Effects of long-term estrogen replacement therapy. I. Metabolic effects

Remnant cholesterol can identify individuals at higher risk of metabolic syndrome in the general population

Remnant cholesterol (RC) is a highly atherogenic lipid. Previous studies have shown that RC was closely associated with many metabolism-related diseases. However, the relationship of RC with metabolic syndrome (MetS) remains unclear. This study's objective is to investigate the relationship of RC with MetS. A total of 60,799 adults who received health assessments were included in this study. RC was calculated by subtracting the directly measured values for low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) from total cholesterol (TC) and divided into 5 groups according to its quintile. MetS diagnosis according to National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) definitions. Application of receiver operating characteristic (ROC) curve analysis and multivariate logistic regression to assess the association of RC with MetS. In RC quintile groups, the prevalence of MetS was 0.84, 1.10, 1.92, 3.87 and 37.71%, respectively. Multivariate logical regression analysis showed that RC and MetS maintained a stable independent positive correlation between both sexes. An interaction test further showed that the MetS risk associated with RC was significantly higher in women than in men. Moreover, ROC analysis results showed that RC had high accuracy in identifying MetS, especially among young and middle-aged men [(area under the curve: AUC) < 30 years: 0.9572, 30-39 years: 0.9306, 40-49 years: 0.9067]. The current study provided the first evidence of a positive association between RC and MetS, and that this correlation was stronger in women than in man, which may be due to the relative deficiency of estrogen in women.

Hormone Therapy in Menopause: Concepts, Controversies, and Approach to Treatment

Hormone therapy (HT) is an effective treatment for menopausal symptoms, including vasomotor symptoms and genitourinary syndrome of menopause. Randomized trials also demonstrate positive effects on bone health, and age-stratified analyses indicate more favorable effects on coronary heart disease and all-cause mortality in younger women (close proximity to menopause) than in women more than a decade past menopause. In the absence of contraindications or other major comorbidities, recently menopausal women with moderate or severe symptoms are appropriate candidates for HT. The Women's Health Initiative (WHI) hormone therapy trials-estrogen and progestin trial and the estrogen-alone trial-clarified the benefits and risks of HT, including how the results differed by age. A key lesson from the WHI trials, which was unfortunately lost in the posttrial cacophony, was that the risk:benefit ratio and safety profile of HT differed markedly by clinical characteristics of the participants, especially age, time since menopause, and comorbidity status. In the present review of the WHI and other recent HT trials, we aim to provide readers with an improved understanding of the importance of the timing of HT initiation, type and route of administration, and of patient-specific considerations that should be weighed when prescribing HT.

Puerarin Attenuates Cadmium-Induced Neuronal Injury via Stimulating Cadmium Excretion, Inhibiting Oxidative Stress and Apoptosis

Cadmium (Cd) is a potential pathogenic factor in the nervous system associated with various neurodegenerative disorders. Puerarin (Pur) is an isoflavone purified from the Chinese medical herb, kudzu root, and exhibits antioxidant and antiapoptotic properties in the brain. In this study, the detailed mechanisms underlying the neuroprotective potential of Pur against Cd-induced neuronal injury was evaluated for the first time in vivo in a rat model and in vitro using primary rat cerebral cortical neurons. The results of the in vivo experiments showed that Pur ameliorated Cd-induced neuronal injury, reduced Cd levels in the cerebral cortices, and stimulated Cd excretion in Cd-treated rats. We also observed that the administration of Pur rescued Cd-induced oxidative stress, and attenuated Cd-induced apoptosis by concomitantly suppressing both the Fas/FasL and mitochondrial pathways in the cerebral cortical neurons of rats both in vivo and in vitro. Our results demonstrate that Pur exerted its neuroprotective effects by stimulating Cd excretion, ameliorating Cd-induced oxidative stress and apoptosis in rat cerebral cortical neurons.

Role of Estrogens in the Regulation of Liver Lipid Metabolism

Before menopause, women are protected from atherosclerotic heart disease associated with obesity relative to men. Sex hormones have been proposed as a mechanism that differentiates this risk. In this review, we discuss the literature around how the endogenous sex hormones and hormone treatment approaches after menopause regulate fatty acid, triglyceride, and cholesterol metabolism to influence cardiovascular risk.The important regulatory functions of estrogen signaling pathways with regard to lipid metabolism have been in part obscured by clinical trials with hormone treatment of women after menopause, due to different formulations, routes of delivery, and pairings with progestins. Oral hormone treatment with several estrogen preparations increases VLDL triglyceride production. Progestins oppose this effect by stimulating VLDL clearance in both humans and animals. Transdermal estradiol preparations do not increase VLDL production or serum triglycerides.Many aspects of sex differences in atherosclerotic heart disease risk are influenced by the distributed actions of estrogens in the muscle, adipose, and liver. In humans, 17β-estradiol (E2) is the predominant circulating estrogen and signals through estrogen receptor alpha (ERα), estrogen receptor beta (ERβ), and G-protein-coupled estrogen receptor (GPER). Over 1000 human liver genes display a sex bias in their expression, and the top biological pathways are in lipid metabolism and genes related to cardiovascular disease. Many of these genes display variation depending on estrus cycling in the mouse. Future directions will likely rely on targeting estrogens to specific tissues or specific aspects of the signaling pathways in order to recapitulate the protective physiology of premenopause therapeutically after menopause.

Trends of postmenopausal estrogen plus progestin prevalence in the United States between 1970 and 2010

OBJECTIVE

To estimate long term trends in estrogen-progestin prevalence for the U.S. female population by year and age.

METHODS

We integrated data on oral estrogen-progestin use from the National Health and Nutrition Examination Survey 1999-2010 with data from the National Prescription Audit 1970-2003. Distributions of estrogen-progestin by age from the National Health and Nutrition Examination Survey were applied to the prescription data, and calibration and interpolation procedures were used to generate estrogen-progestin prevalence estimates by single year of age and single calendar year for 1970-2010.

RESULTS

Estimated prevalence of oral estrogen-progestin was below 0.5% in the 1970s, began to rise in the early 1980s, and almost tripled between 1990 and the late 1990s. The age-adjusted prevalence for women aged 45-64 years peaked at 13.5% in 1999 with highest use among 57-year-old women (23.2%). Prevalence of estrogen-progestin use declined dramatically in the early 2000s with only 2.7% of women aged 45-64 years using estrogen-progestin in 2010, which is comparable to prevalence levels in the mid-1980s.

CONCLUSION

The dramatic rise and fall of estrogen-progestin use over the past 40 years provides an illuminating case study of prescription practices before, during, and after the development of evidence regarding benefits and harms.

LEVEL OF EVIDENCE

: II.

Hormone therapy administration in postmenopausal women and risk of stroke

HRT, consisting of estrogens alone, or in combination with a progestogen, is widely used for the relief of symptoms in postmenopausal women. Early observational studies have suggested that HRT might be associated with a reduced risk of cardio- and cerebro-vascular events. These encouraging results prompted randomized controlled trials assessing the risks and benefits of HRT in primary and secondary prevention of arterial vascular events. However, these clinical trials and further observational studies did not confirm the protective effect of HRT; it is now established that HRT increases the risk of stroke. This increased risk is mainly related to an increased risk of ischemic stroke. Oral estrogen alone and combined with progestogen are associated with a similar increased risk, which may be dose dependent. Conversely, a low dose of transdermal estrogens with or without a progestogen does not seem to be associated with such an increased risk of stroke, whereas the impact of tibolone, a synthetic steroid, remains uncertain. In summary, there is now a large amount of evidence demonstrating that HRT is associated with increased risk of stroke, in particular, ischemic subtype.

The association between a functional CYP1A1 polymorphism and colorectal neoplasia risk in post menopausal women

BACKGROUND

The impact of estrogen on risk of colorectal neoplasia is uncertain. Carriers of the AA and CA genotype allele of the C4887A polymorphism of the CYP1A1 gene have enhanced estrogen metabolism relative to carriers of the CC genotype.

AIMS

This study examined whether this genetic marker of enhanced estrogen catabolism segregated with colorectal neoplasia (CRN) in postmenopausal women.

METHODS

We enrolled hormone negative postmenopausal women having screening or surveillance colonoscopy. Demographic and medical data were gathered. Blood was collected and analyzed for CYP1A1 polymorphisms of the C4887A allele by PCR-RFLP. Colonoscopy and pathology data were gathered from hospital databases.

RESULTS

One hundred sixty-eight women were enrolled in the study. Twenty-one subjects (12.5%) carried at least one A allele, and 147 subjects (87.5%) carried the CC alleles for the C4887A polymorphism of the CYP1A1 gene. Seventy subjects (41.7%) had CRN and 98 subjects (58.3%) did not have CRN. Of the subjects who carried the A allele, 57% had CRN as compared to 39% of those who carried the CC allele; the association was not statistically significant (P = 0.16). In a multivariate logistic regression analysis, age, BMI, current tobacco use, and first degree relative with CRN were independent risk factors for CRN but the C4887A polymorphisms remained not statistically significant (P = 0.35).

CONCLUSIONS

Carriers of the A allele of the C4887A polymorphism have enhanced estrogen catabolism and lower free estradiol. Our results suggest, however, that inherent estrogen metabolism as determined by C4887A polymorphisms is not associated with CRN risk.

Menopausal hormone therapy and risk of colorectal cancer

We evaluated colorectal cancer risk associated with the duration and recency of specific menopausal hormone therapy formulations (i.e., unopposed estrogen versus estrogen plus progestin) and regimens (i.e., sequential versus continuous estrogen plus progestin use) among 56,733 postmenopausal women participating in the Breast Cancer Detection Demonstration Project follow-up study. Hormone therapy use and other risk factors were ascertained through telephone interviews and mailed questionnaires from 1979 to 1998. The final cancer group included 960 women who were identified from self-report, medical records, state registry data, and the National Death Index. Poisson regression was used to generate multivariable rate ratios (RR) and 95% confidence intervals (95% CI). We observed a decreased risk of colorectal cancer among ever users of unopposed estrogen therapy (RR, 0.83; 95% CI, 0.70-0.99). Among estrogen users, the largest reduced risk was observed for current users (RR, 0.75; 95% CI, 0.54-1.05) and users of >or=ten years duration (RR, 0.74; 95% CI, 0.56-0.96). We found a reduced risk among users of estrogen plus progestin therapy (RR, 0.78; 95% CI, 0.60-1.02), with sequential regimen users (progestin <15 days per cycle) having the largest risk reduction (RR, 0.64; 95% CI, 0.43-0.95). Past users of >or=5 years ago (RR, 0.55; 95% CI, 0.32-0.98) had the largest risk reduction. In this study, estrogen plus progestin use, especially sequential regimen use, was associated with the largest overall reduction of colorectal cancer risk.

Randomized double-blind trial of estrogen replacement therapy versus placebo in stage I or II endometrial cancer: a Gynecologic Oncology Group Study

PURPOSE

To determine the effect of estrogen replacement therapy (ERT) on recurrence rate and survival in women who have undergone surgery for stage I or II endometrial cancer.

PATIENTS AND METHODS

After surgery, eligible patients were allocated to therapy with ERT or placebo after undergoing hysterectomy with or without pelvic and aortic nodal sampling. Planned duration of hormonal versus placebo treatment was 3 years, with an additional 2 years of follow-up.

RESULTS

The median follow-up time for all 1,236 eligible and assessable patients was 35.7 months. Stage, grade, histologic subtype, and percentage of patients receiving adjuvant therapy were similarly distributed between the groups. The median age at diagnosis for the 618 patients randomly assigned to ERT was 57 years (range, 26 to 91 years). Two hundred fifty-one patients (41.1%) were compliant with ERT for the entire treatment period. Disease recurrence was experienced in 14 patients (2.3%). Eight patients (1.3%) developed a new malignancy. There were 26 deaths (4.2%), and five deaths (0.8%) were a result of endometrial cancer. The median age at diagnosis for the 618 patients in the placebo group was 57 years (range, 30 to 88 years). Twelve patients (1.9%) experienced disease recurrence. Ten patients (1.6%) developed a new malignancy. There were 9 deaths (3.1%) in the placebo group, and four deaths (0.6%) were a result of endometrial cancer.

CONCLUSION

Although this incomplete study cannot conclusively refute or support the safety of exogenous estrogen with regard to risk of endometrial recurrence, it is noteworthy that the absolute recurrence rate (2.1%) and the incidence of new malignancy were low.

Current Status of Combined Hormone Replacement Therapy in Clinical Practice

Approximately 20 million women worldwide use hormone replacement therapy (HRT). Formerly, it was thought to confer beneficial cardiac protection and reduce osteoporosis in addition to relieving the symptoms of menopause. However, many recent trials have contradicted these beliefs. The risk of breast cancer associated with HRT use has been well documented but underestimated. Many recent trials have reported higher than expected breast cancer incidence rates, particularly associated with combined HRT. Although it was believed estrogen conferred cardiac protection and reduced the incidence of myocardial ischemic events and cerebrovascular accidents, the more recent literature indicates that this is not true and that HRT users have a higher risk of cardiac and cerebral events. The role of HRT in clinical practice has been redefined. It is no longer an acceptable form of treatment for most women. The evidence indicates that the use of long-term HRT is no longer clinically justifiable.

Oestrogens and insulin secretion

There is a persistent perception that oestrogens have an adverse effect on carbohydrate metabolism. It might therefore be expected that their use would result in a corresponding increase in the incidence of diabetes. Recent evidence from clinical trials suggesting that women on postmenopausal oestrogen hormone replacement therapy (HRT) have a reduced incidence of type 2 diabetes therefore appears paradoxical. Short-term supraphysiological oestrogen administration has an adverse effect on glucose tolerance, resulting from suppression of first-phase insulin secretion and increased insulin resistance. Oestrogen-induced increases in glucocorticoid activity could account for these effects. Oestrogen-induced deterioration in glucose tolerance is, however, accompanied by a reduction in fasting glucose, an effect that could be accounted for by glucagon antagonism. These short-term effects contrast with long-term preservation of insulin secretion and glucose homeostasis by oestrogens. In animal studies, ovariectomy is associated with decreased insulin secretion and increased risk of diabetes, whereas oestrogen administration protects against diabetes and increases the insulin response to glucose. The mechanism is uncertain, but direct effects on the pancreas via steroid receptors or indirect effects via oestrogen-induced glucagon antagonism and subclinical increases in glucocorticoids and growth hormone could all contribute. Recent evidence that HRT increases the risk of cardiovascular disease suggests that it should not be used for the prevention of diabetes, but the mechanism responsible for this benefit merits further investigation and might lead to new therapies.

A systematic review of drug therapy to delay or prevent type 2 diabetes

OBJECTIVE

To systematically review the evidence for the prevention of type 2 diabetes by pharmacological therapies.

RESEARCH DESIGN AND METHODS

Randomized controlled trials and cohort studies examining the effect of oral hypoglycemic agents, antiobesity agents, antihypertensive agents, statins, fibrates, and estrogen on the incidence of type 2 diabetes were identified from MEDLINE, EMBASE, the Cochrane Controlled Trials Registry, and searches of reference lists. Two reviewers independently assessed studies for inclusion and performed data extraction.

RESULTS

Ten studies of oral hypoglycemic agents and 15 studies of nonoral hypoglycemic agents were found. Oral hypoglycemic agents and orlistat are the only drugs that have been studied in randomized controlled trials with diabetes incidence as the primary end point. In the largest studies of 2.5-4.0 years' duration, metformin (relative risk [RR] 0.69, 95% CI 0.57-0.83), acarbose (0.75, 0.63-0.90), troglitazone (0.45, 0.25-0.83), and orlistat (hazard ratio [HR] 0.63, 95% CI 0.46-0.86) have all been shown to decrease diabetes incidence compared with placebo; however, follow-up rates varied from 43 to 96%. Current evidence for statins, fibrates, antihypertensive agents, and estrogen is inconclusive. In addition, the critical question of whether drugs are preventing, or simply delaying, onset of diabetes remains unresolved.

CONCLUSIONS

Currently, no single agent can be definitively recommended for diabetes prevention. Future studies should be designed with diabetes incidence as the primary outcome and should be of sufficient duration to differentiate between genuine diabetes prevention as opposed to simple delay or masking of this condition.

Hormone replacement therapy and cardiovascular disease: increased risks of venous thromboembolism and stroke, and no protection from coronary heart disease

Hormone replacement therapy (HRT) was increasingly promoted over the last 40 years to improve quality of life, and to reduce the risks of osteoporotic fractures and coronary heart disease (CHD). In recent years, observational studies, randomized trials and systematic reviews of such trials have shown that HRT does not reduce, but actually increases cardiovascular risk. HRT increases the relative risks of venous thromboembolism (twofold), and of fatal or disabling stroke (by 50%); whilst increasing the early risk of myocardial infarction and having no protective effect against CHD on longer term use. Possible mechanisms for these increased cardiovascular risks include down-regulation of several inhibitory pathways of blood coagulation, resulting in increased coagulation activation, which promotes venous and arterial thrombosis. The implications for prescription are discussed, as are lessons for future evaluation of health care interventions.

Postmenopausal Hormone Therapy Is Associated With Atherosclerosis Progression in Women With Abnormal Glucose Tolerance

Background— Abnormal glucose tolerance (AGT; diabetes or impaired glucose tolerance) is associated with increased risk of cardiovascular disease, especially in women. Cardiovascular disease rates in women increase after menopause. The Women’s Health Initiative found that postmenopausal hormone therapy (PHT) increased the risk of cardiovascular disease and that effects in diabetic women did not differ from those in women without diabetes. In this study, we hypothesized that PHT would have a worse effect on disease among women with AGT.

Methods and Results— We randomly assigned 423 postmenopausal women with angiographically defined atherosclerosis (321 women had exit angiograms) with (n=140) or without (n=181) AGT to receive estrogen, estrogen plus progestin, or a placebo for 2.8±0.9 years. LDL was lower and HDL and triglycerides were higher after PHT in non-AGT and AGT women, but more adverse changes occurred in C-reactive protein and fibrinogen in women with AGT ( P =0.11 and P =0.02 for interactions). PHT had no effect on fasting glucose or insulin concentrations in women without AGT, but in women with AGT, fasting glucose levels, insulin concentration, and insulin resistance as assessed by the HOMA (homeostasis model) calculation decreased slightly ( P =0.28, P =0.25, P =0.14 for interaction, respectively). Atherosclerotic progression was greater in women with AGT. Atherosclerotic progression in previously nondiseased segments was enhanced by PHT to a greater extent in women with AGT ( P =0.11 for interaction).

Conclusions— PHT is associated with a worsening of coronary atherosclerosis and exacerbation of the profile of inflammatory markers in women with AGT. Therefore, PHT is not warranted for use in diabetic women. Further study is needed to explore the improvement in insulin resistance and glycemia that appears to occur with PHT in women with AGT.

Effect of oestrogen plus progestin on the incidence of diabetes in postmenopausal women: results from the Women's Health Initiative Hormone Trial

AIMS/HYPOTHESIS

Studies examining the effect of postmenopausal hormone therapy on concentrations of glucose, insulin and diabetes incidence have been inconclusive, in part because many of the studies were too small. We examined the effect of oestrogen plus progestin on diabetes incidence and insulin resistance.

METHODS

The study was a randomised, double-blind trial comparing the effect of daily 0.625 mg conjugated equine oestrogens plus 2.5 mg medroxyprogesterone acetate with that of placebo during 5.6 years of follow-up. The participants were 15,641 postmenopausal women enrolled in the Women's Health Initiative Hormone Trial. These women were aged 50 to 79 and all had an intact uterus. Diabetes incidence was ascertained by self-report of treatment with insulin or oral hypoglycaemic medication. Fasting glucose, insulin, and lipoproteins were measured in a random sample at baseline and at 1 and 3 years.

RESULTS

The cumulative incidence of treated diabetes was 3.5% in the hormone therapy group and 4.2% in the placebo group (hazard ratio 0.79, 95% CI 0.67-0.93, p=0.004). There was little change in the hazard ratio after adjustment for changes in BMI and waist circumference. During the first year of follow-up, changes in fasting glucose and insulin indicated a significant fall in insulin resistance in actively treated women compared to the control subjects (Year 1 to baseline between-group difference -0.22+/-0.10, p=0.03). INTERPRETATIONS/CONCLUSION: These data suggest that combined therapy with oestrogen and progestin reduces the incidence of diabetes, possibly mediated by a decrease in insulin resistance unrelated to body size. Future studies of alternative postmenopausal hormone therapy regimens and selective oestrogen agonists and/or antagonists should consider the effects of these regimens on insulin resistance and diabetes.

Effects of low and high dose oestradiol and dydrogesterone therapy on insulin and lipoprotein metabolism in healthy postmenopausal women

OBJECTIVE

Menopause diminishes insulin secretion and elimination, increases risk of diabetes and adversely affects lipoprotein metabolism. This study was undertaken to establish whether oral oestradiol plus dydrogesterone postmenopausal hormone therapy can modify these changes.

DESIGN

Randomized prospective trial of postmenopausal women taking low dose therapy (1 mg/day oestradiol-17 beta with 5 or 10 mg/day dydrogesterone for days 17-28 of each cycle, n = 15) or high dose therapy (2 mg/day oestradiol-17 beta with 10 or 20 mg/day orally administered dydrogesterone, n = 9).

MEASUREMENTS

Patients underwent measurement of glucose, insulin and C-peptide in the fasting state and during an intravenous glucose tolerance test (IVGTT) at baseline and after 12 and 24 cycles of treatment. Modelling analysis was used to derive measures of insulin secretion, elimination and sensitivity. Fasting serum lipids, lipoproteins and apolipoproteins were also measured.

RESULTS

In both groups there were significant reductions in fasting glucose, insulin and C-peptide. Pancreatic insulin secretion during the IVGTT was increased by treatment (ranging from 45% to 92%, P < 0.01). Insulin elimination was increased at both the peripheral (16% to 43%, P < 0.05) and hepatic (18% to 31%, P < 0.05) levels. Insulin sensitivity was unaffected. Low density lipoprotein (LDL) cholesterol was reduced and high density lipoprotein (HDL) cholesterol increased with treatment.

CONCLUSIONS

Postmenopausal hormone therapy with oestradiol plus dydrogesterone can favourably affect lipoprotein concentrations and can reverse menopause-associated changes in insulin secretion and elimination.

Androgenicity and obesity are independently associated with insulin sensitivity in postmenopausal women

An increase in androgenicity may contribute to the development of insulin resistance in postmenopausal women. Increased androgenicity in women has been found to be associated with the development of type 2 diabetes. In addition, obesity and central obesity are associated with greater androgenicity. Insulin sensitivity, androgenicity, and body composition were characterized in 34 nondiabetic postmenopausal women age 72 +/- 1 years (mean +/- SEM) to test the hypothesis that androgenicity is a predictor of insulin sensitivity independent of measures of obesity. Androgenicity was measured using levels of sex hormone-binding globulin (SHBG), total and free testosterone, dehydroepiandrosterone sulfate (DHEA-S), androstenedione, and free androgen index (FAI). Insulin sensitivity (S(I)) was determined from a frequently sampled intravenous glucose tolerance test. Body composition measures included body mass index (BMI) and dual energy x-ray absorptiometry measurements of total and central fat mass. S(I) was found to be associated with total fat mass (r = -.51, P =.002), central fat mass (r = -.62, P =.0001), BMI (r = -.55, P =.0008), SHBG levels (r =.65, P =.0001), and FAI (r = -.41, P =.01). SHBG levels were inversely correlated with central fat mass (r = -.59, P =.0002). Using multiple regression, SHBG and central fat mass were the only significant independent predictors of S(I), accounting for 50% of its variance (r =.71, P =.0001); total fat mass, BMI, total and free testosterone, DHEA-S, androstenedione, and FAI did not enter the model. We conclude that there is a significant association between insulin sensitivity and androgenicity in postmenopausal women that is independent of obesity. Interventions to decrease androgenicity may therefore be useful in improving insulin sensitivity in postmenopausal women.

Combining Bisphosphonates with Hormone Therapy for Postmenopausal Osteoporosis

Osteoporosis affects many women after menopause. It is a major health problem, as fragility fractures create significant morbidity in this population, especially with advancing age. Available therapies include estrogens, selective estrogen receptor modulators, bisphosphonates, and calcitonin. They all inhibit bone resorption, although through different mechanisms. Several combinations of these agents have been studied in order to determine their effectiveness in comparison with monotherapy. We reviewed eight prospective randomized clinical trials of hormone therapies combined with bisphosphonates (etidronate, alendronate, and risedronate) and one study of a selective estrogen receptor modulator (raloxifene) in combination with a bisphosphonate (alendronate). Bone mineral density change at the lumbar spine was the primary endpoint of all the studies, with one or more measurements of the bone density at the femur as secondary endpoints. None of the studies had the statistical power to determine the relative reduction in fracture risk. All the studies reported greater increases in bone mineral density in patients treated with combination therapies as opposed to single agents. The bone turnover markers were also suppressed to a greater degree in the combination treatment groups, remaining however within normal premenopausal ranges. Four studies reported bone histomorphometry data, indicating no impairment of bone quality by combination therapies. The combination treatments were well tolerated in all the trials and the discontinuation rates did not vary among the groups. However, most patients will not require combination therapy. Combining bisphosphonates with hormone therapy may offer an additional benefit to women who either continue to lose bone mass despite taking estrogen or who need estrogen to control postmenopausal symptoms. The benefit of adding raloxifene to a bisphosphonate is smaller. However, it may be clinically useful if raloxifene reduces the risk of breast cancer.

Differential effects of raloxifene and estrogen on insulin sensitivity in postmenopausal women

OBJECTIVES

To test the hypothesis that both raloxifene and estrogen would improve insulin sensitivity in postmenopausal women and that the magnitude of the effect would be similar for both drugs.

DESIGN

Placebo-controlled, double-blind, randomized study.

SETTING

The General Clinical Research Center of the University of Michigan Medical Center, a university hospital.

PARTICIPANTS

Forty-four healthy postmenopausal women 73 +/- 7 years old (mean age +/- standard deviation) who were not receiving hormone replacement therapy.

INTERVENTION

Eight weeks of drug therapy with randomization to raloxifene (n = 16), estrogen (n = 14), or placebo (n = 14).

MEASUREMENTS

These subjects underwent a frequently sampled intravenous glucose tolerance test to determine insulin sensitivity (SI) and total and regional (central) body composition measurements by dual-energy x-ray absorptiometry at baseline and after 8 weeks of drug therapy.

RESULTS

There were no statistically significant differences in age, body mass index, total or central fat mass, or SI between the three groups at baseline. The major outcome variable was SI. After 8 weeks of drug therapy, there was no significant change in SI in the placebo group or in the estrogen group and a significant decrease in SI in the raloxifene group, P =.003.

CONCLUSION

In contrast to estrogen's ability to maintain insulin sensitivity, raloxifene decreases insulin sensitivity in healthy nondiabetic postmenopausal women. The clinical significance of this effect of raloxifene to impair insulin sensitivity in postmenopausal women warrants further evaluation in future studies.

New bone formation with teriparatide [human parathyroid hormone-(1-34)] is not retarded by long-term pretreatment with alendronate, estrogen, or raloxifene in ovariectomized rats

With the ready availability of several osteoporosis therapies, teriparatide [human PTH-(1-34)] is likely to be prescribed to postmenopausal women with prior exposure to agents that prevent bone loss, such as bisphosphonates, estrogen, or selective estrogen receptor modulators. Therefore, we evaluated the ability of once daily teriparatide to induce bone formation in ovariectomized (Ovx) rats with extended prior exposure to various antiresorptive agents, such as alendronate (ABP), 17 alpha-ethinyl estradiol (EE), or raloxifene (Ral). Sprague Dawley rats were Ovx and treated with ABP (28 microg/kg, twice weekly), EE (0.1 mg/kg per d), or Ral (1 mg/kg per d) for 10 months before switching to teriparatide 30 microg/kg per d for another 2 months. Analysis of the proximal tibial metaphysis showed that all three antiresorptive agents prevented ovariectomy-induced bone loss after 10 months, but were mechanistically distinct, as shown by histomorphometry. Before teriparatide treatment, ABP strongly suppressed activation frequency and bone formation rate to below levels in other treatment groups, whereas these parameters were not different from sham values for EE or Ral. Trabecular area for ABP, EE, and Ral were greater than that in Ovx controls. However, the trabecular bone effects of ABP were attributed not only to effects on the secondary spongiosa, but also to the preservation of primary spongiosa, which was prevented from remodeling. After 2 months of teriparatide treatment, lumbar vertebra showed relative bone mineral density increases of 18%, 7%, 11%, and 10% for vehicle/teriparatide, ABP/teriparatide, EE/teriparatide, and Ral/teriparatide, respectively, compared with 10 month levels. Histomorphometry showed that trabecular area was increased by 105%, 113%, 36%, and 48% for vehicle/teriparatide, ABP/teriparatide, EE/teriparatide, and Ral/teriparatide, respectively, compared with 10 month levels. Teriparatide enhanced mineralizing surface, mineral apposition rate, and bone formation rate in all groups. Compression testing of vertebra showed that teriparatide improved strength (peak load) and toughness in all groups to a proportionately similar extent compared with 10 month levels. These data showed a surprising ability of the rat skeleton to respond to teriparatide despite extensive pretreatment with ABP, EE, or Ral. Therefore, the mature skeleton of Ovx rats remains highly responsive to the appositional effects of teriparatide regardless of pretreatment status in terms of cancellous bone area or rate of bone turnover.

Angiotensin II type 1 receptor blockade to control blood pressure in postmenopausal women: influence of hormone replacement therapy

BACKGROUND

Hypertension is twice as common in postmenopausal than in premenopausal women. This study evaluated the effectiveness of a blockade of the renin-angiotensin-aldosterone system (RAAS) with candesartan cilexetil (CC) to control blood pressure (BP) in hypertensive menopausal women, and the influence of hormone replacement therapy (HRT).

METHODS

This was designed as a prospective, open-label and non-comparative study. Included were 618 hypertensive menopausal women grade I/II according to the Sixth Report of the Joint National Committee (VI-JNC), with an average age 52+/-4.7 years (95% CI 52.3-53.0) and with a last menstrual period (LMP) at least one year before. BP was determined by measurement in four visits during six months of follow-up, according to the recommendations of the OMS/SIH. Optimal control of BP was considered as BP <140/90 mm Hg.

RESULTS

A statistically significant decrease in systolic (SBP; 19.9+/-11.2) and diastolic (DBP; 11.5+/-7.3) blood pressure mm Hg values was observed (P<0.01). The control of BP increased significantly over time to 61.2% (P<0.01). In multivariate analysis, only age was associated with control of BP (beta= -0.062; P=0.004). Of the women not controlled in the second visit, 12.5 mg of hydrochlorothiazide (HCTZ) were added to 31.5% (N=122), with 80% more BP control achieved in visit 3 than in the non-supplement group (OR=1.8; 95% CI 1.04-3.05; P<0.03). One hundred and three (16.7%) patients were receiving HRT for 2.01+/-2.23 years (95% CI 1.55-2.46). HRT did not affect the control of BP. No severe adverse reactions were reported.

CONCLUSIONS

Candesartan cilexetil significantly reduced SBP and DBP and increased control (61.2%) of BP in hypertensive menopausal women. Only age had an inverse association with control of BP. In this study, HRT did not affect the control of BP.

Update on cardiovascular disease in post-menopausal women

Cardiovascular disease (CVD), and in particular coronary artery heart disease (CAHD), is the leading cause of morbidity and mortality in women. Until recently, most of our knowledge about the pathophysiology of CVD in women - and, subsequently, management guidelines - were based on studies conducted mostly in men. While similar mechanisms operate to induce CVD in women and men, gender-related differences exist in the anatomy and physiology of the myocardium, and sex hormones modify the course of disease in women. Women, more than men, have their initial manifestation of CAHD as angina pectoris; are likely to be referred for diagnostic tests at a more advanced stage of disease, and are less likely than men to have corrective invasive procedures. The overall morbidity and mortality following the initial ischaemic heart event is worse in women, and the case fatality rate is greater in women than in men. Also, the relative impact of impaired vasoreactivity of the coronary artery, increased viscosity of the blood and dysregulation of automaticity and arrhythmia, is greater in women than in men. The most effective means of decreasing the impact of CVD on women's health is by an active approach from childhood to proper principles of healthcare in order to modify the contribution of specific risk factors. The latter include obesity, abnormal plasma lipid profile, hypertension, diabetes mellitus, cigarette smoking, sedentary lifestyle, increased blood viscosity, augmented platelet aggregability, stress and autonomic imbalance. The use of lipid-lowering drugs has not been adequately studied in women but reports from studies conducted mostly in men do predict an advantage also to women. Oestrogen deficiency after spontaneous or medically induced menopause is an important risk factor for CVD and CAHD. Observational and mechanistic data suggest a role for oestrogen replacement after menopause for primary, and possibly secondary, prevention of CVD. However, two recent prospective trials suggest that treatment de novo with hormone replacement of older post-menopausal women after an acute coronary event may not confer cardiovascular protection and may increase the risk of thromboembolic disease. Results of ongoing long-term studies may determine the beneficial role of hormone replacement versus potential risks involved with this treatment.

Affective syndrome during perimenopause

Perimenopause is characterized by decreasing levels of estrogens and progesterone until gonadal secretion comes to a complete halt. There are still very different views and positions on the significance of the menopause. Physical, mental-vegetative and depressive symptoms during climacteric are different in each culture. Currently, there is some controversy as to whether or not there really is a rise in actual depression during the perimenopausal phase of woman's life. The observations from humans taken together indicate that depressive disorders, as defined in ICD-10, do not occur more frequently during perimenopause. In this context, the terms subthreshold depression and or subsyndromal depression are important, describing depressive symptoms which do not fulfil the complete clinical picture of a depressive episode, either because there are not enough symptoms or because they are not severe enough. The affected women still suffer, but until now not enough studies have been carried out on this particular area. In view of the complexity and relevance of the perimenopausal period in a woman's life, it is necessary to establish and maintain a network of treatment between the family physician, gynecologist, psychiatrist and or psychotherapist, as soon as significant depressive symptoms occur.

The effect of estrogen use on levels of glucose and insulin and the risk of type 2 diabetes in american Indian postmenopausal women : the strong heart study

OBJECTIVE

To examine the associations between estrogen use and levels of insulin and glucose as well as the effect of estrogen use on the risk of type 2 diabetes.

RESEARCH DESIGN AND METHODS

This report is based on 857 women who were both nondiabetic and postmenopausal at the baseline examination (1989-1992) and who completed a second examination (1993-1995) an average of 4 years later. The participants were divided into three groups: never, past, and current users based on their baseline estrogen use status. ANCOVA was used to compare the insulin and glucose levels among estrogen use groups. Logistic regression was used to evaluate the association between estrogen use and the incidence of type 2 diabetes.

RESULTS

Postmenopausal estrogen use was associated with lower fasting glucose (0.2 mmol/l lower) but higher 2-h glucose levels (0.4 mmol/l higher) compared with never users. It was not significantly associated with the risk of type 2 diabetes compared with past and never users, based on American Diabetes Association or World Health Organization definitions of diabetes or on only a 2-h glucose level > or = 11.1 mmol/l. However, the risk of type 2 diabetes increased with increasing duration of estrogen use among current users, with an odds ratio of 1.10 per year of use (95% CI: 1.01-1.19).

CONCLUSIONS

The data suggest that estrogen use in American Indian postmenopausal women may relate to deterioration of glucose tolerance. Longer duration of estrogen use among current users may relate to an increased risk of type 2 diabetes.

Antiresorptive treatment of postmenopausal osteoporosis: comparison of study designs and outcomes in large clinical trials with fracture as an endpoint

Antiresorptive treatments for postmenopausal osteoporosis have been studied extensively, but due to the volume of published data and lack of head-to-head trials, it is difficult to evaluate and compare their fracture reduction efficacy. The objective of this review is to summarize the results from clinical trials that have fracture as an endpoint and to discuss the factors in study design and populations that can affect the interpretation of the results. Although there are numerous observational studies suggesting that estrogen and hormone replacement therapies may reduce the risk of vertebral and nonvertebral fractures, there is no large, prospective, randomized, placebo-controlled, double-blind clinical trial demonstrating fracture efficacy. The effects of raloxifene, alendronate, risedronate, and salmon calcitonin on increasing bone mineral density (BMD) and decreasing fracture risk have been shown in randomized, placebo-controlled, double-blind clinical trials of postmenopausal women with osteoporosis. Although the increases in lumbar spine BMD vary greatly in these trials, the decrease in relative risk of vertebral fractures is similar among therapies. However, nonvertebral fracture efficacy has not been consistently demonstrated. Combined administration of two antiresorptive therapies results in greater BMD increases, but the effects on fracture risk are unknown. Direct comparisons of clinical trial results should be considered carefully, given the differences in study design and populations. Differences in study design that may influence the efficacy of fracture risk reduction include calcium and vitamin D supplementation, primary fracture endpoints, definition of vertebral deformity or fracture, discontinuation rates, and statistical power. Factors in the study population that may influence fracture efficacy include the age of the population and the proportion of subjects with prevalent fractures. The use of surrogate endpoints such as BMD to predict fracture risk should be approached with caution, as the relationship between BMD changes and fracture risk reduction with antiresorptive therapies is uncertain. Consideration of these results from clinical trials can contribute to clinical judgment in selecting the best treatment option for postmenopausal osteoporosis.

HRT in women with diabetes--review of the effects on glucose and lipid metabolism

Hormone replacement therapy (HRT) is prescribed less frequently to women with diabetes. In this article, we review the effects of HRT on glucose metabolism and plasma lipids in women with type 2 diabetes. Current evidence is reassuring about the effects of HRT in women with diabetes, although as in all women, HRT should be prescribed on an individual basis with appropriate consideration given to advantages and disadvantages of therapy.

Cell cycle analysis and detection of proliferative cell nuclear antigen of the endometrium after hormone replacement therapy

BACKGROUND

To understand the effect of sequential combined hormone replacement therapy (HRT) on the postmenopausal endometrium.

METHODS

Sonographic endometrial thickness, endometrial histopathology, flow cytometric cell cycle analysis and the level of proliferative cell nuclear antigen (PCNA) were studied.

RESULTS

One hundred and thirty-eight postmenopausal women were enrolled in this study. Among which, 97 women had their endometrium being adequately obtained; the most frequent type of histopathology was normal endometrium (91.8%). Endometrial hyperplasia was found in seven patients (7.2%), including typical simple hyperplasia (n=1, 1%), focal simple hyperplasia (n=5, 5.2%) and complex hyperplasia without atypia (n=1, 1%). The proliferative fractions (PF; S plus G2-M phase) of cells from normal and hyperplastic endometrium of menopausal women after HRT were 8.18 and 8.95%, respectively, which were lower than those from 29 premenopausal women without HRT. The level of PCNA of normal and hyperplastic endometrium in postmenopausal women after HRT was about 80 and 84%, respectively, of that from premenopausal endometrium.

CONCLUSIONS

Our study showed the PF of the cell cycle and the level of PCNA were not increased in the menopausal endometrium under HRT as compared to the premenopausal controls.

Hormone replacement therapy and stroke: risk, protection or no effect?

Despite declining death rates due to stroke over the last several decades, stroke remains the third leading killer (after heart disease and cancer) of women in most developed countries. Because stroke not only kills but also leaves many survivors mentally and physically impaired, control of the disease must be through primary prevention. Several observations lead to the speculation that estrogen may reduce stroke risk. This paper reviews the epidemiologic studies that have evaluated the association of hormone replacement therapy (HRT) and stroke. In the past 25 years, 29 studies have produced no conclusive evidence of a beneficial effect. The lack of consistency in stroke endpoints, definition of HRT user, estrogen preparation, and influence of combined regimen might account in part for the unclear relationship. Nonetheless, the preponderance of evidence suggests that HRT does not increase stroke risk. Some data indicate that estrogen users have a moderately reduced risk of fatal stroke, but details about the optimal dose, duration and type of estrogen are insufficient. The apparent difference in the findings of studies of fatal and non-fatal stroke suggests that estrogen may prevent the most lethal form of stroke or may improve survival. Additional data from ongoing randomized clinical trials in the coming years may help resolve the question of the effect of HRT on stroke morbidity and mortality.

Cardioprotective benefits of hormone replacement therapy

PURPOSE

To examine the effect of hormone replacement therapy (HRT) on adverse cardiac events in postmenopausal women.

DATA SOURCES

A systematic review of all available scientific literature (513 articles) on the cardioprotective benefits of HRT, including research reports, meta-analyses, and commentaries.

CONCLUSIONS

Epidemiological studies have consistently suggested that HRT administered to postmenopausal women significantly lowers the risks of cardiovascular events. However, the claimed benefits might have been exaggerated. The results of the only large randomized clinical trial did not show similar benefits as those reported from observational studies. Research findings about cardiovascular protection of HRT remain inconclusive.

IMPLICATIONS FOR PRACTICE

While waiting for more definitive data, it is appropriate to consider other options that have been proven safe and effective in the prevention of cardiovascular disease.

Glycaemic control and hormone replacement therapy: implications of the Postmenopausal Estrogen/Progestogen Intervention (PEPI) study

Despite evidence that supports the beneficial effects of postmenopausal hormone replacement therapy (HRT), concerns remain about its possible adverse effects. However, entry into the postmenopausal state is associated with many characteristics of the insulin resistance syndrome, including increased cardiovascular morbidity and mortality, accretion of generalised and visceral adiposity and insulin resistance. Studies carried out in postmenopausal women have revealed that an increase in visceral obesity is associated with an increase in androgenicity that, in turn, is associated with type 2 (non-insulin-dependent) diabetes mellitus. Short term studies of HRT containing conjugated estrogens (CEE) and medroxyprogesterone (MPA) have shown prevention of the accretion of visceral fat. However, longer term studies using other techniques suggest that these effects may be evanescent. A few trials suggest that oral estrogen therapy reduces postmenopausal insulin resistance, as suggested by reductions in fasting insulin and glucose levels and an increase in glucose metabolism rates, whereas most studies do not show an adverse effect upon carbohydrate metabolism. MPA may decrease these beneficial effects. Transdermal estrogen is essentially neutral with regard to insulin sensitivity and oral estradiol (17beta-estradiol) may also be neutral or enhance sensitivity. Different progestogens vary in their effects upon carbohydrate metabolism. The Postmenopausal Estrogen/Progestogen Intervention (PEPI) Study was a prospective, 3-year, randomised trial in 875 women that compared placebo, unopposed CEE, CEE plus continuous MPA, CEE plus cyclical MPA, and CEE plus cyclical micronised progesterone. Fasting insulin and glucose levels decreased significantly by 16.1% and 0.122 mmol/L, respectively, in all drug treatment groups. However, after a 75g glucose load, glucose levels at 2 hours increased by 0.33 mmol/L in the active treatment groups without a corresponding increase in insulin levels. No beneficial effects on waist/hip ratio could be demonstrated. Data from the PEPI trial also suggested that the maximum benefit regarding carbohydrate metabolism was achieved in patients who were the most hyperglycaemic and hyperinsulinaemic at the start of therapy. It can be concluded, therefore, that HRT has few, if any, harmful effects on carbohydrate metabolism and that it may be of benefit in women in modifying the long term complications of the postmenopausal state.

Dangerous and common drug interactions in patients with diabetes mellitus

As more medications are made available to the prescriber, the likelihood of drug interactions will increase. The number of drug interactions encountered by the provider treating the patient with diabetes has increased over the past few years because the number of medications used in the management of hyperglycemia has dramatically increased during that time. These interactions are complex but can be predicted.

Cardiovascular risk markers in hypothalamic amenorrhoea

OBJECTIVE

To determine whether women with oestrogen deficiency due to hypothalamic amenorrhoea (HA) would demonstrate a lipid and lipoprotein pattern similar to that seen in menopause with higher total cholesterol (TC), LDL, triglyceride and Lp(a) and lower HDL levels than women with regular menstrual cycles.

DESIGN

Cross-sectional.

PATIENTS

Fifty subjects: 21 women with HA and 30 eumenorrhoeic controls (NL) matched for age, BMI and fat-free mass.

MEASUREMENTS

Lipid and lipoprotein levels.

RESULTS

There was a significant difference in Lp(a) levels in the HA group between women with >19% fat intake and those <19% fat intake (352+/-231 vs. 116+/-62 mg/l, P = 0.006). Percent fat intake was the most significant determinant of Lp(a) levels in HA, accounting for 51% of the variation in Lp(a) levels. Mean HDL levels were higher in the women with HA compared with the controls (1.3+/- 0.3 vs. 1.1+/-0.2 mmol/l, P = 0.002). There was no significant difference between the groups in TC [4.4+/-0.9 (HA) vs. 4.1+/-0.8 mmol/l (NL), P>0.05], LDL [2.8+/-0.6 (HA) vs. 2.7+/-0.7 mmol/l (NL), P>0.05], triglycerides [1.8+/-0.5 (HA) vs. 1.7+/-0.5 mmol/l (NL), P>0.05] or Lp(a) [234+/-199 (HA) vs. 247+/-222 (NL) mg/l, P>0.05] levels.

CONCLUSION

Reduced Lp(a) levels were associated with low dietary fat in women with HA. Moreover, in contrast to menopausal oestrogen deficiency, young women with HA and oestrogen deficiency have increased levels of HDL and no increases in TC, LDL and triglycerides. These data suggest that the negative effects of oestrogen deficiency on cardiovascular risk factors may be modified in women with hypothalamic amenorrhoea.

Hormone replacement therapy and the risk of myocardial infarction in women with coronary risk factors

To assess the risk of myocardial infarction in users of post-menopausal hormone replacement therapy who are at high risk of coronary disease because of hypertension, diabetes mellitus, or smoking, we used data from a previously published case-control study of women 45-74 years. After adjustment for age, ethnicity, and education, the odds ratio for myocardial infarction in current users of hormone replacement therapy was 0.9 (95% confidence interval (CI) = 0.5-1.6) in women with no major coronary risk factors, 0.8 (95% CI = 0.5-1.8) in women with one risk factor, and 1.1 (95% CI = 0.5-2.2) in women with two risk factors.

Hormone replacement therapy and glucose tolerance in EPIC-Norfolk: a population-based study

BACKGROUND

Hormone replacement therapy (HRT) can affect glucose homeostasis in postmenopausal women but it is unclear whether long-term use is associated with changes in glucose tolerance. The objective was to examine the relationship of glycated haemoglobin (HbA(1C)) concentration with HRT use in non-diabetic postmenopausal women.

METHODS

A cross-sectional analysis of baseline data on 2753 postmenopausal women, aged 45-74 years who were recruited to the EPIC-Norfolk study between 1995 and 1998 was performed. Women completed a health and lifestyle questionnaire from which information on HRT use was obtained and gave blood for HbA(1C) assay.

RESULTS

Of the women, 23% were current HRT users and 14% were former users. Mean HbA(1C) was significantly lower in current users compared to former and never users. This difference was independent of age, body mass index (BMI), waist-to-hip ratio (WHR), family history of diabetes, educational status, employment status, smoking history, history of alcohol consumption, parity, known illness and hysterectomy status. Compared to never users of HRT, the unadjusted odds ratio (OR) for being in the highest quintile of HbA(1C) distribution as opposed to the lowest was 0.28 (95% CI 0.20-0.39) for current users and 0.41 (0.32-0.53) for ever users. After adjustment for confounders, the OR were 0.52 (0.34-0.79) and 0.72 (0. 51-1.03) for current and ever users, respectively.

CONCLUSION

Women currently using HRT have lower HbA(1C) levels not explained by known confounders though we cannot completely exclude a healthy user effect. Nevertheless, this population study suggest that current use of HRT was not associated with impairment of glucose tolerance in postmenopausal women.

Postmenopausal hormone therapy and the risk of colorectal cancer: a review and meta-analysis

PURPOSE

Colorectal cancer is the fourth most common cancer and the second leading cause of cancer death in the United States. Accumulating evidence indicates that postmenopausal hormone therapy may reduce the risk of colorectal cancer in women.

METHODS

Through MEDLINE computer searches (January 1966 to September 1998) and a review of references, we identified English-language articles with quantitative data on the relation of postmenopausal hormone therapy to colorectal cancer. We reviewed the studies and made summary estimates of relative risks (RR) by weighting the results of each study in proportion to its precision, using a general variance-based, fixed-effects model.

RESULTS

In our meta-analysis of 18 epidemiologic studies of postmenopausal hormone therapy and colorectal cancer, we found a 20% reduction [RR = 0.80, 95% confidence interval (CI), 0.74 to 0.86] in risk of colon cancer and a 19% decrease (RR = 0.81, 95% CI, 0.72 to 0.92) in the risk of rectal cancer for postmenopausal women who had ever taken hormone therapy compared with women who never used hormones. Much of the apparent reduction in colorectal cancer was limited to current hormone users (RR = 0.66, 95% CI, 0.59 to 0.74).

CONCLUSION

Observational studies suggest a reduced risk of colorectal cancer among women taking postmenopausal hormones. There is biologic evidence to support this association.

A case-control study of hormone replacement therapy after primary surgical breast cancer treatment

AIMS

To investigate the presumed influence of hormone replacement therapy (HRT) on the progression of and death due to breast cancer.

METHODS

In order to make a detailed analysis, we selected a group of 21 patients with the diagnosis of invasive breast cancer who had HRT after primary surgical treatment. Each patient from the selected group was compared with two patients from the control group with the diagnosis of invasive breast cancer who did not have HRT after primary surgical treatment. The control cases were matched to selected HRT patients with regard to age at time of the diagnosis, year of diagnosis, diameter of the tumour, metastatic spread in the axillary lymph nodes, and disease-free interval until applying HRT. The same criteria were applied in all analyses. The data were analysed by odds ratio (OR) calculation with a confidence interval of 95%, taking into account residual malignancy and death due to breast cancer in both groups (including carcinoma in the contralateral breast).

RESULTS

HRT was applied in 21 patients treated for breast cancer. In 33% of them, radical mastectomy revealed metastases in the axillary lymph nodes. Hormone receptors could not be found in 57% of patients. In the majority of patients the tumour measured 17.6mm in diameter. HRT was started on average 62 months (range 1-180 months) after diagnosis, and lasted an average of 28 months (range 3 72 months). All 21 patients used oestradiol as HRT, i.e. a non-conjugated oestrogen. Combined hormonal therapy (oestrogens + progestagens) was given to 95% of patients with median age of 47 years (range 41-59 years) at the beginning of HRT. Relapse was observed in four patients (19%) of the HRT group; of these, one had a carcinoma of the contralateral breast. In the control group, relapse was observed in five patients (11%); one of these five patients had a carcinoma of the contralateral breast. In the HRT group, there were no deaths among the patients with confirmed relapse, while one patient died in the control group. The estimated risk (OR= 1.74, 95%S CI 0.34-8.88) of relapse of breast cancer was calculated by comparing data from HRT users, who had received HRT for 28 months (range 3-72 months) on average, with data from the control group. The estimated risk of breast cancer relapse in HRT users who had been receiving HRT for less than 24 months was 0.65 (OR = 0.65, 95% CI 0.02-7.85).

CONCLUSION

Despite the inherent limitations of retrospective data and the need for prospective randomized trials to assess the possible influence of HRT on progression after breast cancer treatment, the present observations suggest that HRT treatment for less than 24 months does not appear to have a pronounced adverse effect on cancer outcome. Nevertheless, until appropriate clinical trials determine that HRT is safe, caution is needed.

Physiological doses of estradiol decrease nocturnal blood pressure in normotensive postmenopausal women

The effect of a 2-mo treatment with transdermal estradiol (50 microgram/day) versus placebo on 24 h of blood pressure rhythm was investigated in 18 normotensive healthy postmenopausal women. Whereas daytime blood pressure was not modified, nighttime blood pressure was reduced by estradiol. Estradiol magnified the nocturnal decrement of systolic (14.3 +/- 7.2 vs. 9.8 +/- 6.7 mmHg, P = 0. 0033), diastolic (11.6 +/- 5.0 vs. 7.5 +/- 7.3 mmHg, P = 0.028), and mean (10.8 +/- 5.6 vs. 7.2 +/- 4.5 mmHg, P = 0.011) blood pressure. As a consequence, the 24-h rhythm of mean blood pressure was restored in 50% of the subjects (P = 0.045) in whom it was absent and was amplified in the remaining 50% of the subjects. Body mass index was an independent determinant of blood pressure values being directly related to the amplitude of the 24-h mean blood pressure rhythm (r2 = 0.38; P = 0.0067). In normotensive postmenopausal women, physiological doses of estradiol amplify the nocturnal decline of blood pressure.

Transdermal estrogen replacement therapy and plasma lipids in 693 French women

OBJECTIVES

The cardiovascular effects of transdermal estrogen are not so well established than those induced by oral estrogen. In a representative sample of French postmenopausal women, we assessed plasma lipid changes induced by transdermal 17 beta-estradiol.

METHODS

This cross-sectional study was carried out among the population sample of the third MONICA survey on cardiovascular risk factors. We selected 693 postmenopausal women according to the followed criteria; women with intact uterus and no menstruation for more than 12 months, women with bilateral oophorectomy, hysterectomized women older than 55 years and hysterectomized women who had followed hormone replacement therapy. We used multivariate linear regression models, taking into account confounding variables, to assess lipid changes induced by estrogen.

RESULTS

We compared 192 women currently taking transdermal 17 beta-estradiol (27 unopposed estrogen and 165 estrogen plus progestin) with 501 women without any hormonal treatment. After adjustment for living area, education level, income tax, smoking, alcohol consumption, physical activity, age and body mass index, transdermal estrogen replacement therapy (ERT) was significantly associated with lower levels of serum total cholesterol [6.10 (S.E., 0.11) vs 6.35 (0.09) mmol/l, P < 0.01], triglycerides [1.06 (0.06) vs 1.23 (0.05) mmol/l, P < 0.001], LDL-cholesterol [3.93 (0.11) vs 4.13 (0.09) mmol/l, P < 0.05], VLDL-cholesterol [0.48 (0.03) vs 0.56 (0.02) mmol/l, P < 0.001] and apolipoprotein B [1.20 (0.03) vs 1.26 (0.02) g/l, P < 0.01]. Levels did not differ significantly for HDL-cholesterol [1.68 (0.05) vs 1.66 (0.04) mmol/l] and apolipoprotein A1 [1.79 (0.03) vs 1.81 (0.02) g/l].

CONCLUSION

Transdermal ERT may confer a cardiovascular protection by lowering atherogenic lipoproteins.

Estrogen replacement reverses endothelial dysfunction in postmenopausal women

PURPOSE

To measure the effect of long-term clinical hormone replacement therapy on brachial artery vasomotor responses, and to compare these responses in premenopausal and postmenopausal women.

PATIENTS AND METHODS

We studied 23 postmenopausal women, including 18 who were evaluated prior to starting clinically indicated oral hormone replacement therapy. Twelve postmenopausal women received estrogen alone, the other 6 were treated with estrogen/medroxyprogesterone combinations. Eleven premenopausal volunteers served as a comparison group. Change in brachial artery diameter in response to postischemic hyperemic flow and sublingual nitroglycerin was measured by ultrasound.

RESULTS

The 18 postmenopausal subjects receiving hormone replacement showed a progressive improvement in their postischemic vasodilation. Mean (+/-SD) postischemic vasodilation was 0.4%+/-7.1% prior to estrogen replacement. There were significant increases in postischemic vasodilation of 4.8%+/-6.6% after 1 month and 8.3%+/-3.4% after 6 months of estrogen replacement. The response to nitroglycerin was similar at all time points studied. Women with the most abnormal responses to hyperemic flow at baseline demonstrated the greatest improvement after 6 months of hormone replacement therapy. Premenopausal and postmenopausal subjects differed in their response to hyperemic flow, with premenopausal women showing 5.8% vasodilatation compared with a 0.6% vasodilation in postmenopausal women (P=0.046).

CONCLUSIONS

Endothelial function is abnormal in many postmenopausal women compared with premenopausal women, and in some postmenopausal women it can be enhanced by estrogen replacement therapy. This effect may increase with prolonged use.

Ischemic stroke and use of estrogen and estrogen/progestogen as hormone replacement therapy

BACKGROUND AND PURPOSE

Information about the risk of stroke in current postmenopausal hormone users is limited.

METHODS

In this case-control study, women aged 45 to 74 years hospitalized with a fatal or nonfatal stroke in any of 10 Northern California Kaiser Permanente facilities during the period November 1991 to November 1994 were identified as cases. Controls were selected at random from female Health Plan members. Data regarding use of estrogen plus progestogen or estrogen alone were obtained in interviews.

RESULTS

The analysis was based on nonproxy responses from 349 cases of ischemic stroke and 349 matched control subjects. After adjustment for confounders, the odds ratio for ischemic stroke in current hormone users was 1.03 (95% confidence interval, 0.65 to 1.65). The odds ratios for ischemic stroke in current hormone users showed no clear trend of increasing or decreasing risk in relation to duration of hormone use. The odds ratio for ischemic stroke in past hormone users was 0.84 (95% confidence interval, 0.54 to 1.32).

CONCLUSIONS

In this study postmenopausal hormone use was not associated with an increase or decrease in the risk of ischemic stroke, a finding that is consistent with the body of literature on this topic.

Hormone replacement therapy and risk of non-fatal stroke

BACKGROUND

The effect of postmenopausal hormone replacement therapy (HRT) on the risk of subtypes of stroke is as yet unclear. To investigate the effect of oestrogen and combined oestrogen-progestagen therapy on the risk of non-fatal haemorrhagic and thromboembolic stroke, we carried out a case-control study.

METHODS

From the Danish National Patient Register we identified all Danish women aged 45-64 years who had a non-fatal, first-ever cerebrovascular attack during 1990-92. Two age-matched controls were randomly selected for each case from the Danish National Person Register. Important correlates of hormone use and stroke, on which information was obtained from postal questionnaires, were controlled for by multivariate analyses based on log-linear graphical models. The analyses included data on 1422 cases classified in four subtypes of stroke (160 subarachnoid haemorrhage, 95 intracerebral haemorrhage, 846 thromboembolic infarction, 321 transient ischaemic attack) and 3171 controls.

FINDINGS

After adjustment for confounding variables and correction for the trend in sales of HRT preparations, no significant associations were detected between current use of unopposed oestrogen replacement therapy and non-fatal subarachnoid haemorrhage (odds ratio 0.52 [95% CI 0.23-1.22]), intracerebral haemorrhage (0.15 [0.02-1.09]), or thromboembolic infarction (1.16 [0.86-1.58]), respectively, compared with never use. Current use of combined oestrogen-progestagen replacement therapy had no significant influence on the risk of subarachnoid haemorrhage (1.22 [0.79-1.89]), intracerebral haemorrhage (1.17 [0.64-2.13]), or thromboembolic infarction (1.17 [0.92-1.47]). A significantly increased incidence of transient ischaemic attacks among former users of HRT and among current users of unopposed oestrogen may to some extent be explained by selection--HRT users being more aware of symptoms than non-users.

INTERPRETATION

Unopposed oestrogen and combined oestrogen-progestagen replacement therapy have no influence on the risk of non-fatal thromboembolic or haemorrhagic stroke in women aged 45-64 years.

HRT and the risk of deep vein thrombosis

Venous thromboembolism (VTE) has long been recognized as a risk of oral contraceptive use in women, but until recently hormone replacement therapy (HRT) was not thought to be associated with a similar risk; the epidemiological literature having been reassuring. The recent publication of four independent epidemiological studies has changed our perspective on VTE risk on HRT. These studies suggest that the risk of VTE may be increased by up to three-fold during HRT. However, the absolute risk remains low at approximately one occurrence in 5000 woman-years and appears greatest in the early years of HRT use. However, given that mortality from VTE is low, it seems unlikely that these new findings will substantially change the overall balance of benefits and risks associated with long-term HRT.

Androgen deprivation is associated with enhanced endothelium-dependent dilatation in adult men

Male gender is an independent risk factor for coronary artery disease, and androgen administration has been associated with increased atherosclerosis in experimental animals. Since endothelial dysfunction is an important event in the atherogenic process, we hypothesized that androgen deprivation in adult men might be associated with enhanced arterial endothelial function. Using external vascular ultrasound, brachial artery diameter was measured at rest, after flow increase (causing endothelium-dependent dilatation) and after nitroglycerin (an endothelium-independent dilator). We studied 30 adult males aged 40 to 70 years: 10 had had bilateral orchidectomy and/or maximal androgen blockade for > or = 6 months for treatment of prostate cancer, and all were in complete remission (group 1). Ten healthy controls (group 2) and 10 controls who had remission from nonprostate cancers (group 3) were matched for age and smoking history. Testosterone levels were lower in men in group 1 versus groups 2 or 3 (0.8 +/- 0.1 versus 19.2 +/- 8.4 or 16.1 +/- 4.9 nmol/L, P < .001). By contrast, endothelium-dependent dilatation was markedly higher in group 1 than in groups 2 or 3 (6.2 +/- 3 versus 2.7 +/- 2 or 2.0 +/- 1.9%, P < .001). The nitroglycerin response was similar in all three groups (P = .92). On multivariate analysis, increased endothelium-dependent dilatation was significantly associated with low serum testosterone levels (P = .001) but not with cholesterol levels or with a past history of malignancy (P > .25). The withdrawal of male sex hormones may be associated with enhanced endothelial function in adult men. This is consistent with a deleterious effect of physiologic levels of male sex steroids on the arterial wall.

Effect of hormone replacement therapy on non-invasive cardiovascular haemodynamics

OBJECTIVE

To determine the detailed effects of hormone replacement therapy (HRT) on non-invasive haemodynamics, including an assessment of the effect on the pulsatile afterload assessed in terms of the augmentation index and pulse-wave velocity.

DESIGN

A cross-sectional study of healthy postmenopausal women using carotid and radial tonometry and pulse-wave velocity measurements.

SETTING

Community-based ambulatory women attending the menopause centre at a tertiary hospital.

PATIENTS

Seventy postmenopausal women divided into those not currently being administered HRT (n = 38, aged 46-72 years) and those who were being administered a variety of HRT (n = 32, aged 49-67 years).

METHODS

Central arterial pressure waveforms were measured using carotid applanation tonometry to derive the augmentation index and ejection duration. The arterial pulse-wave velocity was assessed using paired carotid, radial and dorsalis tonometry waveforms.

RESULTS

Women being administered HRT had a significantly lower augmentation index (20.4 +/- 8.6 versus 27.0 +/- 10.2%, P = 0.005) and shorter ejection times (320 +/- 17 versus 329 +/- 18 ms, P = 0.037). There was no significant difference in brachial blood pressure (131/76 versus 129/77 mmHg). Women being administered HRT exhibited a greater reversal in the age-related loss of amplification which occurs owing to arterial stiffening. This amplification between central and peripheral systolic blood pressures was greater among women being administered HRT (5.3 +/- 6.2 versus 2.2 +/- 4.0 mmHg, P = 0.014). There was no difference in pulse-wave velocity between the two groups.

CONCLUSIONS

HRT appears to improve the pulsatile vascular afterload by decreasing the augmentation of the late systolic blood pressure. This effect is not apparent from routine brachial cuff measurements, which, as a result, may underestimate haemodynamic benefits. Such effects may help to explain a portion of the improvement in cardiovascular morbidity found in other trials.

Estrogen replacement therapy following oophorectomy in women with a family history of ovarian cancer

Compliance with estrogen replacement therapy (ERT) following surgical menopause is poor. In women who have a family history of ovarian cancer, fear of the oncogenic potential of estrogen might affect compliance with ERT following oophorectomy. Compliance with ERT in such a select group of women has not been previously reported. The aim of the present study was to report on compliance with and side effects of ERT in women with a family history of ovarian cancer who underwent oophorectomy either prophylactically or for benign disease. Eighty women with a family history of ovarian cancer who underwent oophorectomy at Roswell Park Cancer Institute were followed for a median duration of 4.2 years (range, 5 months to 14 years). Of the 76 women who were given prescriptions for ERT, the rates of commencement and maintenance of ERT at 1, 2, and 5 years were calculated. Side effects related to the different modalities of ERT were recorded. Seventy-one of 76 women (93.4%) who were given prescriptions for ERT initiated treatment. The rate of commencement of ERT was higher in premenopausal than in postmenopausal women (98.3% versus 75%, respectively, P = 0.003). Except for one patient who developed breast cancer after the oophorectomy and was advised to stop estrogen, all patients said they continued to use ERT. The maintenance rates at 1, 2, and 5 years were 100% as per patients' history. The pharmacy records for ERT prescription refills were reviewed for 52 patients who were on ERT for more than 1 year. ERT compliance was confirmed in 42 patients (80.7%). Seven of 30 patients (23.3%) who retained their uterus developed irregular uterine bleeding and 4 underwent endometrial biopsies. The incidence of irregular uterine bleeding was significantly higher after continuous compared to cyclic estrogen and progestogen (37.6 and 7% respectively, P = 0.049). Four patients (5.6%) complained of hot flashes and were managed by changing the dose or formula of estrogen. Compliance with ERT among patients with a family history of ovarian cancer who underwent oophorectomy either prophylactically or for benign disease was excellent. The presence of the uterus and the incidence of irregular uterine bleeding did not affect patients' compliance with ERT.