Perspectives in hormone replacement therapy

Menopausal Hormone Therapy: Current Considerations

Menopausal hormone therapy (MHT) is the most effective treatment for vasomotor and vaginal symptoms. Today, symptomatic women younger than 60 years of age or less than 10 years since onset of menopause yield the greatest benefit of MHT with the lowest risks when compared with older women remote from menopause. Careful assessment before initiating therapy includes severity of bothersome symptoms, treatment preferences, medical history, presence of contraindications to MHT, and personal risk of cardiovascular disease and breast cancer. Considerations of type of MHT, dosing, and route of administration, and recommendations regarding duration of therapy are discussed.

Structure-based approach for the study of estrogen receptor binding affinity and subtype selectivity

Estrogens exert important physiological effects through the modulation of two human estrogen receptor (hER) subtypes, alpha (hERalpha) and beta (hERbeta). Because the levels and relative proportion of hERalpha and hERbeta differ significantly in different target cells, selective hER ligands could target specific tissues or pathways regulated by one receptor subtype without affecting the other. To understand the structural and chemical basis by which small molecule modulators are able to discriminate between the two subtypes, we have applied three-dimensional target-based approaches employing a series of potent hER-ligands. Comparative molecular field analysis (CoMFA) studies were applied to a data set of 81 hER modulators, for which binding affinity values were collected for both hERalpha and hERbeta. Significant statistical coefficients were obtained (hERalpha, q(2) = 0.76; hERbeta, q(2) = 0.70), indicating the internal consistency of the models. The generated models were validated using external test sets, and the predicted values were in good agreement with the experimental results. Five hER crystal structures were used in GRID/PCA investigations to generate molecular interaction fields (MIF) maps. hERalpha and hERbeta were separated using one factor. The resulting 3D information was integrated with the aim of revealing the most relevant structural features involved in hER subtype selectivity. The final QSAR and GRID/PCA models and the information gathered from 3D contour maps should be useful for the design of novel hER modulators with improved selectivity.

Quantitative structure-activity relationships for a series of selective estrogen receptor-beta modulators

The estrogen receptor-beta subtype (ERbeta) is an attractive drug target for the development of novel therapeutic agents for hormone replacement therapy. Hologram quantitative structure-activity relationships (HQSAR) were conducted on a series of 6-phenylnaphthalene and 2-phenylquinoline derivatives, employing values of ERbeta binding affinity. A training set of 65 compounds served to derive the models. The best statistical HQSAR model (q(2) = 0.73 and r(2) = 0.91) was generated using atoms, bonds, connections and donor and acceptor as fragment distinction parameters, and fragment size default (4-7) with hologram length of 199. The model was used to predict the binding affinity of an external test set of 16 compounds, and the predicted values were in good agreement with the experimental results. The final HQSAR model and the information obtained from 2D contribution maps should be useful for the design of novel ERbeta modulators having improved affinity.

Hormone therapy and raloxifene reduce the coagulation inhibitor potential

The coagulation inhibitor potential (CIP) assay may detect major thrombophilia at a sensitivity of 100% and a specificity of 70-80%. Subnormal CIP might be associated with increased risk of thrombosis. This study compared the effect on CIP in plasma samples from postmenopausal women treated with four different regimens. Fibrin aggregation in plasma was monitored after activation with tissue factor. The effect of potentiated inhibition of coagulation was measured. Plasma samples from 202 healthy women randomly assigned to receive treatment for 12 weeks with conventional-dose or low-dose hormone therapy, raloxifene or tibolone were examined. Major thrombophilias were excluded. Compared with baseline, the median level in CIP was reduced by 64% in the conventional-dose group, by 38% in the low-dose group and by 31% in the raloxifene group, whereas for those treated with tibolone the median CIP increased by 9%. The median changes in CIP were significant for both hormone therapy groups (P < 0.0001) and for the raloxifene group (P = 0.003), but not for the tibolone group (P = 0.653). The 12 women with heterozygous factor V Leiden mutation had a significantly reduced median CIP level (P < 0.0001) at baseline. Hormone therapy and raloxifene, associated with venous thromboembolism, reduce the CIP. Tibolone does not reduce the CIP.

Exploring the continuum: medical information to effective clinical practice. Paper I: the translation of knowledge into clinical practice

This paper investigates the translation of medical information into clinical practice and the role of thoughtful dissent by exploring the influence of sociological factors on change, the impact of evidence-based medicine (EBM), and the role of industry. Changing practice related to hormone therapy for menopausal and post-menopausal women provides context for this discussion. Medical change involves diffusion of ideas to potential users and ongoing reconciliation of new information with old ideas; this process is influenced by sociological factors including values and experiences, interpersonal relationships and local context. While EBM has alerted doctors to the importance of high quality research and theoretically provides a tool for translating research into practice, there are important problems with its application: (1) it has resulted in a reductionist approach to research and illness; (2) there is a considerable gap between research findings and the complex environment of clinical practice; and (3) EBM has been appropriated by experts, thus corporately developed 'standard-of-care' documents have become instruments of external regulation, and EBM has ceased to be a tool in the hand of individual clinicians. In addition, industry impacts the translation of knowledge by significantly influencing academia, researchers, medical publications, consensus conferences, and practising doctors. While questioning doctrinaire practices or directives is a daunting prospect for individual clinicians, the translation of knowledge into practice and evolution of medical thought is dependent on the progressive role of thoughtful dissent.

Effects of endogenous sex hormones on the periodontium--review of literature

Hormones are specific regulatory molecules that have potent effects on the major determinants of the development and the integrity of the skeleton and oral cavity including periodontal tissues. It is clear that periodontal manifestations occur when an imbalance of these steroid hormones take place. The authors conducted a Medline search up to 2004 and in addition, a manual search was also performed including bibliographies of relevant papers, review articles and books. This review focuses on the effects of endogenous sex hormones on the periodontium and the goal was to inform and update practitioners' knowledge about the impact of these hormones on periodontal status. In addition, this review article will analyze how these hormones influence the periodontium at different life stages such as puberty, menstruation, pregnancy, menopause and post-menopause. Moreover, the effects of contraceptives and hormone replacement therapies on the periodontium will be discussed. It is clear that endogenous sex steroid hormones play significant roles in modulating the periodontal tissue responses. A better understanding of the periodontal changes to varying hormonal levels throughout life can help the dental practitioner in diagnosis and treatment.

The effect of education and counseling services on compliance to therapy of women taking hormone therapy for the first time

OBJECTIVE

The purpose of this experimental research was to examine the effect of hormone therapy (HT)-related education and counseling on compliance.

DESIGN

The 119 women in both the experimental and the control group were being seen in a referral maternity and women's health teaching hospital's menopause outpatient clinic. Similarity between experimental and control groups was ensured using one-to-one pairing. The data were collected using a questionnaire and a follow-up form. The experimental group was given group education and an educational booklet on the first day they began therapy and counseling in the third and sixth months of therapy. The control group was not given counseling or education. Chi-square was used in data evaluation.

RESULTS

There was no difference between the groups at the third month for those who were continuing HT (P > 0.05), but at the sixth month a significant difference was found (P < 0.05). The primary reason for stopping HT at the third month in the experimental group was fear of cancer and in the control group it was the side effects of HT. At 6 months, the primary reason for stopping HT in the experimental group was, again, fear of cancer but in the control group it was the woman's desire not to continue. There was no significant difference in the groups at either 3 or 6 months in experiencing benefits or side effects from HT (P > 0.05).

CONCLUSION

Education and counseling services given by nurses or other health care personnel have an effect on long-term compliance with HT.

Use of hormone replacement therapy in Italian women aged 50-70 years

OBJECTIVES

The aim of the present cross-sectional analysis was to describe patterns and determinants of use of hormone replacement therapy (HRT) in a large sample of women attending mammographic screening.

METHODS

Between 1999 and 2001, 8533 women aged 50-70 years were recruited by 11 screening centres, and structured interviews were made collecting information on socio-demographic characteristics, lifestyle habits, medical and reproductive history (overall response rate 87%).

RESULTS

Current HRT use was reported by 6.9% of women (n=585), the average duration of use being 3.5 years; 13.2% were ever HRT users. Binomial and multinomial logistic regression (MLR) analyses showed that younger age, higher educational level, past mammographic examination and history of bilateral oophorectomy were the major predictors of current and ever HRT use. Current use was also more frequently reported by women who were thinner, nulliparae, had had induced menopause, had a later onset of menopause, with history of oral contraceptive use and hysterectomy without bilateral oophorectomy. By contrast, those who were diabetics or had positive history of cardiovascular disease were less likely to be current HRT users. No differences were found in HRT use according to marital status, type of occupation, menopausal status, smoking, history of breast cancer, hypercholesterolemia, hypertension and phlebitis.

CONCLUSIONS

Our results support previous findings indicating that HRT use in Italian women is uncommon and of short duration. Current HRT users were less likely than non-users to report several characteristics associated with higher mortality and morbidity, in accordance with the healthy-user phenomenon described in other countries.

Postmenopausal hormone therapy: impact on menopause-related symptoms, chronic disease and quality of life

Quality of life in climacteric and postmenopausal women is often compromised. This overview addresses the many factors that may interfere with health and well-being in such women. Hormonal changes during the menopausal transition, finally resulting in estrogen deficiency, play a pivotal role in the incidence of climacteric symptoms and also in the development of chronic diseases. Such symptoms and diseases can contribute to impaired quality of life in climacteric and postmenopausal women. Postmenopausal hormone therapy (PHT) is the treatment of first choice to alleviate symptoms of estrogen deficiency. Besides effectively relieving climacteric symptoms and complaints, PHT can also protect against some chronic diseases, such as osteoporosis and colorectal cancer. Presently, available PHTs vary widely in type, estrogen and progestogen dosage, and route and duration of administration. Furthermore, the number of alternatives to treat climacteric symptoms, and/or to prevent chronic diseases, has increased. Therefore, doctors involved in the care of climacteric women in the 21st century are much more able to meet the specific needs of individual patients and improve health and quality of life.

Side-effects of hormone replacement therapy and influence on pattern of use among women aged 45-64 years. The Norwegian Women and Cancer (NOWAC) study 1997

BACKGROUND

Use of hormone replacement therapy (HRT) increased considerably in Norway during the 1990s. The aim of this study was to investigate reasons for starting and discontinuing HRT use and examine the prevalence of side-effects and what impact they had on pattern of use.

METHODS

The Norwegian Woman and Cancer (NOWAC) study is a population-based, prospective study based on mailed questionnaires to women 30-70 years. This report is limited to a random sample of 4996 Norwegian women aged 45-64 years who participated in 1997 (response rate 62%). The questionnaire included detailed questions about HRT: reasons for starting and stopping, type of preparation, duration of use and side-effects experienced.

RESULTS

Most women started HRT to ameliorate climacteric complaints (75.9%). Only 8.7% had prevention of osteoporosis as the only reason for therapy. Mean duration of use was 4.9 years among current users. Side-effects were reported by 43% of the ever users, nearly half of them reporting more than one side-effect. Weight gain was the most frequent stated side-effect (56.3%), although not statistically significant in association with HRT. Among ever users 28.2% discontinued therapy, more than half of them because of side-effects.

CONCLUSIONS

The women's primary reason for starting HRT was climacteric complaints. Side-effects were common and constituted the major reason for discontinuation of therapy. The women perceived weight gain as a side-effect.

[Impact of HRT on the arterial carotid vascular tree]

Hormone replacement therapy (HRT) and arterial impact, this is a controversial subject since it is a large field that needs weeding, a theme in which new questions are raised by the cross-results of various studies conducted, and in which doubt is perhaps one of, or even the only, certitude that all the various specialists agree on. In this controversial climate, we feel that three important points should be underlined: the American studies, however reliable they may be, have been conducted with conjugated estrogens and the generalisation to the results of other types of hormones such as those prescribed in Europe is perhaps a little hasty; other factors of risk should be taken into consideration in the eventual potentialisation of the risk induced by such treatment; the venous and arterial vascular risks are not based on the same physiopathological mechanisms. Hence the increased risk in one or the other network system should perhaps not be amalgamated either.

Veralipride administered in combination with raloxifene decreases hot flushes and improves bone density in early postmenopausal women

We evaluated the administration of raloxifene and veralipride in postmenopausal women with high osteoporosis risk and hot flushes in whom hormone replacement therapy (HRT) was contraindicated. A group of early postmenopausal women (n = 29) (mean age 51.8 +/- 4.1), complaining of severe vasomotor symptoms and with a bone mineral density (BMD) T-score between -1.5 and -2.5 were evaluated. They were randomly assigned to two treatment groups: raloxfene (60 mg/day) continuously in association with veralipride (100 mg/day) on alternate days (n = 17); or on alternate months (n = 12). BMD, serum prolactin concentration and endometrial thickness were assessed at baseline and after 6 months of therapy. Kupperman Index and hot flushes were assessed before and after 3 and 6 months of therapy. BMD was significantly higher at the end of therapy with an increase of 1.1%. Kupperman Index was significantly reduced after 3 months and a further decrease at 6 months was observed with both protocols. Both treatments led to a significant reduction of hot flushes after 3 and 6 months. No signifcant changes of prolactin levels were observed in either protocol. We found that the combined raloxifene-veralipride treatment, both every other day and every other month, led to a significant improvement in bone density and was effective in hot flushes and other menopause-associated symptoms. These protocols could represent a new way to administer raloxifene in early postmenopausal women at high osteoporosis risk with HRT contraindication.

Hormone replacement therapy and risk of malignancy

PURPOSE OF REVIEW

The fact that today our concern is oriented towards the risks rather than the benefits of hormone replacement therapy could be the clearest message about our current position. The safety of hormone replacement therapy, an estrogen-progestin combination which has been sympathetic to and supportive of disturbing menopausal symptoms of women, is seriously challenged.

RECENT FINDINGS

Four randomized trials have now reported on the results of hormone replacement therapy in major potentially fatal conditions, in more than 20,000 women studied for about 5 years. The main concern regarding the increased risk of malignancy in healthy postmenopausal women in western countries has been breast cancer. It is estimated to cause an extra case in about six per 1000 users aged 50-59 and 12 per 1000 aged 60-69. Over the same period the estimated risk of endometrial cancer rates are not increased, with a relative risk of 0.76 per 1000 users aged 50-59. Overall, however, the increased incidence of malignancies is greater than any reduction, one per 230 users aged 50-59 and one per 150 aged 60-69. Randomized trials examining other important but rarer malignancies, like ovarian, gall bladder and urinary bladder cancer, are either nonexistent or too small to reliably describe any effects of hormone replacement therapy.

SUMMARY

Conclusively epidemiological evidence suggests that hormone replacement therapy is associated with a small but substantial increase in breast cancer risk and combined estrogen-progesterone regimens further increase this hazard. Additionally, the evidence from the recent double blind placebo controlled randomized trial on the slight increase in the incidence of adverse cardiovascular events, has turned our orientation away from hormone replacement therapy as a long term therapy in postmenopausal women. In this review, the effort is to approach comprehensively and globally the information on the risks of hormone replacement therapy on several cancer sites.

Influence of sex hormones on the periodontium

OBJECTIVES

Sex hormones have long been considered to play an influential role on periodontal tissues, bone turnover rate, wound healing and periodontal disease progression. The objectives of this review article are to (1) address the link between sex hormones and the periodontium, (2) analyse how these hormones influence the periodontium at different life times and (3) discuss the effects of hormone supplements/replacement on the periodontium.

MATERIALS AND METHODS

Two autonomous searches were performed in English language utilizing Medline, Premedline and Pubmed as the online databases. Publications up to 2002 were selected and further reviewed. In addition, a manual search was also performed including specific related journals and books.

RESULTS

It is certain that sexual hormones play a key role in periodontal disease progression and wound healing. More specifically, these effects seem to differentiate by gender as well as lifetime period. In addition, the influence of sex hormones can be minimized with good plaque control and with hormone replacement.

CONCLUSION

Despite profound research linking periodontal condition with sex hormones kinetics, more definitive molecular mechanisms and therapy still remain to be determined.

Hormonal replacement therapy in an animal model with chronic renal failure and ovariectomy: biochemical and densitometric study

BACKGROUND

In spite of estrogen replacement therapy being extensively used in clinical and experimental studies without renal impairment, there are no long-term studies concerning estrogen replacement in chronic renal failure.

METHODS

In this experimental study, six groups of nephrectomized and ovariectomized animals were treated with different doses of 17beta-estradiol, alone or in combination with calcitriol, to evaluate the effect of these treatments on bone metabolism.

RESULTS

Biochemical results showed that estrogen alone did not have any effect neither on calcium nor on PTH serum levels. By contrast, in the groups treated with calcitriol, the levels of serum calcium were significantly higher, and the levels of iPTH were significantly lower than those observed in the control group. Animals receiving the combined treatment with estrogen and calcitriol showed the greater gain in uterus weight and a better bone mineral density at the lumbar site and the proximal and distal tibia sites.

CONCLUSION

The combination of estrogen and calcitriol is the most effective therapy to prevent bone mass loss in animals with chronic renal failure and estrogen deprivation.

Compliance with hormone replacement therapy in Thai women

A retrospective study was performed to determine the compliance of hormone replacement therapy (HRT), the characteristics of women who continue to use HRT and the reasons for discontinuation. This study comprised of 821 postmenopausal women who attended the menopause clinic between January 1993 and December 1997. A total of 613 women (74.67%) were considered to be good compliant users. They had been on HRT for at least 1 year. Two hundred and eight women (25.33%) discontinued the treatment, with an average of 5.1 months duration of use. The younger age group at time of consultation and at menopause and those with previous hysterectomy were factors associated with higher degree of compliance. Its compliance decreased with age and the duration of menopause. The common reasons in the women's decision to discontinue HRT were bleeding episodes (23.08%), undesirable side effects (15.05%) and on physicians' advice (13.46%), respectively. Compliance with HRT appears to be similar to that reported in other specialist centres. Factors affecting compliance were age, age at menopause, duration of menopause, and hysterectomy. Irregular vaginal bleeding was the major reason for discontinuation.

Selective modulation of postmenopausal women: cutting the Gordian knot of hormone replacement therapy with breast carcinoma

BACKGROUND

Hormone replacement therapy (HRT) has proven and presumable benefits for women desiring postmenopausal health preservation. Among HRT-associated risks, the fear of breast carcinoma intimidates women and physicians contemplating hormonal treatment and limits long-term compliance. Identifying effective alternative medications that are not associated with breast carcinoma or that even may prevent its development would be a major advance.

METHODS

This article discusses the clinical perspective of HRT and selective estrogen receptor modulators (SERMs) in light of the molecular and cellular mechanisms of estrogen and progesterone action on the breast. Emphasis is placed on the potential of selective receptor modulation as the future of postmenopausal treatment.

RESULTS

Current epidemiologic evidence suggests that HRT is associated with a small but substantial increase in the risk of breast carcinoma, and combined estrogen-progesterone regimens further increase this hazard. Ample biologic data support this clinical association and propose multiple molecular mechanisms for the effects of estrogen and progesterone on breast cells. SERMs are a novel class of drugs that demonstrate estrogen agonistic and antagonistic actions in a tissue specific manner. SERMs act by binding the estrogen receptor and selectively modulating its effect on gene transcription at target tissues.

CONCLUSIONS

SERMs offer an alternative to HRT that can successfully circumvent the intimidating side-effect of breast carcinoma. Further insight into the molecular mechanisms of SERM action may enable the development of agents with improved target-tissue selectivity. Identifying selective modulators with unique pharmacologic properties would facilitate the creation of individualized treatment for the postmenopausal woman according to her particular predisposition for menopause-related morbidities and her overall clinical profile.

Intranasal hormone replacement therapy

Although the optimal route of delivery for hormone replacement therapy has not yet been determined, desirable qualities would include good efficacy, easy administration, minimal side effects, and optimal therapeutic profile. This would potentially serve to improve patient compliance and satisfaction. The intranasal route has been evaluated for the administration of menopausal hormones and seems to fulfill these requirements. The intranasal route would also seem to be a viable alternative for drugs that are poorly absorbed after ingestion by avoiding hepatic first-pass elimination. The intranasal route is, therefore, innovative for the delivery of natural sex steroids in postmenopausal women receiving hormone replacement therapy. Early studies demonstrate that it is safe, effective, and acceptable to postmenopausal women. In addition, the nasal administration of a combination of estradiol and progesterone would seem to be an attractive way to deliver hormones to nonhysterectomized postmenopausal women. Providing alternative routes of administration may also enhance compliance.

Commuting the death sentence: how oocytes strive to survive

Programmed cell death claims up to 99.9% of the cells in the mammalian female germ line, which eventually drives irreversible infertility and ovarian failure - the menopause in humans. New insights into the mechanisms that underlie germ-cell apoptosis have been provided by the study of oocyte death in lower organisms and in genetically manipulated mice that lack apoptosis-regulatory proteins. With new therapeutic tools to control fertility, oocyte quality and ovarian lifespan on the horizon, understanding how and why the female body creates, only to delete, so many germ cells is imperative.