Reprint of "Use of medroxyprogesterone acetate for hormone therapy in postmenopausal women: Is it safe?"

Hormone therapy effect on menopausal systemic lupus erythematosus patients: a systematic review

Systemic lupus erythematosus (SLE) primarily affects women, who may need hormone therapy (HT) in menopause. There is, however, some concern as to its efficacy and safety. This systematic review aimed to determine the effect of HT on the activity of SLE and its safety. The study was a qualitative systematic review. Research was conducted with data retrieved from Embase, MEDLINE and Cochrane databases using MESH terms up to April 2021, with no bar on date or language. Sixteen studies were selected for analysis. Most of them showed HT to be effective in the treatment of menopausal symptoms with no impact in SLE activity, but one randomized clinical trial showed an increase in the number of thrombotic events. The present systematic review demonstrated the efficacy of HT for treating the menopausal symptoms of SLE patients. The risk of flare and thrombosis seems to be very low.

Use of Hormone Therapy in Postmenopausal Women with Alzheimer's Disease: A Systematic Review

BACKGROUND

Around two-thirds of patients with Alzheimer's disease (AD) are women, which could be related to the depletion of female sexual hormones at menopause. The replacement of these hormones with hormone therapy (HT) to possibly decrease AD risk or treat AD patients has generated conflicting results in the literature.

OBJECTIVE

Our aim was to systematically review the relationship between HT use in postmenopausal women with AD and the risk of developing or treating AD symptoms.

DATA SOURCES

The PubMed, LILACS, Scopus, Scielo, and Web of Science databases were searched from January 1994 to December 2020 using the descriptors 'Alzheimer Disease OR Alzheimer's Disease' and 'Hormone Replacement Therapy OR Estrogen Replacement Therapy'.

STUDY SELECTION

Observational and controlled clinical trials including postmenopausal women diagnosed with AD and evaluating HT efficacy were eligible for inclusion.

DATA EXTRACTION

Extracted data comprise study design, covariates, inclusion criteria for sample selection, AD diagnosis criteria, biases, HT regimen, and cognitive measurement tools used.

RESULTS

Overall, 25 studies were selected. Among the 14 observational studies, 8 reported an improvement in cognitive function and a decrease in AD risk, especially in younger postmenopausal women. Five observational studies did not demonstrate any association between HT and AD, and one study reported an increase in AD risk, regardless of time of HT initiation. Of the 11 controlled clinical trials included, 7 showed an amelioration in cognitive function after HT. The remaining 4 trials saw no difference between HT and control.

CONCLUSION

Both observational and controlled clinical trials had methodological issues and discrepancies in inclusion criteria and HT protocols. These inconsistencies made it difficult to establish an association between HT and AD.

Progress in progestin-based therapies for neurological disorders

Hormone therapy, primarily progesterone and progestins, for central nervous system (CNS) disorders represents an emerging field of regenerative medicine. Following a failed clinical trial of progesterone for traumatic brain injury treatment, attention has shifted to the progestin Nestorone for its ability to potently and selectively transactivate progesterone receptors at relatively low doses, resulting in robust neurogenetic, remyelinating, and anti-inflammatory effects. That CNS disorders, including multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS), spinal cord injury (SCI), and stroke, develop via demyelinating, cell death, and/or inflammatory pathological pathways advances Nestorone as an auspicious candidate for these disorders. Here, we assess the scientific and clinical progress over decades of research into progesterone, progestins, and Nestorone as neuroprotective agents in MS, ALS, SCI, and stroke. We also offer recommendations for optimizing timing, dosage, and route of the drug regimen, and identifying candidate patient populations, in advancing Nestorone to the clinic.

McCoubrey L, Freire C, W. Basit A, Conlan RS, Gonzalez D. Progestogens Are Metabolized by the Gut Microbiota: Implications for Colonic Drug Delivery

Following oral administration, the bioavailability of progestogens is very low and highly variable, in part due to metabolism by cytochrome P450 enzymes found in the mucosa of the small intestine. Conversely, the mucosa in the colon contains much lower levels of cytochrome P450 enzymes, thus, colonic delivery of progestogens may be beneficial. Microbiota in the colon are known to metabolize a great number of drugs, therefore, it is important to understand the stability of these hormones in the presence of colonic flora before developing formulations. The aim of this study was to investigate the stability of three progestogens: progesterone, and its two synthetic analogues, medroxyprogesterone acetate (MPA) and levonorgestrel (LNG), in the presence of human colonic microbiota. Progesterone, MPA, and LNG were incubated in mixed fecal inoculum (simulated human colonic fluid) under anerobic conditions. Progesterone was completely degraded after 2 h, whereas levels of MPA and LNG were still detectable after 24 h. The half-lives of progesterone, MPA, and LNG in fecal inoculum were 28, 644, and 240 min, respectively. This study describes the kinetics of colonic microbial metabolism of these hormones for the first time. MPA and LNG show promise for delivery to the colon, potentially improving pharmacokinetics over current oral delivery methods.

In vitro effects of progesterone and the synthetic progestin medroxyprogesterone acetate on vascular remodeling

In this work we tested the hypothesis whether progesterone (Pg) or the synthetic progestin medroxyprogesterone acetate (MPA) could be involved in the regulation of events involved in vascular remodeling. Results revealed an enhancement in the capillary-like tubes formation induced by both progestogens. Unlike MPA, Pg acts through VEGF, nitric oxide, PI3K and ERK1/2 signaling pathways. However, the MPA effect depends on platelet activation. Under stress conditions, the proangiogenic action of Pg and MPA was sustained. The progestogens exhibit the ability to prevent vascular smooth muscle cells (VSMC) osteogenic transdifferentiation. Besides this antiosteogenic action, on bone cells the progestogens induced osteoblast maturation and mineralization. The mechanism of action of both steroids on vascular and bone cells involves the participation of progesterone receptor. The data presented in this work provide evidence that the progestogens reduce osteogenic-like transdifferentiation of VSMC and promote angiogenesis with a slight different mechanism of action elicited by each steroid.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY POSITION STATEMENT ON MENOPAUSE-2017 UPDATE

EXECUTIVE SUMMARY This American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology (ACE) Position Statement is designed to update the previous menopause clinical practice guidelines published in 2011 but does not replace them. The current document reviews new clinical trials published since then as well as new information regarding possible risks and benefits of therapies available for the treatment of menopausal symptoms. AACE reinforces the recommendations made in its previous guidelines and provides additional recommendations on the basis of new data. A summary regarding this position statement is listed below: New information available from randomized clinical trials and epidemiologic studies reported after 2011 was critically reviewed. No previous recommendations from the 2011 menopause clinical practice guidelines have been reversed or changed. Newer information enhances AACE's guidance for the use of hormone therapy in different subsets of women. Newer information helps to support the use of various types of estrogens, selective estrogen-receptor modulators (SERMs), and progesterone, as well as the route of delivery. Newer information supports the previous recommendation against the use of bioidentical hormones. The use of nonhormonal therapies for the symptomatic relief of menopausal symptoms is supported. Newer information enhances AACE's guidance for the use of hormone therapy in different subsets of women. Newer information helps to support the use of various types of estrogens, SERMs, and progesterone, as well as the route of delivery. Newer information supports the previous recommendation against the use of bioidentical hormones. The use of nonhormonal therapies for the symptomatic relief of menopausal symptoms is supported. New recommendations in this position statement include: 1.

RECOMMENDATION

the use of menopausal hormone therapy in symptomatic postmenopausal women should be based on consideration of all risk factors for cardiovascular disease, age, and time from menopause. 2.

RECOMMENDATION

the use of transdermal as compared with oral estrogen preparations may be considered less likely to produce thrombotic risk and perhaps the risk of stroke and coronary artery disease. 3.

RECOMMENDATION

when the use of progesterone is necessary, micronized progesterone is considered the safer alternative. 4.

RECOMMENDATION

in symptomatic menopausal women who are at significant risk from the use of hormone replacement therapy, the use of selective serotonin re-uptake inhibitors and possibly other nonhormonal agents may offer significant symptom relief. 5.

RECOMMENDATION

AACE does not recommend use of bioidentical hormone therapy. 6.

RECOMMENDATION

AACE fully supports the recommendations of the Comité de l'Évolution des Pratiques en Oncologie regarding the management of menopause in women with breast cancer. 7.

RECOMMENDATION

HRT is not recommended for the prevention of diabetes. 8.

RECOMMENDATION

In women with previously diagnosed diabetes, the use of HRT should be individualized, taking in to account age, metabolic, and cardiovascular risk factors.

ABBREVIATIONS

AACE = American Association of Clinical Endocrinologists; ACE = American College of Endocrinology; BMI = body mass index; CAC = coronary artery calcification; CEE = conjugated equine estrogen; CEPO = Comité de l'Évolution des Pratiques en Oncologie; CAD = coronary artery disease; CIMT = carotid intima media thickness; CVD = cardiovascular disease; FDA = Food and Drug Administration; HDL = high-density lipoprotein; HRT = hormone replacement therapy; HT = hypertension; KEEPS = Kronos Early Estrogen Prevention Study; LDL = low-density lipoprotein; MBS = metabolic syndrome; MPA = medroxyprogesterone acetate; RR = relative risk; SERM = selective estrogen-receptor modulator; SSRI = selective serotonin re-uptake inhibitor; VTE = venous thrombo-embolism; WHI = Women's Health Initiative.

The other side of progestins: effects in the brain

Progestins are a broad class of progestational agents widely differing in their chemical structures and pharmacological properties. Despite emerging data suggest that progestins, besides their action as endometrial protection, can also have multiple nonreproductive functions, much remains to be discovered regarding the actions exerted by these molecules in the nervous system. Here, we report the role exerted by different progestins, currently used for contraception or in postmenopausal hormone replacement therapies, in regulating cognitive functions as well as social behavior and mood. We provide evidence that the effects and mechanisms underlying their actions are still confusing due to the use of different estrogens and progestins as well as different doses, duration of exposure, route of administration, baseline hormonal status and age of treated women. We also discuss the emerging issue concerning the relevant increase of these substances in the environment, able to deeply affect aquatic wildlife as well as to exert a possible influence in humans, which may be exposed to these compounds via contaminated drinking water and seafood. Finally, we report literature data showing the neurobiological action of progestins and in particular their importance during neurodegenerative events. This is extremely interesting, since some of the progestins currently used in clinical practice exert neuroprotective and anti-inflammatory effects in the nervous system, opening new promising opportunities for the use of these molecules as therapeutic agents for trauma and neurodegenerative disorders.