Drospirenone, a progestin with a unique cardiovascular profile, for safe contraception and treatment of menopausal symptoms

Effect of hormone therapy on blood pressure and hypertension in postmenopausal women: a systematic review and meta-analysis

IMPORTANCE

Menopausal hormone therapy (HT) includes a wide variety of hormonal compounds, and its effect on blood pressure is still uncertain.

OBJECTIVE

The aim of this study was to assess evidence regarding the effect of HT on blood pressure in postmenopausal women and its association with arterial hypertension.

EVIDENCE REVIEW

This systematic review and meta-analysis included randomized clinical trials and prospective observational studies. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and the incidence of hypertension were assessed. All stages were independently performed by two reviewers. For blood pressure outcome, standardized mean differences (SMD) and 95% confidence intervals (95% CI) were calculated as effect measures. Heterogeneity was assessed using the I2 statistic. The results are presented based on the HT type. The incidence of hypertension was compared using descriptive analyses.

FINDINGS

Eleven studies were included with 81,041 women evaluated, of which 29,812 used HT. The meta-analysis, conducted with 8 studies and 1,718 women, showed an increase in SBP with the use of oral conjugated equine estrogens plus progestogen (SMD = 0.60 mm Hg, 95% CI = 0.19 to 1.01). However, oral or transdermal use of estradiol plus progestogen (SMD = -2.00 mm Hg, 95% CI = -7.26 to 3.27), estradiol alone, and tibolone did not show any significant effect. No significant effect on DBP was observed for any formulation. Women who used oral estrogen plus progestogen had a higher risk of incident hypertension than those who never used it.

CONCLUSIONS AND RELEVANCE

The effect of HT on blood pressure is influenced by the formulation used, especially the type of estrogen. The combined formulations of conjugated equine estrogens plus progestogen increased SBP and the risk of hypertension, which was not observed among estradiol plus progestogen, estradiol alone, and tibolone users.

Comparative effectiveness of the approaches to correct vascular structural and functional disturbances in postmenopausal women

Aim.To compare the effects of Mildronate and hormone replacement therapy (HRT) with estradiol (1 mg) and drospirenone, DSPR (2 mg) on circadian blood pressure (BP) profile, arterial structure and function, and vascular stiffness parameters in women with early postmenopause and climacteric syndrome (CS).Material and methods.The study included 94 women with early postmenopause and CS, who provided written informed consent to participate and were divided into two groups. Group I included 36 women receiving Mildronate (500 mg twice a day), while Group II included 28 women who were administered, according to clinical indications, HRT (1 mg 17β-estradiol and 2 mg DRSP once a day). The control group (CG) included 30 women who did not receive either Mildronate or DRSP. At baseline and 16 weeks later, all participants underwent the assessment of blood biochemistry; intima-media thickness (IMT) of common carotid artery (CCA); endothelium-dependent vasodilatation (EDVD) of brachial artery (BA); antithrombogenic activity of vascular wall; aortal pulse wave velocity (aPWV); arterial stiffness; and 24-hour BP monitoring (BPM).Results.The study demonstrated positive effects of Mildronate therapy and HRT (1 mg 17β-estradiol and 2 mg DRSP) on metabolic status, circadian dynamics and variability (Var) of BP, and arterial structure and function. The largest positive changes in blood lipid profile were observed in Group I and II patients. By the end of the study, these patients demonstrated significantly decreased levels of systolic and diastolic BP and reduced BP Var, particularly in Group II. Mildronate therapy, but not HRT, was associated with normalisation of vascular wall antiaggregant potential. Group II demonstrated a significant reduction in CCA IMT levels, with a similar tendency in Group I. In both groups, the degree of endothelial dysfunction (ED) decreased, which was manifested in increased BA EDVD, decreased aPWV, and reduced arterial stiffness and was more pronounced in Group II.Conclusion.In menopausal women with CS, the effects of Mildronate and HRT on metabolic, structural, and functional disturbances were similar. Therefore, Mildronate therapy could be a new method of correction of these systemic disturbances.

Cardiorenal disturbances in perimenopausal women

Aim. To identify early signs of renal dysfunction; to investigate the associations between renal function and vascular remodelling; to evaluate the role of metabolic and hydrodynamic disturbances in the development of cardiorenal syndrome among perimenopausal women; and to assess the potential of hormone replacement therapy (17β-estradiol 1 mg and drospirenone 2 mg) for the correction of the above-mentioned disturbances. Material and methods. In total, 69 perimenopausal women were divided into two groups. Group I included 69 premenopausal women, while Group II consisted of 43 women in early postmenopause. Mean age in Group I was 49,0 years (95% CI 48,0-51,0 years); in Group II, it was 54,0 (50,0-56,0) years (p<0,01). Age at menopause reached 50,3 (48,0-52,0) years, with median duration of menopause of 3,5 (2,0-5,0) years. All participants underwent biochemical blood tests (creatinine (Cr), uric acid (UA), lipid profile, and glucose tolerance test (GTT)). Large elastic artery remodelling was assessed by intima-media thickness (IMT) of common carotid artery (CCA). Non-invasive assessment of endothelial vasoregulatory function involved the measurement of brachial artery (BA) endothelium-dependent vasodilatation (EDVD) in the reactive hyperemia test (RHT). Renal function was assessed by glomerular filtration rate (GFR) and Cr clearance (CrC). Monoalbuminuria (MAU) was qualitatively assessed with a urine strip test. Postmenopausal women were additionally divided into two groups: 23 patients were administered HRT (17β-estradiol 1 mg and drospirenone 2 mg; Angelique medication), while 20 women not receiving HRT comprised a control group. At the end of the study, after 12 months, the assessment of metabolic status, body mass dynamics, endothelial vasoregulatory function, and CCA IMT was repeated. Results. In most postmenopausal women, lipid and carbohydrate metabolism disturbances were observed, which were typical for metabolic syndrome (MS). Lipid metabolism disturbances were observed as early as in premenopause, but reached their maximum during early postmenopause. Postmenopausal women, compared to their peers in premenopause, had significantly higher fasting and postprandial levels of blood glucose. Structural and functional changes in vascular wall were more severe in postmenopausal vs. premenopausal women (p<0,001). While blood flow velocity in the RHT was comparable in both groups, postmenopausal women did not demonstrate a comparable increase in BA EDVD, in contrast to premenopausal females. This could point to the decrease in BA sensitivity to endothelial shear stress among women in postmenopause. Reduced GFR was observed only in postmenopausal women. MAU was registered in premenopausal women with normal GFR, as well as in postmenopausal females. These data on independent role of MAU and reduced GFR suggest an increase in the proportion of women with subclinical renal injury, as a manifestation of target organ damage. Conclusion. The associations between vascular structure and function, renal function, and main MS components were demonstrated. HRT (17β-estradiol 1 mg and drospirenone 2 mg) had beneficial effects on BP dynamics, visceral obesity, metabolic status, and arterial structure and function.

Safety, efficacy and patient acceptability of drospirenone and estradiol in the treatment of menopausal vasomotor symptoms: a review

During menopause vasomotor symptoms are one of the main complaints about which women seek medical advice. For symptom control, several therapies have been used, among which hormone therapy has produced good results. One of these is estrogen monotherapy, which unfortunately may induce endometrial hyperplasia in women with an intact uterus. A progestin must be added to avoid this risk. Progestins may induce several secondary effects such as breast tenderness, hirsutism, edema and unfavorable lipid profile modifications. Recently a new progestin called drospirenone has been synthesized and used in combination with estradiol for the treatment of postmenopausal women. This progestin is derived from spironolactone, and lacks estrogenic, androgenic and glucocorticoid activities. Several studies have evaluated safety, efficacy and patient tolerability, and have shown a good profile in all these parameters. All studies agree that the combination of estradiol 1 mg plus drospirenone 2 mg is a good choice for postmenopausal women with vasomotor symptoms.

Hormones and cardiovascular health in women

Cardiovascular diseases (CVDs) may have their origin before birth: the combination of being small at birth and having an overly rich post-natal diet increases the likelihood of obesity and of acquiring a specific metabolic syndrome in adulthood that carries an increased risk of CVD. The incidence of CVD and mortality is very low in women of reproductive age but rises to a significant level in older women. In this article, we discuss CVD in relation to hormonal contraception, pregnancy and polycystic ovarian syndrome (PCOS) in younger women and menopause in older women. Women with PCOS have a higher risk of diabetes and hypertension, but studies to date have not shown an effect on CVD events. Use of combined hormonal contraception has only small effects on CVD because of the low baseline incidence of myocardial infarction (MI), stroke and venous thromboembolism (VTE) among young women. Women with existing risk factors or existing CVD, however, should consider alternative contraception. In pregnancy, CVD is rare, although, in the West, it now accounts for a significant proportion of maternal mortality as the frequency of obstetrical causes of mortality has substantially declined. The frequency of VTE is 15 per 10,000 during pregnancy and the post-partum period. In older women, menopause causes a slightly higher risk of MI after allowing for age, although there is substantial heterogeneity in the results of studies on menopause and age at menopause and MI. A larger effect might have been expected, because estrogen reduces the risk of developing atherosclerosis in premenopausal women, whereas in post-menopausal women who may have established atherosclerotic disease, estrogen increases the risk of myocardial disease through the effects on plaque stability and clot formation. Recent trial results indicate that hormone treatment in menopause does not favourably affect the risk of MI, stroke or other vascular disease. Thus, prevention of CVD should rely on diet and fitness, low-dose aspirin and treatment of hypertension, hyperglycaemia and hyperlipidaemia.