 1.8, ns), type 2 diabetes (HR 1.7, ns), in levels of blood lipids, glucose, insulin or thyroid hormones. Comparing baseline data from the deceased and living women with PCOS, no differences were found regarding age, menopausal age, BMI, HOMA-IR, FAI, total testosterone or SHBG. However, deceased women with PCOS had a higher WHR (0.87 vs. 0.80; p-value < 0.01) at baseline.

CONCLUSIONS

No evidence of increased all-cause mortality or CVD was found in women with PCOS. The elevated testosterone levels and CVD risk profile in PCOS present during perimenopause do not seem to be associated with increased CVD morbidity/mortality risk later in life.

Cardiometabolic risk factors and endogenous sex hormones in postmenopausal women: a cross-sectional study

Context

It is uncertain which cardiovascular risk factors are associated with sex hormone levels in postmenopausal women.

Objective

This work aimed to investigate the association between cardiometabolic risk factors and sex hormones in a cross-sectional, observational population study.

Methods

In this Swedish population study, participants were physically examined from 2002 to 2004, and endogenous sex hormones were analyzed by liquid chromatography–tandem mass spectrometry. Women aged 55 years or older with estradiol levels below 20 pg/mL and not using any hormonal therapy were eligible for inclusion in the study (N = 146). Variable selection and bootstrap stability analyses were performed and linear regression models presented, with each of the 8 hormones as outcome variables.

Results

Body mass index (BMI) was positively associated with estradiol (β = 0.054, P < .001), but negatively associated with 17-α-hydroxyprogesterone (β = –0.023, P = .028). Waist-to-hip ratio (WHR) was negatively associated with dihydrotestosterone (β = –2.195, P = .002) and testosterone (β = –1.541, P = .004). The homeostatic model assessment of insulin resistance was positively associated with androstenedione (β = 0.071, P = .032), estradiol (β = 0.091, P = .009), estrone (β = 0.075, P = 0.009), and 17-α-hydroxyprogesterone (β = 0.157, P = .001). Age was positively associated with testosterone (β = 0.017, P = .042). C-reactive protein showed an inverse association with progesterone (β = –0.028, P = .037). Lower low-density lipoprotein cholesterol was associated with higher estradiol levels (β = –0.093, P = .049), whereas lower triglycerides were associated with higher concentrations of dihydrotestosterone (β = –0.208, P = .016).

Conclusion

In postmenopausal women, WHR was strongly inversely associated with androgens, while BMI was positively associated with estrogens.

High Prevalence of Asymptomatic Intracranial Atherosclerosis in Elder Women With Tubal Ligation: Result From a Community-Based Study in Shandong, China

Background

In addition to traditional cardiovascular risk factors, gender-specific factors may also contribute to intracranial atherosclerosis. This study aimed to comprehensively investigate the association between asymptomatic intracranial atherosclerosis (aICAS) and menstrual or reproductive history (MRH), namely, menstruation, pregnancy, childbirth, menopause, and contraception.

Methods

Participants in this study were selected from the Kongcun town aICAS study. MRH was collected through structured case report forms, in which menarche age, menstrual regularity, dysmenorrhea, number of pregnancies, number of childbirths, age of first pregnancy, breastfeeding, menopause, menopause age, and contraceptive methods were all involved. All characteristics were compared by chi-squared and nonparametric tests as applicable. Logistic regression model and sensitivity analysis were used to analyze the association between aICAS and MRH.

Results

A total of 1,052 female participants were involved in this study, of which 5.7% had moderate to severe aICAS. Tubal ligation was significantly associated with aICAS in univariate analysis [crude odds ratio (OR), 2.85; 95% CI, 1.22–6.62; P = 0.015]. This association was still significant among female participants over 60 years old after multivariate adjustment (adjusted OR, 4.36; 95% CI, 1.55–12.24; P = 0.005). Sensitivity analysis showed a similar result (adjusted OR, 3.76; 95% CI, 1.24–11.41; P = 0.020). Menopause lost significant association with aICAS after multivariate adjustment (adjusted OR, 1.68; 95% CI, 0.66–4.24; P = 0.275). No other MRH factors were found to be associated with aICAS.

Conclusion

Tubal ligation may be associated with a higher prevalence of aICAS in Chinese elderly women. This provides a new perspective to study the epidemiological characteristics of ICAS.

Effect of the phthalates exposure on sex steroid hormones in the US population

BACKGROUND

New alternative phthalates have been increasingly substituted for certain phthalates in some consumer products due to safety concerns. However, research on the steroidal effect of exposure to the newer replacement phthalates in the general adult population is lacking.

OBJECTIVES

This study aimed to examine the associations of exposure to the older generation and newer replacement phthalates with sex hormone levels in the U.S. general population.

METHODS

The current cross-sectional study was based on the National Health and Nutrition Examination Survey (NHANES) 2015-2016. Sixteen urinary phthalates metabolites and three serum sex hormones were measured in 1768 adults. Gender-specific associations between urinary phthalate concentrations and sex hormones were estimated by using adjusted multiple linear regression. Logistic regression was performed to calculate the risk of phthalates exposure on hormones dysfunction.

RESULTS

Most phthalates metabolites concentrations were lower than 50 ng/mL. MEP, MBP, MiBP, MECPP, MCOP, MEHHP, MEOHP were higher than others, suggesting that new alternative DEP, DBP, and DiNP were exposed at high levels in daily life while DINCH was at a low level. Phthalates exposure was associated with decreased testosterone levels and increased estradiol and SHBG in total samples. Testosterone level was negatively associated with MnBP (β: -0.05, 95% CI: -0.09, 0), MEOHP (β:-0.05, 95% CI:-0.09,-0.01), MEHHP (β:-0.04, 95% CI:-0.08,0), MECPP (β:-0.07, 95% CI:-0.11,-0.03), MEP (β: -0.03, 95% CI: -0.06, 0), MiBP (β: -0.05, 95% CI: -0.10, -0.01) in males; ln-transformed estradiol were increased by 0.18 pg/mL (95% CI: 0.05,0.31), 0.15 pg/mL (95% CI: 0.01,0.29) with each 1 ln-concentration increase in MEHP and MNP, respectively, in females.

CONCLUSIONS

Our results suggest that phthalates exposure may disturb the hormone homeostasis in adults. The safe alternative should be used with caution in industrial production in the future and the need for further research into the safety of the new alternative replacements is necessary.

Associations between blood sex steroid concentrations and risk of major adverse cardiovascular events in healthy older women in Australia: a prospective cohort substudy of the ASPREE trial

BACKGROUND

Blood testosterone concentrations in women decline during the reproductive years and reach a nadir in the seventh decade, after which concentrations increase and are restored to those of reproductive-aged women early in the eighth decade. We aimed to establish the association between the concentration of testosterone in the blood and risk of major adverse cardiovascular events (MACE) and all-cause mortality in healthy older women.

METHODS

SHOW was a prospective cohort substudy of the longitudinal randomised ASPREE trial. Eligible participants were women aged at least 70 years from Australia with unimpaired cognition, no previous MACE, and a life expectancy of at least 5 years. Participants who were receiving hormonal or steroid therapy were ineligible for inclusion. We measured serum concentrations of sex steroids with liquid chromatography-tandem mass spectrometry and of SHBG with immunoassay. We compared lower concentrations of sex hormones with higher concentrations using four quartiles. Primary endpoints were risk of MACE and all-cause mortality, the associations of which with sex steroid concentrations were assessed using Cox proportional hazards regression that included age, body-mass index, smoking status, alcohol consumption, diabetes, hypertension, dyslipidaemia, impaired renal function, and treatment allocation in the ASPREE trial (aspirin vs placebo). ASPREE is registered with ClinicalTrials.gov, NCT01038583.

FINDINGS

Of the 9180 women recruited to the ASPREE trial between March 10, 2010, and Dec 31 2014, 6358 participants provided sufficient biobank samples at baseline and 5535 were included in the final analysis. Median age at entry was 74·0 years (IQR 71·7-77·7). During a median 4·4 years of follow-up (24 553 person-years), 144 (2·6%) women had a first MACE (incidence 5·9 per 1000 person-years). During a median 4·6 years of follow-up (3·8-5·6), 200 women died (7·9 per 1000 person-years). In the fully adjusted models, higher concentrations of testosterone were associated with a lower incidence of MACE (quartile 4 vs quartile 1: hazard ratio 0·57 [95% CI 0·36-0·91]; p=0·02), as were higher concentrations of DHEA (quartile 4 vs quartile 1: 0·61 [0·38-0·97]; p=0·04). For oestrone, a lower risk of MACE was seen for concentrations in quartile 2 only, compared with quartile 1 (0·55 [0·33-0·92]; p=0·02). In fully adjusted models, no association was seen between SHBG and MACE, or between any hormone or SHBG and all-cause mortality.

INTERPRETATION

Blood concentrations of testosterone and DHEA above the lowest quartile in older women were associated with a reduced risk of a first-ever MACE. Given that the physiological effects of DHEA are mediated through its steroid metabolites, if the current findings were to be replicated, trials investigating testosterone therapy for the primary prevention of ischaemic cardiovascular disease events in older women would be warranted.

FUNDING

The National Health and Medical Research Council of Australia, US National Institute on Aging, the Victorian Cancer Agency, the Commonwealth Scientific and Industrial Research Organisation, and Monash University.

Sex Hormone-Specific Neuroanatomy of Takotsubo Syndrome: Is the Insular Cortex a Moderator?

Takotsubo syndrome (TTS), a transient form of dysfunction in the heart’s left ventricle, occurs predominantly in postmenopausal women who have emotional stress. Earlier studies support the concept that the human circulatory system is modulated by a cortical network (consisting of the anterior cingulate gyrus, amygdala, and insular cortex (Ic)) that plays a pivotal role in the central autonomic nervous system in relation to emotional stressors. The Ic plays a crucial role in the sympathovagal balance, and decreased levels of female sex hormones have been speculated to change functional cerebral asymmetry, with a possible link to autonomic instability. In this review, we focus on the Ic as an important moderator of the human brain–heart axis in association with sex hormones. We also summarize the current knowledge regarding the sex-specific neuroanatomy in TTS.

Influence of endogenous estrogen on a network model of female brain integrity

Recent reports document sex differences in midlife brain integrity and metabolic health, such that more relationships are detectable between metabolic syndrome (MetS) components and markers of brain health in females than in males. Midlife is characterized by a rapid decrease in endogenous estrogen levels for women which is thought to increase risk for cardiometabolic disease and neurocognitive decline. Our study used network models, designed to explore the interconnectedness and organization of relationships among many variables at once, to compare the influence of endogenous estrogen and chronological age on a network of brain and metabolic health in order to investigate the utility of estrogen as a biomarker for brain vulnerability. Data were analyzed from 82 females (ages 40-62). Networks consisted of known biomarkers of risk for late-life cognitive decline: the five components of MetS; Brain-predicted age difference calculated on gray and white matter volume; white matter hyperintensities; Default Mode Network functional connectivity; cerebral concentrations of N-acetyl aspartate, glutamate and myo-inositol; and serum concentrations of estradiol. A second network replaced estradiol with chronological age. Expected influence (EI) of estradiol on the network was -1.190, relative to chronological age at -0.524, indicating that estradiol had a stronger expected influence over the network than age. A negative expected influence indicates that higher levels of estradiol would be expected to decrease the number of relationships in the model, which is thought to indicate lower risk. Overall, levels of estradiol appear more influential than chronological age at midlife for relationships between brain integrity and metabolic health.

Mechanisms and implications of sex differences in cardiac aging

Aging promotes structural and functional remodeling of the heart, even in the absence of external factors. There is growing clinical and experimental evidence supporting the existence of sex-specific patterns of cardiac aging, and in some cases, these sex differences emerge early in life. Despite efforts to identify sex-specific differences in cardiac aging, understanding how these differences are established and regulated remains limited. In addition to contributing to sex differences in age-related heart disease, sex differences also appear to underlie differential responses to cardiac stress such as adrenergic activation. Identifying the underlying mechanisms of sex-specific differences may facilitate the characterization of underlying heart disease phenotypes, with the ultimate goal of utilizing sex-specific therapeutic approaches for cardiac disease. The purpose of this review is to discuss the mechanisms and implications of sex-specific cardiac aging, how these changes render the heart more susceptible to disease, and how we can target age- and sex-specific differences to advance therapies for both male and female patients.

Associations of endogenous sex hormone levels with the prevalence and progression of valvular and thoracic aortic calcification in the Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND AND AIMS

Sex hormones (SH) may contribute to sex differences in cardiovascular disease (CVD). High free testosterone (T) and low sex hormone binding globulin (SHBG) have been associated with progression of coronary artery calcification in women. We now examined the association of SH with extra-coronary calcification (ECC) prevalence and progression among MESA participants.

METHODS

We studied 2,737 postmenopausal women and 3,130 men free of clinical CVD with baseline SH levels. ECC measurements [ascending and descending thoracic aortic calcification (ATAC, DTAC), mitral annular calcification (MAC), aortic valve calcification (AVC)] were obtained by computed tomography at baseline and after 2.4 ± 0.9 years. We used multivariable Poisson regression to evaluate associations with ECC prevalence and incidence (Agatston scores >0) and linear mixed effects models for ECC progression, per 1-SD increment in log(SH) in women and men separately.

RESULTS

The mean age was 65 ± 9 and 62 ± 10 years for women and men, respectively. In women, greater free T and lower SHBG were associated with MAC incidence in a demographic-adjusted model only. In men, lower free T was associated with MAC prevalence, DTAC incidence and progression, while greater SHBG was associated with MAC prevalence and DTAC progression after further adjusting for CVD risk factors.

CONCLUSIONS

In this diverse cohort free of CVD, we found some associations of SH with ECC measures. In particular, free T was inversely associated with prevalent MAC and DTAC progression in men independent of CVD risk factors. SH may influence vascular calcification, but further work is needed to understand clinical implications of these findings.

Menopause, androgens, and cardiovascular ageing: a narrative review

Cardiovascular disease is the leading cause of death worldwide; however, women tend to be less affected than men during their reproductive years. The female cardiovascular risk increases significantly around the time of the menopausal transition. The loss of the protective action of ovarian oestrogens and the circulating androgens has been implicated in possibly inducing subclinical and overt changes in the cardiovascular system after the menopausal transition. In vitro studies performed in human or animal cell lines demonstrate an adverse effect of testosterone on endothelial cell function and nitric oxide bioavailability. Cohort studies evaluating associations between testosterone and/or dehydroepiandrosterone and subclinical vascular disease and clinical cardiovascular events show an increased risk for women with more pronounced androgenicity. However, a mediating effect of insulin resistance is possible. Data on cardiovascular implications following low-dose testosterone treatment in middle-aged women or high-dose testosterone supplementation for gender affirmatory purposes remain primarily inconsistent. It is prudent to consider the possible adverse association between testosterone and endothelial function during the decision-making process of the most appropriate treatment for a postmenopausal woman.

Prognostic Nutritional Index as a Novel Predictor of Long-Term Prognosis in Patients with Coronary Artery Disease After Percutaneous Coronary Intervention

BACKGROUND

The Prognostic Nutritional Index (PNI) has been reported to be correlated with long-term outcomes after gastrointestinal tumor surgery. However, to our knowledge, only a few studies have shown that the PNI is related to cardiovascular diseases. Therefore, we aimed to assess the association between the PNI and long-term outcomes in patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI).

METHODS

This was retrospective observational study. A total of 3561 patients with CAD after PCI were retrospectively enrolled in the CORFCHD-ZZ study from January 2013 to December 2017. The patients (3519) were divided into three groups according to PNI tertiles: the first tertile (PNI < 47.12, n = 1173), the second tertile (47.12 ≤ PNI < 51.50, n = 1185), and the third tertile (PNI ≥ 51.50, n = 1161). The mean follow-up time was 37.59 ± 22.24 months. The primary endpoint long-term mortality, including all-cause mortality (ACM) and cardiac mortality (CM).Secondary endpoints were major adverse cardiovascular events (MACEs) and major adverse cardiovascular and cerebrovascular events (MACCEs).

RESULT

In our study, the incidences of ACM in the first, second, and third tertiles were 3.8%, 1.8% and 1.4%, respectively (P < 0.001). The incidences of CM occurring in the first, second, and third tertiles were 1.7%, 3.1% and 2.1%, respectively (P < 0.001).There was statistically significant different in primary endpoints incidence. MACEs occurred in 139 patients (11.8%) in the first tertile, 121 patients(11.1%) in the second tertile and 123 patients(10.8%) in the third tertile(P = 0.691). MACCEs occurred in 183 patients (15.6%) in the first tertile, 174 patients(14.7%) in the second tertile and 160 patients(13.85%) in the third tertile(P = 0.463).There was no statistically significant different in secondary endpoints incidence. Kaplan-Meier analyses showed that elevated PNI was significantly related to long-term CM (log rank, P < 0.001) and long-term ACM (log-rank, P < 0.001). Cox regression analyses suggested that compared with the patients in the first tertile, the risk of ACM was decreased to 60.9% (HR = 0.609, 95% CI: 0.398-0.932, P = 0.029) in the second tertile and 40.3%(HR = 0.403, 95% CI: 0.279-0.766, P = 0.003) in the third tertile, while the risk of CM was decreased to 58.8%(HR = 0.588, 95% CI: 0.321-0.969, P = 0.038) in the second tertile and 46.6%(HR = 0.466, 95% CI: 0.250-0.870, P = 0.017) in the third tertile. Multivariate Cox regression analyses showed that the PNI was an independent predictor of long-term ACM and CM.

CONCLUSION

Our finding shown that PNI is an independent predictor in CAD patients after PCI，the higher the PNI, the less occurring adverse event. Therefore，PNI may be an new biomarker to predict long-term outcome of CAD patients after PCI.

Associations between endogenous sex hormone levels and adipokine levels in the Multi-Ethnic Study of Atherosclerosis

Background

Differences in sex hormone levels contribute to differences in cardiovascular disease (CVD) risk. Adipokines play a role in cardiometabolic pathways and have differing associations with CVD. Adipokine levels differ by sex; however, the association between sex hormone profiles and adipokines is not well established. We hypothesized that a more androgenic sex hormone profile would be associated with higher leptin and resistin and lower adiponectin levels among postmenopausal women, with the opposite associations in men.

Methods

We performed an analysis of 1,811 adults in the Multi-Ethnic Study of Atherosclerosis who had both sex hormones and adipokines measured an average of 2.6 years apart. Sex hormones [Testosterone (T), estradiol (E2), sex hormone binding globulin (SHBG), and dehydroepiandrosterone (DHEA)] were measured at exam 1; free T was estimated. Serum adipokines (leptin, resistin, adiponectin) were measured at exams 2 or 3. We used multivariable linear regression to examine the cross-sectional associations between sex hormones and adipokines.

Results

The mean (SD) age was 63 (10) years, 48% were women; 59% non-White participants. For leptin, after adjusting for demographics only, higher free T and lower SHBG, were associated with higher leptin in women; this association was attenuated after further covariate adjustment. However in men, higher free T and lower SHBG were associated with greater leptin levels in fully adjusted models. For adiponectin, lower free T and higher SHBG were associated with greater adiponectin in both women and men after adjustment for CVD risk factors. For resistin, no significant association was found women, but an inverse association with total T and bioT was seen in men.

Conclusion

Overall, these results further suggest a more androgenic sex profile (higher free T and lower SHBG) is associated with a less favorable adipokine pattern. These findings may provide mechanistic insight into the interplay between sex hormones, adipokines, and CVD risk.

Obesity, Body Composition, and Sex Hormones: Implications for Cardiovascular Risk

Cardiovascular disease (CVD) continues to be the leading cause of death in adults, highlighting the need to develop novel strategies to mitigate cardiovascular risk. The advancing obesity epidemic is now threatening the gains in CVD risk reduction brought about by contemporary pharmaceutical and surgical interventions. There are sex differences in the development and outcomes of CVD; premenopausal women have significantly lower CVD risk than men of the same age, but women lose this advantage as they transition to menopause, an observation suggesting potential role of sex hormones in determining CVD risk. Clear differences in obesity and regional fat distribution among men and women also exist. While men have relatively high fat in the abdominal area, women tend to distribute a larger proportion of their fat in the lower body. Considering that regional body fat distribution is an important CVD risk factor, differences in how men and women store their body fat may partly contribute to sex-based alterations in CVD risk as well. This article presents findings related to the role of obesity and sex hormones in determining CVD risk. Evidence for the role of sex hormones in determining body composition in men and women is also presented. Lastly, the clinical potential for using sex hormones to alter body composition and reduce CVD risk is outlined. © 2022 American Physiological Society. Compr Physiol 12:1-45, 2022.

The Associations of Lipid Profiles With Cardiovascular Diseases and Death in a 10-Year Prospective Cohort Study

Background: Dyslipidemia is one of the modifiable risk factors for cardiovascular diseases (CVD). Identifying subjects with lipid abnormality facilitates preventative interventions.

Objectives: To evaluate the effects of lipid indices on the risks of ischemic stroke (IS), coronary heart disease (CHD), CVD, all-cause death, and CVD death.

Methods: The cohort study of 4,128 subjects started in May 2009 and followed up to July 2020. Restricted cubic spline (RCS) regression analysis was used to explore the dose-response relationship between lipid indices with outcomes. Cox proportional hazard regression analysis was used to estimate the association with a hazard ratio (HR) and 95% CI.

Results: RCS analysis showed that there were significant linear associations of TG with IS, non-high-density lipoprotein cholesterol (HDL-C), apolipoprotein B (ApoB), and total cholesterol (TC)/HDL-C ratio with all-cause death, non-HDL-C and RC with CVD death, and significant non-linear associations of ApoB with IS and CVD, TC, LDL-C, ApoAI, and TC/HDL-C ratio with CHD, and TC with all-cause death (all P <0.1). Cox regression analysis revealed that subjects with TC <155 mg/dl (vs. 155–184 mg/dl), > 185 mg/dl (vs. 155–184 mg/dl), and ApoB <0.7 g/l (vs. ≥0.7 g/l) had higher risks of CHD (P < 0.05), the adjusted HRs (95% CIs) were 1.933 (1.248–2.993), 1.561 (1.077–2.261), and 1.502 (1.01–2.234), respectively. Subjects with ApoAI > 2.1 g/l (vs. 1.6–2.1 g/l) and TG <80 mg/dl (vs. 80–177 mg/dl) had higher risks of CVD and all-cause death (P < 0.05), the adjusted HRs (95% CIs) were 1.476 (1.031–2.115) and 1.234 (1.002–1.519), respectively.

Conclusions: Lower or higher levels of TC, higher level of ApoAI, and lower level of ApoB were associated with increased risks of CVD, and lower level of TG was associated with increased all-cause death. Maintaining optimal lipid levels would help to prevent CVD and reduce mortality.

The Effect of Testosterone on Cardiovascular Disease and Cardiovascular Risk Factors in Men: A Review of Clinical and Preclinical Data

Cardiovascular disease (CVD) is the leading cause of death worldwide. The effects of testosterone, the primary male sex hormone, on cardiovascular risk have been of special interest due to the increased risk of CVD in men. Although it is well established that testosterone levels decline and cardiovascular mortality increases with age, the association between testosterone and CVD remains unclear. Observational and randomized studies on the effects of endogenous and exogenous testosterone have produced conflicting data, and meta-analyses have been inconclusive, suggesting significant study heterogeneity. Despite a lack of adequately powered randomized controlled trials, large observational studies in the early 2010s led to advisories on the use of testosterone replacement therapy. Similar advisories have been mandated for certain types of androgen deprivation therapy. Additional research suggests that testosterone shortens the heart-rate-corrected QT interval, improves glycemic control, induces vasodilation, is prothrombotic, and has anti-obesity effects, whereas associations with atherosclerosis and inflammation are less clear. Despite inconclusive evidence on cardiovascular risk and inconsistencies among clinical practice guidelines, millions of men continue to use testosterone replacement and androgen deprivation therapy. In addition to summarizing clinical and preclinical data, this review provides insight on potential mechanisms of action of testosterone on CVD, applications of this knowledge to clinical settings, and avenues for future research.

Whole-diet interventions and cardiovascular risk factors in postmenopausal women: A systematic review of controlled clinical trials

OBJECTIVES

Menopause is accompanied by many metabolic changes, increasing the risk of cardiometabolic diseases. The impact of diet, as a modifiable lifestyle factor, on cardiovascular health in general populations has been well established. The purpose of this systematic review is to summarize the evidence on the effects of whole diet on lipid profile, glycemic indices, and blood pressure in postmenopausal women.

METHODS

Embase, Medline, Cochrane Central Register of Controlled Trials, and Google Scholar were searched from inception to February 2021. We included controlled clinical trials in postmenopausal women that assessed the effect of a whole-diet intervention on lipid profile, glycemic indices, and/or blood pressure. The risk of bias in individual studies was assessed using RoB 2 and ROBINS-I tools.

SUMMARY OF EVIDENCE

Among 2,134 references, 21 trials met all eligibility criteria. Overall, results were heterogenuous and inconsistent. Compared to control diets, some studies showed that participants experienced improvements in total cholesterol (TC), low-density lipoprotein cholesterol (LDL), systolic blood pressure (SBP), fasting blood sugar (FBS), and apolipoprotein A (Apo-A) after following fat-modified diets, but some adverse effects on triglycerides (TG), very low-density lipoprotein cholesterol (VLDL), lipoprotein(a) (Lp(a)), and high-density lipoprotein cholesterol (HDL) concentrations were also observed. A limited number of trials found some effects of the Paleolithic, weight-loss, plant-based, or energy-restricted diets, or of following American Heart Association recommendations on TG, TC, HDL, insulin, FBS, or insulin resistance.

CONCLUSION

Current evidence suggests that diet may affect levels of some lipid profile markers, glycemic indices, and blood pressure among postmenopausal women. However, due to the large heterogeneity in intervention diets, comparison groups, intervention durations, and population characteristics, findings are inconclusive. Further well-designed clinical trials are needed on dietary interventions to reduce cardiovascular risk in postmenopausal women.

Modification of the toxic effects of methylmercury and thimerosal by testosterone and estradiol in SH-SY5Y neuroblastoma cell line

Short-chained alkyl mercury compounds accumulate in particularly in the brain. Exposure to these compounds is associated with various neurotoxic effects. Gender-based differences are observed in neurodevelopmental disorders, and testosterone and estradiol may alter the toxic effect of the compounds. The present study aimed to investigate the toxic effects of methylmercury and thimerosal on SH-SY5Y cells in high testosterone/low estradiol and high estradiol/low testosterone containing cellular environment and estimate whether male and female brains react differently to the toxic effects of methylmercury and thimerosal. Study groups (n = 3) were designed as control: growth medium, thimerosal (T): 1.15-μM thimerosal, methylmercury (M): 2.93-μM methylmercury, high testosterone/low estradiol + thimerosal (TT): 1-μM testosterone + 0.75-μM estradiol + 1.15-μM thimerosal, high estradiol/low testosterone + thimerosal (ET): 0.1-μM testosterone + 7.5-μM estradiol + 1.15-μM thimerosal, high testosterone/low estradiol + methylmercury (TM): 1-μM testosterone + 0.75-μM estradiol + 2.93-μM methylmercury and high estradiol/low testosterone + methylmercury (EM): 0.1-μM testosterone + 7.5-μM estradiol + 2.93-μM methylmercury. While a significant decrease in glutathione levels was observed in M group, it was not seen in EM group. A significant increase in the protein carbonyl levels was detected in T group. A similar increase was observed in the TM and TT groups in which testosterone was dominant. It was determined that methylmercury, but not thimerosal, caused significant DNA damage and in TT group. The results showed that both thimerosal and methylmercury are toxic on SH-SY5Y cells and toxic effects of methylmercury are more severe than thimerosal. It has been determined that testosterone and estradiol alter the toxic effects of thimerosal and methylmercury.

Heart Failure with Reduced Ejection Fraction-Does Sex Matter?

PURPOSE OF REVIEW

There is an increasing recognition of the importance of sex in susceptibility, clinical presentation, and outcomes for heart failure. This review focusses on heart failure with reduced ejection fraction (HFrEF), unravelling differences in biology, clinical and demographic features and evidence for diagnostic and therapeutic strategies. This is intended to inform clinicians and researchers regarding state-of-the-art evidence relevant to women, as well as areas of unmet need.

RECENT FINDINGS

Females are well recognised to be under-represented in clinical trials, but there have been some improvements in recent years. Data from the last 5 years reaffirms that women presenting with HFrEF women are older and have more comorbidities like hypertension, diabetes and obesity compared with men and are less likely to have ischaemic heart disease. Non-ischaemic aetiologies are more likely to be the cause of HFrEF in women, and women are more often symptomatic. Whilst mortality is less than in their male counterparts, HFrEF is associated with a bigger impact on quality of life in females. The implications of this for improved prevention, treatment and outcomes are discussed. This review reveals distinct sex differences in HFrEF pathophysiology, types of presentation, morbidity and mortality. In light of this, in order for future research and clinical medicine to be able to manage HFrEF adequately, there must be more representation of women in clinical trials as well as collaboration for the development of sex-specific management guidelines. Future research might also elucidate the biochemical foundation of the sex discrepancy in HFrEF.

Genetically predicted sex hormone binding globulin and ischemic heart disease in men and women: a univariable and multivariable Mendelian randomization study

Men are more vulnerable to ischemic heart disease (IHD) than women, possibly due to testosterone. Correspondingly, sex hormone binding globulin (SHBG) which lowers circulating testosterone might protect men against IHD. SHBG may also affect IHD independent of testosterone, which has not previously been examined. To assess the sex-specific role of SHBG in IHD, in univariable Mendelian randomization (MR), we used sex-specific, genome-wide significant genetic variants to predict SHBG, and examined their association with IHD in the UK Biobank. We also replicated using genetic instruments from Japanese men and applied to Biobank Japan. To assess the role of SHGB independent of testosterone in men, we used multivariable MR controlling for testosterone. Genetically predicted SHBG was associated with lower IHD risk in men [odds ratio (OR) 0.78 per standard deviation, 95% confidence interval (CI) 0.70 to 0.87], and the association was less clear in women. The estimates were similar in Japanese. The inverse association remained after controlling for testosterone in men (OR 0.79, 95% CI 0.71 to 0.88). SHBG might lower the risk of IHD in men, with a role independent of testosterone. Exploring intervention strategies that increase SHBG is important for targeting IHD treatments.

Female specific risk factors for the development of Alzheimer's disease neuropathology and cognitive impairment: Call for a precision medicine approach

Alzheimer's disease (AD) includes a long asymptomatic stage, which precedes the formal diagnosis of dementia. AD biomarker models provide a framework for precision medicine approaches during this stage. However, such approaches have ignored the possible influence of sex on cognition and brain health, despite female sex noted as a major risk factor. Since AD-related changes may emerge in midlife, intervention efforts are being redirected around this period. Midlife coincides with several endocrinological changes, such as the menopausal transition experienced by women. In this narrative review, we discuss evidence for sex-differences in AD neuropathological burden and outline key endocrinological mechanisms for both sexes, focussing on hormonal events throughout the lifespan that may influence female susceptibility to AD neuropathology and dementia onset. We further consider common non-modifiable (genetic) and modifiable (lifestyle and health) risk factors, highlighting possible sex-dependent differential effects for the AD disease course. Finally, we evaluate the studies selected for this review demonstrating sex-differences in cognitive, pathological and health factors, summarising the state of sex differences in AD risk factors. We further provide recommendations for targeted research on female-specific risk factors, to inform personalised strategies for AD-prevention and the promotion of female brain health.

Menopause and cardiometabolic diseases: What we (don't) know and why it matters

This narrative review discusses the current understanding, knowledge gaps and challenges in expanding our knowledge of the association between menopause and the reproductive aging process and cardiometabolic disease (CMD) in women, with a focus on type 2 diabetes and cardiovascular disease. The physiological changes that occur at different stages of the reproductive life span, as well as type of menopause and timing, are factors widely associated with CMD risk; however, the underlying mechanisms remain either unclear or insufficiently studied. Decreased ovarian estrogen production and relative androgen excess around menopause onset are the most studied factors linking menopause and cardiometabolic health; nevertheless, the evidence is not persuasive and other hypotheses might explain the changes in CMD risk during menopausal transition. In this context, hormone therapy has been widely adopted in the treatment and prevention of CMD, although uncertainty regarding its cardiometabolic effects has raised the need to optimize therapeutic modalities. Mechanisms such as the "iron overload theory" and new "omics" platforms could provide new insights into potential pathways underlying the association between menopause and cardiometabolic health, such as the DNA damage response. Although it has been widely reported that environmental and lifestyle factors affect both menopause and cardiometabolic health, there is little evidence on the role of these exposures in menopause-associated CMD risk.

The impact of physical activity on psychological well-being in women aged 45-55 years during the Covid pandemic: A mixed-methods investigation

Evidence suggests that being physically active may improve quality of life through the menopausal transition. This study is one of the first to investigate how meeting the UK Physical Activity Guidelines (PAG) impacted quality of life, stress, coping and menopausal symptoms in UK midlife women, aged 45-55 years, during the unfolding Covid pandemic (Phase 1 quantitative, n=164). The study also explored their motivation to undertake regular physical activity during Covid lockdown (Phase 2 qualitative, n=4). An explanatory sequential mixed-methods design was used to collate quantitative (survey) and qualitative (focus group) data. Participants who met PAG experienced fewer depressive symptoms and less perceived stress, and had better physical and mental health and quality of life than women who did not. This was supported by focus group discussions reporting lack of facilities, time constraints, reduced social support and existing health complaints as barriers to physical activity. Factors motivating women to exercise during Covid lockdown were benefits for physical and mental health, and support from friends (Qualitative). Women are postmenopausal for one-third of their lives, and health interventions need to promote positive healthy ageing around menopause. Menopausal changes could be used by clinicians as cues to action to promote female health and well-being. Clinicians should be promoting the health benefits of exercise and making women aware of the importance of aiming to meet the PAG for optimal health benefits. Women should be encouraged to increase their levels of physical activity by making plans and setting goals and gaining support by exercising with friends or family, as a way to better control menopausal symptoms.

Effects of Sex and 17 β-Estradiol on Cardiac Fibroblast Morphology and Signaling Activities In Vitro

Several studies have demonstrated estrogen's cardioprotective abilities in decreasing the fibrotic response of cardiac fibroblasts (CFs). However, the majority of these studies are not sex-specific, and those at the cellular level utilize tissue culture plastic, a substrate with a much higher stiffness than physiological conditions. Understanding the intrinsic differences between male and female CFs under more physiologically "healthy" conditions will help to elucidate the divergences in their complex signaling networks. We aimed to do this by conducting a sex-disaggregated analysis of changes in cellular morphology and relative levels of profibrotic signaling proteins in CFs cultured on 8 kPa stiffness plates with and without 17 β-estradiol (E2). Cyclic immunofluorescent analysis indicated that there was a negligible change in cellular morphology due to sex and E2 treatment and that the differences between male and female CFs occur at a biochemical rather than structural level. Several proteins corresponding to profibrotic activity had various sex-specific responses with and without E2 treatment. Single-cell correlation analysis exhibited varied protein-protein interaction across experimental conditions. These findings demonstrate the need for further research into the dimorphisms of male and female CFs to develop better tailored sex-informed prevention and treatment interventions of cardiac fibrosis.

The poorly conducted orchestra of steroid hormones, oxidative stress and inflammation in frailty needs a maestro: Regular physical exercise

This review outlines the various factors associated with unhealthy aging which includes becoming frail and dependent. With many people not engaging in recommended exercise, facilitators and barriers to engage with exercise must be investigated to promote exercise uptake and adherence over the lifespan for different demographics, including the old, less affluent, women, and those with different cultural-ethnic backgrounds. Governmental and locally funded public health messages and environmental facilitation (gyms, parks etc.) can play an important role. Studies have shown that exercise can act as a conductor to balance oxidative stress, immune and endocrine functions together to promote healthy aging and reduce the risk for age-related morbidities, such as cardiovascular disease and atherosclerosis, and promote cognition and mood over the lifespan. Like a classic symphony orchestra, consisting of four groups of related musical instruments - the woodwinds, brass, percussion, and strings - the aging process should also perform in harmony, with compassion, avoiding the aggrandizement of any of its individual parts during the presentation. This review discusses the wide variety of molecular, cellular and endocrine mechanisms (focusing on the steroid balance) underlying this process and their interrelationships.

Efficacy of hyaluronic acid 0.3%, cyanocobalamin, electrolytes, and P-Plus in menopause patients with moderate dry eye disease

Purpose

To study the treatment efficacy of hyaluronic acid 0.3%, cyanocobalamin (vitamin B12), electrolytes, and P-Plus in menopausal patients with moderate dry eye disease.

Methods

Thirty female patients of mean age 53.06 ± 5.20 years (45–65) were enrolled in this prospective longitudinal study. Meibomian gland loss assessment was determined using a scale with four levels. The Ocular Surface Disease Index (OSDI) questionnaire, phenol red thread (PRT) test, and tear film break-up time (TFBUT) were also completed by the patients. Tear eye drops were formulated with 0.3 g of sodium hyaluronate, P-Plus ™, vitamin B12, sodium chloride, potassium chloride, calcium chloride, magnesium chloride, and SCO® (stabilized complex oxychloride). After 30 days, the patients were re-evaluated.

Results

The mean meibomian gland loss percentage was 37.97 ± 19.02 % (7.20 to 88.30%). Before treatment, the OSDI was 22.53 ± 14.03 score points (6.25 to 77.08). Posterior OSDI decreased to 16.26 ± 13.69 score points (0.00 to 70.83) (W = 58.00, P < 0.01). Before treatment, PRT was 10.31 ± 4.48 mm (4.00 to 21.00). Posterior PRT increased to 15.41 ± 6.27 mm (4.00 to 21.00) (W = 1520.50, P < 0.01). Before treatment, TFBUT was 6.23 ± 1.75 s (3.00 to 9.00). The posterior TFBUT increased to 8.10 ± 2.06 s (4.00 to 14.00) (W= 1382.50, P < 0.01).

Conclusion

The hyaluronic acid 0.3% and vitamin B12 eye drops effectively decreased dry eye symptoms in menopausal women and improved tear stability and volume.

Effect of diabetes mellitus on the development of left ventricular contractile dysfunction in women with heart failure and preserved ejection fraction

Background

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome with sex-specific pathophysiology. Estrogen deficiency is believed to be responsible for the development of HFpEF in women. However, estrogen deficiency does not seem to be completely responsible for the differences in HFpEF prevalence between sexes. While diabetes mellitus (DM) frequently coexists with HFpEF in women and is associated with worse outcomes, the changes in myocardial contractility among women with HFpEF and the DM phenotype is yet unknown. Therefore, we aimed to investigate sex-related differences in left ventricular (LV) contractility dysfunction in HFpEF comorbid with DM.

Methods

A total of 224 patients who underwent cardiac cine MRI were included in this study. Sex-specific differences in LV structure and function in the context of DM were determined. LV systolic strains (global longitudinal strain [GLS], circumferential strain [GCS] and radial strain [GRS]) were measured using cine MRI. The determinants of impaired myocardial strain for women and men were assessed.

Results

The prevalence of DM did not differ between sexes (p > 0.05). Despite a similar LV ejection fraction, women with DM demonstrated a greater LV mass index than women without DM (p = 0.023). The prevalence of LV geometry patterns by sex did not differ in the non-DM subgroup, but there was a trend toward a more abnormal LV geometry in women with DM (p = 0.072). The magnitudes of systolic strains were similar between sexes in the non-DM group (p > 0.05). Nevertheless, in the DM subgroup, there was significant impairment in women in systolic strains compared with men (p < 0.05). In the multivariable analysis, DM was associated with impaired systolic strains in women (GLS [β = 0.26; p = 0.007], GCS [β = 0.31; p < 0.001], and GRS [β = −0.24; p = 0.016]), whereas obesity and coronary artery disease were associated with impaired systolic strains in men (p < 0.05).

Conclusions

Women with DM demonstrated greater LV contractile dysfunction, which indicates that women with HFpEF comorbid with DM have a high-risk phenotype of cardiac failure that may require more aggressive and personalized medical treatment.

Sex differences in the association between green tea consumption and hypertension in elderly Chinese adults

BACKGROUND

Green tea has been one of the most popular beverages in China since ancient times. Mixed results concerning the effect of green tea consumption on the incidence of hypertension have been published over the past decades. However, no previous studies have focused on longevous individuals in China and the sex differences in the association between habitual green tea intake and hypertension.

METHODS

The data extracted from the database of the Chinese Longitudinal Healthy Longevity Survey (CLHLS) in 2018 were used for a secondary analysis. Logistic regression models were employed to examine the odds ratio (OR) of daily green tea consumption on the incidence of hypertension by sex.

RESULTS

A total of 9277 individuals were included in the analysis (39.8% were men). The included individuals had a mean age of 80.9 and 84.8 years for those who drank green tea daily and those who had never, respectively (p <  0.001). The incidence of hypertension varied at baseline according to green tea drinking habit and sex. For women who had a habitual green tea intake or had never drunk green tea, the incidence of hypertension was 47.3 and 43.9%, respectively (p = 0.241), whereas it was 51.6 and 39.7% for men (p <  0.001). After adjusting for potential confounders, a 38% increase in the risk of hypertension was observed in men who consumed green tea daily (OR, 1.38; 95% CI, 1.15-1.67; p <  0.001).

CONCLUSIONS

Chinese longevous men had a 38% higher risk of developing hypertension when drinking green tea daily. However, no effect of green tea consumption on the incidence of hypertension in women was found. More attention should be paid to the lifestyle of longevous individuals for health promotion, and a sex-specific approach to deliver care for very elderly people is warranted.

The Role of Testosterone in Menopause Management: A Review of Literature

Background: Despite the lack of approved testosterone formulations for women in most countries, testosterone therapy is still being offered to women worldwide. Aging and loss of ovarian or adrenal function, among others, can lower testosterone levels in women. However, international guidelines currently do not routinely recommend androgen replacement therapy due to lack of long-term safety data. Evidence on its benefits and risks still remains uncertain.

Objectives: The aim of this literature review is to present current studies and guidelines that examined the effects of testosterone therapy for postmenopausal women, including its role on cognition and mood; breast and endometrial cancer risks; musculoskeletal, cardiovascular, and genitourinary health; and sexual function.

Methodology: A review of literature was done using PubMed, EMBASE, Science Direct, OVID, and Google scholar, with the following key words: androgen, testosterone, menopause, and hypoactive sexual desire dysfunction. We identified reviews, clinical trials, and guidelines. The population was limited to postmenopausal women.

Results: There is no evidence from current published literature to support the use of testosterone therapy for female well-being, mood and cognition, bone and cardiovascular health. Intravaginal testosterone appears to be a promising alternative for the treatment of genitourinary symptoms of menopause (GSM) but efficacy and safety are yet to be confirmed. Well-designed, randomized, and placebo-controlled trials are needed to establish long-term safety, efficacy, and appropriate dosing and route of testosterone therapy in postmenopausal women. The only evidence-based indication for testosterone therapy in women is for the treatment of postmenopausal hypoactive sexual desire disorder (HSDD). Should a trial of testosterone therapy be given for HSDD, the transdermal route is the preferred method of delivery. Baseline total testosterone concentration should be determined before starting treatment, and repeated after 3–6 months. Serum testosterone levels should be monitored at regular intervals to avoid supraphysiologic dosing.

Conclusion: Currently, there is no robust evidence to support the use of exogenous testosterone to improve female well-being, musculoskeletal health, mood and cognition, as well as bone and cardiovascular health among postmenopausal women. The only evidence-based indication for testosterone therapy in women is the treatment of postmenopausal hypoactive sexual desire disorder, but only after all other causes of sexual dysfunction have been ruled out. To date, testosterone therapy has no US Food and Drug Administration (US FDA) approval due to the lack of long-term efficacy and safety data.