Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial

Clinical correlation between intestinal flora profiles and the incidence of postmenopausal osteoporosis

PURPOSE

This study aimed to explore the characteristics of intestinal microflora polymorphism in postmenopausal women, and to determine the pathophysiological changes of gene polymorphism of intestinal flora and bone metabolism in postmenopausal osteoporosis (PMOP) patients.

METHODS

A total of 104 postmenopausal women with PMOP or normal bone density were included. Lifestyle, hip T-score, bone metabolism indexes (25(OH)D, PTH, β-CTX, PINP), intestinal mucous membrane barrier function (diamine oxidase, D-lactic acid, LPS), gene polymorphisms, and characteristics of gut microbiota were examined.

RESULTS

Women with PMOP had reduced physical activity, less dietary protein and calcium intake, lower levels of 25(OH)D, hip T-score, and BMD, but PMOP group had increased total energy and fat intake, and higher levels of PTH, β-CTX, diamine oxidase, D-lactic acid, and LPS (p < .05 for all), as compared with normal subjects. Analyses of the α- and β-diversity of fecal microbiota indicated remarkably differences in postmenopausal women with or without PMOP. In details, individuals with PMOP had increased abundances of some genera (e.g. Roseburia and Bacteroides), but decreased abundances of some genera (e.g. Streptococcus and Dorea). Furthermore, use of a random forest model based on differential abundant taxa and ROC analysis could efficiently identify women with PMOP in the present cohort (AUC = 0.93).

CONCLUSION

The incidence of PMOP was closely associated with fecal microbial compositions and intestinal functional changes. The present findings supported potential applications of gut microbiome analysis for early diagnosis of PMOP, and provided potential therapeutic targets.

Cardiovascular outcomes of menopause hormone therapy initiated in women aged ≥60 years or ≥10 years post-menopause: A systematic review of the literature

IntroductionMenopause hormone therapy (MHT) is the most effective treatment for climacteric syndrome. However, its cardiovascular effects remain complex. The 'timing hypothesis' suggests these effects depend on the timing of initiation, but this has been increasingly questioned. This study evaluates evidence on cardiovascular risks associated with late MHT initiation in healthy women aged ≥60 years or ≥10 years post-menopause.MethodsA comprehensive literature search was conducted from the inception of each database until November 2023. The databases searched included PubMed, SciELO, Embase, and Cochrane. RCTs of human studies examining the cardiovascular effects of MHT in healthy women aged ≥60 years or those ≥10 years post-menopause were included. Eligibility screening, data extraction, risk of bias assessment were performed independently and in duplicate.ResultsNine RCTs comprising 36,051 participants were included. We focus on results from participants aged ≥60 years. The mean follow-up was 7.2 years. Six studies were sub-analyses of the Women's Health Initiative (WHI) trial, while three studies originated from other trials. Results from the WHI indicated no significant increase in cardiovascular risks with either CEE + MPA or Estrogen-only therapy. Non-WHI studies showed an elevated stroke risk with tibolone and higher doses of combined MHT, but no cardiovascular complications were observed with low doses.ConclusionThe increased risk of cardiovascular events in our target population is not statistically significant. There is a lack of high-quality evidence to suggest an increased risk of adverse cardiovascular outcomes in healthy women who initiate MHT at age ≥60 years or ≥10 years post-menopause.

Cardiovascular disease and female sexual health across the life span: a bidirectional link

Epidemiological research reveals that around 40 % of women aged 18-59 report significant concerns about their sexual experiences. Endothelial function and proper arterial blood flow through the hypogastric and pudendal arteries are critical in women for a normal vasculogenic response to sexual stimulation. Organic causes of female sexual dysfunction (FSD) often stem from neuropathy or vascular complications linked to cardiovascular risk factors. The relationship between cardiovascular disease (CVD) and FSD is multifactorial, influenced by various factors such as disease severity, physical and physiological factors, social determinants and factors related to medication use. Additionally, the pathophysiological mechanisms implicated in FSD of CVD patients include vascular, physical, psychological and hormonal factors. Hypertension, stroke, and myocardial infarction are closely interrelated with FSD, which is not the case for coronary heart disease, dyslipidemia, and peripheral obstructive artery disease. Hormonal treatment for sexual dysfunction in women with cardiovascular risk factors is discussed, concerning menopausal hormone therapy, tibolone, selective estrogen receptor modulators, vaginal estrogen, prasterone and testosterone therapy. On the other hand, the beneficial effect of sexual activity on cardiovascular health has been gaining supportive evidence. In healthy postmenopausal women aged 45-60, penile-vaginal intercourse has been suggested to positively influence cardiac autonomic functions, as indicated by heart rate variability. However, effectively addressing the challenges of aging and further highlighting the positive impact of sexual activity on cardiac health in selected female populations could significantly enhance life motivation and promote a healthy lifestyle during this stage. The present review elucidates the bidirectional relationship between CVD and female sexual function.

Lipid metabolism in women: A review

The menopausal transition, defined by the cessation of menstruation due to declining ovarian follicular function, results in a marked decrease in endogenous estrogen levels. This phase is associated with significant metabolic changes and a shift towards a more atherogenic lipid profile. Specifically, there are increases in total cholesterol, low-density lipoprotein cholesterol, and triglycerides and unfavorable alterations in high-density lipoprotein cholesterol and lipoprotein(a) levels. These lipid changes, which contribute to an increased risk of atherosclerotic cardiovascular disease, are influenced by diminished estrogen levels and chronological aging. However, the specific mechanisms driving this increased risk are not fully understood. A thorough understanding of these lipid profile alterations is important for developing strategies to reduce cardiovascular disease risk in women. This review provides an overview of how lipid metabolism is affected during the menopausal transition and the resulting implications for cardiovascular risk.

Longitudinal changes of automated volumetric breast density with postmenopausal hormone therapy

OBJECTIVE

To evaluate how volumetric percent density (VPD) changes longitudinally with postmenopausal hormone therapy (HT).

STUDY DESIGN

Medical records of 297 women who visited the outpatient clinic in a tertiary medical center between 2011 and 2019 were retrospectively reviewed. Study participants were postmenopausal hormone never-users (n = 103), estrogen therapy (ET) users (n = 95), and estrogen plus progestogen (EPT) users (n = 99). All hormone users were naïve to HT before the study. VPD was measured at least twice over 3 years, and was measured before and after HT in all hormone users. Longitudinal VPD changes were analyzed using a linear mixed effects model adjusted for age and body mass index (BMI) at index mammography.

RESULTS

The mean age (standard deviation) of study participants at index mammography was 53.0 years (3.3 years). Baseline characteristics, including baseline VPD, were similar across the three groups. After adjustment for age and BMI, the predicted slopes of annual VPD change did not differ among never-users, ET users, and EPT users (-6.8 % (95 % CI -12.1 % to -1.6 %), 0.2 % (95 % CI -4.4 % to 4.8 %), and 0.4 % (95 % CI -5.1 % to 4.3 %), respectively (P = 0.21)). Furthermore, subgroup analyses stratified by estrogen formulation did not demonstrate any difference in the slopes of annual VPD change among never-users, conjugated equine estrogen users, estradiol valerate users, and EPT users (-7.0 %, -1.2 %, 4.9 %, and -0.5 %, respectively; P = 0.27).

CONCLUSION

The predicted annual VPD change did not differ by HT during 3 years of follow-up. Neither ET nor EPT increased VPD.

Cooling the flames: Navigating menopausal vasomotor symptoms with nonhormone medications

PURPOSE

While the gold standard for vasomotor symptoms remains hormone therapy, prescription menopause therapies are significantly underutilized. Nonhormone therapies represent an alternative treatment modality that may improve access to care for patients who cannot or choose not to take hormones. This review aims to update pharmacists on the evidence behind new-to-market fezolinetant and all other nonhormone prescription treatment options for menopausal vasomotor symptoms.

SUMMARY

Prescription nonhormone therapy options for vasomotor symptoms include selective serotonin reuptake inhibitors, including Food and Drug Administration-approved low-dose paroxetine, serotonin-norepinephrine reuptake inhibitors, gabapentin, pregabalin, oxybutynin, and fezolinetant. Evidence supporting the use of these options is summarized in this review. All have an important place in treatment for those unable to take the gold standard of hormone therapy; however, most offer only mild to moderate improvement in symptoms. Fezolinetant has been shown to result in a significant reduction in vasomotor symptom frequency when compared to other nonhormone therapies and was not different when compared to hormone therapies. However, additional studies and efforts to address the affordability of fezolinetant and head-to-head comparisons with other agents are needed.

CONCLUSION

Vasomotor symptoms of menopause can severely impact the health and well-being of individuals. However, treatment of these symptoms is underutilized due to real and perceived drawbacks of therapy. Pharmacists are ideally suited to bridge this gap, but first it is important for pharmacists to be knowledgeable about and comfortable with the evidence supporting all treatment options.

Long-Term Changes to Cardiovascular Biomarkers After Hormone Therapy in the Women's Health Initiative Hormone Therapy Clinical Trials

OBJECTIVE

To assess the long-term changes in cardiovascular biomarkers during the WHI (Women's Health Initiative) hormone therapy (HT) clinical trials of conjugated equine estrogens (CEE) alone and CEE plus medroxyprogesterone acetate (MPA).

METHODS

HT trial participants from the CEE alone (n=1,188, 0.625 mg/d CEE or placebo) and the CEE+MPA (n=1,508, 0.625 mg/d CEE plus continuous 2.5 mg/d MPA or placebo) trials provided blood samples at baseline and after 1, 3, and 6 years. Low-density lipoprotein cholesterol (LDL-C; primary endpoint), high-density lipoprotein cholesterol (HDL-C), triglycerides, total cholesterol, lipoprotein(a), glucose, insulin, and homeostatic model assessment for insulin resistance were measured. Repeated-measures regression models estimated the geometric means of each log-transformed biomarker by restricted maximum likelihood. A constant treatment effect across visits was used to estimate the overall effect, expressed as a ratio of geometric means, and was complemented with geometric means (95% CIs) by randomization group and corresponding ratios of geometric means (95% CI; HT vs placebo) at each visit.

RESULTS

During the intervention phase of the CEE-alone trial, randomization to CEE reduced LDL-C by 11% over 6 years (ratio of geometric means 0.89, 95% CI, 0.88-0.91, P <.001). The overall reduction in LDL-C was similar for CEE+MPA relative to placebo (ratio of geometric means 0.88, 95% CI, 0.86-0.89, P <.001). Relative to placebo, HDL-C and triglycerides were 13.0% and 7.0% higher with CEE and CEE+MPA, respectively. The homeostatic model assessment for insulin resistance decreased by 14.0% and 8.0% for CEE-alone and CEE+MPA trial participants, respectively. Relative to placebo, lipoprotein(a) decreased by 15.0% and 20.0% for participants randomized to CEE alone and CEE+MPA, respectively.

CONCLUSION

Lipoprotein(a), LDL-C, and homeostatic model assessment for insulin resistance were lower and HDL-C levels were higher for HT compared with placebo. Triglycerides increased in both the CEE and CEE+MPA trials, however. Future research should assess whether other progestogens attenuate the effect of estrogen on HDL-C. These results may be used to counsel younger menopausal women with bothersome symptoms who are deciding whether to initiate oral HT within the context of published effects of oral HT on rates of cardiovascular events.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT00000611.

Pendulums in medical practice

Medicine is taught as a science, but in reality, as with other areas that undergo much public scrutiny, it is often more of an art than a science. Particularly when dealing with controversial areas, physicians often attempt to employ the "standard of care" as a guide to practising medicine, and to protect themselves. However, the standard of care itself is often a reactive and temporary construct. A number of practices serve as good examples of accepted patient care that has swung completely from one extreme to another. The history of opiate prescribing in this country exemplifies a complete swing in practice fundamentals among US physicians, where opiates have been repeatedly embraced, and then vilified. Numerous other practices demonstrating this phenomenon can be cited, including the use of electroconvulsive therapy for depression, and hormone replacement for postmenopausal women. Research funding itself has been subject to pendulum swings, such as occurred during the recent pandemic. Currently, there are a number of similar, very active issues of debate, such as marijuana for widespread medical use, and the employment of hallucinogens for addiction and other mental health disorders. Considerable harm has occurred to some patients when extremes of these pendulum swings have impacted their medical care. It is urged that in practising medicine, physicians consider the entire body of medical evidence accumulated during these pendulum swings, and then have the courage and wisdom to represent the best interests of their patients.

A multi-metabolite signature robustly predicts long-term mortality in the PREDIMED trial and several US cohorts

Metabolome-based biomarkers contribute to identify mechanisms of disease and to a better understanding of overall mortality. In a long-term follow-up subsample (n = 1878) of the PREDIMED trial, among 337 candidate baseline plasma metabolites repeatedly assessed at baseline and after 1 year, 38 plasma metabolites were identified as predictors of all-cause mortality. Gamma-amino-butyric acid (GABA), homoarginine, serine, creatine, 1-methylnicotinamide and a set of sphingomyelins, plasmalogens, phosphatidylethanolamines and cholesterol esters were inversely associated with all-cause mortality, whereas plasma dimethylguanidino valeric acid (DMGV), choline, short and long-chain acylcarnitines, 4-acetamidobutanoate, pseudouridine, 7-methylguanine, N6-acetyllysine, phenylacetylglutamine and creatinine were associated with higher mortality. The multi-metabolite signature created as a linear combination of these selected metabolites, also showed a strong association with all-cause mortality using plasma samples collected at 1-year follow-up in PREDIMED. This association was subsequently confirmed in 4 independent American cohorts, validating the signature as a consistent predictor of all-cause mortality across diverse populations.

Insights into Perimenopause: A Survey of Perceptions, Opinions on Treatment, and Potential Approaches

Perimenopause, the transitional phase leading up to menopause, affects millions of women worldwide, yet it remains poorly understood and under-addressed in healthcare. Despite the availability of treatment options like hormone replacement therapy (HRT) and non-hormonal alternatives, the awareness and utilization of these options vary significantly among women. Here, we conducted a cross-sectional survey with 1000 adults, both men and women, from the United States and Canada. We evaluated the perceived familiarity of participants with the timing, duration, and symptoms of perimenopause, as well as their satisfaction with their treatment options and communication with their healthcare providers. We found that, in general, women and older people were more likely to feel familiar with perimenopause, although the youngest age group surveyed also reported relatively high familiarity. We also found that there is a disconnect between people reporting high familiarity with perimenopause and its symptoms but overall middling and lower familiarity with the age and duration of onset and satisfaction with treatment options. Our results suggest further investigation into where people obtain their information concerning perimenopause, as well as into how knowledge of perimenopause may vary based on demographics.

Prevalence and predictors of bone mineral density testing after distal radius fracture in menopausal women

BACKGROUND

Osteoporosis screening guidelines recommend bone mineral density (BMD) testing following fragility fractures. Nevertheless, previous studies have demonstrated low rates of osteoporosis screening. Diagnosis and treatment of osteoporosis is essential for prevention of future fractures, however not much is known about the factors associated with receiving BMD testing in this patient population. The purpose of this study was to evaluate the prevalence, timing, and predictors of BMD testing following distal radius fractures (DRF) in menopausal women.

METHODS

We queried a national insurance database to identify menopausal women aged 45-64 years with a DRF between years 2013 and 2020. The rate of BMD testing within 1 year of injury was calculated. Multivariable logistic regression analysis was used to evaluate the effect of patient- and injury-related variables on the likelihood of undergoing BMD testing following DRF.

RESULTS

Among 31,728 patients meeting inclusion criteria (mean ± SD age: 57.5 ± 4.3), 3,886 (12.2 %) received a BMD test within 1 year following DRF. The rate of BMD tests decreased with the highest rate of 14.5 % in 2015 and the lowest rate of 10.5 % in 2020. Mean time from DRF to BMD testing was 143 ± 102 days. Patients aged 60-64 had the highest adjusted odds of receiving BMD testing (OR 2.85 [95 % CI: 2.26 to 3.64]). Factors associated with increased likelihood of BMD testing included surgical intervention (OR 1.38 [1.28-1.48]), rheumatoid arthritis (OR 1.22 [1.06-1.40]), osteoarthritis (OR 1.28 [1.19-1.37]), breast cancer (OR 1.35 [1.16-1.56]), and vitamin D deficiency (OR 1.29 [1.17-1.43]). Factors associated with decreased likelihood of testing included tobacco use (OR 0.90 [0.84-0.97]), patients with Medicaid (OR 0.73 [0.61-0.86]) or Medicare (OR 0.76 [0.65-0.88]) insurance, and living in Southern (OR 0.67 [0.62-0.73]) or Western (OR 0.69 [0.62-0.77]) regions of the United States. Obesity, diabetes, renal disease, and early menopause were not associated with BMD testing.

CONCLUSIONS

Despite guidelines recommending BMD testing after low-energy fractures, rates of BMD testing were low and decreased among menopausal women with DRF. Mean time to BMD testing was 4.7 months, indicating substantial delays in workup. Known risk factors for osteoporosis did not reliably predict likelihood of BMD testing.

LEVEL OF EVIDENCE

Level III, prognostic.

Updates in Hormone Replacement Therapy for Survivors of Gynecologic Cancers

OPINION STATEMENT

Symptoms of menopause and the sequelae of gynecologic cancer treatment can be severe in their physical and mental impact on patient quality of life. Survivors of certain gynecologic cancers - namely, early-stage, low-grade endometrial cancers; epithelial and germ cell ovarian cancers; and early-stage squamous cell cervical, vulvar, and vaginal cancers - as well as those who have undergone risk-reducing surgery for BRCA or Lynch syndrome mutations may safely use hormone replacement therapy (HRT). Treatment is ideally initiated in patients younger than age 60 or within ten years of menopause. The decision to start treatment should be made on an individualized basis after discussion of risks, benefits, and symptom severity with patients. Data suggest that the safest HRT regimens in this population include low-dose vaginal estrogen for the treatment of vulvovaginal symptoms, or low-dose systemic estrogen for the treatment of vasomotor symptoms, combined with progesterone in patients with an intact uterus. Therapies such as SSRIs/SNRIs, vaginal moisturizers, pelvic floor physical therapy, and psychosocial counseling should also be considered when appropriate for their effectiveness in managing menopausal symptoms without the potential risk of hormones.

Estrogens and breast cancer

Estrogens have been associated with an increase in breast cancer risk. Yet emerging clinical and experimental evidence points to progestogens [endogenous progesterone or synthetic progesterone (progestin)] as the primary hormonal driver underlying seemingly estrogen-associated breast cancer risk. Estrogens may contribute to breast cancer risk indirectly by induction of the progesterone receptor and thus amplifying progesterone signaling. Large studies of hormonal contraceptives suggest that the small increase in breast cancer risk from hormonal contraceptives is mainly attributable to progestins, not estrogens. Estrogen-plus-progestin hormone replacement therapy (HRT) has consistently shown an increase in breast cancer risk among postmenopausal women, whereas estrogen-alone HRT has little impact on breast cancer risk in naturally or surgically menopausal women. In particular, the long-term follow-up of the Women's Health Initiative (WHI) randomized trials suggests a benefit of estrogen alone. Recent data further indicate that endogenously elevated estrogen during assisted reproductive technology (ART) exhibits little adverse effect on or potentially a reduction in breast cancer risk and recurrence. Also, accumulating evidence suggests that inhibition of progesterone signaling is a critical mechanism underlying the risk-reducing and therapeutic effects of antiestrogens. Estrogen HRT has shown an array of proven benefits, including ameliorating menopausal symptoms and improving bone health. Collective evidence thus suggests that estrogen HRT is likely to offer health benefits to perimenopausal or postmenopausal women, including breast cancer survivors, as well as young BRCA1/2 carriers with prophylactic oophorectomy for ovarian cancer prevention.

Current and emerging bone resorption inhibitors for the treatment of osteoporosis

INTRODUCTION

Osteoporosis is a metabolic skeletal disease characterized by low bone mass and strength, and increased risk for fragility fractures. It is a major health issue in aging populations, due to fracture-associated increased disability and mortality. Antiresorptive treatments are first line choices in most of the cases.

AREAS COVERED

Bone homeostasis is complicated, and multiple factors can compromise skeletal health. Bone turnover is a continuous process regulated by the coupled activities of bone cells that preserves skeletal strength and integrity. Imbalance between bone resorption and formation leads to bone loss and increased susceptibility to fractures. Antiresorptives prevent bone loss and reduce fracture risk, by targeting osteoclastogenesis and osteoclast function and survival. Their major drawback is the coupling of osteoclast and osteoblast activity, due to which any reduction in bone resorption is followed by suppression of bone formation.

EXPERT OPINION

During the last couple of decades significant progress has been made in understanding of the genetic and molecular basis of osteoporosis. Critical pathways and key molecules that mediate regulation of bone resorption have been identified. These factors may underpin novel therapeutic avenues for osteoporosis, but their potential for translation into clinical applications is yet to be tested.

Vascular health and exercise in females throughout the lifespan: Exploring puberty, pregnancy and menopause

This narrative review highlights the impact of exercise on vascular health in females over the lifespan with an emphasis on puberty, pregnancy and menopause. These events encompass substantial changes in sex hormone levels, particularly oestrogens and progesterone. They are also accompanied by distinct adaptations of the central, peripheral and cerebral vasculature. Regular exercise is an effective mechanism to reduce vascular risk in females of all ages, especially for those at higher risk for vascular disorders. However, there are large variabilities in the vascular adaptations to exercise in females that may be related to circulating sex hormone levels. In addition, exogenous hormones, such as oral contraceptives taken after puberty or hormonal replacement therapy taken to mitigate symptoms of menopause, may interact with exercise-induced changes in vascular function. We highlight how more research is needed to understand the optimal exercise interventions to promote vascular health in females across the lifespan, especially during times of hormonal transition.

Update on Menopause Hormone Therapy; Current Indications and Unanswered Questions

OBJECTIVE

To provide clinicians involved in managing menopause with a summary of current evidence surrounding menopause hormone therapy (MHT).

DESIGN

The authors evaluate and synthesize existing pooled evidence relating to MHT's clinical indications, efficacy, and safety and explore the limitations of existing data.

PATIENTS

The review focuses on MHT-related outcomes in women with natural-timed menopause captured within observational studies, RCTs, and pooled data from pivotal meta-analyses and reviews.

MEASUREMENTS

Available published data are scrutinized. Available evidence and notably lacking data from women not adequately represented in published MHT trials, such as those with socioeconomic adversity, significant comorbidities, and minority ethnic backgrounds, are highlighted and deliberated.

RESULTS

The impact of MHT differs significantly between demographics. Current consensus recommendations for MHT emphasize the importance of tailoring type, route, dose, and duration of therapy to individual needs and risk/benefit ratio through shared decision-making. MHT impact can change over time. Current MHT data support its benefits for treating menopause symptoms and a potential window of opportunity in midlife to benefit skeletal health. Limitations of current evidence highlight menopause health inequalities and underscores the need for further research.

CONCLUSIONS

This review recommends tailored use of MHT for well-defined indications, recognizing its value for menopause symptom relief and skeletal benefits for many midlife women. MHT may be used as long as benefits outweigh risks, through shared decision-making. There is insufficient clinical evidence to support the long-term use of MHT in some contemporary cohorts of women accessing MHT in clinical practice.

Is it time to revisit the recommendations for initiation of menopausal hormone therapy?

Findings from the Women's Health Initiative studies led to menopausal hormone therapy (MHT) guidelines generally recommending the initiation of MHT be limited to women within 10 years of their menopause or before the age of 60 years. This recommendation has led to women who experience troublesome menopausal symptoms and who have not commenced MHT within these limits often being denied this type of therapy. Similarly, the majority of women who might benefit from the protective effects of MHT against bone loss and fracture are not offered this treatment option if they do not fit with these criteria. Based on review of the evidence that led to the conditional initiation of MHT, and subsequent studies, we propose that the recommendations regarding the initiation of MHT need to change to be more inclusive of women outside these chronological limits.

Unique cardiometabolic factors in women that contribute to modified cardiovascular disease risk

Major risk factors of cardiovascular disease (CVD) include hypertension, obesity, diabetes mellitus and metabolic syndrome; all of which are considered inflammatory conditions. Women are disproportionately affected by inflammatory conditions, with sex differences emerging as early as adolescence. Hormonal fluctuations associated with reproductive events such as menarche, pregnancy and menopause, are hypothesized to promote a pro-inflammatory state in women. Moreover, women who have experienced inflammatory-type conditions such as polycystic ovarian syndrome (PCOS), gestational diabetes or pre-eclampsia, have a cardiometabolic phenotype that pre-disposes to increased risk of myocardial infarction, stroke and coronary heart disease. Women with no notable CVD risk factors are often relatively protected from CVD pre-menopause; but overtake men in risk of major cardiovascular events when the cardiovascular protective effects of oestrogen begin to wane. Sex differences and female-specific factors have long been considered challenging to study and this has led to an underrepresentation of females in clinical trials and lack of female-specific data from pre-clinical studies. However, there is now a clear prerogative to include females at all stages of research, despite inherent complexities and potential variability in data. This review explores recent advancements in our understanding of CVD in women. We summarise the underlying factors unique to women that can promote CVD risk factors, ultimately contributing to CVD burden and the emerging therapies aimed to combat this.

Association of insurance type with unmet need for menopause care in Oregon

OBJECTIVE

To determine unmet need for menopause care in Oregon and evaluate if insurance type is associated with receipt of care.

METHODS

We conducted a cross-sectional survey of patients using an Oregon Listserv. Our primary outcome was use of medication for the treatment of moderate or severe symptoms of menopause. We used the Menopause Rating Scale to evaluate respondents' symptoms: 0-4 none or little symptoms; 5-8 mild symptoms; 9-16 moderate symptoms; and 17+ severe symptoms. We abstracted demographic and clinical information including age, rurality, race, ethnicity, primary language, and insurance type. We used a regression model to determine the association between public insurance and treatment for moderate to severe menopause symptoms. We examined reasons for nonuse of therapy.

RESULTS

Our sample included 845 perimenopausal or postmenopausal individuals who were predominantly White (93.0%), aged 45-49 (32.8%) or 50-54 years (39.1%), and privately insured (81.3%). Overall, 62.4% of individuals with moderate and severe symptoms of menopause were not receiving any therapy. After adjustment for age and rurality, public insurance was associated with an average of 47% increased odds of nontreatment for moderate or severe menopause symptoms (adjusted odds ratio: 1.47, 95% CI: 0.99-2.19). The most common reasons for nontreatment in both groups were "therapy was not recommended by a provider" (43%) and worries about safety or side effects (40%).

CONCLUSIONS

Even in well-insured persons, the majority of people with moderate and severe symptoms of menopause are not receiving treatment. People who are publicly insured are more likely to go untreated than privately insured individuals.

Core Concepts in Pharmacoepidemiology: New-User Designs

In this article, we review the history and key reasons for new-user comparisons in pharmacoepidemiology, highlighting the target trial framework as a unifying framework. We describe three distinct pharmacoepidemiological new-user study designs: (1) new-user versus non-user; (2) active comparator new-user; (i.e., ACNU) and (3) prevalent new-user (i.e., PNU) designs, and discuss how each relates to key issues of defining time zero, choosing appropriate comparator groups, and potential sources of bias they do and do not account for. We use a clinical example of hormone replacement therapy and the risk of coronary heart disease to illustrate practical considerations surrounding the application of the three designs presented.

Helper T cells: A potential target for sex hormones to ameliorate rheumatoid arthritis? (Review)

Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease whose etiology is not fully understood. Defective peripheral immune tolerance and subsequent mis‑differentiation and aberrant infiltration of synovium by various immune cells, especially helper T (Th) cells, play an important role in the development of RA. There are significant sex differences in RA, but the results of studies on the effects of sex hormones on RA have been difficult to standardize and hormone replacement therapy has been limited by the potential for serious side effects. Existing research has amply demonstrated that cellular immune responses are largely determined by sex and that sex hormones play a key role in Th cell responses. Based on the aforementioned background and the plasticity of Th cells, it is reasonable to hypothesize that the action of sex hormones on Th cells will hopefully become a therapeutic target for RA. The present review discussed the role of various Th cell subsets in the pathogenesis of RA and also explored the role of sex hormones on the phenotype and function of these aberrantly regulated immune cells in RA as well as other pathologic effects on RA.

Hormone therapy and venous thromboembolism risk in women of menopausal age: a target trial emulation

Contemporary data from randomized clinical trials focusing on the effect of oral hormone therapy (HT) on venous thromboembolism (VTE) in women aged 50-60 years are scarce despite evolving HT regimens. Here, we evaluated the association between HT and the risk of developing VTE using a target trial emulation among women of menopausal age. This retrospective cohort study applied a target trial emulation framework using claims data from a universal health insurance program in Taiwan. We emulated a sequence of trials in which women aged 50-60 years with no previous history of HT, hysterectomy, gynecologic disorders, or cardiovascular events were enrolled. Eligibility and HT use were evaluated monthly from 2011 to 2019. Eligible women were classified as either HT initiators or non-initiators for each consecutive month. Observational analogs of the intention-to-treat and per-protocol effects were estimated using pooled logistic regression models. Of the 150,686,148 eligible person-trials (3,001,112 women), 192,215 initiators and 768,860 propensity score-matched non-initiators were included in the analysis. The average duration of the HT was 1.25 years. Over a median follow-up of 5.83 years, 3,334 women developed VTE. The estimated hazard ratio (95% confidence interval) was 0.96 (0.88, 1.04) in the intention-to-treat analysis and 0.66 (0.41, 1.05) in per-protocol analysis. The estimated intention-to-treat and per-protocol 5-year VTE-free survival differences (95% confidence interval) were 0.1‰ (- 0.3‰, 0.7‰) and 0.3‰ (- 2.8‰, 4.0‰), respectively. In the contemporary clinical setting, we did not observe an increased VTE risk associated with HT in women aged 50-60 years.

Does menopause hormone therapy prevent Alzheimer's disease and dementia?

Commentary on: Nerattini M, Jett S, Andy C, et al Systematic review and meta-analysis of the effects of menopause hormone therapy on risk of Alzheimer's disease and dementia. Front Aging Neurosci. 2023;15:1260427. Series Editor: Dr Teck Khong, DTB Associate Editor, Clinical Pharmacology, St George's,University of London, UK.

Jun modulates endoplasmic reticulum stress-associated ferroptosis in dorsal root ganglia neurons during neuropathic pain by regulating Timp1

Neuropathic pain (NP) is a complex disorder caused by lesions or diseases affecting the somatosensory nervous system, severely impacting patients' quality of life. Recent studies suggest ferroptosis may be involved in NP induction, but its precise mechanisms remain unclear. We used GO and KEGG pathway enrichment analyses to functionally annotate ferroptosis-related differentially expressed genes (FRDs). Through STRING and the maximum cluster centrality (MCC) algorithm, we identified five hub FRDs (Jun, Timp1, Egfr, Cdkn1a, Cdkn2a). Single-cell analysis revealed significant expression of Jun and Timp1 in neurons. Our study confirmed the association between ferroptosis and endoplasmic reticulum stress (ERS) in NP and validated changes in hub FRD expression across various NP animal models. In vitro experiments demonstrated that Jun regulates neuronal ferroptosis and ERS, particularly by modulating Timp1 expression. Transcription factor prediction and JASPAR binding site analysis elucidated the regulatory network involving Jun. ROC curve analysis of external datasets highlighted the diagnostic potential of hub FRDs and ERS-related differentially expressed genes (ERSRDs) in NP. Using the Comparative Toxicogenomics Database (CTD), we identified estradiol (E2) as a potential therapeutic drug targeting hub FRDs and ERSRDs. Molecular docking predicted its binding sites with Jun and Timp1, and in vivo experiments confirmed that E2 alleviated NP and reversed the expression of Jun and Timp1. This study underscores the crucial role of Jun and Timp1 in the interplay between ferroptosis and ERS, offering new insights and promising avenues for NP treatment.

Proteomic Analysis Reveals Major Proteins and Pathways That Mediate the Effect of 17-β-Estradiol in Cell Division and Apoptosis in Breast Cancer MCF7 Cells

Despite extensive research, the genes/proteins and pathways responsible for the physiological effects of estrogen remain elusive. In this study, we determined the effect of estrogen on global protein expression in breast cancer MCF7 cells using a proteomic method. The expression of 77 cytosolic, 74 nuclear, and 81 membrane/organelle proteins was significantly altered by 17-β-estradiol (E2). Protein enrichment analyses suggest that E2 may stimulate cell division primarily by promoting the G1 to S phase transition and advancing the G2/M checkpoint. The effect of E2 on cell survival was complex, as it could simultaneously enhance and inhibit apoptosis. Bioinformatics analysis suggests that E2 may enhance apoptosis by promoting the accumulation of the pore-forming protein Bax in the mitochondria and inhibit apoptosis by activating the PI3K/AKT/mTOR signaling pathway. We verified the activation of the PI3K signaling and the accumulation of Bax in the membrane/organelle fraction in E2-treated cells using immunoblotting. Treatment of MCF7 cells with E2 and the PI3K inhibitor Ly294002 significantly enhanced apoptosis compared to those treated with E2 alone, suggesting that combining estrogen with a PI3K inhibitor could be a promising strategy for treating ERα-positive breast cancer. Interestingly, many of the E2-upregulated proteins contained the HEAT, KH, and RRM domains.

Diet and Chronic Disease Research in the Women's Health Initiative

The Women's Health Initiative (WHI) has been a major contributor to diet and chronic disease research among postmenopausal US women over its 30+ year history (1993 to present). The WHI program included full-scale randomized trials of a low-fat dietary pattern high in fruits, vegetables, and grains, and of calcium and vitamin D supplementation, each with designated primary and secondary chronic disease outcomes. The history of these trials will be briefly reviewed here, along with principal findings that included evidence for breast cancer-related benefits for each of the 2 interventions. In recent years, WHI investigators have developed an active research program in nutritional biomarker development and in the application of these biomarkers in WHI cohorts, among various other nutritional epidemiology uses of WHI observational study resources. The intake biomarker work, which primarily relies on blood and urine metabolomics profiles, lends support to the low-fat dietary pattern trial results, and supports chronic disease benefits of higher carbohydrate diets more generally, especially through the fiber component of carbohydrate.

Site-specific O-GlcNAcylation of progesterone receptor (PR) supports PR attenuation of interferon stimulated genes (ISGs) and tumor growth in breast cancer

Hormone receptor positive (HR+) breast cancer, defined by expression of estrogen receptor (ER) and/or progesterone receptor (PR), is the most commonly diagnosed type of breast cancer. PR alters the transcriptional landscape to support tumor growth in concert with, or independent of, ER. Understanding the mechanisms regulating PR function is critical to developing new strategies to treat HR+ breast cancer. O-linked β-N-acetylglucosamine (O-GlcNAc) is a posttranslational modification responsible for nutrient sensing that modulates protein function. Although PR is heavily posttranslationally modified, through both phosphorylation and O-GlcNAcylation, specific sites of O-GlcNAcylation on PR and how they regulate PR action have not been investigated. Using established PR-expressing breast cancer cell lines, we mapped several sites of O-GlcNAcylation on PR. RNA-sequencing after PR O-GlcNAc site mutagenesis revealed site-specific O-GlcNAcylation of PR is critical for ligand-independent suppression of interferon signaling, a regulatory function of PR in breast cancer. Furthermore, O-GlcNAcylation of PR enhances PR-driven tumor growth in vivo. Herein, we have delineated one contributing mechanism to PR function in breast cancer that impacts tumor growth and provided additional insight into the mechanism through which PR attenuates interferon signaling.

Proteomic analysis of APOEε4 carriers implicates lipid metabolism, complement and lymphocyte signaling in cognitive resilience

BACKGROUND

Apolipoprotein E (APOE) ε4 allele is the strongest genetic risk factor for late onset Alzheimer's disease (AD). This case-cohort study used targeted plasma biomarkers and large-scale proteomics to examine the biological mechanisms that allow some APOEε4 carriers to maintain normal cognitive functioning in older adulthood.

METHODS

APOEε4 carriers and APOEε3 homozygotes enrolled in the Women's Health Initiative Memory Study (WHIMS) from 1996 to 1999 were classified as resilient if they remained cognitively unimpaired beyond age 80, and as non-resilient if they developed cognitive impairment before or at age 80. AD pathology (Aß42/40) and neurodegeneration (NfL, tau) biomarkers, as well as 1007 proteins (Olink) were quantified in blood collected at study enrollment (on average 14 years prior) when participants were cognitively normal. We identified plasma proteins that distinguished between resilient and non-resilient APOEε4 carriers, examined whether these associations generalized to APOEε3 homozygotes, and replicated these findings in the UK Biobank.

RESULTS

A total of 1610 participants were included (baseline age: 71.3 [3.8 SD] years; all White; 42% APOEε4 carriers). Compared to resilient APOEε4 carriers, non-resilient APOEε4 carriers had lower Aß42/40/tau ratio and greater NfL at baseline. Proteomic analyses identified four proteins differentially expressed between resilient and non-resilient APOEε4 carriers at an FDR-corrected P < 0.05. While one of the candidate proteins, a marker of neuronal injury (NfL), also distinguished resilient from non-resilient APOEε3 homozygotes, the other three proteins, known to be involved in lipid metabolism (ANGPTL4) and immune signaling (PTX3, NCR1), only predicted resilient vs. non-resilient status among APOEε4 carriers (protein*genotype interaction-P < 0.05). Three of these four proteins also predicted 14-year dementia risk among APOEε4 carriers in the UK Biobank validation sample (N = 9420). While the candidate proteins showed little to no association with targeted biomarkers of AD pathology, protein network and enrichment analyses suggested that natural killer (NK) cell and T lymphocyte signaling (via PKC-θ) distinguished resilient from non-resilient APOEε4 carriers.

CONCLUSIONS

We identified and replicated a plasma proteomic signature associated with cognitive resilience among APOEε4 carriers. These proteins implicate specific immune processes in the preservation of cognitive status despite elevated genetic risk for AD. Future studies in diverse cohorts will be needed to assess the generalizability of these results.

Navigating Hormone Therapy in Postmenopausal Women: Balancing Symptom Relief With Cancer Risk

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

Menopausal Hormone Therapy and Ovarian and Endometrial Cancers: Long-Term Follow-Up of the Women's Health Initiative Randomized Trials

PURPOSE

Menopausal hormone therapy's influence on ovarian and endometrial cancers remains unsettled. Therefore, we assessed the long-term influence of conjugated equine estrogen (CEE) plus medroxyprogesterone acetate (MPA) and CEE-alone on ovarian and endometrial cancer incidence and mortality in the Women's Health Initiative randomized, placebo-controlled clinical trials.

MATERIALS AND METHODS

Postmenopausal women, age 50-79 years, were entered on two randomized clinical trials evaluating different menopausal hormone therapy regimens. In 16,608 women with a uterus, 8,506 were randomly assigned to once daily 0.625 mg of CEE plus 2.5 mg once daily of MPA and 8,102 placebo. In 10,739 women with previous hysterectomy, 5,310 were randomly assigned to once daily 0.625 mg of CEE-alone and 5,429 placebo. Intervention was stopped for cause before planned 8.5-year intervention after 5.6 years (CEE plus MPA) and after 7.2 years (CEE-alone). Outcomes include incidence and mortality from ovarian and endometrial cancers and deaths after these cancers.

RESULTS

After 20-year follow-up, CEE-alone, versus placebo, significantly increased ovarian cancer incidence (35 cases [0.041%] v 17 [0.020%]; hazard ratio [HR], 2.04 [95% CI, 1.14 to 3.65]; P = .014) and ovarian cancer mortality (P = .006). By contrast, CEE plus MPA, versus placebo, did not increase ovarian cancer incidence (75 cases [0.051%] v 63 [0.045%]; HR, 1.14 [95% CI, 0.82 to 1.59]; P = .44) or ovarian cancer mortality but did significantly lower endometrial cancer incidence (106 cases [0.073%] v 140 [0.10%]; HR, 0.72 [95% CI, 0.56 to 0.92]; P = .01).

CONCLUSION

In randomized clinical trials, CEE-alone increased ovarian cancer incidence and ovarian cancer mortality, while CEE plus MPA did not. By contrast, CEE plus MPA significantly reduced endometrial cancer incidence.

Estrogen Plus Progestin and Colorectal Cancer: Long-Term Findings From the Women's Health Initiative Randomized Clinical Trial

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.We report long-term colorectal cancer findings from the Women's Health Initiative trial where 16,608 postmenopausal women with a uterus were randomly assigned to daily conjugated equine estrogen (CEE) 0.625 mg, plus medroxyprogesterone acetate (MPA) 2.5 mg, or placebo. When intervention ended after 5.6 years, although there were 44% fewer colorectal cancers in the intervention group (43 v 72, P = .003), the cancers were more commonly lymph node-positive (59.0% v 29.4%, P = .003). Now after cumulative 24-year follow-up, with 431 colorectal cancers, CEE plus MPA no longer influenced colorectal cancer incidence (215 [0.15, annualized rate %] v 216 [0.15], hazard ratio [HR], 0.95 [95% CI, 0.79 to 1.15]). Although not statistically significant, there were more colorectal cancer deaths with CEE plus MPA (87 [0.049] v 69 [0.041] deaths, HR, 1.20 [95% CI, 0.87 to 1.65], P = .26). Vaginal bleeding (54.1% v 5.2% at 6 months) and breast changes were more frequent in the intervention group. After adjusting for postrandomization vaginal bleeding and breast changes, bowel examinations were significantly delayed in intervention group participants (P = .005), potentially contributing to diagnostic delay. Taken together, the findings suggest no clinically meaningful benefit for about 5 years of CEE plus MPA use on colorectal cancer outcome.

Real-World Effectiveness of Menopausal Hormone Therapy in Preventing Relapse in Women With Schizophrenia or Schizoaffective Disorder

OBJECTIVE

Antipsychotic effectiveness in preventing relapse declines around menopausal age in women with schizophrenia or schizoaffective disorder (SSD). It is not known whether systemic menopausal hormone therapy (MHT) can help to prevent psychosis relapse.

METHODS

A within-subject study design was used to study the effectiveness of MHT in preventing relapse in a Finnish nationwide cohort of women with SSD between 40 and 62 years of age who used MHT during follow-up (1994-2017). Hazard ratios adjusted for age and psychotropic drug use were calculated for psychosis relapse as main outcome and any psychiatric hospitalization as secondary outcome.

RESULTS

The study population comprised 3,488 women using MHT. Use of MHT was associated with a 16% lower relapse risk (adjusted hazard ratio [aHR]=0.84, 95% CI=0.78-0.90) when compared to non-use. Stratified by age, MHT was associated with decreased relapse risks when used between ages 40-49 (aHR=0.86, 95% CI=0.78-0.95) and ages 50-55 (aHR=0.74, 95% CI=0.66-0.83), but not between ages 56-62 (aHR=1.11, 95% CI=0.91-1.37). Similar effectiveness was found for estrogen alone or combined with fixed or sequential progestogens (aHRs between 0.79 and 0.86), transdermal and oral formulations (aHRs 0.75-0.87), and for most specific formulations (aHRs 0.75-0.85), except tibolone (aHR=1.04, 95% CI=0.75-1.44) and formulations with dydrogesterone (aHR=1.05, 95% CI=0.85-1.30). Similar results were observed with any psychiatric hospitalization as outcome measure.

CONCLUSIONS

The findings underscore the potential value of MHT in preventing psychosis relapse among women with SSD of menopausal age. These findings translate clinical evidence on the neuroprotective effects of estrogens to real-world settings, encompassing a group of women for whom current antipsychotic treatment options may be insufficient.

The risk of endocrine interventions in carriers of a genetic predisposition for breast and gynecologic cancers: recommendations of the German Consortium for Hereditary Breast and Ovarian Cancer

PURPOSE

To support doctors in counselling women with genetic predisposition for breast or gynecologic cancers on endocrine interventions.

METHODS

Evidence on the safety of endocrine interventions for fertility treatment, contraception, hormone replacement therapy after risk-reducing salpingo-oophorectomy (RRSO) or treatment of symptoms during peri- and postmenopause was analysed for carriers of probably pathogenic and pathogenic variants in BRCA1 or BRCA2 (BRCA1/2-pV), in other breast and ovarian cancer genes and the Lynch Syndrome. Cancer risks were compared with data on risks for the general population.

RESULTS

Data on risk modulation of endocrine interventions in women with genetic predisposition is limited. Ovarian hyperstimulation for fertility treatment may be performed. Oral contraceptives should not be used to reduce ovarian cancer risk in BRCA1/2-pV carriers. Premenopausal BRCA1/2-pV carriers and carriers of pV in Lynch Syndrome genes should be offered hormone replacement therapy (HRT) after RRSO, to prevent diseases caused by estrogen deficiency.

CONCLUSION

Effect direction and strength of risk modulation by endocrine interventions is similar to the general population. Participation of individuals at risk in prospective registries is recommended.

Estrogen Regulated Genes Compel Apoptosis in Breast Cancer Cells, Whilst Stimulate Antitumor Activity in Peritumoral Immune Cells in a Janus-Faced Manner

Background: Breast cancer incidence and mortality exhibit a rising trend globally among both premenopausal and postmenopausal women, suggesting that there are serious errors in our preventive and therapeutic measures. Purpose: Providing a series of valuable, but misunderstood inventions highlighting the role of increasing estrogen signaling in prevention and therapy of breast cancer instead of its inhibition. Results: 1. Breast cells and breast cancer cells with germline BRCA1/2 mutations similarly show defects in liganded estrogen receptor (ER) signaling, demonstrating its role in genomic instability and cancer initiation. 2. In breast tumors, the increased expression of special receptor family maybe an effort for self-directed improvement of genomic defects, while the weakness or loss of receptors indicates a defect requiring medical repair. 3. ER overexpression in breast cancer cells is capable of strengthening estrogen signaling and DNA repair, while in ER negative tumors, HER2 overexpression tries to upregulate unliganded ER activation and genome stabilization. 4. ER-positive breast cancers responsive to endocrine therapy may show a compensatory ER overexpression resulting in a transient tumor response. Breast cancers non-responsive to antiestrogen treatment exhibit HER2-overexpression for compensating the complete inhibition of hormonal ER activation. 5. In breast tumors, somatic mutations serve upregulation of ER activation via liganded or unliganded pathway helping genome stabilization and apoptotic death. 6. The mutual communication between breast cancer and its inflammatory environment is a wonderful partnership among cells fighting for genome stabilization and apoptotic death of tumor. 7. In breast cancers, there is no resistance to genotoxic or immune blocker therapies, but rather, the nonresponsive tumor cells exhaust all compensatory possibilities against therapeutic damages. Conclusions: Understanding the behavior and ambition of breast cancer cells may achieve a turn in therapy via applying supportive care instead of genotoxic measures.

Clinical Management of Endometriosis in Menopause: A Narrative Review

Endometriosis, an inflammatory disease primarily affecting the pelvis and peritoneum, manifests with pelvic pain, dysmenorrhea, dyschezia, dyspareunia, and infertility. Despite its ubiquity, the management of endometriosis is challenging due to its heterogeneous presentation, limitations in diagnostic methods, variable therapeutic responses, and personal and socio-cultural impact on quality of life. This review attempts to consolidate the current literature on endometriosis occurring during and beyond menopause, and to present details regarding management strategies that take into account individual outcomes and goals when managing this condition. The topics included in this review are the clinical features and differential diagnosis of pelvic pain in postmenopausal patients, imaging considerations, serum and laboratory biomarkers, indications for surgery, the principles of hormone replacement therapy, the de novo development of endometriosis after menopause, and malignant transformation. Each topic includes a summary of the current literature, utilizing clinical research, case reports, and expert opinion. Despite a better understanding of the impact of endometriosis beyond menopause, there are many limitations to this condition, specifically with regard to cancer risk and indications for surgery. The existing evidence supports the use of shared decision making and the incorporation of patient preferences in guiding clinical management. Future research endeavors must shed light on the natural history of postmenopausal endometriosis through longitudinal studies in order to foster a deeper understanding of its complicated disease course across women's lifespans.

Factors affecting shared decision-making concerning menopausal hormone therapy

Menopausal hormone therapy (MHT) is an effective treatment for menopause-related symptoms. Menopause management guidelines recommend a personalized approach to menopause care, including MHT use. Decision-making around menopause care is a complex, iterative process influenced by multiple factors framed by perspectives from both women and healthcare providers (HCPs). This narrative review aims to summarize evidence around factors affecting decision-making regarding menopause-related care. For HCPs, the provision of individualized risk estimates is challenging in practice given the number of potential benefits and risks to consider, and the complexity of the data available, especially within time-limited consultations. Women seeking menopause care have the difficult task of making sense of the benefit versus risk profiles to make choices in line with their decisional needs influenced by sociocultural/economic, educational, demographic, and personal characteristics. The press, social media, and influential celebrities also impact the perception of menopause and decision-making around it. Understanding these factors can lead to improved participation in shared decision-making, satisfaction with the decision and decision-making process, adherence to treatment, reduced decisional regret, efficient use of resources, and ultimately long-term satisfaction with care.

Hormone Therapy and Biological Aging in Postmenopausal Women

Importance

Menopause is associated with biological aging, and hormone therapy (HT) is associated with health outcomes in postmenopausal women.

Objective

To evaluate the association between HT use and discrepancies between chronological and biological age in postmenopausal women as well as the potential modifying role of socioeconomic status (SES).

Design, Setting, and Participants

This population-based, retrospective cohort study included postmenopausal women registered in the UK Biobank. A baseline survey on HT use and biological aging biomarkers was conducted from March 2006 to October 2010. Data analyses were conducted in December 2023.

Exposures

Information regarding HT use, the age at starting HT, and HT duration was collected via a touchscreen questionnaire. SES was evaluated by education, family income, occupation, and the Townsend Deprivation Index.

Main Outcomes and Measures

Biological aging discrepancy was evaluated using validated phenotypic age, which was calculated using chronological age and 9 biomarkers measured at baseline. All-cause and cause-specific mortality were also assessed.

Results

Among the 117 763 postmenopausal women (mean [SD] age, 60.2 [5.4] years), 47 461 (40.3%) ever used HT. The mean phenotypic age was 52.1 (7.9) years. Ever use of HT was associated with a smaller biological aging discrepancy than never use of HT (β, -0.17 years; 95% CI, -0.23 to -0.10 years). This smaller aging discrepancy was more evident in those who started HT at age 55 years or older (β, -0.32 years; 95% CI, -0.48 to -0.15 years) and in those who used HT for 4 to 8 years (β, -0.25 years; 95% CI, -0.35 to -0.15 years). The association between HT and a smaller aging discrepancy was more evident in women with low SES, with a significant interaction observed for education (higher education: β, -0.08 years [95% CI, -0.17 to 0.01]; other education: β, -0.23 [95% CI, -0.32 to -0.14] years; P for interaction = .02). Phenotypic aging discrepancy mediated 12.7% (95% CI, 6.3% to 23.9%) of the association between HT and all-cause mortality and cause-specific mortality.

Conclusions and Relevance

In this study, postmenopausal women with historical HT use were biologically younger than those not receiving HT, with a more evident association observed in those with low SES. The biological aging discrepancy mediated the association between HT and decreased mortality. Promoting HT in postmenopausal women could be important for healthy aging.

Effect of menopausal hormonal therapy on cardiovascular risks in Korean postmenopausal women: A nationwide cohort study

OBJECTIVE

To evaluate the association between menopausal hormonal therapy (MHT) and the risk of cardiovascular disease (CVD), according to various regimens, dosages, routes of administration and starting ages of MHT.

DESIGN

A population-based cohort study using the Korean National Health Insurance Services database.

SETTING

Nationwide health insurance database.

POPULATION

Women who reported entering menopause at an age of ≥40 years with no history of CVD in the national health examination.

METHODS

The study population comprised 1 120 705 subjects enrolled between 2002 and 2019, categorised according to MHT status (MHT group, n = 319 007; non-MHT group, n = 801 698).

MAIN OUTCOME MEASURES

Incidence of CVD (a composite of myocardial infarction and stroke).

RESULTS

The incidence of CVD was 59 266 (7.4%) in the non-MHT group and 17 674 (5.5%) in the MHT group. After adjusting for confounding factors, an increased risk of CVD was observed with the administration of tibolone (hazard ratio, HR 1.143, 95% CI 1.117-1.170), oral estrogen (HR 1.246, 95% CI 1.198-1.295) or transdermal estrogen (HR 1.289, 95% CI 1.066-1.558), compared with the non-MHT group; the risk was based on an increased risk of stroke. The risk trends were consistent regardless of the age of starting MHT or the physicians' specialty. Among tibolone users, a longer period from entering menopause to taking tibolone and the use of any dosage (1.25 or 2.5 mg) were linked with a higher risk of CVD, compared with non-MHT users.

CONCLUSIONS

This nationwide cohort study demonstrated an increased risk of CVD, driven mainly by an increased risk of stroke, among tibolone and oral or transdermal estrogen users, compared with that of non-MHT users.

Hormone replacement therapy and myocardial infarction and stroke in postmenopausal Korean women

OBJECTIVE

This study aimed to investigate the association of hormone replacement therapy (HRT) use, type, duration and age of commencement with myocardial infarction (MI) and stroke in postmenopausal Korean women.

METHODS

This nested case-control study used data from the National Health Insurance Service database to analyze 2017 data from women aged ≥50 years and diagnosed with natural menopause between 2004 and 2007. Among 356,160 eligible women, 36,446 used HRT for ≥1 year and 319,714 did not (controls). These two groups were matched 1:1 for statistical analysis. Type and duration were categorized into three categories.

RESULTS

Women who started estrogen-progestogen therapy (EPT) or estrogen therapy (ET) in their 50s, or EPT or tibolone in their ≥60s exhibited a lower stroke risk than controls. MI risk was lower among women who used tibolone - regardless of duration - or EPT or ET for 1-3 years than among controls. Stroke risk was lower with tibolone use for ≥5 years or with EPT or ET use for 1-3 years or ≥5 years than non-users.

CONCLUSION

Our study may support the beneficial effect of HRT by showing that Korean postmenopausal women who used HRT at a relatively younger and healthier age had a relative benefit for MI and stroke.

Endocrine consequences of breast cancer therapy and survivorship

Breast cancer survivorship is increasing, due to earlier diagnosis of the disease and more effective therapies. Long-term endocrine sequelae, including early menopause, bone health, fertility implications and menopausal symptoms, are important survivorship issues. Ovarian failure is common with chemotherapy and options for preserving fertility in young women include ovarian suppression during chemotherapy and oocyte or embryo cryopreservation before chemotherapy. Tamoxifen as adjunct therapy in premenopausal women leads to ovarian stimulation, sometimes ovulation and occasionally pregnancy with important teratogenic implications. Aromatase inhibitor therapy with or without gonadotrophin releasing hormone (GnRH) agonist leads to profound bone loss and anti-resorptive therapy is advised to prevent fracture. Tamoxifen acts to preserve bone in postmenopausal women but not premenopausal women. Pregnancy is not discouraged in young women with early breast cancer, even to the point of pausing adjunct therapy in order to conceive. However, menopausal hormone therapy is discouraged even years later. Non-hormonal therapy for menopausal symptoms in breast cancer survivors is available but, in some cases, estrogen-containing therapy may be worthy of consideration for quality of life in the informed patient.

Understanding the Role of Sex Hormones in Cardiovascular Kidney Metabolic Syndrome: Toward Personalized Therapeutic Approaches

Cardiovascular kidney metabolic (CKM) syndrome represents a complex interplay of cardiovascular disease (CVD), chronic kidney disease (CKD), and metabolic comorbidities, posing a significant public health challenge. Gender exerts a critical influence on CKM syndrome, affecting the disease severity and onset through intricate interactions involving sex hormones and key physiological pathways such as the renin-angiotensin system, oxidative stress, inflammation, vascular disease and insulin resistance. It is widely known that beyond the contribution of traditional risk factors, men and women exhibit significant differences in CKM syndrome and its components, with distinct patterns observed in premenopausal women and postmenopausal women compared to men. Despite women generally experiencing a lower incidence of CVD, their outcomes following cardiovascular events are often worse compared to men. The disparities also extend to the treatment approaches for kidney failure, with a higher prevalence of dialysis among men despite women exhibiting higher rates of CKD. The impact of endogenous sex hormones, the correlations between CKM and its components, as well as the long-term effects of treatment modalities using sex hormones, including hormone replacement therapies and gender-affirming therapies, have drawn attention to this topic. Current research on CKM syndrome is hindered by the scarcity of large-scale studies and insufficient integration of gender-specific considerations into treatment strategies. The underlying mechanisms driving the gender disparities in the pathogenesis of CKM syndrome, including the roles of estrogen, progesterone and testosterone derivatives, remain poorly understood, thus limiting their application in personalized therapeutic interventions. This review synthesizes existing knowledge to clarify the intricate relationship between sex hormones, gender disparities, and the progression of CVD within CKM syndrome. By addressing these knowledge gaps, this study aims to guide future research efforts and promote tailored approaches for effectively managing CKD syndrome.

The risk of ovarian cancer in hormone replacement therapy users: a systematic review and meta-analysis

Background

With the increasing use of hormone replacement therapy (HRT), there is a need to understand its impact on the occurrence of female malignant tumors. This systematic review and meta-analysis aimed to assess the risk of ovarian cancer associated with HRT and its related risk factors.

Methods

PUBMED, OVID, Embase, Cochrane, and Web of Science were searched from 1980 to April 2022 to identify studies on the risk of ovarian cancer and hormone replacement therapy. The random-effects model was used to estimate the pooled risk of HRT in ovarian cancer, both in cohort studies and case-control studies. Additionally, the analysis examined the outcomes associated with different types of estrogen plus progesterone regimens. Meta-regression and sensitive analysis were performed to evaluate the heterogeneity.

Results

21 cohort studies (involving 15,313 cases and 4,564,785 participants) and 30 case-control studies (including 18,738 cases and 57,747 controls) were analyzed. The pooled risks of ovarian cancer for HRT users were 1.20 (95% confidence interval [CI] 1.01-1.44) from cohort studies and 1.13 (95%CI 1.04-1.22) from case-control studies. However, after restricting the study period to recent decades, the significant results indicating a higher risk disappeared in cohort studies conducted after 2010 and in case-control studies conducted after 2006. Furthermore, the continuous use of estrogen-progesterone replacement therapy (EPRT) was associated with a risk comparable to that of sequential use. Subgroup analysis showed that both estrogen replacement treatment (ERT) and EPRT had minor risks; The risk further increased with prolonged exposure time, particularly for durations exceeding 10 years. Additionally, serous ovarian cancer appeared to be more susceptible than other pathological types.

Conclusion

The risk of ovarian cancer associated with HRT has been decreasing over time. However, ERT may increase this risk, particularly when used for an extended period. It is recommended that long-time users consider continuous EPRT as a safer alternative.

Systematic review registration

www.crd.york.ac.uk/prospero/, identifier CRD42022321279.

A Simple Mathematical Model Demonstrates the Potential for Cell-Based Hormone Therapy to Address Dysregulation of the Hypothalamus-Pituitary-Ovary Axis in Females with Loss of Ovarian Function

Tissue-engineering and cell-based strategies provide an intriguing approach to treat complex conditions such as those of the endocrine system. We have previously developed a cell-based hormone therapy (cHT) to address hormonal insufficiency associated with the loss of ovarian function. To assess how the cHT strategy may achieve its efficacy, we developed a mathematical model to determine if known autocrine, paracrine, and endocrine effects of the native hypothalamus-pituitary-ovary (HPO) axis could explain our previously observed effects in ovariectomized rats following treatment with cHT. Our model suggests that cHT constructs participate in the complex machinery of the HPO axis. We were able to describe the in vivo behaviors of estrogen, progesterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), inhibin, and androgen with good accuracy. A sensitivity analysis indicated that some parameters impact the broader HPO system more than others, but that most changes in model parameters led to proportional changes in the system. We also conducted a predictive analysis on the effect of cHT dose on HPO axis hormones and found that, with the exception of estrogen, the other HPO hormones analyzed reach a saturation level within the physically possible number of constructs.

A Contemporary View of Menopausal Hormone Therapy

Enthusiasm for the use of hormones to ameliorate symptoms of perimenopause and menopause has waxed and waned over the years. Both treatment for symptoms and training of women's health care practitioners in the management of menopause have sharply declined since publication of the Women's Health Initiative initial results in 2002. Findings from that trial, which treated a population of older, asymptomatic patients, have been extrapolated over the past 21 years to all estrogen products, all menopausal women, and all delivery mechanisms. Our patients deserve a more nuanced, individualized approach. Conjugated equine estrogens and medroxyprogesterone acetate are no longer the predominant medications or medications of choice available for management of menopausal symptoms. All hormones are not equivalent any more than all antiseizure medications or all antihypertensives are equivalent; they have different pharmacodynamics, duration of action, and affinity for receptors, among other things, all of which translate to different risks and benefits. Consideration of treatment with the right formulation, at the right dose and time, and for the right patient will allow us to recommend safe, effective, and appropriate treatment for people with menopausal symptoms.

Exploring the Feasibility of Estrogen Replacement Therapy as a Treatment for Perimenopausal Depression: A Comprehensive Literature Review

Perimenopausal depression (PMD) is a psychological disorder that occurs in women during perimenopause. In addition to the common clinical symptoms of depression, it often manifests as a perimenopausal complication, and its notable cause is the decline in estrogen levels. Despite numerous studies and trials confirming the benefits of estrogen replacement therapy (ERT) for PMD, ERT remains unapproved for treating PMD. Therefore, we conducted a literature search using selected keywords in PubMed and Google Scholar to write a review discussing the feasibility of using ERT for PMD. This review examines the potential of ERT for PMD in terms of its underlying mechanisms, efficacy, safety, and time window. These four aspects suggest that ERT is a viable option for PMD treatment. However, the risk of thrombosis and stroke with ERT is a matter of contention among medical experts, with a paucity of clinical data. Consequently, further clinical trial data are required to ascertain the safety of ERT.

The impact of female sex hormones on cardiovascular disease: from mechanisms to hormone therapy

Cardiovascular disease remains the leading cause of mortality in women, yet it has not raised the awareness from the public. The pathogenesis of cardiovascular disease differs significantly between females and males concerning the effect of sex hormones. Estrogen and progestogen impact cardiovascular system through genomic and non-genomic effects. Before menopause, cardiovascular protective effects of estrogens have been well described. Progestogens were often used in combination with estrogens in hormone therapy. Fluctuations in sex hormone levels, particularly estrogen deficiency, were considered the specific risk factor in women's cardiovascular disease. However, considerable heterogeneity in the impact of hormone therapy was observed in clinical trials. The heterogeneity is likely closely associated with factors such as the initial time, administration route, dosage, and formulation of hormone therapy. This review will delve into the pathogenesis and hormone therapy, summarizing the effect of female sex hormones on hypertension, pre-eclampsia, coronary heart disease, heart failure with preserved ejection fraction, and cardiovascular risk factors specific to women.