Menopausal Hormone Therapy, Age, and Chronic Diseases: Perspectives on Statistical Trends

Menopausal hormone therapy use among active duty service women

OBJECTIVE

Menopausal hormone therapy (HT) has been shown to be effective in alleviating symptoms of menopause. While previous literature has described the frequency of HT use for the relief of menopausal symptoms in both the general and veteran female populations, there is currently no literature describing this frequency within the female active duty population. This study aims to address this gap in knowledge by conducting a retrospective cross-sectional study of HT receipt in active duty service women (ADSW) ages 45 to 64 during fiscal years (FYs) 2018 to 2022.

METHODS

We used the Military Health System (MHS) Data Repository (MDR) to conduct a retrospective study of ADSW ages 45 to 64 in the US Army, Air Force, Navy, and Marine Corps during FY 2018 to 2022. Study analyses included descriptive statistics on participant demographics and HT type. Logistic regressions were performed to assess for significant associations between participant demographics and receipt of HT.

RESULTS

We identified a total of 13,629 women aged 45 to 64 on active duty service in the US Army, Air Force, Navy, and Marine Corps during FY 2018 to 2022, of whom 1,290 (9.5%) received HT. Significantly lower odds for receipt of HT was observed among ADSW ages 45 to 49, 60 to 64, of Asian/Pacific Islander race, and all ranks below Senior Officer. No significant associations were observed by Service branch.

CONCLUSIONS

The prevalence of HT use among ADSW ages 45 to 65 is lower than HT use among the US veteran population age 45 and older but higher than among the US general population age 45 and older.

Estrogenic Activity of 4-Hydroxy-Benzoic Acid from Acer tegmentosum via Estrogen Receptor α-Dependent Signaling Pathways

Acer tegmentosum, a deciduous tree belonging to Aceraceae, has been used in traditional oriental medicine for treating hepatic disorders, such as hepatitis, cirrhosis, and liver cancer. We evaluated the estrogen-like effects of A. tegmentosum using an estrogen receptor (ER)-positive breast cancer cell line, namely MCF-7, to identify potential phytoestrogens and found that an aqueous extract of A. tegmentosum promoted cell proliferation in MCF-7 cells. Five phenolic compounds (1-5) were separated and identified from the active fraction using bioassay-guided fractionation of crude A. tegmentosum extract and phytochemical analysis. The chemical structures of the compounds were characterized as vanillic acid (1), 4-hydroxy-benzoic acid (2), syringic acid (3), isoscopoletin (4), and (E)-ferulic acid (5) based on the analysis of their nuclear magnetic resonance spectra and liquid chromatography-mass spectrometry data. All five compounds were evaluated using an E-screen assay for their estrogen-like effects on MCF-7 cells. Among the tested compounds, only 4-hydroxy-benzoic acid (2) promoted the proliferation of MCF-7 cells, which was mitigated by the ER antagonist, ICI 182,780. The mechanism underlying the estrogen-like effect of 4-hydroxy-benzoic acid (2) was evaluated via western blotting analysis to determine the expression levels of extracellular signal-regulated kinase (ERK), phosphoinositide 3-kinase (PI3K), serine/threonine kinase (AKT), and ERα. Our results demonstrated that 4-hydroxy-benzoic acid (2) induced the increase in the protein expression levels of p-ERK, p-AKT, p-PI3K, and p-Erα, concentration dependently. Collectively, these experimental results suggest that 4-hydroxy-benzoic acid (2) is responsible for the estrogen-like effects of A. tegmentosum and may potentially aid in the control of estrogenic effects during menopause.

ET-1 as a Sex-Specific Mechanism Impacting Age-Related Changes in Vascular Function

Aging is a primary risk factor for cardiovascular disease (CVD), which is the leading cause of death in developed countries. Globally, the population of adults over the age of 60 is expected to double by the year 2050. CVD prevalence and mortality rates differ between men and women as they age in part due to sex-specific mechanisms impacting the biological processes of aging. Measures of vascular function offer key insights into cardiovascular health. Changes in vascular function precede changes in CVD prevalence rates in men and women and with aging. A key mechanism underlying these changes in vascular function is the endothelin (ET) system. Studies have demonstrated sex and sex hormone effects on endothelin-1 (ET-1), and its receptors ETA and ETB. However, with aging there is a dysregulation of this system resulting in an imbalance between vasodilation and vasoconstriction. Thus, ET-1 may play a role in the sex differences observed with vascular aging. While most research has been conducted in pre-clinical animal models, we describe more recent translational data in humans showing that the ET system is an important regulator of vascular dysfunction with aging and acts through sex-specific ET receptor mechanisms. In this review, we present translational evidence (cell, tissue, animal, and human) that the ET system is a key mechanism regulating sex-specific changes in vascular function with aging, along with therapeutic interventions to reduce ET-mediated vascular dysfunction associated with aging. More knowledge on the factors responsible for the sex differences with vascular aging allow for optimized therapeutic strategies to attenuate CVD risk in the expanding aging population.

Estrogenic Activity of Mycoestrogen (3β,5α,22E)-Ergost-22-en-3-ol via Estrogen Receptor α-Dependent Signaling Pathways in MCF-7 Cells

Armillariella tabescens (Scop.) Sing., a mushroom of the family Tricholomataceae, has been used in traditional oriental medicine to treat cholecystitis, improve bile secretion, and regulate bile-duct pressure. The present study evaluated the estrogen-like effects of A. tabescens using a cell-proliferation assay in an estrogen-receptor-positive breast cancer cell line (MCF-7). We found that the methanol extract of A. tabescens fruiting bodies promoted cell proliferation in MCF-7 cells. Using bioassay-guided fractionation of the methanol extract and chemical investigation, we isolated and identified four steroids and four fatty acids from the active fraction. All eight compounds were evaluated by E-screen assay for their estrogen-like effects in MCF-7 cells. Among the tested isolates, only (3β,5α,22E)-ergost-22-en-3-ol promoted cell proliferation in MCF-7 cells; this effect was mitigated by the ER antagonist, ICI 182,780. The mechanism underlying the estrogen-like effect of (3β,5α,22E)-ergost-22-en-3-ol was evaluated using Western blot analysis to detect the expression of extracellular signal-regulated kinase (ERK), phosphatidylinositol 3-kinase (PI3K), Akt, and estrogen receptor α (ERα). We found that (3β,5α,22E)-ergost-22-en-3-ol induced an increase in phosphorylation of ERK, PI3K, Akt, and ERα. Together, these experimental results suggest that (3β,5α,22E)-ergost-22-en-3-ol is responsible for the estrogen-like effects of A. tabescens and may potentially aid control of estrogenic activity in menopause.

Gender differences in comorbidities and risk factors in ischemic stroke patients with a history of atrial fibrillation

BACKGROUND

Atrial Fibrillation (AF) is a common cardiac arrhythmia and has been identified as a major risk factor for acute ischemic stroke (AIS). Gender differences in the disease process, causative mechanisms and outcomes of AF have been investigated. In the current study, we determined whether there is a gender-based disparity in AIS patients with baseline AF, and whether such a discrepancy is associated with specific risk factors and comorbidities.

METHODS

Baseline factors including comorbidities, risk and demographic factors associated with a gender difference were examined using retrospective data collected from a registry from January 2010 to June 2016 in a regional stroke center. Univariate analysis was used to differentiate between genders in terms of clinical risk factors and demographics. Variables in the univariate analysis were further analyzed using logistic regression. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for each factor were used to predict the increasing odds of an association of a specific comorbidity and risk factor with the male or female AIS with AF.

RESULTS

In the population of AIS patients with AF, a history of drug and alcohol use (OR = 0.250, 95% CI, 0.497-1.006, P = 0.016), sleep apnea (OR = 0.321, 95% CI, 0.133-0.777, P = 0.012), and higher serum creatinine (OR = 0.693, 95% CI, 0.542-0.886 P = 0.003) levels were found to be significantly associated with the male gender. Higher levels of HDL-cholesterol (OR = 1.035, 95% CI, 1.020-1.050, P < 0.001), LDL-cholesterol (OR = 1.006, 95% CI, 1.001-1.011, P = 0.012), and the inability to ambulate on admission to hospital (OR = 2.258, 95% CI, 1.368-3.727, P = 0.001) were associated with females.

CONCLUSION

Our findings reveal that in the AIS patients with atrial fibrillation, migraines, HDL, LDL and poor ambulation were associated with females, while drugs and alcohol, sleep apnea, and serum creatinine level were associated with male AIS patients with AF. Further studies are necessary to determine whether gender differences in risk factor profiles and commodities require consideration in clinical practice when it comes to AF as a risk factor management in AIS patients.

Evaluation of menopausal hormone therapy use in Korea (2002-2013): A nationwide cohort study

OBJECTIVE

The study aimed to evaluate the degree of menopausal hormonal therapy (MHT) use and the related trends, as well as the characteristics of Korean women who used MHT by type of hormone therapy.

METHODS

Women aged ≥40 years were selected using data from the Korea National Insurance Service-National Sample Cohort 2002-2013 database. MHT entailed either estrogen therapy or estrogen plus progestogen therapy, as categorized by the Anatomical Therapeutic Chemical system. The prevalence of MHT use was calculated as the number of women with prescriptions annually and the level of hormone consumption was calculated using the defined daily dose (DDD).

RESULTS

The proportion of MHT users among women aged ≥40 years was 7.8 % in 2002, which decreased to 6.3 % in 2013. The overall MHT consumption level in 2002 was 27.5 DDDs/1000 inhabitants/day. There was a sharp decline in the first few years after 2002 and this value decreased to 12.5 DID in 2013; however, the decrease had lessened from 2006 to 2013 and differed by HT type, administration route, age, and income level. During the 11-year follow-up, over 70 % of women were prescribed MHT for less than 1 year, while only 11.8 % had a prescription for 3 years or more, and women who started treatment at age 45-59 years showed longer treatment duration.

CONCLUSIONS

Since 2002, MHT use among Korean women, especially overall MHT consumption, has declined remarkably. Regarding the pattern of use among women who took hormone preparations during 2002-2013, MHT was used around menopause, over the short term only, and at low dose.

Unnecessary bilateral salpingo-oophorectomy at the time of hysterectomy and potential for ovarian preservation

OBJECTIVE

To evaluate predictors of bilateral salpingo-oophorectomy at hysterectomy and determine rate of unnecessary bilateral salpingo-oophorectomy.

METHODS

Retrospective review of hysterectomies at six Ontario, Canada hospitals from July 2016 to June 2018. Data was extracted from health records coding and electronic medical records. Of patients with concurrent bilateral salpingo-oophorectomy, age, preoperative diagnoses, surgical factors (presence of endometriosis/adhesions), and surgeon training (fellowship/no fellowship) were recorded. Chi-square tests compared indicated and nonindicated bilateral salpingo-oophorectomy cases based on preoperative diagnosis. Criteria for unnecessary bilateral salpingo-oophorectomy were: age under 51 years, benign preoperative diagnosis, and absence of intraoperative endometriosis and adhesions.

RESULTS

Concurrent bilateral salpingo-oophorectomy occurred in 749/2,656 (28%) cases with 509/749 (68%) indicated based on preoperative diagnosis. There was interhospital variation in rate of indicated bilateral salpingo-oophorectomy based on preoperative diagnosis (45.3%-76.9%, χ2P < 0.001). Concurrent bilateral salpingo-oophorectomy at academic centers was more likely to have preoperative indications versus those at community hospitals (70% vs 63%, OR 1.42, 95% CI 1.02-1.97, P = 0.04). BSO performed by fellowship-trained surgeons were more likely to be indicated than those performed by generalists (75% vs 63%, OR 1.76, 95% CI 1.26-2.44, P = 0.001). Of patients without preoperative indications for bilateral salpingo-oophorectomy, 105/239 (44%) were under 51 years of age, of which 59 (58%) had no intraoperative endometriosis/adhesions. Ovarian preservation may have been reasonable in 8% (59/749).

CONCLUSIONS

Concurrent bilateral salpingo-oophorectomy performed by generalists and at community hospitals was less likely to have preoperative indications. Ovarian preservation was potentially possible for 8%.

Dietary phytoestrogens modulate aggression and activity in social behavior circuits of male mice

Phytoestrogens comprise biologically active constituents of human and animal diet that can impact on systemic and local estrogen functions in the brain. Here we report on the importance of dietary phytoestrogens for maintaining activity in a brain circuit controlling aggressive and social behavior of male mice. After six weeks of low-phytoestrogen chronic diet (diadzein plus genistein <20 μg/g) a reduction of intermale aggression and altered territorial marking behavior could be observed, compared to littermates on a standard soy-bean based diet (300 μg/g). Further, mice on low-phyto diet displayed a decrease in sociability and a reduced preference for social odors, indicating a general disturbance of social behavior. Underlying circuits were investigated by analysing the induction of the activity marker c-Fos upon social encounter. Low-phyto diet led to a markedly reduced c-Fos induction in the medial as well as the cortical amygdala, the lateral septum, medial preoptic area and bed nucleus of the stria terminalis. No difference between groups was observed in the olfactory bulb. Together our data suggest that dietary phytoestrogens critically modulate social behavior circuits in the male mouse brain.

A polydopamine-based platform for anti-cancer drug delivery

Cancer is the second leading cause of death in the world with around 9.6 million deaths in 2018, approximately 70% of which occurred in the middle- and low-income countries; moreover, the economic impact of cancer is significant and escalating day by day. The total annual economic cost of cancer treatment in 2010 was estimated at approximately US$ 1.16 trillion. Researchers have explored cancer mitigation therapies such as chemo-thermal therapy, chemo-photothermal therapy and photodynamic-photothermal therapy. These combinational therapies facilitate better control on the tunability of the carrier for effectively diminishing cancer cells than individual therapies such as chemotherapy, photothermal therapy and targeted therapy. All these therapies come under novel drug delivery systems in which anti-cancer drugs attack the cancerous cells due to various stimuli (e.g. pH, thermal, UV, IR, acoustic and magnetic)-responsive properties of the anti-cancer drug carriers. Compared to conventional drug delivery systems, the novel drug delivery systems have several advantages such as targeted drug release, sustained and consistent blood levels within the therapeutic window, and decreased dosing frequency. Among the numerous polymeric carriers developed for drug delivery, polydopamine has been found to be more suitable as a carrier for these drug delivery functions due to its easy and cost-effective fabrication, excellent biocompatibility, multi-drug carrier capacity and stimuli sensitivity. Therefore, in this review, we have explored polydopamine-based carriers for anti-cancer drug delivery systems to mitigate cancer and simultaneously discussed basic synthesis routes for polydopamine.

Estrogen receptor 1 gene polymorphisms (PvuII and XbaI) are associated with type 2 diabetes in Palestinian women

Background

Type 2 diabetes mellitus (T2DM) is a multifactorial disease where both genetic and environmental factors contribute to its pathogenesis. The PvuII and XbaI polymorphisms of the estrogen receptor 1 (ESR1) gene have been variably associated with T2DM in several populations. This association has not been studied in the Palestinian population. Therefore, the aim of this study was to investigate the association between the PvuII and XbaI variants in the ESR1 and T2DM and its related metabolic traits among Palestinian women.

Methods

This case-control study included 102 T2DM and 112 controls in which PvuII and XbaI variants of the ESR1 gene were genotyped using amplicon based next generation sequencing (NGS).

Results

Allele frequencies of both PvuII and XbaI variants were not significantly different between patients and control subjects (P > 0.05). In logestic regression analysis adjusted for age and BMI, the ESR1 PvuII variant was associated with risk of T2DM in three genotypic models (P < 0.025) but the strongest association was observed under over-dominant model (TT+CC vs. TC) (OR = 2.32, CI [1.18-4.55] adjusted P = 0.013). A similar but non-significant trend was also observed for the ESR1 XbaI variant under the over-dominant model (AA+GG vs. AG) (OR = 2.03, CI [1.05-3.95]; adjusted P = 0.035). The frequencies of the four haplotypes (TA, CG, CA, TG) were not significantly different in the T2DM patients compared with control group (P > 0.025). Among diabetic group, an inverse trend with risk of cardio vascular diseases was shown in carriers of CG haplotype compared to those with TA haplotype (OR = 0.28, CI [0.09-0.90]; adjusted P = 0.035). Further, stratified analyses based on ESR1 PvuII and XbaI genotypes revealed no evidence for association with lipid levels (TC, TG, HDL, LDL).

Conclusions

This is the first Palestinian study to conclude that ESR1 PuvII and XbaI variants may contribute to diabetes susceptibility in Palestinian women. Identification of genetic risk markers can be used in defining high risk subjects and in prevention trials.

A join point regression analysis of trends in mortality due to osteoporosis in Spain

Osteoporosis is a major health problem in terms of fracture probability and disability. The aim of this ecological study is to identify the temporal trends in osteoporosis mortality in Spain from 1999 to 2015. Data on the Spanish population and number of deaths due to osteoporosis were obtained from the Spanish National Institute for Statistics. Age-adjusted mortality rates were estimated. Join point regression was used to identify the years when changes in mortality s and annual percentage change in mortality rates took place. Women presented a greater mortality rate decrease (p < 0.001), though this mortality difference by sex was reduced by half at the end of the period. The higher the age, the faster the mortality rate declined in women, while no clear pattern could be identified in men. In women, significant changes in trends were identified in three age groups (50-54, 60-64 and 80-84 years old). A sustained decrease in osteoporosis-associated mortality was found in women aged 75-79 and ≥85 years and men aged 60-64. In conclusion, mortality caused by osteoporosis in Spain is decreasing faster in the older age ranges especially in women.

Raloxifene as a treatment for cognition in women with schizophrenia: the influence of menopause status

Cognitive impairments cause significant functional issues for people with schizophrenia, often emerging before the onset of hallucinations, delusions and other psychosis symptoms. Current pharmacological treatments do not target cognitive dysfunction. Several lines of evidence support the beneficial effects of estrogens on cognition. Raloxifene hydrochloride, a selective estrogen receptor modulator, has been associated with cognitive improvements in healthy postmenopausal women and in schizophrenia, although findings are inconsistent. Using pooled data from two clinical trials, the aim of the current study was to compare the efficacy of 120 mg/day adjunctive raloxifene to placebo for 12 weeks on cognitive performance in women with schizophrenia who were stratified by menopause status (pre-menopausal; peri-menopausal or post-menopausal). A total of sixty-nine participants with a diagnosis of schizophrenia or schizoaffective disorder were included. Cognition was assessed at baseline and study end using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Results indicated that after stratifying for menopause status (strata) and adjusting for endogenous hormone levels (estrogen, progesterone, follicle stimulating hormone and luteinising hormone), semantic fluency, picture naming and list recognition change from baseline scores for the raloxifene group differed significantly from the placebo group. The findings from the current study highlight the importance of considering menopause status when interpreting the effects of hormonal treatments.

Red Clover Aryl Hydrocarbon Receptor (AhR) and Estrogen Receptor (ER) Agonists Enhance Genotoxic Estrogen Metabolism

Many women consider botanical dietary supplements (BDSs) as safe alternatives to hormone therapy for menopausal symptoms. However, the effect of BDSs on breast cancer risk is largely unknown. In the estrogen chemical carcinogenesis pathway, P450 1B1 metabolizes estrogens to 4-hydroxylated catechols, which are oxidized to genotoxic quinones that initiate and promote breast cancer. In contrast, P450 1A1 catalyzed 2-hydroxylation represents a detoxification pathway. The current study evaluated the effects of red clover, a popular BDS used for women’s health, and its isoflavones, biochanin A (BA), formononetin (FN), genistein (GN), and daidzein (DZ), on estrogen metabolism. The methoxy estrogen metabolites (2-MeOE₁, 4-MeOE₁) were measured by LC-MS/MS, and CYP1A1 and CYP1B1 gene expression was analyzed by qPCR. Nonmalignant ER-negative breast epithelial cells (MCF-10A) and ER-positive breast cancer cells (MCF-7) were derived from normal breast epithelial tissue and ER+ breast cancer tissue. Red clover extract (RCE, 10 μg/mL) and isoflavones had no effect on estrogen metabolism in MCF-10A cells. However, in MCF-7 cells, RCE treatments downregulated CYP1A1 expression and enhanced genotoxic metabolism (4-MeOE₁/CYP1B1 > 2-MeOE₁/CYP1A1). Experiments with the isoflavones showed that the AhR agonists (BA, FN) preferentially induced CYP1B1 expression as well as 4-MeOE₁. In contrast, the ER agonists (GN, DZ) downregulated CYP1A1 expression likely through an epigenetic mechanism. Finally, the ER antagonist ICI 182,780 potentiated isoflavone-induced XRE-luciferase reporter activity and reversed GN and DZ induced downregulation of CYP1A1 expression. Overall, these studies show that red clover and its isoflavones have differential effects on estrogen metabolism in “normal” vs breast cancer cells. In breast cancer cells, the AhR agonists stimulate genotoxic metabolism, and the ER agonists downregulate the detoxification pathway. These data may suggest that especially breast cancer patients should avoid red clover and isoflavone based BDSs when making choices for menopausal symptom relief.