The 2012 hormone therapy position statement of: The North American Menopause Society

Stage of the estrous cycle does not influence myocardial ischemia-reperfusion injury in rats (Rattus norvegicus)

Even though cardiovascular disease is the leading cause of death for men and women, the vast majority of animal studies use male animals. Because female reproductive hormones have been associated with cardioprotective states, many investigators avoid using female animals because these hormones are cyclical and may introduce experimental variability. In addition, no studies have investigated the specific effects of the estrous cycle on cardiac ischemic injury. This study was conducted to determine whether the estrous cycle stage influences the susceptibility to ischemic injury in rat hearts. Estrous cycle stage was determined by using vaginal smear cytology, after which hearts underwent either in vivo (surgical) or ex vivo (isolated) ischemia-reperfusion injury. For in vivo studies, the left anterior coronary artery was ligated for 25 min of ischemia and subsequently released for 120 min of reperfusion. Infarct sizes were 42% ± 6%; 49% ± 4%; 40% ± 9%; 47% ± 9% of the zone-at-risk for rats in proestrus, estrus, metestrus, and diestrus, respectively. For ex vivo studies, isolated, perfused hearts underwent global ischemia and reperfusion for 25 and 120 min, respectively. Similar to our in vivo studies, the ex vivo rat model showed no significant differences in susceptibility to infarction or extent of cardiac arrhythmia according to estrous stage. To our knowledge, these studies provide the first direct evidence that the stage of estrous cycle does not significantly alter cardiac ischemia-reperfusion injury in rats.

Challenging and complex decisions in the management of the BRCA mutation carrier

Women afflicted by the hereditary breast and ovarian cancer syndrome face complex decisions regarding medical interventions aimed at reducing their risk of ovarian and breast cancer, interventions which in turn may interfere with their fertility and cause early menopause. This review addresses selected topics of importance and controversy in the management of the BRCA mutation carrier, such as psychological well-being and quality of life, breast and ovarian cancer screening, risk-reducing interventions for breast cancer and ovarian cancer, the issue of hysterectomy at the time of the risk-reducing salpingo-oophorectomy, health consequences of early surgical menopause, and safety of hormonal therapy after oophorectomy. The information presented is based on an extensive review of the literature on the selected topics and on the expertise of our multidisciplinary team.

Postmenopausal hormone therapy is not associated with risk of all-cause dementia and Alzheimer's disease

The relationship of postmenopausal hormone therapy with all-cause dementia and Alzheimer's disease dementia has been controversial. Given continued interest in the role of hormone therapy in chronic disease prevention and the emergence of more prospective studies, we conducted a systematic review to identify all epidemiologic studies meeting prespecified criteria reporting on postmenopausal hormone therapy use and risk of Alzheimer's disease or dementia. A systematic search of Medline and Embase through December 31, 2012, returned 15 articles meeting our criteria. Our meta-analysis of any versus never use did not support the hypothesis that hormone therapy reduces risk of Alzheimer's disease (summary estimate = 0.88, 95% confidence interval: 0.66, 1.16). Exclusion of trial findings did not change this estimate. There were not enough all-cause dementia results for a separate meta-analysis, but when we combined all-cause dementia results (n = 3) with Alzheimer's disease results (n = 7), the summary estimate remained null (summary estimate = 0.94, 95% confidence interval: 0.71, 1.26). The limited explorations of timing of use-both duration and early initiation-did not yield consistent findings. Our findings support current recommendations that hormone therapy should not be used for dementia prevention. We discuss trends in hormone therapy research that could explain our novel findings and highlight areas where additional data are needed.

Estrogen replacement therapy and asthma

A growing body of clinical and experimental evidence indicates that female sex hormones, particularly estrogen, have significant effects on normal airway function as well as on respiratory disorders, such as asthma. These effects are very complex and are exerted at several levels, directly on airway reactivity or indirectly through regulation of the immune and inflammatory responses in the lung. They can have relevant clinical implications not only according to the phases of the reproductive life in women, but also in relation to the therapeutical administration of estrogen, as in the case of menopausal hormone therapy. Clinical evidence suggests that administration of estrogen to menopausal women is associated with increased rates of newly diagnosed asthma. Conversely, functional studies show that estrogen can improve objective indexes of respiratory functionality.

Perspective on hormone therapy 10 years after the WHI

The Women's Health Initiative (WHI) hormone trials are among the most influential and debated research studies in women's health in recent medical history. This year (2013) marked the 10th anniversary of the publication of the WHI results and this past decade has been nothing less than revolutionary. We have witnessed a transformative evolution in our understanding of, and in the practice of, menopause management and herein summarize the strides the field has traversed over the past 10 years.

Menopause effects on verbal memory: findings from a longitudinal community cohort

CONTEXT

Although cognitive complaints are common among menopausal women, it is debatable whether there is an objective decline in cognition with menopause that exceeds what is expected with normal aging.

OBJECTIVE

The objective of the study was to determine whether reproductive senescence is associated with an age-independent decline in verbal memory.

DESIGN AND SETTING

The study was a 14-year, longitudinal, population-based cohort study of women who underwent yearly endocrine, behavioral, and cognitive assessments from pre- to postmenopause.

PARTICIPANTS

Caucasian and African American premenopausal women (n = 403), who were enrolled in the Penn Ovarian Aging Study, participated in the study.

MAIN OUTCOME MEASURES

Buschke Selective Reminding Test (immediate and delayed verbal recall), the digit symbol substitution task, and the symbol copy task were used to measure outcomes.

RESULTS

A total of 3958 assessments were conducted in this sample of 403 women. In models that were adjusted for age and important cofactors, immediate (P = .03) and delayed (P = .03) recall on the Buschke Selective Reminding Test declined from the pre- to postmenopausal stages. Further evaluation identified a significant decline (P < .002) in delayed recall early in the transition and immediate recall (P = .04) late in the transition. Race was a significant factor in performance on all tasks (all P < .0001) except the delayed verbal recall task (P = .06) in adjusted models. Endocrine measures were significantly associated with cognitive performance in unadjusted models.

CONCLUSIONS

Certain cognitive domains are sensitive to the physiological changes of reproductive senescence independent of age. The differences in cognitive performance between African American and Caucasian women were not explained by factors examined in this study but are of important public health concern that warrants further investigation.

Oral estrogen therapy may mitigate the effects of aerobic training on cardiorespiratory fitness in postmenopausal women: a double-blind, randomized clinical pilot study

OBJECTIVE

The aim of this study was to evaluate the isolated and associated effects of oral estrogen therapy and aerobic training on cardiorespiratory fitness in postmenopausal women.

METHODS

Forty-two hysterectomized healthy postmenopausal women were randomly divided (in a double-blind manner) into four groups: placebo-control (n = 9), estrogen therapy-control (n = 12), placebo-aerobic training (PLA-AT; n = 11), and estrogen therapy-aerobic training (ET-AT; n = 10). The estrogen therapy groups received estradiol valerate (1 mg/day) and the aerobic training groups trained on a cycle ergometer three times per week at moderate intensity. Before and 6 months after the interventions, all women underwent a maximal cardiopulmonary exercise test on a cycle ergometer.

RESULTS

Regardless of hormone therapy, aerobic training increased oxygen uptake at anaerobic threshold (P = 0.001), oxygen uptake at respiratory compensation point (P = 0.043), and oxygen uptake at peak exercise (P = 0.020). The increases at respiratory compensation point and peak exercise were significantly greater in the groups receiving placebo than in the groups receiving estrogen (oxygen uptake at respiratory compensation point: PLA-AT +5.3 [2.8] vs ET-AT +3.0 [2.5] mL kg(-1) min(-1), P = 0.04; oxygen uptake at peak exercise: PLA-AT +5.8 [3.4] vs ET-AT +2.8 [1.4] mL kg(-1) min(-1), P = 0.02).

CONCLUSIONS

Oral estrogen therapy may mitigate the cardiorespiratory fitness increase induced by aerobic training in hysterectomized healthy postmenopausal women.

Conjugated estrogens for the treatment of menopausal symptoms: a review of safety data

INTRODUCTION

Conjugated equine estrogens (CEE) are widely used for the treatment of menopausal symptoms, such as vasomotor symptoms and vulvovaginal atrophy, and for the prevention of bone loss, in postmenopausal women. The safety profile of CEE has been extensively published over the past 20 years.

AREAS COVERED

Data from randomized controlled trials and from observational studies on the effects of CEE on the risk of breast cancer, endometrial cancer or hyperplasia, other cancers, cardiovascular outcomes, and cognitive function are reviewed. When used alone, CEE are not associated with an increased risk of breast cancer and may be associated with reduced mortality. The risk of cardiovascular events with CEE may be reduced in women who are more recently postmenopausal.

EXPERT OPINION

Numerous clinical studies have evaluated the safety of CEE. The data reviewed in this article describe the breast, endometrial, and cardiovascular safety of unopposed CEE. International recommendations describe CEE as the menopausal symptom treatment of choice, particularly in young or recently postmenopausal hysterectomized women.

Acupuncture for menopausal hot flushes

BACKGROUND

Hot flushes are the most common menopausal vasomotor symptom. Hormone therapy (HT) has frequently been recommended for relief of hot flushes, but concerns about the health risks of HT have encouraged women to seek alternative treatments. It has been suggested that acupuncture may reduce hot flush frequency and severity.

OBJECTIVES

To determine whether acupuncture is effective and safe for reducing hot flushes and improving the quality of life of menopausal women with vasomotor symptoms.

SEARCH METHODS

We searched the following databases in January 2013: the Cochrane Menstrual Disorders and Subfertility Group Specialised Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, CINAHL, PsycINFO, Chinese Biomedical Literature Database (CBM), Chinese Medical Current Content (CMCC), China National Knowledge Infrastructure (CNKI), VIP database, Dissertation Abstracts International, Current Controlled Trials, Clinicaltrials.gov, National Center for Complementary and Alternative Medicine (NCCAM), BIOSIS, AMED, Acubriefs, and Acubase.

SELECTION CRITERIA

Randomized controlled trials comparing any type of acupuncture to no treatment/control or other treatments for reducing menopausal hot flushes and improving the quality of life of symptomatic perimenopausal/postmenopausal women were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Sixteen studies, with 1155 women, were eligible for inclusion. Three review authors independently assessed trial eligibility and quality, and extracted data. We pooled data where appropriate and calculated mean differences (MDs) and standardized mean differences (SMDs) with 95% confidence intervals (CI). We evaluated the overall quality of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

MAIN RESULTS

Eight studies compared acupuncture versus sham acupuncture. No significant difference was found between the groups for hot flush frequency (MD -1.13 flushes per day, 95% CI -2.55 to 0.29, 8 RCTs, 414 women, I(2) = 70%, low-quality evidence) but flushes were significantly less severe in the acupuncture group, with a small effect size (SMD -0.45, 95% CI -0.84 to -0.05, 6 RCTs, 297 women, I(2) = 62%, very-low-quality evidence). There was substantial heterogeneity for both these outcomes. In a post hoc sensitivity analysis excluding studies of women with breast cancer, heterogeneity was reduced to 0% for hot flush frequency and 34% for hot flush severity and there was no significant difference between the groups for either outcome.Three studies compared acupuncture versus HT. Acupuncture was associated with significantly more frequent hot flushes than HT (MD 3.18 flushes per day, 95% CI 2.06 to 4.29, 3 RCTs, 114 women, I(2) = 0%, low-quality evidence). There was no significant difference between the groups for hot flush severity (SMD 0.53, 95% CI -0.14 to 1.20, 2 RCTs, 84 women, I(2) = 57%, low-quality evidence).One study compared electroacupuncture versus relaxation. There was no significant difference between the groups for either hot flush frequency (MD -0.40 flushes per day, 95% CI -2.18 to 1.38, 1 RCT, 38 women, very-low-quality evidence) or hot flush severity (MD 0.20, 95% CI -0.85 to 1.25, 1 RCT, 38 women, very-low-quality evidence).Four studies compared acupuncture versus waiting list or no intervention. Traditional acupuncture was significantly more effective in reducing hot flush frequency from baseline (SMD -0.50, 95% CI -0.69 to -0.31, 3 RCTs, 463 women, I(2) = 0%, low-quality evidence), and was also significantly more effective in reducing hot flush severity (SMD -0.54, 95% CI -0.73 to -0.35, 3 RCTs, 463 women, I(2) = 0%, low-quality evidence). The effect size was moderate in both cases.For quality of life measures, acupuncture was significantly less effective than HT, but traditional acupuncture was significantly more effective than no intervention. There was no significant difference between acupuncture and other comparators for quality of life. Data on adverse effects were lacking.

AUTHORS' CONCLUSIONS

We found insufficient evidence to determine whether acupuncture is effective for controlling menopausal vasomotor symptoms. When we compared acupuncture with sham acupuncture, there was no evidence of a significant difference in their effect on menopausal vasomotor symptoms. When we compared acupuncture with no treatment there appeared to be a benefit from acupuncture, but acupuncture appeared to be less effective than HT. These findings should be treated with great caution as the evidence was low or very low quality and the studies comparing acupuncture versus no treatment or HT were not controlled with sham acupuncture or placebo HT. Data on adverse effects were lacking.

Impact of vulvovaginal health on postmenopausal women: a review of surveys on symptoms of vulvovaginal atrophy

Several recent, large-scale studies have provided valuable insights into patient perspectives on postmenopausal vulvovaginal health. Symptoms of vulvovaginal atrophy, which include dryness, irritation, itching, dysuria, and dyspareunia, can adversely affect interpersonal relationships, quality of life, and sexual function. While approximately half of postmenopausal women report these symptoms, far fewer seek treatment, often because they are uninformed about hypoestrogenic postmenopausal vulvovaginal changes and the availability of safe, effective, and well-tolerated treatments, particularly local vaginal estrogen therapy. Because women hesitate to seek help for symptoms, a proactive approach to conversations about vulvovaginal discomfort would improve diagnosis and treatment.

Tissue-selective estrogen complexes for postmenopausal women

Although hormone therapy using estrogens plus progestogens (EPT) is effective for the management of menopausal symptoms (e.g., vasomotor symptoms and vulvar/vaginal atrophy) and prevention/treatment of postmenopausal osteoporosis, EPT is associated with safety and tolerability concerns. A new alternative to EPT is the tissue selective estrogen complex (TSEC), which partners a selective estrogen receptor modulator (SERM) with one or more estrogens and is designed to treat menopausal symptoms and prevent postmenopausal osteoporosis without the tolerability concerns associated with EPT. The first TSEC to reach advanced clinical development is a combination of the SERM bazedoxifene (BZA) with conjugated estrogens (CE). BZA has been shown to inhibit the stimulatory activity of CE on uterine tissue and breast in vitro and in vivo. In clinical studies, BZA/CE treatment has been associated with significant improvements in menopausal symptoms including hot flushes and vulvar/vaginal atrophy and significant increases in bone mineral density, coupled with reductions in bone turnover marker levels and improvements in sleep and health-related quality of life. Additionally, BZA/CE has been shown to have a neutral effect on endometrial and breast tissue because BZA inhibits the stimulatory effects of estrogens in tissue-selective fashion in these 2 organs. Taken together, results of these preclinical and clinical studies indicate that the benefits of estrogens for treating menopausal symptoms are maintained with BZA/CE without endometrial or breast stimulation, resulting in a safe and effective treatment for symptomatic postmenopausal women.

Pharmacokinetic properties of once-daily oral low-dose mesylate salt of paroxetine (LDMP 7.5 mg) following single and multiple doses in healthy postmenopausal women

BACKGROUND

Low-dose mesylate salt of paroxetine (LDMP 7.5 mg) is being investigated for the treatment of vasomotor symptoms associated with menopause.

OBJECTIVE

This Phase I, open-label, single- and multiple-dose study evaluated the pharmacokinetic properties, safety and tolerability of LDMP in postmenopausal, nonsmoking women aged ≥40 years.

METHODS

After a 3-week screening period, subjects received LDMP 7.5-mg capsules as a single dose on day 1 and then as multiple doses (once daily for 14 days) on Days 6-19. Blood samples were collected predose and up to 120 hours postdose on day 1 (single-dose pharmacokinetic profile), at predose (after 12 doses) on day 18, and at predose and up to 24 hours postdose on day 19 (multiple-dose pharmacokinetic profile). Capsules were taken with 240 mL of water while subjects were fasted. Safety was evaluated throughout the study.

RESULTS

Twenty-four women (mean age, 56 years) completed the study. On day 1, median Tmax was ~6 hours, and mean t1/2 was 17.30 hours. Mean plasma concentrations attained predose on days 18 and 19 (days 13 and 14 of multiple dosing) and at 24 hours postdose (day 20) were similar, suggesting that steady state was achieved by day 13 of multiple dosing after 12 daily doses. Mean AUC0-24 h at steady state (day 14 of multiple dosing) was ~3-fold greater than AUC0-∞ on day 1, indicating nonlinear pharmacokinetics. Mean Cmax on day 14 of multiple dosing was ~5-fold greater than that attained on day 1, and the accumulation index (AUCday 19/AUCday 1) at steady state was 9.71. Fluctuation index (calculated as [(Cmax - Cmin)/Cavg ss] × 100) was 75.8%. Most subjects (23/24 [95.8%]) experienced at least 1 treatment-emergent adverse event (AE); however, most AEs (67 events in 22/24 subjects [91.7%]) were mild, and the remainder were moderate. Seventeen subjects experienced 33 AEs that were deemed possibly or probably related to LDMP. No serious AEs were reported, and no clinically meaningful changes in laboratory values, vital signs, or ECGs were observed.

CONCLUSIONS

On multiple dosing, LDMP exhibited nonlinear pharmacokinetics and was well tolerated in these healthy postmenopausal women; the extent of accumulation was consistent with data from the published literature.

Translational cognitive endocrinology: designing rodent experiments with the goal to ultimately enhance cognitive health in women

Understanding the cognitive impact of endogenously derived, and exogenously administered, hormone alterations is necessary for developing hormone treatments to support healthy brain function in women, especially during aging. The increasing number of studies in the burgeoning area of translational cognitive neuroendocrinology has revealed numerous factors that influence the extent and direction of female steroid effects on cognition. Here, we discuss the decision processes underlying the design of rodent hormone manipulation experiments evaluating learning and memory. It is noted that even when beginning with a clear hypothesis-driven question, there are numerous factors to consider in order to solidify a sound experimental design that will yield clean, interpretable results. Decisions and considerations include: age of animals at hormone administration and test, ovariectomy implementation, when to administer hormones relative to ovarian hormone loss, how and whether to monitor the estrous cycle if animals are ovary-intact, dose of hormone, administration route of hormone, hormone treatment confirmation protocols, handling procedures required for hormone administration and treatment confirmation, cognitive domains to be tested and which mazes should be utilized to test these cognitive domains, and control measures to be used. A balanced view of optimal design and realistic experimental practice and protocol is presented. The emerging results from translational cognitive neuroendocrinology studies have been diverse, but also enlightening and exciting as we realize the broad scope and powerful nature of ovarian hormone effects on the brain and its function. We must design, implement, and interpret hormone and cognition experiments with sensitivity to these tenets, acknowledging and respecting the breadth and depth of the impact gonadal hormones have on brain functioning and its rich plasticity. This article is part of a Special Issue entitled Hormone Therapy.

Neuroprotective action of acute estrogens: animal models of brain ischemia and clinical implications

The ovarian hormone 17β-estradiol (E2) exerts profound neuroprotective actions against ischemia-induced brain damage in rodent models of global and focal ischemia. This review focuses on the neuroprotective efficacy of post-ischemic administration of E2 and non-feminizing estrogen analogs in the aging brain, with an emphasis on studies in animals subjected to a long-term loss of circulating E2. Clinical findings from the Women's Health Initiative study as well as data from animal studies that used long-term, physiological levels of E2 treatment are discussed in this context. We summarize major published findings that highlight the effective doses and timing of E2 treatment relative to onset of ischemia. We then discuss recent findings from our laboratory showing that under some conditions the aging hippocampus remains responsive to E2 and some neuroprotective non-feminizing estrogen analogs even after prolonged periods of hormone withdrawal. Possible membrane-initiated signaling mechanisms that may underlie the neuroprotective actions of acutely administered E2 are also discussed. Based on these findings, we suggest that post-ischemic treatment with high doses of E2 or certain non-feminizing estrogen analogs may have great therapeutic potential for treatment of brain damage and neurodegeneration associated with ischemia.

The role of estrogens in control of energy balance and glucose homeostasis

Estrogens play a fundamental role in the physiology of the reproductive, cardiovascular, skeletal, and central nervous systems. In this report, we review the literature in both rodents and humans on the role of estrogens and their receptors in the control of energy homeostasis and glucose metabolism in health and metabolic diseases. Estrogen actions in hypothalamic nuclei differentially control food intake, energy expenditure, and white adipose tissue distribution. Estrogen actions in skeletal muscle, liver, adipose tissue, and immune cells are involved in insulin sensitivity as well as prevention of lipid accumulation and inflammation. Estrogen actions in pancreatic islet β-cells also regulate insulin secretion, nutrient homeostasis, and survival. Estrogen deficiency promotes metabolic dysfunction predisposing to obesity, the metabolic syndrome, and type 2 diabetes. We also discuss the effect of selective estrogen receptor modulators on metabolic disorders.

Antiosteoclastic activity of milk thistle extract after ovariectomy to suppress estrogen deficiency-induced osteoporosis

Bone integrity abnormality and imbalance between bone formation by osteoblasts and bone resorption by osteoclasts are known to result in metabolic bone diseases such as osteoporosis. Silymarin-rich milk thistle extract (MTE) and its component silibinin enhanced alkaline phosphatase activity of osteoblasts but reduced tartrate-resistant acid phosphatase (TRAP) activity of osteoclasts. The osteoprotective effects of MTE were comparable to those of estrogenic isoflavone. Low-dose combination of MTE and isoflavone had a pharmacological synergy that may be useful for osteogenic activity. This study attempted to reveal the suppressive effects of MTE on bone loss. C57BL/6 female mice were ovariectomized (OVX) as a model for postmenopausal osteopenia and orally administered 10 mg/kg MTE or silibinin for 8 weeks. The sham-operated mice served as estrogen controls. The treatment of ovariectomized mice with nontoxic MTE and silibinin improved femoral bone mineral density and serum receptor activator of nuclear factor- κB ligand/osteoprotegerin ratio, an index of osteoclastogenic stimulus. In addition, the administration of MTE or silibinin inhibited femoral bone loss induced by ovariectomy and suppressed femoral TRAP activity and cathepsin K induction responsible for osteoclastogenesis and bone resorption. Collectively, oral dosage of MTE containing silibinin in the preclinical setting is effective in preventing estrogen deficiency-induced bone loss.

Where are we 10 years after the Women's Health Initiative?

The media attention surrounding the publication of the initial results of WHI in 2002 led to fear and confusion regarding the use of hormonal therapy (HT) after menopause. This led to a dramatic reduction in prescriptions for HT in the United States and around the world. Although in 2002 it was stated that the results pertained to all women receiving HT, subsequent studies from the Women's Health Initiative (WHI) and others clearly showed that younger women and those close to menopause had a very beneficial risk-to-benefit ratio. Indeed, the results showed similar protective effects for coronary disease and a reduction in mortality that had been shown in earlier observational studies, which had also focused on younger symptomatic women. In younger women, the increased number of cases of venous thrombosis and ischemic stroke was low, rendering them "rare" events using World Health Organization nomenclature. Breast cancer rates were also low and were found to be decreased with estrogen alone. In women receiving estrogen and progestogen for the first time in the WHI, breast cancer rates did not increase significantly for 7 years. Other data suggest that other regimens and the use of other progestogens may also be safer. It has been argued that in the 10 years since WHI, many women have been denied HT, including those with severe symptoms, and that this has significantly disadvantaged a generation of women. Some reports have also suggested an increased rate of osteoporotic fractures since the WHI. Therefore, the question is posed as to whether we have now come full circle in our understanding of the use of HT in younger women. Although it is appropriate to treat women with symptoms at the onset of menopause, because there is no proven therapy for primary prevention, in some women the use of HT for this role may at least be entertained.

Conjugated equine estrogens and estradiol benzoate differentially modulate the natriuretic peptide system in spontaneously hypertensive rats

OBJECTIVE

The purpose of this study was to compare the effects of conjugated equine estrogens (CEE) and estradiol benzoate on the blood pressure and body weight of spontaneously hypertensive rats (SHRs) and the associated changes in several components of the natriuretic peptide system.

METHODS

The blood pressure of randomly distributed female SHRs and Wistar rats was determined by tail plethysmography. The rats were ovariectomized and, after 3 weeks, injected daily for 4 days with estradiol benzoate (5 μg/100 g/d), CEE (50 μg/100 g/d), or vehicle (corn oil 0.1 mL/100 g/d). One day after the last injection, the rats were decapitated, and their blood was collected to measure atrial natriuretic peptide (ANP) and estradiol. The atria were removed to measure ANP levels using radioimmunoassay and to quantify ANP messenger RNA expression using real-time polymerase chain reaction. The kidneys and adipose tissue were removed to analyze the expression of natriuretic peptide clearance receptor messenger RNA.

RESULTS

A reduction in blood pressure was observed in estradiol-treated SHRs, but CEE treatment had no effect. Estradiol decreased the body weight and parametrial adipose tissue mass of SHRs. Estradiol-induced alterations in SHRs were accompanied by increased synthesis and release of ANP. CEE had no effect on body weight but increased the mesenteric adipose tissue mass of SHRs.

CONCLUSIONS

These results indicate that estradiol and CEE have different effects on the reduction in body weight and blood pressure. These results are correlated with changes in plasma ANP levels.

An update on menopausal hormone replacement therapy in women and cardiovascular disease

PURPOSE OF REVIEW

This review presents the available evidence for effects of menopausal hormone replacement therapy (MHT), more specifically estrogen, and selective estrogen receptor modulators on the cardiovascular system with a focus on randomized controlled trials (RCTs) published since 2010.

RECENT FINDINGS

In contrast to early observational studies, the Women's Health Initiative, the largest randomized controlled trial of MHT in generally healthy women, suggested harmful cardiovascular effects. Subsequent subanalyses of the Women's Health Initiative and other studies suggest the cardiovascular effects of MHT may vary by age and time since menopause, giving rise to a 'timing hypothesis'. Recent trials have looked at this issue by evaluating surrogate markers of cardiovascular disease (CVD) or CVD events adjudicated as secondary outcomes in RCTs and show a reduction in events with MHT.

SUMMARY

Athough the data overall do not support the use of MHT or selective estrogen receptor modulator for primary prevention of CVD, evidence is accumulating that careful use of MHT for perimenopausal symptoms may not carry CVD harm. This review highlights some of the strengths and weaknesses of these recent reports. Ongoing studies of MHT will shed more light on the interaction between age or time after menopause and the vascular effects of MHT.

Postmenopausal hormone therapy: risks and benefits

Postmenopausal hormone therapy (PMHT) is used for the relief of menopausal symptoms, but the dosage has varied greatly throughout its existence. By the end of the 1990s, PMHT was mainly used to prevent chronic diseases such as osteoporosis, coronary heart disease and dementia, and large prevention trials were undertaken in this context. Following the initial negative reports of these trials, use of PMHT dramatically decreased. These reports noted surprisingly increased risks, notably of coronary heart disease, stroke and breast cancer, in people who used PMHT. Nowadays, considering the currently available data, it seems that an important distinction should be made between the treatment of climacteric symptoms in young, generally healthy, postmenopausal women and the prevention of chronic diseases in elderly women. PMHT seems to be beneficial and safe for postmenopausal symptomatic women aged <60 years. Treatments with a high safety profile should be the preferred option, including low-dose PMHT, oestrogen-only therapy in women who have had a hysterectomy, and vaginal oestrogen therapy for women with atrophic vaginitis. Nonandrogenic progestin might have a reduced thrombotic and breast cancer risk, and transdermal oestrogen could have a reduced thrombotic risk. Nevertheless, PMHT should not be used for the prevention of chronic diseases in the elderly (>70 years old) owing to the increased risk of stroke and breast cancer in these patients.

Ovarian hormones promote recovery from sleep deprivation by increasing sleep intensity in middle-aged ovariectomized rats

Sleep disturbances are commonly associated with menopause. Hormone replacement therapy is often used to treat various menopausal symptoms, but its efficacy for improving sleep is a matter of debate. We addressed this question by using a rodent model of ovarian hormone loss and replacement in midlife. Middle-aged female rats were ovariectomized and implanted with capsules containing estradiol with or without progesterone, or oil. After two weeks, sleep/wake states were recorded polygraphically during a 24-h baseline period, followed by 6h of sleep deprivation in the second half of the light phase, and a 24-h recovery period. During the baseline dark phase, hormone treatments increased wakefulness, and decreased non-rapid eye movement sleep (NREMS) by shortening NREMS episodes; however, NREMS EEG delta power or energy (cumulative power) was unaffected by combined hormones. Following sleep deprivation, all the groups showed NREMS and rapid eye movement sleep (REMS) rebounds, with similar relative increases from respective baseline levels. The increases in NREMS EEG delta power/energy during recovery were enhanced by combined hormones. These results from middle-aged ovariectomized rats indicate that replacement with estrogen with or without progesterone reduces baseline NREMS without affecting sleep intensity, particularly during the dark (active) phase, whereas following sleep deprivation the same hormone treatments do not affect the ability to increase NREMS or REMS, but treatment with both hormones, in particular, enhances the intensity of recovery sleep. These results support the usefulness of ovariectomized middle-aged rats as a model system to study the biological effects of hormone replacement on sleep regulation.

Changes in pituitary function with ageing and implications for patient care

The pituitary gland has a role in puberty, reproduction, stress-adaptive responses, sodium and water balance, uterine contractions, lactation, thyroid function, growth, body composition and skin pigmentation. Ageing is marked by initially subtle erosion of physiological signalling mechanisms, resulting in lower incremental secretory-burst amplitude, more disorderly patterns of pituitary hormone release and blunted 24 h rhythmic secretion. Almost all pituitary hormones are altered by ageing in humans, often in a manner dependent on sex, body composition, stress, comorbidity, intercurrent illness, medication use, physical frailty, caloric intake, immune status, level of exercise, and neurocognitive decline. The aim of this article is to critically discuss the mechanisms mediating clinical facets of changes in the hypothalamic-pituitary axis during ageing, and the extent to which confounding factors operate to obscure ageing-related effects.

Estrogen plus progestin and breast cancer incidence and mortality in the Women's Health Initiative Observational Study

BACKGROUND

In the Women's Health Initiative (WHI) randomized trial, estrogen plus progestin increased both breast cancer incidence and mortality. In contrast, most observational studies associate estrogen plus progestin with favorable prognosis breast cancers. To address differences, a cohort of WHI observational study participants with characteristics similar to the WHI clinical trial was studied.

METHODS

We identified 41 449 postmenopausal women with no prior hysterectomy and mammogram negative within 2 years who were either not hormone users (n = 25 328) or estrogen and progestin users (n = 16 121). Multivariable-adjusted Cox proportional hazard regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CI). All statistical tests were two-sided.

RESULTS

After a mean of 11.3 (SD = 3.1) years, with 2236 breast cancers, incidence was higher in estrogen plus progestin users than in nonusers (0.60% vs 0.42%, annualized rate, respectively; HR = 1.55, 95% CI = 1.41 to 1.70, P < .001). Women initiating hormone therapy closer to menopause had higher breast cancer risk with linear diminishing influence as time from menopause increased (P < .001). Survival after breast cancer, measured from diagnosis, was similar in combined hormone therapy users and nonusers (HR = 1.03, 95% CI = 0.79 to 1.35). On a population basis, there were somewhat more deaths from breast cancer, measured from cohort entry (HR = 1.32, 95% CI = 0.90 to 1.93, P = .15), and more all-cause deaths after breast cancer (HR = 1.65, 95% CI = 1.29 to 2.12, P < .001) in estrogen plus progestin users than in nonusers.

CONCLUSIONS

Consistent with WHI randomized trial findings, estrogen plus progestin use is associated with increased breast cancer incidence. Because prognosis after diagnosis on combined hormone therapy is similar to that of nonusers, increased breast cancer mortality can be expected.

Women's Health Initiative Hormone Therapy Trials: New insights on Cardiovascular Disease from Additional Years of Follow up

Debate and controversy surrounding the benefits and risks of menopausal hormone therapy (MHT) for prevention of cardiovascular disease has continued in the decade since the cessation of the Women's Health Initiative (WHI) hormone therapy interventions. As a result, many women and their physicians have been reluctant to turn to MHT for relief of vasomotor and other menopausal symptoms. However, several follow-up studies of WHI participants provide additional insight into clinical characteristics of women who are more likely to have favorable outcomes and lower rates of adverse events associated with MHT. This report focuses on those studies that identify characteristics and biomarkers helpful in stratifying risk for an individual. Incorporation of these factors into a benefit:risk model could assist in patient-oriented decision making regarding use of MHT. Personalizing treatment offers the potential to minimize risk and improve health outcomes.

Barriers to effective treatment of vaginal atrophy with local estrogen therapy

Vaginal atrophy is a common condition among postmenopausal women, among whom many exhibit both vulvovaginal symptoms (eg, dryness, irritation, itching, and pain with intercourse) and urinary symptoms (eg, increased frequency, urgency, incontinence, urinary tract infections, and dysuria). Unfortunately, few women with symptoms of vaginal atrophy report seeking treatment from a health care provider. The goal of this article is to examine reasons why patients and health care providers do not engage in discourse regarding this important topic. It is important to initiate conversations with postmenopausal women and counsel them on both why the changes occur and potential treatment options.

Exploring the contribution of estrogen to amyloid-Beta regulation: a novel multifactorial computational modeling approach

According to the amyloid hypothesis, Alzheimer Disease results from the accumulation beyond normative levels of the peptide amyloid-β (Aβ). Perhaps because of its pathological potential, Aβ and the enzymes that produce it are heavily regulated by the molecular interactions occurring within cells, including neurons. This regulation involves a highly complex system of intertwined normative and pathological processes, and the sex hormone estrogen contributes to it by influencing the Aβ-regulation system at many different points. Owing to its high complexity, Aβ regulation and the contribution of estrogen are very difficult to reason about. This report describes a computational model of the contribution of estrogen to Aβ regulation that provides new insights and generates experimentally testable and therapeutically relevant predictions. The computational model is written in the declarative programming language known as Maude, which allows not only simulation but also analysis of the system using temporal-logic. The model illustrates how the various effects of estrogen could work together to reduce Aβ levels, or prevent them from rising, in the presence of pathological triggers. The model predicts that estrogen itself should be more effective in reducing Aβ than agonists of estrogen receptor α (ERα), and that agonists of ERβ should be ineffective. The model shows how estrogen itself could dramatically reduce Aβ, and predicts that non-steroidal anti-inflammatory drugs should provide a small additional benefit. It also predicts that certain compounds, but not others, could augment the reduction in Aβ due to estrogen. The model is intended as a starting point for a computational/experimental interaction in which model predictions are tested experimentally, the results are used to confirm, correct, and expand the model, new predictions are generated, and the process continues, producing a model of ever increasing explanatory power and predictive value.

Impact of age and body mass on the intensity of menopausal symptoms in 5968 Brazilian women

OBJECTIVE

To assess the relationship of onset of menopause and body mass on the menopausal symptoms in post-menopausal Brazilian women.

DESIGN

Observational study conducted by the selection and inclusion of 5968 Brazilian women after menopause. The following variables were analyzed in this study: time at menopause; the relationship between age at menarche and age at menopause; vasomotor symptoms compared with age at the time of menopause and the time of menopause; Kupperman menopausal index (KMI) versus total time of menopause; body mass index (BMI) compared to the time of menopause, vasomotor symptoms, and KMI total score. We used the Chi-square test, and the significance level was set at 5%.

RESULTS

The age at natural menopause ranged from 41 to 62 years (mean 48.1 ± 4.07 years). A younger age at menopause was associated with a high intensity of vasomotor symptoms. These symptoms were more intense in the first 5 years of menopause and decreased with time. The KMI total also decreased with time after menopause, with the exception of arthralgia, myalgia, and insomnia, which did not tend to improve over time. In addition, the vasomotor symptoms and total KMI were more frequent with increasing BMI.

CONCLUSIONS

Our results suggested that the age of menopause and BMI may influence the intensity of vasomotor symptoms.

Window of opportunity: estrogen as a treatment for ischemic stroke

The neuroprotection research in the last 2 decades has witnessed a growing interest in the functions of estrogens as neuroprotectants against neurodegenerative diseases including stroke. The neuroprotective action of estrogens has been well demonstrated in both in vitro and in vivo models of ischemic stroke. However, the major conducted clinical trials so far have raised concern for the protective effect of estrogen replacement therapy in postmenopausal women. The discrepancy could be partly due to the mistranslation between the experimental stroke research and clinical trials. While predominant experimental studies tested the protective action of estrogens on ischemic stroke using acute treatment paradigm, the clinical trials have mainly focused on the effect of estrogen replacement therapy on the primary and secondary stroke prevention which has not been adequately addressed in the experimental stroke study. Although the major conducted clinical trials have indicated that estrogen replacement therapy has an adverse effect and raise concern for long term estrogen replacement therapy for stroke prevention, these are not appropriate for assessing the potential effects of acute estrogen treatment on stroke protection. The well established action of estrogen in the neurovascular unit and its potential interaction with recombinant tissue Plasminogen Activator (rtPA) makes it a candidate for the combined therapy with rtPA for the acute treatment of ischemic stroke. On the other hand, the "critical period" and newly emerged "biomarkers window" hypotheses have indicated that many clinical relevant factors have been underestimated in the experimental ischemic stroke research. The development and application of ischemic stroke models that replicate the clinical condition is essential for further evaluation of acute estrogen treatment on ischemic stroke which might provide critical information for future clinical trials. This article is part of a Special Issue entitled Hormone Therapy.