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Mueck AO, Römer T. Choice of progestogen for endometrial protection in combination with transdermal estradiol in menopausal women. Horm Mol Biol Clin Investig 2018; 37:hmbci-2018-0033. [PMID: 30063464 DOI: 10.1515/hmbci-2018-0033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 06/18/2018] [Indexed: 01/14/2023]
Abstract
Transdermal estradiol (TE) application (using gels, patches or a novel spray) is now a preferred route of hormone therapy (HT) in menopausal women, because various risks such as venous thromboembolism, stroke and unwanted hepatic effects can be reduced compared with oral HT. However, in the presence of an intact uterus, concurrent administration of progestogen is needed for endometrial protection. Due to the variety of progestogens available and differences in their clinical effects, the selection of the most appropriate substance and dosing for individual combination therapy can be difficult. This is especially true for TE gels and the novel spray because no fixed combination products are commercially available, meaning all progestogens must be added separately, and even for patches only two transdermal synthetic progestogens are available. The aim of this review was to summarize data on the endometrial effects of the different progestogens and to provide practical recommendations for the choice of progestogen (type and dosing), with a focus on endometrial protection when using TE, especially when using the novel estradiol (E2) spray.
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Affiliation(s)
- Alfred O Mueck
- Department of Women's Health, University Clinical Centre Tuebingen, Tuebingen, Germany.,Department of Gynecological Endocrinology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China, Phone: +49 7071 298 4801
| | - Thomas Römer
- Department of Obstetrics and Gynecology, Academic Hospital Weyertal, University Cologne, Cologne, Germany
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Abstract
OBJECTIVE The p53 signature, which (although morphologically unremarkable) displays diffuse and strong p53 nuclear staining, has been proposed to be a precursor of serous endometrial intraepithelial carcinoma. We examined the overexpression of p53 in postmenopausal endometrial glands. METHODS Postmenopausal endometrial tissues of 82 women with benign disease, including 10 hormone users, were evaluated in this study. Tissues with endometrial hyperplasia and/or polyps were excluded based on a histopathologic review. Expressions of estrogen receptor-α, Ki-67, and p53 were immunohistochemically examined. Apoptotic cells were identified using a terminal deoxynucleotidyl transferase dUTP nick end labeling assay. Overexpression of p53 was categorized as moderate to strong in more than 50% of glandular cell nuclei. RESULTS Focal glandular overexpression of p53 was observed in 1 (9%) of 10 and in 8 (11%) of 72 postmenopausal endometrial tissue specimens in women with and women without a history of hormone use, respectively. Among nonhormone users, the median Ki-67 and apoptotic indices in the postmenopausal endometrial glands of women with and women without overexpression of p53 were 16% and 6% (P = 0.007) and 1% and 1% (P = 0.345), respectively. All postmenopausal endometrial glands were positive for estrogen receptor-α, regardless of the overexpression of p53. The postmenopausal endometrial glands of estrogen users exhibited significantly higher Ki-67 and apoptotic indices than those of nonestrogen users (P = 0.001 and P < 0.001, respectively). CONCLUSIONS Overexpression of p53 may be responsible for the high proliferative activity of postmenopausal endometrial glandular cells associated with conditions of low apoptotic cell death.
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de Medeiros SF, Yamamoto MMW, Barbosa JS. Abnormal bleeding during menopause hormone therapy: insights for clinical management. CLINICAL MEDICINE INSIGHTS. WOMEN'S HEALTH 2013; 6:13-24. [PMID: 24665210 PMCID: PMC3941181 DOI: 10.4137/cmwh.s10483] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Our objective was to review the involved mechanisms and propose actions for controlling/treating abnormal uterine bleeding during climacteric hormone therapy. METHODS A systemic search of the databases SciELO, MEDLINE, and Pubmed was performed for identifying relevant publications on normal endometrial bleeding, abnormal uterine bleeding, and hormone therapy bleeding. RESULTS Before starting hormone therapy, it is essential to exclude any abnormal organic condition, identify women at higher risk for bleeding, and adapt the regimen to suit eachwoman's characteristics. Abnormal bleeding with progesterone/progestogen only, combined sequential, or combined continuous regimens may be corrected by changing the progestogen, adjusting the progestogen or estrogen/progestogen doses, or even switching the initial regimen to other formulation. CONCLUSION To diminish the occurrence of abnormal bleeding during hormone therapy (HT), it is important to tailor the regimen to the needs of individual women and identify those with higher risk of bleeding. The use of new agents as adjuvant therapies for decreasing abnormal bleeding in women on HT awaits future studies.
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Affiliation(s)
- Sebastião Freitas de Medeiros
- Department of Gynecology and Obstetrics, Medical Science School, Federal University of Mato Grosso (UFMT), Cuiabá, Mato Grosso, Brazil. ; Tropical Institute of Medicine Reproductive and Menopause, Cuiabá, Mato Grosso, Brazil
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Lima SMRR, Reis BF, Yamada SS, Postigo S, Grande RM, Botogoski SR, Campaner AB, Hueb CK, Galvão MAL. Effects of drospirenone/estradiol on steroid receptors and Bcl-2 in the postmenopausal endometrium. Climacteric 2011; 14:551-7. [DOI: 10.3109/13697137.2011.559604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Wilhelm F, Kovács KA, Lengyel F, Menyhart C, Vizer MG, Vértes M, Szabó I. Akt/protein B and estradiol receptor alpha expressions in postmenopausal endometrium. Eur J Obstet Gynecol Reprod Biol 2011; 156:190-3. [PMID: 21295396 DOI: 10.1016/j.ejogrb.2011.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Revised: 11/13/2010] [Accepted: 01/05/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Estrogen receptor interacts in several types of cells with phosphatidyl-inositol 3-kinase/Akt pathway regulating cell survival and apoptosis. No data are available of the Akt/PKB signaling and its role in the endometrial homeostasis of the postmenopausal uterus. The aim of the present investigation was to study the Akt/protein kinase B signaling in tissue samples retrieved from postmenopausal endometrium of the human uterus with parallel observation of the changes of the expression and phosphorylation of ERalpha. STUDY DESIGN Sixty disease-free postmenopausal women were enrolled in the study. Endometrial tissue samples were obtained from diagnostic curettage or direct from the uterus after hysterectomy done for benign uterine lesions other than endometrial disease. For comparison, the studied parameters were also analyzed in endometrial samples of women with regular menstrual cycles (n=16). In each individual tissue sample the expression and phosphorylation of ERalpha, Akt, and cyclin D1 was analyzed by Western blotting. RESULTS The level of Akt protein did not show significant change, however, the activation of Akt proteins and the expression of ERalpha increased parallel with serum estrogen (E2) levels, suggesting the role of E2 in Akt activation and ERalpha expression. The level of pERalpha(Ser167) changed parallel with pAkt(Ser473) levels. Significant correlation was found between the changes of pERalpha and ERalpha (r=0.650399, p<0.005), and in that of pERalpha and pAkt (r=0.639643, p<0.007), respectively. The expression of cyclin D1 was increased in samples with elevated pAkt levels. CONCLUSION The results are indicating that the postmenopausal endometrium responds to E2 by both genomic and nongenomic mechanism. The interaction between ERalpha and Akt plays crucial role in the regulation of proliferative activity in postmenopausal endometrium.
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Affiliation(s)
- Ferenc Wilhelm
- Department of Obstetrics and Gynecology, Pécs University Medical School, Pécs, Hungary.
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Razavi P, Pike MC, Horn-Ross PL, Templeman C, Bernstein L, Ursin G. Long-term postmenopausal hormone therapy and endometrial cancer. Cancer Epidemiol Biomarkers Prev 2010; 19:475-83. [PMID: 20086105 DOI: 10.1158/1055-9965.epi-09-0712] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Estrogen-alone therapy (ET) or estrogen and progestin (EPT) as menopausal hormone therapy (HT) has been commonly used to alleviate menopausal symptoms. Treatments containing > or = 10 days per month of progestin are considered relatively safe with respect to endometrial cancer risk. However, the endometrial safety of long-term EPT regimens is uncertain. We conducted a case-control study of 311 invasive endometrial cancer cases and 570 controls nested within the California Teachers Study cohort. We used unconditional logistic regression to obtain odds ratios (OR) and 95% confidence intervals (95% CI) for the association between long-term HT use and endometrial cancer risk, and to assess the modifying effect of body mass index (BMI). Long-term (> or = 10 years) use of ET, sequential EPT with <10 days per month progestin, and continuous-combined EPT (> or = 25 days/month progestin) were all associated with an elevated risk of endometrial cancer (OR, 4.5; 95% CI, 2.5-8.1; OR, 4.4; 95% CI, 1.7-11.2; and OR, 2.1; 95% CI, 1.3-3.3, respectively; all P(trend) < 0.001). The risk associated with short-term use was elevated only for ET preparations. The association for continuous-combined EPT was confined to thinner women (BMI, <25 kg/m2; P(interaction) = 0.03). Among heavier women (BMI, > or = 25 kg/m2), use of continuous-combined EPT was associated with a statistically nonsignificant reduction in risk. These findings confirm that long-term use of ET, sequential EPT, or, among normal weight women, continuous-combined EPT is associated with increased risk of endometrial cancer.
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Affiliation(s)
- Pedram Razavi
- University of Southern California, Department of Preventive Medicine, Norris Comprehensive Cancer Center, Los Angeles, California, USA
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Hickey M, Ambekar M. Abnormal bleeding in postmenopausal hormone users—What do we know today? Maturitas 2009; 63:45-50. [DOI: 10.1016/j.maturitas.2009.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Revised: 03/12/2009] [Accepted: 03/12/2009] [Indexed: 10/20/2022]
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Vani S, Critchley HOD, Fraser IS, Hickey M. Endometrial expression of steroid receptors in postmenopausal hormone replacement therapy users: relationship to bleeding patterns. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2008; 34:27-34. [DOI: 10.1783/147118908783332302] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Effect of hormone replacement therapy on postmenopausal endometrial bleeding. Pathol Oncol Res 2007; 13:351-9. [PMID: 18158572 DOI: 10.1007/bf02940316] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Accepted: 10/10/2007] [Indexed: 10/21/2022]
Abstract
The aim of the study was to determine the effect of postmenopausal hormone replacement therapy (HRT) (treatment using estrogen only and sequential and continuous combined estrogen-progestogen treatment) on endometrial bleeding and histological changes of the endometrium. In a six-year period (2000-2005), 5893 patients were given care and the incidence of postmenopausal uterine bleeding was detected in groups of patients having and not having received hormonal treatment at the Menopause Outpatient Unit of the authors' department. In the case of bleeding, fractioned abrasion was performed and the samples were analyzed histologically. Among the postmenopausal patients who had not been given hormonal treatment, the incidence of bleeding episodes was significantly higher as among those having received hormonal treatment. In the samples, findings of proliferative endometrium occurred significantly more often in case of non-treated patients and those treated with sequential combined hormone therapy compared to patients receiving continuous combined hormone therapy. Although it was statistically not significant, hyperplasia simplex and complex together showed a tendency of reduced incidence in patients medicated by continuous combined treatment. These findings suggest that continuous combined hormonal treatment started at the right time (even before the menopause) may reduce the chances of the development of hyperplasia. A significantly higher incidence of hyperplasia was noted in patients using estrogen treatment only. It is possible that unopposed estrogen treatment further engraves an already diagnosed endometrial hyperplasia. In the group having received hormonal treatment, no complex hyperplasia accompanied by atypia occurred, only hyperplasia simplex was diagnosed in these cases. As a result of continuous reliance on combined preparations, the endometrium had become atrophied, therefore the chance of hyperplasia-related changes and of bleeding as a side effect decreased significantly. According to the authors' experience, hormonal treatment does not pose a risk to the development of endometrial carcinoma; on the contrary, continuous combined preparations appear to reduce the risk of hyperplasia and, indirectly, the chances of the development of adenocarcinoma.
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Magyar Z, Csapó Z, Papp Z. The effect of postmenopausal hormone replacement therapy on endometrial bleeding. Orv Hetil 2007; 148:1451-9. [PMID: 17656335 DOI: 10.1556/oh.2007.28000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Cékitűzés:
A vizsgálat célja meghatározni a postmenopausalis hormonterápia (kizárólagos ösztrogén-, szekvenciális és folyamatosan kombinált ösztrogén-progesztogén kezelés) hatását az endometrialis vérzésre és a méhnyálkahártya szövettani átalakulására.
Beteganyag:
Szerzők klinikájának Menopauza Ambulanciáján ötéves időszakban (2000–2005) 5893 beteget gondoztak, és vizsgálták a postmenopausalis méhvérzések előfordulását a hormonterápiában részesültek és nem részesültek csoportjában. Vérzés esetén mindig frakcionált abrasiót végeztek, és a mintákat szövettanilag feldolgozták.
Eredmények:
A postmenopausában lévő betegek hormonkezelésben nem részesítettek csoportjában több mint kétszer több vérzés fordult elő, mint a hormonkezelésben részesültek között. Anyagukban a proliferatiós és a hyperplasiás endometrium-leletek elsősorban a nem kezelt páciensek közül kerültek ki, ami amellett szól, hogy a megfelelő időben, akár már a menopausa előtt megkezdett hormonkezelés csökkentheti a hyperplasia és ezáltal közvetve az adenocarcinoma kialakulásának az esélyét. A kizárólag ösztrogént alkalmazó betegekben gyakoribb volt a hyperplasia. Elképzelhetőnek tartják, hogy az ellensúlyozatlan ösztrogénkezelés a már meglévő endometrium-hyperplasiát tovább súlyosbíthatja. A hormonkezeltek csoportjában atípiával járó komplex hyperplasia nem, csak simplex hyperplasia fordult elő. A folyamatosan kombinált készítmények alkalmazása mellett az esetek döntő részében a méhnyálkahártya atrófizálódott, így lényegesen csökkent a hyperplasiával járó eltérések s a mellékhatásként jelentkező vérzés esélye. A hormonkezeltek között gyakoribb volt az endometrium-polip, és nem tudják megmagyarázni, de a cervicalis polypusok aránya is.
Következtetés:
A szerzők tapasztalata szerint a hormonkezelés nem rizikótényezője az endometrium-karcinómának, hanem a kombinált készítmények a hyperplasia és ezen keresztül az adenocarcinoma eredeti esélyét csökkentik.
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Affiliation(s)
- Zoltán Magyar
- Semmelweis Egyetem, Altalános Orvostudományi Kar, I. Szülészeti és Nogyógyászati Klinika, Budapest.
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