Progestagen supplementation of exogenous oestrogens and risk of endometrial cancer

Hormone replacement therapy for women previously treated for endometrial cancer

BACKGROUND

Endometrial cancer is the sixth most common cancer in women worldwide and most commonly occurs after the menopause (75%) (globocan.iarc.fr). About 319,000 new cases were diagnosed worldwide in 2012. Endometrial cancer is commonly considered as a potentially 'curable cancer,' as approximately 75% of cases are diagnosed before disease has spread outside the uterus (FIGO (International Federation of Gynecology and Obstetrics) stage I). The overall five-year survival for all stages is about 86%, and, if the cancer is confined to the uterus, the five-year survival rate may increase to 97%. The majority of women diagnosed with endometrial cancer have early-stage disease, leading to a good prognosis after hysterectomy and removal of the ovaries (oophorectomy), with or without radiotherapy. However, women may have early physiological and psychological postmenopausal changes, either pre-existing or as a result of oophorectomy, depending on age and menopausal status at the time of diagnosis. Lack of oestrogen can cause hot flushes, night sweats, genital tract atrophy and longer-term adverse effects, such as osteoporosis and cardiovascular disease. These changes may be temporarily managed by using oestrogens, in the form of hormone replacement therapy (HRT). However, there is a theoretical risk of promoting residual tumour cell growth and increasing cancer recurrence. Therefore, this is a potential survival disadvantage in a woman who has a potentially curable cancer. In premenopausal women with endometrial cancer, treatment induces early menopause and this may adversely affect overall survival. Additionally, most women with early-stage disease will be cured of their cancer, making longer-term quality of life (QoL) issues more pertinent. Following bilateral oophorectomy, premenopausal women may develop significant and debilitating menopausal symptoms, so there is a need for information about the risk and benefits of taking HRT, enabling women to make an informed decision, weighing the advantages and disadvantages of using HRT for their individual circumstances.

OBJECTIVES

To assess the risks and benefits of HRT (oestrogen alone or oestrogen with progestogen) for women previously treated for endometrial cancer.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL 2017, Issue 5), MEDLINE (1946 to April, week 4, 2017) and Embase (1980 to 2017, week 18). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of review articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), in all languages, that examined the efficacy of symptom relief and the safety of using HRT in women treated for endometrial cancer, where safety in this situation was considered as not increasing the risk of recurrence of endometrial cancer above that of women not taking HRT.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We identified 2190 unique records, evaluated the full text of seven studies and included one study with 1236 participants. This study reported tumour recurrence in 2.3% of women in the oestrogen arm versus 1.9% of women receiving placebo (risk ratio (RR) 1.17, 95% confidence interval (CI) 0.54 to 2.50; very low-certainty evidence). The study reported one woman in the HRT arm (0.16%) and three women in the placebo arm (0.49%) who developed breast cancer (new malignancy) during follow-up (RR 0.80, 95% CI 0.32 to 2.01; 1236 participants, 1 study; very low-certainty evidence). The study did not report on symptom relief, overall survival or progression-free survival for HRT versus placebo. However, they did report the percentage of women alive with no evidence of disease (94.3% in the HRT group and 95.6% in the placebo group) and the percentage of women alive irrespective of disease progression (95.8% in the HRT group and 96.9% in the placebo group) at the end of the 36 months' follow-up. The study did not report time to recurrence and it was underpowered due to closing early. The authors closed it as a result of the publication of the Women's Health Initiative (WHI) study, which, at that time, suggested that risks of exogenous hormone therapy outweighed benefits and had an impact on study recruitment. No assessment of efficacy was reported.

AUTHORS' CONCLUSIONS

Currently, there is insufficient high-quality evidence to inform women considering HRT after treatment for endometrial cancer. The available evidence (both the single RCT and non-randomised evidence) does not suggest significant harm, if HRT is used after surgical treatment for early-stage endometrial cancer. There is no information available regarding use of HRT in higher-stage endometrial cancer (FIGO stage II and above). The use of HRT after endometrial cancer treatment should be individualised, taking account of the woman's symptoms and preferences, and the uncertainty of evidence for and against HRT use.

Committee Opinion No. 698: Hormone Therapy in Primary Ovarian Insufficiency

Primary ovarian insufficiency describes a spectrum of declining ovarian function and reduced fecundity due to a premature decrease in initial follicle number, an increase in follicle destruction, or poor follicular response to gonadotropins. The sequelae of primary ovarian insufficiency include vasomotor symptoms, urogenital atrophy, osteoporosis and fracture, cardiovascular disease, and increased all-cause mortality. In women with primary ovarian insufficiency, systemic hormone therapy (HT) is an effective approach to treat the symptoms of hypoestrogenism and mitigate long-term health risks if there are no contraindications to treatment. Hormone therapy is indicated to reduce the risk of osteoporosis, cardiovascular disease, and urogenital atrophy and to improve the quality of life of women with primary ovarian insufficiency. Although exogenous estrogen replacement is recommended for women with primary ovarian insufficiency, data comparing various hormonal regimens for disease prevention, symptom amelioration, and safety are lacking in this population. As a first-line approach, HT (either orally or transdermally) that achieves replacement levels of estrogen is recommended. Combined hormonal contraceptives prevent ovulation and pregnancy more reliably than HT; despite only modest odds of spontaneous pregnancy in women with primary ovarian insufficiency, this is a critical consideration for those who deem pregnancy prevention a priority. Treatment for all women with primary ovarian insufficiency should continue until the average age of natural menopause is reached (age 50-51 years). Finally, considering the challenges that adolescents and young women may face in coping with the physical, reproductive, and social effects of primary ovarian insufficiency, comprehensive longitudinal management of this condition is essential.

Levonorgestrel intrauterine system for endometrial protection

Progestogen is added to estrogen in hormone replacement therapy solely to provide endometrial protection, so it is logical to deliver it to its site of action. The levonorgestrel intrauterine system, which delivers 20 mug levonorgestrel per day, is now licensed for use as the progestogen component of continuous combined hormone replacement therapy. No cases of endometrial hyperplasia or carcinoma, and no significant increase in endometrial thickness, have been reported in clinical trials. The bleeding profile is similar to that obtained with other types of continuous combined hormone replacement therapy. The levonorgestrel intrauterine system thus provides a potentially bleed-free alternative to sequential therapy for perimenopausal women.

Risk-reducing surgery in hereditary gynecological cancer: Clinical applications in Lynch syndrome and hereditary breast and ovarian cancer

Risk-reducing surgery (RRS) is defined as a prophylactic approach with removal of organs at high risk of developing cancer, which is performed in cases without lesions or absence of clinically significant lesions. Hereditary gynecological cancers for which RRS is performed include hereditary breast and ovarian cancer (HBOC) and Lynch syndrome. For HBOC, RRS in the United States (US) is recommended for women with mutations in the breast cancer susceptibility (BRCA)1 and BRCA2 genes and bilateral salpingo-oophorectomy (BSO) is generally performed. This procedure may reduce the risk of breast, ovarian, Fallopian tube and primary peritoneal cancer, although ovarian deficiency symptoms occur postoperatively. For Lynch syndrome, RRS in the US is considered for postmenopausal women or for women who do not desire to bear children and BSO and hysterectomy are usually performed. This approach may reduce the risk of endometrial and ovarian cancer, although ovarian deficiency symptoms also occur. For RRS, there are several issues that must be addressed to reduce the risk of cancer development in patients with HBOC or Lynch syndrome. To the best of our knowledge, this is the first review to discuss RRS with a focus on hereditary gynecological cancer.

Risk-Benefit Analysis of Combination vs. Unopposed HRT in Post-Menopausal Women

Many trials on the use of hormone replacement therapy (HRT) have provided contradictory results on its risks and benefits in post-menopausal women. The use of HRT declined globally following publication of the first data from the Women’s Health Initiative (WHI) trial in 2002, with the revelation that there was an increased risk of breast cancer and coronary heart disease (CHD) in postmenopausal women taking HRT. Following this, other leading studies published results that were consistent with these findings, which reduced enthusiasm for HRT use. However, recent publications from the International Menopause Society indicate that HRT is the first-line and most effective treatment for menopausal symptoms. Moreover, when the full results of the WHI trial were subsequently published, it appeared that HRT may confer benefits for CHD prevention below age 60. The statements from the British Menopause Society and the International Menopause Society (IMS) published in 2008 also supported this opinion. These revelations renew interest in HRT use. This paper analyzes the effects of combination versus unopposed HRT on osteoporosis, breast and CHD, endometrial cancer induction, venous thromboembolic disease, lipids and lipoproteins, neuroprotection, and cognitive function in post-menopausal women.

Bazedoxifene/conjugated estrogens for menopausal symptom treatment and osteoporosis prevention

Postmenopausal women with vasomotor and vaginal symptoms are commonly treated with estrogens or combined estrogen/progestin therapy (hormone therapy). However, hormone therapy is associated with some safety and tolerability concerns and its benefit/risk profile may vary for women based on their time since menopause. The tissue selective estrogen complex (TSEC) pairs a selective estrogen receptor modulator with one or more estrogens, with the goal of relieving menopausal symptoms and preserving bone mineral density without stimulating the breast or endometrium. Bazedoxifene/conjugated estrogens (BZA/CE) is the first TSEC in clinical development. BZA 20 mg/CE 0.45 and 0.625 mg have been shown in phase-3 clinical trials to significantly improve hot flushes and vulvar/vaginal atrophy measures in symptomatic postmenopausal women and to prevent bone loss in postmenopausal women at risk for osteoporosis while ensuring endometrial safety. These doses of BZA/CE have also demonstrated significant improvements in quality-of-life scores, sleep parameters, and treatment satisfaction compared with placebo. BZA 20 mg/CE 0.45 and 0.625 mg showed high cumulative rates of amenorrhea and low rates of breast pain, similar to those with placebo. The favorable treatment effects seen with BZA/CE were generally consistent in women < 5 or ≥ 5 years since menopause. Based on its demonstrated efficacy and safety in women both closer to or further from menopause, BZA/CE may be an appropriate alternative to hormone therapy for the treatment of menopausal symptoms and the prevention of osteoporosis.

Incorporating bazedoxifene/conjugated estrogens into the current paradigm of menopausal therapy

Many women experience bothersome vasomotor and vaginal symptoms during the menopausal transition. Decreasing levels of estrogens during menopause are also associated with reduced bone density and an increased risk of osteoporosis. Combined estrogen/progestin therapy (hormone therapy) effectively treats menopausal symptoms and prevents bone loss, but has been associated with some safety and tolerability concerns. A novel menopausal therapy is the tissue selective estrogen complex, which pairs a selective estrogen receptor modulator with one or more estrogens. In preclinical studies, the tissue selective estrogen complex partnering bazedoxifene (BZA) with conjugated estrogens (CE) antagonized stimulation of breast and endometrial tissue, reduced vasomotor instability, and preserved bone mass in rat and mouse models. The specific attributes seen with BZA/CE were different from those observed with other selective estrogen receptor modulator/estrogen pairings. BZA/CE has undergone clinical evaluation in the Phase III Selective estrogens, Menopause, And Response to Therapy (SMART) trials in postmenopausal women with an intact uterus. Of the various doses of BZA/CE evaluated, BZA 20 mg/CE 0.45 mg and 0.625 mg were associated with a low incidence of endometrial hyperplasia (<1%) similar to placebo, and showed significant improvements in hot flushes and vulvar/vaginal symptoms and increases in bone mineral density. BZA 20 mg/CE 0.45 mg and 0.625 mg were associated with a low incidence of breast-related adverse events and demonstrated no difference from placebo in age-related changes in mammographic breast density. Both BZA/ CE doses showed a favorable tolerability profile, with no increases in uterine bleeding or breast tenderness, and had positive effects on metabolic parameters and quality of life. BZA/CE may be a promising alternative to hormone therapy for the treatment of menopausal symptoms and prevention of osteoporosis in nonhysterectomized postmenopausal women.

Nitric oxide production and blood corpuscle dynamics in response to the endocrine status of female rats

INTRODUCTION

Menopause is associated with marked changes in the endocrine profile, and increases the risk of vascular disease. However, the effect of hormones on the vascular system is still unclear. Therefore, the aim of this study was to examine the effects of endocrine status in female rats on nitric oxide (NO) production, inflammatory reactions and thrombus organization potency in the mesenteric microcirculation.

MATERIALS AND METHODS

Female Wistar rats were divided into four groups: proestrus, metestrus, ovariectomized (OVX) and OVX plus estradiol treatment (OVX+E2). NO was imaged using an NO-sensitive dye. The leukocyte and platelet velocities relative to the erythrocyte velocity (VW/VRC and VP/VRE, respectively) and thrombi sizes created by laser radiation were measured as thrombogenesis indices.

RESULTS

Changes in endocrine status did not affect vascular function in the arterioles. However, in venules, NO production, VW/VRC and VP/VRE were decreased in the OVX group compared with the proestrus and metestrus states. Thrombus size was significantly greater in the OVX group than in the proestrus and metestrus states. Administration of E2 for 2 weeks restored NO production, VW/VRC and VP/VRE to control levels.

CONCLUSIONS

Changes in endocrine status did not affect arterioles. In contrast, in venules, reduced estrogen levels led to a decrease in NO production, thereby increasing thrombogenesis. Estrogen replacement restored NO production and leukocyte and platelet velocities, reducing thrombus formation relative to OVX. Although it is unclear how E2 reduces thrombus formation, our results indicate that leukocyte and platelet adhesion to the endothelium is a target for E2 via NO.

Estrogen after ischemic stroke: clinical basis and design of the Women's Estrogen for Stroke Trial

BACKGROUND AND PURPOSE

Observational studies have found that women who take estrogen after menopause are less likely to have a stroke than women who do not take estrogen. Although these findings indicate that estrogen may prevent stroke, an alternative explanation for the improved outcome of estrogen users is that they are healthier before starting therapy than nonusers. To test the therapeutic effect of estrogen with research methods that avoid this selection bias, we designed a randomized controlled trial.

TRIAL DESIGN

The Women's Estrogen For Stroke Trial (WEST) is a double-blind, randomized trial with a primary goal of determining whether 1 mg 17beta-estradiol daily, when compared with placebo, reduces the risk of recurrent stroke or death among postmenopausal women who have experienced a transient ischemic attack or nondisabling ischemic stroke. Exclusion criteria include use of estrogen at the time of stroke, breast or uterine cancer, inability to speak English, and estimated survival less than 5 years. Once randomized, women remain under the care of their personal physicians for management of stroke risk factors. For early detection of endometrial hyperplasia and cancer, asymptomatic women receive medroxyprogesterone yearly (5 mg for 12 days) and vaginal ultrasonography or biopsy at the end of the trial. Unscheduled uterine bleeding is evaluated with biopsy. A total of 652 women are sought at 20 hospitals in Connecticut and one in Massachusetts.

CONCLUSIONS

The WEST promises to provide critical guidance to women and their physicians regarding the effectiveness of estrogen in secondary stroke prevention.

Transdermal estradiol for postpartum depression: a promising treatment option

Postpartum depression (PPD) is the most common unrecognized complication of childbirth and affects 1 out of 7 childbearing women. Although conventional pharmacologic and psychotherapeutic antidepressant treatments are effective for PPD, a natural alternative may be preferred by postpartum women, especially those who breastfeed their infants. The treatment of PPD with synthetic forms of naturally occurring estrogen is mechanistically appealing because PPD occurs in the context of estrogen withdrawal at parturition. Preliminary evidence suggests that PPD is a disorder of hormone-related mood dysregulation (similar to perimenopausal depression) that can be effectively treated with estrogen. This review provides the basic science and clinical background as well as safety considerations to support the application of transdermal estradiol as a treatment for PPD. We conclude that estradiol treatment for PPD requires confirmation of efficacy in a randomized clinical trial before routine clinical use as monotherapy. Additional data regarding maternal tolerability of cyclic progestins, long-term safety of estradiol treatment, estradiol passage into breast milk and infants, and interdisciplinary collaboration among psychiatrists and gynecologists is also needed before estradiol is used in women who decline or fail to respond to first-line antidepressant treatments, or as an augmentation of conventional antidepressant treatment.

Bazedoxifene/conjugated estrogens and quality of life in postmenopausal women

OBJECTIVE

To assess the effects of bazedoxifene/conjugated estrogens (BZA/CE) on sleep parameters and health-related quality of life (HR-QOL).

METHODS

This was a 12-week, multicenter, double-blind, placebo-controlled phase 3 study. Postmenopausal women with an intact uterus and experiencing >or=7 moderate-to-severe hot flushes daily were randomized to BZA 20 mg/CE 0.45 mg, BZA 20 mg/CE 0.625 mg, or placebo. In these secondary efficacy analyses, the Medical Outcomes Study (MOS) sleep scale and Menopause-Specific Quality of Life (MENQOL) questionnaires and the Menopause Symptoms Treatment Satisfaction Questionnaire (MS-TSQ) evaluated measures of sleep, menopausal symptoms, and satisfaction with treatment, respectively.

RESULTS

A total of 318 subjects (mean age, 53.4 years) received >or=1 dose of study drug. At Week 12, BZA 20 mg/CE 0.45 and 0.625 mg showed significant improvements over placebo in the MOS sleep scale for time to fall asleep, sleep adequacy, sleep disturbance, and sleep problems indexes I and II (P<0.001). A reduction in hot flush frequency was significantly associated with improvement in sleep parameters (P<0.05) based on linear regression and responder analyses. Both BZA/CE doses showed significantly greater improvements over placebo in vasomotor function and total MENQOL score (P<0.001). Results of the MS-TSQ showed that subjects treated with BZA/CE versus placebo reported significantly greater overall satisfaction with treatment (P<0.05), as well as greater satisfaction with sleep quality, ability to control hot flushes during the day and night, effect on mood/emotions, and tolerability.

CONCLUSION

Symptomatic postmenopausal women treated with BZA/CE experienced significant improvements in sleep parameters and overall HR-QOL.

Comparative analysis of oestrogen and raloxifene effects on the phospholipid composition of high density lipoproteins in healthy postmenopausal women

The beneficial effect of selective oestrogen receptor modulators such as raloxifene in cardiovascular disease may be mediated partly by favourable changes in the phospholipid composition of high density lipoprotein (HDL) subclasses. In Group A (oestrogen alone) HDL2 phosphatidylcholine increased (P<0.001), while there was a decrease in HDL2 phosphatidylinositol (P<0.05) and HDL2 phosphatidylethanolamine (P<0.05) compared to controls (baseline). In the same group, HDL3 phosphatidylcholine increased (P<0.001) and HDL3 phosphatidylethanolamine decreased (P<0.01). In Group B (raloxifene) HDL2 phosphatidylcholine increased (P<0.001) as well as HDL2 diphosphatidylglycerol (P<0.01) while there were decreases in HDL2 sphingomyelin (P<0.01) and HDL2 phosphatidylethanolamine (P<0.05). In the same group, an increase in HDL3 phosphatidylcholine (P<0.001) and a reduction in HDL3 phosphatidylinositol (P<0.05) were observed as well as a decrease in HDL3 phosphatidylethanolamine (P<0.01) and HDL3 diphosphatidylglycerol (P<0.05). The significance of these results is discussed.

Endometrial hyperplasia risk in relation to recent use of oral contraceptives and hormone therapy

PURPOSE

We sought to examine the relationship between recent use of oral contraceptives and hormone therapy and endometrial hyperplasia (EH) risk.

METHODS

Cases comprised women diagnosed with complex EH (n = 289) or atypical EH (n = 173) between 1985 and 2003. One age-matched control was selected for each case; excluded were women with a prior hysterectomy or diagnosis of EH or endometrial cancer. Hormone use in the 6 months prior to the date of the case's first symptoms was ascertained using a pharmacy database and medical records. Odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

Three (1.1%) cases had used oral contraceptives, compared to 16 (6.0%) controls (OR = 0.2, 95% CI: 0.0-0.6). Fifty-one (16.8%) cases had taken estrogen-only hormone therapy, in contrast to two (0.7%) controls (OR = 37.6, 95% CI: 8.8-160.0). The risk of EH among estrogen plus progestin hormone users did not differ from that of non-users (OR = 0.7, 95% CI: 0.4-1.1).

CONCLUSIONS

This study suggests that previous findings of the association of estrogen-only hormone therapy with increased risk of EH and the lack of an association between estrogen plus progestin hormone therapy and EH risk are likely to apply to both complex EH and atypical EH. Further examination of the association between oral contraceptives and EH, with greater numbers of OC users, is warranted.

Hormonal influences on seizures: basic neurobiology

There are sex differences and effects of steroid hormones, such as androgens, estrogens, and progestogens, that influence seizures. Androgens exert early organizational and later activational effects that can amplify sex/gender differences in the expression of some seizure disorders. Female-typical sex steroids, such as estrogen (E2) and progestins, can exert acute activational effects to reduce convulsive seizures and these effects are mediated in part by the actions of steroids in the hippocampus. Some of these anticonvulsive effects of sex steroids are related to their formation of ligands which have agonist-like actions at gamma-aminobutyric acid (GABAA) receptors or antagonist actions at glutamatergic receptors. Differences in stress, developmental phase, reproductive status, endocrine status, and treatments, such as anti-epileptic drugs (AEDs), may alter levels of these ligands and/or the function of target sites, which may mitigate differences in sensitivity to, and/or tolerance of, steroids among some individuals. The evidence implicating sex steroids in differences associated with hormonal, reproductive, developmental, stress, seizure type, and/or therapeutics are discussed.

Intracoronary genistein acutely increases coronary blood flow in anesthetized pigs through beta-adrenergic mediated nitric oxide release and estrogenic receptors

Various studies have suggested that the phytoestrogen genistein has beneficial cardioprotective and vascular effects. However, there has been scarce information regarding the primary effect of genistein on coronary blood flow and its mechanisms including estrogen receptors, autonomic nervous system, and nitric oxide (NO). The present study was planned to determine the primary effect of genistein on coronary blood flow and the mechanisms involved. In anesthetized pigs, changes in left anterior descending coronary artery caused by intracoronary infusion of genistein at constant heart rate and arterial pressure were assessed using ultrasound flowmeters. In 25 pigs, genistein infused at 0.075 mg/min increased coronary blood flow by about 16.3%. This response was graded in a further five pigs by increasing the infused dose of the genistein between 0.007 and 0.147 mg/min. In the 25 pigs, blockade of cholinergic receptors (iv atropine; five pigs) and alpha-adrenergic receptors (iv phentolamine; five pigs) did not abolish the coronary response to genistein, whose effects were prevented by blockade of beta(2)-adrenergic receptors (iv butoxamine; five pigs), nitric oxide synthase (intracoronary N(omega)-nitro-L-arginine methyl ester; five pigs) and estrogenic receptors (ERs; ERalpha/ERbeta; intracoronary fulvestrant; five pigs). In porcine aortic endothelial cells, genistein induced the phosphorylation of endothelial nitric oxide synthase and NO production through ERK 1/2, Akt, and p38 MAPK pathways, which was prevented by the concomitant treatment by butoxamine and fulvestrant. In conclusion, genistein primarily caused coronary vasodilation the mechanism of which involved ERalpha/ERbeta and the release of NO through vasodilatory beta(2)-adrenoreceptor effects.

Progesterone enhances performance of aged mice in cortical or hippocampal tasks

Ovarian steroids alter cognitive performance of young individuals. Whether progesterone enhances learning and memory in tasks involving the prefrontal cortex and/or hippocampus in aged mice was investigated. Aged mice received progesterone (10 mg/kg, s.c.) or vehicle and were tested for cortical and/or hippocampal learning and memory. Progesterone increased spontaneous alterations in the T-maze and time spent exploring novel objects in the object recognition task. Progesterone increased the time mice spent in the quadrant of the water maze where the hidden platform had been during training, increased latencies to crossover to the shock-associated side of the inhibitory avoidance chamber, and increased freezing in the contextual fear conditioning task. Progesterone did not enhance performance in tasks mediated by the amygdala (cued conditioning), striatum (conditioned place preference), or cerebellum (rotarod) in these aged mice. Thus, progesterone improved learning and memory in tasks mediated by the prefrontal cortex and/or hippocampus of aged mice.

[Hormone replacement therapy and endometrial cancer]

Hormone replacement therapy (HRT) has been used worldwide to relieve menopausal symptoms. The evolution in clinical knowledge of its risks has lagged persistently behind its application in clinical practice. In the 1970s, endometrial cancer incidence increased in developed countries, and exogenous estrogen therapy in postmenopausal women was the most important factor. In the 1980s and 90s, combined estrogen-progesterone therapy was prescribed on a large scale, based on its potential beneficial effects on the musculoskeletal and cardiovascular systems without increasing the risk of endometrial carcinoma. However, once again, recent reports argue against the safety of HRT, and the most important issues are now the increased risk of cardiovascular disease and total cancer in combined formulations. We conclude that the recently reported risks on combined HRT may have a significant public health impact, and that this treatment regimen should not be prescribed to protect postmenopausal women from endometrial carcinoma, since the risks outweigh the benefits.

Menopause hormone replacement therapy and cancer risk: an Italian record linkage investigation

BACKGROUND

The effects of persistence with hormone replacement therapy (HRT) on the risk of hospitalization for cancer and of the route of HRT administration on the risk of breast and colorectal cancer were explored in a large cohort study.

PATIENTS AND METHODS

The 73 505 women residing in Lombardia (Italy), aged 45-75 years, who received at least one HRT prescription during 1998-2000 were followed until 2005. Among these, 3687 experienced cancer hospitalization. Proportional hazards model was fitted to estimate the association between cumulative HRT persistence and cancer risk.

RESULTS

Compared with women who took HRT for <6 months, those exposed for >2 years showed hazard ratios (HR) of 0.78 (95% confidence interval 0.68-0.92) for colorectal cancer and 1.34 (1.13-1.58) for breast cancer. HR for breast cancer associated with long-term use of transdermal and oral HRT were, respectively, 1.27 (1.07-1.51) and 2.14 (1.43-3.21).

CONCLUSIONS

Evidence that long-term use of HRT is associated with increased risk of breast cancer and decreased risk of colorectal cancer is supplied from this study from a southern European population. Our findings indicate that transdermal therapy might have lower effect than oral therapy in increasing breast cancer risk.

Long-term use of postmenopausal estrogen and progestin hormone therapies and the risk of endometrial cancer

OBJECTIVE

The purpose of this study was to assess whether endometrial cancer risk among long-term users of (1) sequential estrogen plus progestin 10-24 days per month exceeds that of nonusers and (2) daily estrogen plus progestin (continuous combined hormone therapy) is below that of nonusers.

STUDY DESIGN

In this population-based case-control study with 1038 endometrial cancer cases diagnosed in 1985-1999 and 1453 control subjects, exclusive users of a single form of hormone therapy were compared with never users of hormone therapy.

RESULTS

For sequential therapy, only long-term use (> or = 6 years) was associated with increased risk (odds ratio, 2.0; 95% CI, 1.2-3.5). Continuous combined therapy was associated with decreased risk (odds ratio, 0.59; 95% CI, 0.40-0.88), with no increased risk among long-term users (odds ratio, 0.77; 95% CI, 0.45-1.3).

CONCLUSION

These results support the hypotheses that continuous combined therapy does not increase (and may decrease) endometrial cancer risk and that long-term sequential therapy can lead to a modest increased risk. However, the collective results of all studies of these questions and their clinical implications remain unclear.

Endometrial cancer and menopausal hormone therapy in the National Institutes of Health-AARP Diet and Health Study cohort

BACKGROUND

Menopausal hormone therapy formulations for women without hysterectomy have included estrogen plus progestin for years, but endometrial cancer risks associated with the use of sequential and continuous estrogen-plus-progestin regimens remain unclear.

METHODS

The National Institutes of Health-AARP Diet and Health Study included 73,211 women who were ages 50 years to 71 years at baseline and who completed 2 questionnaires (1995-1996 and 1996-1997). Linkage to state cancer registries and mortality indices identified 433 incident endometrial cancers through 2000. Using proportional hazards regression, the authors estimated relative risks (RRs) and 95% confidence intervals (95% CIs) relative to never-use of hormone therapy.

RESULTS

In 51,312 women who never used hormones or only used estrogen-plus-progestin regimens at doses consistent with current practice, neither sequential estrogen plus progestin (daily estrogen plus progestin for 10-14 days per cycle: RR, 0.74; 95% CI, 0.39-1.40) nor continuous estrogen plus progestin (daily estrogen plus progestin for >/=20 days per cycle: RR, 0.80; 95% CI, 0.55-1.15) had any statistically significant association with endometrial cancer. Long durations (>/=5 years) of sequential regimen use (RR, 0.79; 95% CI, 0.38-1.66) and of continuous regimen use (RR, 0.85; 95% CI, 0.53-1.36) were not associated with endometrial cancer.

CONCLUSIONS

Confirmation that these estrogen-plus-progestin regimens neither increase nor decrease the risk of endometrial cancer could influence menopausal symptom management for women who are considering estrogen-plus-progestin therapy.

Does immediate hormone replacement therapy affect the oncologic outcome in endometrial cancer survivors?

The purpose of this study was to evaluate the effect of immediate hormone replacement therapy (HRT) on oncologic outcome of patients with endometrial cancer. The patients were recruited prospectively after extensive discussion of risks and benefits of HRT. Continuous daily regimen of 0.625 mg conjugated equine estrogen plus 2.5 mg medroxyprogesterone acetate was initiated 4-8 weeks after surgery at first postoperative visit. The patients who had the same characteristics with the HRT group were assigned as a control group. Overall, 50 patients received HRT. There was no significant difference with respect to prognosticators between the HRT users and the control group. Seven patients (14%) stopped the use of HRT. Only two patients stopped the therapy before 24 months, and all the remaining patients used HRT for at least 24 months, with a mean value of 49.1 months. Neither the patients who used HRT nor the ones who left the therapy had recurrence at the time of writing of this article. This prospective case-control study showed that immediate postoperative use of HRT did not increase the recurrence or death rates in endometrial cancer survivors.

Phytoestrogen derivatives differentially inhibit arterial neointimal proliferation in a mouse model

Neointimal proliferation is a key element in atherosclerotic plaque formation and in arterial restenosis following angioplasty. Estrogen-like compounds, including naturally occurring plant phytoestrogens, are known to alter the extent of neointimal proliferation. This study investigates the anti-atherogenic/restenotic effect of several synthetic metabolites of isoflavone phytoestrogens (dihydrodaidzein, tetrahydrodaidzein and dehydroequol) (Novogen, Sydney, Australia). Acute neointimal proliferation was induced in the iliac artery of cholesterol-fed mice, by mechanically damaging the endothelium. Phytoestrogens were administered orally for 4 weeks and the damaged arteries harvested. Intimal area, as a percentage of the iliac artery wall area, was measured. Dihydrodaidzein significantly halved the intimal response (intima approximately 25% of wall area; p < 0.01) compared with placebo diet-fed mice (intima approximately 50% of wall area), while tetrahydrodaidzein and dehydroequol showed no inhibitory effects. Immunohistochemistry demonstrated that alpha-actin-positive vascular smooth muscle cells were the major cell type in the proliferating neointima. A single layer of endothelium covered the thickened intima by 4 weeks. Thus, a specific phytoestrogen isoflavone compound (dihydrodaidzein) can selectively inhibit neointimal proliferation, either by inhibition of vascular smooth muscle cell migration and proliferation, and/or by enhancing endothelial proliferation and function, and inhibition of endothelial apoptosis.

Cost-effectiveness of alternative treatments for women with osteoporosis in Canada

BACKGROUND

During the years following menopause, estrogen levels decline leading to accelerated bone loss and an increased risk of osteoporosis and osteoporosis-related fractures.

METHODS

Using a Markov model and decision analytic techniques, the long-term costs and outcomes of five treatment and secondary prevention strategies for osteoporosis were compared: 'no intervention', alendronate, etidronate, risedronate, and raloxifene. The base case analysis examined postmenopausal (65 year old) osteoporotic women without prior fracture. Probabilistic sensitivity analysis (PSA) was used to incorporate the impact of parameter uncertainty, and deterministic sensitivity analysis (DSA) was used to compare alternative patient populations and modeling assumptions. Life years and Quality Adjusted Life Years (QALYs) were used as measures of effectiveness.

RESULTS

In the base case analysis, risedronate was dominated by etidronate and alendronate. Alendronate and etidronate were projected to have similar costs and QALYs, and the efficiency frontier was represented by 'no intervention', etidronate, alendronate, and raloxifene (Can$32 571, Can$38 623 and Can$114 070 per QALY respectively). Alternative assumptions of raloxifene's impact on CHD and breast cancer, alternative discount rates and alternative patient risk factors (e.g., starting age of therapy, CHD risk, and prior fracture risk) had significant impacts on the overall cost-effectiveness results for both the bisphosphonates and raloxifene.

DISCUSSION

Using conventionally quoted benchmarks and compared to no therapy, alendronate, etidronate, and raloxifene would all be considered cost-effective alternatives for treating women with osteoporosis. Potential limitations of this study include the usual caveats and cautions associated with long-term projection models and the fact that not all inputs into the model are Canadian data sources.

Effects of genistein on angiotensin-converting enzyme in rats

Genistein (4,5,7-trihydroxyisoflavone), a phytoestrogen with selective estrogen receptor modulator properties, has received a great deal of attention over the last few years because of its potentially preventive roles against cardiovascular diseases. However, the precise molecular mechanisms for this modulation are not fully elucidated. In this study, we investigated (both in vivo and in vitro) the relationship between genistein and the changes of angiotensin-converting enzyme (ACE) in rat aortic endothelial cells (RAECs), serum and tissue (aorta). ACE expression was assessed by the immunofluorescence and the reverse transcriptase-polymerase chain reaction (RT-PCR) assay. Serum and tissue ACE activity was detected with a commercial kit. Genistein exhibited a concentration-dependent inhibitory effect on the expression of ACE, particularly at higher concentrations (24.70+/-1.20 at 100microM, P<0.01, and 18.22+/-0.92 at 200microM, P<0.01 compared with the control group 50.49+/-5.19). The estrogen receptor blocker tamoxifen at 100microM attenuated this effect of genistein. The extracellular signal-regulated kinase 1/2 (ERK1/2) blocker PD98059 also markedly inhibited this effect. The observations in vivo were highly consistent with the data in RAECs. These results indicate that genistein inhibits the expression of ACE via estrogen receptor and subsequently ERK1/2 signaling pathway in RAECs. Our results suggest that the down-regulation of ACE with a consequent change in the circulating levels of angiotensin II (Ang II), vasorelaxant angiotensin-(1-7) [Ang-(1-7)] and bradykinin plays an important role in cardiovascular effects of genistein through the ERK1/2 pathway.

Action by and sensitivity to neuroactive steroids in menstrual cycle related CNS disorders

Neuroactive steroids are a large group of substances having effect in the brain and on brain function. The steroids most studied are allopregnanolone (ALLO), tetrahydrodesoxycorticosterone (THDOC), pregnenolone sulfate (PS) dihydroepiandrosteronesulfate (DHEAS), and estradiol (E2). ALLO and THDOC are called gamma-aminobutyric acid (GABA) steroids as they are positive modulators of the GABAA receptor in a similar way as benzodiazepines, barbiturates, and alcohol. GABA steroids not only have similar behavioral effects as benzodiazepines and barbiturates but, possibly, also similar adverse effects as well. This review aims to elucidate the possible role that neuroactive steroids play in the development of mood disorders in women. One of the most clear-cut examples of the interaction between mood, neuroactive steroids, and the GABA system is premenstrual dysphoric disorder (PMDD), which is a cluster of negative mood symptoms occurring during the luteal phase of the menstrual cycle in 2-6% of reproductive women. Furthermore, certain women also experience adverse mood effects during sequential progestin addition to postmenopausal estrogen treatment, which is why the role of neuroactive steroids in postmenopausal women is also addressed in this review.

Exploratory study of premenstrual symptoms and serotonin variability

Premenstrual symptoms can pose significant problems for a large number of women; this small exploratory study was designed to investigate biological markers that may provide etiological clues. Using an algorithm based on daily symptom charting for two months, 15 participants were assigned to one of three study groups: non-symptomatic (n = 9), probable PMS (n = 3) and probable PMDD (n = 3). During two overnight admissions, one prior to and one following the onset of menses, participants had blood drawn to assess the level of available serotonin via one of its metabolites, 5-HIAA. The three groups exhibited potentially significant differences in several biological markers. This study's results are consistent with a hypothesis implicating serotonin in the generation of premenstrual symptomology.

Bleeding profile and endometrial safety of continuous combined regimens 1 mg 17beta-estradiol/trimegestone versus 1 or 2 mg 17beta-estradiol/norethisterone acetate in postmenopausal women

OBJECTIVE

To compare the bleeding profile and endometrial safety of continuous combined 1 mg 17beta-estradiol (17beta-E2) and 0.125 mg trimegestone (TMG) with those of two continuous combined 17beta-E2 and norethisterone acetate (NETA) regimens.

STUDY DESIGN

This was a double-blind, randomized, multicenter study conducted in 12 European countries and Israel over a 2-year period. Healthy postmenopausal women with an intact uterus were given either 1 mg 17beta-E2/0.125 mg TMG, 2 mg 17beta-E2/1 mg NETA or 1 mg 17beta-E2/0.5 mg NETA for up to 26 cycles, each of 28 days.

RESULTS

The percentage of amenorrheic women was greater in most cycles up to cycle 13 in the 1 mg 17beta-E2/0.125 mg TMG group than in the comparator groups. The mean number of bleeding days was similar in the 1 mg 17beta-E2/0.125 mg TMG and the 1 mg 17beta-E2/0.5 mg NETA groups, but greater in the 2 mg 17beta-E2/1 mg NETA group. No endometrial hyperplasia was observed for any group.

CONCLUSION

Continuous combined 1 mg 17beta-E2/0.125 mg TMG exhibits a more favorable bleeding profile than 1 mg 17beta-E2/0.5 mg NETA up to 1 year, while providing an adequate protective effect on the endometrium.

Practical aspects of sharing controls between case-control studies

PURPOSE

We discuss the practical advantages and challenges of sharing controls among two or more concurrently conducted case-control studies.

METHODS

We conducted two case-control studies, one of breast cancer and the other of endometrial cancer, with overlapping, shared control groups. The studies had overlapping geographic areas, identical telephone questionnaires and biosample collection, and identical age and race eligibility.

RESULTS

Sharing controls reduced the number of potential controls that had to be identified by random-digit dialing by 25% and the number of eligible controls that had to be interviewed by 32%. The cost savings were approximately 2,96,000 dollars, or 7% of the program project that funded the studies.

CONCLUSIONS

The disadvantage of sharing controls was the complexity of the design and the additional investigator time required to plan, monitor, and adjust the design. In the situation presented here, the complexities would have been reduced greatly if we had not attempted to frequency match on age in both studies. Generally, sharing controls is likely to work well when strict frequency matching is not required and there is a large overlap of interview questions, other data to be collected, and eligibility criteria among the studies.

Endometrial cancer and hormone-replacement therapy in the Million Women Study

BACKGROUND

Postmenopausal women who use hormone-replacement therapy (HRT) containing oestrogen alone are at increased risk of endometrial cancer. To minimise this risk, many HRT users who have not had a hysterectomy use combined oestrogen-progestagen preparations or tibolone. Limited information is available on the incidence of endometrial cancer in users of these therapies.

METHODS

716,738 postmenopausal women in the UK without previous cancer or previous hysterectomy were recruited into the Million Women Study in 1996-2001, provided information about their use of HRT and other personal details, and were followed up for an average of 3.4 years, during which time 1320 incident endometrial cancers were diagnosed.

FINDINGS

320,953 women (45%) reported at recruitment that they had used HRT, among whom 69,577 (22%) last used continuous combined therapy (progestagen added daily to oestrogen), 145,486 (45%) last used cyclic combined therapy (progestagen added to oestrogen, usually for 10-14 days per month), 28,028 (9%) last used tibolone, and 14,204 (4%) last used oestrogen-only HRT. These HRT types had sharply contrasting effects on the overall risk of endometrial cancer (p<0.0001 for heterogeneity). Compared with never users of HRT, risk was: reduced with last use of continuous combined preparations (relative risk 0.71 [95% CI 0.56-0.90]; p=0.005); increased with last use of tibolone (1.79 [1.43-2.25]; p<0.0001) and oestrogen only (1.45 [1.02-2.06]; p=0.04); and not significantly altered with last use of cyclic combined preparations (1.05 [0.91-1.22]; p=0.5). A woman's body-mass index significantly affected these associations, such that the adverse effects of tibolone and oestrogen-only HRT were greatest in non-obese women, and the beneficial effects of combined HRT were greatest in obese women.

INTERPRETATION

Oestrogens and tibolone increase the risk of endometrial cancer. Progestagens counteract the adverse effect of oestrogens on the endometrium, the effect being greater the more days every month that they are added to oestrogen and the more obese that women are. However, combined oestrogen-progestagen HRT causes a greater increase in breast cancer than the other therapies do. Thus, when endometrial and breast cancers are added together, there is a greater increase in total cancer incidence with use of combined HRT, both continuous and cyclic, than with use of the other therapies.

Effects of the phytoestrogen genistein on cardiovascular risk factors in postmenopausal women

OBJECTIVE

The phytoestrogen genistein has been shown to be the most efficacious in clinical and experimental studies. We studied whether genistein treatment affects some cardiovascular risk markers in postmenopausal women.

DESIGN

Sixty healthy postmenopausal women, who were 52 to 60 years of age, were enrolled in a 6-month double-blind, placebo-controlled, randomized study. After a 4-week stabilization on a standard fat-reduced diet, participants were randomly assigned to receive either genistein (n = 30; 54 mg/d) or placebo (n = 30). At baseline and after a 6-month treatment, we measured fasting glucose, insulin, insulin resistance (HOMA-IR), osteoprotegerin (OPG), fibrinogen, and sex hormone-binding globulin (SHBG).

RESULTS

By comparison with placebo, genistein treatment decreased significantly fasting glucose (genistein = -8.7 +/- 2.3%; placebo = 3.2 +/- 2.3%; P < 0.001), fasting insulin (genistein = -12 +/- 3.33%; placebo = 36 +/- 3.29%; P < 0.001), and HOMA-IR (genistein = -14 +/- 5.8%; placebo = 42 +/- 0.6%; P < 0.001). After genistein-treatment, fibrinogen decreased (genistein = 3.18 +/- 0.12 g/L; placebo = 3.83 +/- 0.04 g/L; P < 0.001) with respect to placebo. In the genistein group, serum OPG was lower (-2 +/- 0.3%) than in placebo (9 +/- 1.5%; P < 0.001), and serum SHBG was higher (63 +/- 3.8 nmol/L) compared with placebo (53 +/- 2.9 nmol/L; P < 0.05).

CONCLUSION

Our study suggests that genistein may have a favorable effect on some cardiovascular markers.

Trimegestone in a low-dose, continuous-combined hormone therapy regimen prevents bone loss in osteopenic postmenopausal women

OBJECTIVE

To determine the efficacy of estrogen + progestogen therapy with 1 mg 17beta-estradiol and 0.125 mg trimegestone in the prevention of postmenopausal osteoporosis.

DESIGN

For this study, 360 healthy, postmenopausal women with osteopenia [lumbar spine bone mineral density (BMD) between -1.0 and -2.5 SD of the premenopausal mean value] were enrolled in a 2-year prospective, randomized study, and 70% completed. Treatments were 1 mg 17beta-estradiol + 0.125 mg trimegestone (n = 179) or placebo (n = 181), given as daily oral therapy. All received a daily supplement of 500 mg calcium and 400 IU vitamin D. BMD measurements at the lumbar spine, total hip, and femoral neck as well as blood and urinary biochemical markers of bone turnover (serum osteocalcin), serum bone-specific alkaline phosphatase, serum CrossLaps, and urinary CrossLaps took place regularly.

RESULTS

BMD increases relative to placebo were 6.3%, 3.9%, and 3.8% at the lumbar spine, total hip, and femoral neck, respectively (all P < 0.001). The biochemical markers of bone turnover were suppressed accordingly. Serum CrossLaps and urinary CrossLaps decreased rapidly, by 52% and 54%, respectively, whereas serum osteocalcin and serum bone-specific alkaline phosphatase revealed a more retarded decrease of 40% and 33%, respectively. Of the women receiving hormone therapy, 75% had amenorrhea from the first cycle, and 5% withdrew prematurely due to metrorrhagia or mastalgia.

CONCLUSION

This new estrogen + progestogen therapy is efficient in increasing BMD in an osteopenic postmenopausal population. Furthermore, it is well tolerated, with few adverse events and an early bleeding control, which is likely to improve compliance to the treatment over the long term.

Medroxyprogesterone improves cardiac autonomic control in postmenopausal women with respiratory insufficiency

OBJECTIVE

To study the effect of medroxyprogesterone acetate (MPA) on autonomic cardiac control in respiratory insufficiency in postmenopausal women.

DESIGN

A prospective, single-blind study.

SUBJECTS

Eighteen postmenopausal women with respiratory insufficiency and eight asymptomatic postmenopausal women with nocturnal hypoxaemia as controls.

METHODS

Oral MPA treatment was given at 30 mg twice daily for 2 weeks. All-night polysomnography including a two-channel electroencephalogram, an electro-oculogram, an electromyogram, an electrocardiogram, arterial oxyhaemoglobin saturation, maximum end-tidal CO2 partial pressure, a ballistocardiogram and breathing movements were recorded at baseline and at the end of MPA treatment. Heart rate variability (HRV) was calculated in time and frequency domains during various sleep stages on and off MPA, and the results were correlated to respiratory variables.

RESULTS

At baseline, patients had higher heart rate and lower HRV than controls, suggesting increased cardiac sympathetic output. MPA increased HRV in patients, but not in controls. End-tidal CO2 partial pressure decreased, and respiratory rate increased during treatment in both groups.

CONCLUSIONS

HRV is compromised in women with respiratory insufficiency. Peroral MPA increases their HRV to levels comparable with those in controls. This suggests an improvement in vagal cardiac control beneficial to cardiovascular health.

Vaginal administration of allopregnanolone to postmenopausal women undergoing estrogen replacement therapy: preliminary results

OBJECTIVE

To assess the tolerability and endometrial effects of vaginal administration of an allopregnanolone gel to postmenopausal women undergoing estrogen therapy.

METHODS

Thirteen postmenopausal women included in the study were divided into two groups and submitted to two consecutive cycles of 28 days during which they received 2 mg oral estradiol valerate daily and vaginally administered allopregnanolone gel during the last 10 days of the second cycle (group 1) or during the last 10 days of each cycle (group 2). Systemic adverse effects, vaginal bleeding and endometrial histology were characterized, with group 1 patients being submitted to two endometrial biopsies (days 28 and 56) and group 2 patients to one biopsy (day 56).

RESULTS

Five patients did not show any adverse effect. Mastalgia was the most frequently reported adverse effect (four cases), followed by headache and abdominal pain (two cases each). The adverse effects were mild and did not interfere with the adequate use of the medication prescribed. Vaginal bleeding due to deprivation was observed in three of the seven patients submitted to one treatment cycle with allopregnanolone (group 1) and in two of six patients submitted to two treatment cycles (group 2). Endometrial biopsy findings did not suggest any secretory action after exposure to allopregnanolone.

CONCLUSIONS

Tolerability of vaginal administration of allopregnanolone gel was good. Studies employing a larger series and longer time of follow-up are necessary to determine the endometrial effects of this drug.

Effects of trimonthly progestin administration on the endometrium in elderly postmenopausal women who receive hormone replacement therapy: a pilot study

OBJECTIVE

The purpose of this study was to determine the effect of trimonthly progestin administration on the endometrium in elderly postmenopausal women who receive hormone replacement therapy.

STUDY DESIGN

This was a prospective, randomized, double-blind, placebo-controlled study at a university teaching program. Twenty-five postmenopausal women who were >or=75 years old with an intact uterus were assigned randomly to receive conjugated equine estrogens (0.625 mg/d plus medroxyprogesterone acetate 5 mg/d for 13 days every 3 months (n = 13) or placebo (n = 12) for 9 months). At the end of the 9 months, patients in the hormone replacement therapy arm continued therapy for an additional 9 months. Statistical analysis was performed with the Student t test, the chi(2) test, and the Fisher exact test.

RESULTS

Transvaginal sonography was performed at baseline and at 9 and 18 months. Endometrial biopsy was performed if the endometrial thickness was >4 mm or as clinically indicated at 18 months. Patients in the hormone replacement therapy group demonstrated a significant increase in endometrial thickness between baseline (3.9 + 0.8 mm) and 9 months (8.0 + 4.8 mm). There were no cases of endometrial hyperplasia at the 18-month endometrial biopsy.

CONCLUSION

Trimonthly progestin administration in elderly postmenopausal women who receive hormone replacement therapy may be a reasonable alternative to the monthly administration of progestin in hormone replacement therapy.

Management of premenstrual dysphoric disorder

Premenstrual dysphoric disorder is a complex disorder characterized by severe physical and psychological symptoms. The pathophysiology and effective treatment of premenstrual dysphoric disorder are presented. Evidence for the effective treatment of premenstrual dysphoric disorder by correction of neuroendocrine abnormalities or suppression of cyclical ovarian activity is reviewed.

Comparison of the difference in histopathology and cell cycle kinetics among the postmenopausal endometrium treated with different progestins in sequential-combined hormone replacement therapy

OBJECTIVE

To investigate the difference in histopathology and cell cycle kinetics in the menopausal endometrium treated with sequential-combined hormone replacement therapy (HRT) using different types and doses of progestins.

DESIGN

A randomized, double-blind, 1-year study was conducted. In a menopause clinic of a university hospital, 241 postmenopausal women using HRT were included for the study of histopathology and cell cycle analysis. Conjugated equine estrogens, 0.625mg/day, were administered for 25 days (days 1-25) of each month, and the following were also administered for 14 days (days 12-25): in group A ( n= 102), medroxyprogesterone acetate (MPA), 5 mg/day; in group B ( n= 66), MPA, 10mg/day; and in group C ( n= 73), dydrogesterone, 20mg/day. Endometrial sampling was performed after at least 10 months of treatment. Fifty-two premenopausal women were also enrolled for the comparative studies (group Y). The S-G2-M fractions in the cell cycle were used as the marker of proliferation.

RESULTS

Most menopausal endometria were normal regardless of the regimens of HRT. Endometrial hyperplasia was only found in two cases (both in group A). The S-G2-M fractions of the endometrial cells in all three menopausal groups showed no statistically significant difference. It appeared that S-G2-M fractions increased from normal postmenopausal to normal premenopausal endometria to postmenopausal hyperplasia to premenopausal hyperplasia. The S-G2-M fractions of the normal menopausal endometrial cells were lower than those of the premenopausal controls either in normal or in hyperplastic categories.

CONCLUSIONS

Our study showed that there is no difference between the effect of MPA and dydrogesterone used in sequential-combined HRT based on the cycle kinetics of the menopausal endometrium.

Effect of tibolone administration on heart rate variability and free fatty acid levels in postmenopausal women

OBJECTIVE

To evaluate the effects of tibolone on heart rate variability and plasma free fatty acid levels in postmenopausal women.

DESIGN

Randomized, placebo-controlled trial.

SETTING

University hospital.

PATIENT(S)

Thirty postmenopausal women.

INTERVENTION(S)

Tibolone, 2.5 mg/d, or placebo for 4 months.

MAIN OUTCOME MEASURES

Variability in heart rate and changes in the lipid profile.

RESULT(S)

Anthropometric data were unchanged throughout the study. Compared with placebo, long-term tibolone administration was associated with a decrease in plasma levels of low-density lipoprotein cholesterol, triglyceride, and free fatty acid and homeostasis model assessment index. Furthermore, tibolone administration was associated with an increase in RR interval, total power, and high frequency and decrease in low frequency and the low frequency/high frequency ratio. Finally, the delta decrease in plasma free fatty acid levels correlated with delta low frequency/high frequency ratio independently of age, delta body mass index, delta homeostasis model assessment index, and low-density lipoprotein cholesterol levels.

CONCLUSION(S)

Long-term tibolone administration improves the ratio of cardiac sympathetic tone to parasympathetic tone in postmenopausal women.

Perimenopausal use of reproductive hormones effects on breast and endometrial cancer

The effect of reproductive hormone use in the form of oral contraception or HRT on endometrial cancer incidence is not caused by simply bias: the epidemiologic studies are consistent; the effect of ERT is large; the biologic rationale cited is a plausible mechanism; and the response to progestin in oral contraception or combined HRT tends to confirm the biologic mechanism. In contrast, it remains unclear whether changes in breast cancer incidence following use of oral contraception and HRT are caused by hormone exposure or to other factors: the results of epidemiologic studies are not entirely consistent, and the smaller relative effect on risk of breast cancer is susceptible to bias and other sources of error. Although the exact nature of the association between repro ductive hormone use and breast cancer incidence is not yet clear, breast cancer is a common neoplasm in older women. Prescribers and users should take this into account in weighing benefits to ensure that unnecessary risks are avoided.

The effect of the phytoestrogen genistein on plasma nitric oxide concentrations, endothelin-1 levels and endothelium dependent vasodilation in postmenopausal women

The phytoestrogen genistein improves endothelial dysfunction in ovariectomized rats through a nitric oxide-dependent mechanism. We investigated whether genistein alters the balance between the nitric oxide products and endothelin-1 and influences endothelium-dependent vasodilation in postmenopausal women. Sixty healthy postmenopausal women were enrolled in the study. A double-blind, placebo controlled, randomized design was employed. After a 4-week stabilization on a standard fat-reduced diet, participants to the study were randomly assigned to receive either genistein (n=30; 54 mg/day) or placebo (n=30). Flow-mediated, endothelium-dependent vasodilation of the brachial artery, plasma nitric oxide breakdown products and endothelin-1 levels were measured at baseline and after 6 months of genistein therapy. The mean baseline level of nitrites/nitrates was 22+/-10 micromol/l and increased to 41+/-10 micromol/ml after 6 months of treatment. The mean baseline plasma endothelin-1 level was 14+/-4 pg/ml and decreased to 7+/-1 pg/ml following 6 months of treatment with genistein. The mean baseline ratio of nitric oxide to endothelin also significantly increased at the end of treatment. Flow-mediated, endothelium-dependent vasodilation of the brachial artery was 3.9+/-0.8 mm at baseline and increased to 4.4+/-0.7 mm after 6 months of treatment. Placebo-treated women showed no changes in plasma nitrites/nitrates, endothelin-1 levels and flow-mediated vasodilation. Genistein therapy improves flow-mediated endothelium dependent vasodilation in healthy postmenopausal women. This improvement may be mediated by a direct effect of genistein on the vascular function and could be the result of an increased ratio of nitric oxide to endothelin.

Cancer risk in menopausal women

The incidence for breast and other female-hormone-related neoplasms levels off after menopause. The relative risk (RR) of breast cancer is moderately elevated in current and recent users of hormone replacement therapy (HRT) and increases by about 2.3% per year with longer duration of use, but the effect drops after cessation. Unopposed oestrogen use is strongly related to endometrial cancer risk but cyclic combined oestrogen-progestin treatment appears to reduce this side-effect. However, combined HRT may be associated with higher risk of breast cancer as compared to unopposed oestrogens. Ovarian cancer may also be unfavourably influenced by the use of HRT. HRT has been related to decreased risk of colorectal cancer, the overall RR being about 0.8. Tamoxifen and other selective oestrogen receptor modulators (SERMs) may have a favourable effect on the risk of breast cancer but their risk-benefit profile requires further quantification. The potential effect of 'natural' SERMs (phytoestrogens) on cancer risk remains undefined.

The female menopause--now and in the millennium: new treatment options for a better quality of life

Estrogen has traditionally been the only agent effective for the prevention and treatment of post-menopausal osteoporosis. Estrogen's positive effects are often outweighed by negative ones. Newer agents provide safer alternatives that should increase compliance and improve quality of life.

Factors associated with endometrial bleeding in continuous hormone replacement therapy

OBJECTIVE

To identify clinical and laboratory parameters associated with the occurrence of endometrial bleeding within the first 6 months of treatment in postmenopausal women taking continuous hormone replacement therapy.

DESIGN

We performed a prospective study of 55 postmenopausal women who had amenorrhea for at least 12 months before baseline screening and were taking 0.625 mg conjugated estrogen and 5 mg medroxyprogesterone acetate daily on a continuous basis. Postmenopausal duration was defined as the interval, in months, between the last menstruation and the commencement of treatment. All subjects were instructed to monitor bleeding episodes in a diary and were followed up monthly for at least 12 months.

RESULTS

Thirty-four women (62%) experienced bleeding within the first 6 months of treatment. Using a multivariate approach, a woman with a postmenopausal duration of 24 months or less had a relative risk of 8.2 (95% confidence limits: 1.3, 53.1) of bleeding, as compared with those with a postmenopausal duration of more than 24 months. Furthermore, pretreatment endometrial thickness greater than 5 mm (p < 0.05) and serum estradiol levels greater than 25 pg/mL (p < 0.01) were noted to be significantly correlated with the occurrence of bleeding in women with a postmenopausal duration of more than 24 months.

CONCLUSIONS

Women with a postmenopausal duration of 24 months or less, a pretreatment endometrial thickness greater than 5 mm, and serum estradiol level greater than 25 pg/mL are at risk to have endometrial bleeding within the first 6 months of continuous hormone replacement therapy.

Hormone replacement therapy (HRT) in women after genital cancer

Women treated for genital cancer are not only suffering from the disease itself, but are in most cases confronted with the side effects of the loss of ovarian function. Therefore, it is of utmost importance for the gynecologist, who cares for these patients, to strongly consider the benefits and drawbacks of hormone replacement therapy (HRT) in these women. Overall, it appears, that in women with vulva, vaginal, cervical, ovarian and tubal cancer individually adjusted HRT can be employed for the benefit and well-being of these patients considering psychosomatic, functional and organic aspects. Patients after endometrial cancer should be differentiated according to the stage of the disease. In all cases the individual minimal effective dose of HRT should be searched for.