Risks of estrogens and progestogens

The Impact of Medical and Sexual Politics on Women's Health

Hidden agendas impacting women's health care are explored in the context of the intersecting effects of capitalism as the ideology of medical politics, and patriarchy as the ideology of sexual politics. The mutually enhancing forces of medical and sexual politics collide in scientific reductionism - biological determinism for her'. Women are valued according to their ability and willingness to bear and raise children; illnesses and remedies for those women who are unwilling or unable to conform are invented. Thus, the `raging hormones' of puberty and pregnancy tend to be viewed as good and healthy while those associated with the menstrual cycle and menopause are portrayed as unhealthy and in need of alteration. The medical and psychological professions maintain and enhance their power, prestige and profits and serve the patriarchy by labeling events in the normal life course of women as illnesses, reinforcing social misogyny with medical misogyny, emphasizing reproduction rather than health in prioritizing empirical and clinical research, and attributing women's emotions and behaviors to hormonal fluctuations rather than economic, political and social causes.

Risk of stroke and hormone replacement therapy. A prospective cohort study

OBJECTIVE

The purpose of this study was to examine the risk of first-ever stroke in relation to use of hormone replacement therapy (HRT) among middle-aged and older Swedish women.

MATERIALS

A total of 16,906 women, 45-73 years old, from the 'Diet and Cancer' study in Malmö, Sweden were examined. Women were considered as HRT users if they took systemic hormone therapy regularly. Incidence of stroke was followed for a mean period of 10.5 years.

RESULTS

In all, 2148 (12.7%) women used HRT. A total of 461 stroke cases occurred during follow-up, 48 of them in HRT users. Incidence of total stroke and ischemic subtype had no significant relation to HRT use. However, an increased risk of hemorrhagic stroke was found in women taking unopposed estrogen (RR=2.55, 95%CI: 1.03-6.35) or un-native estrogen regimens (RR=4.27, 95%CI: 1.71-10.66). Although not significantly, the risk of stroke was 33% lower in women who started their treatment before menopause. Among HRT users, the risk of stroke was associated with advancing age, smoking, excess body weight and hypertension.

CONCLUSIONS

There is no significant association between hormone therapy and risk of total stroke in women during 10.5 years follow-up. Preparations of estrogen and time for initiation of treatment may affect the risk of stroke.

Best practice in primary care pathology: review 2

This second best practice review examines five series of common primary care questions in laboratory medicine: (1) laboratory testing for allergy, (2) diagnosis and monitoring of menopause, (3) the use of urine cytology, (4) the usefulness of the erythrocyte sedimentation rate, and (5) the investigation of possible urinary tract infection. The review is presented in a question-answer format. The recommendations represent a précis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents, and evidence based medicine reviews, supplemented by MEDLINE EMBASE searches to identify relevant primary research documents. They are standards but form a guide to be set in the clinical context. Most are consensus rather than evidence based. They will be updated periodically to take account of new information.

Effects of estradiol and estradiol sulfamate on the liver of ovariectomized or ovariectomized and hypophysectomized rats

This study was performed to evaluate and compare the effects of estradiol sulfamate (J995) and estradiol (E2) on the hepatic levels of the estrogen receptor (ER) and its mRNA, in ovariectomized (OVX) and OVX+hypophysectomized (OVXHX) female rats and to study the effects on the liver-derived serum compounds angiotensin I, triglycerides, high-density lipoprotein (HDL) and cholesterol. ER concentrations were determined using ligand-binding assay (LBA) and enzyme immuno assay (EIA), and the mRNA levels using solution hybridization. The rats were treated orally (p.o.) or subcutaneously (s.c.) for 7 days, with treatments initiated 14 days after surgery. No differences were found in ER mRNA levels between J995 and E2 treated rats. The s.c. administered estrogens increased ER levels in OVX rats. Addition of GH+DEX to OVXHX rats restored the ER to levels above those seen in intact rats, whereas simultaneous oral treatment with E2 significantly decreased ER levels again. The s.c. treatment with either J995 or E2 limited the increase caused by addition of GH+DEX. After oral treatment angiotensin I levels were increased by E2, but not by J995, while triglycerides, HDL and cholesterol levels were decreased by oral E2, J995 showing a similar pattern but was less effective. In summary, these results on hepatic ER levels and estrogen dependent compounds produced by the liver showed that J995 has a lower impact on the normal liver functions after oral treatment than E2. Thus, J995 is a very promising substance for development of oral estrogen treatment with reduced hepatic side effects.

Effect of hormone replacement therapy on lipids in perimenopausal and early postmenopausal women

OBJECTIVE

To determine the effects of oral sequential hormone replacement therapy (HRT) on lipid-profile in perimenopausal and early postmenopausal women.

METHODS

We performed a single-center, randomized, placebo-controlled trial. The trial was double blind with respect to 17beta-estradiol/desogestrel (17beta-E-D) and placebo and open with respect to conjugated estrogens/norgestrel (CEE-N). A total of 125 healthy perimenopausal and early postmenopausal women, aged 43-58 years, were recruited from the general population in Zoetermeer, the Netherlands. The intervention consisted of 6 months treatment with 1.5 mg 17beta-estradiol/0.15 mg desogestrel (n=53), 0.625 mg conjugated estrogens/0.15 mg norgestrel (n=36) or placebo (n=36). At baseline, cycle 1, 3 and 6, overnight fasting blood samples were obtained in which lipids were determined. We used linear regression analysis to calculate differences in mean change from baseline in lipids in the active treatment groups compared to placebo.

RESULTS

In both treatment groups significant (P<0.05) falls in low-density-lipoprotein (LDL)-cholesterol (17beta-E-D: -7.8% and CEE-N: -8.4%) and lipoprotein(a) (17beta-E-D: -11.7% and CEE-N: -28.3%) were found compared to placebo. Apolipoprotein A1 (17beta-E-D: 6.8% and CEE-N: 7.3%) and HDL-cholesterol (17beta-E-D: 6.4% and CEE-N: 8.0%) significantly increased compared to placebo. No significant changes were found in the other lipids. Mean changes from baseline in total cholesterol, LDL-cholesterol and apolipoprotein B were significantly more pronounced in postmenopausal women compared to perimenopausal women, adjustment for age-differences did not change the results.

CONCLUSION

Treatment of perimenopausal and early postmenopausal women with 17beta-E-D or CEE-N changes their lipid-profile in a potentially anti-atherogenic direction. Changes appear to be more pronounced in postmenopausal women compared to perimenopausal women.

Portraits of menopause in the mass media

This examination of menopause as presented by the popular print media was conducted in the context of furthering our understanding of the development of attitudes toward menopause. All articles indexed under "menopause" in the Reader's Guide in the years 1981, 1982, 1985, 1986, 1989, 1990, 1993, and 1994 were located and examined. The data revealed that, although there has been an increase in the frequency of articles on menopause in the last 15 years, the media's portrayal of menopause is problematic in several respects: (a) in spite of the increased attention, the information available on menopause through the popular media is minimal and insufficient; (b) there was little variability in terms of perspective, discipline, or focus; almost all were focused on menopause as a negative experience or disease and in need of medical treatment; (c) there was considerable contradiction and inconsistency among the articles with respect to descriptions of menopause and intervention advice for menopausal women; (d) aging, stress, life-style factors, race and ethnicity, exercise and diet were, with few exceptions, ignored or trivialized.

The estrogen receptor gene: promoter organization and expression

The estrogen receptor (ER) is a ligand-activated transcription factor and a member of a large family of nuclear hormone receptors. As a mediator of estrogen hormone action, the ER is involved in many important physiological processes. ER gene expression has been demonstrated to be restricted to certain tissues and under complex hormonal control. However, the molecular mechanisms involved have remained largely unknown. Due to this lack of knowledge an investigation was undertaken to characterize the promoter organization of ER gene and investigate its expression. Approximately 3 kb of the 5' flanking region of the human ER (hER) gene was isolated and sequenced. By performing RT-PCR and RACE experiments it was shown that the hER gene is transcribed from three different promoters. Transcription of the hER gene from these promoters yields three different mRNA isoforms with unique 5' untranslated regions (5'UTRs), but identical coding regions. The expression pattern of the hER mRNA isoforms was investigated by RT-PCR. Both the A- and B-mRNA isoforms were found to be expressed in breast and uterus, whereas expression of the C-transcript was predominantly detected in liver. In bone cells only expression of the B-mRNA could be detected. The steady-state levels of the A- and B-transcripts in normal breast and uterus were quantified and compared with the hER mRNA levels in established cancer cell lines derived from the same tissues. This demonstrated approximately equal levels of the two transcripts in normal tissues whereas the A-mRNA was the most abundant isoform in the cancer cell lines investigated. Approximately 4.5 kb of the 5' flanking region of the rat ER (rER) gene were sequenced. Sequence analysis and PCR experiments suggested that the promoter organization of the rat and human ER genes is only partially conserved which might indicate species-specific differences in the regulation of ER expression. In conclusion, this work suggests tissue-specific alternative promoter usage as a mechanism in the regulation of human and rat ER gene expression.

Effects of hormonal replacement therapy on plasma sex hormone-binding globulin, androgen and insulin-like growth factor-1 levels in postmenopausal women

Plasma sex hormone-binding globulin (SHBG) levels are important in the regulation of plasma free and albumin-bound androgens and estrogens. In postmenopausal women associated to the decrease of estrogen production, a decrease of plasma SHBG levels occurs. Hormone replacement therapy (HRT) in postmenopausal women modulates plasma SHBG levels, in relationship with the different regimens and routes of administration. The present study aimed to compare the effect of different HRT on plasma SHBG levels in relationship with the changes of plasma androgen [dehydroepiandrosterone sulphate (DHEAS), testosterone (T), androstenedione (A)] and insulin-like growth factor-1 (IGF-1) levels. In a retrospective study 443 postmenopausal women were studied and divided into 2 groups. The group 1 (n = 170) was subdivided in 4 groups of women as follows: A) treated with transdermal 17-beta estradiol + medroxyprogesterone acetate, B) treated with oral conjugated estrogens, C) treated with sequential HRT (estradiol valerate (EV) + norgestrel), and D) treated with a combined HRT (micronized estradiol (E2) + noretisterone acetate). Women of group 2 (n = 273) did not receive HRT and served as controls. All groups of women treated with different HRT showed plasma estradiol levels significantly higher than controls (p < 0.01), showing the highest values in women treated with oral HRT. Plasma SHBG levels were not significantly different between patients treated with transdermal 17-beta estradiol + medroxyprogesterone acetate and controls. On the other hand, all the groups of patients treated with oral conjugated estrogen with or without progestagens showed plasma SHBG levels significantly higher than controls (p < 0.01). Plasma SHBG levels were higher in the group treated with estrogen alone than in groups of women treated with sequential or combined HRT. Plasma DHEAS, T and A levels in patients treated with different HRT regimens were in the same range of levels as control women. Plasma IGF-1 levels were not significantly affected by the various HRT regimens and remained in the same range as controls. In conclusion, plasma SHBG levels increase following oral HRT while are not affected by transdermal HRT. Plasma IGF-1 and androgen levels are not influenced from oral or transdermal HRT.

Transdermal estroprogestins versus transdermal estrogen plus oral dihydrogesterone replacement in menopause

We studied 18 early (6 to 36 months) postmenopausal patients with a mean age of 51 years (47-53), who had never undergone hormone replacement therapy before and had no contraindications to hormone replacement. All cases of menopause were spontaneous. The treatment consisted in the continuous transdermal administration of 17-beta-estradiol (50 microg/daily) by skin patch to be replaced every 84 hours. The patients were further treated with a two-week progestogen administration every fortnight. This consisted of transdermal norethisterone acetate (0.25 mg/daily) combined with estradiol in the same patch in the first year, and oral dihydrogesterone (10 mg/daily) in the second year, without wash-out period. Before treatment (T0), and at the 12th (T1) and 24th (T2) month we measured the body mass index, the arterial blood pressure (AP), lipoproteins, coagulation parameters and bone metabolism parameters. The systolic pressure presented mean values (+/-SD) equal to 128.5+/-10.2 mmHg (T0), 131.1+/-7.4 mmHg (T1) and 130.4+/-7.5 mmHg (T2). Diastolic pressure values showed mean value ranging from 85.4+/-8.7 mmHg (T0) to 83.9+/-5.3 (T1) and 83.4+/-5.8 mmHg (T2). The detailed analysis of values of triglycerides, HDL cholesterol, apolipoprotein A1, apolipoprotein B and coagulation parameters at different times of therapy showed no statistically significant changes. With regard to bone metabolism, no statistically significant changes from baseline values were observed in parathormone, alkaline phosphatase, calcitonin, urinary calcium/creatinine ratio, and bone mineral content expressed by the bone density.

Influence of two hormone replacement therapy regimens, oral oestradiol valerate and cyproterone acetate versus transdermal oestradiol and oral dydrogesterone, on lipid metabolism

OBJECTIVE

To compare the influence on lipid metabolism of two discontinuous, sequentially combined hormone replacement therapy (HRT) regimens.

STUDY DESIGN

In an open, randomized study in 60 women, a full lipid profile including Lp(a) and liver function tests were assessed in a fasting state at the end of treatment cycles 6 and 12. Group A was treated with 2 mg oestradiol valerate (days 1-21) sequentially combined with 1 mg cyproterone acetate (days 12-21); group B was treated with a patch releasing 50 micrograms oestradiol daily, twice a week (3 weeks), sequentially combined with 20 mg dydrogesterone (days 12-21) orally. Statistical analysis by two-sided one-way analysis of covariance (covariable is baseline) for adjusted means of lipid parameters and rank transformation analysis for lipoprotein(a) (Lp(a)) was performed.

RESULTS

Both groups were statistically comparable. The trial was completed by 45 subjects. Protocol violations occurred in 3 cases. Twelve subjects, equally divided between the groups, dropped out mainly because of adverse reactions. Both treatments were equally effective in the treatment of climacteric complaints. Liver function tests during the treatment period were normal in both groups. In group A, a statistically significant (P < 0.05) decrease versus baseline was observed in the serum levels (adjusted means) of the following parameters after 6 and 12 treatment cycles: total cholesterol (TC)-5% and -7%, respectively; low-density lipoprotein cholesterol (LDL-C) -13% and -14%, respectively; low-density lipoprotein cholesterol/high-density lipoprotein cholesterol ratio (LDL-C/HDL-C ratio) -16% and -18%, respectively. Triglycerides (TG) levels were significantly increased by 28% and nearly significantly (P = 0.07) by 25% after 6 and 12 treatment cycles, respectively. In group B, all lipid parameters (with the exception of apolipoprotein A-II which was significantly decreased after 12 treatment cycles) remained unchanged during therapy. Statistically significant differences for all aforementioned variables were found between the groups after 6 and 12 treatment cycles, respectively, with the exception of TC after 12 treatment cycles. After 6 treatment cycles, Lp(a) was decreased significantly (-18%) in group A as compared with baseline; after 12 months the decrease was -17% without reaching statistical significance. In group B, Lp(a) showed a slight but not statistically significant tendency to increase by 2% and 12% after 6 and 12 treatment cycles, respectively. Differences between both groups did not reach the level of significance.

CONCLUSION

In this randomized, comparative study, a sequentially combined oral HRT regimen consisting of oestradiol valerate (2 mg daily on days 1-21) and cyproterone acetate (1 mg daily on days 12-21), induced a lipid pattern and probably also a change in Lp(a) levels, which is generally viewed to be more beneficial with regard to the prevention of cardiovascular disease than the lipid pattern induced by a sequentially combined regimen of transdermal 17 beta-oestradiol (50 micrograms twice weekly during three weeks) and oral dydrogesterone (20 mg daily on days 12-21).

Tibolone and climacteric symptoms

Tibolone (Livial) has advantages over other forms of hormone replacement therapy (HRT); it is easy to use and does not induce withdrawal bleeding in postmenopausal women. The evidence for the effect of tibolone on climacteric symptoms is reviewed and shows that tibolone is effective in reducing vasomotor symptoms and vaginal dryness. Tibolone's effect on a range of other symptoms such as headache and insomnia is unclear. There are reports that tibolone improves mood and libido but much of this research is methodologically flawed. Methodologically sound research is required to investigate tibolone's effect on mood and libido; such a study is in progress.

Androgenic progestogens oppose the decrease of insulin-like growth factor I serum level induced by conjugated oestrogens in postmenopausal women. Preliminary report

Oral oestrogen treatment in postmenopausal women causes a decrease of insulin-like growth factor I (IGF-I) serum level, probably through a hepatocellular effect. To explore the possibility that the androgenic progestogens oppose this effect, serum IGF-I and sex hormone binding globulin (SHBG) were evaluated in two groups of patients treated respectively with oral conjugated oestrogens (oCE) or transdermal oestradiol (tdE2), in a first phase with the addition of dydrogesterone (DYDR), a non-androgenic progestogen, and subsequently with the addition of norethisterone acetate (NETA). With respect to basal values, treatment with oCE+DYDR caused an increase of SHBG (P < 0.002) and a decrease of IGF-I serum levels (P < 0.05); the shift to NETA addition opposed both effects: SHBG levels decreased partially but significantly (P < 0.01 vs. oCE + DYDR) and IGF-I returned to basal values with a significant increase with respect to the oCE + DYDR phase (P < 0.02). No changes were observed in the tdE2 + DYDR treated women; in this group the shift to NETA addition caused a significant decrease of SHBG values (P < 0.001 vs. before treatment and vs. tdE2 + DYDR phase) and a slight increase of IGF-I values. These differential effects on IGF-I and SHBG serum levels might be relevant as far as breast cancer risk is concerned.

Long-term hormone replacement treatment in menopause: new choices, old apprehensions, recent findings

In recent years there has been an increase in the use of parenteral oestradiol as an alternative to the conventional oral preparations used in hormone replacement treatment (HRT) in menopause, such as conjugated equine oestrogens (CEE). The latter have been subject in the past to apprehensions, partly due to misunderstanding and oversimplification but also in relation to problems that have arisen during the history of HRT, for example the increase in endometrial cancer risk deriving from the use of non-progestogen-opposed treatment. However, confidence in long-term HRT comes from the epidemiological findings, which refer mainly to the use of oral CEE unopposed by progestogen: a reduced risk of osteoporotic fractures and of cardiovascular disease, and a very limited risk of breast cancer. Oral oestrogens produce marked hepatocellular effects. These effects are, on the whole, favourable from the point of view of cardiovascular risk. In addition, it cannot be excluded that some hepatocellular effects of oral oestrogen, for example increased sex hormone binding globulin levels and reduced circulating insulin-like growth factor I activity, offer protection to the breast. As progestogen supplementation is needed in non-hysterectomized women, priority should be given to preparations, such as progesterone or dydrogesterone, that feature good endometrial activity without opposing oestrogen hepatocellular effects.

Differential effects of oral conjugated estrogens and transdermal estradiol on insulin-like growth factor 1, growth hormone and sex hormone binding globulin serum levels

In postmenopausal women oral ethinylestradiol causes a reduction in circulating insulin-like growth factor 1 (IGF-1) and an increase in serum growth hormone levels. There are no data on the effect of conjugated estrogens, the preparation most often used in estrogen replacement treatment (ERT), on these parameters. We evaluated serum IGF-1 and growth hormone levels, together with the levels of sex hormone binding globulin (SHBG), an indicator of estrogen hepatocellular action, before and after 6 months of ERT in two comparable groups of postmenopausal women. Sixteen women were treated with oral conjugated estrogens, 0.625 mg/day, and 14 with transdermal estradiol, 0.05 mg/day. In the women treated with oral conjugated estrogens, an increase in SHBG (p < 0.001), a decrease in IGF-1 (p < 0.001) and an increase in growth hormone (p < 0.05) serum levels were observed. No such effects were seen with the use of transdermal estradiol, devoid of hepatocellular effects. Undoubtedly, oral conjugated estrogens, 0.625 mg/day, through a hepatocellular effect, cause marked modifications in the IGF-1/growth hormone axis, which may have clinical relevance. For instance, the decreased IGF-1 level, together with the increased level of SHBG, might provide some explanation of the favorable epidemiological data on breast cancer risk in women receiving oral conjugated estrogens.

Proliferative activity as revealed by Ki-67 in uterine adenocarcinoma of endometrioid type: comparison of tumours from patients with and without previous oestrogen therapy

The Ki-67 antibody recognizes a nuclear antigen related to cell proliferation, which in some studies has been shown to reflect the aggressiveness of tumours. The percentage of Ki-67-positive cells was estimated by immunohistochemistry on frozen tissue sections from 73 adenocarcinomas of endometrioid type (EC) (40 tumours from patients who had never received postmenopausal oestrogen treatment and 33 tumours from patients with previous postmenopausal oestrogen treatment). The Ki-67 content was weakly but significantly (P < 0.05) correlated to nuclear grade, architectural grade, and crude mitotic count, but not to stage or progesterone receptors. Ki-67 expression in EC from patients with previous oestrogen therapy was much lower (median 10 per cent Ki-67) than that in EC from patients who had never received oestrogen treatment (median 24 per cent Ki-67), suggesting that a prognostic cut-off point may be different in tumours from the two groups of patients. The mitotic count discriminated the two groups of patients to a much smaller degree. It is also shown that a quick qualitative Ki-67 estimate can replace the time-consuming quantitative assessment.

Proliferating cell nuclear antigen in endometrial adenocarcinomas of endometrioid type correlated with histologic grade, stage, previous hormonal treatment, and survival

Only a small number of endometrial carcinomas have been examined for proliferating cell nuclear antigen. The results indicate that a high proliferating cell nuclear antigen content correlates with a poor prognosis. One hundred eight endometrial carcinomas of endometrioid type were examined with the monoclonal antibody PC10 (48 tumors from postmenopausal estrogen users and 60 tumors from nonusers). The PC10 content was weakly but significantly correlated with mitotic count and architectural grade, but not with nuclear grade, stage, or survival. PC10 values in estrogen users were much lower (median, 14%) than in nonusers (median, 26%); the difference was independent of histologic grade and stage. After a median follow-up of 30 months (range, 12 to 66 months) 17 patients had died. The cause of death was established as cancer in only nine cases. No overall difference in PC10 values existed between survivors and nonsurvivors. However, if only the estrogen nonusers were examined the survivors showed a mean PC10 value of 27%, while the nonsurvivors showed a mean PC10 value of 45%. The present study indicates that carcinomas from patients with and without previous hormonal treatment are different with regard to their PC10 content. The quantitative and qualitative estimates of PC10 correlated well.

Endometrial effects during hormone replacement therapy with a sequential oestradiol valerate/cyproterone acetate preparation

Three sequential oestradiol valerate (E2V) and cyproterone acetate (CPA) combinations based on 11 days of oestrogen and 10 days of oestrogen-progestogen administration were investigated during hormone replacement therapy in two prospective, double-blind randomized trials. Treatment A comprised 2 mg E2V and 1 mg CPA, treatment B, 1 mg and 0.5 mg and treatment C, 2 mg and 2 mg, respectively. During treatment A hot flushes (P < 0.0001), night sweating (P < 0.0001), depression (P = 0.0001), dizziness (P = 0.0001) and insomnia (P = 0.003) decreased significantly. The only side effect was breast tenderness, which was experienced by 18% of the women. Weight and blood pressure, thyroid, adrenal, liver and kidney functions, parathyroid hormone and vitamin D, platelets and blood cell counts did not change during the 12 months of therapy. In the women who received treatment A the menstrual flow became less abundant during the early months of treatment (P < 0.0001), the menses being scanty in around 30% of the women, while some 10% had amenorrhoea. Spotting occurred in 10-20% of the subjects. Endometrial biopsies were atrophic in 10% of the women, whereas a normal secretory phase was observed in 45% and irregular secretion in 45%. After careful analysis using visual analog scales, these findings were interpreted as indicating a high-normal progestational effect. In comparison with the pattern observed in normal menstrual cycles the women who received treatment A had a more heterogenic glandular epithelium, with more papillae, larger stromal cells, a more pronounced decidual reaction and more fibrinoid material. No cases of hyperplasia were seen. Treatment B was less effective than treatment A in relieving climacteric complaints. Irregular bleeding was troublesome in over 20% of cases and amenorrhoea occurred in 50%. Endometrial biopsies were atrophic in 57% of the women. The effectiveness of treatment C in alleviating flushes, sweating, dizziness and depression was the same as that of treatment A. The decrease in menstrual flow during the early months and the incidence of amenorrhoea (approx. 10%) and atrophic endometria (approx. 10%) were comparable. Detailed analysis revealed that C had an even stronger progestational effect than A. It was concluded that A was the treatment of choice in comparison with B and C. It proved highly effective in treating climacteric complaints, had no side effects apart from breast tenderness, provided good cycle control and induced a physiological secretory transformation of the endometrium.(ABSTRACT TRUNCATED AT 400 WORDS)

The risk of acute myocardial infarction after oestrogen and oestrogen-progestogen replacement

OBJECTIVE

To determine the relative risk of developing a first acute myocardial infarction after treatment with oestrogens alone or oestrogen-progestogen combinations.

DESIGN

Prospective cohort study utilizing a prescription-based and record linkage system for a follow-up period from 1977 to 1983. Average individual observation time was 5.8 years.

SETTING

The entire female population of the Uppsala Health Care Region (1.4 million inhabitants), one-sixth of the total Swedish population.

SUBJECTS

23,174 women aged 35 years and older, identified from pharmacy records as having been prescribed non-contraceptive oestrogens during 1977-1980.

OUTCOMES

Admissions to hospitals for first acute myocardial infarctions.

RESULTS

Overall, 227 cases of a first acute myocardial infarction were observed as against 281:1 expected, RR = 0.81 (95% confidence limits 0.71 to 0.92). Women who were younger than 60 years at entry into the study and prescribed oestradiol compounds (1-2 mg) or conjugated oestrogens (0.625-1.25 mg) showed a significant 30% reduction of the relative risk (RR = 0.69, 0.54 to 0.86). Those prescribed a combined oestradiol-levonorgestrel brand also demonstrated a significantly lowered relative risk (RR = 0.53, 0.30 to 0.87). The risk estimates were near unity during the first year of follow-up but decreased during subsequent years. Exposure to the weak oestrogen oestriol did not alter the risk.

CONCLUSION

Hormonal replacement therapy with oestrogens alone, and maybe also when cyclically combined with progestogens, can reduce the risk of acute myocardial infarction.

Oestrogen and cyclical progestogen in postmenopausal hormone replacement therapy

OBJECTIVE

To ascertain the effectiveness, safety and incidence of side effects of a postmenopausal hormone replacement regimen consisting of continuous conjugated equine oestrogens and cyclical medroxyprogesterone acetate given for the first 14 days of each calendar month.

DESIGN

A six month, prospective, open label, two centre, outpatient study of continuous Premarin (0.625 mg; Wyeth-Ayerst) and cyclical Provera (10 mg; Upjohn). Dosage adjustment was allowed in one centre.

STUDY POPULATION

Seventy-six postmenopausal women in Adelaide and Brisbane.

MAIN OUTCOME MEASURES

Menopausal symptom score, serum lipid levels, routine biochemical and haematological indices, endometrial histology and clinical bleeding pattern, blood pressure, weight changes, side effects, withdrawal from the study, compliance and necessary dose adjustment.

MAIN RESULTS

Eight women withdrew from the study and nearly 50% experienced some minor side effect. Where dosage adjustment was allowed, almost all side effects were eliminated. Most patients had acceptable regular withdrawal bleeds although some were deemed heavy. There was a statistically highly significant 54% reduction in the menopausal symptoms score at three months and a 62% reduction at six months. Endometrial biopsy at six months showed atrophic or secretory endometrium with no inappropriate proliferation or hyperplasia. Total cholesterol and low density lipoprotein (LDL) cholesterol levels were significantly decreased. The high density lipoprotein (HDL) cholesterol level remained unchanged and triglyceride levels were raised within the normal range. There were no other clinically relevant biochemical, haematological or clinical changes.

CONCLUSION

Continuous conjugated equine oestrogens (0.625 mg) and cyclical medroxyprogesterone acetate (10 mg) for the first 14 days of each calendar month proved to be a safe and effective postmenopausal therapy regimen. Initial minor side effects were common but could be readily ameliorated with early follow-up and dose titration.

The benefits and risks of hormone replacement therapy: an epidemiologic overview

In postmenopausal women estrogens alone are effective in reversing vasomotor symptoms and vaginal atrophy. They also prevent the bone loss associated with osteoporosis and reduce the risk of cardiovascular disease, probably through their beneficial effects on lipid metabolism. Unopposed long-term estrogen therapy, however, increases the risk of developing endometrial hyperplasia, endometrial cancer, and possibly breast cancer as well. The risk of developing endometrial cancer can be reduced by combining a progestin with the estrogen, by controlling obesity, and by rigorous clinical screening and surveillance. The effect of progestins on the risk of developing breast cancer is still controversial. Although some progestins may reverse the cardioprotective effect of estrogens, those with minimal androgenicity appear less likely to do so. Hormone replacement therapy that combines estrogen with a progestin of minimal androgenicity is thus a rational alternative to unopposed estrogen therapy. Current epidemiologic knowledge suggests that the benefits of hormone replacement therapy, with or without any progestins, strongly outweigh the risks.