Safety and benefit considerations for menopausal hormone therapy

Ameliorating Effect of Standardized Rice Bran Supplement on Depressive-Like Behaviors in Ovariectomized Mice

Menopausal depression, often associated with hormonal fluctuations such as decreased estrogen levels, imposes significant mental health burdens. Despite the antidepressant biological properties of standardized rice bran supplement (RBS), its impact on menopausal depression and underlying mechanisms remains largely unexplored. In this study, we investigated the antidepressant effects of RBS in a mouse model of estrogen deficiency-induced depression. Ovariectomized (OVX) mice received oral doses of RBS (250 and 1000 mg/kg) and 17β estradiol over a 20-week period. RBS administration resulted in decreased immobility time in the tail suspension and forced swim tests, along with increased locomotor activity in the open field test. Furthermore, RBS enhanced nitric oxide production and neuronal nitric oxide synthase (nNOS) expression in the hippocampi of OVX mice. Additionally, RBS administration phosphorylated extracellular signal-regulated kinase (ERK), cAMP response element-binding protein (CREB), and tropomyosin receptor kinase B and increased the protein expression of brain-derived neurotrophic factor (BDNF) in the hippocampus. These findings suggest that RBS alleviated depressive behaviors in OVX mice by augmenting hippocampal nNOS expression and activating the ERK-CREB-BDNF signaling pathway. Therefore, based on these results, we propose that RBS is a promising agent to treat menopausal depression, a challenging condition.

Female reproductive status and exogenous sex hormone use in rheumatoid arthritis patients treated with tocilizumab and csDMARDs

OBJECTIVES

Sex is well known to influence risk, severity and treatment outcomes of RA, although the underlying causes are uncertain. The aim of this research was to examine whether factors influencing female sex hormones (reproductive status and exogenous sex hormone use) are associated with the efficacy of DMARDs.

METHODS

Individual participant data were pooled from five phase 3 clinical trials where RA patients were treated with tocilizumab and/or conventional synthetic DMARDs. The primary outcome was the time to first remission according to the Simplified Disease Activity Index. The relationship between menopausal status or use of exogenous sex hormones and the time of first remission was assessed via Cox proportional analysis. Analysed data included sex, baseline menopausal status (premenopausal, perimenopausal, early postmenopausal and postmenopausal), participant age, body mass index, race, number of previous DMARDs and baseline disease activity.

RESULTS

Analysis included 4474 female patients, of whom 2817 (62.9%) were postmenopausal, 202 (4.5%) were early postmenopausal, 1021 (22.8%) were premenopausal and 414 (9.2%) were perimenopausal. Of these, 221 (7.8%), 13 (6.4%), 255 (25%) and 47 (11.4%), respectively, were taking exogenous sex hormones. In the pooled analysis, perimenopausal status was associated with reduced remission compared with premenopausal status [adjusted HR 0.78 (95% CI 0.61, 0.99)]. Sex hormone use was associated with significantly higher remission [adjusted HR 1.20 (95% CI 1.01, 1.43)].

CONCLUSION

Perimenopausal women were less likely to achieve remission compared with premenopausal RA patients. The use of exogenous sex hormones appeared to be associated with more frequent remission in female RA patients, particularly those who were perimenopausal and early postmenopausal, although further research is required to confirm and identify the drivers for this observation and how it interacts with menopausal status.

Estrogen rapid effects: a window of opportunity for the aging brain?

Estrogen produces several beneficial effects in healthy neurological tissues and exhibits cardioprotective effects. Hormone therapy has been widely used to treat menopausal estrogen deficiency for more than 80 years. Despite high initial expectations of cardioprotective effects, there has been substantial distrust following important randomized clinical trials, such as the Women's Health Initiative. Subsequently, the timing of treatment in relation to the onset of menopause came under consideration and led to the proposal of the timing hypothesis, that early initial treatment is important, and benefits are lost as the timing since menopause becomes prolonged. Subsequent analyses of the Women's Health Initiative data, together with more recent data from randomized and observational trials, consistently show reductions in coronary heart disease and mortality in younger menopausal women. Regarding cognitive function, the timing hypothesis is consistent with observations from basic and animal studies. There is some clinical evidence to support the benefits of hormonal therapy in this context, though skepticism remains due to the paucity of clinical trials of substantial length in younger menopausal women. It is likely that the effects of estrogens on cognitive performance are due to rapid mechanisms, including mechanisms that influence Ca2+ homeostasis dynamics, provide protection in a hostile environment and reduce inflammatory signals from neural tissues. In the future, inflammatory profiles accounting for early signs of pathological inflammation might help identify the 'window of opportunity' to use estrogen therapy for successful cognitive protection.

Evaluation of Estrogen Receptor Agonistic Activity of Medicinal Herbs Using Organization for Economic Cooperation and Development Transactivation Assay with Rat Liver S9 Fraction

A number of studies employing different in vitro assays have demonstrated the estrogen-like activity of natural substances. All assays have their advantages and limitations as a screening tool. No single in vitro assay is considered ideal for predicting estrogenic action in a complex in vivo system. To assess agonistic activities of several medicinal herbs on the estrogen receptor (ER) and their metabolic alteration, the Organization for Economic Cooperation and Development (OECD) Performance-Based Test Guideline No. 455 in vitro assay was performed in this study using recombinant VM7Luc4E2 cells in combination with rat liver S9 fractions. Ethanol extracts of medicinal herbs showed binding affinities for ER-α and ER-β at different levels. However, luciferase reporter assay using VM7Luc4E2 cells revealed that only two test extracts [Pueraria lobata root extract (PLE); Glycyrrhiza glabra root extract (GGE)] exhibited ER transcriptional activity when their activities were compared with the response by 17β-estradiol. Importantly, incubation of PLE or GGE with rat liver S9 fractions increased their ER transcriptional activities, in particular when phase I metabolic enzymes were activated. Puerarin and glabridin were the most abundant isoflavones found in PLE and GGE, respectively. The present results demonstrate that PLE and GGE possess potential as ER agonists with their metabolic activation. This study also suggests that the application of OECD in vitro assay with rat liver S9 fraction is an efficient screening tool to evaluate estrogenic activities of natural substances.

PGRMC1 Promotes Progestin-Dependent Proliferation of Breast Cancer Cells by Binding Prohibitins Resulting in Activation of ERα Signaling

Simple Summary

Combined menopausal hormone therapy is associated with increased breast cancer risk in postmenopausal women. In our previous studies, progesterone receptor membrane component 1 (PGRMC1) was shown to play a role in progestins’ elicitation of enhanced proliferation of breast cancer cells. Here we describe a potential mechanism by which PGRMC1 contributes to breast cancer progression via interaction with prohibitins, inhibiting their function as transcriptional repressors. This facilitates estrogen receptor alpha (ERα) transcriptional activity and enhances oncogenic signaling upon treatment with certain progestins, including norethisterone and dydrogesterone. Our data underline the contribution of PGRMC1 to especially hormone receptor positive breast cancer pathogenesis and demonstrate the need for further studies to understand its role in cancer.

Abstract

In previous studies, we reported that progesterone receptor membrane component 1 (PGRMC1) is implicated in progestin signaling and possibly associated with increased breast cancer risk upon combined hormone replacement therapy. To gain mechanistic insight, we searched for potential PGRMC1 interaction partners upon progestin treatment by co-immunoprecipitation and mass spectrometry. The interactions with the identified partners were further characterized with respect to PGRMC1 phosphorylation status and with emphasis on the crosstalk between PGRMC1 and estrogen receptor α (ERα). We report that PGRMC1 overexpression resulted in increased proliferation of hormone receptor positive breast cancer cell lines upon treatment with a subgroup of progestins including norethisterone and dydrogesterone that promote PGRMC1-phosphorylation on S181. The ERα modulators prohibitin-1 (PHB1) and prohibitin-2 (PHB2) interact with PGRMC1 in dependency on S181-phosphorylation upon treatment with the same progestins. Moreover, increased interaction between PGRMC1 and PHBs correlated with decreased binding of PHBs to ERα and subsequent ERα activation. Inhibition of either PGRMC1 or ERα abolished this effect. In summary, we provide strong evidence that activated PGRMC1 associates with PHBs, competitively removing them from ERα, which then can develop its transcriptional activities on target genes. This study emphasizes the role of PGRMC1 in a key breast cancer signaling pathway which may provide a new avenue to target hormone-dependent breast cancer.

1,3-Dicaffeoylquinic Acid as an Active Compound of Arctium lappa Root Extract Ameliorates Depressive-Like Behavior by Regulating Hippocampal Nitric Oxide Synthesis in Ovariectomized Mice

Menopause is a risk factor for depression. Although 1,3-dicaffeoylquinic acid (1,3-diCQA), a phenolic compound in Arctium lappa (A. lappa) root, has various health benefits, its effects on menopausal depression remain to be determined. Therefore, this study investigates the antidepressant-like effects of 1,3-diCQA from an A. lappa root extract (AE) and the associated molecular mechanisms. Ovariectomized (OVX) mice were orally administered AE for 20 weeks, following which depression-like behaviors were assessed. Although the mice exhibited depression-like behaviors, AE administration mitigated these symptoms by activating the ERK–CREB–BDNF pathway and increasing nNOS levels in the hippocampus. Similarly, a significant increase in nNOS-derived NO production and activation of the ERK–CREB–BDNF pathway was observed in the primary hippocampal neurons. Although this stimulatory effect of 1,3-diCQA was not significantly affected by treatment with estrogen receptor agonist or antagonist, it was inhibited by 7-NI, an nNOS inhibitor. Moreover, mice treated with 1,3-diCQA exhibited a marked improvement in their forced swimming test and tail suspension test immobility, while pretreatment with 7-NI reversed the antidepressant-like effects of 1,3-diCQA. Our results suggest that 1,3-diCQA regulates nNOS in an estrogen recepters-independent manner to increase NO production in OVX mice.

Thromboembolic safety profile of low-dose estradiol (valerate) in combined hormonal preparations: Implications for the development of new hormonal endometriosis and uterine fibroid therapies

Background:

Several promising new medications containing low-dose estradiol (E2) in combination with a progestin and an additional component, such as gonadotropin-releasing hormone antagonists, are currently being developed for use in pre-menopausal women.

Objective:

This pooled analysis was designed to estimate the thromboembolic safety profile of E2 and its ester, estradiol valerate (E2Val), when used in combined hormonal treatments in a pre-menopausal population.

Methods:

Data regarding users of combined oral contraceptives (COCs) and combined menopausal hormonal therapy (MHT) containing either E2/E2Val or ethinylestradiol (EE) ⩽ 30 µg were retrieved from five large prospective, non-interventional, cohort studies in Europe, US, and Canada with similar study design but differing medication cohorts. Propensity score sub-classification was applied to balance baseline parameters between cohorts and time-to-event analysis of venous thromboembolic events (VTE) was carried out based on the extended Cox model to calculate crude and adjusted hazard ratios (HR).

Results:

(1) Crude incidence rates of VTE were higher in MHT users compared to pre-menopausal COC users, (2) the VTE risk in menopausal users of E2/E2Val-norethindrone acetate was not higher than that in menopausal users of E2/E2Val-progestin (adjusted HR 0.71; 95% confidence interval, 0.41-1.26) and (3) the VTE risk in pre-menopausal users of E2/E2Val-progestin was similar, or lower, than pre-menopausal users of EE⩽30µg-progestin (adjusted HR 0.49; 95% confidence interval, 0.28–0.84).

Conclusion:

Our data presents a solid safety assessment of combined hormonal preparations containing E2/E2Val. We conclude that the risk of E2/E2Val-norethindrone acetate in pre-menopausal users is unlikely to be higher than the known risk of COCs containing EE ⩽ 30 µg-progestin.

Climacteric symptoms and quality of life in yoga practitioners

BACKGROUND

Yoga is among the most commonly studied complementary therapies for managing climacteric symptoms. However, it is unclear whether yoga practices in premenopause can affect the occurrence of symptoms when women reach menopause.

OBJECTIVE

To assess climacteric symptoms and quality of life in regular yoga practitioners and to determine whether yoga practices before menopause may avoid or mitigate climacteric-related symptoms.

DESIGN

This study of 108 women between 40 and 65 years old included 28 women who started to practice yoga in premenopause and had already practiced for at least five years, and as controls 30 physical activity practitioners (PA) who had practiced for at least five years, and 50 sedentary women.

MAIN OUTCOME MEASURES

Climacteric symptoms were evaluated with the Kupperman Menopausal Index (KMI) and the Women's Health Questionnaire (WHQ). Moreover, we measured the quality of life with the WHQ.

RESULTS

The KMI showed that 39.3% of yoga practitioners had no menopausal symptoms, and none reported severe symptoms. The WHQ indicated a few symptoms and a good quality of life for yoga practitioners (3.56; 3.35-3.80). In addition, we found that the yoga group had significantly less moderate and severe symptoms (p = 0.002) compared with the sedentary group. We also observed that yoga practitioners had less vasomotor symptoms and memory/concentration disorders than PA practitioners (p = 0.010 and p = 0.047) and sedentary women (p = 0.001 and p = 0.001) and also used fewer drugs than the PA (p < 0.001) and the sedentary groups (p = 0.001).

CONCLUSIONS

Yoga practitioners who started to practice in premenopause had satisfactory results on the frequency and intensity of climacteric symptoms and quality of life. Although further research is required to support our findings, we conclude that yoga practice may represent an efficient non-pharmacological approach to manage and prevent climacteric symptoms.

Complementary and alternative medicine for natural and treatment-induced vasomotor symptoms: An overview of systematic reviews and meta-analyses

BACKGROUND AND PURPOSE

Vasomotor symptoms (VMS) are very common in menopausal populations and cancer patients and can cause physical and mental discomfort. We aim to summarize the findings of systematic reviews and meta-analyses (SRs/MAs) that assessed the effectiveness of complementary and alternative medicines(CAMs)on VMS to provide solid evidence for future practice.

METHODS

PubMed, Embase, the Cochrane Library, and Web of Science were searched from inception to May 2019 to identify relevant SRs/MAs. The methodological quality of SRs/MAs and evidence levels of the outcomes were assessed.

RESULTS

A total of 29 SRs/MAs were reviewed. Evidence has shown that acupuncture, hypnosis, paced respiration, cognitive behavioural therapy, genistein, soy isoflavones, S-equol, combined preparations of black cohosh, and omega-3 supplements could significantly reduce VMS. The methodological quality of the SRs/MAs was moderate or high.

CONCLUSION

CAMs might be beneficial for reducing VMS, but the evidence levels were not high. Several priorities for future practice were identified.

Choice of progestogen for endometrial protection in combination with transdermal estradiol in menopausal women

Transdermal estradiol (TE) application (using gels, patches or a novel spray) is now a preferred route of hormone therapy (HT) in menopausal women, because various risks such as venous thromboembolism, stroke and unwanted hepatic effects can be reduced compared with oral HT. However, in the presence of an intact uterus, concurrent administration of progestogen is needed for endometrial protection. Due to the variety of progestogens available and differences in their clinical effects, the selection of the most appropriate substance and dosing for individual combination therapy can be difficult. This is especially true for TE gels and the novel spray because no fixed combination products are commercially available, meaning all progestogens must be added separately, and even for patches only two transdermal synthetic progestogens are available. The aim of this review was to summarize data on the endometrial effects of the different progestogens and to provide practical recommendations for the choice of progestogen (type and dosing), with a focus on endometrial protection when using TE, especially when using the novel estradiol (E2) spray.