Hormone replacement therapy use over a decade in an Australian population

Glutamatergic and GABAergic neurons in the preoptic area of the hypothalamus play key roles in menopausal hot flashes

During menopause, when estrogen levels are low, abnormalities in the hypothalamic preoptic area (POA) of the thermoregulatory center can cause hot flashes. However, the involved neural population has not been identified. Proteomics showed that under low estrogen, differentially expressed proteins in the hypothalamus were associated with glutamatergic and GABAergic synapses. RNAscope, Western blotting and qRT-PCR indicated that the number of glutamatergic neurons in the POA was decreased, while the number of GABAergic neurons was increased. Chemogenetics showed that the rat body temperature decreased slowly after glutamatergic neurons were activated and increased quickly after glutamatergic neurons were inhibited, while it increased quickly after GABAergic neurons were activated and decreased slowly after GABAergic neurons were inhibited. RNAscope, immunofluorescence, Western blotting and qRT-PCR further showed that glutamate decarboxylase (GAD) 1 expression in the POA was increased, while GAD2 expression in the POA was decreased; that thermosensitive transient receptor potential protein (ThermoTRP) M (TRPM) 2 expression in glutamatergic neurons was decreased, while TRPM8 expression in GABAergic neurons was increased; and that estrogen receptor (ER) α and β expression in the POA was decreased, and ERα and ERβ expressed in both glutamatergic and GABAergic neurons. Estrogen therapy corrected these abnormalities. In addition, CUT&Tag and Western blot after injection of agonists and inhibitors of ERs showed that ERα and ERβ were both transcription factors in glutamatergic and GABAergic synapses. Mechanistically, during menopause, estrogen may regulate the transcription and expression of GADs and ThermoTRPs through ERs, impacting the number and function of glutamatergic and GABAergic neurons, resulting in unbalanced heat dissipation and production in the POA and ultimately triggering hot flashes.

Estimates of overdiagnosis of invasive breast cancer associated with screening mammography

PURPOSE

To estimate the extent of overdiagnosis of invasive breast cancer associated with screening in New South Wales, Australia, a population with a well-established mammography screening program which has achieved full geographic coverage.

METHODS

We calculated overdiagnosis as the observed annual incidence of invasive breast cancer in NSW in 1999-2001 (a screened population) minus the expected annual incidence in this population at the same time, as a percentage of the expected incidence. We estimated expected incidence without screening in 1999-2001 from the incidence of invasive breast cancer in: (1) women in unscreened age groups (interpolation method); and (2) women in all age groups prior to the implementation of screening (extrapolation method). We then adjusted these estimates for trends in major risk factors for breast cancer that may have coincided with the introduction of mammography screening: increasing obesity, use of hormone replacement therapy (HRT) and nulliparity. Finally, we adjusted for lead time to produce estimates of expected incidence in 1999-2001. These were compared with the observed incidence in 1999-2001 to calculate overdiagnosis of breast cancer associated with screening.

RESULTS

Overdiagnosis of invasive breast cancer among 50-69 year NSW women was estimated to be 42 and 30% using the interpolation and extrapolation methods, respectively.

CONCLUSION

Overdiagnosis of invasive breast cancer attributable to mammography screening appears to be substantial. Our estimates are similar to recent estimates from other screening programmes. Overdiagnosis merits greater attention in research and in clinical and public health policy making.

Continuing decline in hormone therapy use: population trends over 17 years

OBJECTIVE

To describe the prevalence of menopausal hormone therapy (HT) in 2008 and trends over the last 17 years in an Australian population.

METHODS

Data were obtained from nine representative population face-to-face interview surveys of the South Australian population from 1991 to 2008. The surveys used consistent method and quality control procedures. In 2008, demographic data, HT use and eight dimensions of health, using the SF-36 health survey questionnaire, were measured. Participants Over 3000 South Australian adults were interviewed in their own home by trained health interviewers in each of the surveys; in the 2008 survey, 1555 women participated, of whom 953 were over age 40.

RESULTS

After a peak in use in the 2000 survey, HT use fell from 2003 and has continued to decline in 2008. In 2008, current use over age 50 of registered conventional HT products is now 11.8%, with a further 4.0% using non-registered alternative 'hormonal' products. Current HT use is highest between the ages of 50 and 59 years, where 13.4% use conventional HT and 7.7% use unconventional alternative hormones. Use of these unregistered hormonal products was rare in previous surveys. Median and mean length of conventional HT use were 10.0 and 10.5 years, respectively. HT users continued to have a demographic profile similar to those in previous surveys, i.e. they were better educated, employed, partnered, had a higher income and were less inclined to use complementary and alternative medicines.

CONCLUSIONS

There has been a continuing decline in both the overall prevalence and length of use of conventional HT from 2003, probably in association with negative media about HT. Of medical concern is that about one-quarter of women using HT around menopause now chooses unregistered hormonal mixtures that are untested for long-term safety and efficacy.

Seminars may increase recruitment to randomised controlled trials: lessons learned from WISDOM

Background

Recruiting patients to large randomised controlled trials (RCTs) in the primary care setting can be challenging. Research teams need to identify and utilise strategies that both maximise the efficiency of recruitment and minimise the burden on general practitioners.

Purpose

To describe our methods for identifying, approaching and recruiting female patients aged 50–69 years to a long-term double-blind RCT of hormone therapy (HT) – the Women's International Study of long Duration Oestrogen after Menopause (WISDOM). The effectiveness of conducting group seminars with patients prior to one-to-one screening is discussed.

Methods

Female patients aged between 50 and 69 years were sent letters from participating general practitioners in Adelaide inviting them to participate in WISDOM and attend an initial seminar providing information about HT and the trial prior to a screening interview with a trial nurse. Recruitment rates for those who did or did not attend group seminars were compared.

Results

Women who attended a group seminar conducted by the research team were twice as likely to attend an initial screening visit and enrol to participate in WISDOM than women who did not attend a seminar (p < 0.001). In addition, it was estimated that the time required to randomise a woman in the trial, and the number and duration of telephone calls to screen out uninterested women, was reduced for the seminar group.

Conclusion

Conducting group seminars with potential participants may be a useful strategy for maximising recruitment from general practice, by increasing patient information and reducing a research team's workload.

Trial registration

Current Controlled Trials ISRCTN63718836

Hormones down under: Hormone therapy use after the Women's Health Initiative

AIMS

The primary objective was to describe the usage pattern of hormone therapy (HT) in a sample of urban Australian women in 2001 and to assess the characteristics of users vs. non-users. The second objective was to determine whether there had been any change in usage since the publication of the results of the combined oestrogen plus progestagen arm of the Women's Health Initiative (WHI) in 2002.

METHODS

A cohort of 374 postmenopausal women aged 50-80 years participated in this substudy of the LAW (Longitudinal Assessment of Ageing in Women) project: a 5-year multidisciplinary, observational study. Participants completed an annual medical assessment including details of the use of HT and the reasons for use, as well as demographic and psychosocial data.

RESULTS

In December 2001, 30.8% of the participants were using HT, whereas 55.4% were ever users. The management of vasomotor symptoms and mood disturbance were the primary reasons for use. Of those who had been using HT in December 2001 (24.4%) women ceased using HT in the 3 months following publication of the WHI results. The percentage of women using HT in December 2003 (13.9%) was less than half of that of December 2001.

CONCLUSION

The rate of HT use and the reasons for use, in 2001 in Brisbane was similar to that of other Australian regions. Usage of HT decreased since the publication of the WHI results in 2002 which may reflect changing attitudes by patients and practitioners regarding HT.

Postmenopausal hormone therapy: who now takes it and do they differ from non-users?

BACKGROUND

Considerable changes in hormone therapy use have taken place in the last few years.

AIMS

To determine current usage of postmenopausal hormone therapy and assess the trend and rate of change in hormone therapy usage over the last 13 years. Additionally, to assess differences between current users and non-users for health-related and risk factor variables.

METHODS

Questions regarding hormone therapy use have been included in an annual face to face population health survey of South Australians eight times since 1991. In 2004, additional questions on health status and quality of life were included.

RESULTS

In 2004, current use of hormone therapy was 15.4, 19.8 and 31.2% in all women over 40, 50 and 50-59 years, respectively. Ever use of hormone therapy among all women over 50 years was 46.5% with a mean duration of use of 7.46 years. Hormone therapy users did not differ from non-users in chronic disease indicators, body mass index, complementary medicine or therapist use, other health service use, socioeconomic status or quality of life. Increased hormone therapy use was associated with higher income, better educated, employed and married women in their sixth decade. Current use has varied over the years, with an increase to 2000, but a drop in 2003 and 2004.

CONCLUSION

Apart from menopausal symptoms, there is no evidence to support differences between users and non-users in terms of quality of life or health characteristics, requiring more appropriate selection of women for hormone therapy.

Population-based mammography screening and breast cancer incidence in New South Wales, Australia

OBJECTIVE

To analyse breast cancer incidence trends in New South Wales (NSW), Australia, in relation to population-based mammography screening targeting women aged 50 to 69 years.

METHODS

Trends in age-specific incidence of invasive breast cancers in NSW women aged > or = 40 years were examined in relation to mammography screening rates and screening cancer detection rates.

RESULTS

Incidence of invasive breast cancer in NSW women increased in all age-groups over 1972 to 2002. The incidence trend for women aged 50 to 69 years showed that the steepest rise was associated with increased participation in population-based mammography screening, which was implemented from 1988 and achieved state-wide coverage in 1995. The elevated incidence of invasive cancer significantly exceeded pre-screening levels, and persisted after rates of initial screens declined. This elevated incidence was sustained by the contribution of cancers diagnosed through subsequent screening, and resulted from increased cancer detection rates in subsequent screens.

CONCLUSIONS

The recent increase in invasive breast cancer incidence in NSW is associated with mammography screening, and occurred mostly in the target age-group women. Persistence of higher incidence after 1994 was not explicable by inflation of cancer incidence due to detection of prevalent screen cases, but was associated with a trend of increased cancer detection rates in subsequent screening rounds, probably consequent to quality improvements in mammography screening diagnosis.

Hormone replacement therapy and cognitive performance in postmenopausal women—a review by cognitive domain

Laboratory, animal and neuroimaging evidences suggest that hormone replacement therapy (HRT) may be beneficial to human cognition. This systematic review includes 26 studies on the association between HRT and cognition and 17 studies on HRT and risk of dementia. It was hypothesised that HRT would have a positive association with cognitive speed and verbal memory and possibly visual memory but not with executive functioning, and would be associated with a decreased risk of dementia. Evidence for HRT's neuroenhancing and neuroprotective properties was also evaluated. There was significant statistical and clinical heterogeneity among studies precluding meta-analysis. Results showed no consistent relationship between HRT and performance in any cognitive domain. Cross-sectional studies tended to report more positive results than longitudinal studies and randomised-controlled trials, particularly in the areas of verbal memory and executive functioning. HRT was associated with decreased risk of dementia in observational studies, but with increased risk in one randomised-controlled trial. Cognitive improvement or maintenance are not secondary benefits of HRT.