Estrogen replacement therapy: indications, contraindications, and agent selection

Women with Genitourinary Syndrome of Menopause Treated with Vaginal Estriol, Microablative Fractional CO2 Laser and Microablative Fractional Radiofrequency: A Randomized Pilot Study

Objective: This pilot study intended to assess the feasibility of a large-scale randomized clinical trial designed to analyze the effectiveness of microablative fractional CO2 laser (CO2L) and microablative fractional radiofrequency (RF) compared with vaginal estriol (VE) as treatments for women with moderate-to-severe Genitourinary Syndrome of Menopause (GSM). Methods: Participants were randomized into VE, CO2L, or RF groups. In the VE group, women were required to use vaginal estriol cream for 14 days and then twice a week for 4 months. In the CO2L and RF groups, three energy therapies were administered at monthly intervals. Visual Analog Scale (VAS) for GSM symptoms, Female Sexual Function Index (FSF-I), Vaginal Health Index (VHI), and Nugent Score (NS) were analyzed before and 120 days after the beginning of the treatments. Pain scores were verified after each CO2L and RF session. Results: Thirty-four participants completed the study: 11 in the VE group, 11 in the CO2L group, and 12 in the RF group. No unexpected or serious adverse events were observed. We also verified that GSM symptoms, sexual function, and VHI significantly improved (p < 0.05) with no difference among the groups. NS did not show statistically significant difference before and after the treatments. Pain during RF application was associated with higher scores. Conclusions: The study is feasible and does not seem to have safety implications. Preliminary results suggest that CO2L and RF are good alternatives to VE for ameliorating clinical symptoms, FSF-I, and VHI in patients with GSM. Clinical Trial Registration number: NCT04045379.

Bioidentical Hormone Therapy: A Review of the Evidence

Bioidentical hormone therapy (BHT) uses bioidentical hormones (BHs), derivatives of plant extracts chemically modified to be structurally indistinguishable from human endogenous hormones. BHTs are available commercially or can be compounded into different dosages and for different routes of administration. Typically, compounded preparations of BHs may include estriol, estrone, estradiol, testosterone, micronized progesterone, and occasionally dehydroepiandrosterone (DHEA). It is generally accepted that estrogen-based hormone therapies share similar efficacies as well as risks. Many FDA-approved and regulated pharmaceutically manufactured and branded conventional hormone therapies (CHTs) employ BHs. Since the publication of the Women's Health Initiative (WHI) trial results publicizing an increased risk of stroke, venous thrombosis, and breast cancer and no beneficial effect on coronary heart disease (CHD), use of CHT has declined, and there has been increased interest in alternative approaches. This review of the literature related to compounded BHT and the practices of its advocates is to determine if sufficient scientific evidence supports claims of greater efficacy and safety and any additional risks and uncertainties not generally associated with CHTs. Compounded BHTs have been promoted by some as natural, safer, and in some cases more efficacious than conventional hormone therapies, but there is a dearth of scientific evidence to support these claims. Compounded BHTs lack well controlled studies examining route of administration, pharmacokinetics, safety, and a critical, science-based rationale for the mixture and ratios of bioidentical estrogens employed in many preparations. Many advocates of compounded BHTs customize prescriptions based on saliva tests or blood sera levels in direct contradiction to evidence-based guidelines, which support tailoring HT individually according to symptoms. Currently, scientific uncertainties associated with compounded BHTs make their use less preferable to that of CHTs, as CHTs have been and continue to be assessed by clinical trials regarding both benefits and risks and are indicated for use according to evidence-based guidelines.

Isoflavonas en mujeres menopáusicas

Phytoestrogens are composed derivatives of vegetables. The 2 main classes of interest to human health are lignans and isoflavones. Isoflavones exist in at least 15 different chemical forms and their effect on human health has been investigated to some extent (particularly, genistein and daidzein as high levels of these compounds are present in soybean). Isoflavones have similar structure to oestrogen and have the capacity to exert both oestrogenic and anti oestrogenic effects. They may block the effects of oestrogen in some tissues (e. g., the breast and endometrium), but act like an oestrogen in providing possible protection against bone loss and heart disease. Lignans are much more widespread in plant foods but investigation has been limited due to the complexity of measurement. The increasing interest in the use of the soybean and the phytoestrogens derived from the soybean is due to the results published on experimental animal actions, and in human case-control studies. There are many observational and epidemiologists studies that suggest the potential benefit of isoflavones on the menopause symptoms, the cardiovascular system, the osteoporosis and the estrogen dependent cancers, but many open questions exist. We must be very strict with certain observational studies by the possible influences of collateral factors to the isoflavones (exercise, type of diet, etc.), and attribute the beneficial effects may be due to own treatment.

Serum level of vascular endothelial growth factor is increased by estrogen replacement therapy in normotensive and DOCA–Salt hypertensive ovariectomized rats

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in developed countries. Previous studies have shown that hormone replacement therapy reduces the risk of CVD in postmenopausal women, however, the mechanism remains unclear. This study was designed to evaluate the effect of estrogen on serum vascular endothelial growth factor (VEGF) concentration in normotensive and hypertensive ovariectomized rats.

METHODS

Forty-eight female rats were ovariectomized and randomly divided into 6 groups. Hypertension was induced by DOCA-Salt method. DOCA was injected 30 mg/kg of body weight subcutaneously, twice a week with NaCl 1% instead of tap water for drinking throughout the experiment. Estradiol valerate (Es) was injected 2 mg/week i.m. The groups were as follows: (i) DOCA (4 weeks) and DOCA+Es (6 weeks); (ii) DOCA (10 weeks); (iii) Normal saline (N/S) (4 weeks) and Es (6 weeks); (iv) N/S 10 weeks; (v) DOCA (4 weeks), and (vi) N/S (4 weeks). Serum VEGF concentration was measured in groups 1 to 4.

RESULTS

Results showed that in normotensive animals that received estrogen treatment, serum VEGF concentration was significantly higher than those not receiving estrogen (269+/-41 vs. 106+/-36 pg/ml) (P<0.05). In hypertensive group, serum VEGF level was also increased after estrogen therapy compare to those not receiving estrogen (326+/-55 vs. 121+/-28 pg/ml (P<0.05).

CONCLUSION

It is possible that the increase in serum VEGF concentration after estrogen therapy may contribute to the cardiovascular effects of estrogen in normotensive and hypertensive conditions.

Hormone replacement therapy, cancer, controversies, and women's health: historical, epidemiological, biological, clinical, and advocacy perspectives

Routine acceptance of use of hormone replacement therapy (HRT) was shattered in 2002 when results of the largest HRT randomised clinical trial, the women's health initiative, indicated that long term use of oestrogen plus progestin HRT not only was associated with increased risk of cancer but, contrary to expectations, did not decrease, and may have increased, risk of cardiovascular disease. In June 2004 a group of historians, epidemiologists, biologists, clinicians, and women's health advocates met to discuss the scientific and social context of and response to these findings. It was found that understanding the evolving and contending knowledge on hormones and health requires: (1) considering its societal context, including the impact of the pharmaceutical industry, the biomedical emphasis on individualised risk and preventive medicine, and the gendering of hormones; and (2) asking why, for four decades, since the mid-1960s, were millions of women prescribed powerful pharmacological agents already demonstrated, three decades earlier, to be carcinogenic? Answering this question requires engaging with core issues of accountability, complexity, fear of mortality, and the conduct of socially responsible science.

Menopause: a review of botanical dietary supplements

Since the release of the Women's Health Initiative (WHI) findings, an increasing number of dietary supplement products specifically targeting women in menopause have appeared in the American marketplace. This growth highlights the need for a critical evaluation of the tolerability and effectiveness of these products. The purpose of this article is to assess the evidence for safety and benefit of botanical monopreparations used for relief of menopause-related symptoms. The Cochrane Library and Medline databases were searched from January 1966 to October 2004, using a detailed list of terms related to botanicals and menopausal symptoms. Studies were considered eligible (1) if they were controlled trials of a botanical monopreparation administered orally for a minimum of 6 weeks to perimenopausal or postmenopausal women with hot flashes and (2) if they included a placebo or comparative treatment arm. Topical preparations, botanical combinations, and dietary interventions, such as soy food or protein, were not included. No language restrictions were imposed on the search. A total of 19 studies met the inclusion criteria. The majority of studies indicate that extract of black cohosh (Actaea racemosa L.) improves menopause-related symptoms; however, methodologic shortcomings in the trials were identified. To date, 4 case reports of possible hepatotoxicity have been published, although previous safety reviews suggest that black cohosh is well tolerated and that adverse events are rare when it is used appropriately. The results of 6 clinical studies on soy (Glycine max L.) isoflavone extracts are mixed. Moreover, the composition and dose of soy supplements varies widely across studies, making comparisons and definitive conclusions difficult. One study challenged the long-term safety of high-dose soy isoflavone extract (150 mg/day for 5 years) on the uterine endometrium. Clinical data from 5 controlled trials assessing the efficacy of semipurified isoflavone red clover (Trifolium pratense L.) leaf extracts to reduce hot flash frequency and severity or to relieve symptoms associated with the domains of the Greene Menopausal Symptom Scale are contradictory. The largest study showed no benefit for reducing symptoms associated with menopause for 2 different red clover isoflavone products compared with placebo. No significant adverse events have been reported in the literature. Single clinical trials do not support the use of dong quai (Angelica sinensis L.), ginseng (Panax ginseng C.A. Mey), or evening primrose seed oil (Oenothera biennis L.) for improving menopausal symptoms. We conclude that black cohosh extracts appear to ease menopausal symptoms; ongoing studies funded by the National Institutes of Health (NIH) will provide more definitive safety and efficacy data. Soy isoflavone extracts appear to have minimal to no effect, although definitive conclusions are difficult given the wide variation in product composition and dose. Long-term safety of higher dosage (150 mg/day) soy isoflavone extracts is uncertain. Semipurified isoflavone red clover leaf extracts have minimal to no effect in reducing menopausal symptoms. Dong quai, ginseng extract, and evening primrose seed oil appear to be ineffective in ameliorating menopausal symptoms at the dosages and in the preparations used in these studies.

Effect of conjugated equine estrogen in combination with two different progestogens on the risk factors of coronary heart disease in postmenopausal Chinese women in Taiwan: a randomized one-year study

BACKGROUND

To compare the effect of hormone replacement therapy (HRT) using estrogen plus dydrogesterone or estrogen plus medroxyprogesterone acetate (MPA) on the risk factors for coronary heart disease (CHD) in postmenopausal women.

METHODS

A randomized, prospective 1-year clinical trial was designed. All of the postmenopausal women (n = 279) received sequential conjugated equine estrogen (CEE) at a dose of 0.625 mg/day for 25 days (days 1-25) of each month. These women were also randomly assigned to receive either dydrogesterone 10 mg/day (E + D group, n = 140) or MPA 5 mg/day (E + P group, n = 139) for 14 days (days 12-25) of each month. Serum biochemical markers, lipoproteins, plasma prothrombin time (PT), partial prothrombin time (PPT) and antithrombin III-antigen (ATIII-Ag) were analyzed at baseline, and after 6 and 12 months of treatment.

RESULTS

Liver function, renal function, PT and PPT did not change significantly during the 12-month trial. The E + D group had a more pronounced increase in high density lipoprotein cholesterol (HDL-C) than the E + P group (10.6% vs. 2.7%) after 12 months of treatment (p < 0.05). Both groups showed reduced concentrations of total cholesterol (T-CHO), low density lipoprotein cholesterol (LDL-C) and ATIII, whereas triglyceride (TG) was increased at the end of the trial (without intergroup difference).

CONCLUSIONS

Our study demonstrated a favorable effect on lipoprotein profiles with both hormone replacement therapy regimens. Dydrogesterone appears to be superior to medroxyprogesterone acetate from the perspective of modification of coronary heart disease risk factors.

Low-dose transdermal estradiol for symptomatic perimenopause

OBJECTIVE

To determine whether low-dose transdermal estrogen therapy is associated with a reduction in vasomotor symptoms in women who continue to have menstrual cycles.

DESIGN

An open-label, observational evaluation conducted over 12 months in 22 consecutive perimenopausal women with vasomotor symptoms.

RESULTS

Improvement in vasomotor symptoms was reported by 16 (73%) of women evaluated. Of responders, 11 characterized symptom relief as complete and 6 as moderate. Fifteen (68%) of the women remained on transdermal estrogen at 12 months. No adverse health-related events were attributed to estrogen therapy.

CONCLUSION

Low-dose transdermal estrogen is well tolerated and was associated with a reduction in complaints of vasomotor symptoms before menopause. The steady-state pharmacokinetics of transdermal delivery of unopposed estrogen may be advantageous in a population sensitive to fluctuations in circulating hormone levels.

Herbal product use and menopause symptom relief in primary care patients: a MetroNet study

OBJECTIVES

The four study objectives were to determine (1) the prevalence of use of four herbal product types promoted to reduce menopause symptoms (phytoestrogens, St. John's wort, Ginkgo biloba, and ginseng) among primary care patients approaching or in menopause, (2) the extent to which women who use these types of herbal products report menopause-related symptoms compared with herbal product nonusers, (3) the frequency of reported symptom reduction after use, and (4) if use was disclosed to their physicians.

METHODS

A cross-section of ethnically diverse women 40-55 years of age (35.5% African American, 60.2% Caucasian) who were recruited from eight primary care centers in Michigan to complete a self-report survey. The questionnaire included demographic items, health history, recent use of four herbal product types purported to relieve menopause symptoms and perception of symptom improvement, and interest in additional herbal product information.

RESULTS

Of 397 women, 24.9% reported taking, in the previous 6 months, at least one of the four study herbs. Herbal product use did not vary by patient demographics or health characteristics. Herbal product users reported more menopause symptoms than nonusers, and 68% of the users said that the herbs improved their symptoms; 56.4% said that their physician was aware of their herbal product use.

CONCLUSIONS

Primary care patients experiencing common menopausal symptoms are likely to use herbal products that are purported to provide menopause symptom relief, and many believe that these products improve their menopausal symptoms. Healthcare providers should be aware of patient's positive attitude, use patterns, and lack of disclosure of use of herbal medicines. Inquiry of herbal product use is another way for physicians to learn about patient self-medication of bothersome symptoms.

Effect of soy-derived isoflavones on hot flushes, endometrial thickness, and the pulsatility index of the uterine and cerebral arteries

OBJECTIVE

To determine the effect of soy-derived isoflavones on hot flushes, endometrial thickness, and the vascular reactivity of uterine and cerebral arteries.

DESIGN

Double-blind, randomized, placebo-controlled trial.

SETTING

Healthy volunteers in an academic research environment.

PATIENT(S)

Sixty-two postmenopausal women aged 45-60 years attending the Outpatient Menopause Clinic of our gynecological departments.

INTERVENTION(S)

The patients were administered 72 mg of soy-derived isoflavones or placebo under double-blind conditions. The daily number of hot flushes was recorded in a diary. Endometrial thickness was measured by means of transvaginal ultrasound; the uterine, internal carotid, and middle cerebral arteries were evaluated using Doppler ultrasound.

MAIN OUTCOME MEASURE(S)

The daily number of hot flushes, endometrial thickness, and arterial pulsatility index (PI).

RESULT(S)

Both treatments led to a 40% reduction in the number of hot flushes. Soy-derived isoflavones had no effect on endometrial thickness or the PI of the uterine and cerebral arteries.

CONCLUSION(S)

The daily administration of 72 mg of soy-derived isoflavones is no more effective than placebo in reducing hot flushes in postmenopausal women. It also has no effect on endometrial thickness or the PI of the uterine and cerebral arteries.

Menopause, energy expenditure, and body composition

OBJECTIVES

The effects of menopause transition on metabolic and cardiovascular disease risk in women are unclear. It is unknown whether estrogen deficiency, aging, or a combination of both factors are independent contributors to a worsening health profile in women. We considered the effects of menopause transition and hormone replacement therapy on body composition, regional body fat, energy expenditure, and insulin sensitivity.

METHODS

A brief review of current literature that has considered the role of menopause transition and hormone replacement therapy on body composition, energy expenditure, and insulin sensitivity with an emphasis on longitudinal investigations.

RESULTS

Preliminary evidence suggests that natural menopause is associated with reduced energy expenditure during rest and physical activity, an accelerated loss of fat-free mass, and increased central adiposity and fasting insulin levels. Hormone replacement therapy has been shown to attenuate these changes. Longitudinal and longer intervention studies are needed to confirm these initial findings.

CONCLUSIONS

Menopause transition may represent a risky period in a woman's life, 'triggering' adverse metabolic and cardiovascular processes that predispose women to a greater incidence of obesity-related comorbidities. Dietary, exercise, and hormonal interventions specifically targeted at premenopausal women may help mitigate the worsening cardiovascular and metabolic risk profile associated with menopause.

The medicalization of menopause: critique and consequences

Menopause is in the process of becoming medicalized. Midlife and older women are being told that natural menopause is actually a deficiency condition requiring replacement hormones to maintain health and increase longevity. The three major diseases that are being linked with the lower estrogen levels of midlife and older women are heart disease, osteoporosis and, most recently, Alzheimer's disease. Primary prevention of these diseases is the rationale used for urging healthy women to take long-term hormones. Although there have been many challenges to these links and warnings against the widespread use of hormones, they have been either ignored or trivialized. In this article, the author examines mortality and morbidity statistics across and within nations and over time, critiques the major arguments used to support the notion that menopause places women at an increased risk of disease and that exogenous hormones reduce this risk, and discusses the adverse consequences of defining all midlife and older women as hormonally deficient and in need of medical intervention.

Effect of long-term hormone replacement therapy on angiotensin-converting enzyme activity and bradykinin in postmenopausal women with essential hypertension and normotensive postmenopausal women

OBJECTIVE

Hormone replacement therapy (HRT) reduces the incidence of cardiovascular disease in postmenopausal women. Three-month short-term HRT in postmenopausal women with essential hypertension increased the plasma concentrations ofbradykinin with decreased serum angiotensin-converting enzyme (ACE) activity, which may be partially responsible for the cardioprotective effects of HRT. The objective was to determine whether 12-month long-term HRT in postmenopausal women with essential hypertension would maintain the decreased ACE activity and increased bradykinin levels and whether long-term HRT would increase the plasma bradykinin concentrations of normotensive postmenopausal women who had shown no significant changes in the 3-month HRT study, despite their decreased serum ACE activity.

DESIGN

Twenty hypertensive and 15 normotensive postmenopausal women were treated with conjugated estrogens (0.625 mg/day) and medroxyprogesterone (2.5 mg/day) for 12 months. Twenty hypertensive and 15 normotensive postmenopausal women were used as controls. The controls were not treated with HRT. Serum ACE activity and plasma bradykinin concentrations were measured at baseline and at 12 months.

RESULTS

Long-term HRT in both hypertensive and normotensive postmenopausal women significantly decreased serum ACE activity from 15.5+/-0.7 IU/L and 16.0+/-0.9 IU/L, respectively, at baseline to 13.3+/-0.5 IU/L and 14.2+/-0.9 IU/L, respectively, 12 months after the start of HRT (p < 0.05 and p < 0.05, respectively). Long-term HRT in both hypertensive and normotensive postmenopausal women also significantly increased plasma bradykinin concentrations from 22.1+/-4.4 pg/mL and 19.2+/-3.0 pg/mL, respectively, at baseline to 86.7+/-21.2 pg/mL and 73.5+/-23.0 pg/mL, respectively, 12 months after the start of HRT (p < 0.01 and p < 0.05, respectively). No significant changes in serum ACE activity or plasma bradykinin concentrations were observed in the control groups.

CONCLUSIONS

Long-term HRT in hypertensive and normotensive postmenopausal women decreases their serum ACE activity and increases their plasma bradykinin concentrations. Thus, maintenance of elevated bradykinin with decreased serum ACE activity by HRT may be useful in reducing the risk of cardiovascular disease in both hypertensive and normotensive postmenopausal women.

Course of primary headaches during hormone replacement therapy

OBJECTIVE

The aim of the present study was to evaluate how hormone replacement therapy (HRT) could influence the course of primary headaches in postmenopausal women.

METHODS

Fifty patients presenting for clinical evaluation of menopausal status and suffering from headache were enrolled. The observational period lasted 7 months during which women filled in a diary with the clinical characteristics of headache attacks (frequency, days with headache, severity) and the analgesic use (no. of analgesic/month). Climacteric symptoms and both anxiety and depression were also measured. At the first visit the patients were divided into two groups: those suffering from migraine without aura (MwA) and those suffering from episodic tension-type headache (ETTH) and separately randomized. After a month of run-in period, they received two different HRT regimen, either: (1) transdermal estradiol 50 mcg every 7 days for 28 days plus medroxyprogesterone acetate (MAP) 10 mg/day from 15th to 28th day, or (2) oral conjugated estrogens 0.625 mg/day for 28 days plus MAP 10 mg/day for the last 14 days. Follow up evaluations were planned after 1, 3 and 6 months of treatment.

RESULTS

While we did not observe any significance change regarding headache parameters in ETTH patients during both transdermal and oral treatment, the course of migraine was significantly affected by the route of HRT. Both frequency of attacks (F = 8.5; P < 0.000) and days with headache (F = 6.9; P < 0.000) significantly increased during HRT in the subgroup assuming oral formulation. On the contrary, no changes in the same parameters were found in the group taking transdermal treatment. Moreover, while severity of migraine was unaffected by HRT, analgesic consumption was significantly increased in the subgroup on oral treatment (F = 6.3; P = 0.001).

CONCLUSIONS

HRT significantly affects the course of headache in postmenopausal migraine sufferers. Indeed, while the clinical pattern of ETTH remained stable throughout the observational period, patients suffering from MwA worsened their symptoms within the first 3 months of treatment. In particular, the oral route of administration significantly worsened migraine in comparison to the transdermal route.

Clinical evidence supporting the rationale for constant oestrogen, intermittent progestogen hormone replacement therapy

Hormone replacement therapy (HRT) effectively relieves vasomotor and other symptoms associated with menopause, yet is underutilised by the majority of menopausal women. Current HRT regimens combine continuous oestrogen with continuous or sequential progestogen in order to achieve the beneficial effects of oestrogen while avoiding the potential for increased risk of endometrial cancer. Uterine bleeding and other adverse progestogenic effects are major reasons for patient noncompliance and early discontinuation of combination HRT, which can ultimately limit the achievement of long-term oestrogenic benefits. A novel constant 17beta-oestradiol, intermittent norgestimate regimen has been developed based on theoretical hormone receptor dynamics in an attempt to minimise the hormonal doses needed, thereby potentially reducing the occurrence of adverse effects associated with higher oestrogen and progestogen doses. Clinical trial data with this novel low-dose HRT regimen demonstrate effective relief of vasomotor symptoms in postmenopausal women, acceptable bleeding rates, no endometrial hyperplasia, beneficial effects on lipids, and excellent tolerability. This regimen has the potential to increase long-term use resulting in important clinical benefits.

Thromboembolic complications associated with reproductive endocrinologic procedures

Thromboembolism as a complication of hormonal ovarian stimulation in the context of artificial reproductive techniques is rare and seems to occur when OHS is present. Although accompanied by high serum estrogen concentrations, hCG seems to play a central role in the development of OHS, which has been observed in women with 17,18-desmolase deficiency who have low estrogen levels after induction of ovulation with hGC. Although there is some evidence that hormonal ovarian stimulation with HMG, leading to elevated estrogen levels, and ovulation induction with hCG in preparation for in vitro fertilization are associated with a state of hypercoagulability, the exact role of estrogens, hCG and the physicochemical changes (fluid shift into third spaces) involved in OHS remain to be elucidated.

Serum level of vascular endothelial growth factor is decreased by hormone replacement therapy in postmenopausal women without hypercholesterolemia

The administration of hormone replacement therapy (HRT) to postmenopausal women (PMW) reportedly has beneficial effects on their levels of lipid and lipoproteins. Estrogen retards the development of atherosclerosis induced by a high-fat diet in animals. Although vascular endothelial growth factor (VEGF) may be involved in the development of atherosclerosis in humans, there is no information on effect of estrogen administration on VEGF level and lipid metabolism. We evaluated 64 healthy normotensive or hypertensive PMW before and during the administration of HRT (0.625 mg conjugated equine estrogen combined with 2.5 mg medroxyprogesterone acetate orally) daily for 6 months. All hypertensive PMW were well-controlled on antihypertensive drug therapy. According to their total cholesterol level at baseline, we divided the PMW with HRT (n=54) into a normocholesterolemic group (NC, total cholesterol <220 mg/dl, n=35) and a hypercholesterolemic group (HC, total cholesterol >/=220 mg/dl, n=19). We evaluated the serum levels of VEGF at baseline, and again at 3 and 6 months after starting HRT. HRT significantly (P<0.01) reduced the mean VEGF level from 31.5+/-4.3 pg/ml at baseline to 18.2+/-2.3 pg/ml after 6 months in the NC group. However, the VEGF levels in the HC group and the control group exhibited no significant change at either 3 or 6 months after starting HRT. In summary, HRT, using a combination of conjugated equine estrogen and medroxyprogesterone acetate, reduced the level of VEGF in normocholesterolemic PMW more effectively than in those with hypercholesterolemia.

Health potential of soy isoflavones for menopausal women

OBJECTIVE

To review the current literature on the effects of soy isoflavones, one class of phyto-oestrogens, on cardiovascular diseases, osteoporosis, cancer and climacteric symptoms.

DESIGN

Many study designs were employed in the reports reviewed here, including prospective human trials, observational human studies, animal experiments and in vitro cell studies that explored the protective or preventive effects of soy isoflavones (genistein, daidzein and glycitein alone or mixed).

SETTING

Diverse settings were employed, depending on study design.

SUBJECTS

Human subjects, mostly menopausal or postmenopausal, were included, as were animal models and specific cell types.

RESULTS

The findings were: (i) isoflavones plus soy protein together were needed to obtain the highly significant beneficial results on blood lipids and arterial dimensions; (ii) isoflavone treatments alone at high doses (relative to above) consistently improved bone parameters in rodent ovariectomized models, but not in humans or primates; (iii) isoflavones were not consistent in exerting positive effects regarding the prevention or treatment of cancers of the mammary glands, uterus and colon; and (iv) the effects of isoflavones on climacteric symptoms were not clear-cut.

CONCLUSIONS

The promise of soy isoflavones reducing chronic disease risk seems to be non-uniform, with the most conclusive benefits occurring in the prevention of cardiovascular diseases, but other organ systems, such as skeletal and reproductive tissues, may also benefit from the consumption of soy and soy-derived products.

Reduction of serum uric acid by hormone replacement therapy in postmenopausal women with hyperuricaemia

Reduction of serum uric acid by hormone replacement therapy in postmenopausal women with hyperuricaemia is one of the cardiovascular protective mechanisms by which hormone replacement therapy reduces the risk of cardiovascular disease.

Persistence with estrogen therapy in a postmenopausal Medicaid population

We evaluated rates of persistence with estrogen replacement therapy in postmenopausal Georgia Medicaid recipients adjusted for age and race. Data files for 1992-1994 were examined to estimate 3-year conditional survival probabilities using the Kaplan-Meier model, and 3800 subjects were identified. Over 54% of women remained compliant over 29 months, and 17% continued therapy for the entire 35 months of observation. Kaplan-Meier predictors indicated that white women have a 70% chance of being compliant for 3 years, whereas black women have a 60% chance. Monthly discontinuation rates ranged from 1-1.5% after the second month of therapy. Younger, white women were the most likely to maintain and comply with therapy.

Estrogen and tamoxifen metabolites protect smooth muscle cell membrane phospholipids against peroxidation and inhibit cell growth

The goal of this study was to test the hypothesis that antioxidant estrogens, by a mechanism independent of the estrogen receptor, protect phospholipids residing in the plasma membrane of vascular smooth muscle cells from peroxidation and peroxidation-induced cell growth and migration. Peroxidation of membrane phospholipids was assessed by HPLC analysis of phospholipids extracted from rat aortic vascular smooth muscle cells prelabeled with cis-parinaric acid (a fatty acid that is susceptible to peroxidation, which quenches its fluorescent properties). Incubation of cells for 2 hours with the peroxyl radical donor 2,2'-azobis-2,4-dimethylvaleronitrile (AMVN) caused peroxidation of all measured membrane phospholipids. This effect was attenuated by pretreating cells for 15 minutes with 50 to 5000 ng/mL of 2-hydroxyestradiol (strong antioxidant but weak estrogen-receptor ligand) or 4-hydroxytamoxifen (strong antioxidant and potent estrogen-receptor ligand), but not by estrone or droloxifene (both weak antioxidants but potent estrogen-receptor ligands). Moreover, pretreatment of cells for 20 hours with physiological concentrations (0.3 ng/mL) of 2-hydroxyestradiol or pharmacologically relevant concentrations of 4-hydroxytamoxifen (40 ng/mL) also decreased AMVN-induced phospholipid peroxidation. Both 2-hydroxyestradiol and 4-hydroxytamoxifen were as effective as 2,2,5, 7,8-pentamethyl-6-hydrochromane (an antioxidant homolog of vitamin E) in attenuating AMVN-induced peroxidation of membrane phospholipids. Also, physiological concentrations of 2-hydroxyestradiol, but not estrone, and pharmacologically relevant concentrations of 4-hydroxytamoxifen attenuated AMVM-induced DNA synthesis, cell proliferation, and cell migration. These studies demonstrate in vascular smooth muscle cells that antioxidant estrogens via a non-estrogen receptor-dependent mechanism attenuate peroxidation of membrane phospholipids and peroxidation-induced cell growth and migration.

Evaluation and treatment of hypertension in active individuals

Hypertension is a very common vascular disease. It is seen in adolescents, obese persons, postmenopausal women, and the elderly. A nonpharmacologic approach to treatment is a critical first step in management. The modalities include a diet low in salt and saturated fat, exercise, less than 2 ounces of alcohol daily, and abstinence from smoking. Dynamic (aerobic) exercise is effective in lowering blood pressure (BP) only if performed regularly. Weight reduction by diet must be combined with exercise if there is to be a reduction in BP. Strength training is not to be considered as an alternative to aerobic training for reducing BP. Antihypertensive mediation can be added to nonpharmacologic interventions for additional BP reduction. Beta-blockade is not a contraindication to exercise training.

Menopause: lessons from anthropology

OBJECTIVES

In North America and Europe, it is usually assumed that biological changes associated with the end of menstruation and the onset of specific diseases commonly associated with the postmenopausal condition are universal. Using an anthropological approach in which menopause is understood as a concept that is historically and culturally produced, an argument is made for additional systematic investigation of what protects the majority of women from distress at menopause, and what factors contribute to a healthy old age.

METHOD

Survey research based on questionnaire responses, together with open-ended interviews and textual analyses, were used.

RESULTS

Differences are demonstrated in postmenopausal experiences and symptom reporting in Japan as compared with Canada and the United States. Reporting of hot flashes and nights sweats is significantly lower in Japan. These findings, together with the well established figures about greater longevity and lower incidence of heart disease, breast cancer, and osteoporosis in Japan, compared with North America, indicate that cultural and biological variables act in concert to produce this variation. Theories about the evolution of menopause and demographic data on aging are also discussed. This data challenges the widely held assumption that populations of postmenopausal women only recently have come into existence because of cultural and technological interventions.

CONCLUSIONS

Postmenopausal women have been present in human populations since homo sapiens first evolved. Culturally mediated life styles affect both the menopausal experience and the health of women as they age. Additional investigations are needed.

Gender and transcriptional regulation of NO synthase and ET-1 in porcine aortic endothelial cells

Experiments were designed to determine whether normal fluctuations in sex steroid hormones alter gene transcription for endothelial nitric oxide synthase (NOS) and preproendothelin-1 (prepro-ET-1). Aortic endothelial cells were removed from adult, gonadally intact male and female or ovariectomized Yorkshire pigs. Endothelial cells were prepared for Northern blot analysis, Western blot analysis or enzyme activity. Nitric oxide products (NOx) and endothelin-1 (ET-1) in plasma were measured by chemiluminescence and radioimmunoassay, respectively. Northern blot analysis identified single bands corresponding to endothelial NOS and prepro-ET-1. Quantification of the blots showed an increase in expression of mRNA for both endothelial NOS and prepro-ET-1 in ovariectomized pigs compared with gonadally intact male and female pigs. There were no differences in amount of endothelial NOS protein identified by Western blot analysis among groups. On the contrary, plasma concentrations of NOx were significantly decreased in ovariectomized pigs, and there were no differences either in the concentrations of ET-1 in the plasma or extracts from the coronary arteries. These results suggest that expression of endothelial NOS and prepro-ET-1 may be regulated at transcriptional level by ovarian hormones. In addition, the ovarian hormones may regulate production of these endothelium-derived factors at the posttranscriptional level.

In vitro platelet function in controlled ovarian hyperstimulation cycles

OBJECTIVE

To determine the effects of elevated endogenous E2 levels on in vitro platelet function in patients undergoing controlled ovarian hyperstimulation (COH).

DESIGN

Women with normal ovulatory cycles and patients undergoing COH on cycle day 3 and near ovulation (preovulatory follicles were at least 16 mm in diameter) were studied. Serum E2, Thrombostat 4000, (V. d. Goltz, Seeon, Germany), von Willebrand factor antigen (vWF-Ag), and platelet aggregation and adenosine triphosphate (ATP) release to adenosine diphosphate (ADP), collagen (COL), and arachidonic acid (AA) were measured.

SETTING

University-based outpatient infertility clinic.

PATIENT(S)

Twenty-two consenting infertile women undergoing COH cycles and 14 women with documented ovulatory cycles.

MAIN OUTCOME MEASURE(S)

Whole blood platelet aggregation with ADP, COL, AA, and Thrombostat 4000.

RESULTS(S)

Estradiol levels rose significantly at peak times (P = 0.011). No changes were noted in in vitro platelet function measured by the Thrombostat 4000 and by whole blood platelet aggregation with ADP and AA and in ATP release with ADP, COL, or AA. Aggregation with collagen was increased because of likely elevations in vWF-Ag levels.

CONCLUSION(S)

No significant changes in in vitro platelet function were noted in 19 women undergoing COH with E2 levels two to three times that observed in oral contraceptive or hormone replacement therapy users, suggesting no increased risk for arterial thromboembolism.

Risk factors associated with women's compliance with estrogen replacement therapy

An epidemiologic study was carried out in 2106 women 46-63 years of age to determine risk factors associated with their compliance or noncompliance with estrogen replacement therapy (ERT). Data were obtained from prescription refill and medical claims information from centralized prescription and medical claims databases of a United Healthcare-affiliated health plan in Minnesota. Study participants filled their first ERT prescription during calendar year 1989 or 1990. Our results indicate that women who are older, use a progestin, experience hormone replacement therapy side effects, or see a gynecologist or male physician are more likely to be noncompliant. Women who have cardiovascular problems, experience menopausal symptoms, or use transdermal estrogen are more likely to be compliant. These results suggest that the factors associated with compliance are those that indicate that women perceive a benefit from ERT use. The factors associated with noncompliance are hormone side effects and gender and specialty of the physician prescribing the estrogen.

The effect of sequential three-monthly hormone replacement therapy on several cardiovascular risk estimators in postmenopausal women

OBJECTIVE

To investigate the changes in plasma lipids and lipoproteins, low-density lipoprotein (LDL) oxidizability, and plasma homocysteine during postmenopausal sequential 3-monthly hormone replacement therapy.

DESIGN

Open longitudinal prospective study.

SETTING

Gynecological outpatient department of a university hospital.

PATIENT(S)

Thirty-nine healthy nonhysterectomized postmenopausal women.

INTERVENTION(S)

Oral conjugated estrogen, 0.625 mg/d, combined with oral medrogestone 10 mg/d during the last 14 days of each 84-day treatment cycle. The treatment was given for four treatment cycles of 84 days (1 year).

MAIN OUTCOME MEASURE(S)

Plasma lipids and lipoproteins, LDL oxidizability, and plasma homocysteine.

RESULT(S)

After 1 year of treatment plasma concentrations of total cholesterol and LDL cholesterol were 3.5% and 8.7% lower, respectively. High density lipoprotein cholesterol, apolipoprotein A-I, and triglycerides were 6.5%, 9.0% and 16% higher, respectively. Apolipoprotein B concentration remained unchanged. The results on LDL oxidizability were inconsistent. Plasma homocysteine decreased with 12.3% during the first 6 months of treatment in women with higher homocysteine concentrations at baseline. These values returned to baseline levels during the second half year of treatment.

CONCLUSION(S)

This sequential hormone regimen induced beneficial changes in the conventional lipid and lipoprotein risk estimators, whereas the observed changes in the other markers remained inconclusive and/or of minor importance.

Effects of hormone replacement modalities on low density lipoprotein composition and distribution in ovariectomized cynomolgus monkeys

This study was designed to determine the effect of several hormone replacement therapies on LDL size, density, heterogeneity, and composition in surgically postmenopausal cynomolgus monkeys fed an atherogenic diet. Groups (n = 5 each) of ovariectomized cynomolgus monkeys were untreated (control), or treated with conjugated equine estrogens, medroxyprogesterone acetate (progesterone), combined estrogen-progesterone, or tamoxifen for 9 weeks. There were no differences among treatment groups in total plasma, LDL, or HDL cholesterol or triglyceride concentrations. Plasma LDL were isolated by ultracentrifugation and size exclusion chromatography and subfractionated by density gradient centrifugation for subsequent chemical analysis. Estrogen treatment was associated with significantly smaller (measured as LDL molecular weight, 3.9 +/- 0.2 g/mu mol) and denser plasma LDL (1.034 g/ml peak density) compared with control (4.5 +/- 0.1 g/mu mol; 1.030 g/ml peak density) or progesterone-treated animals (4.6 +/- 0.2; 1.029 g/ml peak density). LDL from the estrogen group were relatively enriched in protein and triglyceride and poor in cholesteryl ester and apolipoprotein F (apoE) compared to the control group. Triglyceride enrichment with estrogen treatment occurred predominantly in the lighter, larger LDL subfractions (d = 1.015-1.025 g/ml), which were reduced in concentration (26 +/- 10 mg cholesterol/dl) compared to control (61 +/- 19 mg/dl) or progesterone treated animals (67 +/- 16 mg/dl). Combined estrogen-progesterone or tamoxifen treatment resulted in changes in LDL that followed the same trend as those observed with estrogen treatment. We conclude that short-term estrogen treatment of ovariectomized cynomolgus monkeys results in changes in plasma LDL size, density, and composition while having no apparent effect on overall plasma lipid concentrations.

Osteoporosis: the need for comprehensive treatment guidelines

Osteoporosis is a debilitating disease that results in nearly 1.3 million fractures per year in the United States. The cost of treating these fractures has been estimated to be as high as $10 billion per year. These costs are expected to more than double during the next 50 years unless comprehensive programs of prevention and treatment are initiated. Both pharmacologic and nonpharmacologic interventions (eg, diet and exercise) have been shown to have a significant impact on the incidence of osteoporosis, depending on the time of their application. Unfortunately, osteoporosis is often not diagnosed until after fractures have occurred, when it may be too late for treatment to have a major impact. To be most effective, therapy should be started early, before serious bone loss has occurred. Because of its efficacy and relatively low acquisition cost, long-term hormone replacement therapy (HRT) is considered first-line pharmacologic therapy for the prevention of osteoporosis. However, for various reasons, less than 25% of US women who might benefit from HRT are receiving it. Aside from HRT, the only other products approved by the US Food and Drug Administration for the treatment of osteoporosis are salmon calcitonin and alendronate. Several other agents are under development, including sustained-release fluoride and other products in the bisphosphonate class. The development and adoption of early detection programs and treatment guidelines are crucial to help ease the economic burden of osteoporosis. These guidelines should incorporate preventive measures such as diet and exercise, risk assessment through proper screening programs, and the appropriate use of pharmaceutical products. The purpose of this paper is to discuss relevant economic issues associated with osteoporosis and discuss the need for a management algorithm that could be used to more efficiently prevent and treat this disease. We conclude that further modeling is needed to determine which programs and treatments are most cost-effective within each at-risk subgroup. As clinicians better understand the need for preventive care and the advantages of the various pharmacologic therapies, patients with osteoporosis will receive higher-quality and more efficient medical care.

Circulating nitric oxide (nitrite/nitrate) levels in postmenopausal women substituted with 17 beta-estradiol and norethisterone acetate. A two-year follow-up study

Postmenopausal women (PMW) have an increased risk of cardiovascular disease that is attenuated by hormone replacement therapy (HRT). Inasmuch as hypertension and atherosclerosis are associated with diminished endothelium-derived nitric oxide (NO), we investigated whether HRT augments NO release in PMW. We determined serum levels of nitrite/nitrate (NO2 + NO3) at baseline and during the 6th, 12th, and 24th months of the study in two groups of PMW. One group (HRT-PMW, n = 13) received continuous transdermal administration of 17 beta-estradiol (Estraderm-TTS-50) supplemented with oral norethisterone acetate (NETA) on days 1 through 12 of each month, and the other group (control PMW, n = 13) did not receive HRT. Blood samples in the HRT-PMW group were collected without regard to whether subjects were taking NETA at the time of blood sampling. Serum NO2 + NO3 levels increased in HRT-PMW for the duration of the study, whereas serum NO2 + NO3 levels remained unchanged in control PMW. When all samples regardless of timing of collection with respect to NETA treatment were included in the statistical analysis, the change in NO2 + NO3 levels in HRT-PMW was significantly greater compared with the change in control PMW (P = .037). Likewise, when only those samples collected when estradiol-treated subjects were not taking oral NETA were included in the statistical analysis, the change in NO2 + NO3 levels in the HRT-PMW group remained significant (P = .047) compared with control PMW.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperestrogenism induced by menotropins alone or in conjunction with luprolide acetate in in vitro fertilization cycles: the impact on hemostasis

OBJECTIVE

To evaluate coagulation parameters during IVF cycles with elevated E2.

DESIGN

Prospective clinical study.

SETTING

Human volunteers in an IVF clinic.

PATIENTS

Infertile women undergoing IVF procedures.

INTERVENTIONS

Coagulation factors were measured in blood along with E2 and P after singular hMG or leuprolide acetate (LA) plus hMG up to 14 days after hCG.

MAIN OUTCOME MEASURES

Plasma coagulation factors.

RESULTS

Some coagulation factors were statistically but not clinically elevated after LA-hMG-induced hyperestrogenism. For the most part, this was not correlated with E2.

CONCLUSION

This study suggests that endogenous E2 increases due to fertility drugs cause a molecular activation of some coagulation factors, which do not result in an increased thrombosis.

Menopause and perceived health status among the women of the French GAZEL cohort

The aim of this study was to evaluate the effect of menopause on women's quality of life. Women (1171) aged from 45-52 years who work for the French national gas and electricity company volunteered for this study (response rate 75%). They completed a self-administered questionnaire pertaining to general health. Quality of life was measured by the Nottingham Health Profile (NHP). Within this group 289 women were postmenopausal. After controlling for age, those women were more likely to show a lower quality of life than women still menstruating for 4 of the 6 sections of the NHP: social isolation (odds ratio 1.4; 95% confidence interval 1.1-1.9), pain, sleep and energy (odds ratios 1.5; 95% confidence intervals 1.1-2.0). Those alterations of quality of life are explained by the climacteric complaints the women report. Those findings suggest that the treatment of menopausal symptoms with medication of proven efficacy may prevent lowering of quality of life due to menopause.

Aspects of hormone replacement therapy

The most important benefit of ERT may well be its cardioprotective effect. But unopposed estrogen therapy also carries the risk of inducing endometrial cancer. A compelling body of evidence indicates that adjunctive progestogen protects effectively against estrogen-induced endometrial adenocarcinoma, and that progestogen therapy is effective in the treatment of hyperplasia in most women who have taken unopposed estrogen. Yet there is concern that adjunctive progestogen may attenuate the cardioprotective effects of estrogen. It is therefore agreed that adjunctive progestogen therapy is not indicated for hysterectomized women, and should be given at the lowest effective dose to non-hysterectomized women. Phase II dose-ranging clinical trials using secretory transformation as an efficacy endpoint to estimate protective effects of different doses of progestogen against endometrial hyperplasia/adenocarcinoma are complicated by the possibility that the doses protecting against hyperplasia may differ from those producing secretory changes. Further work is needed to identify one or several progestogen-regulated markers that most closely correlate with protection against estrogen-induced endometrial cancer.

Management of postmenopausal osteoporosis

More than 25% of postmenopausal women are at risk of osteoporosis. In order to avoid its consequences, it is necessary to find an appropriate prevention and/or treatment. We studied: (1) 15 postmenopausal women treated with percutaneous estradiol (50 micrograms/24 h) plus MPA (10 mg/10 days/month); (2) 15 postmenopausal women treated with synthetic calcitonin nasal spray at the daily dose of 100 IU; (3) 10 postmenopausal women treated with nandrolone decanoate (50 mg every 3 weeks); (4) 10 postmenopausal women treated with ipriflavone (600 mg/day); and (5) 10 postmenopausal women treated with sodium fluoride (20 mg) plus calcium (600 mg). Clinical examination, bone mass measurement (total BMD), hematochemical and urinary parameters of bone metabolism (calcium, urinary hydroxyproline, PTH) and growth factors (as IGF-I and TNF-beta) were evaluated. After 6 months of therapy, a complete prevention of bone resorption was achieved. In agreement with current literature, we observed that the various therapeutic approaches have all some positive effect on BMD, with different results on pain, blood biochemical parameters and growth factors' concentrations.

A study on the use of medication for climacteric complaints in western Europe--II

Samples of about 300 women aged 40-69 were interviewed in Denmark and the Netherlands about consultations with a physician for climacteric complaints, awareness regarding the menopause and hormone replacement therapy (HRT), and use of medication. Twenty percent of Danish and 13% of Dutch respondents had consulted a physician. Fifty percent of Danish and 16% of Dutch respondents were informed about the menopause, and 46% of Danish and 10% of Dutch respondents were informed about HRT, the mass media being the most important information source. In Denmark and the Netherlands HRT use rates were 12% and 4%, respectively, those for non-hormonal treatment being 6% and 2%, and for tranquillizers 11% and 7%. Pooling of the data with those from a similar study conducted in Italy, the United Kingdom, West Germany and France [6] revealed that consultation for climacteric complaints was a universal phenomenon in all six countries which correlated mainly with perimenopausal status. Awareness of the menopause and HRT, and actual use of HRT were predominantly associated with the individual countries. These findings suggest that HRT prescription and use for climacteric complaints depend greatly on country-specific reservations about HRT among both physicians and women. Surprisingly, these appeared more prevalent in the countries where GPs played a predominant role in climacteric counselling.

Effects of transdermal 17 beta-oestradiol combined with oral progestogen on lipids and lipoproteins in hypercholesterolaemic postmenopausal women

OBJECTIVES

The purpose of the study was to evaluate the effect of transdermal 17 beta-oestradiol with oral progestogen on the plasma levels of lipids, lipoproteins and apolipoproteins in hypercholesterolaemic postmenopausal women.

DESIGN

During 6 months of replacement therapy with transdermal 17 beta-oestradiol combined with oral progestogen, plasma lipids, lipoproteins and apolipoproteins after 3 and 6 months were measured and compared with pretreatment values by Student's t-test.

SETTING

From January 1992 until September 1992 patients were diagnosed and treated in an out-patient clinic of the Department of Endocrinology Medical Centre for Postgraduate Education, Warsaw.

SUBJECTS

The patients studied were 11 non-obese postmenopausal women with hypercholesterolaemia based on the World Health Organization criteria.

INTERVENTIONS

Venous blood samples were obtained before and 3 and 6 months after the beginning of cyclic replacement therapy with transdermal 17 beta-oestradiol (E2 100 micrograms day-1 combined with oral chlormadinone acetate (2 mg day-1 for 7 days in each cycle).

MAIN OUTCOME MEASURES

The antiatherogenic effect of transdermal oestrogen replacement therapy exerted by increased levels of high-density lipoprotein subfraction 2 cholesterol (HDL2-C) leading to the decrease of the total cholesterol level was anticipated.

RESULTS

After 6 months of the treatment the concentrations of HDL2 cholesterol (HDL2-C) increased from 0.45 +/- 0.07 mmol l-1 to 0.73 +/- 0.03 mol l-1 (P < 0.05) but the levels of HDL3 cholesterol (HDL3-C) decreased from 1.15 +/- 0.06 mmol l-1 to 0.89 +/- 0.07 mmol l-1 (P < 0.05). The concentrations of total cholesterol decreased from 6.9 +/- 0.13 mmol l-1 to 6.2 +/- 0.2 mmol l-1 (P < 0.05). No changes were observed in the plasma levels of total triglycerides, HDL cholesterol, low-density lipoprotein (LDL) cholesterol, very-low-density lipoprotein (VLDL) cholesterol, VLDL triglycerides, apolipoproteins A-I and B.

CONCLUSIONS

In hypercholesterolaemic postmenopausal women, transdermally administered 17 beta-oestradiol 100 micrograms daily in combination with oral chlormadinone acetate has a beneficial effect through raising the level of the antiatherogenic HDL2-C subfraction and decreasing the level of total cholesterol.

Estrogen Replacement Therapy: The Benefit Outweighs the Risk

Menopause and the related decline in estrogen result in multiple symptoms including genitourinary atrophy, vasomotor instability, and osteoporosis. The most significant long-term effect of estrogen deficiency is increased risk of cardiovascular disease. Estrogen replacement therapy (ERT) decreases osteoporosis and associated fractures, decreases symptoms associated with menopause, and offers cardioprotection. However, ERT is not without risk because it may lead to increased risk of endometrial cancer if used without progestin, and has been questionably linked to breast cancer. Educating the post-menopausal woman concerning the risks and benefits of ERT is essential to assure compliance. ERT decreases mortality incidence and improves quality of life, and its use for any post-menopausal woman without contraindications is recommended.

Localization of estrogen receptors in long bones and vertebrae of human fetuses

In order to investigate the possible role of estrogen in the development of cartilage and bone we studied by immunofluorescence immunohistochemistry and autoradiography 26 human embryos and fetuses 7-22 weeks in gestational age associated with pregnancy interrupted for non-medical reasons. In order to demonstrate the presence of estrogen receptors (ERs) in human fetal cartilage, cryostat sections of long bones and lumbar and thoracic vertebrae were prepared for (1) fluorescent immunocytochemistry using an antiidiotypic monoclonal antibody to anti-estradiol receptor monoclonal Ab labeled with fluorescein isothiocyanate (FITC), (2) immunohistochemistry using monoclonal antihuman estradiol receptor antibody, labeled with strept. A-B immunoperoxidase, and (3) autoradiographic localization of estradiol using labeled (3H) 17 beta estradiol. In fetuses aged 10 weeks or older, intranuclear and perinuclear localization of ER was demonstrated by all methods, mainly amongst chondrocytes of the proliferating and higher hypertrophic zones of the epiphyses and in the cartilage of vertebral bodies. These data suggest that estrogen acts directly on chondrocytes of human fetuses through an ER-mediated mechanism.

Dutch general practitioners' attitudes towards the climacteric and its treatment

In order to obtain insight into general practitioners' (GPs) point of view regarding climacteric problems and possible treatment, a survey was conducted among 195 GPs in the Limburg Province in the Netherlands. Ultimately, 159 GPs participated (response-rate 82%). The GPs were either members of the Society for the Improvement of the Expertise of GPs, or filled out the questionnaire previous to participation in a medical training course. The climacteric and its typically related complaints were generally well recognized by the surveyed GPs. Ninety-five percent of the GPs were of the opinion that women with climacteric complaints need some kind of medical help, and 62% were found to prescribe medication, mainly hormone replacement therapy (HRT). Remarkably, 75% of all GPs were of the opinion that prescribing HRT for climacteric complaints is a form of medicalization. Twelve percent of the GPs stated they never prescribe HRT for solely preventive purposes. In case of preventive treatment merely 32% of the GPs prescribed HRT for a period longer than 5 years.

Effect of long-term spleen dialysate (Solcosplen) administration on plasma lipids and lipoproteins in early postmenopausal women

A total of 46 early postmenopausal women with elevated levels of total cholesterol, triglycerides, low-density lipid (LDL) cholesterol and lowered high density lipoprotein cholesterol (HDL) cholesterol was treated with spleen dialysate (Solcosplen), 2 x 2 tablets daily for 6 months. Serum estradiol levels rose from 42.3 +/- 15.4 pg/ml to 60.6 +/- 23.6 pg/ml and the Kupperman Index decreased significantly after 6 months of treatment. Also, a significant decrease of total cholesterol, triglycerides, LDL cholesterol, and an increase of HDL cholesterol was observed. The changes showed no correlation with the estradiol concentration and no side-effects were evident. Solcosplen is recommended as a beneficial therapy for women in the early postmenopause.

Association of hormone-replacement therapy with various cardiovascular risk factors in postmenopausal women. The Atherosclerosis Risk in Communities Study Investigators

BACKGROUND

Most epidemiologic studies of cardiovascular disease in postmenopausal women suggest that estrogen-replacement therapy has a protective effect. The effects of the use of estrogen combined with progestin are less well studied.

METHODS

To examine the associations of hormone-replacement therapy with concentrations of plasma lipids and hemostatic factors, fasting serum concentrations of glucose and insulin, and blood pressure, we studied 4958 postmenopausal women participating in a population-based investigation. Using cross-sectional data, we classified the women into four groups according to their use of hormone-replacement therapy: current users of estrogen alone, current users of estrogen with progestin, nonusers who had formerly used these hormones, nonusers who had never used them.

RESULTS

Current users had higher mean levels of high-density lipoprotein cholesterol, its subfractions high-density lipoprotein2 and high-density lipoprotein3, and apolipoprotein A-I than nonusers and lower mean levels of low-density lipoprotein cholesterol, apolipoprotein B, lipoprotein(a), fibrinogen, antithrombin III, and fasting serum glucose and insulin. However, current users of estrogen alone had higher triglyceride, factor VII, and protein C levels than either nonusers or current users of estrogen with progestin. After making certain assumptions, we estimated that the findings, if causal, would translate into a reduction of 42 percent in the risk of coronary heart disease in users of hormones as compared with nonusers. Women using estrogen with progestin would have an even greater estimated benefit.

CONCLUSIONS

A randomized trial is needed to eliminate possible selection biases in our observational study that are related to the prescription of replacement hormones. Nevertheless, hormone-replacement therapy appears to be associated with a favorable physiologic profile, which probably mediates its protective effects on cardiovascular disease. The use of estrogen combined with progestin appears to be associated with a better profile than the use of estrogen alone.

Complications of menopause and the risks and benefits of estrogen replacement therapy

Every woman who lives long enough will become menopausal. While menopause is not a disease, the increased mortality and morbidity in menopausal women due to osteoporotic fractures, cardiovascular disease, and coronary heart disease are felt by many to be related to the decrease in endogenous estrogen. Therefore, one possible solution is estrogen replacement therapy. This article reviews recent literature on the complications of menopause and the risks and benefits of estrogen replacement therapy. The article also will discuss how a nurse practitioner can utilize the theory of care seeking behavior to implement this knowledge into practice.

Menopausal age of Ghanaian women

OBJECTIVE

The purpose of the study was to determine the age of menopause among Ghanaian women.

METHOD

A prospective survey involving 152 women in Akosombo District in Ghana was conducted. A questionnaire was developed including: age at menopause, symptoms of hot flushes or flashes, palpitations, anxiety, sleeplessness, headaches, frequency of urine, depression, irritability, tiredness, weight gain, poor memory and attitudes to coitus.

RESULT

Of 152 women interviewed, 29 were excluded because they were not sure of their birth dates and 123 women were analyzed. The mean and median ages at menopause were 48.05 years +/- 3.62 S.D. and 48 years respectively. The major symptoms at menopause were tiredness 79.9%, sleeplessness 71.0%, palpitations 63.7%, weight gain 61.8%, hot flushes 56.5%, and irritability 56.5%. However, 85.6% of the women who experienced hot flushes reported this to be the most unpleasant.

CONCLUSION

1. The age at menopause in Ghanaian population was 48.05 +/- 3.62. 2. Tiredness, sleeplessness, palpitations, weight gain, hot flushes, irritability, anxiety and headache were the major symptoms at menopause. 3. Hot flushes or flashes was the most disturbing symptom at menopause.