Impaired ovarian function and risk factors for atherosclerosis in premenopausal women

Relative energy deficiency in sports (RED-S): elucidation of endocrine changes affecting the health of males and females

The purpose of this review is to present a different perspective of the relative energy deficiency syndrome, to improve understanding of associated endocrine alterations, and to highlight the need for further research in this area. The term "female athlete triad" was coined over 25 years ago to describe three interrelated components: disordered eating, menstrual dysfunction, and low bone mass. The syndrome's etiology is attributed to energy intake deficiency relative to energy expenditure required for health, function, and daily living. Recently, it became clear that there was a need to broaden the term, as the disorder is not an issue of only three interrelated problems but of a whole spectrum of insults resulting from low energy availability (LEA; i.e., insufficient energy availability to cover basic physiological demands) that can potentially affect any exerciser, irrespective of gender. The new model, termed relative energy deficiency in sport (RED-S), has received greater scrutiny in sports medicine due to its effects on both health and performance in athletes of both sexes. RED-S results from low-energy diets (intentional or unintentional) and/or excessive exercise. Energy deficiency reduces hypothalamic pulsatile release of gonadotropin-releasing hormone, this impairing anterior pituitary release of gonadotropins. In women, reduced FSH and LH pulsatility produces hypoestrogenism, causing functional hypothalamic amenorrhea and decreased bone mass. In men, it reduces testosterone and negatively affects bone health. Moreover, LEA alters other hormonal pathways, causing physiological consequences, such as alteration of the thyroid hormone signaling pathways, leptin levels, carbohydrate metabolism, the growth hormone/insulin-like growth factor-1 axis, and sympathetic/parasympathetic tone. This review explains and clarifies the effects of RED-S in both sexes.

Indazole-Cl inhibits hypoxia-induced cyclooxygenase-2 expression in vascular smooth muscle cells

Atherosclerosis is the most common root cause of arterial disease, such as coronary artery disease and carotid artery disease. Hypoxia is associated with the formation of macrophages and increased inflammation and is known to be present in lesions of atherosclerotic. Vascular smooth muscle cells (VSMCs) are one of the major components of blood vessels, and hypoxic conditions affect VSMC inflammation, proliferation and migration, which contribute to vascular stenosis and play a major role in the atherosclerotic process. Estrogen receptor (ER)-β is thought to play an important role in preventing the inflammatory response in VSMCs. In this report, we studied the anti-inflammatory effect of indazole (In)-Cl, an ERβ-specific agonist, under conditions of hypoxia. Expression of cyclooxygenase-2 reduced by hypoxia was inhibited by In-Cl treatment in VSMCs, and this effect was antagonized by an anti-estrogen compound. Additionally, the production of reactive oxygen species induced under conditions of hypoxia was reduced by treatment with In-Cl. Increased cell migration and invasion by hypoxia were also dramatically decreased following treatment with In-Cl. The increase in cell proliferation following treatment with platelet-derived growth factor was attenuated by In-Cl in VSMCs. RNA sequencing analysis was performed to identify changes in inflammation-related genes following In-Cl treatment in the hypoxic state. Our results suggest that ERβ is a potential therapeutic target for the suppression of hypoxia-induced inflammation in VSMCs.

Hypothalamic Amenorrhea and the Long-Term Health Consequences

The menstrual cycle is a reproductive vital sign and provides insight into hormonal imbalance as well as pregnancy. The significance of estrogen, however, extends beyond fertility and plays a role on tissues and organs throughout the body. Functional hypothalamic amenorrhea is a common form of secondary amenorrhea resulting in estrogen deficiency in young premenopausal women. While reversible, the cause of this disorder is related to psychological stress, excessive exercise, disordered eating or a combination of these factors resulting in suppression of the hypothalamic–pituitary–ovarian axis. The resulting loss of estrogen has profound effects on many systems throughout the body including cardiac, skeletal, psychological and reproductive. Often, these young women are the ‘walking well’ as they do not have bothersome symptoms of low estrogen and are unaware of the consequences of estrogen deficiency. This review focuses on the health consequences of hypothalamic amenorrhea, current research and available treatment options.

Does accelerated reproductive aging underlie premenopausal risk for cardiovascular disease?

OBJECTIVE

The menopausal transition is associated with an increase in risk for cardiovascular disease; however, whether variability in reproductive aging relates to cardiovascular risk factors in the premenopausal period has not been studied.

METHODS

In a multiethnic sample of 951 healthy, regularly cycling women aged 25 to 45 years (mean [SD] age, 35.2 [5.5] y), we examined antimüllerian hormone (AMH), a validated marker of ovarian reserve, in relation to the overall number of cardiometabolic risk factors, calculated as the sum of the five components of metabolic syndrome (triglycerides ≥150 mg/dL; high-density lipoprotein <50 mg/dL; homeostasis model assessment of insulin resistance ≥2.6; waist circumference equal to or higher than race-specific cutoff; and hypertensive [vs normotensive] status), and in relation to each of these risk factors individually.

RESULTS

In age-adjusted models, results showed that the number of cardiometabolic risk factors was 52.1% higher among women with low versus high AMH levels and 46.0% higher among women with mid versus high AMH levels. In addition, results showed that low and mid levels of AMH (vs high) were associated with an increase in risk with respect to high-density lipoprotein (odds ratio [OR], 1.814; 95% CI, 1.211-2.718 and OR, 1.568; 95% CI, 1.083-2.269, respectively), waist circumference (OR, 2.012; 95% CI, 1.380-2.934 and OR, 1.881; 95% CI, 1.333-2.654, respectively), and hypertensive status (OR, 2.373; 95% CI, 1.095-5.143 and OR, 2.052; 95% CI, 0.976-4.314, respectively) outcomes. Associations, however, attenuated when body mass index was covaried (Ps > 0.05).

CONCLUSIONS

Cross-sectional evidence suggests that having a greater ovarian reserve is associated with having a healthier cardiometabolic risk factor profile. Future longitudinal studies are needed to determine whether this association may be mediated by body mass index.

Disruptions in ovarian function are related to depression and cardiometabolic risk during premenopause

OBJECTIVE

The aim of this study was to evaluate the extent to which mild disruptions in ovarian function, indexed by changes in menstrual cycle length, may relate to cardiometabolic and psychological health in premenopausal women.

METHODS

Among 804 healthy, regularly cycling women (aged 25-45 y; mean [SD] age, 35.5 [5.5] y), patterns of any change (shortening, lengthening, or increased variability) versus no change in menstrual cycle length were examined in relation to a composite of cardiometabolic risk and individual risk factors (high-density lipoprotein, triglycerides, waist circumference, glucose, and hypertensive status), as well as in relation to depression indicators (Center for Epidemiological Studies Depression Scale score ≥16 [yes/no], lifetime depression diagnosis [yes/no], and lifetime antidepressant medication use [yes/no]). Models were also explored to test whether changes in menstrual cycle length mediated relations between depression history and cardiometabolic risk.

RESULTS

In covariate-adjusted models compared with no change, any change in menstrual cycle length was associated with higher cardiometabolic risk composite scores and lower high-density lipoprotein (P < 0.05). In addition, compared with no change, any change in menstrual cycle length was associated with a Center for Epidemiological Studies Depression Scale score of 16 or higher, having received a depression diagnosis, and having used antidepressant medications (P < 0.05). In exploratory analyses, any change in menstrual cycle length partially mediated the relation between depression history and cardiometabolic risk (b = 0.152, P = 0.040), which attenuated (b = 0.129, P = 0.083) when any change in menstrual cycle length was covaried.

CONCLUSIONS

Findings suggest that disruptions in ovarian function, marked by subtle changes in menstrual cycle length, may relate to aspects of cardiometabolic and psychological health among healthy, premenopausal women.

Arterial stiffness and related variables across menopausal status: an epidemiologic study

OBJECTIVES

To determine if postmenopausal women have different arterial stiffness, blood pressure (BP) values, or metabolic patterns in comparison to fertile women and to men at a population level.

METHODS

This is a population-based epidemiologic study of 1853 representative men and women aged 18-95 years. Clinostatic humeral BP was measured using Omron 705CP. Aortic BP, augmentation index (AI), and pulse wave velocity (PWV) were determined using applanation tonometry. Body mass index (BMI) and subscapular skinfold thickness were used as measures of adiposity. Fasting and postload blood glucose, homeostasis model assessment (HOMA), low-density and high-density lipoprotein serum cholesterol (LDL-C and HDL-C) and triglycerides were assessed.

RESULTS

Age was higher in postmenopausal women than in fertile women (68.8 ± 9.5 vs. 35.7 ± 10.2 years, p<0.001), and BMI was 16% higher (p<0.01) in the postmenopausal women after age adjustment. Humeral and aortic BP, carotid and radial AI, carotid-femoral PWV, BMI, LDL-C, LDL-C/HDL ratio, triglycerides, glucose tolerance, HOMA, and skinfold thickness were apparently higher in postmenopausal than in fertile women. Using multivariate analysis, however, all these differences were abolished after adjusting for confounders (age and, when appropriate, BMI), except for LDL-C, which remained 19% higher (p<0.01) in postmenopausal women than in fertile women after adjusting for many confounders (age, BMI, cholesterol, ethanol intake, caloric intake, and triiodothyronine).

CONCLUSIONS

Only LDL-C increases in postmenopausal women, whereas other differences attributed to menopause, including BP and arterial stiffness, seem to be confounding effects of age and BMI.

Pregnancy followed by delivery may affect circulating soluble lectin-like oxidized low-density lipoprotein receptor-1 levels in women of reproductive age

Background/Objective. It is known that menopause or lack of endogenous estrogen is a risk factor for endothelial dysfunction and CAD. Lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1) is involved inmultiple phases of vascular dysfunction.The purpose of the current study was to determine the association between soluble LOX-1 (sLOX-1) and pregnancy followed by delivery in women of reproductive age. Materials/Methods. Sixty-eight subjects with pregnancy followed by delivery (group 1) and 57 subjects with nongravidity (group 2) were included in this study. Levels of sLOX-1 were measured in serum by EL SA. Results. Plasma levels of sLOX-1 were significantly lower in Group 1 than Group 2 in women of reproductive age (0.52 ± 0.18 ng/mL and 0.78 ± 0.13, resp., P < 0.001). There were strong correlations between sLOX-1 levels and the number of gravida (r = −0.645, P < 0.001). The levels of sLOX-1 highly correlated with the number of parous (r = −0.683, P < 0.001). Conclusion. Our study demonstrated that serum sLOX-1 levels were associated with pregnancy followed by delivery that might predict endothelial dysfunction. We conclude that pregnancy followed by delivery may delay the beginning and progress of arteriosclerosis and its clinical manifestations in women of reproductive age.

Menopause does not affect blood pressure and risk profile, and menopausal women do not become similar to men

OBJECTIVE

Menopause is considered to be a cardiovascular risk factor, but this belief is based on opinions rather than on evidence. Confounding effects of age are often neglected.

DESIGN

Population-based study with further subanalysis of case-to-case age-matched cohorts of men and fertile and menopausal women.

SETTING

Epidemiology in primary, public, institutional frame.

PARTICIPANTS

Nine thousand three hundred and sixty-four men and women aged 18-70 years representative of Italian general population followed-up for 18.8 +/- 7.7 years.

MAIN OUTCOME MEASURES

Blood pressure (BP), prevalence and incidence of hypertension, serum total, high-density lipoprotein and low-density lipoprotein cholesterol, glucose tolerance, body adiposity, vascular reactivity, target organ damage, overall and cardiovascular mortality and morbidity, by gender and by menopausal status.

RESULTS

Cross-sectional: crude BP, pressor response to cold, orthostatic BP decrease, BMI, skinfold thickness, fasting and postload blood glucose and insulin, serum lipids, left ventricular mass, serum creatinine, microalbuminuria and augmetantion index were higher in menopausal than in fertile women, and comparable in menopausal women and men, a difference that was no longer present when adjusting for age or considering age-matched cohorts. Longitudinal: BP increase during follow-up, cardiovascular mortality and morbidity were greater in menopausal than in fertile women, and comparable in menopausal women and men, a difference no longer present in age-matched cohorts. Menopausal status was rejected from multivariate Cox analysis also including age.

CONCLUSION

The cardiovascular effects usually attributed to menopause seem to be a mere consequence of the older age of menopausal women.

Ovarian dysfunction and the premenopausal origins of coronary heart disease

OBJECTIVE

The menopausal loss of cyclic ovarian function is believed to contribute to coronary heart disease (CHD). However, ovarian function varies substantially throughout the premenopausal years, with disruptions in hormonal activity ranging from mild to profound. Here we propose our "precocious acceleration" hypothesis, which holds that to the extent cyclic ovarian function affords protection against CHD, even mild ovulatory abnormalities in young women will accelerate development of this disease.

DESIGN

Data relating to the expression and incidence of premenopausal ovarian dysfunction in women and its relationship to CHD are reviewed. Also reviewed are the results from experiments conducted with socially housed cynomolgus monkeys (Macaca fascicularis), focused on the causes, occurrence, and pathobiological sequelae of premenopausal ovarian dysfunction. The implications of the foregoing material for understanding the health of peri- and postmenopausal women are then considered.

RESULTS

Epidemiological and clinical studies indicate that common premenopausal reproductive abnormalities (manifested along a continuum from mild subclinical alterations to complete suppression) are associated with increased risk of CHD. This increased risk is probably mediated by different pathways, depending on whether the reproductive deficits relate to hypoestrogenemia (functional hypothalamic anovulatory syndrome) or hyperandrogenemia (polycystic ovary syndrome). Furthermore, although clinically obvious expressions of these syndromes affect perhaps 10% of premenopausal women, evidence suggests that a much larger number may experience subclinical dysfunction capable of increasing CHD risk.

CONCLUSIONS

Epidemiological data and systematic studies in nonhuman primates provide initial support for the precocious acceleration hypothesis, suggesting that efforts to protect the health of postmenopausal women would best begin during the premenopausal years.

Need for research on estrogen receptor function: importance for postmenopausal hormone therapy and atherosclerosis

BACKGROUND

Cardiovascular disease is the leading cause of morbidity and mortality in men and women worldwide. Although rare in premenopausal women, its incidence rises sharply after menopause, indicating atheroprotective effects of endogenous estrogens.

OBJECTIVE

This review discusses the differential effects of estrogen receptor function on atherosclerosis progression in pre- and postmenopausal women, including aspects of gender differences in vascular physiology of estrogens and androgens.

METHODS

Recent advances in the understanding of the pathogenesis of atherosclerosis, estrogen receptor function, and hormone therapy are reviewed, with particular emphasis on clinical and molecular issues.

RESULTS

Whether hormone therapy can improve cardiovascular health in postmenopausal women remains controversial. Current evidence suggests that the vascular effects of estrogen are affected by the stage of reproductive life, the time since menopause, and the extent of subclinical atherosclerosis. The mechanisms of vascular responsiveness to sex steroids during different stages of atherosclerosis development remain poorly understood in women and men.

CONCLUSION

In view of the expected increase in the prevalence of atherosclerotic vascular disease worldwide due to population aging, research is needed to determine the vascular mechanism of endogenous and exogenous sex steroids in patients with atherosclerosis. Such research may help to define new strategies to improve cardiovascular health in women and possibly also in men.

Fatty acid and cholesterol composition of the uterine artery intima in relation to menopausal status, age, and serum cholesterol

OBJECTIVES

Estrogens modulate lipid metabolism and the increased risk of atherosclerosis in postmenopausal women is at least partly due to the reduction of estrogen production after menopause. We studied the effect of menopause on the contents of long-chain fatty acids, free cholesterol (FC) and cholesterol ester (CE) in uterine artery wall.

METHODS

The uterine artery intima samples were obtained in connection with surgery of 21 postmenopausal and 51 premenopausal women. The amount of FC, CE and phospholipid fatty acids were measured by gas chromatography after extraction and fractionation and these lipid values were related to menopausal status, age and serum total and low-density lipoprotein (LDL) cholesterol levels.

RESULTS

Premenopausal females had significantly less intimal FC (161 +/- 50 vs. 407 +/- 276 microg/100 mg wet weight, P = 0.003) and CE (19 +/- 34 vs. 305 +/- 348 microg/100 mg wet weight, P = 0.050) and smaller proportion of linoleic acid out of all phospholipid fatty acids (4.2 vs. 7.2%, P = 0.002) than postmenopausal women after adjustment with age. The content of CE (r = 0.34, P = 0.025) and the FC-to-CE ratio (r = -0.45, P = 0.002) correlated with age in premenopausal but not in postmenopausal women. Moreover, the intimal content of CE correlated with the percentage of intimal phospholipid linoleic acid in postmenopausal women (r = 0.79, P = 0.020). The same was true for FC (r = 0.73, P < 0.001).

CONCLUSIONS

These results indicate that CE and FC accumulation into the wall of uterine artery depends on menopausal status, independently of age, and that the phospholipid long-chain fatty acid composition differs significantly between premenopausal and postmenopausal women. This suggests that estrogens may be involved in the regulation of artery wall lipid composition.

Can a healthy endothelium influence the cardiovascular effects of hormone replacement therapy?

Emerging clinical and observational evidences suggest that estrogen confers physiologic benefits that are receptor mediated and depend on the integrity and functional status of the endothelium within the coronary vasculature. In postmenopausal women, estrogen replacement therapy (ERT) and hormone replacement therapy (HRT) regimens can enhance the lipoprotein panel; blunt the expression of numerous cytokines, chemokines, and other proinflammatory mediators of endothelial injury and vascular smooth muscle cell proliferation; up-regulate endothelial nitric oxide synthase activity and nitric oxide production; and augment fibrinolysis potential and vasodilator capacity (diminish arterial resistance). Advancing age and atherosclerotic injury to the vessel wall tend to deplete estrogen receptors, compromise endothelial function, promote thrombus formation, and thus potentially diminish the efficacy of ERT and HRT. Therefore, optimizing the clinical benefits of these regimens in postmenopausal women depends largely on promoting a healthy endothelium through life-style modifications that diminish coronary risk.

Reproductive hormones and cardiovascular disease mechanism of action and clinical implications

The bulk of the experimental data suggest beneficial effects of estrogen (both premenopausal use of OCs and postmenopausal use of ERT-HRT). An intriguing finding from the monkey studies is that social subordination, which induces estrogen deficiency in female monkeys, accelerates atherosclerosis premenopausally and predicts extent of postmenopausal atherosclerosis. This effect can be inhibited by exogenous estrogen, premenopausally. The results suggest that more effort on detecting and regulating premenopausal ovarian dysfunction may be justified. A complication in understanding estrogen action may be the result of varying extents of arterial damage. For example, primary prevention studies in both postmenopausal animals and women have provided strong evidence of atheroprotection with a variety of estrogens. In contrast, the results of secondary prevention studies [10,12] have in general suggested little cardioprotection with either ERT or HRT. Studies in rabbits suggest the antiatherogenic effect of estrogen may not be present when the endothelium is damaged [64]. The state of the endothelium may be critical for some estrogen actions. For those effects of estrogen that require the ER, be it ERalpha or ERbeta, the presence of the receptor may vary with age, disease state, or type of hormone therapy. If continuous combined HRT therapy decreases ER in the artery as it does in the uterus, this may eliminate those estrogen actions requiring the ER, but not others. Older women who have not been exposed to estrogens for many years may be more sensitive to some estrogen effects, and may need lower doses of ERT-HRT. Recent reports suggest that lower doses of estrogens maintain beneficial effects on lipoproteins and coagulation factors [95], while also requiring lower doses of progestogens to protect the uterus [96]. These beneficial findings are very promising in light of the improvements in CHD risk and decreased stroke risk reported with low-dose estrogens [5]. It ill be interesting to see if CRP is increased with lower doses of estrogens and whether these changes are associated with increased early risk of CHD. Perhaps older women with CHD are also more obese, may have diabetes, and may be more susceptible to inflammatory and thrombotic effects of higher doses of estrogens. There are many questions left unanswered. It is hoped that some of the answers may come from the WHI, which is a large prospective trial assessing ERT and HRT. The age range is also relatively large and may be able to determine if older women respond differently than younger women. Some initial data from the WHI have been made available suggesting a small increased risk in the first 2 years and a trend for decreasing risk in the last months of the first 2 years [34]. Just recently, the CEE + MPA arm of the study was stopped early by the data and-safety monitoring board as the overall health risks exceeded benefits with increases in both breast cancer and CVD [97]. The remainder of the study groups including an estrogen-only arm, are expected to continue until 2005.

Sex differences in hospital mortality after coronary artery bypass surgery: evidence for a higher mortality in younger women

BACKGROUND

Data are conflicting over whether women have higher mortality than men after coronary artery bypass graft (CABG) surgery. Younger but not older women hospitalized for acute myocardial infarction have higher in-hospital mortality rates than men. We hypothesized that younger women also have higher in-hospital mortality rates after CABG.

METHODS AND RESULTS

We studied 51 187 patients (30% women) included in the National Cardiovascular Network database who received CABG at 23 clinical centers between October 1993 and December 1999. Compared with men, fewer women were white and more women had risk factors and comorbidities. These differences were more apparent in younger patients. In all age groups, however, women had higher left ventricular ejection fraction and fewer diseased vessels. Women had higher in-hospital mortality rates than men, but sex differences in mortality were more marked among younger patients. Women <50 years of age were 3 times more likely to die than men (3.4% versus 1.1%), and women 50 to 59 years of age were 2.4 times more likely to die than men (2.6% versus 1.1%). In the older age categories, the sex difference in in-hospital mortality was less marked (P<0.001 for the interaction between sex and age). Adjustment for preoperative risk factors only slightly decreased the strength of this interaction.

CONCLUSIONS

Younger women undergoing CABG surgery are at a higher risk of in-hospital death than men, but this difference in risk decreases with advancing age. Additional investigation is needed to determine why in-hospital mortality is higher in women after CABG, with particular focus on younger women.

Selected contribution: estrogen receptor-alpha gene transfer inhibits proliferation and NF-kappaB activation in VSM cells from female rats

Epidemiological studies have demonstrated that hormone replacement therapy with estrogen (E2) or E2 plus progesterone in postmenopausal women decreases the age-associated risk of cardiovascular disease by 30-50%. Treatment of vascular smooth muscle (VSM) cells with physiological concentrations of E2 has been shown to inhibit growth factor-stimulated cell proliferation. In this study, we tested the hypothesis that E2 inhibits the age-associated increase in VSM cell proliferation by inhibiting nuclear factor (NF)-kappaB pathway. We investigated the effects of E2 treatment and adenovirus-mediated estrogen receptor (ER)-alpha gene transfer on cell proliferation and NF-kappaB activation using VSM cells cultured from 3-mo-old and 24-mo-old Fischer 344 female rats. Our results demonstrate that VSM cell proliferation was significantly increased (P < 0.05) in aged compared with young adult female rats. Treatment of VSM cells with physiological concentrations of E2 inhibited VSM cell proliferation, and this inhibition was significantly greater (P < 0.05) in cells from aged female rats compared with young adults. The inhibitory effects of E(2) on cell proliferation in aged female rats were significantly potentiated by overexpression of the human ER-alpha gene into VSM cells. Constitutive and interleukin (IL)-1beta-stimulated NF-kappaB activation was significantly greater (P < 0.05) in VSM cells from aged compared with young female rats. E2 treatment of VSM cells from aged female rats inhibited both constitutive and IL-1beta-stimulated NF-kappaB activation. ER-alpha gene transfer into VSM cells from aged female rats further augmented the inhibitory effects of E2. In conclusion, our data demonstrate that constitutive and IL-1beta-stimulated NF-kappaB activation is increased in VSM cells from aged female rats due to loss of E2 and this can be restored back to normal levels by ER-alpha gene transfer and E2 treatment. In addition, increased NF-kappaB signaling may be responsible for increased incidence of cardiovascular disease in postmenopausal females.

Postmenopausal oestrogen replacement therapy and atherosclerosis: can current compounds provide cardiovascular protection?

The natural oestrogen, 17 beta-oestradiol, has been implicated in protection from atherosclerosis, a chronic systemic vascular disease with an inflammatory component accounting for the majority of morbidity and mortality in Western countries. Despite the protective effects of 17 beta-oestradiol in premenopausal women and experimental evidence demonstrating inhibitory effects of oestrogen on atherosclerosis progression, it is currently unclear whether hormone replacement therapy can affect cardiovascular morbidity and mortality in postmenopausal women. The recent advances in understanding the mechanisms of oestrogen action demonstrated roles for different oestrogen receptors and oestrogen metabolites in the pathogenesis of vascular injury and endothelial cell dysfunction. However, their respective role in the process of atherogenesis remains yet to be elucidated. Moreover, the availability of novel drugs with tissue- and/or receptor-specific actions will help to understand the role of oestrogen in cardiovascular diseases. Several ongoing large-scale clinical trials using opposed or unopposed replacement therapy with natural or synthetic oestrogens, or selective oestrogen receptor modulators (SERMs) will resolve the question whether the drugs currently available have therapeutic potential to interfere with the progression of atherosclerosis and its complications.

Hormone replacement therapy in the prevention and treatment of atherosclerosis

As the population ages, the increasing number of women at risk for cardiovascular disease represents both a potential crisis and an opportunity in healthcare management. Although the overall death rate from cardiovascular disease in the general population is decreasing, the absolute numbers for women are increasing. A reduction in modifiable risk factors in women must be aggressively pursued by clinicians and health systems. Menopause is associated with many adverse effects on cardiovascular-disease risk factors in women. Estrogen replacement therapy has been shown to favorably influence many risk factors for cardiovascular disease. Despite this biologic plausibility and supporting evidence from epidemiologic studies, data from confirmatory clinical trials are lacking. Because of this, recommendations for hormone replacement therapy should be made on an individual basis.

Status, stress, and atherosclerosis: the role of environment and individual behavior

Atherosclerosis induced by moderate hyperlipoproteinemia in group-housed cynomolgus monkeys differs significantly between animals of dominant and subordinate social status. The nature of this association also varies by sex, and in males, by stability of the social environment. Dominant males develop more extensive atherosclerosis than subordinates when housed in unstable, but not stable, social groups; in contrast, subordinate females develop greater atherosclerosis than dominants, and do so irrespective of the conditions of social housing. Experimental investigations reveal that the first of these associations (males) is mediated by concomitant sympathoadrenal activation and the second (females) by ovarian impairment associated with the stress of social subordination. We believe our findings offer clues to the neuroendocrine mediation of behavioral influences on coronary artery disease in humans. This is particularly true where these influences reflect asymmetries in the power or status relationships among individuals within similar social environments, or when dimensions of temperament or disposition give rise to such relationships. We propose that these data also may be informative regarding the pathophysiological sequelae of social stratification (in which disease incidence varies by class membership within populations), but only where social environments engendered by class inequalities exacerbate status-dependent behavioral differences among individuals within communities of associates.

Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy

Recent studies provide clear and convincing evidence that psychosocial factors contribute significantly to the pathogenesis and expression of coronary artery disease (CAD). This evidence is composed largely of data relating CAD risk to 5 specific psychosocial domains: (1) depression, (2) anxiety, (3) personality factors and character traits, (4) social isolation, and (5) chronic life stress. Pathophysiological mechanisms underlying the relationship between these entities and CAD can be divided into behavioral mechanisms, whereby psychosocial conditions contribute to a higher frequency of adverse health behaviors, such as poor diet and smoking, and direct pathophysiological mechanisms, such as neuroendocrine and platelet activation. An extensive body of evidence from animal models (especially the cynomolgus monkey, Macaca fascicularis) reveals that chronic psychosocial stress can lead, probably via a mechanism involving excessive sympathetic nervous system activation, to exacerbation of coronary artery atherosclerosis as well as to transient endothelial dysfunction and even necrosis. Evidence from monkeys also indicates that psychosocial stress reliably induces ovarian dysfunction, hypercortisolemia, and excessive adrenergic activation in premenopausal females, leading to accelerated atherosclerosis. Also reviewed are data relating CAD to acute stress and individual differences in sympathetic nervous system responsivity. New technologies and research from animal models demonstrate that acute stress triggers myocardial ischemia, promotes arrhythmogenesis, stimulates platelet function, and increases blood viscosity through hemoconcentration. In the presence of underlying atherosclerosis (eg, in CAD patients), acute stress also causes coronary vasoconstriction. Recent data indicate that the foregoing effects result, at least in part, from the endothelial dysfunction and injury induced by acute stress. Hyperresponsivity of the sympathetic nervous system, manifested by exaggerated heart rate and blood pressure responses to psychological stimuli, is an intrinsic characteristic among some individuals. Current data link sympathetic nervous system hyperresponsivity to accelerated development of carotid atherosclerosis in human subjects and to exacerbated coronary and carotid atherosclerosis in monkeys. Thus far, intervention trials designed to reduce psychosocial stress have been limited in size and number. Specific suggestions to improve the assessment of behavioral interventions include more complete delineation of the physiological mechanisms by which such interventions might work; increased use of new, more convenient "alternative" end points for behavioral intervention trials; development of specifically targeted behavioral interventions (based on profiling of patient factors); and evaluation of previously developed models of predicting behavioral change. The importance of maximizing the efficacy of behavioral interventions is underscored by the recognition that psychosocial stresses tend to cluster together. When they do so, the resultant risk for cardiac events is often substantially elevated, equaling that associated with previously established risk factors for CAD, such as hypertension and hypercholesterolemia.

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.