Enhanced verbal memory in nondemented elderly women receiving hormone-replacement therapy

Testosterone and gonadotropins but not estrogen associated with spatial ability in women suffering from schizophrenia: a double-blind, placebo-controlled study

The aim of this study was to investigate the association between estrogen and spatial ability tasks in women suffering from schizophrenia. For this purpose, a placebo-controlled, double-blind, three-time cross-over study using 17beta-estradiol combined with norethisterone acetate for replacement therapy and as an adjunct to a naturalistic maintenance antipsychotic treatment was carried out over a period of 8 months. Nineteen women (mean age=38.0 years, SD=9.9 years) with schizophrenia hospitalized for the first time or repeatedly were included in the study. Sex hormones - 17beta-estradiol, luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, testosterone, and dehydroepiandrosterone sulfate - were measured and the patients completed a neuropsychological test in the last two active drug and/or placebo phases. Three different spatial ability tasks - spatial orientation, spatial visualization, and flexibility of closure - were measured by a paper-and-pencil test. No association between estrogen and spatial ability was found; however, in an additional exploratory data analysis, high levels of testosterone, LH, and FSH correlated significantly with performance in the flexibility of closure task. This is the very first study, based on estrogen intervention instead of physiological hormone changes, to examine the association between estrogen and spatial ability in women with schizophrenia.

Physiological variation in estradiol and brain function: a functional magnetic resonance imaging study of verbal memory across the follicular phase of the menstrual cycle

Women frequently complain of memory problems at times in their reproductive lives that are associated with changes in estrogen concentration (e.g. around menopause and childbirth). Further, behavioural studies suggest that memory performance may fluctuate across the menstrual cycle. For example, performance on verbal tasks has been reported to be greatest during phases associated with high estrogen concentrations whereas the opposite has been reported with visuo-spatial tasks. The biological basis of these reported effects remains poorly understood. However, brain imaging studies into the effects of estrogen therapy in postmenopausal women suggest that estrogen modulates the metabolism and function of brain regions sub-serving memory. Furthermore, we have recently reported that acute suppression of ovarian function in young women (with a Gonadotropin Hormone Releasing Hormone agonist) is associated with decreased activation in left prefrontal cortex, particularly the left inferior frontal gyrus (LIFG), during successful verbal memory encoding. We therefore investigated whether physiological variation in plasma estradiol concentration is associated with differences in activity of the LIFG during successful verbal encoding. We hypothesised that higher plasma concentrations of estradiol would be associated with increased brain activity at the LIFG and improved recall performance. Although we did not find a significant relationship between plasma estradiol concentration and verbal recall performance, we report a positive correlation between brain function and estradiol concentration at the LIFG.

[The effects of meridian massage on menopausal symptoms and Shin-Hur in middle-aged menopausal women]

PURPOSE

The purpose of this study was to identify the effects of meridian massage on menopausal symptoms and Shin-Hur in middle-aged menopausal women.

METHOD

The research design was a nonequivalent control group pre-post experimental design. The subjects of the study were middle-aged women who had had no menstruation in the last 12 months after the last menstrual bleeding. Cards of invitation on bulletin boards of several apartments were placed to recruit the subjects. The cards of invitation included: purpose of the study, eligibility criteria, method and period. Eighteen women in the experimental group and 16 women in the control group were conveniently assigned, respectively. The experimental group received 20 min meridian massage 3 times per week for 4 weeks. The menopausal symptoms and Shin-Hur were measured and compared between the two groups before and after the intervention. Data were analyzed with the SPSS program by Fisher's exact test, Wilcoxon Sign Rank test, Mann Whitney U-test and Spearman's rank correlation.

RESULT

The experimental group showed a significant decrease of menopausal symptoms (U=77.00, p=.020) and Shin-Hur (U=76.00, p=.017). There was a significantly positive correlation between menopausal symptoms and Shin-Hur (r=.497, p=.003).

CONCLUSION

Meridian massage was effective in improving menopausal symptoms and Shin-Hur in middle-aged menopausal women. Thus it can be useful as a nursing intervention for menopausal women.

Psicologia evolucionista e a seleção sexual: o caso da linguagem

Na tentativa de entender o caráter adaptativo e a história evolucionária dos processos cognitivos subjacentes ao comportamento lingüístico, uma série de mecanismos e conceitos advindos da teoria evolucionária tem tido, recentemente, sua potencial relevância aferida em uma série de estudos, entre eles, o chamado "Efeito Baldwin" e a teoria da seleção inclusiva (Kin Selection Theory). No presente trabalho, é oferecida, além de uma breve revisão do conceito de seleção sexual e do seu uso e status na Psicologia Evolucionista, uma crítica de uma proposta particular acerca do papel que o processo de seleção sexual possa ter tido no desenvolvimento da capacidade de linguagem na linhagem do Homo sapiens sapiens. Além de pontos específicos à hipótese sujeita à análise, são levantados também problemas e questões de natureza mais ampla e relevante para pesquisas posteriores.

Long-term estrogen therapy and 5-HT(2A) receptor binding in postmenopausal women; a single photon emission tomography (SPET) study

Variation in estrogen level is reported by some to affect brain maturation and memory. The neurobiological basis for this may include modulation of the serotonergic system. No neuroimaging studies have directly examined the effect of extended estrogen therapy (ET), on the 5-HT(2A) receptor in human brain. We investigated the effect of long-term ET on cortical 5-HT(2A) receptor availability in postmenopausal women. In a cross-sectional study, we compared cortical 5-HT(2A) receptor availability in 17 postmenopausal ERT-naive women and 17 long-term oophorectomised estrogen-users, age- and IQ-matched using single photon emission tomography and the selective 5-HT(2A) receptor ligand (123)I-5-I-R91150. Also, we used the Revised Wechsler Memory Scale to relate memory function to 5-HT(2A) receptor availability. Never-users had significantly higher 5-HT(2A) receptor availability than estrogen-users in hippocampus (1.17 vs. 1.11, respectively, p=0.02), although this did not remain significant after correction for multiple comparisons. Hippocampal 5-HT(2A) receptor availability correlated negatively with verbal and general memory and delayed recall (r=-0.45, p=0.01; r=-0.40, p=0.02; r=-0.36, p=0.04). Right superior temporal 5-HT(2A) receptor availability correlated negatively with verbal memory (r=-0.36, p=0.04). In estrogen-users, receptor availability correlated negatively with verbal and general memory (r=-0.70, p=0.002; r=-0.69, p=0.002); and in never-users, receptor availability negatively correlated with attention and concentration (r=-0.54, p=0.02). Long-term ET may be associated with lower 5-HT(2A) receptor availability in hippocampus. This may reflect increased activity within the serotonergic pathway leading to down-regulation of post-synaptic receptor. Also, increased availability of the 5-HT(2A) receptor in hippocampus is associated with poorer memory function.

More than a decade of estrogen neuroprotection

Considerable evidence has emerged through more than a decade of research supporting the neuroprotective and cognition-preserving effects of estrogens. Such basic research coupled with various epidemiological studies led quickly to the assessment of Premarin for the treatment of mild to moderate Alzheimer's disease (AD), initiated by the Alzheimer's Disease Cooperative Study Group and headed by Dr. Leon Thal. While this and subsequent trials with Premarin (Wyeth Research, Monmouth Junction, New Jersey) and PremPro (Wyeth Research), a conjugated equine estrogen preparation plus medoxyprogresterone acetate, have not supported the use of estrogens in treating advanced AD, considerable inferences have been made from these placebo controlled trials of estrogens. Here, we aimed to put these AD trials of estrogens in perspective by considering the potential mechanisms of these potent neuroprotective estrogens, the role of estrogens in other neurodegenerative conditions, such as cerebral ischemia, and based on our current understanding of estrogen neurobiology, offer insight into the design of future clinical trails of estrogens for neuronal protection.

Life-long environmental enrichment differentially affects the mnemonic response to estrogen in young, middle-aged, and aged female mice

The present study was designed to examine whether life-long exposure to standard or enriched housing affects the ability of estrogen to improve spatial and object memory throughout the lifespan. Three-week-old female mice were maintained in standard or enriched housing up to and through ovariectomy and behavioral testing at 5, 17, or 22 months of age. Spatial memory was tested in the Morris water maze and object memory was tested using an object recognition task. Immediately after training each day, mice were injected intraperitoneally with vehicle or 0.2 mg/kg 17beta-estradiol. Among young females, object recognition was enhanced by estradiol alone, an effect that was reduced by enrichment. In contrast, spatial water maze performance was impaired by estradiol alone, but improved by the combination of both estradiol and enrichment. At middle-age, object recognition was enhanced by estradiol or enrichment alone, and the combination of both treatments. Spatial memory in the water maze was also improved by both treatments at middle-age, but the beneficial effects of estradiol were limited to standard-housed females. Finally, whereas enrichment in aged females significantly enhanced performance in both tasks, estradiol had no effect at this age in either task. In total, the data indicate that life-long enrichment can significantly alter the extent to which estradiol affects memory in mice throughout the lifespan. Importantly, the interaction between these treatments is highly dependent on age and type of memory tested.

Intramuscular testosterone treatment in elderly men: evidence of memory decline and altered brain function

CONTEXT

Recent clinical trials of im testosterone in eugonadal men suggest positive effects on verbal memory, but other studies find no effect.

OBJECTIVE

Our objective was to determine whether supraphysiological testosterone influences verbal memory and brain function during a verbal memory task in healthy eugonadal older men.

PATIENTS, DESIGN, AND SETTING

Fifteen cognitively normal men, aged 66-86 yr, participated in a randomized, double-blind, placebo-controlled crossover trial involving 9 months of participation per participant at a hospital-based research facility.

INTERVENTION

We used testosterone enanthate (200 mg im every other week for 90 d) crossed over with placebo (sesame oil vehicle im) with a 90-d washout between treatments.

MAIN OUTCOME MEASURES

Performance was assessed on a standardized verbal memory test, and brain activity (relative glucose metabolic rates) in medial temporal and frontal regions was measured with positron emission tomography during a verbal memory task.

RESULTS

Treatment increased total testosterone by 241%. Behavioral results showed a significant decrease in short-delay verbal memory with treatment (P < 0.05, effect size = 0.59 sd) and a nonsignificant decrease on a composite verbal memory measure (P = 0.09, effect size = 0.48 sd). Positron emission tomography scans revealed decreased relative activity in ventromedial temporal cortex (i.e. right amygdala/entorhinal cortex) and increased relative activity in bilateral prefrontal cortex with treatment.

CONCLUSIONS

Decreased verbal memory and altered relative activity in medial temporal and prefrontal regions suggest possible detrimental effects of supraphysiological testosterone supplementation in elderly men. The results do not rule out potential benefits with other regimens, cognitive tests, or populations.

Estrogen: effects on normal brain function and neuropsychiatric disorders

Many women complain of memory and other cognitive/emotional difficulties at times that are associated with changes in estrogen levels. However, the biological mechanisms through which estrogen may exert these effects remain poorly understood. The effect of estrogen treatment on cognition and brain function in healthy women, and those with Alzheimer's disease, is controversial. Here we review the evidence that, in healthy women, estrogen affects the dopaminergic, serotonergic, and cholinergic systems, and brain regions crucial to higher cognitive function and mood. We will also present results from recent in vivo randomized-controlled neuroimaging experiments in our laboratory demonstrating that, in young females, and those in mid-life: (1) brain function is modulated by normal variation in ovarian function; (2) acute loss of ovarian hormones increases neuronal membrane breakdown; and (3) acute suppression of ovarian function is associated with reduced activation of brain regions critical to memory.

Reversal of lindane-induced impairment of step-down passive avoidance and oxidative stress by neurosteroids in rats

Neurosteroids (NS) are recognized as important modulators of functioning of the nervous system. Lindane, an organochlorine pesticide has been shown to adversely affect memory and induce oxidative stress on both acute and chronic exposure. The present study was designed to explore the modulation of effects of lindane over cognitive function by progesterone (PROG), pregnenolone sulfate (PREG-S) and 4'-chlorodiazepam (4CD). Cognitive function was assessed using step-down latency (SDL) on a passive avoidance apparatus and transfer latency (TL) on a plus maze. Oxidative stress was assessed by examining brain malondialdehyde (MDA) and non-protein thiol (NP-SH) levels. A significant reduction in SDL was found for the lindane treated group at weeks 6 and 7 as compared to control (p<0.001). One-week treatment by PREG-S or 4CD antagonized the effect of lindane on SDL. PROG failed to modulate the effect of lindane on SDL. Lindane caused a significant prolongation of TL as compared to control (p<0.001) from second week onwards. One-week administration of PROG, PREG-S or 4CD was unable to reverse this prolongation of TL. Lindane produced a statistically significant increase in the brain MDA levels (p<0.001) and significant decrease in the brain NP-SH levels (p<0.001). Treatment with PREG-S and 4CD attenuated the effect of lindane on MDA (p<0.001) and NP-SH levels. PROG failed to influence oxidative stress induced by lindane. Results of the present study thus show that some NS have potential in reversing cognitive dysfunction and oxidative stress induced by toxicants like lindane in the brain.

Gonadotropin hormone releasing hormone agonists alter prefrontal function during verbal encoding in young women

Gonadotropin hormone releasing hormone agonists (GnRHa) are commonly used in clinical practice to suppress gonadal hormone production in the management of various gynaecological conditions and as a treatment for advanced breast and prostate cancer. Animal and human behavioural studies suggest that GnRHa may also have significant effects on memory. However, despite the widespread use of GnRHa, the underlying brain networks and/or stages of memory processing that might be modulated by GnRHa remain poorly understood. We used event-related functional magnetic resonance imaging to examine the effect of GnRHa on verbal encoding and retrieval. Neuroimaging outcomes from 15 premenopausal healthy women were assessed at baseline and 8 weeks after Gonadotrophin Releasing Hormone analogue (GnRHa) treatment. Fifteen matched wait-listed volunteers served as the control group and were assessed at similar intervals during the late follicular phase of the menstrual cycle. GnRHa was associated with changes in brain response during memory encoding but not retrieval. Specifically, GnRHa administration led to a change in the typical pattern of prefrontal activation during successful encoding, with decreased activation in left prefrontal cortex, anterior cingulate, and medial frontal gyrus. Our study suggests that the memory difficulties reported by some women following GnRHa, and possibly at other times of acute ovarian hormone withdrawal (e.g. following surgical menopause and postpartum), may have a clear neurobiological basis; one that manifest during encoding of words and that is evident in decreased activation in prefrontal regions known to sub-serve deep processing of to-be-learned words.

The clinical relevance of the relationship between estrogen and cognition in women

Randomized controlled trials (RCTs) and observational and longitudinal studies provide positive, albeit, inconsistent evidence that estrogen might protect against cognitive decline in postmenopausal women. The fact that the Women's Health Initiative Memory Study (WHIMS), the largest RCT to date, failed to find that estrogen therapy (ET) had a protective effect against cognitive aging led to the formulation of the critical period hypothesis which holds that ET will effectively protect against memory decline when it is initiated around the time of menopause but not when considerable time has elapsed since the menopause. Evidence from basic neuroscience, and from rodent, nonhuman primate, and human studies that supports this theory is presented. Although much work remains to be done on the timing of initiation of treatment, on the most effective hormonal compounds and on their routes of administration, the hope is that, eventually, hormonal treatments may be able to attenuate or prevent the decline in aspects of cognition that occur with normal aging.

Effects of hormone replacement therapy and aging on cognition: evidence for executive dysfunction

The present study was designed to explore whether the frontal lobe hypothesis of cognitive aging may be extended to describe the cognitive effects associated with estrogen use in postmenopausal women. Postmenopausal estrogen-only users, estrogen + progesterone users, and non-users (60-80 years old), as well as young, regularly cycling women (18-30 years old) completed an item and source memory task. Since source memory is thought to rely more on executive processes than item memory, we hypothesized that aging and estrogen effects would be greater for source memory than for item memory. Neuropsychological tests explored whether the effects of aging and estrogen use were revealed on other tests of frontal lobe function. Results from the experimental task revealed greater aging and estrogen effects for source memory than for item memory, and neuropsychological results revealed aging and estrogen effects on a subset of tests of executive function. Women on estrogen + progesterone therapy did not outperform non-users, suggesting that the addition of progesterone to hormone therapy may mitigate the benefits induced by estrogen use alone. Overall, findings support the hypothesis that estrogen use may temper age-related cognitive decline by helping to maintain functions subserved by the frontal lobes.

Menopause Transition Stage and Endogenous Estradiol and Follicle-Stimulating Hormone Levels are Not Related to Cognitive Performance: Cross-Sectional Results from the Study of Women's Health across the Nation (SWAN)

BACKGROUND

By one estimate, 60% of women experiencing the menopause transition perceive that they have memory problems, but most studies that have used cognitive function tests have not substantiated a relation between menopause stage and cognitive performance. We sought to describe the cross-sectional relation between menopause status, estradiol (E(2)), follicle-stimulating hormone (FSH), and measured cognitive function.

METHODS

Cross sectional analysis of a community-based cohort of midlife women was used. Cognitive tests were the East Boston Memory Test, Symbol Digit Modalities, and Digits Span Backward. Menopause categories (premenopausal, early perimenopausal, late perimenopausal, and postmenopausal) were defined based on menstrual patterns. One set of general linear models assessed the relations between each cognitive test and menopause transition category, initially adjusted for age, race/ethnicity, education, symptoms, self-rated general health, and body mass index (BMI); next, these were additionally adjusted for FSH and E(2). A second set of models, stratified by menopause status, examined the possible relations between each cognitive test and either E(2) or FSH, adjusted for age, race/ethnicity, education, symptoms, self-related general health, and BMI.

RESULTS

The mean age of the analytical sample (n = 1657) was 49.7 years. Only 5% of the sample had less than a high school education, 16% graduated from high school, and the rest had at least some college. The percent of women in each menopause category was premenopausal (9.0%), early perimenopausal (57.0%), late perimenopausal (13.4%), postmenopausal (20.6%). Although clinical-site adjusted models showed moderate differences between menopause transition groups and cognitive performance, no association was found between each of the measured cognitive performance tests and menopause transition status when adjusting for covariates. Similarly, no association between each cognitive test and E(2) or FSH was found.

CONCLUSIONS

This study does not support a cross-sectional relation between cognitive test performance and menopause stage, FSH, or E(2).

Estrogen therapy and brain muscarinic receptor density in healthy females: a SPET study

Estrogen Therapy (ET) may protect against age-related cognitive decline and neuropsychiatric disorders (e.g. Alzheimer's disease). The biological basis for this putative neuroprotective effect is not fully understood, but may include modulation of cholinergic systems. Cholinergic dysfunction has been implicated in age-related memory impairment and Alzheimer's disease. However, to date no one has investigated the effect of long-term ET on brain cholinergic muscarinic receptor aging, and related this to cognitive function. We used Single Photon Emission Tomography (SPET) and (R,R)[(123)I]-I-QNB, a novel ligand with high affinity for m(1)/m(4) muscarinic receptors, to examine the effect of long-term ET and age on brain m(1)/m(4) receptors in healthy females. We included 10 younger premenopausal subjects and 22 postmenopausal women; 11 long-term ET users (all treated following surgical menopause) and 11 ET never-users (surgical menopause, n=2). Also, verbal memory and executive function was assessed in all postmenopausal subjects. Compared to young women, postmenopausal women (ET users and never-users combined) had significantly lower muscarinic receptor density in all brain regions examined. ET users also had higher muscarinic receptor density than ET never-users in all the brain regions, and this reached statistical significance in left striatum and hippocampus, lateral frontal cortex and thalamus. Moreover, in ET users, (R,R)[(123)I]-I-QNB binding in left hippocampus and temporal cortex was significantly positively correlated with plasma estradiol levels. We also found evidence for improved executive function in ET users as compared to ET never-users. However, there was no significant relationship between receptor binding and cognitive function within any of the groups. In healthy postmenopausal women use of long-term ET is associated with reduced age-related differences in muscarinic receptor binding, and this may be related to serum estradiol levels.

Diabetes mellitus and dementia

Alzheimer's disease (AD) and diabetes mellitus (DM) are two of the most common and devastating health problems in the elderly. They share a number of common features amongst which high prevalence after 65 years, important impact of patient's quality of life, substantial health care costs. Reviews on the epidemiological studies on cognitive impairment in patients with DM found evidence of cross-sectional and prospective associations between type 2 DM and moderate cognitive impairment, on memory and executive functions. There is also evidence for an elevated risk of both vascular dementia and AD in patients with type 2 DM, albeit with strong interaction of other factors such as hypertension, dyslipidaemia and ApoE genotype. DM is an independent predictor of post-stroke dementia. DM being an atherogenic risk factor, it may increase the risk of dementia through associations with stroke, causing vascular dementia. In addition, vascular reactivity may be adversely affected by advanced glycosylation end products resulting in more subtle perfusion abnormalities. Cerebrovascular disease may exacerbate AD through direct interactions between the two pathological processes or through cognitive impairment secondary to cerebrovascular disease "unmasking" AD at an earlier stage than it would otherwise become apparent. The increased risk of AD may also be mediated by the exacerbation of B-amyloid neurotoxicity by advanced glycosylation end products identified in the matrix of neurofibrillary tangles and amyloid plaques in AD brains, or associations with insulin functions. Decreased cholinergic transport across the blood-brain barrier observed in diabetic animals may exacerbate cognitive impairment in AD. Many interventions could reduce the cognitive decline associated with DM, yet not enough are taken into account so far.

Oestrogen, cognition and the maturing female brain

Many women complain of memory and other cognitive difficulties at times that are associated with changes in ovarian steroid levels. However, the biological mechanisms through which ovarian steroids exert these effects remains poorly understood. Furthermore, the effect of hormone therapy, especially oestrogen therapy, on cognition and brain function in healthy women, and its role in the prevention of Alzheimer's disease, remains controversial. Here, we review the evidence that, in healthy women, ovarian steroids/oestrogen affects brain regions crucial to higher cognitive function at the macroscopic, microscopic, functional and neurotransmitter levels.

Estrogen, cognition and female ageing

Starting from fetal life, estrogens are crucial in determining central gender dimorphism, and an estrogen-induced synaptic plasticity is well evident during puberty and seasonal changes as well as during the ovarian cycle. Estrogens act on the central nervous system (CNS) both through genomic mechanisms, modulating synthesis, release and metabolism of neurotransmitters, neuropeptides and neurosteroids, and through non-genomic mechanisms, influencing electrical excitability, synaptic function and morphological features. Therefore, estrogen's neuroactive effects are multifaceted and encompass a system that ranges from the chemical to the biochemical to the genomic mechanisms, protecting against a wide range of neurotoxic insults. Clinical evidences show that, during the climacteric period, estrogen withdrawal in the limbic system gives rise to modifications in mood, behaviour and cognition and that estrogen administration is able to improve mood and cognitive efficiency in post-menopause. Many biological mechanisms support the hypothesis that estrogens might protect against Alzheimer's disease (AD) by influencing neurotransmission, increasing cerebral blood flow, modulating growth proteins associated with axonal elongation and blunting the neurotoxic effects of beta-amyloid. On the contrary, clinical studies of estrogen replacement therapy (ERT) and cognitive function have reported controversial results, indicating a lack of efficacy of estrogens on cognition in post-menopausal women aged >or=65 years. These findings suggest the presence of a critical period for HRT-related neuroprotection and underlie the potential importance of early initiation of therapy for cognitive benefit. In this review, we shall first describe the multiple effects of steroids in the nervous system, which may be significant in the ageing process. A critical update of HRT use in women and a discussion of possible prospectives for steroid use are subsequently proposed.

Estradiol and tryptophan depletion interact to modulate cognition in menopausal women

Despite an abundance of data in animals, there is little research in humans regarding how estrogen and serotonin (5-HT) may interact to influence cognition. Through the use of estrogen treatment (ET) and tryptophan depletion (TRP-D) in a within-subject design involving healthy menopausal women, we have manipulated both estrogen and 5-HT in order to evaluate their individual and joint effects. Although neither manipulation influenced visuospatial learning, a significant interaction suggested that estrogen exerted a protective effect on verbal memory, such that TRP-D impaired performance to a greater extent before the administration of ET. In consonance with this finding, ET was associated with a small, but positive mood effect on the day following active TRP-D. In addition, ET significantly improved letter-cued verbal fluency with and without TRP-D. Finally, time since last menstrual period was significantly associated with verbal memory scores, such that longer length of hypogonadism resulted in decreased verbal memory performance. These data support the interaction of estrogen and 5-HT in nonreproductive behavior in humans as well as highlight the role of ovarian steroids in cognition.

Differences in brain volumes among males and female hormone-therapy users and nonusers

Numerous studies have shown gender differences in the brain volumes of elderly adults. Some evidence shows that higher estrogen levels may be neuroprotective, suggesting that hormone therapy (HT) may in part be responsible for these gender differences; however, few studies have examined the relation between HT and brain volumes. Brain volumes of caudate, putamen, hippocampus, gray matter, white matter, white-matter lesions, and cerebrospinal fluid were measured on magnetic resonance imaging scans. A comprehensive neuropsychological battery was administered. Women were separated into two groups based on HT use, and we used multiple regression analyses to compare these groups with one another and with men. Results of brain-volume measurements showed that HT users had significantly less gray matter and more cerebrospinal fluid than nonusers. Results of the neuropsychological testing showed that HT users performed better on the Shipley Vocabulary Test than males did.

Sex differences in baseline neuropsychological function and concussion symptoms of collegiate athletes

OBJECTIVE

To investigate sex differences in baseline neuropsychological function and concussion symptoms between male and female collegiate athletes.

METHODS

A post-test only design was used to examine baseline neuropsychological test scores and concussion symptoms. A total of 1209 NCAA Division I collegiate athletes from five northeastern universities in the USA completed a baseline ImPACT test. ImPACT, a computerised neuropsychological test battery, was administered during an athlete's pre-season.

RESULTS

Female athletes performed significantly better than male athletes on baseline verbal memory scores (p = 0.001), while male athletes performed significantly better than female athletes on baseline visual memory scores (p = 0.001). Female athletes endorsed a significant number of mild baseline symptoms as compared to male athletes.

CONCLUSIONS

Male and female athletes exhibit differences on baseline neuropsychological test performance and concussion symptoms.

The Women's Health Initiative Study of Cognitive Aging (WHISCA): a randomized clinical trial of the effects of hormone therapy on age-associated cognitive decline

The Women's Health Initiative Study of Cognitive Aging (WHISCA) was a two armed, randomized, placebo controlled, clinical trial designed to assess the efficacy of postmenopausal hormone therapy on age related changes in specific cognitive functions. WHISCA was an ancillary study to the Women's Health Initiative (WHI) and the WHI Memory Study (WHIMS) and enrolled 2302 women aged 66 to 84 years (mean 73.9; standard deviation 3.8) who did not meet criteria for dementia. Women were randomly assigned by the WHI to hormone treatment (unopposed conjugated estrogens (CEE) 0.625 mg/day if they were without a uterus; CEE combined with medroxyprogesterone acetate (MPA) 2.5 mg/day otherwise) or placebo for an average of three years before the first WHISCA assessment. WHISCA investigated the effects of hormone therapy on rates of change over time in memory, other aspects of cognition (language, attention, spatial ability), motor function, and mood. In this paper, we present the study rationale and design, including specific cognitive measures, and the challenges of incorporating WHISCA into an ongoing randomized trial. WHISCA provided a unique opportunity to investigate the potential of hormone therapy to modify age related changes in specific cognitive functions. WHISCA also demonstrated the feasibility of adding a detailed cognitive assessment into an ongoing clinical trial to address an important issue in women's health, despite the challenges of maintaining the integrity of the parent studies, ensuring high retention, and achieving high quality assurance across sites.

Progesterone reverses the spatial memory enhancements initiated by tonic and cyclic oestrogen therapy in middle-aged ovariectomized female rats

While some research has indicated that ovarian hormone therapy (HT) benefits memory and decreases risk of Alzheimer's disease in menopausal women, several newer studies have shown null or detrimental effects. Despite the null and negative cognitive findings, the numerous studies showing positive effects beg the question of what factors determine whether HT acts as a neuroprotectant or a risk factor for brain functioning. Using middle-aged female rats, we directly compared six HTs. We evaluated the effects of ovariectomy, tonic low-dose, tonic high-dose and biweekly cyclic estradiol treatment, as well as whether progesterone altered the effectiveness of any one of these oestrogen regimens. Animals were tested on spatial and complex cued (intramaze patterns) reference memory using variants of the Morris maze. The tonic low-dose and cyclic estradiol treatments improved spatial performance, while the addition of progesterone reversed these beneficial cognitive effects of estradiol. Additionally, all groups learned to locate the platform on the cued task; however, an egocentric circling strategy was used with sham ovary-intact and hormone-replacement groups showing the most efficient search strategy. Although the question of memory retention 8 weeks after the first cognitive assessment was addressed, a large number of animals died between the first and second test, rendering the retest uninterpretable for many group comparisons. Specifically, both doses of tonic estradiol dramatically increased the number of deaths during the 17-week experiment, while the cyclic estradiol treatment did not. Progesterone decreased the number of deaths due to tonic estradiol treatment. Our findings suggest that the dose of estradiol replacement as well as the presence of progesterone influences the cognitive outcome of estradiol treatment. Further, there appears to be a dissociation between HT effects on cognition and mortality rates.

Estrogen therapy selectively enhances prefrontal cognitive processes: a randomized, double-blind, placebo-controlled study with functional magnetic resonance imaging in perimenopausal and recently postmenopausal women

OBJECTIVE

Estrogen therapy (ET) seems to differentially effect cognitive processes in younger versus older postmenopausal women, suggesting a window of opportunity when ET is most beneficial. Cognitive improvement in younger postmenopausal women has been attributed to ET's influence on hot flushes and sleep, but empiric examination of the mediating role of menopause symptoms versus direct effects of ET on the brain is limited.

DESIGN

In a double-blind trial, 52 women were randomly assigned to estradiol 0.05 mg/day (n = 26) or placebo transdermal patches (n = 26) for 12 weeks. Women completed tests of memory, learning, and executive functioning, and hot flush and sleep assessments at baseline and study end. A subset of women (five ET treated, six placebo treated) also underwent blood oxygenation level-dependent (BOLD) functional magnetic resonance imaging (fMRI) studies.

RESULTS

Nondepressed perimenopausal and postmenopausal women were studied. The majority had hot flushes and sleep impairment. Compared with placebo, ET selectively reduced errors of perseveration during verbal recall (P = 0.03), a frontal system-mediated function, but did not influence other cognitive processes. Women with baseline hot flushes had greater cognitive benefit with ET (P < 0.05). Cognitive benefit was not associated with sleep problems or its improvement. Measures of fMRI BOLD activation during tests of verbal and spatial working memory showed significant increases in frontal system activity with ET (P < 0.001).

CONCLUSIONS

Estrogen therapy selectively improves executive functioning as demonstrated by reduced perseverative errors and prefrontal cortex activation during verbal recall tasks. Cognitive improvement with ET is associated with hot flushes, but not with sleep, suggesting that ET has a direct central nervous system effect, rather than an indirect effect mediated through improvement of sleep.

Neuroactive steroid effects on cognitive functions with a focus on the serotonin and GABA systems

This article will review neuroactive steroid effects on serotonin and GABA systems, along with the subsequent effects on cognitive functions. Neurosteroids (such as estrogen, progesterone, and allopregnanolone) are synthesized in the central and peripheral nervous system, in addition to other tissues. They are involved in the regulation of mood and memory, in premenstrual syndrome, and mood changes related to hormone replacement therapy, as well as postnatal and major depression, anxiety disorders, and Alzheimer's disease. Estrogen and progesterone have their respective hormone receptors, whereas allopregnanolone acts via the GABA(A) receptor. The action of estrogen and progesterone can be direct genomic, indirect genomic, or non-genomic, also influencing several neurotransmitter systems, such as the serotonin and GABA systems. Estrogen alone, or in combination with antidepressant drugs affecting the serotonin system, has been related to improved mood and well being. In contrast, progesterone can have negative effects on mood and memory. Estrogen alone, or in combination with progesterone, affects the brain serotonin system differently in different parts of the brain, which can at least partly explain the opposite effects on mood of those hormones. Many of the progesterone effects in the brain are mediated by its metabolite allopregnanolone. Allopregnanolone, by changing GABA(A) receptor expression or sensitivity, is involved in premenstrual mood changes; and it also induces cognitive deficits, such as spatial-learning impairment. We have shown that the 3beta-hydroxypregnane steroid UC1011 can inhibit allopregnanolone-induced learning impairment and chloride uptake potentiation in vitro and in vivo. It would be important to find a substance that antagonizes allopregnanolone-induced adverse effects.

Effects of estrogen and progesterone on spatial memory consolidation in aged females

Interpretation of data illustrating that estrogen, with or without progestin, is detrimental to memory in post-menopausal women is complicated by the fact that little is known about the effects of progestins on memory. The present study examined if estrogen, alone or with progesterone, affects spatial memory consolidation in ovariectomized aged female mice. Mice received eight training trials in a spatial Morris water maze followed immediately by injection of water-soluble 17beta-estradiol (E(2); 0.2 mg/kg) or vehicle. Mice were re-tested 24 h later. All mice learned to find the platform on Day 1. On Day 2, the performance of control, but not E(2) mice, deteriorated, suggesting that E(2) enhanced memory for the platform location. In a second experiment, mice were injected with E(2) and 10 or 20 mg/kg water-soluble progesterone. The 10 mg/kg dose of progesterone did not affect estrogen's ability to enhance spatial memory consolidation, but 20 mg/kg blocked this effect. These data indicate that estrogen can improve spatial memory consolidation in aged females and that this effect can be attenuated by progesterone.

Hormone replacement therapy and cognition in an Australian representative sample aged 60–64 years

OBJECTIVE

To investigate the relationship between hormone replacement therapy (HRT) and level of cognitive performance intra-individual variability, and interactions with statin use, progesterone therapy and type of menopause.

METHODS

A representative sample of 60-64 year olds was recruited from the Canberra and Queanbeyan regions in Australia. They were administered tests of verbal memory, working memory, speed of information processing, simple and complex reaction time, verbal intelligence and the Mini-Mental State Exam. Intra-individual variation (consistency) on performance on simple and complex reaction time tasks was calculated. Women provided information on HRT use and demographic, health and lifestyle variables.

RESULTS

Four hundred and four (35.0%) current postmenopausal HRT users, 316 (27.4%) previous HRT users and 434 (37.6%) women who had never used HRT, were included in this study. There were significant overall differences between HRT current and previous users on age, prevalence of diabetes, alcohol use, body mass index, level of anxiety and lung function. After controlling for potentially confounding health and demographic variables, there were no significant main effects detected between HRT groups on any cognitive measure. Significant interactions were detected between HRT group and statin use on intra-individual variability on simple reaction time, and between HRT group and menopause type on intra-individual variability on choice reaction time. All other interactions were non-significant.

CONCLUSIONS

HRT use had no effect on level of cognitive performance. Two interactions were detected between HRT use and statin use, and type of menopause on intra-individual variability. Given the large number of comparisons, little weight can be placed on these significant results.

Hormone therapy and cognitive function: is there a critical period for benefit?

The large majority of women receiving hormone therapy initiate therapy early in life for the treatment of menopausal symptoms. However, the Women's Health Initiative Memory Study, the only randomized clinical trial to date on hormone therapy and dementia, was carried out in women age 65 and older. That trial provided important insights into the detrimental effects of hormone therapy on dementia in women initiating later in life. The generalizability of those findings to the typical hormone therapy user who initiates earlier in life is unknown. To address this important issue, this review focuses on observational trials of hormone therapy and dementia risk, randomized clinical trials of hormone therapy and cognitive function, and basic science studies. These lines of research provide suggestive, but not definitive, evidence that early initiation of hormone therapy may provide cognitive benefits, particularly to verbal memory and other hippocampally mediated functions. Other forms of hormone therapy, other cognitive domains, and cyclic hormone regimens may not conform to this "critical period hypothesis." Further research is needed to test the validity and limits of this hypothesis.

Hormone therapy, timing of initiation, and cognition in women aged older than 60 years: the REMEMBER pilot study

OBJECTIVE

The aim of this pilot study was to assess any trends related to the timing of initiation, and duration, of hormone therapy (HT) use on cognitive function to facilitate the design and power calculations for a future large cohort study entitled Research into Memory, Brain function and Estrogen Replacement (REMEMBER).

DESIGN

A total of 428 women aged older than 60 years were recruited from a computer-generated random selection of Adelaide households. Demographic and lifestyle characteristics, and HT use history were recorded and confirmed. The Center for Epidemiological Studies-Depression score was used to assess mood. Cognitive tests were administered measuring global cognition (Mini-Mental State Examination), attention and concentration (Trail Making Test Parts A and B), verbal learning and memory (Consortium to Establish a Registry for Alzheimer's Disease [CERAD] word list immediate and delayed recall), and verbal expression (letter fluency [FAS], category fluency [Animals], and the Boston Naming Test [short form]). Analyses were adjusted for age, education, mood, body mass index, smoking, alcohol intake, and history of cerebrovascular disease. HT use was defined as the use of systemic HT for at least 1 year. Early initiation of HT use was defined as commencement of HT before age 56 years for women with a uterus and ovaries, or within 5 years of a hysterectomy and bilateral oophorectomy. Late initiation of HT use was defined as HT commencing after these times.

RESULTS

Early initiators of HT performed better than late initiators on the Mini-Mental State Examination (P = 0.04) and were faster than never users on the Trail Making Test Part A (P = 0.02). Women aged 70-79 years who initiated HT early performed better on the FAS test than never users (P = 0.0008). Late initiators performed worse than never users on the Mini-Mental State Examination (P = 0.09), and on the FAS test in the 60-69 year (P = 0.06) and 80 years and older (P = 0.095) age groups. However, late initiators performed better than never users on the FAS test in the 70-79 year age group (P = 0.015). HT users of less than 11 years (P = 0.09), HT users of more than 11 years (P = 0.04), and estrogen-only users (P = 0.024) performed faster than never users on the Trail Making Test Part A. Combined estrogen plus progestin users performed better than never users on the Boston Naming Test short form (P = 0.07).

CONCLUSIONS

For some cognitive domains, early initiation of HT from around menopause may be beneficial, and initiation of HT in late menopause may be detrimental. The timing of the initiation of HT seems critical. To fully test these hypotheses and to further examine these trends by route and type of HT regimen in this population, a study size of 2,500 women would be required.

Hormone replacement therapy and cognitive performance in postmenopausal women—a review by cognitive domain

Laboratory, animal and neuroimaging evidences suggest that hormone replacement therapy (HRT) may be beneficial to human cognition. This systematic review includes 26 studies on the association between HRT and cognition and 17 studies on HRT and risk of dementia. It was hypothesised that HRT would have a positive association with cognitive speed and verbal memory and possibly visual memory but not with executive functioning, and would be associated with a decreased risk of dementia. Evidence for HRT's neuroenhancing and neuroprotective properties was also evaluated. There was significant statistical and clinical heterogeneity among studies precluding meta-analysis. Results showed no consistent relationship between HRT and performance in any cognitive domain. Cross-sectional studies tended to report more positive results than longitudinal studies and randomised-controlled trials, particularly in the areas of verbal memory and executive functioning. HRT was associated with decreased risk of dementia in observational studies, but with increased risk in one randomised-controlled trial. Cognitive improvement or maintenance are not secondary benefits of HRT.

Cross-sex hormone treatment does not change sex-sensitive cognitive performance in gender identity disorder patients

Cognitive performance in untreated early onset gender identity disorder (GID) patients might correspond to their born sex and not to their perceived gender. As a current mode of intervention, cross-sex hormone treatment causes considerable physical changes in GID patients. We asked, as has been suggested, whether this treatment skews cognitive performance towards that of the acquired sex. Somatically healthy male and female early onset GID patients were neuropsychologically tested before, 3 and 12 months after initiating cross-sex hormone treatment, whereas untreated healthy subjects without GID served as controls (C). Performance was assessed by testing six cognitive abilities (perception, arithmetic, rotation, visualization, logic, and verbalization), and controlled for age, education, born sex, endocrine differences and treatment by means of repeated measures analysis of variance. GID patients and controls showed an identical time-dependent improvement in cognitive performance. The slopes were essentially parallel for males and females. There was no significant three-way interaction of born sex by group by time for the six investigated cognitive abilities. Only education and age significantly influenced this improvement. Despite the substantial somatic cross-sex changes in GID patients, no differential effect on cognition over time was found between C and GID participants. The cognitive performance of cross-sex hormone-treated GID patients was virtually identical to that of the control group. The documented test-retest effect should be taken into consideration when evaluating treatment effects generally in psychiatry.

Estrogen and cognitive aging in women

Although several randomized controlled trials of surgically menopausal women have provided evidence that estrogen protects aspects of memory, many cross-sectional and longitudinal studies, including those from the Women's Health Initiative Memory Study, have failed to confirm these findings. One critical difference between studies that found a protective effect of estrogen on memory and those that did not is that, in the former studies, treatment with estrogen began at the time of menopause and in the latter studies, it was first administered many years after the menopause had occurred. Recent evidence from rodent, nonhuman primate, and human studies consistently suggests that the timing of the initiation of estrogen treatment with regard to the menopause may be critical to our understanding of the estrogenic effect on memory. Results of these animal and human studies indicate that the initiation of estrogen treatment at the time of menopause, or soon after ovariectomy, provides a window of opportunity for the protection of memory in females whereas the administration of the hormone following a considerable delay in time after ovariectomy or following a natural menopause has little or no beneficial effect on cognition.

Effects of ovarian hormones on cognitive function in nonhuman primates

Several studies have suggested that estrogen benefits verbal memory and lowers the risk of Alzheimer's disease in women, and improves cognitive function in animal models. However, the negative outcome of the Women's Health Initiative Memory Study has challenged the rationale for using estrogen as a protective agent against age-related cognitive decline. In view of the limitations of the Women's Health Initiative Memory Study, it is clear that our understanding of estrogen effects would greatly benefit from further interactions between clinical and basic science. Animal models of menopause can provide crucial information regarding the consequences of estrogen loss and replacement on several systems, including cognition. In this paper, I review the evidence that nonhuman primates, who share numerous cognitive and physiological characteristics with humans, can substantially contribute to our understanding of estrogen influences on the brain and cognition. Studies in young adult females suggest that some aspects of cognition fluctuate with the menstrual cycle, but that ovariectomy and estrogen replacement have only modest effects on cognitive function. In contrast, data in aged, naturally or surgically menopausal monkeys indicate that estrogen modulates a broad range of cognitive domains. Neurobiological data are consistent with the cognitive findings and demonstrate an array of morphological and physiological changes in brain areas important for cognition following ovariectomy and/or estrogen replacement. It is concluded that nonhuman primates, by providing a bridge between rodent and human data, constitute invaluable models to further our understanding of hormonal actions on the brain and cognition and to develop effective hormonal interventions against brain and cognitive aging.

Oestrogen receptor {alpha} gene polymorphisms in systemic lupus erythematosus

OBJECTIVE

To analyse associations of two oestrogen receptor alpha (ORalpha) gene polymorphisms in 260 patients with SLE from northern Sweden. The two polymorphisms, PvuII T/C and the XbaI A/G, are located in the first intron of the ORalpha gene.

METHODS

All patients fulfilling at least four of the ACR criteria for SLE were consecutively recruited during one year. The SLEDAI score and SLICC damage index were recorded. 670 individuals from the same geographical area served as controls. DNA from the patients and controls was extracted and genotyped using the 5' nuclease assay with an ABI PRISM 7900HT instrument. The genotype/phenotype relationships were calculated using SPSS.

RESULTS

The unusual PvuII C allele was associated with malar rash and the unusual XbaI G allele with photosensitivity (p = 0.001, OR = 2.53, 95% CI = 1.43 to 4.47 and p = 0.007, OR = 2.12, 95% CI = 1.22 to 3.66, respectively). The common XbaI AA genotype was associated with serositis (p = 0.013, OR = 1.92, 95% CI = 1.15 to 3.22). Based on the SLICC damage index associations of the common TT genotype and AA genotype with cognitive impairment were identified (p = 0.018, OR = 2.47, 95% CI = 1.17 to 5.25 and p = 0.018, OR = 2.75, 95% CI = 1.19 to 6.38 respectively). There was also an association of the XbaI AA genotype with the angina/coronary artery bypass variable (p = 0.042, OR = 2.58, 95% CI = 1.03 to 6.43). Of the variables describing disease severity and duration it was found that carriers of the unusual PvuII C allele showed a later onset of SLE (p = 0.02) and carriers of the unusual XbaI G allele a lower SLICC damage index.

CONCLUSIONS

The unusual PvuII C and XbaI G alleles were associated with a milder form of SLE characterised by skin manifestations, later onset, and less organ damage.

Age-related cognitive decline in the menopause: effects of hormone replacement therapy on cognitive event-related potentials

OBJECTIVE

Although epidemiological and clinical studies suggest that hormone replacement therapy (HRT) may protect against cognitive disorders and neurodegenerative diseases, the relation between estrogen and cognition in postmenopausal women remains controversial.

METHODS

In a double-blind placebo-controlled, parallel group design study the effects of HRT with the estrogen-progestogen combination Presomen 1.25 compositum((R)) (1.25mg equine conjugated estrogens administered for 21 days plus the progestogen 5mg medrogeston given for 11 days) on event-related potentials (ERPs) in postmenopausal patients with age-related cognitive decline (DSM-IV code 780.9, ICD-10 code R 41.8) were investigated. After a pre-drug comparison with age-matched normal postmenopausal controls, 48 psychotropic drug-free patients aged 60 +/- 6 years were randomized to receive either placebo or verum for 4 months. ERPs were recorded before as well as on the 91-92 days of the study, which thus fell into the estrogen phase of the treatment during the fourth cycle.

RESULTS

At baseline, patients showed a lengthening of P300 latency and an attenuation of P300 amplitudes as compared with normal controls. After HRT with Presomen, a significant shortening of P300 latency as compared with placebo was observed.

CONCLUSIONS

The baseline P300 differences suggest that in the patient group the aging process was advanced, while after HRT with Presomen a significant improvement and normalization of information processing as indexed by P300 was observed.

New insights into the role of neuroactive steroids in cognitive aging

The aim of this article is to describe neuroactive steroid research that has been focused on their physiological role in cognitive aging, an attractive new field in experimental gerontology. Neuroactive steroids have been recently proposed as biomarkers of cognitive aging, however, their specific functions have not yet been fully established. For instance, data emerging from human and animal studies suggest a complex relationship between neuroactive steroids and/or metabolites and cognitive processes during aging. Thus, a better knowledge of neuroactive steroid brain distribution and function could broaden our understanding of their physiological roles and lead to novel and more effective treatments for the management of age-related brain disorders. To this end, newly developed sensitive, specific, and accurate mass spectrometry assays may allow the quantification of neuroactive steroids in discrete brain regions and greatly contribute to unravel their role in age-related cognitive deficits.

Benefits and risks of sex hormone replacement in postmenopausal women

Because cardiovascular disease (CVD), which is far less common in young women than in men, but increases in prevalence in the postmenopausal years to that of men, estrogen repletion therapy (ERT) or combined hormone replacement therapy (HRT), has been widely used to protect against development of both CVD and osteoporosis, and possibly to delay or prevent cognitive loss or Alzheimer's disease (AD). To test the validity of favorable findings in many small-scale studies, and in clinical practice, a large-scale trial: the Women's Health Initiative (WHI) was undertaken by the National Institutes of Health (NIH), a trial that was prematurely ended because of increased CVD complications, despite some lessening of hip fractures. This paper suggests that the customary high intake of calcium (Ca)-advised to protect against osteoporosis, and the marginal magnesium (Mg) intake in the USA, might well be contributory to the adverse CV effects, that were all thromboembolic in nature. The procoagulant effect of estrogen is intensified by Ca; Mg-which counteracts many steps in the coagulation cascade and inhibits platelet aggregation and adhesion-is commonly consumed in sub-optimal amounts. The high American dietary Ca/Mg ratio might also be contributory to the WHI failure to confirm ERT's favorable mental effects. Discussed are mechanisms by which Mg enhances estrogen's central nervous system protective effects. Mg's improvement of cerebral blood flow, which improves brain metabolism, can also enhance removal of the beta amyloid peptide, accumulation of which is implicated in AD.

Selective estrogen receptor modulators (SERMs) for the brain: current status and remaining challenges for developing NeuroSERMs

Multiple issues regarding the efficacy of estrogen action in the brain remain unresolved. These include the timing, formulation and duration of the therapy intervention. Moreover, issues of thrombotic and neoplastic risks must be factored into the design of estrogen alternatives developed to prevent age-associated neurodegenerative disorders, as well as other climacteric symptoms such as hot flush and sleep dysfunction. One strategy to address these issues is to develop molecules that selectively target and activate estrogen mechanisms of action in the brain while avoiding activation of estrogen receptors peripheral to the brain, particularly in reproductive organs. An overview of recent advances in our understanding of the molecular mechanisms of estrogen action is discussed in the context of designing an efficacious NeuroSERM that will activate cellular, biochemical and genomic events required for the promotion of memory function and neuronal survival. Pharmacological analyses of estrogen receptor subtypes and the case for a membrane-associated estrogen receptor splice variant in mediating these mechanisms are provided along with a summary of the activation profiles of existing clinically relevant estrogen alternatives or SERMs in neurons. Results of these endeavors have yielded insights into strategies for developing novel molecules with NeuroSERM potential in order to prevent brain related climacteric symptoms and neurodegenerative diseases.

Menopausal Hormone Therapy

BACKGROUND

Although estrogen has been clinically available for more than 6 decades, women have been confused by different opinions regarding the risks and benefits of menopausal hormone therapy (HT), estrogen therapy (ET), and estrogen-progestin therapy (EPT). The publication of recent randomized controlled trials (RCTs), notably, the Heart and Estrogen Replacement Study (HERS), Women's Health Initiative (WHI), and Women's Health Initiative Memory Study (WHIMS), has intensified the risk versus benefit controversy and prompted this review.

OBJECTIVE

We provide a systematic, comprehensive, and critical review of selected literature that addresses the basic and clinical aspects of menopausal HT.

RESULTS

Solid, consistent evidence based on observational, epidemiologic, and randomized controlled trials underpins the efficacy of menopausal HT for its regulatory agency-approved indications: vasomotor symptoms, vulvovaginal atrophy symptoms, and osteoporosis-related fracture prevention. ET and EPT increase the risk for venous thromboembolism, although the absolute number of events and the risk are both small. Though there is a small increase in the number of breast cancers in women who have used menopausal HT for more than 10 years, the biological meaning of this observation (cause versus unmasking versus chance) is unresolved. Most evidence shows that menopausal HT does not affect breast cancer recurrence and that overall longevity is higher in breast cancer survivors who select menopausal HT. Strong basic science and clinical observational evidence show a benefit of menopausal HT in the cardiovascular and central nervous systems. Data from recent RCTs that included predominantly overweight women aged between 63 and 71 years have been reported to show more harm than benefit; the rush to generalize these studies to all women and all menopausal HT regimens is unjustified.

CONCLUSION

Menopausal HT improves vasomotor symptoms and vulvovaginal atrophy symptoms and prevents osteoporosis-related fracture. Menopausal HT increases the likelihood of venous thromboembolism, but other harms such as breast cancer require further controlled studies. A clinical benefit of menopausal HT for cardiovascular or central nervous system disease prevention is unproven. RCTs of menopausal HT in newly menopausal women, or in women less than 3 years from menopause, are urgently needed to investigate the prevention of cardiovascular and central nervous system aging diseases.

Inter- and intraindividual variability in recognition memory: effects of aging and estrogen use

Traditionally, studies of cognitive aging have focused on comparing the average performance of younger and older adults, whereas variability around the mean has been attributed to task-irrelevant noise. The present study examined the hypothesis that variability in memory performance increases with age and that estrogen helps temper age-related increases in variability. Postmenopausal estrogen users, estrogen and progestin (est + prog) users, and nonusers, as well as younger women, completed 16 blocks of an item-source memory task. Older women showed greater variability than younger women on measures of dispersion and consistency. Estrogen users, but not est + prog users, performed more consistently than nonusers. Overall, age-related increases in variability differed with the type of variability measured, and estrogen use, but not est + prog use, appeared to reduce age-related increases in at least 1 form of variability.

Hormone replacement therapy: controversies, pros and cons

Hormone replacement therapy (HRT) is a complicated clinical issue that requires an in-depth risk/benefit assessment. The term HRT includes both oestrogen plus progestin therapy (OPT) and oestrogen-only therapy (OT). Much research has been done with the former, but additional research is still needed for the latter. This chapter aims to provide a comprehensive overview of the key risks and benefits in order to assist clinicians and patients confronting this issue. In approaching the vast amount of data on HRT a caveat is in order: many of the issues involved are not black and white. The clinical data are often conflicting and careful analysis is required. Despite the discrepancies between the various HRT studies, there is much to be gleaned from a close examination of the data. The primary risks associated with HRT use are related to breast cancer and cardiovascular health. Recent clinical trial data have pointed to a slight increase in the number of breast cancers among women using HRT compared to placebo. With regard to cardiovascular health, the data have shown an increase in stroke and (VTE) but there is also evidence of a possible cardioprotective effect. The major benefits include relief of menopausal symptoms (including vasomotor instability, sexual dysfunction, mood, fatigue and skin issues) and a decrease in fracture risk.

Impact of estrogen therapy on Alzheimer's disease: a fork in the road?

The results of recent clinical studies have challenged our previously held view that estrogen therapy promotes neurological health and prevents or ameliorates Alzheimer's disease. A major question emerging from these studies is: how can there be such disparity between the basic science and epidemiological data that show that estrogen can protect neurons against degenerative insults and reduce the risk of Alzheimer's disease and the recent data (from the Women's Health Initiative Memory Study [WHIMS] trial and the trial of estrogen treatment for Alzheimer's disease), which show that hormone replacement therapy (HRT) showed no benefit and even a potential deleterious effect? Which set of data is correct? The proposition put forth in this review is that both sets of data are correct and that two major factors determine the efficacy of estrogen or HRT. First is the time at which estrogen therapy is initiated. The data indicate that initiation of therapy early in menopause and when neurons are in a healthy state, reduces the risk of Alzheimer's disease; whereas, estrogen therapy initiated after the disease has developed or decades following menopause is without benefit. Second, estrogen therapy is not the same as HRT and the type of progestogen used determines the outcome of the therapeutic intervention. Insights into the mechanisms of action of estrogen and progestogen in the brain provide a framework for understanding the paradox of the benefit of estrogen in the prevention of Alzheimer's disease versus the lack of benefit in treatment trials and in trials when HRT is instituted many years after menopause. Based on estrogen-inducible mechanisms, which have been elucidated in healthy neuron model systems, it would be predicted that estrogen therapy could be highly effective in preventing neurodegenerative disease by promoting neuronal defence and memory mechanisms. The mechanisms of action of estrogen also predict that estrogen therapy would be an ineffective strategy for reversing the pathology of Alzheimer's disease. In summary, the time at which estrogen therapy is initiated, the neurological status of the brain at the time of estrogen therapy initiation and the type of progestogen used all contribute to the efficacy of estrogen in preventing neurodegenerative disease and to sustaining neurological health and function. An estrogen advantage hypothesis is put forth that provides a unifying mechanism of estrogen action with implications for both the benefits and risks of estrogen therapy.

Cognitive function in relation with bone mass and nutrition: cross-sectional association in postmenopausal women

BACKGROUND: It has been suggested that bone loss and cognitive decline are co-occurring conditions, possibly due to their relationship with estrogen. Cognitive decline has been associated with various nutritional deficiencies as well. The purpose of this study was to determine if cognitive function is related to bone mineral density of various skeletal sites as well as to various dietary components. METHODS: Cross-sectional study with 97 healthy, Caucasian, postmenopausal women (59.4-85.0 years) enrolled in a larger longitudinal study, investigating the effects of sodium on bone mass. The subjects were divided into two groups based on cognition scores. Group 1 represented lower and Group 2 higher scores on cognitive function. Bone mineral density from the whole body, lumbar spine, femur and forearm were measured with the Lunar DPX-MD instrument. Anthropometry was measured by standard methods. Cognition was assessed using the Mini Mental State Examination. Cumulative (over 2 years) dietary intake from 3-day records was analyzed by Food Processor(R) (ESHA Research, Salem, OR) and cumulative physical activity was assessed using Allied Dunbar National Fitness Survey for older adults. RESULTS: Subjects' cognition scores ranged from 22-30 (normal, 27-30), indicating all subjects had either mild or no cognitive impairment. Multiple Analysis of Covariance adjusted for age, height, weight, physical activity, alcohol, calcium, sodium and energy intake, showed a statistically significant association between cognition and bone mineral density of all measurable sites (eta2 = 0.21, P < 0.01). However, after Analysis of Covariance follow-up tests and Bonferroni correction, the differences for individual bone sites diminished, though Group 2 had higher adjusted means for all sites except for the femoral neck, Ward's triangle and trochanter. There was a positive significant association between cognition score and carbohydrate and potassium intake (eta2 = 0.07, P = 0.050). Group 2 did have a significantly higher potassium intake (P = 0.023). In multiple regression, saturated fat had a significant negative relationship with cognitive function. CONCLUSIONS: It appears mild degree of cognitive impairment may be a marker for lower bone mineral density as well as for a diet lower in carbohydrate and potassium intake, and higher in saturated fat. Consequently, older women with cognitive impairment may benefit of being screened for potential bone loss and poor nutrition.

Brain regions activated during an auditory discrimination task in insomniac postmenopausal patients before and after hormone replacement therapy: low-resolution brain electromagnetic tomography applied to event-related potentials

Electrical sources of auditory event-related potentials (ERPs) determined by means of low-resolution brain electromagnetic tomography (LORETA) in 48 unmedicated insomniac postmenopausal patients aged between 46 and 67 years were compared with those obtained in 48 age-matched normal female controls. Subsequently, the patients were included in a double-blind, placebo-controlled, comparative, randomized 3-arm trial phase - Climodien 2/3 [estradiol valerate (EV) 2 mg + the progestin dienogest 3 mg] was compared with EV 2 mg and placebo - followed by an open-label phase in which all of them received Climodien 2/2 (EV 2 mg + dienogest 2 mg). The double-blind and the open-label phase lasted 2 months. ERPs were recorded from 19 EEG leads in a two-tone oddball paradigm and electrical sources of standard N1 and P2 as well as target N2 and P300 components were estimated. In both patients and controls, LORETA revealed an activation of the superior temporal gyrus [auditory cortex, Brodmann areas (BA) 41, 42, 22] for all four components. For standard P2, an additional activation was observed medially parietally in the precuneus (BA 7, 5). For target N2, also a medial frontal source (BA 9, 10, 32) was identified. Finally, for the target P300 component - in addition to the aforementioned sources - activations in the prefrontal cortex (BA 9, 10, 46, 47), the inferior parietal cortex (supramarginal gyrus, BA 40, 39) and the posterior cingulum (BA 31) were found. Thus, patients and controls did not differ in the structural processes engaged in these fundamental aspects of information processing. However, patients demonstrated significantly reduced source strength - for standard ERP components predominantly in the temporal lobe and for target components predominantly in the frontal lobe, indicating reduced energetic resources available for perceptual and cognitive demands of the discrimination task. While, as compared with placebo, estrogen alone had only minor effects on ERP source strength, Climodien generally increased the impressed current density at the ERP peak latencies, predominantly in the temporal lobe, indicating an increased stimulus-induced cortical arousal in the primary and higher-order auditory cortex. Specifically, Climodien enhanced P300 source strength in the left middle temporal gyrus and in the left superior frontal gyrus, brain regions that on the one hand have been shown to be affected by hormone therapy in positron emission tomography and functional magnetic resonance neuroimaging studies and that on the other hand are among those critical for encoding and memory processes.

Effects of estradiol and progesterone on radial maze performance in middle-aged female rats fed a low-calcium diet

There is increasing evidence that ovarian steroids and calcium ions are involved in learning and memory. To examine the effect of ovarian steroids on learning and memory under a low-calcium condition, middle-aged female rats were fed either a low-calcium (0.02% Ca) or a normal-calcium (1.25% Ca) diet. All rats were ovariectomized (OVX), and these animals were divided into eight groups: 1) an OVX group with a normal-calcium diet (OVX-normal-Ca group), 2) an OVX group with 17beta-estradiol treatment and a normal-calcium diet (E2 group), 3) an OVX with progesterone treatment and a normal-calcium diet (P4 group), 4) an OVX with 17beta-estradiol and progesterone treatments and a normal-calcium diet (E2 + P4 group), 5) an OVX group with a low-calcium diet (OVX-low-Ca group), 6) an OVX group with 17beta-estradiol treatment and a low-calcium diet (LE2 group), 7) an OVX group with progesterone treatment and a low-calcium diet (LP4 group), and 8) an OVX group with 17beta-estradiol and progesterone treatments and a low-calcium diet (LE2 + LP4). Seventy-seven days after the OVX operation, the learning and memory abilities of the rats were examined by using an eight-arm radial maze task. E2 and E2 + P4 groups learned in fewer trials, and performed better in the radial maze and the working memory task than the other groups under the normal-calcium condition. Rats in the LE2 group learned in fewer trials, and performed better in the maze and working memory task than the other low-calcium groups, but in combination with progesterone under the low-calcium condition (LE2 + LP4 group), the facilitative effect of estradiol in all the tasks was inhibited. Treatment with progesterone alone did not inhibit the learning and memory task performance. These results suggest the possibility that treatment with estradiol under low-calcium conditions cannot improve impaired learning and memory when progesterone is applied simultaneously, and that the intake of adequate calcium may be necessary and effective for patients with learning and memory hypofunction receiving hormone replacement therapy.