Development of low-dose reproductive hormone therapies in China

Cardiovascular health and the menopausal woman: the role of estrogen and when to begin and end hormone treatment

Reports have correlated the use of estrogen for the treatment of menopausal symptoms with beneficial effects on the cardiovascular system. Molecular, biochemical, preclinical, and clinical studies have furnished a wealth of evidence in support of this outcome of estrogen action. The prospective randomized Women's Health Initiative (WHI) and the Early Versus Late Intervention Trial (ELITE) showed that starting menopausal hormone treatment (MHT) within 5 to 10 years of menopause is fundamental to the success of estrogen's cardioprotection in post-menopausal women without adverse effects. Age stratification of the WHI data has shown that starting hormone treatment within the first decade after menopause is both safe and effective, and the long-term WHI follow-up studies are supportive of cardioprotection. This is especially true in estrogen-treated women who underwent surgical menopause. A critique of the WHI and other relevant studies is presented, supporting that the timely use of estrogens protects against age- and hormone-related cardiovascular complications. Salutary long-term hormone treatment for menopausal symptoms and prevention of complications has been widely reported, but there are no prospective trials defining the correct length to continue MHT. At present, women undergoing premature menopause receive estrogen treatment (ET) until evidence of hormone-related complications intervenes. Normal women started on MHT who receive treatment for decades without hormone-related complications have been reported, and the WHI follow-up studies are promising of long-term post-treatment cardioprotection. A prevention-based holistic approach is proposed for timely and continuing MHT/ET administration as part of the general management of the menopausal woman. But this should be undertaken only with scheduled, annual patient visits including evaluations of cardiovascular status. Because of the continued occurrence of reproductive cancers well into older ages, these visits should include genital and breast cancer screening.

Reproductive history and risk of depressive symptoms in postmenopausal women: A cross-sectional study in eastern China

BACKGROUND

Although there are potential mechanisms of female hormones in depression, conflicting results still exist in epidemiological studies. This study aimed to determine whether reproductive history, an important indicator of estrogen exposure across the lifetime, is associated with risk of depressive symptoms in postmenopausal women.

METHODS

We analyzed the baseline data from Zhejiang Ageing and Health Cohort Study including 5537 postmenopausal women. Depressive symptoms were assessed through the application of Patient Health Questionnaire-9 scale (PHQ-9). Logistic regression models, controlling for an extensive range of potential confounders, were generated to examine the association between reproductive history and risk of depressive symptoms in later life.

RESULTS

Longer reproductive period (Odds Ratio (OR) = 0.972, 95% Confidence Interval (CI) 0.955-0.989), regular menstrual cycle (OR = 0.723, 95% CI 0.525-0.995), later age at first gave birth (OR = 0.953, 95% CI 0.919-0.988) were significantly associated with a reduced risk of late-life depressive symptoms. Among women with regular menstrual cycle, longer cycle length increased the risk (OR = 1.050, 95% CI 1.016-1.085). Meanwhile, more full-term pregnancies and more incomplete pregnancies were related to higher prevalence of depressive symptoms. Women who underwent tubal sterilization as only type of contraceptive surgery were found less likely to suffer depressive symptoms in later life (OR = 0.433, 95% CI 0.348-0.538).

LIMITATIONS

Cross-sectional data could not make a causation conclusion.

CONCLUSIONS

Our results indicated that reproductive factors were significantly associated with risk of depressive symptoms in postmenopausal women. Further longitudinal studies are needed.

Awareness of hormone replacement therapy in medical care personnel in Jiaxing, China: a questionnaire survey

This study was aimed to investigate the attitudes and knowledge of medical personnel on hormone replacement therapy (HRT) in treating perimenopausal syndrome. A total of 2580 self-administered questionnaire forms were sent to medical care professionals and the responses collected were anonymous. The questionnaire included information on levels of awareness, benefits, and potential risks of HRT. A total of 2158 questionnaire forms were filled and used for statistical analysis; 61.4% of gynecologists believed that it was necessary to conduct HRT in suitable patients, 89.1% would like to recommend the therapy to patients with perimenopausal syndrome, and 83.2% of the participants were willing to take training on HRT. The mean score of awareness of HRT among the respondents was 3.14 out of 10. The main reason for them to avoid HRT was fear of cancer (43.8%), weight gain (30.4%), addiction (21.9%), and thrombus (3.9%). These results indicated that a large proportion of gynecologists are willing to recommend HRT to a woman complaining of climacteric disorders. However, awareness of HRT among the health workers (including gynecologists) is relatively low. They are also worried about the risks. A more concerted effort should be made to better disseminate information on HRT.

Aromatase: Contributions to Physiology and Disease in Women and Men

Aromatase (estrogen synthetase; EC 1.14.14.1) catalyzes the demethylation of androgens' carbon 19, producing phenolic 18-carbon estrogens. Aromatase is most widely known for its roles in reproduction and reproductive system diseases, and as a target for inhibitor therapy in estrogen-sensitive diseases including cancer, endometriosis, and leiomyoma (141, 143). However, all tissues contain estrogen receptor-expressing cells, the majority of genes have a complete or partial estrogen response element that regulates their expression (61), and there are plentiful nonreceptor effects of estrogens (79); therefore, the effect of aromatase through the provision of estrogen is almost universal in terms of health and disease. This review will provide a brief but comprehensive overview of the enzyme, its role in steroidogenesis, the problems that arise with its functional mutations and mishaps, the roles in human physiology of aromatase and its product estrogens, its current clinical roles, and the effects of aromatase inhibitors. While much of the story is that of the consequences of the formation of its product estrogens, we also will address alternative enzymatic roles of aromatase as a demethylase or nonenzymatic actions of this versatile molecule. Although this short review is meant to be thorough, it is by no means exhaustive; rather, it is meant to reflect the cutting-edge, exciting properties and possibilities of this ancient enzyme and its products.

Sex Steroids Block the Initiation of Atherosclerosis

Atherosclerosis is the main cause of death in men and women. This so-called "hardening of the arteries" results from advanced atherogenesis, the accumulation and death of subendothelial fat-laden macrophages (vascular plaque). The macrophages are attracted as the result of signals from injured vessels recruiting and activating cells to quell the injury by inflammation. Among the recruited cells are circulating monocytes that may be captured by the formation of neural cell adhesion molecule (nCAM) tethers between the monocytes and vascular endothelium; the tethers are dependent on electrostatic binding between distal segments of apposed nCAM molecules. The capture of monocytes is followed by their entry into the subendothelial area as macrophages, many of which will remain and become the fat-laden foam cells in vascular plaque. Neural cell adhesion molecules are subject to sialylation that blocks their electrostatic binding. We showed that estradiol-induced nCAM sialylases are present in vascular endothelial cells and tested whether sex steroid pretreatment of human vascular endothelium could inhibit the capture of monocytes. Using in vitro techniques, pretreatment of human arterial endothelial cells with estradiol, testosterone, dehydroepiandrosterone and dihydrotestosterone all induced sialylation of endothelial cells and, in a dose-response manner, reduced the capture of monocytes. Steroid hormones are protective against atherogenesis and its sequellae. Sex steroid depletion is associated with atherosclerosis. Based on this knowledge plus our results using sex steroid pretreatment of endothelial cells, we propose that the blockade of the initial step in atherogenesis by sex steroid-induced nCAM sialylation may be crucial to hormonal prevention of atherosclerosis.

The Women's Health Initiative trial and related studies: 10 years later: a clinician's view

The Women's Health Initiative (WHI) assessed the long-term effects of hormone therapy (HT) in postmenopausal women. The WHI started HT treatment on women aged 50-79 years in order to ascertain these effects. The study was ended early, due to findings of increased risk of coronary heart disease, breast cancer, stroke, and thromboembolic complications in women receiving estrogen plus progestin, compared to placebo. An increased risk of thromboembolic complications was also demonstrated in the estrogen only component of the WHI. The WHI results were initially reported for all subjects, and showed little difference when data were not analyzed by age. New WHI sub-analyses stratifying results by age, and an extended follow-up of the WHI offer a more complete picture of the effects of HT, revealing that starting HT in postmenopausal women less than ten years from last menstrual period appears to have less risk. In addition, hysterectomized women treated with estrogen only in the WHI have showed less risk of adverse outcomes than women in the estrogen plus progestin group. In this paper, we review data supporting the use of HT administered to postmenopausal women, showing it to have more benefit than risk for symptom control, prevention of bone mineral loss and fracture, and improvement of the metabolic profile in women who began HT when they were less than 60 years of age and had their last menstrual period less than ten years previous. In hysterectomized women treated with estrogen only, a reduction in breast cancer risk was noted in all age groups. The WHI raised many important questions. Ten years later, some have been answered, including confirmation that HT for most newly menopausal women is safe and effective. The treatment of the aging woman, including hormone treatment after menopause, should remain one of our highest research priorities. This article is part of a Special Issue entitled 'Menopause'.

Effects of hormone replacement therapy on magnetic resonance imaging of brain parenchyma hyperintensities in postmenopausal women

AIM

To apply 3.0 magnetic resonance imaging (MRI) to study the effects of long-term, low dose hormone replacement therapy (HRT) on the brain parenchyma of postmenopausal women.

METHODS

A total of 155 postmenopausal healthy female medical staff members from Peking Union Medical College Hospital were enrolled. The HRT group was composed of 71 subjects who had been given a low dose of HRT for over 4 years, while 84 women who had never been given HRT were enrolled in the control group. The Mini-Mental State Examination (MMSE) was used to evaluate mental state, and an Enzyme-Linked ImmunoSorbent Assay (ELISA) was used to detect plasma levels of sex hormones. In addition, all participants were subjected to an MRI, including axial T2 weighted imaging (T2WI), fluid-attenuated inversion recovery (FLAIR), T1 weighted imaging (T1WI, oblique coronal, vertical to the hippocampus, slice thickness 3 mm without gaps), and a 3D image of the whole brain.

RESULTS

The ELISA showed that the plasma level of estradiol in the HRT group was significantly higher than that in the control group (P<0.05). No differences were observed in the MMSE between the two groups. In participants older than 70 years of age, the number of deep white matter hyperintensities (DWMHs) in the control group was significantly higher than that in the HRT group (P=0.0013); however, in other age subgroups, no statistical differences were observed. Finally, no significant difference in periventricular hyperintensity (PVH) between the two groups was observed.

CONCLUSION

We found that a high plasma level of estradiol in postmenopausal women receiving long-term HRT was correlated with the survival of brain parenchyma.Acta Pharmacologica Sinica (2009) 30: 1065-1070; doi: 10.1038/aps.2009.81.

Can menopausal hormone therapy prevent coronary heart disease?

Observational studies show that women who take menopausal hormone therapy (MHT) have a greatly reduced risk of coronary heart disease (CHD). But in some large randomized controlled trials, MHT failed to decrease CHD and so has been deemed inappropriate for long-term prophylaxis against atherosclerosis or other chronic diseases associated with the menopause. Despite the apparent strength of this conclusion, several recent reports suggest that MHT could be atheroprotective when started close to the menopause, and effects of early discontinuation of MHT have never been studied in randomized trials. Here, we examine these reports and highlight existing uncertainty regarding the effects of long-term continuation versus early discontinuation of early-start MHT on atherosclerosis and CHD risk. We call for new research on this question, and an evidence-based review of existing recommendations for MHT.

Effects of long-term low-dose hormone replacement therapy on the binding capacity of platelet peripheral-type benzodiazepine receptor in postmenopausal women

The effects of long-term low-dose hormone replacement therapy (HRT) on the level of hormone in plasma and on the binding capacity of peripheral-type benzodiazepine receptor (PBR) on the platelet membranes were investigated among women. This study was a retrospective and case-controlled study where 64 women using long-term low-dose HRT for over 4 years entered the study and 99 women, age and education matched, were enrolled as control. Plasma hormone level and platelet PBR binding capacity of two groups were analyzed. A significant increase in plasma estradiol level in women using HRT was observed, compared to those in the control group. Meanwhile, women in the HRT group displayed higher platelet PBR binding capacity. Further analysis demonstrated that the binding capacity of platelet PBR was closely related to estradiol plasma level in all subjects. These results suggest that long-term low-dose HRT could relieve the decrease of estradiol level in plasma and PBR binding capacity on platelets in postmenopausal women, alleviate the endocrine imbalance process, and might be beneficial for reducing the risks of some diseases.