Fibrinogen and plasminogen modifications during oral estradiol replacement therapy

[Russian eligibility criteria prescribing menopausal hormonal hormones therapy for patients with cardiovascular and metabolic diseases. Consensus document of the Russian Cardiological Society, Russian Society of Obstetricians and Gynecologists, Russian Association of Endocrinologists, Eurasian Association of Therapists, Association of Phlebologists of Russia]

Menopausal symptoms can disrupt the life course of women at the peak of their career and family life. Currently, the most effective treatment for these manifestations is menopausal hormone therapy (MHT). The presence of cardiovascular and metabolic diseases in itself does not exclude the possibility of prescribing MHT to relieve menopausal symptoms and improve quality of life. However, often an obstacle to the use of this type of hormonal therapy is the fear of doctors who are afraid of doing more harm to patients than good. Caution is especially important when it comes to women with underlying health conditions. Moreover, it should be recognized that there is a lack of high-quality research regarding the safety of MHT for major chronic non-infectious diseases and common comorbid conditions. The presented consensus document analyzed all currently available data obtained from clinical trials of various designs and created a set of criteria for the acceptability of prescribing MHT to women with concomitant cardiovascular and metabolic diseases. Based on the presented document, doctors of various specialties who advise women in menopause will receive an accessible algorithm that will allow them to avoid potentially dangerous situations and reasonably prescribe MHT in real practice.

[Russian Eligibility Criteria for Prescribing Menopausal Hormone Therapy to Patients With Cardiovascular and Metabolic Diseases. Consensus Document of RSC, RSOG, RAE, EUAT, RAP]

Menopausal symptoms can impair the life of women at the peak of their career and family life. At the present time, the most effective treatment for these manifestations is menopausal hormone therapy (MHT). The presence of cardiovascular and metabolic diseases in itself does not exclude the possibility of prescribing MHT to relieve menopausal symptoms and improve quality of life. However, often an obstacle to the use of this type of hormone therapy is the fear of physicians to do more harm to patients than good. Caution is especially important when it comes to women with concurrent diseases. Moreover, it should be recognized that there is a shortage of high-quality research on the safety of MHT for underlying chronic non-infectious diseases and common comorbidities. The presented consensus analyzed all currently available data from clinical trials of various designs and created a set of criteria for the appropriateness of prescribing MHT to women with concomitant cardiovascular and metabolic diseases. Based on the presented document, physicians of various specialties who advise menopausal women will receive an accessible algorithm that will allow them to avoid potentially dangerous situations and reasonably prescribe MHT in real-life practice.

The Effects of Menopause Hormone Therapy on Lipid Profile in Postmenopausal Women: A Systematic Review and Meta-Analysis

Importance: The incidence of dyslipidemia increases after menopause. Menopause hormone therapy (MHT) is recommended for menopause related disease. However, it is benefit for lipid profiles is inconclusive. Objective: To conduct a systematic review and meta-analysis of randomized controlled trials to evaluate the effects of MHT on lipid profile in postmenopausal women. Evidence Review: Related articles were searched on PubMed/Medline, EMBASE, Web of Science, and Cochrane Library databases from inception to December 2020. Data extraction and quality evaluation were performed independently by two reviewers. The methodological quality was assessed using the "Cochrane Risk of Bias checklist". Results: Seventy-three eligible studies were selected. The results showed that MHT significantly decreased the levels of TC (WMD: -0.43, 95% CI: -0.53 to -0.33), LDL-C (WMD: -0.47, 95% CI: -0.55 to -0.40) and LP (a) (WMD: -49.46, 95% CI: -64.27 to -34.64) compared with placebo or no treatment. Oral MHT led to a significantly higher TG compared with transdermal MHT (WMD: 0.12, 95% CI: 0.04-0.21). The benefits of low dose MHT on TG was also concluded when comparing with conventional-dose estrogen (WMD: -0.18, 95% CI: -0.32 to -0.03). The results also showed that conventional MHT significantly decreased LDL-C (WMD: -0.35, 95% CI: -0.50 to -0.19), but increase TG (WMD: 0.42, 95%CI: 0.18-0.65) compared with tibolone. When comparing with the different MHT regimens, estrogen (E) + progesterone (P) regimen significantly increased TC (WMD: 0.15, 95% CI: 0.09 to 0.20), LDL-C (WMD: 0.12, 95% CI: 0.07-0.17) and Lp(a) (WMD: 44.58, 95% CI:28.09-61.06) compared with estrogen alone. Conclusion and Relevance: MHT plays a positive role in lipid profile in postmenopausal women, meanwhile for women with hypertriglyceridemia, low doses or transdermal MHT or tibolone would be a safer choice. Moreover, E + P regimen might blunt the benefit of estrogen on the lipid profile. Clinical Trial Registration: [https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018092924], identifier [No. CRD42018092924].

Hormonal Effects on Urticaria and Angioedema Conditions

Women appear to be more frequently affected with urticaria and angioedema. Sex hormones are believed to have an important mechanistic role in regulating pathways involved in these conditions. This effect is likely nonspecific for chronic spontaneous urticaria (CSU) or many forms of angioedema (AE), because many other chronic diseases such as asthma are also affected by sex hormones. The role of sex hormones has been better elucidated for hereditary AE, because they have been shown to have multiple effects including upregulation of FXII, an important activator of the kallikrein pathway. However, their role in the underlying pathogenesis for CSU is less clear. Autoimmunity is clearly linked to CSU, which is more common in women. This suggests that sex hormones could act as adjuvants in activating or upregulating autoimmune pathways. The purpose of this review is to discuss in detail the role of sex hormones in CSU and AE and how a better understanding of the impact hormones has on these conditions might lead to new treatment advancements with better clinical outcomes.

Measurement of Bradykinin Formation and Degradation in Blood Plasma: Relevance for Acquired Angioedema Associated With Angiotensin Converting Enzyme Inhibition and for Hereditary Angioedema Due to Factor XII or Plasminogen Gene Variants

Bradykinin (BK)-mediated angioedema (AE) states are rare acquired or hereditary conditions involving localized edema of the subcutaneous and submucosal tissues. Citrated plasma from healthy volunteers or patients with hereditary angioedema (HAE) with normal level of C1-inhibitor (C1-INH) was used to investigate pathways of BK formation and breakdown relevant to AE physiopathology. The half-life of BK (100 nM) added to normal plasma was 34 s, a value that was increased ~12-fold when the angiotensin converting enzyme (ACE) inhibitor enalaprilat (130 nM) was added (enzyme immunoassay measurements). The BK half-life was similarly increased ~5-fold following 2 daily oral doses of enalapril maleate in healthy volunteers, finding of possible relevance for the most common form of drug-associated AE. We also addressed the kinetics of immunoreactive BK (iBK) formation and decline, spontaneous or under three standardized stimuli: tissue kallikrein (KLK-1), the particulate material Kontact-APTT™ and tissue plasminogen activator (tPA). Relative to controls, iBK production was rapid (10–20 min) and very intense in response to tPA in plasma of female heterozygotes for variants in gene F12 coding for factor XII (FXII) (p.Thr328Lys, 9 patients; p.Thr328Arg, one). An increased response to Kontact-APTT™ and an early tPA-induced cleavage of anomalous FXII (immunoblots) were also observed. Biotechnological inhibitors showed that the early response to tPA was dependent on plasmin, FXIIa and plasma kallikrein. Results from post-menopausal and pre-menopausal women with HAE-FXII were indistinguishable. The iBK production profiles in seven patients with the plasminogen p.Lys330Glu variant (HAE-PLG) did not significantly differ from those of controls, except for an unexpected, rapid and lanadelumab-resistant potentiation of KLK-1 effect. This enzyme did not cleave plasminogen or factor XII, suggesting a possible idiosyncratic interaction of the plasminogen pathogenic variant with KLK-1 activity. KLK-1 abounds in salivary glands and human saliva, hypothetically correlating with the clinical presentation of HAE-PLG that includes the swelling of the tongue, lips and contiguous throat tissues. Samples from HAE patients with normal C1-INH levels and F12 gene did not produce excessive iBK in response to stimuli. The ex vivo approach provides physiopathological insight into AE states and supports the heterogeneous physiopathology of HAE with normal C1-INH.

Sex steroids as inflammatory regulators

It is becoming increasingly clear that endogenous sex steroids are key players in a range of inflammatory contexts. Androgens and estrogens have been shown to have a profound influence on the function of inflammatory cells including macrophages and on the secretion and activation of a range of plasma-borne inflammatory mediators. The menopause and polymorphisms in estrogen receptor genes have separately been shown to affect the incidence of a range of inflammatory disorders. Sex steroids themselves have been shown to be protective in certain conditions; harmful in others. This review will summarize their documented effects on inflammatory processes, with particular focus on two areas that have received much recent attention: the antiatherosclerotic properties of estrogens in females and the wound healing effects of sex steroids.

Hemostatic markers in healthy postmenopausal women during intranasal and oral hormone therapy

OBJECTIVE

To study changes in the hemostatic balance during intranasal compared with oral administration of 17beta-estradiol (E2) and norethisterone (NET) or NET acetate in postmenopausal women. A wide range of markers of coagulation and fibrinolysis associated with coronary artery disease was tested.

DESIGN

In a two-center, randomized, double-blind, comparative trial, 90 healthy postmenopausal women (aged 56.6 +/- 4.7 y) received daily continuous combined hormone therapy, either E2/NET 175 microg/275 mug intranasally as a spray (n = 47) or E2/NET acetate 1 mg/0.5 mg orally as a capsule (n = 43) for 1 year. Hemostatic markers were measured in blood samples taken at baseline and after 12, 24, and 52 weeks of treatment.

RESULTS

After 52 weeks of treatment, changes in the intranasal group in markers of coagulation-fibrinogen (-1.3%), factor VII activity (-14.0%), and prothrombin fragment 1 + 2 (+5.8%)-were significantly less (P < 0.05) than the changes in the oral group for these parameters (-6.5%, -20.3%, and +19.0%, respectively). Changes in activated factor VII did not differ between the groups. Neither group showed significant changes in thrombin-antithrombin complex. In the intranasal group, decreases in markers of fibrinolysis-tissue-type plasminogen activator (-10.4%) and plasminogen activator inhibitor-1 antigen (-13.8%)-were significantly less (P < 0.05) than the decreases in the oral group (-17.8% and -38.0%, respectively). A decrease in plasminogen activator inhibitor-1 activity and increases in D-dimer and plasmin-alpha2-antiplasmin complex did not differ between the groups. No differences were found between the groups in homocysteine, which overall was unaltered in both groups.

CONCLUSIONS

During intranasal E2/NET therapy, changes in the coagulatory and fibrinolytic markers were to some extent less than those observed during oral therapy.

Comparison of the effects of tibolone and estrogen therapy on hemostasis in surgical menopause: a randomized, double-blind, placebo-controlled study

OBJECTIVE

To examine the effects of unopposed estrogen (E) and tibolone therapy on coagulation and natural anticoagulant systems in surgical menopause.

DESIGN

A randomized, double-blind, placebo-controlled study.

SETTING

University hospital clinic in Turkey.

PATIENT(S)

Ninety healthy surgically postmenopausal women.

INTERVENTION(S)

Ninety surgically postmenopausal women were randomized into three groups: unopposed conjugated ET (0.625 mg/d, group 1), tibolone (2.5 mg/d, group 2), and identical tablets of placebo (group 3).

MAIN OUTCOME MEASURE(S)

Effects on parameters in the clotting cascade at baseline and after 24 weeks of treatment.

RESULT(S)

After 6 months, fibrinogen, lipoprotein (a), and factor VIIa were decreased, and activated partial thromboplastin time was increased significantly in the ET group compared with in the placebo group. However, tibolone significantly decreased only the serum levels of factor VIIa and factor IX and prolonged the activated partial thromboplastin time, compared with placebo group. In addition, conjugated ET caused a significantly greater decrease in serum fibrinogen level than did tibolone.

CONCLUSION(S)

Neither E nor tibolone therapy led to activation of coagulation in the surgically menopausal women. Both preparations changed the overall hemostatic balance to a more fibrinolytic state.

Meta-analysis: effect of hormone-replacement therapy on components of the metabolic syndrome in postmenopausal women

AIM

To quantify the effects of hormone-replacement therapy (HRT) on components of the metabolic syndrome in postmenopausal women.

METHODS

Comprehensive searches of electronic databases were performed from April 1966 to October 2004. We included randomized controlled trials that were of at least 8 weeks duration and evaluated the effect of HRT on metabolic, inflammatory or thrombotic components. Insulin resistance was calculated by homeostasis model assessment (HOMA-IR). Subgroup analysis evaluated the effects for transdermal and oral treatment and for diabetic and non-diabetic women.

RESULTS

Pooled results of 107 trials showed that HRT reduced abdominal fat [-6.8% (CI, -11.8 to -1.9%)], HOMA-IR [-12.9% (CI, -17.1 to -8.6%)] and new-onset diabetes [relative risk 0.7 (CI, 0.6-0.9)] in women without diabetes. In women with diabetes, HRT reduced fasting glucose [-11.5% (CI, -18.0 to -5.1%)] and HOMA-IR [-35.8% (CI, -51.7 to -19.8%)]. HRT also reduced low-density lipoprotein/high-density lipoprotein cholesterol ratio [-15.7% (CI, -18.0 to -13.5%)], lipoprotein(a) [Lp(a)] [-25.0% [CI, -32.9 to -17.1%)], mean blood pressure [-1.7% (CI, -2.9 to -0.5%)], E-selectin [-17.3% (CI, -22.4 to -12.1%)], fibrinogen [-5.5% (CI, -7.8 to -3.2%)] and plasminogen activator inhibitor-1 [-25.1% (CI, -33.6 to -15.5%)]. Oral agents produced larger beneficial effects than transdermal agents, but increased C-reactive protein (CRP) [37.6% (CI, 17.4-61.3%)] and decreased protein S [-8.6% CI, -13.1 to -4.1%)], while transdermal agents had no effect.

CONCLUSIONS

HRT reduces abdominal obesity, insulin resistance, new-onset diabetes, lipids, blood pressure, adhesion molecules and procoagulant factors in women without diabetes and reduced insulin resistance and fasting glucose in women with diabetes. Oral agents adversely affected CRP and protein S, while transdermal agents had no effects.

[Effects of transdermic estrogen therapy, isolated or in association with micronized progesterone, on clotting factors in overweight or normal postmenopausal women]

To evaluate HRT action over hemostasis we treated 45 postmenopausal women, divided in: Group 1 (N= 22, hysterectomized) and Group 2 (N= 23, with uterus), at the average age of 51.6 years and average BMI of 27.1 kg/m(2), with no significant difference in the base-line, with 17beta-oestradiol, 50 mcg/day, transdermic and continuous (group 1) associated to micronized progesterone 200 mg 12 days per month (group 2). The average of 2 samples of TAP, PTT, fibrinogen and platelet number was measured monthly during 3 months. For the total sample, there was a PTT shortening along treatment, from the second evaluation on (p= 0.006). Fibrinogen in Group 2 was significantly higher than in Group 1, from the second evaluation on (p= 0.0005). Patients with BMI > 25 presented a greater TAP shortening (p= 0.040) and a smaller fibrinogen drop (p= 0.033) than patients with BMI < 25. Prothrombotic effects predominated, especially in overweight women and in those who used progesterone.

Transdermal estradiol does not impair hemostatic biomarkers in postmenopausal women

OBJECTIVE

To evaluate the effect of transdermal estradiol therapy (ET) on coagulation and fibrinolysis markers in postmenopausal women.

METHODS

Prospective open trial study in 59 healthy hysterectomized postmenopausal women. Thirty women received transdermal ET (50 microg per day) during 3 months and 29 women formed the untreated arm.

RESULTS

Baseline factor VII-tissue factor complex (VIIa-rTF), fibrinogen and plasminogen activator inhibitor-1 (PAI-1) levels decreased significantly (P < 0.01) after therapy. In contrast, tissue-type plasminogen activator antigen (t-PA) levels increased significantly (P < 0.01). After ET, there was no difference in protein C activity (PC), protein S activity (PS), plasminogen (PLG), and antithrombin III (ATIII) levels. None of participants reported thromboembolic events.

CONCLUSION

ET elicited a decrement in blood biomarkers implicated in coagulation activation which in turn seemed to improve fibrinolytic activity. These results suggest that transdermal route does not impair thrombotic risk.

Mortality associated with hormone replacement therapy in younger and older women: a meta-analysis

OBJECTIVE

To assess mortality associated with hormone replacement in younger and older postmenopausal women.

DESIGN

A comprehensive search of MEDLINE, CINAHL, and EMBASE databases was performed to identify randomized controlled trials of hormone replacement therapy from 1966 to September 2002. The search was augmented by scanning selected journals through April 2003 and references of identified articles. Randomized trials of greater than 6 months' duration were included if they compared hormone replacement with placebo or no treatment, and reported at least 1 death.

MEASUREMENTS

Outcomes measured were total deaths and deaths due to cardiovascular disease, cancer, or other causes. Odds ratios (OR) for total and cause-specific mortality were reported separately for trials with mean age of participants less than and greater than 60 years at baseline.

MAIN RESULTS

Pooled data from 30 trials with 26,708 participants showed that the OR for total mortality associated with hormone replacement was 0.98 (95% confidence interval [CI], 0.87 to 1.12). Hormone replacement reduced mortality in the younger age group (OR, 0.61; CI, 0.39 to 0.95), but not in the older age group (OR, 1.03; CI, 0.90 to 1.18). For all ages combined, treatment did not significantly affect the risk for cardiovascular or cancer mortality, but reduced mortality from other causes (OR, 0.67; CI, 0.51 to 0.88).

CONCLUSIONS

Hormone replacement therapy reduced total mortality in trials with mean age of participants under 60 years. No change in mortality was seen in trials with mean age over 60 years.

Effects of low-dose oral and transdermal estrogen replacement therapy on hemostatic factors in healthy postmenopausal women: A randomized placebo-controlled study

OBJECTIVE

This study was undertaken to investigate the effect of transdermal and oral estrogen replacement therapy in healthy postmenopausal women on markers of coagulation and fibrinolysis associated with coronary artery disease.

STUDY DESIGN

In a randomized, placebo-controlled, double-blind study, healthy hysterectomized postmenopausal women received daily either placebo (n=49), transdermal 17beta-estradiol (E(2)) 50 microg (tE(2) group, n=33), oral E(2) 1 mg (oE(2) group, n=37), or oral E(2) 1 mg combined with gestodene 25 microg (oE(2)+G group, n=33) for thirteen 28-day treatment cycles. Hemostatic variables were measured in blood samples collected at baseline and in cycles 4 and 13.

RESULTS

No significant changes versus baseline and placebo were found in the tE(2) group, except for plasminogen activator inhibitor type-1 (PAI-1) in cycle 13 (-32.4%, P=.01). In the oE(2) group, significant percentage changes from baseline versus placebo in cycle 13 were found in fibrinogen, -5.4% (P<.05); factor VII, -7.3% (P<.05); thrombin-antithrombin III complexes, -13.3% (P<.05); tissue-type plasminogen activator (t-PA), -17.3% (P<.001); and PAI-1, -54.3% (P<.001). In the oE(2)+G group, respective changes were factor VII, -17.6% (P<.001); t-PA, -14.5% (P=.01); PAI-1, -36.4% (P<.01); and D-dimer, +21.8% (P<.05). No significant changes were observed in prothrombin fragment 1+2 and plasmin-alpha(2)-antiplasmin complexes.

CONCLUSION

Low-dose oral estradiol therapy was associated with an increase in fibrinolysis and small decreases in procoagulant variables. Transdermal therapy had minor effects.

Hormone therapy and venous thromboembolism

Convincing data from randomized trials and observational studies have demonstrated a two- to threefold increased risk of venous thromboembolism (VTE) with the use of hormone replacement therapy (HRT) in post-menopausal women. This risk is highest in the first year of use, but an increased risk persists after the first year if HRT use is ongoing. The risk of VTE is increased for oral oestrogen alone, oral oestrogen combined with progestin and probably for transdermal HRT. There is an increase in both idiopathic and non-idiopathic VTE with HRT. Early evidence suggests an interaction of HRT with thrombophilic states such as the factor V Leiden mutation, resulting in a synergistic increase in the risk of VTE. There is also an increased risk of VTE with raloxifene and tamoxifen, but the effects of low-dose HRT and tibolone on VTE risk are less clear.

A splicing donor site point mutation in intron 6 of the plasmin inhibitor (alpha2 antiplasmin) gene with heterozygous deficiency and a bleeding tendency

A new case of familial plasmin inhibitor (alpha2 antiplasmin) deficiency is reported. The bleeding symptoms are moderate, happening after surgery or trauma or consisting of abnormal uterine bleeding induced by hormone replacement therapy. It is easily corrected with tranexamic acid. Gene sequencing makes it possible to find a splicing donor site mutation of intron 6, leading to exon 6 skipping. Neither a shortened variant nor an abnormal plasmin interaction was found in plasma by immunoblotting, and fibrin binding is unaffected. The mutation is heterozygous, associated with an intermediate decrease of both antiplasmin activity and antigen levels, and was found in four other family members out of five tested. It is different from the five mutations previously reported. At the time of diagnosis, the patient was living in Artas, France, allowing the defect to be named plasmin inhibitor (alpha2 antiplasmin) Artas.

Combined oral estradiol valerate-norethisterone treatment over 3 years in postmenopausal women: effect on lipids, coagulation factors, haematology and biochemistry

OBJECTIVE

To determine the effect of continuous estradiol valerate 2 mg and norethisterone 0.7 mg daily as hormone replacement on lipid profiles, coagulation factors, haematology and biochemistry over 3 years.

METHODS

An open label trial with 107-133 postmenopausal women assessed pre-treatment and at annual visits with extensive lipid and coagulation profiles, and observation of circulatory adverse events. Standard haematology and biochemical profiles were also analysed. Results were compared at point of entry and at 36 months.

RESULTS

Total cholesterol (TC) and HDL and LDL fractions fell significantly (P=0.0001) and there was a significant decline in favourable ratios as well as a rise in VLDL mass (P=0.0001). Lipoprotein (a) (Lp(a)) decreased significantly (P=0.0053). Fibrinogen, free protein, prothrombin time and thrombin increased (P=0.0001) while platelets and KPTT were unchanged. Protein C, antithrombin III and total protein S decreased (P=0.0001) and there was a rise in the frequency of lupus anticoagulant positivity. Significant but small changes were seen in haematology and biochemical parameters although this did not raise safety issues and their clinical significance was uncertain.

CONCLUSION

The direction of lipid and coagulation factors move in competing ways, emphasising the complexity of metabolic change and making interpretation of outcome for venous and arterial thrombosis or atherosclerosis difficult to predict. Eight patients developed thromboembolic or ischaemic events over the 3 year period of this study but these patients had lipid changes normally considered beneficial to cardiovascular disease and coagulation changes not thought to be associated with thromboembolism. Decrease in lipoprotein 'a' levels might be an indicator of long-term decreases in atherosclerotic events.

The mechanisms of thrombotic risk induced by hormone replacement therapy

OBJECTIVES

To review the available information on the action of hormones on the mechanisms involved in thrombotic risk.

RESULTS AND CONCLUSIONS

Thrombosis plays a crucial role in the genesis and progression of both coronary heart disease (CHD) and venous thromboembolic disease (VTED), the two main forms of cardiovascular disease. Two main determinants of the thromboembolic phenotype, hypercoagulable state and altered endothelium, accumulate much of the work performed on the influence of hormones on thrombosis. Information has accumulated mainly for oestrogens, but increasing evidences support a role for progestogens. The sensitivity of each of the three components of the hemostatic balance, the coagulation cascade, the anticoagulant system and fibrinolysis, to oestrogens has been widely examined in the literature. Functional tests suggest that HRT is accompanied by a procoagulant state. Much of the work has concentrated on changes induced on reputable indicators of risk for either CHD or VTED. Distinct indicators of increased coagulability, such as resistance to activated C protein, antithrombin or tissue factor pathway inhibitor have been selected for VTED, whereas factor VII, fibrinogen, and defective fibrinolysis, for CHD. Different states of genetic susceptibility have been involved in both forms of the disease. The status of health of endothelium, defines another scenario for attention in CHD. A long-term anti-atherogenic action of oestrogens, which may be associated with short-term risk in cases of atherosclerosis-induced endothelial dysfunction, may most adequately explain much of the clinical observation. In both CHD and VTED, the procoagulant changes initiate soon after HRT administration.

Effects of postmenopausal hormone replacement therapy on lipid, lipoprotein, and apolipoprotein (a) concentrations: analysis of studies published from 1974-2000

OBJECTIVE

To establish reference estimates of the effects of different hormone replacement therapy (HRT) regimens on lipid and lipoprotein levels.

DESIGN

Review and pooled analysis of prospective studies published up until the year 2000.

SETTING

Clinical trials centers, hospitals, menopause clinics.

PATIENT(S)

Healthy postmenopausal women.

INTERVENTION(S)

Estrogen alone, estrogen plus progestogen, tibolone, or raloxifene in the treatment of menopausal symptoms.

MAIN OUTCOME MEASURE(S)

Serum high- and low-density lipoprotein (HDL and LDL) cholesterol, total cholesterol, triglycerides, and lipoprotein (a).

RESULT(S)

Two-hundred forty-eight studies provided information on the effects of 42 different HRT regimens. All estrogen alone regimens raised HDL cholesterol and lowered LDL and total cholesterol. Oral estrogens raised triglycerides. Transdermal estradiol 17-beta lowered triglycerides. Progestogens had little effect on estrogen-induced reductions in LDL and total cholesterol. Estrogen-induced increases in HDL and triglycerides were opposed according to type of progestogen, in the order from least to greatest effect: dydrogesterone and medrogestone, progesterone, cyproterone acetate, medroxyprogesterone acetate, transdermal norethindrone acetate, norgestrel, and oral norethindrone acetate. Tibolone decreased HDL cholesterol and triglyceride levels. Raloxifene reduced LDL cholesterol levels. In 41 studies of 20 different formulations, HRT generally lowered lipoprotein (a).

CONCLUSION(S)

Route of estrogen administration and type of progestogen determined differential effects of HRT on lipid and lipoprotein levels. Future work will focus on the interpretation of the clinical significance of these changes.

Hormone replacement therapy in healthy postmenopausal women: a randomized, placebo-controlled study of effects on coagulation and fibrinolytic factors

OBJECTIVES

To evaluate effects of postmenopausal hormone replacement therapy (HRT) on von Willebrand factor, factor (F)VIII, factor (F)VII, fibrinogen, antithrombin (AT) III, prothrombin fragments 1 and 2, protein C, total and free protein S, plasminogen activator inhibitor-1 (PAI-1), tissue plasminogen activator (tPA) and resistance to activated protein C.

DESIGN

Part 1: double blind randomized trial for 3 months. Part 2: open study for 9 months.

SETTING

Department of Endocrinology, University Hospital, Malmö, Sweden.

SUBJECTS

Fifty-one postmenopausal women with a history of amenorrhoea of at least 6 months and body mass index > or = 24 kg m-2 participated in part 1 and 46 participated in part 2.

INTERVENTION

Randomization for placebo (n=24) or HRT (n=27). HRT was given as 2 mg oestradiol valerate for the first 3 months, with the addition of 10 mg medroxyprogesterone for 10 days every third month thereafter.

MEASUREMENTS

At baseline and after 3 and 12 months.

RESULTS

During 0-3 months in the HRT group, FVII increased (P < 0.01), whereas fibrinogen, AT III and total protein S all decreased (P < 0.001 for all). Changes in variables were expressed as Delta-values. After 3 months Delta-values differed between groups for fibrinogen (P < 0.05), AT III (P < 0.001), total protein S (P < 0.001), and PAI-1 (P < 0.001). During 0-12 months, fibrinogen, total protein S, tPA (P < 0.01 for all) and AT III (P < 0.05) decreased. In the control group, all variables were unchanged during the study, except for increases (P < 0.05) in total protein S after 3 and 12 months, and a decrease (P < 0.01) in FVIII after 12 months. After 12 months Delta-values differed for fibrinogen (P < 0.05), AT III (P < 0.05) and total protein S (P < 0.001).

CONCLUSIONS

Unopposed oestrogen substitution was associated with both potentially beneficial effects, such as decreases in fibrinogen, and potentially thrombogenic effects such as decreasing AT III and protein S and increasing FVII. During prolonged follow-up and addition of progesterone, differences between groups concerning FVII were attenuated. These data suggest that effects of HRT upon coagulation are most pronounced early after institution of unopposed treatment.

Fibrinogen fractions in the third trimester of pregnancy and in puerperium

The concentration of fibrinogen, its fractions, and the concentration of C-reactive protein were determined in 45 healthy pregnant women before and after vaginal (27) or caesarean section 18 delivery. The control group consisted of 33 blood donors. In pregnancy, increased concentration of total fibrinogen and its fractions and a normal concentration of C-reactive protein were noted. Three days after vaginal delivery the concentration of total and high molecular weight fibrinogen fraction decreased slightly and the ratio of high to low molecular weight fibrinogen increased. After caesarean section both total and high molecular weight fibrinogen and the ratio of high to low molecular weight fibrinogen increased. The C-reactive protein concentration increased after either type of delivery. The degree of augmentation, however, was ten times as strong after caesarean section. In all women at the end of puerperium the concentrations of the compounds studied returned to normal values. The results suggest that the mechanisms leading to the increase of fibrinogen during pregnancy and after delivery are different. The increase of all fibrinogen fractions in pregnancy may depend first of all on hormones, whereas the increased proportion of high molecular weight to low molecular weight fibrinogen after delivery depends on the acute phase reaction. The degree of this reaction depends on the type of delivery.

Determinants of chronic venous disease after acute deep venous thrombosis

PURPOSE

The purpose of this investigation was to evaluate the relationship between the presenting features of an acute deep venous thrombosis (DVT), the subsequent natural history of the thrombus, and the ultimate outcome as defined according to the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery reporting standards in venous disease.

METHODS

Patients with an acute DVT were followed with serial clinical and ultrasound examinations. Thrombus extent within 7 venous segments was scored retrospectively according to the reporting standards (scores ranged from 0 to 3), and segmental reflux was scored as present (1) or not present (0). The initial and final thrombus scores, the rates of recanalization and rethrombosis, and the total reflux scores were then calculated from these grading scales and related to ultimate chronic venous disease (CVD) classification.

RESULTS

Sixty-eight patients with an acute DVT in 73 limbs were followed for 18 to 110 months (mean, 55 +/- 26 months). At the completion of the follow-up period, 20 extremities (27%) were asymptomatic (class 0), 13 (18%) had pain or prominent superficial veins (class 1), 25 (34%) had manifested edema (class 3), 13 (18%) had developed hyperpigmentation (class 4), and 2 (3%) had developed ulceration (class 5). In a univariate analysis, CVD classification was correlated with the reflux score (P =.003) but not with the initial or final thrombus score or with the rate of recanalization or rethrombosis. In a multivariate model of features documented at presentation, only the tibial thrombosis score was a significant predictor of CVD classification (R2 =.06). Outcome was better predicted (R2 =.29) with a model that included variables defined during follow-up the final reflux score, the final popliteal score, and the rate of recanalization.

CONCLUSION

The ability to predict the severity of CVD after an acute DVT is currently limited, although the natural history appears more important than the presenting features of the event. The extent of reflux, the presence of persistent popliteal obstruction, and the rate of recanalization are related to ultimate CVD classification, but other determinants remain to be identified.

Wellness in women after 40 years of age: the role of sex hormones and pheromones

In the past twenty years hundreds of peer-reviewed studies have provided a significant body of information to guide the health care of women in the second halves of their lives. The harmonic nature of the fertile reproductive system forms the background against which hormonal replacement therapy can be understood to best serve women. In addition, the 1986 discovery of human pheromones and the subsequent 1998 confirmation of their existence increases certain sexual options for maturing women. Not all hormonal replacement therapies and wellness regimens serve women well. Some regimens have the potential to produce disease, especially over-the-counter remedies like dehydroepiandrosterone and the formulas that contain estrogen. Some regimens profoundly improve the quality of life of many women; some women do not need or want such regimens. All sex hormones affect physiologic systems including the cardiovascular system, bone metabolism, cognitive function, sexual response, and sexual attractiveness. The 7 years before menopause have recently been revealed to be an extremely complex era. During this period, some women increase their estrogen levels to new lifetime highs; others start an unequivocal decline, and still others vary from month to month. Coupled to this variability in estrogen is an equally variable set of changes in progesterone secretion by the ovary as androgen secretion patterns also change. Many women show increases in circulating androgens while many others show deficiencies. Both the adrenal and the ovarian sources of these hormones show age-related changes that alter a woman's capacity to attract sexual attention through both her physical appearance (and condition) and her pheromonal excretions. The complex contributions to the overall health of a woman may not always be understood. Often a hysterectomy can exacerbate--rather than ameliorate--the conditions that led to the surgery. One in 2 American women is offered a hysterectomy, a rate 5 times higher than that of the European countries for which data are available. Ninety percent of hysterectomies are not related to cancer; they are elective procedures. Avoidance of elective hysterectomy helps prevent its side effects: sexual deficits, acceleration of cardiovascular and bone disease, and more rapid aging. No efficacy data exist that suggest that elective hysterectomy works better than the alternative approaches that do not induce these side effects. The health and well-being of women who have already had hysterectomies, with or without ovariectomies, can be improved by a recognition of the cascade of difficulties that must addressed. Estrogen, progesterone, and androgens all tend to be compromised by hysterectomy; all should be considered for replacement. Because hormonal regimens can be prescribed to enhance the quality of life, the review of the available research can allow the medical art to greatly benefit mature women. Not surprisingly, the emerging conclusion reveals that structurally human hormones, prescribed appropriately, almost always best serve the patient.