Available medical choices for the management of menopause

Phytoestrogens and bone health at different reproductive stages

BACKGROUND

Isoflavones are an alternative to hormonal therapy for the relief of menopausal symptoms. Since isoflavones interact with estrogen receptors it has been hypothesized that such substances may have an effect on bone health.

OBJECTIVE

To clarify the effect of isoflavones on bone at experimental and clinical level, and to identify areas that require further clarification and research.

METHOD

A systematic review of studies involving isoflavones and bone health was performed, and a specific search on isoflavone's mechanism of action and the importance of equol production was made based on Internet search engines, MEDLINE (1966-October 2012) and the Cochrane Controlled Clinical Trials Register. This search was supplemented by a handsearch of reference lists of selected papers.

RESULTS

In vitro and animal studies show a positive effect of isoflavones on bone which has not been clearly confirmed by long-term human trials. Equol producers seem to present a more positive response to isoflavone intervention. Isoflavone rich diets could help maintain peak bone mass in premenopausal women. The effect of isoflavones in perimenopausal women is insufficiently studied but it seems to attenuate bone loss in the menopausal transition. In postmenopause, isoflavones may present a modest benefit but its clinical relevance in preventing osteoporotic fractures remains to be determined.

CONCLUSIONS

The present review suggests that isoflavone increase bone mineral density and decrease the bone turnover resorption markers. The effect of soy isoflavones on BMD is mediated by equol production, reproductive status, supplement type, isoflavone dose and intervention duration.

Treatment for the menopause in Central America: use, knowledge, perceptions and attitudes among urban living middle-aged women

BACKGROUND

Data on social and personal aspects of Central America are lacking in relation to hormone therapy (HT) and other treatments for the menopause.

OBJECTIVE

To gain information regarding the treatment of the menopause (HT/alternative): use, knowledge, perceptions and attitudes among middle-aged Central American women.

METHODS

A total of 720 urban living women (35-65 years) from six Central American countries (Guatemala, El Salvador, Honduras, Nicaragua, Costa Rica and Panama) were surveyed with a structured questionnaire that included socio-demographic data and information regarding the menopause and its treatment.

RESULTS

Participating countries displayed significant socio-demographic differences. Forty-one percent of all women were postmenopausal and 5.8% had no education at all. Knowledge regarding menopausal treatment options varied; while 27.2% (196/720) indicated HT as an option a higher rate (36.3%) either did not respond or answered not knowing anything. HT use for the whole sample was rather low 2.7% with differences seen among countries. 13.8% (27/196) indicated to have been on HT but abandoned treatment because of medical indication (51.9%), undesired side effects (29.6%) and costs (11.1%). While more than 50% considered HT served to replace hormones a smaller percentage (<14%) referred HT as bad for health, reduces cancer risk or has many side effects. 9.3% (67/720) acknowledged the existence of phytoestrogens as a menopausal treatment option, considering them as natural estrogens and good for health in 38.8% and 25.4%, respectively.

CONCLUSIONS

HT use in this mid-aged series was rather low in which the demography of Central America may be related factors. Education to women and physicians should be encouraged.

Sexual steroids in urogynecology

The decline in sex hormone levels that accompanies the menopause has substantial effects on the tissues of the urogenital system, leading to atrophic changes. These changes can have negative effects on sexual and urinary function. The authors evaluate the repercussion of hypoestrogenism and sexual steroids on some elements of the pelvic floor and lower urinary tract. They summarize their research work and review significant published papers. They emphasize the changes in urinary mucosae, periurethral vessels, muscular layer, connective tissue, gene expression, autonomic nervous system receptors, as well as the main clinical aspects involved.

The role of intranasal estradiol spray in the management of moderate to severe vasomotor symptoms in menopausal women

Hormone therapy (HT) is the most effective treatment at present available for climacteric symptoms. As harmful effects were highlighted in recent randomized clinical trials, the risk-benefit ratio does not favor the use of HT for prevention of cardiovascular diseases and bone fractures in postmenopausal women. Nevertheless, experimental and clinical trials suggest that adverse effects of HT basically depend on the estrogen and progestin formulation, dosage, route of administration, patient's age, associated diseases, and duration of treatment. All estrogen formulations and routes of administration have comparable beneficial effects on vasomotor and urogenital symptoms and on bone structure. But adverse effects may differ. Thus, cardiovascular and invasive breast cancer risks are higher with oral estrogen than with transdermal estradiol. However, transdermal estradiol is not free of inconveniences such as differences among individuals in absorption rates, loss of patches due to poor adhesion, and skin irritation. HT requires careful adjustment to each individual patient and continuous monitoring of clinical evolution. In the future, this adjustment and maybe the use of alternative routes such as intranasal could benefit from genetic screening to maximize in each individual the ratio between positive and adverse effects of HT.

Effects of strontium ranelate, raloxifene and misoprostol on bone mineral density in ovariectomized rats

OBJECTIVES

To investigate the effects of strontium ranelate, raloxifene and misoprostol on bone mineral density (BMD) in ovariectomized rats to contribute to the individualization of the treatment of postmenopausal osteoporosis.

STUDY DESIGN

Sixty sexually mature female Sprague-Dawley rats weighing 250 g were used. The 60 rats were divided into six groups of 10 rats each: SR, MISO, RAL, SHAM, DW and OVX. All except the SHAM rats were subjected to bilateral ovariectomy. Three days after surgery, rats were administered strontium ranelate (Protelos, 2 g, Servier, Istanbul), 1800 mg/kg/day; misoprostol (Cytotec, 200 mcg, Ali Raif, Istanbul), 200 mcg/kg/day; raloxifene (Evista, 60 mg, Lily and Company, Istanbul), 3 mg/kg/day and 1 cc of distilled water by gavage for 8 weeks. Bone mineral density measurements were then performed.

RESULTS

The strontium ranelate (SR) group had significantly higher vertebral BMD than all other groups. Femoral density in the SR group was also significantly higher than in other groups and there was no difference between femoral density in the strontium ranelate and sham groups.

CONCLUSIONS

Strontium ranelate, raloxifene and misoprostol can prevent bone loss in the vertebrae, whereas strontium ranelate can also prevent bone loss in the femur of ovariectomized rats. Strontium ranelate increases greater than raloxifene and misoprostol BMD in the vertebrae.

CONDENSATION

Strontium ranelate may increase both vertebral and femur BMD in ovariectomized rats while raloxifene and misoprostol may only increase lumbar spine BMD.

Hormone replacement therapy post Women's Health Initiative study: where do we stand?

PURPOSE OF REVIEW

The aim of this review is to look at all publications from the past 18 months, which deal with the impact of the Women's Health Initiative Trial on hormone replacement therapy.

RECENT FINDINGS

There is a definite decline in the use of hormone replacement therapy among menopausal women.

SUMMARY

More research needs to be done on the long-term effects of hormone replacement therapy, especially with regard to ultra-low dose hormone therapy.

Hormone therapy for the management of the menopause in Ecuador: perception, use and knowledge among middle-aged women

BACKGROUND

There is scant data on social and personal aspects related to the use of menopausal hormone therapy (HT) in Latin America.

OBJECTIVES

To obtain information regarding menopausal HT, i.e. use, perception, level and sources of knowledge, and to determine factors affecting several of these issues among middle-aged women of Guayaquil, Ecuador.

DESIGN

A total of 349 women (nursing staff), aged 40 years or more, were included in the present cross-sectional study. Participants completed a structured questionnaire including details related to HT and the reasons for not using it, as well as demographic and psychosocial data.

RESULTS

Only 50.1% of women considered HT beneficial. Current and former HT use was low (1.7% and 14.3%, respectively) and mean HT duration among former users was short (mean +/- standard deviation: 1.0 +/- 1.4 years). Women responded that the main reasons for not using HT were being asymptomatic (49.0%), non-established menopause (30.4%) and physician's advice (27.2%). Only 28.9% of women considered having enough information regarding HT, whereas a high percentage (93.1%) indicated willingness to participate in educational sessions addressing this issue. For most of the women the main sources of information were physicians, educational sessions and television. Logistic regression analysis determined that women with lower income and HT information did not consider HT beneficial at a higher rate than their counterparts. Premenopausal women and those with lower income were more prone to never HT use. Age and professional level were found to be confounding factors.

CONCLUSIONS

HT use in this population was low; hormonal status, economic income and level of HT information determined its use and benefit awareness.

Trends in HRT and anti-osteoporosis medication prescribing in a European population after the WHI study

To assess the prescription patterns of anti-osteoporosis medications, three cross-sectional analyses were performed between 2004 and 2006. Women aged 50 and older were identified from the health insurance claims database of the Rhône-Alpes area. HRT prescriptions decreased while bisphosphonates and raloxifene prescriptions increased, respectively, in different age groups.

INTRODUCTION

The objective of this study was to assess the prescription patterns of hormone replacement therapy (HRT) and anti-osteoporosis medications (AOM) in post-menopausal French women since the WHI and the revision of the French clinical practice guidelines in 2004.

METHODS

Three cross-sectional analyses were performed between 2004 and 2006. Women aged 50 and older who had at least one claim for a prescription for HRT, bisphosphonates or raloxifene were identified from health insurance claims database of the Rhône-Alpes area.

RESULTS

A 39% decrease in the number of women who had HRT was observed (67,241 to 41,024). Twenty-one percent and 18% increases were observed, respectively, for bisphosphonates (39,192 to 47,395) and raloxifene (10,263 to 12,060). HRT and raloxifene were mainly prescribed to women aged 55 to 64 (58% and 39%, respectively), bisphosphonates to women aged 65 to 84 (70%). Ninety-eight percent of women had HRT prescribed by a gynaecologist or a general practitioner (GP). Most AOM were prescribed by a GP; 13% of women had AOM prescribed by a rheumatologist.

CONCLUSION

Prescriptions for HRT in post-menopausal French women have significantly decreased while bisphosphonates and raloxifene prescriptions have increased, respectively, in different age groups but to a lesser extent than the HRT decrease.

Follicle-stimulating hormone does not directly regulate bone mass in human beings: evidence from nature

OBJECTIVE

To evaluate the effect of FSH levels in the development of human osteoporosis.

DESIGN

Case-series study.

SETTING

Gynecology department in a teaching hospital.

PATIENT(S)

A total of 8 women diagnosed with Kallman syndrome (KS) were compared with 11 with Turner syndrome and 11 with pure gonadal dysgenesia (GD, karyotype 46,XX).

INTERVENTION(S)

We assessed the pituitary-gonadal axis, bone turnover markers, bone mass, and patient characteristics.

MAIN OUTCOME MEASURE(S)

Bone mineral density as assessed by dual-energy X-ray absorptiometry, plasma FSH, LH, E(2), osteocalcin (BGP), and urinary type I collagen cross-linked N-telopeptide. Other biochemical markers included 25-hydroxyvitamin D, as well as parathyroid hormone and urine concentration of calcium and creatinine.

RESULT(S)

In girls with Turner syndrome and GD, FSH (64.03 +/- 29.2 and 90.08 +/- 22.41 mIU/mL, respectively) and LH (45.29 +/- 11.90 and 48.83 +/- 12.44 mIU/mL, respectively) levels were significantly higher compared with those observed in girls with KS (FSH: 1.87 +/- 0.64 and LH: 1.02 +/- 0.57), whereas no differences were detected in E(2) or bone marker levels. Bone mineral density correlated positively with FSH levels but not with E(2); however, after adjusting for previous growth-hormone therapy, these differences were not found. In addition, bone mineral density in spine and total hip was significantly lower in patients with KS.

CONCLUSION(S)

Follicle-stimulating hormone does not appear to have a major role in the development of bone loss in young women with primary amenorrhea.