The menopause and HRT. Urogenital effects of hormone therapy

The effects of a real-time temperature monitoring non-ablative monopolar radiofrequency technology on vulvovaginal atrophy symptoms in postmenopausal Chinese women

BACKGROUND

Vulvovaginal atrophy (VVA) includes a wide range of conditions affecting the reproductive and urinary systems, often requiring careful evaluation and management for optimal health.

AIMS

This study aims to evaluate the symptom management effects of a real time temperature-monitored non-ablative RF device for the treatment of postmenopausal Chinese women with VVA symptoms.

METHODS

This pilot study involved 24 postmenopausal Chinese women with one or more VVA symptoms, who wished to remain sexually active. VHIS, VAS, and FSFI were used to track and evaluate various aspects of the patient's condition. Analyses were conducted at the end of the study to verify the statistical significance of the treatment's results.

RESULTS

All patients reported substantial, statistically significant, improvements on every VVA symptom tracked. Approximately 80% of the patients reported total symptom reversal at 12-week post-treatment follow-up.

CONCLUSION

This pilot study demonstrated that non-ablative, monopolar RF technology equipped with real time temperature monitoring is feasible and safe in the treatment of postmenopausal women with VVA symptoms, and efficacious at up to 12 weeks post-treatment.

Response of Vitamin D after Magnesium Intervention in a Postmenopausal Population from the Province of Granada, Spain

Menopause is a stage of hormonal imbalance in women which, in addition to other physiopathological consequences, poses a risk of deficiency of key micronutrients such as magnesium and vitamin D. A study was made of the influence of a magnesium intervention upon vitamin D status in a postmenopausal population from the province of Granada (Spain). Fifty-two healthy postmenopausal women between 44–76 years of age were included. Two randomized groups—placebo and magnesium (500 mg/day)—were treated during eight weeks. Nutrient intake was assessed using questionnaires based on 72-h recall. Vitamin D was analyzed by liquid chromatography—tandem mass spectrometry. Baseline vitamin D proved deficient in over 80% of the subjects. The administration of magnesium resulted in significantly increased vitamin D levels in the intervention group versus the controls (p < 0.05). Magnesium supplementation improved vitamin D status in the studied postmenopausal women.

Modifications in Vaginal Microbiota and Their Influence on Drug Release: Challenges and Opportunities

Vaginal drug delivery represents an attractive alternative to achieve local and systemic effects due to the high contact surface exposed, the mucoadhesion of the epithelium, and the high innervation that facilitates the absorption of drugs into the bloodstream. However, despite the confinement of the vaginal cavity, it is an organ with a highly variable microenvironment. Mechanical alterations such as coitus, or chemical changes such as pH and viscosity, modify the release of drugs. In addition, changes in vaginal microbiota can influence the entire vaginal microenvironment, thus determining the disposition of drugs in the vaginal cavity and decreasing their therapeutic efficacy. Therefore, the influence of microorganisms on vaginal homeostasis can change the pre-established scenario for the application of drugs. This review aims to provide an explanation of normal vaginal microbiota, the factors that modify it, its involvement in the administration of drugs, and new proposals for the design of novel pharmaceutical dosage forms. Finally, challenges and opportunities directed toward the conception of new effective formulations are discussed.

The clinical relevance of the effect of ospemifene on symptoms of vulvar and vaginal atrophy

Objectives

To explore clinically relevant differences in severity of vulvar and vaginal atrophy (VVA) in postmenopausal women treated with ospemifene compared with placebo.

Methods

Analysis of two multicenter, randomized, double-blind, 12-week phase-III studies in postmenopausal women (40–80 years, with VVA, treated with ospemifene 60 mg/day or placebo (Study 310 and Study 821)). Severity of vaginal dryness and dyspareunia were evaluated using a four-point scoring system and clinically relevant differences between ospemifene and placebo were analyzed and are presented as improvement (reduction in ≥ 1 unit on four-point scoring system), substantial improvement (reduction in 2–3 units on four-point scoring system) and relief (severity score of mild/none after 12 weeks).

Results

In Study 310, significantly more women with a most bothersome symptom of dyspareunia had improvement (68.3% vs. 54.1%; p = 0.0255) or relief (57.5% vs. 41.8%; p = 0.0205) in the severity of dyspareunia from baseline to week 12 with ospemifene compared with placebo. For those with a most bothersome symptom of vaginal dryness, significantly more experienced improvement (74.6% vs. 57.7%; p = 0.0101), substantial improvement (42.4% vs. 26.9%; p = 0.0172) and relief (66.1% vs. 49.0%; p = 0.0140) of vaginal dryness from baseline to week 12 with ospemifene compared with placebo. Proportions of women with improvement/substantial improvement/relief of symptoms of vaginal dryness or dyspareunia were similar in Study 821. Clinically relevant differences were noticeable by week 4.

Conclusions

Treatment with ospemifene was consistently associated with greater improvement, substantial improvement or relief in the severity of the most bothersome symptoms of vaginal dryness or dyspareunia compared with placebo.

Effect of extended-term estrogen on voiding in a postpartum ovariectomized rat model

INTRODUCTION

We tested the hypothesis that extended-term (5-week) estrogen therapy would negatively impact voiding function in a postpartum, ovariectomized rat model.

METHODS

Immediately after delivery, 30 primiparous Sprague-Dawley rats underwent intravaginal balloon dilation, followed by ovariectomy 1 week later. Cystometry at postpartum week 2 determined normal or abnormal voiding patterns. After randomization, one-half the normal and abnormal voiding rats received 5 weeks of estrogen therapy, while the remainder received placebo. Estrogen effect was determined by repeat cystometry and immunohistochemical analysis of the urethra and vagina.

RESULTS

Abnormal voiding increased from 60.0% to 73.3% in the estrogen- treated group and declined from 60% to 33% for the placebo group. Rats were then divided into 4 groups for comparison: normal voiding versus placebo (group 1), abnormal voiding versus placebo (group 2), normal voiding versus estrogen (group 3) and abnormal voiding versus estrogen (group 4). Bladder capacity, leak point pressure and maximum voiding pressure were most depressed in group 4. Estrogen treatment was associated with a significant downregulation of alpha(1A) and alpha(1D)-adrenoceptors in the urethral submucosa but an upregulation of nNOS in the urethral smooth muscle.

CONCLUSION

Extended-term estrogen therapy in a rat model of simulated birth trauma and ovariectomy resulted in a higher rate of incontinence. Immunohistochemical examination demonstrated significant downregulation of urethral alpha(1A)- and alpha(1D)-adrenoceptors and upregulation of neuronal nitric oxide synthase (nNOS) in the urethra of estrogen-treated groups. These studies question the use of hormone replacement therapy in the treatment of postmenopausal incontinence.

Recommendations for the management of postmenopausal vaginal atrophy

Unlike hot flushes and night sweats which resolve spontaneously in time, atrophic symptoms affecting the vagina and lower urinary tract are often progressive and frequently require treatment. The prevalence of vaginal dryness increases as a woman advances through the postmenopausal years, causing itching, burning and dyspareunia, and sexual activity is often compromised. But, despite the various safe and effective options, only a minority (about 25% in the Western world and probably considerably less in other areas) will seek medical help. Some of this reluctance is due to the adverse publicity for hormone replacement therapy (HRT) over recent years that has suggested an increased risk of breast cancer, heart disease and stroke. But, regardless of whether these scares are justified, local treatment of vaginal atrophy is not associated with these possible risks of systemic HRT. Other reasons for the continued suffering in silence may be cultural and an understandable reluctance to discuss such matters, particularly with a male doctor, but the medical profession must also take much of the blame for failing to enquire of all postmenopausal women about the possibility of vaginal atrophic symptoms. Vaginal dryness can be helped by simple lubricants but the best and most logical treatment for urogenital atrophy is to use local estrogen. This is safe, effective and with few contraindications. It is hoped that these guidelines and recommendations, produced to coincide with World Menopause Day 2010, will help to highlight this major cause of distress and reduced quality of life and will encourage women and their medical advisers all over the world to seek and provide help.

The acceptability of isoflavones as a treatment of menopausal symptoms: a European survey among postmenopausal women

OBJECTIVE

To investigate determinants of the acceptability of isoflavone products among postmenopausal women with regard to social and lifestyle factors, dietary habits, health concerns, food beliefs, menopausal symptoms and therapies, and to elucidate preferences for specific products.

METHODS

A consumer survey was conducted among postmenopausal women in four European countries (Germany, Denmark, Italy and the UK), including a total of 465 respondents.

RESULTS

The declared acceptability of isoflavones was highest in Germany (80%), followed by Italy (75%), the UK (59%) and Denmark (55%; p < 0.001). Among other factors, prior information about isoflavones (odds ratio (OR) 2.64, 95% confidence interval (CI) 1.54-4.51, p < 0.001) and belief that foods can be used to treat medical conditions (OR 2.18, 95% CI 1.17-4.05, p = 0.014) were the strongest predictors of potential acceptability. The preferred forms in which isoflavones might be taken differed markedly between countries.

CONCLUSIONS

Information about the health effects of isoflavones and health-diet links should be considered the most important factors in attempts to influence the potential acceptability of isoflavone products. Foods enriched with isoflavones need to be developed with regard to specific cultural demands in order to assure consumer acceptance on the marketplace.

Do overactive bladder symptoms improve after repair of anterior vaginal wall prolapse?

This study aims to evaluate the changes of overactive bladder symptoms to anterior vaginal wall prolapse repair. Ninety-three consecutive women with symptomatic anterior vaginal wall prolapse >or= stage II and coexistent overactive bladder symptoms were prospectively studied using a urinalysis, urodynamics, King's Health Questionnaire (KHQ), Prolapse Quality of Life (P-QOL) questionnaire and pelvic organ prolapse quantification (POP-Q) system before and 1 year after surgery. All women underwent a standard fascial anterior repair. Postoperatively, urinary frequency, urgency and urge incontinence disappeared in 60, 70 and 82% of women respectively (p value < 0.001). The vaginal examination findings as well as the quality of life of the women assessed using KHQ and P-QOL significantly improved after surgery (p value < 0.001). This study has demonstrated that anterior vaginal repair does produce significant improvement in overactive bladder symptoms. A larger longer-term study is required to assess if these changes persist over time.

Long-term effects of hormone therapy on skin rigidity and wrinkles

OBJECTIVE

To evaluate the effects of long-term hormone therapy (HT) on skin rigidity and wrinkling.

DESIGN

Single blinded cross-sectional analysis.

SETTING

Academic medical center.

PATIENT(S)

Sixty-five long-term HT users who underwent menopause at least 5 years before evaluation and who have either consistently used HT or have never used HT.

INTERVENTION(S)

Visual assessment of severity of wrinkles at 11 facial locations using the Lemperle scale by a plastic surgeon blinded to HT use. Measurement of skin rigidity at the cheek and forehead with a durometer.

MAIN OUTCOME MEASURE(S)

Lemperle wrinkle score and skin rigidity.

RESULT(S)

Twenty women met inclusion criteria. Eleven women who had not used HT were compared to nine long-term HT users. Demographics including age, race, sun exposure, sunscreen use, tobacco use, and skin type were similar. Rigidity was significantly decreased in HT users compared to nonusers at both the cheek (1.1 vs. 2.7) and forehead (20 vs. 29). Average wrinkle scores were lower in hormone users than in nonhormone users (1.5 vs. 2.2).

CONCLUSION(S)

Long-term postmenopausal HT users have more elastic skin and less severe wrinkling than women who never used HT, suggesting that hormone therapy may have cosmetic benefits.

17β-Estradiol suppresses proliferation of fibroblasts derived from cardinal ligaments in patients with or without pelvic organ prolapse

BACKGROUND

Estrogen replacement therapy (ERT) has been used in the treatment of pelvic organ prolapse (POP) but clinical results are inconclusive. The purpose of this study was to investigate the effect of 17beta-estradiol (E(2)) on the proliferation of fibroblasts derived from cardinal ligaments in women with or without POP.

METHODS

Fibroblasts were derived from seven patients with POP and seven age-matched controls. The growth rate of POP fibroblasts was compared with that of control by 3-(4,5,-dimethyl thiazolyl-2)-2,5-diphenyl tetrazolium bromide (MTT) assay. Four cell strains from each patient and control group were treated with different concentrations of E2 (10(-4), 10(-8), 10(-9) and 10(-10) mol/l). The effect of E2 on cell proliferation was then measured by MTT assay.

RESULTS

The overall growth rate of POP fibroblasts was significantly slower than that of controls under normal culture conditions. Addition of E2 suppressed cell proliferation of all the fibroblasts, especially in POP fibroblasts. POP fibroblasts showed a significantly lower proliferative rate than that of controls at all E2 concentrations, with the most prominent inhibitory effect at physiological concentration (10.83 34.41% versus 81.56 48.10% at 10(-8) mol/l).

CONCLUSIONS

Our results suggest that decreased fibroblast turnover may contribute to the development of POP; and ERT may not be an effective POP treatment.

Prevalence of urinary incontinence in relation to self-reported depression, intake of serotonergic antidepressants, and hormone therapy in middle-aged women: a report from the Women's Health in the Lund Area study

OBJECTIVE

To study a perceived relationship of urinary incontinence with self-reported depression among middle-aged women, and to outline whether hormone therapy, selective serotonin reuptake inhibitors, or serotonin norepinephrine reuptake inhibitors influence the prevalence of urinary incontinence.

DESIGN

A population-based cross-sectional study of 6,642 women from the Lund area, Sweden, aged 50 to 64 years, who answered questions on urinary incontinence. We obtained information on urinary incontinence, self-reported depression, and medication by questionnaire and personal interviews between December 1995 and February 2000.

RESULTS

Thirty-one percent of the women reported urinary incontinence of various severities and 52% reported episodes of depression. Urinary incontinence and self-reported depression were significantly associated [odds ratio (OR) 1.37; 95% CI, 1.23-1.52; P < 0.001]. Among women with self-reported depression, the use of serotonergic antidepressants was statistically associated with urinary incontinence (OR 1.78; 95% CI, 1.33-2.38; P < 0.001). Among women not reporting depression, hormone therapy was significantly associated with urinary incontinence (OR 1.45; 95% CI, 1.22-1.70; P < 0.001). After adjustment for other potential risk factors, serotonergic antidepressants and hormone therapy use were no longer associated with urinary incontinence in women with self-reported depression. However, among women not reporting depression, hormone therapy was still significantly more common in women with urinary incontinence.

CONCLUSIONS

Urinary incontinence and self-reported depression seemed to be associated in middle-aged women. Use of serotonergic antidepressants or hormone therapy does not seem to be associated with a lower prevalence of urinary incontinence.

Effect of estradiol valerate and levonorgestrel on vaginal health

OBJECTIVES

To evaluate the effect of the combined hormone replacement therapy (HRT) estradiol valerate/levonorgestrel on vaginal symptoms, vaginal health index, vaginal pH, and vaginal cytology.

STUDY DESIGN

A prospective, open-label study involving 32 postmenopausal women was performed in Ramathibodi Hospital, Mahidol University, Bangkok, Thailand. All the subjects received sequential oral estrogen-progestogen hormone replacement therapy, which contains 2 mg estradiol valerate and 0.15 mg levonorgestrel, for 6 months. The results in terms of vaginal health index, vaginal pH, and vaginal cytology before and after treatment were analyzed.

RESULTS

The mean age of these postmenopausal women was 52.56 +/- 3.33 years (range: 46-60 years). The mean time since the last menstrual period was 3.41 +/- 2.95 years (range: 1-15 years). The vaginal health index, which indicates vaginal health by means of scores for vaginal moistness, vaginal fluid volume, vaginal elasticity, vaginal mucosa, and vaginal pH rose significantly in all the women. The mean vaginal pH became significantly lower. The vaginal cytology showed an estrogenic effect on the karyopyknotic index (KPI) and the maturation value (MV) after 3 and 6 months of treatment.

CONCLUSION

During estradiol valerate and levonorgestrel treatment, there were demonstrable improvements in the objective signs of vaginal atrophy: atrophic vaginal epithelium became thicker and vaginal pH lower, and the morphology of the vaginal cells was better.