A comparison of the central effects of different progestins used in hormone replacement therapy

Systematic review and meta-analysis of the effects of progestins on depression in post-menopausal women: An evaluation of randomized clinical studies that used validated questionnaires

OBJECTIVE

Hormone therapy (HT) can relieve symptoms of menopause and treat chronic diseases. Its effectiveness in treating psychological symptoms is still debated. Several progestins can be used in HT, but their effects on mood, in particular depressive symptoms, is still unclear. This systematic review evaluates the evidence from randomized clinical trials with postmenopausal women on the effect of adjunctive progestins on symptoms of depression assessed by validated questionnaires. The primary aim was to evaluate scores on the Center for Epidemiologic Studies Depression Scale (CESD). The secondary aim was to assess scores on the Beck Depression Inventory (BDI), the Hamilton Depression Rating Scale (HAMD), and the Zung Self-Rating Depression Scale (SDS).

METHODS

A systematic review and meta-analysis were conducted to identify the most reliable evidence of the effects of progestin on depression to inform decision-making. A PICO- and PRISMA-based framework was established to formulate explicit and reasoned recommendations. The pre-/post-treatment effect was evaluated using standardized mean change (SMC).

RESULTS

We selected and analyzed 16 randomized clinical trials qualitatively and 12 studies quantitatively out of 9320 items identified. Most of the studies used medroxyprogesterone acetate as progestin. The results indicate that depressive symptoms do not increase with the addition of a progestin to estrogen HT. Depressive symptoms improved over time in the progestins-estrogen HT group, independent of progestin type (SMC CES-D -0.08 CI.95-0.10/-0.06, BDI -0.19 CI.95-0.32/-0.06, HAM-D -1.13 CI.95-1.47/-0.78, and SDS -0.11 CI.95-0.82/0.60). Yet similar effects were observed with estrogens alone and did not significantly differ from control groups on placebo. In one study, the addition of fluoxetine greatly increased the reduction of depressive symptoms observed with estrogen-progestin HT.

CONCLUSIONS

In summary, in randomized clinical trials using validated questionnaires adjunctive progestin with estrogens did not increase depressive symptoms of postmenopausal women. Overall, depressive symptoms decreased with estrogen-progestin HT but also with estrogen alone. The decrease was not so pronounced to differ from controls on placebo. HT does not hamper the clinical efficacy of fluoxetine. The scarcity of randomized studies makes it difficult to determine the exact effect on depressive symptoms of different types of progestins. Project protocol registered in PROSPERO, registration number CRD42023454099.

The effect of hormone replacement therapy on cognition and mood

OBJECTIVES

To summarise the available data regarding the effect of hormone replacement therapy (HRT) on cognition and mood in women.

BACKGROUND

Complaints of impaired cognition and mood are common in the peri-menopausal and menopausal period. There is debate as to whether HRT can ameliorate this phenomenon.

DESIGN

A literature search of studies using electronic databases was conducted. Both randomised control trials and observational studies were included.

PATIENTS

Perimenopausal and menopausal women.

RESULTS

Due to the heterogenicity of results it is challenging to draw firm conclusions. The preparations used in many of the studies are older regimes no longer routinely used clinically. The notion of a 'critical window' for HRT is compelling, suggesting HRT has a positive impact on cognition when administered in the peri-menopausal or early postmenopausal period but may have negative effects on cognition in the older, postmenopausal woman. The evidence would seem to suggest importance of hormonal replacement in woman undergoing a surgical menopause, especially when young. It remains unclear for how long they ought to continue HRT though until at least the natural age of the menopause seems reasonable. Evidence for a positive effect of HRT on mood is more convincing, though possibly more efficacious in the younger age group. The effect of HRT on anxiety is less clear.

CONCLUSIONS

Further study, particularly focusing on the more contemporaneous HRT preparations, is warranted before evidence-based conclusions can be drawn.

Strategies to cope with stress and anxiety during the menopausal transition

The menopausal transition is often accompanied by psycho-vegetative symptoms, including stress and anxiety symptoms. Identifying stress and anxiety and intervening early can have an enormous public health impact. Health care practitioners like obstetrician-gynecologists or family doctors play a critical role in the diagnosis, prevention and treatment of stress and anxiety symptoms or disorders, as they often represent women's primary medical contact during the menopausal transition. However, they frequently do not feel confident in identifying and treating mental health problems. The aim of this review was to summarize current (since 2010) knowledge from randomized controlled trials, systematic reviews, and meta-analyses on diagnostics and treatment options, and to provide clinical decision-making algorithms. The recent literature suggests pharmacological, (cognitive) behavioral, and complementary treatments. The choice about which one to use should be discussed with the patient.

Norethisterone and its acetate - what's so special about them?

INTRODUCTION

Progestogens (progestins) are widely used for contraception, in postmenopausal hormone therapy, and in treatment of abnormal uterine bleeding and endometriosis. Norethisterone (NET) and its acetate (NETA) differ from other progestogens by their partial conversion to ethinylestradiol (EE). We review their special characteristics and focus on the clinically relevant risk factors associated with estrogen action, such as migraine with aura and risk of thrombosis.

METHODS

Narrative review based on a medical literature (OvidMedline and PubMed) search.

RESULTS

NET converts to significant amounts of EE; 10-20 mg NET corresponds to 20-30 µg EE. The effects of NET on the endometrium are pronounced, making it a good choice for treating abnormal uterine bleeding, endometriosis, and endometrial hyperplasia. NET also has beneficial effects on bone mineral density and positive or neutral effects on cardiovascular health. Conversely, long-term use of NET is associated with a slightly increased breast cancer risk, and the risk of venous thromboembolism is moderately increased. This risk seems to be dose-dependent; contraceptive use carries no risk, but therapeutic doses might be associated with an increased risk. Studies suggest an association between combinations of EE and progestogens and ischaemic stroke, which in particular concerns women with migraine. No studies have, however, assessed this risk related to the therapeutic use of NET.

CONCLUSIONS

NET is a potent progestogen, especially when considering the endometrium. Its partial conversion to EE, however, is important to remember. Clinical consideration is required with women at high risk for either breast cancer or thromboembolism, or experiencing migraine with aura.

Does pregnancy make women more cautious and calm? The impact of pregnancy on risk decision-making

During pregnancy, a variety of psychological and physical changes occur in women, which may have different impacts on risk decision-making involving different processes systems. Based on the dual-process theories of decision-making, using the Columbia Card Task (CCT) as the experimental paradigm, which can trigger deliberative versus affective decision-makings respectively, this study recruited 240 pregnant women and non-pregnant women aged 20-40 as the experimental group and control group respectively, investigated how pregnancy impacted on women’s risk decision-making, as well as the possible roles played by a series of psychological factors (impulsivity; sensation seeking; emotional state) and physiological factors (gestational age; human Chorionic Gonadotropin, hCG; progesterone) in the above process. The results were as follows: (a) Compared with non-pregnant women, pregnant women tended to choose fewer cards, indicating a higher risk aversion consistent with a more conservative strategy, both in cold and hot CCTs; in both cold and hot CCTs, compared with pregnant women in the second trimester of pregnancy, pregnant women in the first and the third trimesters of pregnancy had a higher risk aversion tendency. (b) Pregnant women had lower levels of all dimensions of sensation seeking than did non-pregnant women, pregnant women in the third trimester of pregnancy had lower levels of Disinhibition (DIS) and Boredom Susceptibility (BS) of sensation seeking than pregnant women in the first and the second trimesters of pregnancy, but there was no significant difference in levels of emotional state or impulsivity between pregnant woman and non-pregnant women. (c) DIS of sensation seeking played a fully mediating role in the impact of pregnancy on hot CCT performance. (d) Both hCG and progesterone levels were negatively correlated with pregnant women’s hot CCT performances. (e) Positive emotion played a partial mediating role in the effect of progesterone on hot CCT performance of pregnant women.

Effects of different menopausal hormone replacement regimens on body composition in Chinese women

PURPOSE

The aim of this study was to determine the effects of different menopausal hormone therapy regimens on body composition in healthy postmenopausal Chinese women.

MATERIALS AND METHODS

One hundred and twenty-three healthy postmenopausal Chinese women were randomly assigned to either group A (0.625 mg conjugated equine estrogens [CEE] plus 100 mg micronized progesterone [MP]), group B (0.3 mg CEE plus 100 mg MP), or group C (0.625 mg CEE plus 10 mg dydrogesterone). Body composition was assessed by dual-energy X-ray absorptiometry.

RESULTS

One hundred and two women completed the trial at 1 year. A small but significant gain in lean body mass (619 ± 1019 g, p = 0.002) and a decrease of fat mass in all separate regions was observed in group A. A significant shift from gynoid to android fat distribution was observed in group B and group C (android/gynoid fat percentage ratios increased by 0.06 ± 0.08, p = 0.000 and 0.03 ± 0.08, p = 0.018, respectively), whereas no significant change was observed in group A (0.02 ± 0.06, p = 0.103).

CONCLUSIONS

In healthy postmenopausal Chinese women, 0.625 mg of CEE combined with 100 mg of MP was associated with a more favorable fat distribution compared with 0.3 mg CEE plus 100 mg MP or 0.625 mg CEE plus 10 mg dydrogesterone.

Development of a novel progesterone analog in the treatment of traumatic brain injury

Although systemic progesterone (PROG) treatment has been shown to be neuroprotective by many laboratories and in multiple animal models of brain injury including traumatic brain injury (TBI), PROG's poor aqueous solubility limits its potential for use as a therapeutic agent. The problem of solubility presents challenges for an acute intervention for neural injury, when getting a neuroprotectant to the brain quickly is crucial. Native PROG (nPROG) is hydrophobic and does not readily dissolve in an aqueous-based medium, so this makes it harder to give under emergency field conditions. An agent with properties similar to those of PROG but easier to store, transport, formulate, and administer early in emergency trauma situations could lead to better and more consistent clinical outcomes following TBI. At the same time, the engineering of a new molecule designed to treat a complex systemic injury must anticipate a range of translational issues including solubility and bioavailability. Here we describe the development of EIDD-1723, a novel, highly stable PROG analog with >10⁴-fold higher aqueous solubility than that of nPROG. We think that, with further testing, EIDD-1723 could become an attractive candidate use as a field-ready treatment for TBI patients. This article is part of the Special Issue entitled "Novel Treatments for Traumatic Brain Injury".

Progestogen safety and tolerance in hormonal replacement therapy

INTRODUCTION

Today, it is a mandatory practice to prescribe a combination of estrogens and progestogens for menopausal women requiring hormone therapy and with a uterus. The WHI study and its reanalysis demonstrate a big difference in results between the conjugated equin estrogen (CEE) only vs.CEE plus medroxyprogesterone acetate (MPA) arms in relation with breast cancer and cardiovascular risk. The conclusion is that risk is clearly higher in the arm with MPA than in the CEE only arm. Although the only progestogen used in the WHI study was medroxyprogesterone acetate, side effects and intolerance have been extrapolated as a class effect to all progestogens. Areas covered: Progestogen tolerance and side effects in hormone therapy were reviewed. For that purpose, a limited literature search was conducted on key resources including Pubmed, the Cochrane Library, ECRI, and major international health technology agencies. Expert opinion: Many of the tolerance effects are based on limited data. There are no double-blind randomized trials comparing long-term safety for breast cancer and cardiovascular risk among different progestogens. Short-term clinical studies, observational, and in animal and in vitro studies indicate that both micronized progesterone and dydrogesterone are the safer progestogens with an acceptable metabolic profile.

Body composition and resting metabolic rate of perimenopausal women using continuous progestogen contraception

OBJECTIVE

The effect on body composition and in particular on fat mass (FM) of 12 months' use of a desogestrel (DSG)-only contraceptive pill or the levonorgestrel-releasing intrauterine system (LNG-IUS) was evaluated in women in the perimenopause.

METHODS

An observational study comprised 102 perimenopausal women: 42 received a 75 μg DSG pill, 34 received the 52 mg LNG-IUS, and 26 received no treatment. Body composition, body weight and resting metabolic rate (RMR) were evaluated at baseline and again after 12 months.

RESULTS

FM did not change in the control group (- 0.5 ± 1.6%) but significantly increased in the LNG-IUS group (+ 1.1 ± 2.9%; p = 0.02 vs. controls) and in the DSG group (+ 2.8 ± 3.5%; p = 0.0001 vs. controls; p = 0.02 vs. LNG-IUS). Women treated with DSG or the LNG-IUS showed a non-significant increase in body weight, body mass index and waist circumference. RMR did not significantly vary in the control group (- 3.8 ± 292.9 kJ/ 24 h) and tended to decrease but not significantly in the LNG-IUS (115.5 ± 531.8 kJ/ 24 h) and DSG groups (305.9 ± 556.9 kJ/24 h).

CONCLUSIONS

The results of this preliminary study seem to indicate that in perimenopausal women continuous use of the DSG-only pill and to a lesser extent the LNG-IUS may favour FM accumulation.

Effect of injectable medroxyprogesterone acetate and etonogestrel implants on GABA-A and serotonin receptors in white and gray matter of the brain: experimental study in rats

The aim of this study was to evaluate the time-dependent effect of progesterone-only contraceptives on the brain and to obtain an improved understanding of mood disorders experienced under this medication. A total of 66 Wistar albino rats were divided into three groups: etonogestrel (ENG) implant (group 1, n = 30); depot medroxyprogesterone acetate (MPA)-injectable (group 2, n = 30); and control (group 3, n = 6) groups. Groups 1 and 2 were each divided into five subgroups, which were examined every 10 d for up to 50 d after medication administration, to evaluate its time-dependent effect. There was no difference in terms of gamma-aminobutyric acid (GABA) and serotonin immunohistochemical staining in white and gray matter among the subgroups of group 1. In group 2, there was a significant decrease in serotonin receptor staining intensity in white and gray matter on day 50, when compared to the control group (p = 0.041). When the subgroups of group 2 were compared, there was a significant decrease in serotonin receptor staining intensity in white and gray matter on days 40 and 50 when compared to day 10. In conclusion, we showed that ENG and MPA have no effect on apoptosis and GABA-A receptors in the brain. We also showed that MPA has time-dependent effects on serotonin receptors, which may be a possible mechanism involved in mood disorders during long-term usage of injectable progesterone-only contraceptives.

Associations between psychological well-being, mental health, and hormone therapy in perimenopausal and postmenopausal women: results of two population-based studies

OBJECTIVE

A proportion of women experience depressive and anxiety symptoms and/or disorders in connection with the menopausal transition. Estrogen-only therapy has been reported to have beneficial effects on mental health, but the effects of combined hormone therapy (HT) on mental health are less clear. We studied the associations between HT use and psychopathology in perimenopausal and postmenopausal women.

METHODS

Data on women who participated in the Health 2000 Survey and the National FINRISK Surveys in Finland were analyzed.

RESULTS

An association between current HT use and psychiatric diagnosis in the previous 12 months was found. In addition, HT use was associated with recent self-reported diagnosis of depression and with depressed mood (FINRISK), as well as with major depressive disorder and anxiety disorder (Health 2000). Associations with the following symptoms were found: nervousness, frightening thoughts, nightmares, and headache (FINRISK), feelings of depression (FINRISK and Health 2000), and unhappiness (Health 2000). No differences between different routes of administration or types of HT emerged.

CONCLUSIONS

Current use of HT in perimenopausal and postmenopausal women is associated with worse psychological well-being and mental health than in women not using HT. It is important to identify women in need of psychiatric support at the time of the menopausal transition.

Effect of medroxyprogesterone on depressive symptoms in depressed and nondepressed perimenopausal and postmenopausal women after discontinuation of transdermal estradiol therapy

OBJECTIVE

Concern about adverse effects of progestins on mood has influenced the use of medroxyprogesterone (MPA) and other progestins. In this brief report, we examined whether the administration of MPA leads to depressive symptoms in two groups of perimenopausal and postmenopausal women randomly assigned to treatment with estrogen: one currently experiencing clinical depression and another without depression.

METHODS

Open-label MPA 10 mg/day was administered for 14 days for endometrial protection after completion of double-blinded treatment with 17β-estradiol 0.1 mg/day for 8 to 12 weeks in 40- to 60-year-old perimenopausal and postmenopausal women enrolled in two separate randomized placebo-controlled trials for treatment of cognitive problems ("nondepressed group") or clinical depression ("depressed group"). Nonparametric tests were used to compare changes in depressive symptoms on the Beck Depression Inventory (BDI) within each group and between groups during MPA therapy.

RESULTS

Of the 24 nondepressed (median BDI at baseline, 5.5; interquartile range [IQR], 2.5-8.5) and 14 depressed (median BDI at baseline, 17; IQR, 15-21) women treated with MPA, the BDI scores did not change during MPA treatment in either group (median change, 0; IQR, -2 to 0.5 and median, 0; IQR, -0.5 to 1.5, P = 0.28 and P = 0.50, respectively). Changes in BDI scores during treatment with MPA did not differ between groups (P = 0.25).

CONCLUSIONS

Among women receiving MPA for 2 weeks after discontinuation of estradiol, depressive symptoms did not emerge on MPA. These findings were consistent for both depressed and nondepressed women, suggesting that, even among women who are currently experiencing depression, brief treatment with MPA is unlikely to disrupt mood.

A prospective study of hormone therapy and depression in community-dwelling elderly women: the Three City Study

BACKGROUND

The potential benefits of hormone therapy (HT) in treating depressed postmenopausal women are controversial, and data on depression (re)emergence in the context of HT discontinuation are lacking.

OBJECTIVE

To determine whether HT is associated with a modified risk of new-onset depressive symptoms in elderly women.

METHOD

Current depressive symptomatology was evaluated in 4,069 community-dwelling postmenopausal women aged 65 years and over who were randomly recruited from 3 French cities between 1999 and 2001. Depressive symptomatology was assessed using the Center for Epidemiologic Studies-Depression Scale at baseline and as part of the 2- and 4-year follow-up.

RESULTS

Over the follow-up period, multivariate logistic regression analyses adjusted for sociodemographic variables, measures of physical health, and cognitive impairment failed to find a significant association between HT at baseline and the incidence of depressive symptoms. However further analysis indicated an increased risk of incident depressive symptoms for women using transdermal estradiol treatment combined with synthetic progestin specifically (odds ratio [OR] = 1.59; 95% CI, 1.01-2.50; P = .046). In addition, while women taking HT continuously over the 4-year follow-up did not show an increased risk of depressive symptoms, women who stopped their treatment early after study inclusion, had a significantly higher risk (OR = 2.63; 95% CI, 1.52-4.55; P = .0005).

CONCLUSIONS

Hormone therapy was not associated with a protective effect against the emergence of depressive symptoms in elderly postmenopausal women. However, discontinuing treatment could increase the risk of depressive symptoms. Data on the appropriate management of depression in the context of HT discontinuation among postmenopausal women require further investigation.

Progesterone, progestins and psychosomatic health of women

Psychosomatics as a medical perspective and discipline focuses on the interaction of physical and mental health in the specific life situation of a patient, taking into account the physical and emotional well-being, role functioning, satisfaction with the partner and family relationship, as well as sexual function and satisfaction. There are two important effects of progesterone on the combined physical, mental and sexual well-being of the climacteric patient. The first is the antiestrogenic effect of progesterone on the peripheral physical level which not only protects the endometrium against overstimulation but also reduces individual suffering from heavy bleeding, breast tension, bloating and general discomfort. The second effect is due to the complex action of progesterone in the brain. Studies using different progestins in different dosages and in different regimens show contradictory results. Some studies demonstrate an increase in depressed mood and reduced well-being while using synthetic progestins. Other studies, however, indicate an anxiolytic and sometimes antidepressant effect of progesterone and progesterone-like progestins with an improvement of emotional well-being and quality of life. In the individual patient, the positive or negative emotional and mental state can be conditioned by various pathways of progesterone and progestins. The antiestrogenic effect can attenuate the psychotropic effect of estradiol (E2) on the brain, thus reducing emotional well-being. Progesterone interacting with many brain areas can have a mood stabilizing and anxiolytic effect through the action on the GABA receptor. This effect seems to be strongest when using natural progesterone and the effect varies considerably among different progestins and different dosages due to metabolic pathways involving the production of allopregnanolone or other metabolites. In conclusion, the positive anxiolytic and sedative effects of progesterone on the central nervous system depend on the type of progestogen, the dosage, the timing of application, the combination with estrogen, etc. Progesterone and progestins have important potential to maintain or improve the psychosomatic health of women. Their use must, however, be tailored to specific symptom clusters and to the individual's pre-existing psychosomatic health status.

Transdermal estradiol for postpartum depression: a promising treatment option

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

A prospective study of hormonal treatment and anxiety disorders in community-dwelling elderly women (the Esprit Study)

BACKGROUND

The impact of hormone therapy use on late-life anxiety disorder in elderly women has not been evaluated.

METHODS

Anxiety disorders were evaluated in 838 community-dwelling postmenopausal women aged 65 years and over, randomly recruited from electoral rolls. Anxiety disorders were assessed using a standardized psychiatric examination based on DSM-IV criteria, at baseline and as part of the 2- and 4-year follow-up.

RESULTS

Multivariate logistic regression analyses adjusted for socio-demographic variables, measures of physical health and cognitive impairment, as well as current depressive symptomatology indicated no significant association between hormone therapy and anxiety disorders at baseline or after the 4-year follow-up period, regardless of type of treatment. Compared to women who have never taken hormonal therapy, no significant difference was observed for women taking continuously hormone therapy over the follow-up or those who stopped their treatment.

CONCLUSIONS

The use of hormone therapy was not associated with improved anxiety symptomatology in elderly postmenopausal women.

Dydrogesterone increases allopregnanolone in selected brain areas and in serum of female rats

OBJECTIVE

To investigate the effects of dydrogesterone (DYD), a synthetic progestin largely used in hormone therapy, on the central nervous system by studying two markers of the neuroendocrine function: the neurosteroid allopregnanolone and the opioid beta-endorphin.

DESIGN

Experimental study on animal model.

SETTING

Academic research environment.

ANIMAL(S)

72 Wistar female rats.

INTERVENTION(S)

One group of fertile and one of ovariectomized rats (receiving placebo) were used as control. After ovariectomy, the rats underwent a 2-week oral treatment of DYD (0.2, 0.6, or 1.0 mg/kg per day), alone or with estradiol valerate (E2V; 0.05 mg/kg per day).

MAIN OUTCOME MEASURE(S)

Allopregnanolone and beta-endorphin, assessed in different brain areas and in circulation.

RESULT(S)

Ovariectomy decreased allopregnanolone anywhere except in the adrenal gland and reduced beta-endorphin central levels; E2V reversed the effects of ovariectomy; and DYD (1 mg/kg per day) increased allopregnanolone levels in frontal lobe, hippocampus, and hypothalamus. Combined administration of DYD at 1 mg/kg per day plus E2V determined a further increase of allopregnanolone levels in frontal lobe, hippocampus, hypothalamus, and serum. Dydrogesterone did not modify the levels of beta-endorphin induced by E2V.

CONCLUSION(S)

Dydrogesterone interacts with allopregnanolone levels (less with beta-endorphin), and it can be considered important modulator of the neuroendocrine function.

Efficacy of hormone therapy with and without methyltestosterone augmentation of venlafaxine in the treatment of postmenopausal depression: a double-blind controlled pilot study

OBJECTIVE

This study evaluated the augmentation of venlafaxine with hormone therapy in the treatment of postmenopausal depression. The hormones evaluated were estrogen (0.625 mg) in combination with medroxyprogesterone acetate (2.5 mg) and methyltestosterone (2.5 mg).

DESIGN

Seventy-two menopausal women (mean age: 53.6 +/- 4.27 years) diagnosed with depression (Montgomery-Asberg Depression Rating Scale [MADRS] scores > or = 20) were treated with venlafaxine and one of the following hormone therapy combinations, in a double-blind regimen: estrogen + medroxyprogesterone + methyltestosterone (group 1, n = 20); estrogen + medroxyprogesterone acetate (group 2, n = 20); methyltestosterone only (group 3, n = 16); and no hormone therapy (group 4, n = 16). Study duration was 24 weeks. Primary efficacy outcome was remission according to the MADRS, whereas secondary efficacy measures included the Clinical Global Impression (CGI), Blatt-Kupperman Index, and Women's Health Questionnaire (WHQ).

RESULTS

Forty-eight patients completed the study. All groups showed significant improvement from baseline. Group 3 demonstrated significant improvement on the MADRS compared with placebo (group 4) at weeks 20 (P = 0.048) and 24 (P = 0.030); effect size 8.04 (0.83; 15.26) (P = 0.029), but also had the highest dropout rate. Groups 1 and 3 had significant CGI improvement rates compared with placebo: 42.23% (P = 0.012) and 44.45% (P = 0.08), respectively. There were no differences in the WHQ or BKI scores among the groups.

CONCLUSIONS

Methyltestosterone 2.5 mg had the highest effect size compared with placebo, but the high dropout rate prevented its efficacy from being determined. Estrogen plus medroxyprogesterone, combined with methyltestosterone or otherwise, demonstrated a trend toward increased efficacy of venlafaxine. Further larger-scale clinical trials are needed to elucidate the findings of this pilot study.

Escitalopram versus ethinyl estradiol and norethindrone acetate for symptomatic peri- and postmenopausal women: impact on depression, vasomotor symptoms, sleep, and quality of life

OBJECTIVE

To examine the efficacy and tolerability of escitalopram (ESCIT) compared to estrogen and progestogen therapy (EPT) for the treatment of symptomatic peri- and postmenopausal women.

DESIGN

Forty women (aged 40-60 years) with depressive disorders and menopause-related symptoms were randomly assigned to an 8-week open trial with ESCIT (flexible dose, 10-20 mg/day; fixed dose, 10 mg/day for the first 4 weeks) or estrogen plus progestogen therapy (ethinyl estradiol 5 microg/day plus norethindrone acetate 1 mg/day). Primary outcome measures included Montgomery-Asberg Depression Rating Scale and the Greene Climacteric Scale at week 8. Secondary outcome measures included the Clinical Global Impressions as well as sleep and quality of life assessments.

RESULTS

Thirty-two women (16 on EPT, 16 on ESCIT) were included in the analyses. Full remission of depression (score of <10 on the Montgomery-Asberg Depression Rating Scale) was observed in 75% (12/16) of subjects treated with ESCIT, compared to 25% (4/16) treated with EPT (P = 0.01, Fisher's exact tests). Remission of menopause-related symptoms (>50% decrease in Greene Climacteric Scale scores) was noted in 56% (9/16) of women treated with ESCIT compared to 31.2% (5/16) on EPT (P = 0.03, Pearson's chi2 tests). Improvement in sleep, hot flashes, and quality of life was observed with both treatments.

CONCLUSIONS

ESCIT is more efficacious than EPT for the treatment of depression and has a positive impact on other menopause-related symptoms. ESCIT may constitute a treatment option for symptomatic menopausal women who are unable or unwilling to use hormone therapy.

Novel perspectives for progesterone in hormone replacement therapy, with special reference to the nervous system

The utility and safety of postmenopausal hormone replacement therapy has recently been put into question by large clinical trials. Their outcome has been extensively commented upon, but discussions have mainly been limited to the effects of estrogens. In fact, progestagens are generally only considered with respect to their usefulness in preventing estrogen stimulation of uterine hyperplasia and malignancy. In addition, various risks have been attributed to progestagens and their omission from hormone replacement therapy has been considered, but this may underestimate their potential benefits and therapeutic promises. A major reason for the controversial reputation of progestagens is that they are generally considered as a single class. Moreover, the term progesterone is often used as a generic one for the different types of both natural and synthetic progestagens. This is not appropriate because natural progesterone has properties very distinct from the synthetic progestins. Within the nervous system, the neuroprotective and promyelinating effects of progesterone are promising, not only for preventing but also for reversing age-dependent changes and dysfunctions. There is indeed strong evidence that the aging nervous system remains at least to some extent sensitive to these beneficial effects of progesterone. The actions of progesterone in peripheral target tissues including breast, blood vessels, and bones are less well understood, but there is evidence for the beneficial effects of progesterone. The variety of signaling mechanisms of progesterone offers exciting possibilities for the development of more selective, efficient, and safe progestagens. The recognition that progesterone is synthesized by neurons and glial cells requires a reevaluation of hormonal aging.

Menopause, estrogens, progestins, or their combination on body weight and anthropometric measures

OBJECTIVE

To evaluate modification in body weight and anthropometric indexes in women at the time of menopause.

DESIGN

Prospective longitudinal study.

SETTING

Menopause Center at the University Hospital of Modena.

PATIENT(S)

Women in perimenopause (n = 87), ovariectomized (n = 60), and in postmenopause (n = 182) without and with treatment.

INTERVENTION(S)

Data were retrieved from the electronic database of the Menopause Center.

MAIN OUTCOME MEASURE(S)

Modification of weight, body mass index (BMI), waist, hip, and waist-to-hip ratio in 12 months.

RESULT(S)

Body weight increased in perimenopausal (0.6 +/- 0.1 kg) women, did not vary in postmenopausal (0.2 +/- 0.1 kg) women, and decreased in ovariectomized (-0.5 +/- 0.3 kg) women. Waist increased significantly in perimenopausal (2.3 +/- 0.4 cm) and in postmenopausal (2.0 +/- 0.4 cm) women. In comparison to no treatment, progestin administration (n = 29) decreased body weight (-0.2 +/- 0.5 kg) and hip (-1.1 +/- 0.9 cm) in perimenopausal women, estrogen (E) administration (n = 38) increased body weight (0.8 +/- 0.3 kg) in ovariectomized women, whereas E plus progestin administration (n = 89) did not induce any modification in postmenopausal women.

CONCLUSION(S)

Present preliminary data indicate that body weight increases in perimenopausal women, decreases in ovariectomized women, and does not increase significantly in naturally postmenopausal women. Estrogens and progestins influence body weight differently, increasing and decreasing it, respectively.

Cyclic progestin administration increases energy expenditure and decreases body fat mass in perimenopausal women

OBJECTIVE

The menopause transition is characterized by luteal phase defect anovulatory cycles, and changes in body weight and body composition. Resting metabolic rate (RMR) is increased in the luteal phase of the menstrual cycle. We evaluated whether progestin administration increases RMR and influences body composition of perimenopausal women.

DESIGN

Thirty-six perimenopausal women were randomly allocated to receive either calcium (1 g/day) continuously plus the progestin nomegestrol acetate (NOMAc; 5 mg/day for 10 days x month for 12 months) or calcium alone. Body composition, RMR, energy intake, and climacteric and psychological symptoms were evaluated at baseline and after 12 months. In the NOMAc group, body composition and RMR analyses were performed twice during the first month of treatment. One evaluation was performed after almost 8 days of NOMAc adjunct, and an another before or almost 15 days after NOMAc administration.

RESULTS

Resting metabolic rate was increased by NOMAc administration of 54.5 +/- 73.8 kcal/24 h (P < 0.01). In women treated with NOMAc, fat mass decreased by 1.2 +/- 0.6 kg (P < 0.001). In comparison with controls, body weight (P < 0.05) and body mass index (P < 0.05) were also reduced after 12 months of therapy with NOMAc.

CONCLUSIONS

In perimenopausal women the use of NOMAc increases RMR. During the menopause transition, cyclic NOMAc administration may contribute to reduce negative modification of body composition.

Progesterone and medroxyprogesterone acetate effects on central and peripheral allopregnanolone and beta-endorphin levels

The increased use of hormonal therapies has led to the study of the properties of different progestin molecules and their effects on the central nervous system. The central and peripheral levels of neurosteroid allopregnanolone and the opioid peptide beta-endorphin (beta-END) are regulated by estrogens. The aim of the present study was to investigate the effects of a 2-week oral treatment with micronized progesterone or medroxyprogesterone acetate (MPA) alone or in addition to estradiol valerate (E2V) on central and peripheral allopregnanolone and beta-END levels in ovariectomized (OVX) female rats. Thirteen groups of Wistar OVX rats received one of the following treatments: oral progesterone (2, 4 or 8 mg/kg/day); oral MPA (0.05, 0.1 or 0.2 mg/kg/day); E2V (0.05 mg/kg/day); E2V + progesterone (0.05 mg/kg/day + 2, 4 or 8 mg/kg/day), or E2V + MPA (0.05 mg/kg/day + 0.05, 0.1 or 0.2 mg/kg/day) for 14 days. One group of fertile and one group of OVX rats were used as controls. The concentration of allopregnanolone was assessed in the frontal and parietal lobes, hypothalamus, hippocampus, anterior pituitary, adrenals and serum, while the beta-END content was assessed in the frontal and parietal lobes, hypothalamus, hippocampus, anterior and neurointermediate pituitary, and plasma. E2V administration reverted the ovariectomy-induced reduction in allopregnanolone and beta-END. Progesterone and MPA increased allopregnanolone levels in all tissues except in the adrenal gland. The combined administration of progesterone or MPA and E2V determined a further increase in allopregnanolone levels with respect to E2V alone except in the adrenal gland and hippocampus only after MPA treatment. Progesterone did not affect beta-END levels in the frontal and parietal lobes, hippocampus and anterior pituitary, while it caused an increase plasma, hypothalamic and neurointermediate pituitary beta-END levels. MPA only affected beta-END levels in the hippocampus and in the neurointermediate lobe. The combined administration of progesterone or MPA and E2V did not alter the effect of estradiol or it determined a further dose-dependent increase in beta-END levels. In conclusion, this study demonstrates that progesterone and MPA have a similar but not identical effect on central and peripheral allopregnanolone and beta-END levels. Their association with an estrogenic compound does not interfere with the positive effects produced by estrogen on allopregnanolone and beta-END brain content.