Effects of non-oral postmenopausal hormone therapy on markers of cardiovascular risk: a systematic review

Effects of transdermal versus oral hormone replacement therapy in postmenopause: a systematic review

PURPOSE

To summarize available evidence comparing the transdermal and the oral administration routes of hormone replacement therapy (HRT) in postmenopausal women.

METHODS

We performed a systematic review of the literature on multiple databases between January 1990 and December 2021. We included randomized controlled trials and observational studies comparing the transdermal and oral administration routes of estrogens for HRT in postmenopausal women regarding at least one of the outcomes of interest: cardiovascular risk, venous thromboembolism (VTE), lipid metabolism, carbohydrate metabolism, bone mineral density (BMD), and risk of pre-malignant and malignant endometrial lesions, or breast cancer.

RESULTS

The systematic literature search identified a total of 1369 manuscripts, of which 51 were included. Most studies were observational and of good quality, whereas the majority of randomized controlled trials presented a high or medium risk of bias. Oral and transdermal administration routes are similar regarding BMD, glucose metabolism, and lipid profile improvements, as well as do not appear different regarding breast cancer, endometrial disease, and cardiovascular risk. Identified literature provides clear evidence only for the VTE risk, which is higher with the oral administration route.

CONCLUSIONS

Available evidence comparing the transdermal and oral administration routes for HRT is limited and of low quality, recommending further investigations. VTE risk can be considered the clearest and strongest clinical difference between the two administration routes, supporting the transdermal HRT as safer than the oral administration route.

The impact of micronized progesterone on cardiovascular events - a systematic review

Biologically identical menopausal hormone therapy (MHT) including micronized progesterone (MP) has gained much attention. We aimed to assess the impact of MP in combined MHT on venous and arterial thromboembolism (VTE/ATE) (e.g. deep venous thrombosis/pulmonary embolism, myocardial infarction [MI] and ischemic stroke). Articles were eligible if they provided endpoints regarding cardiovascular events and use of exogenous MP. Literature searches were designed and executed for the databases Medline, Embase, CINAHL, the Cochrane Library, ClinicalTrials.gov and interdisciplinary database Web of Science. Twelve studies consisting of randomized controlled trials (RCTs), case-control studies and prospective or retrospective cohort studies were included, and risk of bias was assessed. Only a minority assessed thromboembolic events as a primary endpoint, showing that in contrast to norpregnane derivatives, primary and recurrent VTE risk was not altered by combining estrogens with MP, which was also true for ischemic stroke risk. Similarly, in placebo-controlled RCTs assessing VTE/ATE as adverse events there were no significant intergroup differences. Studies on MI as a primary endpoint are missing. In conclusion, while available data suggest that MP as a component in combined MHT may have a neutral effect on the vascular system, more RCTs investigating the impact of MP alone or in combined MHT on vascular primary endpoints are needed.

Diagnosis and Management of Neuroendocrine Disorders of Survivors of Brain Tumors

Advances in the treatment of brain tumors have led to an increase in the number of survivors of this disease. Consequently, the long-term complications associated with past and current treatments are becoming more apparent. Of relevance to patients who receive treatment of brain tumors are the potential neuroendocrine complications that develop either acutely or several years following treatment. Presentation may differ between adults and children (e.g., short stature or adult growth hormone deficiency) but in both settings can complicate treatment and impact quality of life. The risk for the development of these complications depends on the location of the tumor (proximity to the pituitary/hypothalamus) and/or the treatment delivered (chemotherapy/surgery/radiation). Given the potential overlap in symptoms attributable to the underlying brain tumor and neuroendocrine dysfunction, a high level of suspicion, appropriate investigation, and administration of treatment may reduce morbidity and mortality for patients with brain tumors experiencing neuroendocrine dysfunction.

[Menopausal hormone therapy: internal-endocrine point of view]

The history of menopausal hormone therapy (MHT) started in 1942 in the US and became very popular in the 1960s worldwide because of the beneficial effects on vasomotor-vegetative and vulvovaginal symptoms. These symptoms may begin already in the premenopausal period, and can last for more than 10 years with reduced quality of life. Many women with vasomotor-vegetative symptoms do not visit a gynaecologist first but primarily a general physician or cardiologist because of instable blood pressure and palpitations, leading to the focus on the heart. To avoid unnecessary examinations and treatment with ß-blockers or antidepressants, an interdisciplinary look is necessary. In most cases, appropriate and low dose hormone replacement will relieve the symptoms and restore quality of life. In addition, it is worthwhile to know about the long-term effect of hormone deficiency as well as replacement on the different organ systems and the possible influences of hormone replacement therapy including contra indications. This is especially necessary after the uncertainties raised after the first deleterious announcements of the currently corrected results of the WHI (women's health initiative) study.

A current perspective into young female sex hormone replacement: a review

INTRODUCTION

Hormone replacement in females with hypogonadism is advocated to address the various clinical aspects of estrogen deficiency.

AREAS COVERED

This article focuses on hormone replacement in young females with hypogonadism, including a rationale as to why hormone replacement in such patients differs from treatment in postmenopausal females, a summary of symptoms encountered by females with hypogonadism and a comprehensive discussion of the various treatment options available, specifically focusing on the latest advances in the subject. A Medline search was conducted using different combinations of relevant keywords, giving preference to recent publications.

EXPERT OPINION

Whilst traditionally oral contraceptive pills (containing ethynyl estradiol) were commonly used as a form of hormone replacement, it is now increasingly recognized that this is not the optimal treatment option. Physiological hormone replacement with transdermal estradiol is found to be superior. Evidence suggests that micronized progesterone may be associated with fewer side effects, although its effect on endometrial protection is not yet proven. Synthetic progestins confer varying degrees of androgenic and thromboembolic properties which should be kept in mind when prescribing individualized treatment. Further studies in different sub-cohorts of female patients with hypogonadism might help address the specific needs of individual patients.

Association of Surgical Risk With Exogenous Hormone Use in Transgender Patients: A Systematic Review

Importance

A growing number of transgender patients are receiving gender-affirming hormone treatments. It is unclear whether the evidence supports the current practice of routinely discontinuing these hormones prior to surgery.

Objective

To determine how medications used in cross-sex hormone treatment (CSHT) affect perioperative risk.

Evidence Review

A series of searches were carried out in PubMed and Excerpta Medica Database to identify articles using each of the terms testosterone, estrogen, estradiol, oral contraceptive, spironolactone, cyproterone acetate, finasteride, dutasteride, leuprolide, goserelin, and histrelin, in combination with the terms surgery, perioperative, thrombosis, thromboembolism, and operative. The search was not restricted to perioperative outcomes in transgender populations because many surgeons routinely discontinue hormone use prior to surgery in this population, which makes it impossible to study how hormones affect outcomes. Additional sources were also identified from the texts of reviewed articles. Articles were excluded if they were animal studies or case reports, did not explicitly discuss surgical outcomes, or were restricted to removal of hormonally sensitive tissues.

Findings

Eighteen articles addressing perioperative outcomes were identified by this systematic review, including 1 on CSHT, 12 on estrogens and progesterones, 1 on testosterone, and 4 on spironolactone and antiandrogens. Data were limited, but use of exogenous testosterone was not found to be associated with an increased risk of venous thromboembolism or other complications during surgery. Moderate evidence suggests that spironolactone is not associated with negative surgical outcomes. The data linking estrogen use and thrombosis is inconsistent in the perioperative period and does not address the types of estrogens most often used for CSHT.

Conclusions and Relevance

Current evidence does not support routine discontinuation of all CSHT prior to surgery, particularly given the lack of information on risks associated with resuming these medications after they have been stopped. Evidence suggests there is no need to discontinue either testosterone or spironolactone, although their association with perioperative outcome quality has not been studied in depth. Most of the evidence that supports discontinuation of estrogen prior to surgery is based on oral estrogen regimens that are not typically used in transgender patients, and even with those formulations, there are conflicting reports on perioperative risk. Further research is needed to determine the safety of continuing hormone treatment and elucidate risks of short-term discontinuation.

Hormone replacement therapy in young women with primary ovarian insufficiency and early menopause

Primary ovarian insufficiency (POI) is a rare but important cause of ovarian hormone deficiency and infertility in women. In addition to causing infertility, POI is associated with multiple health risks, including bothersome menopausal symptoms, decreased bone density and increased risk of fractures, early progression of cardiovascular disease, psychologic impact that may include depression, anxiety, and decreased perceived psychosocial support, potential early decline in cognition, and dry eye syndrome. Appropriate hormone replacement therapy (HRT) to replace premenopausal levels of ovarian sex steroids is paramount to increasing quality of life for women with POI and ameliorating associated health risks. In this review, we discuss POI and complications associated with this disorder, as well as safe and effective HRT options. To decrease morbidity associated with POI, we recommend using HRT formulations that most closely mimic normal ovarian hormone production and continuing HRT until the normal age of natural menopause, ∼50 years. We address special populations of women with POI, including women with Turner syndrome, women with increased risk of breast or ovarian cancer, women approaching the age of natural menopause, and breastfeeding women.

Hypertension in pregnancy is associated with elevated C-reactive protein levels later in life

OBJECTIVES

We assessed whether hypertension in pregnancy is associated with elevated C-reactive protein (CRP) levels in later life, possibly reflecting an increased risk of cardiovascular disease (CVD).

BACKGROUND

Elevated CRP levels have been associated with hypertension in pregnancy and with CVD.

METHODS

We studied 2463 women from the Genetic Epidemiology Network of Arteriopathy (GENOA) study. Participants were categorized as nulliparous women (n = 219), women with a history of normotensive pregnancies (n = 1839), or women with a history of a hypertensive pregnancy (n = 405). Using multiple linear regression models, we compared mean CRP levels among the groups after adjusting for age, race, education, smoking, hypertension, personal history of coronary heart disease (CHD) or stroke, diabetes, dyslipidemia, statins, hormone replacement therapy, and family history of CHD or stroke. As CRP levels may be influenced by BMI, the model was fit both with and without adjusting for BMI.

RESULTS

There was no significant difference in CRP levels between nulliparous women and those with a history of normotensive pregnancies, either with (P = 0.82) or without (P = 0.46) adjusting for BMI. In contrast, women with hypertensive pregnancies, compared with those with normotensive pregnancies, had higher CRP levels, both with (P = 0.009) and without (P < 0.001) adjusting for BMI.

CONCLUSION

A history of hypertension in pregnancy is associated with elevated CRP levels later in life, independent of traditional CVD risk factors and BMI. An elevated CRP may reflect an inflammatory state in women with a history of hypertensive pregnancy disorders who are at increased risk for CVD.

Concurrent use of statins and hormone therapy and risk of venous thromboembolism in postmenopausal women: a population-based case-control study

OBJECTIVE

Statins and hormone therapy (HT), often used concurrently in postmenopausal women, have antagonist effects on the risk of venous thromboembolism (VTE). This study aims to determine whether statins attenuate the increased VTE risk associated with HT.

METHODS

We conducted a nested case-control study within a population-based cohort of women aged 50 to 79 years between January 1, 1987 and March 1, 2008, who were identified from the UK General Practice Research Database. Cases of VTE occurring during follow-up were identified and each matched with up to 10 controls from the cohort. Odds ratios (ORs) for the effects of concurrent HT and statin use on the risk of VTE were estimated using conditional logistic regression with interaction terms.

RESULTS

The cohort included 955,582 postmenopausal women, with 23,505 cases of VTE matched with 231,562 controls. Regardless of any HT use, current use of statins was associated with a decreased risk of VTE (OR, 0.83; 95% CI, 0.78-0.87). The interaction between statin use and HT use was of borderline significance (P = 0.053). Consequently, among nonusers of statins, the risk of VTE was elevated with current use of oral estrogen and progestogen combinations (OR, 1.55; 95% CI, 1.45-1.66) but this risk was not elevated among users of statins (OR, 0.98; 95% CI, 0.56-1.73). There was no such modification of the OR with statins and other HT types and formulations.

CONCLUSIONS

Statins could potentially attenuate the increased risk associated with HT combinations of oral estrogens and progestogens. This observation needs further confirmation in other large cohorts.

Safe and effective use of chronic transdermal estradiol for life-threatening uremic bleeding in a patient with coronary artery disease

Uremic platelet dysfunction rarely causes significant bleeding in adequately dialyzed patients. When encountered, the management is complicated by a lack of well-supported treatment modalities. Estrogen use in uremic platelet dysfunction has been described, but enthusiasm for the treatment has been dampened by the risk of thrombotic events in vasculopathic dialysis patients. We present a patient on long-term peritoneal dialysis with coronary disease who developed recurrent life-threatening bleeding episodes secondary to uremia, where treatment with transdermal estrogen was used safely and effectively for a 24-month period.

Menopausal hormone therapy: examining cardiovascular and clinical impacts of treatment

Postmenopausal women have reduced levels of female sex hormones and this may play a significant role in the onset of cardiovascular disease. Menopausal hormone therapy (MHT), which is primarily prescribed for the treatment of perimenopausal symptoms, has been associated with risk of coronary heart disease, hypertension and stroke in women. This review will summarize the outcomes of observational studies and randomized clinical trials that have investigated the influence of MHT use on the cardiovascular system. In addition, it will explore how the timing of MHT prescription relative to menopause, dosage and route of administration may alter the impact of MHT on cardiovascular health.

Hypertension in pregnancy is associated with elevated homocysteine levels later in life

OBJECTIVE

Hyperhomocysteinemia is associated with an elevated cardiovascular disease risk. We examined whether women with a history of hypertension in pregnancy are more likely to have a high level of serum homocysteine decades after pregnancy.

STUDY DESIGN

Serum homocysteine was measured at a mean age of 60 years in nulliparous women (n = 216), and women with a history of normotensive (n = 1825) or hypertensive (n = 401) pregnancies who participated in the Genetic Epidemiology Network of Arteriopathy (GENOA) study. Relationships between homocysteine and pregnancy history were examined by linear and logistic regression, controlling for multiple covariates including personal and family history of hypertension, diabetes, obesity, tobacco use, and demographics.

RESULTS

A history of hypertension in pregnancy, when compared with normotensive pregnancy, was associated with a 4.5% higher serum homocysteine level (P = .015) and 1.60-fold increased odds of having an elevated homocysteine (95% confidence interval, 1.15-2.21; P = .005) after adjusting for potentially confounding covariates. In contrast, a history of normotensive pregnancy, as compared with nulliparity, was associated with a 6.1% lower serum homocysteine level (P = .005) and a 0.49-fold reduced odds of elevated homocysteine levels (95% confidence interval, 0.32-0.74; P < .001).

CONCLUSION

Homocysteine levels decades after pregnancy are higher in women with a history of pregnancy hypertension, even after controlling for potential confounders. Thus, pregnancy history may prompt homocysteine assessment and risk modification in an attempt at primary prevention of cardiovascular disease.

Lipoprotein(a): resurrected by genetics

Plasma lipoprotein(a) [Lp(a)] is a quantitative genetic trait with a very broad and skewed distribution, which is largely controlled by genetic variants at the LPA locus on chromosome 6q27. Based on genetic evidence provided by studies conducted over the last two decades, Lp(a) is currently considered to be the strongest genetic risk factor for coronary heart disease (CHD). The copy number variation of kringle IV in the LPA gene has been strongly associated with both Lp(a) levels in plasma and risk of CHD, thereby fulfilling the main criterion for causality in a Mendelian randomization approach. Alleles with a low kringle IV copy number that together have a population frequency of 25-35% are associated with a doubling of the relative risk for outcomes, which is exceptional in the field of complex genetic phenotypes. The recently identified binding of oxidized phospholipids to Lp(a) is considered as one of the possible mechanisms that may explain the pathogenicity of Lp(a). Drugs that have been shown to lower Lp(a) have pleiotropic effects on other CHD risk factors, and an improvement of cardiovascular endpoints is up to now lacking. However, it has been established in a proof of principle study that lowering of very high Lp(a) by apheresis in high-risk patients with already maximally reduced low-density lipoprotein cholesterol levels can dramatically reduce major coronary events.

A decade of postmenopausal hormone therapy prescribing in the United States: long-term effects of the Women's Health Initiative

OBJECTIVE

Nearly a decade ago, landmark clinical trials revealed an increase in the risks associated with hormone therapy in postmenopausal women, leading to early changes in prescribing patterns. Long-term prescribing patterns in the United States after these trials are unknown. The objective of this study was to describe changes in hormone therapy prescribing including dose, formulation, patient age, and prescriber specialty from 2000 to 2009.

METHODS

A national pharmacy claims database was used to describe the annual prevalence and incidence rates of hormone therapy prescribing from 2000 to 2009 in women 50 years and older.

RESULTS

Throughout the decade, a number of prescribing trends were observed: a continuous decline in hormone therapy overall, an initial drop in new therapy that stabilized after 2003, a decline in oral formulations and increase in vaginal formulations, a decline in standard- and high-dose and an increase in low-dose oral formulations, and an increase in the proportion of women who received hormone therapy from gynecologists.

CONCLUSIONS

Overall prescribing of hormone therapy continued to decline during the past decade, suggesting a long-term impact of the Women's Health Initiative findings. During this same time, treatment regimens shifted to favor vaginal and lower-dose oral formulations.

Coagulation and fibrinolytic disturbances are related to carotid intima thickness and arterial blood pressure in Turner syndrome

OBJECTIVE

Turner syndrome (TS) is characterized by growth retardation, hypogonadism and a high risk of cardiovascular complications and atherosclerosis; case reports suggest that thrombo-embolic complications may be present.

DESIGN

Cross-sectional study.

PATIENTS

Sixty women with TS.

MEASUREMENTS

We characterized the activities of the haemostatic system, elucidated by the assessment of a panel of clotting factors and thrombosis risk factors and related these findings to carotid intima thickness (CIMT) and blood pressure.

RESULTS

Most (81%) received hormone replacement therapy. The medians of all measured factors and inflammatory parameters were not different from normative data, but many cases displayed values of C-reactive protein (CRP) (40%), fibrinogen (15%), fibrin D-dimer (15%), factor VIII (25%), von Willebrand factor (vWF) (15%), cholesterol and liver parameters that were greater than normative limits. CRP, fibrinogen, vWF, factor VIII and liver parameters were highly and positively correlated. Haemostatic variables were positively related to both CIMT and blood pressure. The Factor V Leiden G1691A gene polymorphism heterozygosity was detected in 12·5%.

CONCLUSION

We describe a significant proportion of individual TS females having high levels of vWF, factor VIII, fibrinogen and CRP (15-40%) and an increased frequency of the Leiden mutation, with important associations with CIMT and blood pressure, suggesting that a subset of TS may have an unfavourable haemostatic balance, which may contribute to the increased risk of premature ischaemic heart disease and possibly increase the risk of deep venous and portal vein thrombosis.

A review of transdermal nonpatch estrogen therapy for the management of menopausal symptoms

During the transition into menopause, women may experience a wide range of symptoms that negatively impact quality of life. The vasomotor symptoms (VMS) of hot flushes and night sweats are common and vary widely in frequency and severity. The treatment of menopause-associated VMS is a frequently encountered clinical challenge, with the goal of tailoring treatment for each individual woman's needs. Estrogen therapy is the most effective treatment for menopausal VMS. Current guidelines suggest that estrogen therapy be prescribed at the lowest effective dose for the shortest duration of time. Transdermal estrogen therapy has dominated the menopause prescribing practice in Europe for decades; however, in the United States, oral estrogen therapy is most commonly prescribed. Transdermal estrogen therapy can be prescribed at considerably lower doses than oral therapy yet has similar efficacy on the symptoms of menopause. Emerging research demonstrates transdermal estrogen, particularly 17beta-estradiol, may have the potential for fewer health risks than oral estrogen therapy. This review article discusses the spectrum of menopausal symptoms, addresses prevailing issues in the treatment of menopause, elaborates on the risks and benefits of oral and transdermal hormone therapies, and focuses on five nonpatch transdermal estradiol therapies currently available in the United States.

Migraine in women: the role of hormones and their impact on vascular diseases

Migraine is a predominantly female disorder. Menarche, menstruation, pregnancy, and menopause, and also the use of hormonal contraceptives and hormone replacement treatment may influence migraine occurrence. Migraine usually starts after menarche, occurs more frequently in the days just before or during menstruation, and ameliorates during pregnancy and menopause. Those variations are mediated by fluctuation of estrogen levels through their influence on cellular excitability or cerebral vasculature. Moreover, administration of exogenous hormones may cause worsening of migraine as may expose migrainous women to an increased risk of vascular disease. In fact, migraine with aura represents a risk factor for stroke, cardiac disease, and vascular mortality. Studies have shown that administration of combined oral contraceptives to migraineurs may further increase the risk for ischemic stroke. Consequently, in women suffering from migraine with aura caution should be deserved when prescribing combined oral contraceptives.

Stroke risk in women: the role of menopause and hormone therapy

Although women have a lower risk of stroke during middle age than men, the menopausal transition is a time when many women develop cardiovascular risk factors. Additionally, during the 10 years after menopause, the risk of stroke roughly doubles in women. Endogenous oestrogen concentrations decline by 60% during the menopausal transition, leading to a relative androgen excess, which could contribute to the increased cardiovascular risk factors in women. Earlier onset of menopause might affect the risk of stroke, but the data are not clear. Because of the stroke risk associated with it, hormone therapy is recommended only for treatment of vasomotor symptoms, and some formulations might be safer than others. More research is needed to understand which women are at greatest stroke risk during midlife and to identify the safest formulation, dose, and duration of hormone therapy that can be used to treat vasomotor symptoms without increasing the risk of stroke.

Hormone therapy administration in postmenopausal women and risk of stroke

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

No effect of Implanon® on inflammatory cardiovascular parameters

OBJECTIVE

Recently, we found decreased levels of C-reactive protein (CRP) during use of the low-dosed contraceptive implant Implanon®. To further elucidate, whether this finding might be a sign for a lower inflammatory reaction and is associated with changes in levels of other cytokines, we investigated the effect of this implant on interleukin-6 (IL-6) and adiponectin. Plasma lipids and sex hormone levels have been shown to interact with the investigated parameters in vivo and in vitro. Therefore these parameters were measured as well.

DESIGN

Prospective case-control study.

SETTING

Family-planning centre, University hospital.

SUBJECTS

Thirty-six non-smoking women with regular cycles.

INTERVENTIONS

Blood samples for the measurements were taken in the early follicular phase of the cycle in both groups. A second sample was taken 12 weeks after Implanon insertion or in the controls during the early follicular phase of cycle 4.

RESULTS

Implanon did not cause significant changes in IL-6, adiponectin or lipoprotein (Lp)(a). At baseline, there was a significant positive correlation between IL-6 and CRP and a negative correlation between adiponectin and CRP.

CONCLUSION

We did not observe a negative impact of Implanon on risk markers for atherosclerotic disease such as IL-6, adiponectin, and Lp(a). These data are reassuring for clinicians who prescribe progestagen-only preparations as first choice contraceptives in females with cardiovascular risk factors.

Pathogenesis of postoperative adhesion formation

Background

Current views on the pathogenesis of adhesion formation are based on the ‘classical concept of adhesion formation’, namely that a reduction in peritoneal fibrinolytic activity following peritoneal trauma is of key importance in adhesion development.

Methods

A non-systematic literature search (1960–2010) was performed in PubMed to identify all original articles on the pathogenesis of adhesion formation. Information was sought on the role of the fibrinolytic, coagulatory and inflammatory systems in the disease process.

Results

One unifying concept emerged when assessing 50 years of studies in animals and humans on the pathogenesis of adhesion formation. Peritoneal damage inflicted by surgical trauma or other insults evokes an inflammatory response, thereby promoting procoagulatory and antifibrinolytic reactions, and a subsequent significant increase in fibrin formation. Importantly, peritoneal inflammatory status seems a crucial factor in determining the duration and extent of the imbalance between fibrin formation and fibrin dissolution, and therefore in the persistence of fibrin deposits, determining whether or not adhesions develop.

Conclusion

Suppression of inflammation, manipulation of coagulation as well as direct augmentation of fibrinolytic activity may be promising antiadhesion treatment strategies.

Estrogen upregulates hepatic apolipoprotein M expression via the estrogen receptor

Apolipoprotein M (apoM) is present predominantly in high-density lipoprotein (HDL) in human plasma, thus possibly involved in the regulation of HDL metabolism and the process of atherosclerosis. Although estrogen replacement therapy increases serum levels of apoAI and HDL, it does not seem to reduce the cardiovascular risk in postmenopausal women. Therefore, we investigated the effects of estrogen on apoM expression in vitro and in vivo. HepG2 cells were incubated with different concentrations of estrogen with or without the estrogen receptor antagonist, fulvestrant, and apoM expression in the cells was determined. Hepatic apoM expression and serum levels of apoM were also determined in normal and in ovariectomized rats treated with either placebo or estradiol benzoate, using sham operated rats as controls. Estrogen significantly increased mRNA levels of apoM and apoAI in HepG2 cell cultures in a dose- and time-dependent manner; the upregulation of both apolipoproteins was fully abolished by addition of estrogen receptor antagonist. In normal rats, estrogen treatment led to an increase in plasma lipid levels including HDL cholesterol, a marked upregulation of apoM mRNA and a significant increase in serum levels of apoM. The same pattern of regulation was found in ovariectomized rats treated with estrogen. Thus, estrogen upregulates apoM expression both in vivo and in vitro by mechanism(s) involving the estrogen receptor.

Menopausal hot flushes and vascular health

Hot flushes are complained of by approximately 75% of all postmenopausal women, and hormone therapy (HT) is the most effective way to alleviate them. Hot flushes are characterized by altered vascular function and sympathetic nervous system activity. Hot flushes occurred more often in women attending large, non-randomized observational studies (e.g. Nurses' Health Study), where HT use protected against cardiovascular disease (CVD). However, they were absent (or mild) in randomized HT trials where HT use was accompanied with an elevated risk for CVD. Hot flushes, if a factor for cardiovascular health, could partly explain the conflict between observational and randomized trials. Several cross-sectional studies imply that hot flushes are detrimental to the cardiovascular system. However, the data are not uniform, and hot flushes were recalled retrospectively or during HT use. In our prospective study hot flushes were accompanied with a vasodilatory effect during endothelial testing, and this was related to the severity of hot flushes. Night-time hot flushes were followed with transient rises in ambulatory blood pressure (BP). However, no effect of hot flushes on diurnal BP was detected. The use of estradiol showed no harmful effects on endothelial function in women with hot flushes, but in non-flushing women oral, but not transdermal, estradiol led to vasoconstrictive changes. Estradiol complemented with medroxyprogesterone acetate eliminated the vasoconstrictive effect of sole oral estradiol. Thus, both oral and transdermal estradiol are applicable in flushing women, whereas a transdermal route should be favored in non-flushing women if used e.g. for bone protection.

The effect of estrone on thrombin generation may explain the different thrombotic risk between oral and transdermal hormone replacement therapy

BACKGROUND

The metabolism of estrogen contained within hormone replacement therapy (HRT) is influenced by the route of administration, and this may affect the risk of venous thromboembolism. Thrombin generation, a global coagulation assay, is a marker of hypercoagulability and is of potential use in determining the thrombotic risk associated with particular HRT administration routes.

OBJECTIVES

To determine whether any effect of oral and transdermal HRT on thrombin generation is related to the plasma estrogen profile.

METHODS

We investigated the effects of oral, transdermal and no HRT (controls) in 52, 39 and 52 postmenopausal women, respectively, on thrombin generation, standard markers of thrombophilia, estradiol level and estrone level.

RESULTS

All parameters of thrombin generation were altered in women using oral HRT as compared with controls (P<0.001 for all comparisons). No such differences were found in women using transdermal HRT. Estrone levels correlated with peak thrombin generation (R=0.451, P<0.001) in women using oral HRT, but there was no correlation in women using the transdermal route.

CONCLUSIONS

Thrombin generation is significantly increased in women who use HRT administered by the oral route. This is probably mediated by the hepatic first-pass metabolism of estrone, the main metabolite of oral estradiol, which is avoided by the transdermal route. The effect of estrone on thrombin generation may provide the explanation for the higher thrombotic risk seen in women using oral rather than transdermal HRT.

Assessing fatal cardiovascular disease risk with the SCORE (Systematic Coronary Risk Evaluation) scale in post-menopausal women 10 years after different hormone treatment regimens

OBJECTIVE

To assess fatal cardiovascular disease (FCD) risk among women in early post-menopausal years, as evaluated with the Systematic Coronary Risk Evaluation (SCORE) scale.

DESIGN

This was a retrospective study of parallel cohorts. Two hundred seventy-three healthy post-menopausal women. Participants received one of the following hormone treatment (HT) regimens: transdermal estradiol (50 microg) (n = 99), sequential cyclic HT with transdermal estradiol (50 microg/day) plus 200 mg/day natural micronised oral progesterone (cycle days 12-25) (n = 63) and combined HT using transdermal estradiol (50 microg) plus 100 mg/day of micronised oral progesterone (n = 61). A group of women who elected not to use HT served as control group (n = 50). SCORE values were assessed before HT or follow up.

RESULTS

Only one woman displayed a high-risk SCORE value both before and after 10 years of HT, the remaining had low risk values (<5%) for FCD. After 10 years, SCORE values increased significantly as compared to baseline among HT users (all three regimens) and controls. Although post-treatment SCORE values significantly differed among groups, values were all below the high risk cut-off (5%). There were no FCD events during the 10 year observation period.

CONCLUSION

As assessed with the SCORE scale, FCD risk in young post-menopausal women (HT users and controls) had a slight significant increase after 10 years, being values in the low risk range.

Vasomotor hot flushes and 24-hour ambulatory blood pressure in normotensive women: A placebo-controlled trial on post-menopausal hormone therapy

BACKGROUND

Blood pressure (BP) is one of the most powerful determinants of cardiovascular risk in women. This risk may differ between post-menopausal women with and without vasomotor hot flushes, possibly indicating different vascular responses to hormone therapy (HT). Thus, we compared in a clinical trial the effect of HT on ambulatory BP in normotensive, recently post-menopausal women with or without severe hot flushes.

METHODS

A total of 147 women recorded prospectively their hot flushes for 2 weeks; 70 women were symptomatic (>or=7 moderate/severe hot flush episodes/day), whereas 77 women were defined as asymptomatic (<or=3 mild hot flush episodes/day). Women were treated for 6 months with either transdermal estradiol, oral estradiol with or without medroxyprogesterone acetate, or placebo.

RESULTS

In symptomatic women decreases in BPs were seen during estradiol use. In contrast, in asymptomatic women receiving oral but not transdermal estradiol, increases in 24-h and day-time systolic and diastolic BPs were encountered.

CONCLUSION

Hot flushes modify the HT-mediated responses in ambulatory BP. In asymptomatic women oral but not transdermal estradiol show potentially harmful cardiovascular effect by increasing BP. Our results give additional justification to prescribing HT primarily for the treatment of troublesome hot flushes and avoiding HT in women without vasomotor symptoms.

Hormone replacement therapy and the risk of venous thromboembolism: a population-based study

SUMMARY BACKGROUND

Hormone replacement therapy (HRT) using oral estrogen alone or combined with a progestogen is associated with an increased risk of venous thromboembolism (VTE) in postmenopausal women. This risk may differ for tibolone and transdermal HRT.

METHODS

Among the United Kingdom's General Practice Research Database, we identified the cohort of all women aged 50-79 between 1 January 1987 and 1 March 2008. Using a nested case-control approach, all incident cases of VTE occurring during the study period were identified and matched with up to 10 controls selected from the cohort members. Rate ratios (RR) of VTE with current use of tibolone, transdermal and oral HRT were estimated using conditional logistic regression.

RESULTS

The cohort of 955 582 postmenopausal women included 23 505 cases of VTE matched with 231 562 controls. The risk of VTE was not increased with current use of transdermal estrogen alone (RR 1.01; 95% CI, 0.89-1.16) or combined with a progestogen (RR 0.96; 95% CI, 0.77-1.20), or with current use of tibolone (RR 0.92; 95% CI: 0.77-1.10), relative to non-use. On the other hand, the risk was increased with current use of oral estrogen (RR 1.49; 95% CI, 1.37-1.63) and oral estrogen-progestogen (RR 1.54; 95% CI, 1.44-1.65), and increased with estrogen dosage. The risks with oral formulations were particularly elevated during the first year of use but disappeared 4 months after discontinuation.

CONCLUSION

Transdermal HRT and tibolone were not associated with an increased risk of VTE in postmenopausal women.

Health correlates and mode of administration of hormones--are there any differences between parenteral and oral estrogen preparations?

OBJECTIVES

To investigate use-associated differences between parental and oral hormone therapy (HT) users in reference to HT non-users regarding self-rated general health status, quality of life, health service utilization, and selected chronic diseases.

METHODS

All cases of last-week medicine use were recorded among 2248 women aged 40-79 who participated in the German Health Interview and Examination Survey 1997-1999. 89 current parenteral HT users and 322 oral HT users were identified. Health correlates were compared between the two groups in reference to HT non-users.

RESULTS

Oral HT users had a poorer current health status as well as an impaired health status compared to the year before, were less satisfied with their health and life in general, and showed a lower quality of life regarding 'body pain' and 'vitality' in comparison with hormone non-users (all p<.05). Parenteral HT users showed no significant difference compared with HT non-users and oral HT users, respectively, in these health correlates except for a less satisfaction with health found in comparison with HT non-users (p=.002). Prevalences of cerebral-cardiovascular diseases were not different among women using parenteral or oral HT use. Parenteral HT users visited the offices of general practitioner and gynecologists more frequently than oral HT users as well as hormone non-users (all p<.05).

CONCLUSIONS

Oral HT use is associated with a negative assessment for health well-being whereas parenteral HT use shows largely a neutral effect. Further designated studies could clarify whether the mode of hormone administration consistently affects health-related quality of life and whether the mode of hormone treatment influences the choice of outpatient facilities for surveillance of therapy.

Primate models in women's health: inflammation and atherogenesis in female cynomolgus macaques (Macaca fascicularis)

Female cynomolgus monkeys are excellent models for understanding cardiovascular disease and the relationships between inflammatory processes and conditions such as atherogenesis. This review summarizes published research findings obtained through comprehensive, multidisciplinary, multi-investigator studies in nonhuman primates over the past two decades. These studies examined the effects of exogenous estrogens and dietary soy protein/isoflavones (IFs) on atherosclerosis, circulating biomarkers, and tissue inflammation in pre- and postmenopausal female cynomolgus monkeys. Inflammation may play a role in the initiation and progression of disease, be a consequence of the disease, or both. Circulating and tissue biomarkers with inflammatory and anti-inflammatory characteristics (including adhesion molecules such as e-selectin, VCAM-1, and ICAM-1, chemokines such as MCP-1, cytokines such as interleukins, and acute phase reactants such as CRP, and others) may be useful indicators of disease status. Treatment of postmenopausal subjects with estrogen resulted in significant reductions in several key inflammatory mediators as well as atherosclerosis, while dietary IF had a more limited effect on inflammation and atherogenesis. Circulating concentrations of key inflammatory proteins, including monocyte-chemoattractant protein-1 (MCP-1) and interleukin-6 (IL-6), were associated with atherosclerosis and lesion characteristics in these animals. In premenopausal female monkeys, a diet enriched in soy protein reduced arterial inflammation as well as atherogenesis in comparison to a diet enriched in casein-lactalbumin. Expression levels of arterial inflammation associated genes (MCP-1, ICAM-1) and markers for inflammatory cell types (macrophages and T cells) correlated with plaque size, were differentially influenced by treatments, and represent potential targets for interventions. Arterial expression of estrogen receptor alpha, the key mediator of estrogenic effects, was inversely correlated with plaque size and indices of inflammation, suggestive of an atheroprotective role. The findings provide additional evidence that circulating inflammatory markers (particularly MCP-1) may be useful indicators of atherosclerotic disease progression and responses to treatment in female primates, and that estrogens and dietary soy may inhibit atherogenesis in part through anti-inflammatory mechanisms.

Could transdermal estradiol + progesterone be a safer postmenopausal HRT? A review

Hormone replacement therapy (HRT) in young postmenopausal women is a safe and effective tool to counteract climacteric symptoms and to prevent long-term degenerative diseases, such as osteoporotic fractures, cardiovascular disease, diabetes mellitus and possibly cognitive impairment. The different types of HRT offer to many extent comparable efficacies on symptoms control; however, the expert selection of specific compounds, doses or routes of administration can provide significant clinical advantages. This paper reviews the role of the non-oral route of administration of sex steroids in the clinical management of postmenopausal women. Non-orally administered estrogens, minimizing the hepatic induction of clotting factors and others proteins associated with the first-pass effect, are associated with potential advantages on the cardiovascular system. In particular, the risk of developing deep vein thrombosis or pulmonary thromboembolism is negligible in comparison to that associated with oral estrogens. In addition, recent indications suggest potential advantages for blood pressure control with non-oral estrogens. To the same extent, a growing literature suggests that the progestins used in association with estrogens may not be equivalent. Recent evidence indeed shows that natural progesterone displays a favorable action on the vessels and on the brain, while this might not be true for some synthetic progestins. Compelling indications also exist that differences might also be present for the risk of developing breast cancer, with recent trials indicating that the association of natural progesterone with estrogens confers less or even no risk of breast cancer as opposed to the use of other synthetic progestins. In conclusion, while all types of hormone replacement therapies are safe and effective and confer significant benefits in the long-term when initiated in young postmenopausal women, in specific clinical settings the choice of the transdermal route of administration of estrogens and the use of natural progesterone might offer significant benefits and added safety.