Quality of life and menopause: the role of estrogen

Comparison of In Vitro Estrogenic Activity of Polygoni multiflori Radix and Cynanchi wilfordii Radix via the Enhancement of ERα/β Expression in MCF7 Cells

Postmenopausal women experience several symptoms, including inflammation and a sharp rise in oxidative stress caused by estrogen deprivation. Although estrogen replacement therapy (ERT) is generally regarded as an effective treatment for menopause, it has been used less frequently due to some adverse effects and high costs. Therefore, there is an immediate need to develop an effective herbal-based treatment that is affordable for low-income populations. Acordingly, this study explored the estrogen-like properties of methanol extracts from Cynanchum wilfordii (CW) and Poligonum multiflorum (PM), two important medicinal plants in Republic of Korea, Japan, and China. Due to the similar names and morphologies of these two radixes, they are frequently confused in the marketplace. Our previous colleagues discriminated between these two plants. In this study, we investigated the estrogenic activity of PM and CW using several in vitro assays with their possible mechanism of action. First, their phytochemical contents, such as gallic acid, 2,3,5,4'-tetrahydroxystilbene-2-O-glucoside (TSG) and emodin, were quantified using high-performance liquid chromatography (HPLC). Secondly, estrogen-like activity was assessed utilizing the well-known E-screen test and gene expression analysis in estrogen receptor (ER)-positive MCF7 cells. ROS inhibition and anti-inflammatory effects were analyzed using HaCaT and Raw 264.7 cells, respectively. Our findings demonstrate that PM extracts significantly increased the expression of the estrogen-dependent genes (ERα, ERβ, pS2) and boosted MCF7 cell proliferation in comparison to CW extracts. Additionally, PM extract demonstrated a significant reduction in reactive oxygen species (ROS) production as well as an enhanced antioxidant profile compared to the CW extract. Further, the PM extract treatment significantly reduced the generation of nitric oxide (NO) in RAW 264.7 cells, a murine macrophage cell line, demonstrating the anti-inflammatory properties of the extract. Finally, this research offers an experimental foundation for the use of PM as a phytoestrogen to minimize menopausal symptoms.

The impact of calcitriol and estradiol on the SARS-CoV-2 biological activity: a molecular modeling approach

The novel coronavirus disease (COVID-19) is currently a big concern around the world. Recent reports show that the disease severity and mortality of COVID-19 infected patients may vary from gender to gender with a very high risk of death for seniors. In addition, some steroid structures have been reported to affect coronavirus, SARS-CoV-2, function and activity. The entry of SARS-CoV-2 into host cells depends on the binding of coronavirus spike protein to angiotensin converting enzyme-2 (ACE2). Viral main protease is essential for the replication of SARS-CoV-2. It was hypothesized that steroid molecules (e.g., estradiol, progesterone, testosterone, dexamethasone, hydrocortisone, prednisone and calcitriol) could occupy the active site of the protease and could alter the interaction of spike protein with ACE2. Computational data showed that estradiol interacted more strongly with the main protease active site. In the presence of calcitriol, the binding energy of the spike protein to ACE2 was increased, and transferring Apo to Locked S conformer of spike trimer was facilitated. Together, the interaction between spike protein and ACE2 can be disrupted by calcitriol. Potential use of estradiol and calcitriol to reduce virus invasion and replication needs clinical investigation.

The Role of Estradiol in Traumatic Brain Injury: Mechanism and Treatment Potential

Patients surviving traumatic brain injury (TBI) face numerous neurological and neuropsychological problems significantly affecting their quality of life. Extensive studies over the past decades have investigated pharmacological treatment options in different animal models, targeting various pathological consequences of TBI. Sex and gender are known to influence the outcome of TBI in animal models and in patients, respectively. Apart from its well-known effects on reproduction, 17β-estradiol (E2) has a neuroprotective role in brain injury. Hence, in this review, we focus on the effect of E2 in TBI in humans and animals. First, we discuss the clinical classification and pathomechanism of TBI, the research in animal models, and the neuroprotective role of E2. Based on the results of animal studies and clinical trials, we discuss possible E2 targets from early to late events in the pathomechanism of TBI, including neuroinflammation and possible disturbances of the endocrine system. Finally, the potential relevance of selective estrogenic compounds in the treatment of TBI will be discussed.

Olfactory Exposure to β-Caryophyllene Increases Testosterone Levels in Women's Saliva

INTRODUCTION

From previous studies, we hypothesized that olfactory exposure to β-caryophyllene stimulates women's libido. However, Japan's sex culture is so closed that it is difficult to test this possibility without accumulating scientific evidence. Therefore, it is necessary to measure the concentration of sex-related hormones in saliva, an experimental technique that is relatively easy to obtain research permission, and to obtain a scientific basis to convince ethics committee reviewers.

AIM

The aim of this study is to investigate whether β-caryophyllene increases salivary testosterone concentrations associated with libido and vaginal sensation during intercourse in women.

METHODS

19 women in the follicular phase of the menstrual cycle participated in the study. The subjects then sat in front of the odor exposure device we had created. Each subject was exposed to dipropylene glycol for 20 minutes, followed by 3% β-caryophyllene for 20 minutes. Saliva was collected 4 times: before and after control exposure, and before and after β-caryophyllene exposure.

MAIN OUTCOME MEASURE

Salivary testosterone and estrogen concentrations were measured with a competition ELISA.

RESULTS

β-caryophyllene significantly increased the salivary concentration of testosterone (control vs β-caryophyllene; 0.97 ± 0.05 vs 1.13 ± 0.03, P = .00, 95% confidence interval of control: 0.84-1.09, 95% confidence interval of β-caryophyllene: 1.04-1.20) but not estrogen (control vs β-caryophyllene; 1.05 ± 0.03 vs 1.07 ± 0.04, P = .69, 95% confidence interval of control: 0.96-1.12, 95% confidence interval of β-caryophyllene: 0.98-1.15).

STRENGTHS & LIMITATIONS

The personal preferences of the subjects and the order of exposure may have affected the results.

CONCLUSION

β-caryophyllene may be a remedy with fewer side effects for women with decreased libido. We believe that β-caryophyllene may be a remedy for women with decreased libido. However, this hypothesis must be tested by further clinical studies. Wataru Tarumi, Kazuyuki Shinohara. Olfactory Exposure to β-Caryophyllene Increases Testosterone Levels in Women's Saliva. J Sex Med 2020;8:525-531.

Sexual Distress Mediates the Associations Between Sexual Contingent Self-Worth and Well-Being in Women With Genitopelvic Pain: A Dyadic Daily Experience Study

Provoked vestibulodynia (PVD), a common cause of women's genitopelvic pain, is associated with poorer psychological and sexual well-being in affected couples. Greater sexual contingent self-worth (CSW)-defined as self-esteem that is dependent on the perceived success or failure of a sexual relationship-has been linked to poorer well-being in a cross-sectional study of couples coping with PVD. This study aimed to examine whether daily sexual distress mediated the associations between greater sexual CSW and lower sexual satisfaction and greater anxiety, depressed mood, and women's pain in affected couples. Women (N = 125) diagnosed with PVD and their partners completed the Sexual CSW Scale and then online daily surveys for eight weeks measuring sexual distress, sexual satisfaction, anxiety, depressed mood, and women's pain during intercourse. Multilevel analyses were based on the actor-partner interdependence model (APIM). For women who had higher sexual CSW (compared to lower sexual CSW), on sexual activity days when their sexual distress was higher, they reported lower sexual satisfaction and greater anxiety, depressed mood, and pain (compared to their average level across all sexual activity days). Findings suggest that daily sexual distress may be one pathway between greater sexual CSW and poorer day-to-day well-being in women with PVD.

Visible-Near Infrared Spectroscopic Assessment of Urogenital Tissue in Premenopausal and Postmenopausal Women

BACKGROUND

A clinical study was conducted to evaluate the feasibility of using visible and near-infrared (NIR) spectroscopy as a potential noninvasive measure of genital skin health in premenopausal and postmenopausal women.

METHODS

A total of 45 female subjects (aged 21-70 years), all of whom gave fully informed consent to participate, were enrolled in the study and assigned to 1 of 3 groups: 15 premenopausal (Pre-M), 15 postmenopausal receiving hormone replacement therapy (Post-M HRT), and 15 postmenopausal receiving no form of hormone replacement therapy (Post-M non-HRT). Spectral measurements were taken at the vaginal mucosa, and spectral data were evaluated for the erythema index (EI), hemoglobin index (HI), bilirubin/β-carotene, and melanin. The color index (CI; calculated as the ratio of absorbance at 480 nm/540 nm) was also determined. Results were compared with previously published results on biomarkers and physical characteristic of genital tissue measured on the same groups of women.

RESULTS

Spectral measurements from the Post-M Non-HRT subjects indicated a significant reduction in HI compared with the Pre-M group (P = .0003) and to the Post-M HRT group (P < .0001). Similarly, EI was reduced in the Post-M Non-HRT (P < .0001 and P = .0041 for the Pre-M and Post-M HRT groups, respectively). In contrast, the Post-M Non-HRT subjects exhibited a significant increase in β-carotene compared with the Pre-M subjects (P = .0098). Bilirubin and melanin were not significantly affected. The Post-M Non-HRT group exhibited a significant increase in CI, indicating a shift away from the hemoglobin absorption region (510-620 nm wavelength) and toward the bilirubin/β-carotene absorption region (450-490 nm wavelength). This change was significant when compared with both the Pre-M group (P < .0001) and the Post-M HRT group (P = .0048). The changes in spectral measurements were consistent with previously reported changes in physical parameters (vaginal atrophy, increased pH, decreased skin temperature) and with decreased concentrations of the biomarkers histamine and histidine.

CONCLUSIONS

Hemodynamic spectral characteristics differ in postmenopausal vaginal tissue compared with tissue in premenopausal women, with decreased absorbance in the hemoglobin absorption region (510-620 nm wavelength) and an increased absorbance in the bilirubin/β-carotene absorption region (450-490 nm wavelength). A change in absorbance in the visible and NIR wavelengths is a promising, additional measure of genital skin health related to menopause and vulvovaginal atrophy.

Estrogens as neuroprotectants: Estrogenic actions in the context of cognitive aging and brain injury

There is ample empirical evidence to support the notion that the biological impacts of estrogen extend beyond the gonads to other bodily systems, including the brain and behavior. Converging preclinical findings have indicated a neuroprotective role for estrogen in a variety of experimental models of cognitive function and brain insult. However, the surprising null or even detrimental findings of several large clinical trials evaluating the ability of estrogen-containing hormone treatments to protect against age-related brain changes and insults, including cognitive aging and brain injury, led to hesitation by both clinicians and patients in the use of exogenous estrogenic treatments for nervous system outcomes. That estrogen-containing therapies are used by tens of millions of women for a variety of health-related applications across the lifespan has made identifying conditions under which benefits with estrogen treatment will be realized an important public health issue. Here we provide a summary of the biological actions of estrogen and estrogen-containing formulations in the context of aging, cognition, stroke, and traumatic brain injury. We have devoted special attention to highlighting the notion that estrogen appears to be a conditional neuroprotectant whose efficacy is modulated by several interacting factors. By developing criteria standards for desired beneficial peripheral and neuroprotective outcomes among unique patient populations, we can optimize estrogen treatments for attenuating the consequences of, and perhaps even preventing, cognitive aging and brain injury.

A novel mechanism of non-feminizing estrogens in neuroprotection

Estrogens are potent and efficacious neuroprotectants both in vitro and in vivo in a variety of models of neurotoxicity. We determined the structural requirements for neuroprotection in an in vitro assay using a panel of >70 novel estratrienes, synthesized to reduce or eliminate estrogen receptor (ER) binding. We observed that neuroprotection could be enhanced by as much as 200-fold through modifications that positioned a large bulky group at the C2 or C4 position of the phenolic A ring of the estratriene. Further, substitutions on the B, C or D rings either reduced or did not markedly change neuroprotection. Collectively, there was a negative correlation between binding to ERs and neuroprotection with the more potent compounds showing no ER binding. In an in vivo model for neuroprotection, transient cerebral ischemia, efficacious compounds were active in protection of brain tissue from this pro-oxidant insult. We demonstrated that these non-feminizing estrogens engage in a redox cycle with glutathione, using the hexose monophosphate shunt to apply cytosolic reducing potential to cellular membranes. Together, these results demonstrate that non-feminizing estrogens are neuroprotective and protect brain from the induction of ischemic- and Alzheimer's disease (AD)-like neuropathology in an animal model. These features of non-feminizing estrogens make them attractive compounds for assessment of efficacy in AD and stroke, as they are not expected to show the side effects of chronic estrogen therapy that are mediated by ER actions in the liver, uterus and breast.

Influence of obesity and hormone disturbances on sexuality of women in the menopause

OBJECTIVE

To assess influence of obesity and hormone disturbances on sexuality in the menopause.

METHODS

The study included 73 menopausal women, who were divided into groups according to body mass index (BMI) ≥ 26.7 kg/m². Anthropometric characteristics and blood pressure were measured. Blood was taken at 08:00 for hormones. All the participants filled in McCoy Female Sexual Questionnaire for the assessment of sexual life.

STATISTICS

Student's t-test, correlation, analysis of variance (ANOVA).

RESULTS

Follicle-stimulating hormone (FSH), luteinizing hormone (LH) and sex hormone-binding globulin (SHBG) were very significantly lower in obese compared to controls. E₂ and systolic blood pressure were very significantly, while diastolic blood pressure significantly higher in obese compared to controls. Obese women had significantly decreased frequency of pain during sexual intercourse (3.48 ± 2.64 vs. 4.09 ± 2.81). Influence of age on frequency of sexual intercourse was very significant. Significant influence in interaction between BMI and age on frequency of sexual fantasies as well as significant influence of BMI on satisfaction with partner as lover is also found.

CONCLUSION

Obesity has influence on different aspects of sexuality in the postmenopausal women. Our results suggest the need of awareness toward obesity and its impact on sexuality in the menopause.

Health-Related Quality of Life During the Menopausal Transition: Testing a Theoretical Model

The purpose of this study was to test the hypothetical model of health-related quality of life (HRQOL) during the menopausal transition. The model was developed to test specific components of the Wilson and Cleary's model for HRQOL. A cross-sectional, correlational study was carried out using self-report questionnaires on a convenience sample of 162 Korean women in the menopausal transition. The model was tested by a path analysis using Analysis of Moment Structure (AMOS) program. The path analysis showed that 5 affecting variables explained 69% of the variance in HRQOL during the menopausal transition. Based on the results, the Wilson and Cleary's model may be useful in explaining HRQOL during the menopausal transition. Symptoms, functional status, and health perceptions mediated the effect of individual and environmental characteristics on HRQOL. However, the results suggest that some paths need to be added or modified in the model. To date, most research using Wilson and Cleary's model has been conducted in the United States, Africa, and Europe (e.g., Austria, Norway, and Spain). This study shows the applicability of the model in Asian people.

The relationship between estrogen receptors and microtubule dynamics in post-menopausal rat brain

INTRODUCTION

Estrogen is one of the most important regulators of neuron function. There is a broad consensus that a loss of estrogen is associated with neurodegeneration in the hippocampus which leads to cognitive impairment. Hematopoietic-Pbx-interaction-protein (HPIP) is a novel scaffolding protein which interacts with microtubules and estrogen receptors. In this study, we investigated the presence and role of HPIP in hippocampal neurons and examined the relationship between estrogen receptors and microtubule damage in post-menopausal rat brains.

METHOD

Eighty female Wistar albino rats, 12 weeks old, were divided into 10 groups: control, control+17-β-estradiol, control+tamoxifen, control+mitogen-activated protein kinases (MAPK) inhibitor, control+phosphoinositide 3-kinase (PI3-K) inhibitor, ovariectomized, ovariectomized+17-β-estradiol, ovariectomized+tamoxifen, ovariectomized+MAPK inhibitor, and ovariectomized+PI3-K inhibitor. Light and electron microscopic examinations were performed. Real-time polymerase chain reaction (PCR) was used to determine the expression level of HPIP in experimental groups.

RESULTS

Light and electron microscopic examinations revealed morphological changes in hippocampal neuron axons. Axonal fluctuations and shrinkage were detected in all ovariectomized groups. HPIP was detected in all neurons with difference expression levels.

CONCLUSION

Proof that the HPIP protein can be found on hippocampal neurons may give rise to a new focus on neurodegeneration in post-menopausal women. Future molecular and pharmacological studies should be performed to reduce the rate of cognitive symptoms resulting from hippocampal neurodegeneration.

Reliability and validity of the Menopausal Symptom Scale

Menopausal symptom experiences differ by racial/ethnic group. Thus, health care professionals who use instruments to measure menopausal symptoms need to be aware of cultural sensitivities. The purpose of this study was to examine the psychometric properties of the Menopausal Symptom Scale among Korean women. Data from 229 Korean women between the ages of 40 and 65 years, selected by convenience sampling, were collected during 2010-2011. Psychometric properties were evaluated through content validity and item analysis, construct validity, discriminant validity, criterion-related validity, floor/ceiling effects, and internal consistency reliability. Exploratory and confirmatory factor analyses revealed four factors explaining 65% of variance in the items. Discriminant validity and the criterion-related validity were supported. No significant floor/ceiling effects were found. Cronbach's alpha values ranged from 0.90 to 0.95. The Menopausal Symptom Scale developed for Korean menopausal women appeared to be a valid and reliable instrument. It appeared that it measured psychological symptoms more comprehensively and in a culturally-specific or ethnic-specific manner in menopausal women of Asian or traditional cultures. It will be necessary to broaden the scale of research to other ethnic groups and countries to verify the psychometric properties specific to the ethnic group or country.

Synthetic conjugated estrogens-B and postmenopausal nocturnal vasomotor symptoms: a randomized controlled trial

OBJECTIVE

To evaluate two doses of oral synthetic conjugated estrogens-B tablets compared with placebo on the frequency of awakenings resulting from nocturnal vasomotor symptoms in postmenopausal women over a 12-week treatment period.

METHODS

A double-blind, randomized, placebo-controlled multicenter study enrolled a total of 157 women who were experiencing daytime vasomotor symptoms and a minimum of at least three nocturnal awakenings per night as a result of hot flushes. Participants were evenly randomized to one of three treatment groups (0.3 mg, 0.625 mg, or matching placebo) and treated for up to 12 weeks. Subjective sleep quality also was assessed.

RESULTS

Significantly greater reductions from baseline in the weekly mean frequency of awakenings resulting from hot flushes occurred for participants randomized to either synthetic conjugated estrogens-B dose relative to placebo (mean reductions, 3.55, P=.004, and 4.65, P<.001 for 0.3 mg and 0.625 mg, respectively). In addition, a significantly greater proportion of participants at either estrogen dose had complete elimination of nocturnal awakenings (36.5% for 0.3 mg, 34% for 0.625 mg compared with 9.8% for placebo; P ≤.002) with a general finding of improved sleep based on actigraphy data. No differences were observed in measures of sleep quality or daytime sleepiness.

CONCLUSION

In this symptomatic postmenopausal population of women experiencing sleep disruption resulting from nocturnal vasomotor symptoms, a daily dose of synthetic conjugated estrogens-B as low as 0.3 mg appears to be effective in treating nocturnal hot flushes that lead to unwanted awakenings.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00592839.

Cognitive-impairing effects of medroxyprogesterone acetate in the rat: independent and interactive effects across time

RATIONALE

The synthetic progestin medroxyprogesterone acetate (MPA), widely used in hormone therapy (HT) and as the contraceptive Depo Provera, is implicated in detrimental cognitive effects in women. Recent evidence in aged ovariectomized (Ovx) rodents shows that short-term MPA treatment impairs cognition and alters the GABAergic system.

OBJECTIVES

Using rats, we evaluated the long-lasting cognitive and GABAergic effects of MPA administered in young adulthood (Early-MPA), modeling contraception, and how this early exposure interacts with later MPA treatment (Late-MPA), modeling HT.

METHODS

Early-MPA treatment involved weekly anti-ovulatory MPA injections (3.5 mg) from 4 to 8 months of age in ovary-intact rats. At 10 months old, rats were Ovx and weekly MPA injections were re-initiated and continued throughout testing for Late-MPA treatment.

RESULTS

On the water radial-arm maze, all MPA-treated groups showed working memory impairment compared to Controls (p < 0.05); Early + Late-MPA rats were impaired on multiple dimensions of working memory (p < 0.05). On the Morris maze, Late-MPA rats showed greater overnight forgetting compared to Controls (p < 0.05). At study conclusion, MPA was detected in serum in all MPA-treated groups except Early-MPA, confirming treatment and clearance from serum in Early-MPA rats. In animals with detectable serum MPA, higher MPA levels were associated with less dorsal-hippocampal glutamic acid decarboxylase, the synthesizing enzyme for GABA (p = 0.0059).

CONCLUSIONS

Findings suggest that MPA treatment leads to long-lasting cognitive impairments in the rodent, even in the absence of circulating MPA in animals given prior MPA treatment, which may relate to the GABAergic system. Further research defining the parameters of the negative impact of this widely used progestin on brain and cognition is warranted.

Sertraline improves the somatic and psychological symptoms of the climacteric syndrome

OBJECTIVE

To evaluate the efficacy of sertraline versus placebo in the management of somatic and psychological complaints of the climacteric syndrome.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial. A total of 44 women with moderate to severe complaints, defined as 16 or more points according to the Menopause Rating Scale (MRS) considering only the psychological and somatic domains, were incorporated into the trial and randomized to receive either sertraline (50 mg/day) or placebo. Both groups were evaluated at baseline and after 45 and 90 days of treatment. A reduction of 50% or more in the score was considered as a successful response.

RESULTS

Thirty-three patients finished the trial (16 in the sertraline group and 17 in the placebo group), showing an odds ratio of 7.94 (95% confidence interval 1.3-57.3), p = 0.0038 for the sertraline group, in spite of the prominent effect of placebo.

CONCLUSIONS

Sertraline was more effective than placebo in the management of the somatic and psychological complaints of the climacteric syndrome.

Measurement of Quality of Life in Menopausal Women

Use of a wide variety of quality of life (QoL) instruments, each measuring a different aspect of menopause with a different type of underlying scale, has been a major problem in menopause research. The aim of this review was to identify instruments developed for menopausal women and evaluate the psychometric properties and appropriateness of instruments for the study of QoL in menopausal women. Seven measures from 16 papers were chosen for the review. The psychometric evaluations were conducted based on quality judgment criteria. Of the seven measures reviewed in this study, the psychometric quality scores of Women’s Health Questionnaire (WHQ) was the highest. However, the result indicates that most instruments of menopause-specific QoL need further testing and evaluation of the various aspects of their psychometric properties. In addition, future research assessing psychometric properties with cross-cultural samples may be beneficial in adapting measures to specific context and study populations.

Medroxyprogesterone acetate impairs memory and alters the GABAergic system in aged surgically menopausal rats

In women, medroxyprogesterone acetate (MPA) is the most commonly used progestin component of hormone therapy (HT). In vitro, MPA negatively impacts markers of neuronal health and exacerbates experimentally-induced neurotoxicity. There is in vitro evidence that these factors are driven by GABAergic and neurotrophic systems. Whether these effects translate to a negative impact on brain function has not been tested in vivo, clinically or preclinically. Here we evaluate the mnemonic and neurobiological effects of MPA in the surgically menopausal rat. Aged ovariectomized (OVX) rats were given subcutaneous vehicle, natural progesterone, low-dose MPA or high-dose MPA. Multiple cognitive domains were analyzed via the water radial-arm maze (WRAM) and Morris maze (MM). Cognitive brain regions were assayed for changes in the GABAergic system by evaluating GAD protein, the synthesizing enzyme for GABA, and neurotrophins. On the WRAM, both progestin types impaired learning. Further, high-dose MPA impaired delayed memory retention on the WRAM, and exacerbated overnight forgetting on the MM. While neurotrophins were not affected by progesterone or MPA treatment, both progestin types altered GAD levels. MPA significantly and progesterone marginally decreased GAD levels in the hippocampus, and both MPA and progesterone significantly increased GAD levels in the entorhinal cortex. These findings suggest that MPA, the most commonly used progestin in HT, is detrimental to learning and two types of memory, and modulates the GABAergic system in cognitive brain regions, in aged surgically menopausal rats. These findings, combined with in vitro evidence that MPA is detrimental to neuronal health, indicates that MPA has negative effects for brain health and function.

Anxiolytic-like effect of phytoestrogen genistein in rats with long-term absence of ovarian hormones in the black and white model

Postmenopause is mainly characterized by a reduction of ovarian hormones, which is accompanied by a major incidence of physical disorders and mood swings. Clinical and experimental evidence suggest that phytoestrogens could be used to ameliorate these alterations associated with menopause. However, the phytoestrogen effects on anxiety in rats with long-term absence of ovarian hormones, is unknown. Consequently, in the present study the authors compared the anxiolytic-like effect of phytoestrogen genistein (0.25, 0.5 y 1.0 mg/kg, i.p.) in Wistar rats with 12-weeks postovariectomy in the black and white model and in the open field test, and it was compared with diazepam (1.0 mg/kg, i.p.). In the black and white model, genistein (0.5 y 1.0 mg/kg) and diazepam reduced the latency to enter and increased the time spent into the white compartment; also, significantly increased frequency and time spent in exploration toward white compartment was seen, as compared with the control group (p<0.05). In the open field test, genistein and diazepam increased grooming and rearing, without significant changes in locomotor activity, as compared with the control group. In conclusion, phytoestrogen genistein produces an anxiolytic-like effect in Wistar rats with long-term absence of ovarian hormones in the black and white model, supporting the hypotheses that phytoestrogens could be used to ameliorate anxiety associated with menopause.

Treating vasomotor symptoms of menopause: the nurse practitioner's perspective

PURPOSE

This article reviews the pathophysiology of vasomotor symptoms (VMS) of menopause and current management options.

DATA SOURCES

Current scientific literature.

CONCLUSIONS

In most menopausal women, loss of ovarian function results in VMS, including hot flashes, night sweats, and mood and sleep disturbances. Hormone therapy (HT) has been the mainstay of VMS treatment for many years, but safety concerns raised by publication of the Women's Health Initiative (WHI) results have dramatically reduced the use of this treatment. Since the WHI published its findings, attention has focused on other novel treatments for menopausal symptoms, including low-dose oral or transdermal HT and agents such as selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, gabapentin, and clonidine. Many women also use complementary and alternative medications to manage VMS, but little evidence from controlled clinical trials supports their efficacy.

IMPLICATIONS FOR PRACTICE

The increasing number of alternative treatments for VMS requires improvement in patient-provider communication about treatment risks and benefits, individualization of treatment to meet patient needs and attitudes, and careful follow-up to ensure adherence to potentially effective therapy. Nurse practitioners play a leading role in patient evaluation, discussions, and management to help women achieve control over bothersome VMS that dramatically impact their quality of life.

Current Management Strategies of the Postmenopausal Patient with Sexual Health Problems

INTRODUCTION

Sexual health concerns of menopausal women include decreases in sexual interest, arousal, lubrication, and orgasm, and increases in sexual pain, all of which may be associated with distress.

AIM

To review a step-care progression of sexual healthcare management: identification of the sexual health problem; education of the patient and the partner; modification of reversible causes; first-line therapies consisting of devices and medications; and second-line therapies with more invasive treatments including surgery.

METHODS

The healthcare provider is presented with a clinical diagnosis and treatment paradigm that engages mind, body, and relationship issues proceeding step-wise in a rational and cost-effective fashion.

MAIN OUTCOME MEASURE

Literature review in women's sexual health.

RESULTS

Women's health, including sexual health, is a fundamental human right. Supported by evidence-based data, a step-care approach to diagnosis and management of women with sexual health problems is advised. Multidisciplinary interventions should be considered as needed. Identification of sexual health concerns engages diagnostic components of psychologic consultation, history, physical examination, and laboratory testing as appropriate. Key to clinical assessment is the detailed sexual, medical, and psychosocial history. No agreement exists on necessary laboratory tests. Patient (and partner) education improves understanding of treatment options and expectations, and promotes a trusting patient-physician partnership. Modification of reversible causes includes sex therapy, lubricants, altering medications, modifying lifestyle and physical therapy for pelvic floor disorders. First-line therapies should be administered based upon diagnosis, needs, expectations, risks, benefits, and cost, and include medical devices and drugs such as hormones, vasoactive agents, dopamine agonists, topical steroids, anti-infectious agents, and analgesic agents. Second-line therapies, such as surgery, are initiated upon failure, insufficient response, or adverse side effects associated with one or more of the first-line therapies or patient preference.

CONCLUSIONS

For postmenopausal women with sexual dysfunction, a rational clinical management strategy begins with treatment options that are most reversible and least invasive and costly.

ORIGINAL RESEARCH—PSYCHOLOGY: Differences between Pre- and Postmenopausal Women in Cues for Sexual Desire

INTRODUCTION

Recently, McCall and Meston presented an assessment tool for empirically categorizing stimuli associated with sexual desire in women. Significant differences in cues resulting in sexual desire were found between women with and without hypoactive sexual desire disorder (HSDD).

AIM

The present study examined differences in cues resulting in sexual desire between pre- and postmenopausal women with and without sexual desire concerns using the Cues for Sexual Desire Scale (CSDS) which assesses four distinct aspects of desire motivators: (i) Love/Emotional Bonding Cues; (ii) Erotic/Explicit Cues; (iii) Visual/Proximity Cues; and (iv) Implicit/Romantic Cues.

MAIN OUTCOME MEASURES

The Female Sexual Function Index and the CSDS.

METHODS

Women included premenopausal women with no sexual concerns (N = 35), premenopausal women with low sexual desire (N = 30), postmenopausal women with no sexual concerns (N = 21), and postmenopausal women with low sexual desire (N = 39).

RESULTS

Consistent with prior findings, women with low sexual desire reported significantly less Love/Emotional Bonding Cues, Erotic/Explicit Cues, Implicit/Romantic Cues, and had significantly lower CSDS total scores as compared with women with no sexual difficulties. Postmenopausal women were more likely to report cues associated with Love/Emotional Bonding as compared with premenopausal women.

CONCLUSIONS

There were significant differences between women with and without sexual desire concerns in Love/Emotional Bonding Cues, Erotic/Explicit Cues, Implicit/Romantic Cues, and CSDS total scores. There were no significant differences between pre- and postmenopausal women in Erotic/Explicit Cues, Visual/Proximity Cues, or Implicit/Romantic Cues. Interestingly, postmenopausal women with and without HSDD endorsed more Love/Emotional Bonding Cues resulting in feelings of sexual desire as compared with premenopausal women.

Case-control study of postmenopausal hormone replacement therapy and endometrial cancer

This study evaluated recent inconsistent findings that adding progestins to postmenopausal estrogen replacement therapy protects against endometrial cancer. Using a population-based case-control study, the authors compared 511 endometrial cancer cases aged 50-79 years in the Philadelphia, Pennsylvania, region during 1999-2002 with 1,412 random-digit-dialing controls regarding postmenopausal hormone replacement therapy (HRT) use. Telephone interviews were performed with memory aids mailed in advance. An increased risk of endometrial cancer was observed among postmenopausal women using only unopposed estrogen for 3 or more years, compared with women who never used HRT (adjusted odds ratio = 3.4, 95% confidence interval (CI): 1.4, 8.3). Using combination HRT (of any duration) was associated with a substantial reduction in risk (odds ratio = 0.8, 95% CI: 0.6, 1.1). Comparing women using only combined estrogen and progestin for 3 or more years with women using only unopposed estrogen for 3 or more years, the authors found that the adjusted odds ratio was 0.2 (95% CI: 0.1, 0.6). Long-term use of unopposed estrogen is associated with increased risk for endometrial cancer, whereas combined estrogen plus progestin hormone therapy is not. Thus, if HRT is to be used in women with an intact uterus, this study confirms the benefit of adding progestins to the regimen.

Menopause-related quality of life in chronically mentally ill women

OBJECTIVE

Menopause is an important life event that has not yet been well characterized among women with severe mental illness. Our goal was to evaluate menopause-related quality of life among severely mentally ill women.

METHOD

We conducted a cross-sectional assessment of perimenopausal and postmenopausal women, ages 45-55, diagnosed with schizophrenia/schizoaffective disorder, bipolar disorder, or major depression, who were receiving inpatient or outpatient psychiatric care. Women were compared regarding menopausal symptoms and quality of life using the Menopause Specific Quality of Life Scale (MENQOL).

RESULTS

Women with severe mental illnesses who were peri- and post-menopausal experienced considerable vasomotor, physical, sexual, and psychosocial symptoms related to menopause. On seven of 29 MENQOL items, women with major depression reported problems significantly more often than women with other serious mental illnesses.

CONCLUSIONS

This preliminary study indicates that psychiatrists and other physicians should consider the frequency and overlap of menopausal and psychiatric symptoms among women with serious mental illness in this age group.

Pharmacological study on Samia cynthia ricini in old female mice

The effect of the extraction from female moths Samia cynthia ricini (family Saturniidae) on menopausal syndrome was studied in order to search for an effective traditional Chinese medicine to menopausal syndrome and offer a theoretical support for the further research on Samia cynthia ricini. Aged, nonreproductive female mice was used as the model and randomly divided into three groups: control, ethanol extraction group and diethylstilbestrol (DES) group according to the medicine applied. After 4 weeks of treatment, keratinization rates of vagina epithelia, indexes of organs, serum concentrations of estradiol (E2) and progesterone (P), the bone mineral contents (BMC) and the morphological changes of ovary and uterus were measured. And the fingerprint of the extracts was obtained by gas chromatography-mass spectrometry (GC-MS). The results showed that the moth extraction could obviously accelerate the keratinization of aged mice's vagina epithelia, increase the weight of the ovary and ameliorate its degenerative process. It could also, to some extent, increase the serum concentrations of estradiol, progesterone concentrations as well as the bone mineral contents. Furthermore, there is no obvious side effect detected on immune system in our research. The extraction from female moths Samia cynthia ricini could ameliorate the menopause symptom of aged female mice and thus be a potential remedy for it.

Practical aspects in the management of vaginal atrophy and sexual dysfunction in perimenopausal and postmenopausal women

INTRODUCTION

The decline in circulating estrogen levels in peri- and postmenopause has a wide range of physiological effects, including atrophy of tissues in the urogenital tract. Vaginal atrophy is an important contributor to postmenopausal sexual dysfunction.

AIM

To provide a framework for clinical evaluation and clinical management of sexual dysfunction secondary to vaginal atrophy.

METHOD

Conduct a brief overview of literature on evaluation and treatment of vaginal atrophy, augmented with the authors' clinical observations and experience.

RESULTS

Estrogen decline disrupts many physiological responses characteristic of sexual arousal, including smooth muscle relaxation, vasocongestion, and vaginal lubrication; genital tissues depend on continued estrogen and androgen stimulation for normal function. An upward shift in vaginal pH as the result of vaginal atrophy alters the normal vaginal flora. Reduced lubrication capability and reduced tissue elasticity, in addition to shortening and narrowing of the vaginal vault, can lead to painful and/or unpleasant intercourse. At the same time, diminished sensory response may reduce orgasmic intensity. Other contributors to peri- and postmenopausal sexual dysfunction include reduced androgen levels, aging of multiple body systems, and side-effects of medications. Workup of sexual health problems starts by taking a comprehensive sexual, medical, and psychosocial history, followed by complete physical examination and laboratory evaluation. Clinical management includes measures to preserve and enhance overall health, adjustment of medication regimes to reduce or avoid side-effects, and topical or systemic hormone supplementation with estrogens and/or androgens.

CONCLUSIONS

No single therapeutic approach is appropriate for every woman with peri- or postmenopausal sexual dysfunction; instead, treatment should be based on a comprehensive evaluation and consideration of medical and psychosocial contributors to the individual's dysfunction. Further research is required to establish optimal regimens of hormonal and nonhormonal agents, including dosages/dosage forms and duration of treatment, for specific subtypes of sexual dysfunction.

Anxiety attacks following surgical menopause: a case report

Acute onset of surgical menopause rarely complicates a woman's psychological state. Although most women with acute surgical menopause have associated menopausal symptoms, few psychological consequences have been reported. This article presents the case report of a woman who developed immediate postoperative symptoms of severe anxiety that significantly impacted her quality of life. Physiological and psychological changes associated with surgical menopause and hormone replacement therapy are also discussed.

Feeling Normal Women???s Experiences of Menopause After Infertility

PURPOSE

To explore women's experiences of menopause after infertility.

DESIGN

Grounded theory

METHOD

Nine menopausal women, ranging in age from 48 to 72, with previous infertility, at various stages of the menopausal transition, including postmenopause, were interviewed in-depth. Three women had conceived a child after infertility treatment, three had adopted children, and three did not have children. The interviews were audiotaped and transcribed verbatim for data analysis. Data were constantly compared against other data, including previous transcripts, to look for evidence of data saturation.

RESULTS

A core concept was generated, referred to as "finally feeling normal." After feeling abnormal during infertility, these women viewed menopause as a normal transition. They were able to reconcile some aspects of their infertility and embrace a feeling of normalcy.

CLINICAL IMPLICATIONS

Menopause can be positive for women after infertility. Infertility contributed to a unique way of making meaning of menopause that was almost paradoxical: the notion that they can feel normal at the end of their "reproductive" years when they have struggled so long to actually be reproductive. Healthcare providers need to be cognizant of this possible response to menopause, and not automatically "pathologize" these women.

Menopausal Symptoms and Treatment-Related Effects of Estrogen and Progestin in the Womenʼs Health Initiative

OBJECTIVE

To estimate the effects of estrogen plus progestin (E+P) therapy on menopausal symptoms, vaginal bleeding, gynecologic surgery rates, and treatment-related adverse effects in postmenopausal women.

METHODS

Randomized, double-blind, placebo-controlled trial of 16,608 postmenopausal women, ages 50-79 (mean +/- standard deviation 63.3 +/- 7.1) years, with intact uterus, randomized to one tablet per day containing 0.625 mg conjugated equine estrogens plus 2.5 mg medroxyprogesterone acetate (n = 8,506) or placebo (n = 8,102), and followed for a mean of 5.6 years. Change in symptoms and treatment-related effects were analyzed at year 1 in all participants. Bleeding and gynecologic surgery rates were analyzed through study close-out.

RESULTS

Baseline symptoms did not differ between the treatment groups. More women assigned to E+P than placebo reported relief of hot flushes (85.7% versus 57.7%, respectively; odds ratio 4.40; 95% confidence interval 3.40-5.71), night sweats (77.6% versus 57.4%; 2.58; 2.04-3.26), vaginal or genital dryness (74.1% versus 54.6%; 2.40; 1.90-3.02), joint pain or stiffness (47.1% versus 38.4%; 1.43; 1.24-1.64), and general aches or pains (49.3% versus 43.7%; 1.25; 1.08-1.44). Women asymptomatic at baseline who were assigned to E+P more often developed breast tenderness (9.3% versus 2.4%, respectively; 4.26; 3.59-5.04), vaginal or genital discharge (4.1% versus 1.0%; 4.47; 3.44-5.81), vaginal or genital irritation (4.2% versus 2.8%; 1.52; 1.27-1.81), and headaches (5.8% versus 4.7%; 1.26; 1.08-1.46) than women on placebo. Estrogen plus progestin treatment prevented the onset of new musculoskeletal symptoms. Vaginal bleeding was reported by 51% of women on E+P and 5% of women on placebo at 6 months; most bleeding was reported as spotting. Gynecologic surgeries (hysterectomy and dilation and curettage) were performed more frequently in women assigned to E+P (3.1% versus 2.5% for hysterectomy, hazard ratio = 1.23, P = .026; 5.4% versus 2.4% for dilation and curettage, hazard ratio = 2.23, P < .001).

CONCLUSION

Estrogen plus progestin relieved some menopausal symptoms, such as vasomotor symptoms and vaginal or genital dryness, but contributed to treatment-related effects, such as bleeding, breast tenderness, and an increased likelihood of gynecologic surgery.

The role of anxiety and hormonal changes in menopausal hot flashes

OBJECTIVE

To estimate the association of anxiety with menopausal hot flashes in the early transition to menopause.

DESIGN

A randomly identified, population-based cohort of midlife women followed up for 6 years to assess reproductive hormones and other physical, emotional, and behavioral factors. At enrollment, the women were premenopausal, aged 35 to 47 years, and had regular menstrual cycles in the normal range. Enrollment was stratified to obtain equal numbers of African American (n = 219) and white (n = 217) women.

RESULTS

At the 6-year endpoint, 32% of the women were in the early transition stage and 20% reached the late menopausal transition or were postmenopausal. Reports of hot flashes increased with the transition stages, which were determined by bleeding patterns. At endpoint, hot flashes were reported by 37% of the premenopausal women, 48% of those in the early transition, 63% of women in the late transition, and 79% of the postmenopausal women. Anxiety scores were significantly associated with the occurrence of hot flashes and were also significantly associated with the severity and frequency of hot flashes (each outcome at P < 0.001). Compared with women in the normal anxiety range, women with moderate anxiety were nearly three times more likely to report hot flashes and women with high anxiety were nearly five times more likely to report hot flashes. Anxiety remained strongly associated with hot flashes after adjusting for menopause stage, depressive symptoms, smoking, body mass index, estradiol, race, age, and time. In a predictive model, anxiety levels at the previous assessment period and the change in anxiety from the previous assessment period significantly predicted hot flashes (P < 0.001).

CONCLUSIONS

Anxiety is strongly associated with menopausal hot flashes after adjusting for other variables including menopause stage, smoking, and estradiol levels. Anxiety preceded hot flashes in this cohort. Additional studies are needed to examine the duration of menopausal hot flashes and to determine whether treatments that target anxiety effectively reduce menopausal hot flashes.

Treatment of atrophic vaginitis with topical conjugated equine estrogens in postmenopausal Asian women

OBJECTIVE

We investigated the effects of 2 months of treatment with topical estrogens on atrophic vaginitis and gynecological health in Asian women.

STUDY DESIGN

Multicenter, open-label trial of 150 postmenopausal women age <70 years with atrophic vaginitis. Women applied conjugated equine estrogens (CEE) vaginal cream (0.625 mg/g) once daily on days 1-21 of two 28-day cycles. Changes in the vaginal maturation index (VMI) from baseline to days 21 (month 1) and 49 (month 2) were the primary outcome. Physiological changes were assessed by the Genital Health Clinical Examination (GHCE).

RESULTS

The VMI was significantly improved (p < 0.001) from baseline at each assessment period. The significant improvement in GHCE from baseline after 1 month (p < 0.001) was maintained at 2 months.

CONCLUSIONS

Vaginal treatment with CEE cream for 21 days of two consecutive 28-day cycles resulted in beneficial changes in the vaginal tissues and induced an overall genital health pattern more characteristic of the premenopausal state.

Validation of the Women's Health Initiative Insomnia Rating Scale in a multicenter controlled clinical trial

OBJECTIVE

The objective of this study was to evaluate the construct validity of the five-item Women's Health Initiative Insomnia Rating Scale (WHIIRS) by comparing women taking hormone therapy (HT) versus those taking a placebo and by comparing women known to differ in vasomotor symptoms.

METHODS

The WHIIRS was included in two phase III randomized trials intended to evaluate the efficacy of a combination estradiol plus and norethindrone acetate transdermal delivery system in reducing vasomotor symptoms. In all, 850 healthy postmenopausal women participated in these studies. Both trials were double-blind, one was placebo-controlled and the other was positive-controlled. The former trial admitted women with > or =8 hot flashes/day and lasted 12 weeks with data collected on the WHIIRS at baseline, 4, 8, and 12 weeks. The other trial had no entry criteria pertaining to hot flashes and lasted 52 weeks with WHIIRS data collected at baseline, 12, 24, and 52 weeks.

RESULTS

The WHIIRS was sensitive to the effect of HT on sleep disturbance over time. The WHIIRS also detected differences in self-reported sleep disturbance between women with mild vasomotor symptoms compared with those with moderate to severe symptoms. As expected, the study using a positive control revealed that sleep improved over time (p <.0001). Also as predicted, the study using a placebo control found that sleep disturbance in the treatment groups improved at a faster rate than in the control groups (p = .035).

CONCLUSION

The construct validity of the WHIIRS was supported because it was successfully used to detect self-reported sleep disturbance differences in women taking HT versus those taking a placebo as well as in groups known to differ in severity of their vasomotor symptoms.

Endogenous estrogen levels affect sexual function in elderly post-menopausal women

OBJECTIVE

The objective of this study was to determine if there is an association between endogenous serum concentration of estradiol (E2) and changes in sexual function in post-menopausal women over 3 years.

METHODS

Sexually active women (N = 345, mean = 65 years) who participated in the multiple outcomes of raloxifene evaluation trial (MORE) had endogenous E2 levels measured at baseline. All women completed the sexual history questionnaire at baseline and 3 years later. We assessed sexual function (desire, activity, feelings/experiences and sexual problems) among these women by endogenous E2 level (<20 pmol/l or > or =20 pmol/l).

RESULTS

At baseline, women with E2 levels <20 pmol/l had significantly greater discomfort and inability to relax compared with women with E2 > or =20 pmol/l (P < 0.05 for all). After 3 years, women with E2 > or =20 pmol/l had significantly less decline in sexual enjoyment (P < 0.02), satisfaction (P < 0.02), sexual comfort (P < 0.05) and sexual feelings summary score (P = 0.001), when compared with women who had E2 levels <20 pmol/l.

CONCLUSIONS

Endogenous E2 levels are important predictors of change in sexual function in elderly women who are sexually active. However, this result needs to be proven in a study with a bigger sample size of sexually active women, who present with changes in sexual function over several years. Also, future investigations are needed to assess the effects of other endogenous hormones on sexual function in elderly women.

Medroxyprogesterone acetate antagonizes the effects of estrogen treatment on social and sexual behavior in female macaques

Medroxyprogesterone acetate (MPA) commonly is used in contraception and hormone replacement therapy. However, little is known about its effects within the central nervous system. Using ovariectomized pigtail macaques (Macaca nemestrina), we evaluated the potential for MPA to antagonize estradiol (E2) effects on female sociosexual behavior. Subjects (n = 6) were treated sequentially with placebo, E2 alone, E2 + progesterone (P4), and E2 + MPA. The order of treatments was balanced among subjects, and equimolar quantities of P4 and MPA were administered. During each treatment period, female sexual initiation rates, anxiety-related behavior, and aggression were recorded. Treatment with E2 alone induced a substantial rise in female sexual initiation rates. Although concurrent P4 treatment failed to significantly inhibit sexual behavior, MPA treatment markedly antagonized E2's effects. Neither the E2-only nor the E2 + P4 treatment had an impact on aggression rates, but the E2 + MPA treatment induced a significant rise in this behavior. Both MPA and P4 counteracted the effect of E2 on measures of anxiety. These findings suggest that MPA antagonizes certain behavioral effects of E2 that may be beneficial to women, and that it does so more profoundly or in ways that endogenous P4 does not. The marked increase in aggression seen during MPA treatment suggests that production of negative affect may be a particularly serious side effect of MPA.

Effect of the combination of methyltestosterone and esterified estrogens compared with esterified estrogens alone on apolipoprotein CIII and other apolipoproteins in very low density, low density, and high density lipoproteins in surgically postmenopausal women

Androgens are known to lower plasma triglycerides, an independent risk factor for coronary heart disease (CHD). Triglycerides are carried in plasma on very low density (VLDL) and low density (LDL) lipoprotein particles. Apolipoprotein CIII (apoCIII), a strong predictor of CHD, impairs the metabolism of VLDL and LDL, contributing to increased triglycerides. The objective of this study was to assess the effect of oral methyltestosterone (2.5 mg/d), added to esterified estrogens (1.25 mg/d), on concentrations of apolipoproteins and lipoproteins, specifically those containing apoCIII, compared with esterified estrogens alone in surgically postmenopausal women. The women in the methyltestosterone plus esterified estrogen group had significant decreases in total triglycerides, apoCI, apoCII, apoCIII, apoE, and high density lipoprotein (HDL) cholesterol compared with those in the esterified estrogen group. The decreases in apoCIII concentrations occurred in VLDL (62%; P = 0.02), LDL (35%; P = 0.001), and HDL (17%; P < 0.0001). There were also decreases in cholesterol and triglycerides concentrations of apoCIII containing LDL, and apoCI concentration of apoCIII containing VLDL. There was no effect on VLDL and LDL particles that did not contain apoCIII or on apoB concentrations. In conclusion, methyltestosterone, when administered to surgically postmenopausal women taking esterified estrogen, has a selective effect to reduce the apoCIII concentration in VLDL and LDL, a predictor of CHD. Methyltestosterone may lower plasma triglycerides through a reduction in apoCIII.