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Vilar L, Vilar CF, Lyra R, Freitas MDC. Pitfalls in the Diagnostic Evaluation of Hyperprolactinemia. Neuroendocrinology 2019; 109:7-19. [PMID: 30889571 DOI: 10.1159/000499694] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 03/17/2019] [Indexed: 11/19/2022]
Abstract
An appropriate diagnostic evaluation is essential for the most appropriate treatment to be performed. Currently, macroprolactinemia is the third most frequent cause of nonphysiological hyperprolactinemia after drugs and prolactinomas. Up to 40% of macroprolactinemic patients may present with hypogonadism symptoms, infertility, and/or galactorrhea. Thus, the screening for macroprolactin is indicated not only for asymptomatic subjects but also for those without an obvious cause for their prolactin (PRL) elevation. Before submitting patients to macroprolactin screening and pituitary magnetic resonance imaging, one should rule out pregnancy, drug-induced hyperprolactinemia, primary hypothyroidism, and renal failure. The magnitude of PRL elevation can be useful in determining the etiology of hyperprolactinemia. PRL values >250 ng/mL are highly suggestive of prolactinomas and virtually exclude nonfunctioning pituitary adenomas (NFPAs) and other sellar masses as the etiology of hyperprolactinemia. However, they can also be found in subjects with macroprolactinemia, drug-induced hyper-prolactinemia or chronic renal failure. By contrast, most patients with NFPAs, drug-induced hyperprolactinemia, macroprolactinemia, or systemic diseases present with PRL levels <100 ng/mL. However, exceptions to these rules are not rare. Indeed, up to 25% of patients harboring a microprolactinoma or a cystic macroprolactinoma may also have PRL <100 ng/mL. Falsely low PRL levels may result from the so-called "hook effect," which should be considered in all cases of large (≥3 cm) pituitary adenomas associated with normal or mildly elevated PRL levels (≤250 ng/mL). The hook effect may be unmasked by repeating PRL measurement after a 1:100 serum sample dilution.
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Affiliation(s)
- Lucio Vilar
- Division of Endocrinology, Hospital das Clinicas, Federal University of Pernambuco, Recife, Brazil,
- Pernambuco Endocrine Research Center, Recife, Brazil,
| | | | - Ruy Lyra
- Division of Endocrinology, Hospital das Clinicas, Federal University of Pernambuco, Recife, Brazil
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Relationship between sex hormone binding globulin and blood coagulation in women on postmenopausal hormone treatment. Blood Coagul Fibrinolysis 2019; 30:17-23. [DOI: 10.1097/mbc.0000000000000784] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Tikk K, Sookthai D, Johnson T, Dossus L, Clavel-Chapelon F, Tjønneland A, Olsen A, Overvad K, Baglietto L, Rinaldi S, Romieu I, Boeing H, Trichopoulou A, Lagiou P, Trichopoulos D, Masala G, Agnoli C, Tumino R, Sacerdote C, Mattiello A, Buckland G, Sánchez S, Molina-Montes E, Amiano P, Castaño JMH, Barricarte A, Bueno-de-Mesquita HB, Monninkhof EM, Onland-Moret NC, Idahl A, Lundin E, Weiderpass E, Lund E, Waaseth M, Khaw KT, Key TJ, Travis RC, Gunter MJ, Riboli E, Kaaks R. Prolactin determinants in healthy women: A large cross-sectional study within the EPIC cohort. Cancer Epidemiol Biomarkers Prev 2014; 23:2532-42. [PMID: 25143360 DOI: 10.1158/1055-9965.epi-14-0613] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Experimental and epidemiologic data suggest that higher circulating prolactin is associated with breast cancer risk; however, how various risk factors for breast cancer influence prolactin levels in healthy women is not clear. METHODS We analyzed cross-sectional associations between several suggested reproductive and lifestyle risk factors for breast cancer and circulating prolactin among pre- and postmenopausal women, taking into account the use of current postmenopausal hormone therapy, among 2,560 controls from a breast cancer nested case-control study within the EPIC cohort. RESULTS Adjusted geometric mean prolactin levels were significantly higher among premenopausal women, and among postmenopausal women using hormone therapy compared with nonusers (8.2, 7.0, and 6.3 ng/mL, respectively; Pcat = <0.0001). Furthermore, prolactin levels were significantly higher among users of combined estrogen-progestin hormone therapy compared with users of estrogen-alone hormone therapy (6.66 vs. 5.90 ng/mL; Pcat = 0.001). Prolactin levels were lower among parous women compared with nulliparous women (8.61 vs. 10.95 ng/mL; Pcat = 0.0002, premenopausal women); the magnitude of this difference depended on the number of full-term pregnancies (22.1% lower, ≥3 vs. 1 pregnancy, Ptrend = 0.01). Results for parity were similar but lower in magnitude among postmenopausal women. Prolactin did not vary by other studied factors, with the exception of lower levels among postmenopausal smokers compared with never smokers. CONCLUSIONS Our study shows that current hormone therapy use, especially the use of combined hormone therapy, is associated with higher circulating prolactin levels in postmenopausal women, and confirms prior findings of lower circulating prolactin in parous women. IMPACT Our study extends the knowledge linking various breast cancer risk factors with circulating prolactin.
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Affiliation(s)
- Kaja Tikk
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Disorn Sookthai
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Theron Johnson
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Laure Dossus
- Nutrition, Hormones, and Women's Health Team, Centre for Research in Epidemiology and Population Health (CESP), INSERM U1018, Villejuif, France. Univ Paris Sud, UMRS 1018, Villejuif, France. IGR, Villejuif, France
| | - Françoise Clavel-Chapelon
- Nutrition, Hormones, and Women's Health Team, Centre for Research in Epidemiology and Population Health (CESP), INSERM U1018, Villejuif, France. Univ Paris Sud, UMRS 1018, Villejuif, France. IGR, Villejuif, France
| | | | - Anja Olsen
- Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Kim Overvad
- Section for Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Laura Baglietto
- Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia. Centre for Molecular, Environmental, Genetic, and Analytic Epidemiology, The University of Melbourne, Melbourne, Australia
| | - Sabina Rinaldi
- Section of Nutrition and Metabolism, International Agency for Research on Cancer (IARC), Lyon, France
| | - Isabelle Romieu
- Section of Nutrition and Metabolism, International Agency for Research on Cancer (IARC), Lyon, France
| | - Heiner Boeing
- Department of Epidemiology, German Institute of Human Nutrition (DIfE), Nuthetal, Germany
| | - Antonia Trichopoulou
- Department of Hygiene, Epidemiology, and Medical Statistics, University of Athens Medical School, Athens, Greece. Hellenic Health Foundation, Athens, Greece
| | - Pagona Lagiou
- Department of Hygiene, Epidemiology, and Medical Statistics, University of Athens Medical School, Athens, Greece. Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts. Bureau of Epidemiologic Research, Academy of Athens, Athens, Greece
| | - Dimitrios Trichopoulos
- Hellenic Health Foundation, Athens, Greece. Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts. Bureau of Epidemiologic Research, Academy of Athens, Athens, Greece
| | - Giovanna Masala
- Molecular and Nutritional Epidemiology Unit, Cancer Research and Prevention Institute-ISPO, Florence, Italy
| | - Claudia Agnoli
- Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Rosario Tumino
- Cancer Registry and Histopathology Unit, "Civic-M.P.Arezzo" Hospital ASP, Ragusa, Italy
| | - Carlotta Sacerdote
- Center for Cancer Prevention (CPO-Piemonte), Torino, Italy. Human Genetic Foundation (HuGeF), Torino, Italy
| | - Amalia Mattiello
- Department of Clinical and Experimental Medicine, Federico II University, Naples, Italy
| | - Genevieve Buckland
- Unit of Nutrition, Environment, and Cancer, Cancer Epidemiology Research Programme, Catalan Institute of Oncology (ICO-IDIBELL), Barcelona, Spain
| | | | - Esther Molina-Montes
- Escuela Andaluza de Salud Pública, Instituto de Investigación Biosanitario de Granada, Granada, Spain. Consortium for Biomedical Research in Epidemiology and Public Health (CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Pilar Amiano
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain. Basque Regional Health Department, Public Health Division of Gipuzkoa, San Sebastian, Spain
| | - José María Huerta Castaño
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain. Department of Epidemiology, Murcia Regional Health Authority, Murcia, Spain
| | - Aurelio Barricarte
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain. Navarre Public Health Institute, Pamplona, Spain
| | - H Bas Bueno-de-Mesquita
- National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands. Department of Gastroenterology and Hepatology, University Medical Centre, Utrecht, the Netherlands. School of Public Health, Imperial College, London, United Kingdom
| | - Evelyn M Monninkhof
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, the Netherlands
| | - N Charlotte Onland-Moret
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, the Netherlands
| | - Annika Idahl
- Department of Clinical Sciences, Obstetrics and Gynaecology, Faculty of Medicine, Umeå University, Umeå, Sweden
| | - Eva Lundin
- Department of Medical Biosciences, Pathology, Faculty of Medicine, Umeå University, Umeå, Sweden
| | - Elisabete Weiderpass
- Department of Community Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway. Department of Research, Cancer Registry of Norway, Oslo, Norway. Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden. Samfundet Folkhälsan, Helsinki, Finland
| | - Eiliv Lund
- Department of Community Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - Marit Waaseth
- Department of Pharmacy, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - Kay-Tee Khaw
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Timothy J Key
- Cancer Epidemiology Unit, University of Oxford, Oxford, United Kingdom
| | - Ruth C Travis
- Cancer Epidemiology Unit, University of Oxford, Oxford, United Kingdom
| | - Marc J Gunter
- School of Public Health, Imperial College, London, United Kingdom
| | - Elio Riboli
- School of Public Health, Imperial College, London, United Kingdom
| | - Rudolf Kaaks
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
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Kraemer RR, Francois M, Castracane VD. Estrogen mediation of hormone responses to exercise. Metabolism 2012; 61:1337-46. [PMID: 22512823 DOI: 10.1016/j.metabol.2012.03.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Revised: 03/15/2012] [Accepted: 03/15/2012] [Indexed: 10/28/2022]
Abstract
The roles of estrogens extend from the regulation of reproduction to other functions involved in control of metabolism, fluid balance, as well as gastrointestinal, lung, and brain function, with a strong effect on other hormones that subsequently alter the physiology of multiple tissues. As such, alteration of endogenous estrogens across the menstrual cycle, or from oral contraception and estrogen replacement therapy, can affect these tissues. Due to the important effects that estrogens have on different tissues, there are many investigations concerning the effects of a human estrogenic environment on endocrine responses to exercise. The following review will describe the consequences of varying estrogen levels on pituitary, adrenal, gonadal, and endocrine function, followed by discussion of the outcomes of different estrogen levels on endocrine tissues in response to exercise, problems encountered for interpretation of findings, and recommended direction for future research.
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Affiliation(s)
- Robert R Kraemer
- Department of Kinesiology and Health Studies, Southeastern Louisiana University, Hammond, LA 70402, USA.
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Faupel-Badger JM, Sherman ME, Garcia-Closas M, Gaudet MM, Falk RT, Andaya A, Pfeiffer RM, Yang XR, Lissowska J, Brinton LA, Peplonska B, Vonderhaar BK, Figueroa JD. Prolactin serum levels and breast cancer: relationships with risk factors and tumour characteristics among pre- and postmenopausal women in a population-based case-control study from Poland. Br J Cancer 2010; 103:1097-102. [PMID: 20736944 PMCID: PMC2965860 DOI: 10.1038/sj.bjc.6605844] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Previous prospective studies have found an association between prolactin (PRL) levels and increased risk of breast cancer. Using data from a population-based breast cancer case–control study conducted in two cities in Poland (2000–2003), we examined the association of PRL levels with breast cancer risk factors among controls and with tumour characteristics among the cases. Methods: We analysed PRL serum levels among 773 controls without breast cancer matched on age and residence to 776 invasive breast cancer cases with available pretreatment serum. Tumours were centrally reviewed and prepared as tissue microarrays for immunohistochemical analysis. Breast cancer risk factors, assessed by interview, were related to serum PRL levels among controls using analysis of variance. Mean serum PRL levels by tumour characteristics are reported. These associations also were evaluated using polytomous logistic regression. Results: Prolactin levels were associated with nulliparity in premenopausal (P=0.05) but not in postmenopausal women. Associations in postmenopausal women included an inverse association with increasing body mass index (P=0.0008) and direct association with use of recent/current hormone therapy (P=0.0006). In case-only analyses, higher PRL levels were more strongly associated with lobular compared with ductal carcinoma among postmenopausal women (P=0.02). Levels were not different by tumour size, grade, node involvement or oestrogen receptor, progesterone receptor, or human epidermal growth factor receptor 2 status. Conclusions: Our analysis demonstrates that PRL levels are higher among premenopausal nulliparous as compared with parous women. Among postmenopausal women, levels were higher among hormone users and lower among obese women. These results may have value in understanding the mechanisms underlying several breast cancer risk factor associations.
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Affiliation(s)
- J M Faupel-Badger
- Cancer Prevention Fellowship Program, Center for Cancer Training, National Cancer Institute, 6120 Executive Blvd (EPS), Suite 150E, MSC 7105, Bethesda, MD 20892, USA.
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Madhusoodanan S, Parida S, Jimenez C. Hyperprolactinemia associated with psychotropics--a review. Hum Psychopharmacol 2010; 25:281-97. [PMID: 20521318 DOI: 10.1002/hup.1116] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Different classes of psychotropics can cause hyperprolactinemia to varying degrees. Among antipsychotics, typical agents and risperidone are the most frequent and significant offenders. In this review we discuss the pathophysiology, offending medications, assessment and management of hyperprolactinemia. METHODS We did a literature review between 1976 and 2008 using PubMed, MEDLINE, PsychINFO and Cochrane database. Search terms used were prolactin, hyperprolactinemia, psychotropics, antipsychotics, typical antipsychotics, atypical antipsychotics, antidepressants and SSRIs. RESULTS Prolactin elevation is more common with antipsychotics than with other classes of drugs. Typical antipsychotics are more prone to cause hyperprolactinemia than atypical agents. Management options include discontinuation of offending medication, switching to another psychotropic, supplementing concurrent hormonal deficiencies and adding a dopamine agonist or aripiprazole. CONCLUSION Clinicians need to be alert about the potential for hyperprolactinemia and its manifestations with these medications. Prolactin levels need to be monitored and other causes of hyperprolactinemia ruled out in suspected cases.
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Seeger H, Wallwiener D, Mueck AO. Effects of drospirenone on cardiovascular markers in human aortic endothelial cells. Climacteric 2009; 12:80-7. [DOI: 10.1080/13697130802403994] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Mueck AO, Seeger H. Progestogens and target tissues: Vascular systems. Maturitas 2009; 62:356-61. [DOI: 10.1016/j.maturitas.2008.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2008] [Revised: 11/28/2008] [Accepted: 12/02/2008] [Indexed: 11/29/2022]
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Yoshikata R, Miyahara Y, Onoe Y, Okano H, Ohta H. Possible risk factor for postmenopausal women: postprandial hypertriglyceridemia. J Obstet Gynaecol Res 2009; 34:1032-6. [PMID: 19012704 DOI: 10.1111/j.1447-0756.2008.00800.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To explore the clinical implications of postprandial hypertriglyceridemia in postmenopausal Japanese women. METHODS Postprandial blood samples were collected from 91 women at their initial visit, with fasting blood samples collected within the following month to examine their lipid profiles. These women were grouped into normotriglyceridemia (fasting/postprandial triglycerides [TG] < 150; n = 36), mild postprandial hypertriglyceridemia (fasting TG < 150, postprandial TG > or = 150, < 225; n = 27), moderate postprandial hypertriglyceridemia (fasting TG < 150, postprandial TG > or = 225; n = 19) and hypertriglyceridemia (fasting TG > or = 150; n = 9) by using 225 mg/dL as the cut-off value for postprandial hypertriglyceridemia. RESULTS The subjects were 54.1 +/- 7.8 years old; their duration of menopause, 6.0 +/- 7.7 years; body mass index, 21.4 +/- 4.0 kg/m(2); postprandial TG concentration, 189 +/- 110 mg/dL; and fasting TG concentration, 109 +/- 50 mg/dL. Approximately 50% (n = 46) of the women had normal fasting TG (fasting TG < 150), but high postprandial TG (postprandial TG > or = 150). Approximately 10% (n = 9) of the women had hypertriglyceridemia (fasting TG > or = 150 mg/dL). In those with postprandial hypertriglyceridemia (n = 46), postprandial TG negatively correlated with high-density lipoprotein cholesterol (HDL-C), while fasting TG showed no such correlation with HDL-C. CONCLUSION Postprandial TG may provide a better understanding of lipid metabolism in postmenopausal women.
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Affiliation(s)
- Remi Yoshikata
- Department of Obstetrics and Gynecology, Tokyo Women's Medical University, Tokyo, Japan.
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Abstract
Medications commonly cause hyperprolactinemia and their use must be differentiated from pathologic causes. The most common medications to cause hyperprolactinemia are the antipsychotic agents, although some of the newer atypical antipsychotics do not do so. Other medications causing hyperprolactinemia include antidepressants, antihypertensive agents, and drugs which increase bowel motility. Often, the medication-induced hyperprolactinemia is symptomatic, causing galactorrhea, menstrual disturbance, and erectile dysfunction. In the individual patient, it is important differentiate hyperprolactinemia due to a medication from a structural lesion in the hypothalamic-pituitary area. This can be done by stopping the medication temporarily to determine if the prolactin (PRL) levels return to normal, switching to another medication in the same class which does not cause hyperprolactinemia (in consultation with the patient's physician and/or psychiatrist), or by performing an MRI or CT scan. If the hyperprolactinemia is symptomatic, management strategies include switching to an alternative medication which does not cause hyperprolactinemia, using estrogen/testosterone replacement, or cautiously adding a dopamine agonist.
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Affiliation(s)
- Mark E Molitch
- Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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12
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Abstract
In several respects prolactin is unique among anterior pituitary hormones. The primary regulation of prolactin secretion is mediated through hypothalamic inhibition, and the diagnosis of hyperprolactinemia can be established without the use of stimulation or suppression tests. Documenting the presence of hyperprolactinemia is not difficult-the challenge is in identifying the cause of the hormone hypersecretion. With immunoradiometric assays falsely low levels of prolactin are occasionally seen in patients with macroadenomas and very high serum prolactin (the hook effect). Macroprolactin should be suspected when a patient with hyperprolactinemia does not present with typical clinical symptoms, and all hyperprolactinemic sera should be screened for macroprolactin. With prolactinomas, prolactin levels generally parallel tumor size. Prolactin secreting macroadenomas are typically associated with levels that exceed 250 microg/l and may exceed 1,000 microg/l. Large non-functioning adenomas also lead to hyperprolactinemia but levels virtually never exceed 94 microg/l. Acquired and isolated prolactin deficiency is rare.
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Affiliation(s)
- Jaspreet Chahal
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA
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Gao J, Tiwari-Pandey R, Samadfam R, Yang Y, Miao D, Karaplis AC, Sairam MR, Goltzman D. Altered ovarian function affects skeletal homeostasis independent of the action of follicle-stimulating hormone. Endocrinology 2007; 148:2613-21. [PMID: 17332067 DOI: 10.1210/en.2006-1404] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Osteoporosis is a leading public health problem. Although a major cause in women is thought to be a decline in estrogen, it has recently been proposed that FSH or follitropin is required for osteoporotic bone loss. We examined the FSH receptor null mouse (FORKO mouse) to determine whether altered ovarian function could induce bone loss independent of FSH action. By 3 months of age, FORKO mice developed age-dependent declines in bone mineral density and trabecular bone volume of the lumbar spine and femur, which could be partly reversed by ovarian transplantation. Bilateral ovariectomy reduced elevated circulating testosterone levels in FORKO mice and decreased bone mass to levels indistinguishable from those in ovariectomized wild-type controls. Androgen receptor blockade and especially aromatase inhibition each produced bone volume reductions in the FORKO mouse. The results indicate that ovarian secretory products, notably estrogen, and peripheral conversion of ovarian androgen to estrogen can alter bone homeostasis independent of any bone resorptive action of FSH.
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Affiliation(s)
- Jianjun Gao
- Calcium Research Laboratory, McGill University Health Centre, 687 Pine Avenue West, Montreal, Quebec, Canada
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Abstract
BACKGROUND Menopause is a normal milestone experienced annually by 2 million American women each year, and many women are concerned about the relation between menopause and health. Associated hormonal changes have the potential to influence neurologic disease, as do hormonal therapies prescribed for menopausal symptoms or other conditions. The objective of this article is to increase neurologists' awareness of the relation between menopause and neurologic illness. REVIEW SUMMARY This was a focused review of 4 common neurologic disorders potentially influenced by menopause or by estrogen-containing hormone therapy: stroke, epilepsy, Parkinson disease, and Alzheimer disease. Hormonal effects are germane to each illness, although clinical implications are clearer for stroke and Alzheimer disease than for epilepsy and Parkinson disease. For women with epilepsy, few clinical data directly address the role of menopause or estrogen-containing hormone therapy on seizure frequency. Relevant clinical research findings on Parkinson disease are inconsistent and provide an inadequate basis for practice guidelines. There is clinical trial evidence that hormone therapy does not reduce stroke incidence and may increase risk of ischemic stroke; hormone therapy cannot be recommended for stroke prevention. The natural menopausal transition is not characterized by objective memory loss. There is clinical trial evidence that hormone therapy should not be used for the postmenopausal woman age 65 years or older for the preservation of cognitive skills, prevention of dementia, or treatment of dementia due to Alzheimer disease. Long-term cognitive consequences of short-term hormone therapy used by younger women for menopausal symptoms remains an important area of uncertainty. CONCLUSIONS Increased awareness of hormonal influences on neurologic illness is important for the practicing neurologist.
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Affiliation(s)
- Victor W Henderson
- Department of Health Research, Stanford University, Stanford, California 94305-5405, USA.
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Abstract
The main mechanism of possible cardioprotection by estrogens appears to be a direct effect on the vasculature, resulting in an improvement of endothelial function and inhibition of atherogenesis. Numerous observational and experimental studies have demonstrated a positive correlation between estrogens and various biochemical markers surrogating direct vascular effects. In general, most markers are influenced in a similar way by oral and transdermal hormone therapy, although oral therapy may have a faster and more pronounced effect. The main difference between oral and transdermal administration may be confined to markers that are mainly or exclusively produced in the liver. Clinical studies demonstrate that progestogen addition can have an impact on the beneficial estrogen-induced changes of biochemical markers. Concerning the effects of tibolone, inconsistent data have been found. Overall, tibolone-induced beneficial changes on the various biochemical markers appear to be less marked compared with those of hormone therapy. The few data available on the direct effects of androgens on the vascular wall indicate a less favorable action of androgens on biochemical markers than of estrogens. The practical relevance of marker measurements is currently under discussion. Although evidence strongly supports some of these markers as predictors of acute events, it remains to be established whether modifying circulating levels of these markers will influence outcomes.
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Affiliation(s)
- Alfred O Mueck
- Section of Endocrinology and Menopause, University Women's Hospital, Tuebingen, Germany.
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Abstract
Medication use is a common cause of hyperprolactinemia, and it is important to differentiate this cause from pathologic causes, such as prolactinomas. To ascertain the frequency of this clinical problem and to develop treatment guidelines, the medical literature was searched by using PubMed and the reference lists of other articles dealing with hyperprolactinemia due to specific types of medications. The medications that most commonly cause hyperprolactinemia are antipsychotic agents; however, some newer atypical antipsychotics do not cause this condition. Other classes of medications that cause hyperprolactinemia include antidepressants, antihypertensive agents, and drugs that increase bowel motility. Hyperprolactinemia caused by medications is commonly symptomatic, causing galactorrhea, menstrual disturbance, and impotence. It is Important to ensure that hyperprolactinemia in an Individual patient is due to medication and not to a structural lesion in the hypothalamic/pituitary area; this can be accomplished by (1) stopping the medication temporarily to determine whether prolactin levels return to normal, (2) switching to a medication that does not cause hyperprolactinemia (in consultation with the patient's psychiatrist for psychoactive medications), or (3) performing magnetic resonance imaging or computed tomography of the hypothalamic/pituitary area. If the patient's hyperprolactinemia is symptomatic, treatment strategies include switching to an alternative medication that does not cause hyperprolactinemia, using estrogen or testosterone replacement, or, rarely, cautiously adding a dopamine agonist.
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Affiliation(s)
- Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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17
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Lobo RA. Appropriate use of hormones should alleviate concerns of cardiovascular and breast cancer risk. Maturitas 2005; 51:98-109. [PMID: 15883114 DOI: 10.1016/j.maturitas.2005.02.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2004] [Revised: 02/08/2005] [Accepted: 02/08/2005] [Indexed: 11/19/2022]
Abstract
Since the publication of several recent randomized trials in the United States, prescriptions for hormonal therapy have dropped precipitously. This has been due, in large part, to the concerns about the increased risk of cardiovascular (CV) disease and breast cancer among the hormone users. This review takes the perspective that the appropriate use of hormones largely alleviates these concerns. The appropriate use of hormones pertains to treating younger, healthy women who have menopausal symptoms as well as using low-doses of hormones. In the randomized trials, suggesting an increased CV risk, the older women were largely asymptomatic and had other CV risk factors. Data are presented to suggest that there is no increased CV risk with hormonal therapy in younger, healthy women within 5 years of menopause. Moreover, a model is presented to attempt to explain the potential of preventing CV disease when estrogen is begun early, and the relative hazard associated with later use. The risk of breast cancer with hormonal therapy is put into perspective with the realization that this risk is related to hormonal dose and duration of use, and that the absolute risk remains small. Use of progestogens, in particular, appears to enhance this risk. The appropriate use of hormones also pertains to using lower-doses. Here data are presented showing efficacy with lower-doses and improved safety. With the use of lower-doses of estrogens, the progestogen dose, as required in women with a uterus, can be minimized.
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Affiliation(s)
- Rogerio A Lobo
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA.
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Tworoger SS, Missmer SA, Barbieri RL, Willett WC, Colditz GA, Hankinson SE. Plasma sex hormone concentrations and subsequent risk of breast cancer among women using postmenopausal hormones. J Natl Cancer Inst 2005; 97:595-602. [PMID: 15840882 DOI: 10.1093/jnci/dji099] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Sex hormone concentrations are associated with breast cancer risk among women not using postmenopausal hormones (PMH); however, whether a relationship exists among PMH users is unknown. Therefore, we conducted a prospective, nested case-control study within the Nurses' Health Study (NHS) cohort to examine the association between plasma sex hormone concentrations and postmenopausal breast cancer among women using PMH at blood collection. METHODS Blood samples were collected from 1989 to 1990. During follow-up through May 31, 2000, 446 women developed breast cancer and were matched by age, date and time of day of blood collection, and fasting status to 459 control subjects (PMH users) who did not develop cancer. We used conditional logistic regression to estimate relative risks (RRs) and 95% confidence intervals (CIs). We compared hormone concentrations of the 459 control subjects with those of 363 postmenopausal NHS participants not taking PMH. All statistical tests were two-sided. RESULTS PMH users had statistically significantly higher estradiol, free estradiol, sex hormone-binding globulin, and testosterone, and lower free testosterone concentrations than non-PMH users. Among PMH users, we found modest associations with breast cancer risk when comparing the highest versus lowest quartiles of free estradiol (RR = 1.7, 95% CI = 1.1 to 2.7; P(trend) = .06), free testosterone (RR = 1.6, 95% CI = 1.1 to 2.4; P(trend) = .03), and sex hormone-binding globulin (RR = 0.7, 95% CI = 0.5 to 1.1; P(trend) = .04), but not of estradiol or of testosterone. However, estradiol and free estradiol were statistically significantly positively associated with breast cancer risk among women older than 60 years (RR = 2.8, 95% CI = 1.5 to 5.0; P(trend) = .002 and 2.6, 95% CI = 1.4 to 4.7; P(trend) = .001, respectively) and among women with a body mass index of less than 25 kg/m2 (RR = 1.8, 95% CI = 1.1 to 3.1, P(trend) = .01 and 2.4, 95% CI = 1.4 to 4.0, P(trend) = .003, respectively). CONCLUSION Although women using PMH have a different hormonal profile than those not using PMH, plasma sex hormone concentrations appear to be associated with breast cancer risk among PMH users.
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Affiliation(s)
- Shelley S Tworoger
- Channing Laboratory, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
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Abstract
Alzheimer's disease (AD) is the most common cause of dementia. After menopause, circulating levels of oestrogens decline markedly and oestrogen influences several brain processes predicted to modify AD risk. For example, oestrogen reduces the formation of beta-amyloid, a biochemical hallmark of AD. Oestrogen effects on oxidative stress and some effects on inflammation and the cerebral vasculature might also be expected to ameliorate risk. However, AD pathogenesis is incompletely understood and other oestrogen actions could be deleterious. Limited clinical trial evidence suggests that oestrogen therapy, begun after the onset of AD symptoms, is without substantial benefit or harm. Observational studies have associated oestrogen-containing hormone therapy with reduced AD risk. However, in the Women's Health Initiative Memory Study - a randomised, placebo-controlled trial of women 65 - 79 years of age - oral oestrogen plus progestin doubled the rate of dementia, with heightened risk appearing soon after treatment was initiated. Based on current evidence, hormone therapy is thus not indicated for the prevention of AD. Discrepancies between observational studies and the Women's Health Initiative clinical trial may reflect biases and unrecognised confounding factors in observational reports. Other explanations for divergent findings should be considered in future research, including effects of unopposed oestrogen or different hormone therapy preparations and the intriguing theoretical possibility that effects of hormone therapy on AD risk may be modified by the timing of use (e.g., initiation during the menopausal transition or early postmenopause versus initiation during the late postmenopause).
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Affiliation(s)
- Victor W Henderson
- Donald W Reynolda Center on Aging, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
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20
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Abstract
Pharmacologic resistance to dopamine agonists is defined here as failure to normalize PRL levels and failure to decrease macroprolactinoma size by >or=50%. Failure to normalize PRL levels is found in about one-quarter of patients treated with bromocriptine and 10-15% of those treated with pergolide or cabergoline. Failure to achieve at least a 50% reduction in tumor size occurs in about one-third of those treated with bromocriptine and 10-15% of those treated with pergolide or cabergoline. The cause of dopamine resistance is primarily a decrease in D(2) receptors but the receptors have normal affinity for dopamine. Treatment approaches for patients resistant to dopamine agonists include changing to another dopamine agonist and increasing the dose of the drug as long as there is continued response to the dose increases and no adverse effects with higher doses. Transsphenoidal surgery is also an option. Clomiphene, gonadotropins, and GnRH can be used if fertility is desired. For those not desiring fertility, estrogen replacement may be used unless there is a macroadenoma, in which case control of tumor growth is also an issue and dopamine agonists are generally necessary. In many patients modest or even no reduction in tumor size may be acceptable as long as there is not tumor growth. Hormone replacement (estrogen or testosterone) may cause a decrease in efficacy of the dopamine agonist so that it must be carried out cautiously. Reduction of endogenous estrogen, use of selective estrogen receptor modulators, and aromatase inhibitors are potential experimental approaches.
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Affiliation(s)
- Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 303 E. Chicago Avenue, Tarry 15-731, Chicago, IL 60611, USA.
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Järvinen A, Kainulainen P, Nissilä M, Nikkanen H, Kela M. Pharmacokinetics of estradiol valerate and medroxyprogesterone acetate in different age groups of postmenopausal women. Maturitas 2004; 47:209-17. [PMID: 15036491 DOI: 10.1016/j.maturitas.2003.01.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2002] [Revised: 12/30/2002] [Accepted: 01/27/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To study whether ageing affects the pharmacokinetics of estradiol valerate (E2V) or medroxyprogesterone acetate (MPA) in postmenopausal women. METHODS Forty-six postmenopausal women from two essentially similar pharmacokinetic studies were divided into three age categories: under 60 years (n = 15), between 60 and 65 years (n = 18) and over 65 years (n = 13). They all were treated for 12 days or 14 days with four galenically identical tablets containing combinations of 1 mg or 2 mg E2V and 2.5 mg or 5 mg MPA. The studies followed an open, randomised cross-over design with no washout between the periods. Serum estradiol and MPA concentrations were measured at steady state on study day 12 or 14 of each period. RESULTS No statistically significant differences were observed in the peak concentration (Cmax), time to peak (t(max)), AUC or elimination half-life for estradiol or MPA between the different age groups. In spite of the lack of statistical significance the AUC was on an average 1.6-fold and Cmax 1.40-fold higher in the oldest group of women than in the youngest group and age was found significant as a continuous variable for AUC and Cmax for MPA but not for estradiol. CONCLUSIONS The results suggest that there would be no significant changes in the pharmacokinetics of estradiol between women under 60 and over 65 years of age. However, a significant trend towards higher MPA concentrations and bioavailability was observed with increasing age. The results suggest that from the pharmacokinetic point of view the relationship between estradiol and MPA dose to be used in elderly could be different from that in younger postmenopausal women, while no pharmacokinetic reasons to use lower estradiol doses in the elderly were observed.
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Affiliation(s)
- Asko Järvinen
- Department of Medicine, Helsinki University Central Hospital, P.O. Box 348, FIN-00029 HUS, Helsinki, Finland.
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22
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Castelo-Branco C, Colodrón M. Terapia hormonal sustitutiva a bajas dosis. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2004. [DOI: 10.1016/s0210-573x(04)77326-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Mercuro G, Vitale C, Fini M, Zoncu S, Leonardo F, Rosano GMC. Lipid profiles and endothelial function with low-dose hormone replacement therapy in postmenopausal women at risk for coronary artery disease: a randomized trial. Int J Cardiol 2003; 89:257-65. [PMID: 12767550 DOI: 10.1016/s0167-5273(02)00505-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
AIMS To compare the effect of low (0.3 mg) and commonly prescribed (0.625 mg) doses of conjugated equine estrogens (CEE) on brachial artery flow-mediated dilation and lipid profiles. METHODS AND RESULTS Twenty-five postmenopausal women (mean age, 65+/-6 years) at risk for coronary artery disease (CAD) (> or =2 established risk factors) entered a double-blind crossover study. Brachial artery endothelial function was evaluated by means of high-resolution vascular echography. Both CEE doses significantly decreased total cholesterol (-13%, 0.3 mg; -15%, 0.625 mg), low-density lipoprotein-cholesterol (LDL-C) (-15%, 0.3 mg; -16%, 0.625 mg), and lipoprotein(a) (-28%, 0.3 mg; -39%, 0.625 mg) values from baseline levels. Both treatments increased high-density lipoprotein-cholesterol (HDL-C) (5%, 0.3 mg; 7%, 0.625 mg) and triglycerides (3%, 0.3 mg; 8%, 0.625 mg). There was no dose effect for changes in the LDL-C/HDL-C ratio (-21%, 0.3 mg; -23%, 0.625 mg). Both doses improved brachial artery dilation during reactive hyperemia by 63% over baseline. CONCLUSION In women at risk for CAD, low-dose hormone replacement treatment (HRT) improves lipid profiles and brachial artery endothelial function comparably to the most commonly prescribed dose. The benefit:risk ratio of low-dose HRT provides an attractive option for postmenopausal women at risk for CAD.
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Affiliation(s)
- Giuseppe Mercuro
- Cardiovascular Research Unit, Department of Internal Medicine, San Raffaele Hospital, Rome, Italy
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Abstract
Several new products and regimens for estrogen replacement in the postmenopausal woman have recently been introduced, giving physicians and patients greater choice not only in dose but also in route of administration. Estrogen treatment in the postmenopausal woman has several proven benefits for those who have vasomotor symptoms or problems related to urogenital atrophy. However, the most controversial area is in the long-term preventive benefits of estrogen against the development of osteoporosis and cardiovascular disease, particularly in women older than 60 years. It is in these areas that decisions on the dose and optimal route of administration of estrogen replacement therapy (ERT) must be made. Although adding a progestogen to an ERT regimen is mandatory, particularly in a woman with an intact uterus, discussion now focuses on which progestogen least attenuates the beneficial effects of estrogen. Emerging trends suggest that lower doses of estrogen (i.e. ethinylestradiol 5 microg/day, estradiol 0.25 mg/day or conjugated estrogens [CEE] 0.3 mg/day) continuously combined with lower doses of medroxyprogesterone (MPA) are equally effective at relieving vasomotor symptoms as the most commonly prescribed regimen in the US (CEE 0.625mg/MPA 2.5mg daily), with fewer adverse events, leading to greater patient acceptance and likelihood for continuation of therapy. This is especially important when therapy is initiated at an older age.
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Affiliation(s)
- Valerie Montgomery Rice
- Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, Kansas 66160, USA.
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Reindollar R, Koltun W, Parsons A, Rosen A, Siddhanti S, Plouffe L. Effects of oral raloxifene on serum estradiol levels and other markers of estrogenicity. Fertil Steril 2002; 78:469-72. [PMID: 12215319 DOI: 10.1016/s0015-0282(02)03288-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine the effects of raloxifene hydrochloride, 60 mg/d, on serum levels of E(2), estrone, sex steroid-binding globulin, thyroxine-binding globulin, and follicle-stimulating hormone (FSH) in postmenopausal women. DESIGN Randomized placebo-controlled study at 16 centers in the United States. PATIENT(S) Ninety three women 42 to 80 years of age who were at least 2 years postmenopausal. INTERVENTION(S) Raloxifene (n = 47) or placebo (n = 46) for 3 months. MAIN OUTCOME MEASURE(S) Levels of E(2), estrone, sex steroid-binding globulin, thyroxine-binding globulin, and FSH were measured at baseline and after 3 months of therapy. RESULT(S) Raloxifene increased serum levels of sex steroid-binding globulin and thyroxine-binding globulin and decreased FSH levels compared with placebo. Levels of E(2) and estrone were unaffected. CONCLUSION(S) In postmenopausal women, raloxifene (60 mg/d) did not increase serum estrogen levels; however, it increased levels of sex steroid-binding globulin and thyroxine-binding globulin and decreased FSH levels.
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Affiliation(s)
- Richard Reindollar
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Inc, Boston, Massachusetts, USA
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Abstract
After menopause, women have less favorable lipid profiles than before menopause. While regular exercise improves lipid metabolism in men, the specifics for doing so in pre- and postmenopausal women are not fully understood. Literature review suggests that higher-volume aerobic exercise programs increase high-density lipoprotein cholesterol (HDL-C) levels in both pre- and postmenopausal women. Although longitudinal studies of resistance training did not reveal increases in HDL-C levels in women, other favorable benefits observed included decreases in low-density lipoprotein-cholesterol, total cholesterol, and body fat. Cross-sectional studies, however, seem to favor high-volume exercise for increasing HDL-C levels.
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Affiliation(s)
- E A Dowling
- Department of Exercise Science, Physical Education, and Recreation, Old Dominion University, Norfolk, VA, 23529-0196, USA.
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Lobo RA, Bush T, Carr BR, Pickar JH. Effects of lower doses of conjugated equine estrogens and medroxyprogesterone acetate on plasma lipids and lipoproteins, coagulation factors, and carbohydrate metabolism. Fertil Steril 2001; 76:13-24. [PMID: 11438314 DOI: 10.1016/s0015-0282(01)01829-5] [Citation(s) in RCA: 137] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the effects of lower doses of conjugated equine estrogens (CEE) alone or CEE and medroxyprogesterone acetate (MPA) on lipoproteins, carbohydrate metabolism, and coagulation/fibrinolytic factors. DESIGN Randomized, double-blind, placebo-controlled study. SETTING Multicenter substudy of the Women's HOPE trial. PATIENT(S) Seven hundred and forty-nine healthy, postmenopausal women. INTERVENTION(S) Women were randomized to receive the following doses in milligrams per day: 0.625 CEE; 0.625 CEE/2.5 MPA; 0.45 CEE; 0.45 CEE/2.5 MPA; 0.45 CEE/1.5 MPA; 0.3 CEE; 0.3 CEE/1.5 MPA; or placebo. MAIN OUTCOME MEASURE(S) Assessment of lipids, lipoproteins, glucose tolerance, and coagulation/fibrinolytic factors at baseline, cycle 6, and year 1. RESULT(S) One year of treatment with any of the CEE or CEE/MPA regimens studied increased high-density lipoprotein cholesterol (HDL-C); the 10% increase in HDL-C for the CEE 0.45/MPA 1.5 group was similar to the CEE 0.625/MPA 2.5 group. Low-density lipoprotein cholesterol was significantly reduced in all of the active treatment groups except the CEE 0.3/MPA 1.5 group at cycle 13. Apolipoprotein A-I and triglyceride levels increased and apolipoprotein B levels decreased in all groups. The lipoprotein (a) level was reduced in the CEE 0.45/MPA 2.5, CEE 0.45/MPA 1.5, and CEE 0.625/MPA 2.5 groups. Minimal changes were observed in carbohydrate metabolism for all groups. Fibrinogen and PAI-1 activity decreased and plasminogen activity increased in all groups. Decreases in antithrombin III and protein S activities were significant for all active treatment groups except the CEE 0.3/MPA 1.5 group. CONCLUSION(S) Lower doses of CEE and CEE/MPA induce favorable changes in lipids, lipoproteins, and hemostatic factors with minimal changes in carbohydrate metabolism.
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Affiliation(s)
- R A Lobo
- Department of Obstetrics and Gynecology, Columbia-Presbyterian Medical Center, New York, New York 10032-3784, USA.
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Godsland IF. Effects of postmenopausal hormone replacement therapy on lipid, lipoprotein, and apolipoprotein (a) concentrations: analysis of studies published from 1974-2000. Fertil Steril 2001; 75:898-915. [PMID: 11334901 DOI: 10.1016/s0015-0282(01)01699-5] [Citation(s) in RCA: 274] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To establish reference estimates of the effects of different hormone replacement therapy (HRT) regimens on lipid and lipoprotein levels. DESIGN Review and pooled analysis of prospective studies published up until the year 2000. SETTING Clinical trials centers, hospitals, menopause clinics. PATIENT(S) Healthy postmenopausal women. INTERVENTION(S) Estrogen alone, estrogen plus progestogen, tibolone, or raloxifene in the treatment of menopausal symptoms. MAIN OUTCOME MEASURE(S) Serum high- and low-density lipoprotein (HDL and LDL) cholesterol, total cholesterol, triglycerides, and lipoprotein (a). RESULT(S) Two-hundred forty-eight studies provided information on the effects of 42 different HRT regimens. All estrogen alone regimens raised HDL cholesterol and lowered LDL and total cholesterol. Oral estrogens raised triglycerides. Transdermal estradiol 17-beta lowered triglycerides. Progestogens had little effect on estrogen-induced reductions in LDL and total cholesterol. Estrogen-induced increases in HDL and triglycerides were opposed according to type of progestogen, in the order from least to greatest effect: dydrogesterone and medrogestone, progesterone, cyproterone acetate, medroxyprogesterone acetate, transdermal norethindrone acetate, norgestrel, and oral norethindrone acetate. Tibolone decreased HDL cholesterol and triglyceride levels. Raloxifene reduced LDL cholesterol levels. In 41 studies of 20 different formulations, HRT generally lowered lipoprotein (a). CONCLUSION(S) Route of estrogen administration and type of progestogen determined differential effects of HRT on lipid and lipoprotein levels. Future work will focus on the interpretation of the clinical significance of these changes.
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Affiliation(s)
- I F Godsland
- Endocrinology and Metabolic Medicine, Division of Medicine, Imperial College School of Medicine, London, United Kingdom.
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Abstract
It is well known that estrogen deficiency is the major determinant of bone loss in postmenopausal women. Estrogen is important to the bone remodeling process through direct and indirect actions on bone cells. The largest clinical experience exists with estrogen therapy, demonstrating its successful prevention of osteoporosis as well as its positive influence on oral bone health, vasomotor and urogenital symptoms, and cardiovascular risk factors, which may not occur with other nonestrogen-based treatments. Compliance with HRT, however, is typically poor because of the potential side effects and possible increased risk of breast or endometrial cancer. Nevertheless, there is now evidence that lower doses of estrogens in elderly women may prevent bone loss while minimizing the side effects seen with higher doses of estrogen. Additionally, when adequate calcium, vitamin D, and exercise are used in combination with estrogen-based treatments, more positive increases occur in bone density. The benefits and risks of HRT must be assessed on a case-by-case basis, and the decision to use HRT is a matter for each patient in consultation with her physician. Estrogen-based therapy remains the treatment of choice for the prevention of osteoporosis in most postmenopausal women, and there may be a role for estrogen to play in the prevention of corticosteroid osteoporosis. Combination therapies using estrogen should probably be reserved for patients who continue to fracture on single therapy or should be used in patients who present initially with severe osteoporosis.
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Affiliation(s)
- J C Gallagher
- Bone Metabolism Unit, Creighton University Medical Center, St. Joseph's Hospital, Omaha, Nebraska, USA.
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