Effect of hormone replacement therapy with the anti-mineralocorticoid progestin Drospirenone compared to tibolone on endothelial function and central haemodynamics in post-menopausal women

The impact of progestogens on RAAS - a systematic review

BACKGROUND

Progestogens, synthetic analogues of progesterone, are widely used in clinical practice for contraception, hormone replacement therapy, and the management of gynecological disorders. Understanding the specific impacts of different progestogens on the renin-angiotensin-aldosterone system (RAAS) is crucial due to their potential effects on cardiovascular and renal outcomes.

OBJECTIVE

This systematic review aims to synthesize existing research on the effects of various progestogens on the RAAS and associated clinical outcomes.

METHODS

We conducted a comprehensive search of databases up to the search date, including randomized controlled trials (RCTs), cohort studies, case-control studies, cross-sectional studies, and qualitative studies. The NIH Study Quality Assessment Tool for Controlled Intervention Studies was used to evaluate the quality of the included studies. Data extraction and quality assessment were performed independently by two reviewers, with discrepancies resolved through discussion.

RESULTS

Forty-two studies on drospirenone (DRSP) were the most extensively investigated, showing either decreased or unchanged blood pressure (BP), mostly unchanged serum sodium, and an increased risk of hyperkalemia only in patients with mild renal impairment. Sixteen studies on norethindrone (NET/NETA) presented conflicting results on BP and a higher risk of hyperkalemia. Other progestogens, such as levonorgestrel (LNG) and medroxyprogesterone acetate (MPA), showed varied effects on RAAS parameters. Notably, changes in plasma renin activity (PRA), serum aldosterone, and angiotensin II levels were inconsistent across different progestogens and study designs.

CONCLUSION

The effects of progestogens on the RAAS are complex and varied, influenced by the type of progestogen, dosage, and combination with estrogen. While some progestogens like DRSP may offer benefits in BP management with minimal electrolyte disturbances, others like NET/NETA might require more careful monitoring due to their associated risks. These findings highlight the importance of personalized medicine approaches in the use of progestogens, tailored to individual patient characteristics and specific hormonal profiles. Further research with standardized methodologies is needed to clarify these effects and guide clinical practice.

TRIAL REGISTRATION

This review was prospectively registered with PROSPERO.

Extended-release metformin improves cognitive impairment in frail older women with hypertension and diabetes: preliminary results from the LEOPARDESS Study

BACKGROUND

Women have a high risk of frailty independently of age and menopause state. Diabetes and hypertension increase the risk of frailty and cognitive impairment. Metformin has been employed in post-menopausal women and some reports have shown encouraging effects in terms of attenuated frailty. However, the impact on cognitive performance of a recently introduced extended-release formulation of metformin has never been explored.

METHODS

We studied consecutive frail hypertensive and diabetic older women presenting at the ASL (local health authority of the Italian Ministry of Health) Avellino, Italy, from June 2021 to August 2022, who were treated or not with extended-release metformin. We included a control group of frail older males with diabetes and hypertension treated with extended-release metformin and a control group of frail older women with diabetes and hypertension treated with regular metformin.

RESULTS

A total of 145 patients successfully completed the study. At the end of the 6-month follow-up, we observed a significantly different cognitive performance compared to baseline in the group of frail women treated with extended-release metformin (p: 0.007). Then, we compared the follow-up groups and we observed significant differences between frail women treated vs. untreated (p: 0.041), between treated frail women and treated frail men (p: 0.016), and between women treated with extended-release metformin vs. women treated with regular metformin (p: 0.048). We confirmed the crucial role of extended-release metformin applying a multivariable logistic analysis to adjust for potential confounders.

CONCLUSIONS

We evidenced, for the first time to the best of our knowledge, the favorable effects on cognitive impairment of extended-release metformin in frail women with diabetes and hypertension.

Relationship between lipid parameters and vascular mechanical characteristics among a normotensive population without diabetes mellitus residing at the Qinghai-Tibet plateau: a cross-sectional study

Background

There is limited evidence regarding the relationship between lipid parameters and vascular mechanical characteristics in the normotensive population without diabetes mellitus. The aim of this study was to identify an association between lipid parameters and changes in vascular mechanical characteristics between men and women, and in women before and after menopause.

Methods

Six hundred-seventy patients who underwent vascular functional testing and who fulfilled the inclusion and exclusion criteria were enrolled in our cross-sectional study. All participants were from the Qinghai–Tibet Plateau (Luhuo County, Ganzi Tibetan Autonomous Prefecture, Sichuan Province, China; mean altitude: 3860 m). Trained clinical physicians assessed brachial-ankle pulse wave velocity (Ba-PWV) and augmentation index adjusted to a 75-beats-per-minute heart rate (AIx@75). To investigate the relationship between lipid parameters and vascular mechanical characteristics in different sexes and menstrual stages, partial correlation analysis and multiple linear regression were used.

Results

The 670 participants comprised 445 women (103 post-menopausal). Mean Ba-PWV and AIx@75 were 1315.56 ± 243.41 cm/s and 25.07% ± 15.84%, respectively. Men had greater Ba-PWV values compared with women (1341.61 ± 244.28 vs 1302.39 ± 242.17 cm/s, respectively; P < 0.05), while AIx@75 values were higher in women compared with men (27.83% ± 15.85% vs 19.64% ± 14.40%, respectively; p < 0.001). In the partial correlation analysis adjusted for age, total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and non-high-density lipoprotein cholesterol (HDL-C) were associated with Ba-PWV in both men and women (p < 0.05); however, the magnitude was larger in men. Statistical significance was not seen for AIx@75 among both men and women. Multiple linear regression analysis revealed that TC (β = 0.165, p = 0.024) and non-HDL-C (β = 0.151, p = 0.042) remained independent predictors of change in Ba-PWV in men after adjusting for age, mean arterial pressure, waist circumference, hemoglobin, platelet count, fasting blood glucose, estimated glomerular filtration rate, and uric acid. After adjusting for traditional cardiovascular risk factors, pre-menopausal women had a similar association to that of men between LDL-C (β = 0.126, p = 0.030), non-HDL-C (β = 0.144, p = 0.013), TC/HDL-C (β = 0.162, p = 0.005), LDL-C/HDL-C (β = 0.142, p = 0.013) and Ba-PWV; however, post-menopausal women had no association between the lipid parameters and vascular function.

Conclusions

Overall, TC and non-HDL-C were independent associated factors for vascular compliance alterations evaluated through Ba-PWV in normotensive men. In pre-menopausal women, LDL-C, non-HDL-C, TC/HDL-C and LDL-C/HDL-C were independent associated factors for vascular compliance alterations. After controlling for traditional risk factors, lipid profiles were not associated with these metrics for AIx@75, which can measure the amplification of reflex flow, because of the high number of confounding factors that do not genuinely reflect changes in vascular characteristics. Lipid factors did not appear to be linked to vascular function in post-menopausal women.

Effects of menopausal hormone therapy on ambulatory blood pressure and arterial stiffness in postmenopausal Korean women with grade 1 hypertension: a randomized, placebo-controlled trial

Background

Estrogen therapy in early menopausal women decreases the risk of coronary heart disease and parenteral, but not oral, estrogen is reported to reduce blood pressure (BP). Progestogens are typically added to estrogens to prevent unopposed endometrial stimulation. The effects of progestogen on BP have been less well studied to date. This study was conducted to explore the impacts of micronized progesterone (MP4) combined with percutaneous estradiol gel (PEG) on hemodynamics in postmenopausal Korean women with grade 1 hypertension.

Methods

Fifty-two postmenopausal women (aged 49–75 years) with systolic BP (SBP) of 140–160 mmHg or diastolic BP (DBP) of 90–100 mmHg were randomly assigned for 12 weeks to placebo (n = 16), estrogen therapy (ET) (n = 19) with PEG (0.1 %, 1 g./d), or estrogen + progestogen therapy (EPT, n = 17) with PEG and MP4 (100 mg/d). The primary endpoint was ambulatory BP and the secondary endpoints were arterial stiffness as brachial–ankle pulse-wave velocity (baPWV) and aortic parameters on applanation tonometry.

Results

One woman in the ET group dropped out, so 51 participants were finally analyzed. Outcome measures for ambulatory BP and arterial stiffness were not different between groups. Within-group comparisons showed that EPT significantly decreased daytime heart rate and baPWV: the changes from baseline (mean ± standard deviation) were − 2.5 ± 5.7 bpm (P = 0.03) and − 0.6 ± 1.4 m/s (P = 0.04), respectively. After adjusting for baseline, linear regression analysis revealed a significant difference in the relationship between baseline and 12-week baPWV among groups (P = 0.02). The relationship was significantly different between placebo and ET (P = 0.03) and EPT (P = 0.01), respectively, but not between ET and EPT. Additionally, pooled results of active treatments disclosed that SBP, DBP, PWV, and augmentation index at the aorta were significantly reduced relative to baseline.

Conclusions

There was no difference in ambulatory BP between ET and EPT in postmenopausal Korean women with grade 1 hypertension. Further, ET and EPT similarly decreased baPWV from baseline as compared with placebo. MP4 might not adversely influence estrogen effects on ambulatory BP and arterial stiffness.

Trial registration

Clinical Research Information Registry, KCT0005405, Registered 22 September 2020 - Retrospectively registered, https://cris.nih.go.kr/cris/search/detailSearch.do?all_type=Y&search_page=L&pageSize=10&page=1&seq=17608&search_lang=E.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40885-021-00175-1.

Menopausal hyperinsulinism and hypertension - new approach

Aim: to test effects of estradiol (E2) 1 mg and drospirenone (DRSP) 2 mg in treatment of normal weight menopausal women with typical menopausal symptoms, hyperinsulinism, and grade I hypertension.Material and methods: The participants were 133 menopausal women, mean age 51.82 ± 3.25 years, body mass index (BMI) 24.9 ± 2.6 kg/m², waist/hip 0.80 ± 0.05, amenorrhoeic period 2.12 ± 2.10 years. All patients were treated with E2 1 mg and DRSP 2 mg during 12 months period. Blood samples were taken at 8 am before and during 12 months of therapy for: glycemia, lipids, hormonal analysis, follicle-stimulating hormone (FSH), luteinizing hormone (LH), E2, testosterone (T), prolactin (PRL), dehydroepiandrosterone sulfate (DHEAS), and sex hormone-binding globulin (SHBG). Oral glucose tolerance test (OGTT) was performed with 75 g glucose in order to assess insulin secretion. All had grade I hypertension 24 h blood pressure monitoring was performed before and after 12 months of therapy.Results: E2/DRSP significantly decreased total cholesterol, low-density lipoprotein (LDL), apolipoprotein B (ApoB), and increased high-density lipoprotein cholesterol (HDL) and apolipoprotein A (ApoA). Insulin area under the curve (AUC) significantly decreased (6586.1 ± 4194.2 vs. 5315.3 ± 2895.0, p < .05) and homeostatic model assessment (HOMA) (3.53 ± 2.18 vs. 3.0 ± 1.8, p < .05). FSH, LH decreased, E2 increased significantly. Of 24 h day blood pressure decreased significantly.Conclusions: E2/DRSP represents suitable therapy for hyperinsulinemic, grade I hypertensive menopausal women with typical symptoms and normal weight.

[Endogenous and exogenous estrogens]

Before menopause, women are protected from the risk of hypertension and atherosclerosis by endogenous estrogens. Estrogens have a vasoprotective role, while progesterone seems to have a neutral effect. Exogenous estrogens used in menopausal treatment have vascular effects. These effects depend of type, dose and administration type, and with age and atherosclerosis stages. Synthetic progestins have varying clinical effects. Each drug must be evaluated separately.

New insights into arterial stiffening: does sex matter?

This review discusses sexual dimorphism in arterial stiffening, disease pathology interactions, and the influence of sex on mechanisms and pathways. Arterial stiffness predicts cardiovascular mortality independent of blood pressure. Patients with increased arterial stiffness have a 48% higher risk for developing cardiovascular disease. Like other cardiovascular pathologies, arterial stiffness is sexually dimorphic. Young women have lower stiffness than aged-matched men, but this sex difference reverses during normal aging. Estrogen therapy does not attenuate progressive stiffening in postmenopausal women, indicating that currently prescribed drugs do not confer protection. Although remodeling of large arteries is a protective adaptation to higher wall stress, arterial stiffening increases afterload to the left ventricle and transmits higher pulsatile pressure to smaller arteries and target organs. Moreover, an increase in aortic stiffness may precede or exacerbate hypertension, particularly during aging. Additional studies are needed to elucidate the mechanisms by which females are protected from arterial stiffness to provide insight into its mechanisms and, ultimately, therapeutic targets for treating this pathology.

Postural tachycardia syndrome: current perspectives

Postural tachycardia syndrome (POTS) is the combination of an exaggerated heart rate response to standing, in association with symptoms of lightheadedness or pre-syncope that improve when recumbent. The condition is often associated with fatigue and brain fog, resulting in significant disruptions at a critical time of diagnosis in adolescence and young adulthood. The heterogeneity of the underlying pathophysiology and the variable response to therapeutic interventions make management of this condition challenging for both patients and physicians alike. Here, we aim to review the factors and mechanisms that may contribute to the symptoms and signs of POTS and to present our perspectives on the clinical approach toward the diagnosis and management of this complex syndrome.

Biotransformation of drospirenone, a contraceptive drug, with Cunninghamella elegans

Biotransformation of an orally active contraceptive drug, drospirenone (1), by Cunninghamella elegans ATCC 36114 yielded four new metabolites, 6β,7β,15β,16β-dimethylene-3-oxo-14α-hydroxy-17α-pregn-4-ene-21,17-carbolactone (2), 6β,7β,15β,16β-dimethylene-3,11-dioxo-17α-pregn-4-ene-21,17-carbolactone (3), 6β,7β,15β,16β-dimethylene-3,12-dioxo-17α-pregn-4-ene-21,17-carbolactone (4), and 6β,7β,15β,16β-dimethylene-3-oxo-11β,14α-dihydroxy-17α-pregn-4-ene-21,17-carbolactone (5), along with a known metabolite, 6β,7β,15β,16β-dimethylene-3-oxo-11α-dihydroxy-17α-pregn-4-ene-21,17-carbolactone (6). This study provides not only new analogues of orally active contraceptive drug, drospirenone, but also help in understanding the metabolism of this important drug.