Health Hazards in Middle-Aged Women with Cardiovascular Disease: A Case-Control Study of Swedish Women. The Women's Health in the Lund Area (WHILA) Study

The role of bile acids in metabolic regulation

Bile acids (BA), long believed to only have lipid-digestive functions, have emerged as novel metabolic modulators. They have important endocrine effects through multiple cytoplasmic as well as nuclear receptors in various organs and tissues. BA affect multiple functions to control energy homeostasis, as well as glucose and lipid metabolism, predominantly by activating the nuclear farnesoid X receptor and the cytoplasmic G protein-coupled BA receptor TGR5 in a variety of tissues. However, BA also are aimed at many other cellular targets in a wide array of organs and cell compartments. Their role in the pathogenesis of diabetes, obesity and other 'diseases of civilization' becomes even more clear. They also interact with the gut microbiome, with important clinical implications, further extending the complexity of their biological functions. Therefore, it is not surprising that BA metabolism is substantially modulated by bariatric surgery, a phenomenon contributing favorably to the therapeutic effects of these surgical procedures. Based on these data, several therapeutic approaches to ameliorate obesity and diabetes have been proposed to affect the cellular targets of BA.

Specific inhibition of bile acid transport alters plasma lipids and GLP-1

BACKGROUND

Elobixibat is a minimally absorbed ileal bile acid (BA) transporter (IBAT) inhibitor in development against chronic constipation (CC) and constipation-predominant Irritable Bowel Syndrome (IBS-C). CC is associated with an increased risk for cardiovascular disease and type2 diabetes mellitus. The objectives of this study were to evaluate metabolic effects of elobixibat. Effects on plasma lipids and BA synthesis were evaluated utilizing a 4-week, placebo-controlled study in patients with dyslipidemia while changes of glucagon-like peptide-1 (GLP-1) by elobixibat was assayed in samples from a 14 day high-dose elobixibat study in patients with CC.

METHODS

Thirty-six dyslipidemic patients, 21 females, mean age 63 years, were randomized to 2.5 mg or 5 mg elobixibat or placebo once daily for four weeks. The primary endpoint was the change in low density lipoprotein (LDL) cholesterol. Secondary endpoints included other lipid parameters and serum 7α-hydroxy-4-cholesten-3-one (C4), a marker of BA (bile acid) synthesis. Another study, in 36 patients with CC treated with high dose elobixibat; 15 mg or 20 mg/day or placebo for 14 days, was evaluated for changes in GLP-1.

RESULTS

In the dyslipidemia study LDL cholesterol was reduced by 7.4 % (p = 0.044), and the LDL/HDL ratio was decreased by 18 % (p = 0.004). Serum C4 increased, indicating that BA synthesis was induced. No serious adverse events were recorded. In the CC study, GLP-1 increased significantly in both the 15 mg (20.7 ± 2.4 pmol/L; p = 0.03) and the 20 mg group (25.6 ± 4.9 pmol/L; p = 0.02).

CONCLUSIONS

Elobixibat reduces LDL cholesterol and LDL/HDL ratio and increase circulating peak GLP-1 levels, the latter in line with increased intestinal BA mediated responses in humans.

TRIAL REGISTRATIONS

ClinicalTrial.gov: NCT01069783 and NCT01038687 .

Endogenous sex steroid levels and cardiovascular disease in relation to the menopause: a systematic review

Heart disease remains a major cause of death among women in the United States. This article focuses on physiologic endogenous estrogen levels with a systematic review of literature related to endogenous sex steroid levels and coronary artery disease (CAD) among postmenopausal women with natural or surgical menopause. There is adequate reason to seek evidence for associations of circulating estrogen levels and CAD. In the future, even if ovarian senescence-associated hormonal changes are confirmed to be associated with CAD in cohort studies of postmenopausal women, there may be other components explaining the gender differences in CAD patterns.

Systematic review of cardiovascular disease in women: assessing the risk

Cardiovascular disease is the number one cause of death for women. In an effort to reduce cardiovascular burden for women, identifying risk factors and increasing awareness of sex differences are fundamental. This systematic review examines cardiovascular disease risk for women. A search of the literature was undertaken using key health databases. Search terms used were cardiovascular disease AND women OR gender. Additional references were manually identified from this literature; 58 articles were reviewed in total. On average, cardiovascular disease presents 10 years later in women compared to men. By this time, they are more likely to suffer from more comorbidities, placing them at higher risk. The complexity of cardiovascular disease identification in women is accentuated through atypical symptoms, and has the potential to lead to delayed and/or misdiagnosis. It is clear through identifying sex differentiation in cardiovascular risk factors that there has been an increased awareness of symptom presentation for women. In light of the sex differences in risk factors, sex-specific aspects should be more intensively considered in research/practice to improve clinical outcomes for female cardiovascular disease patients.

The women's health in the Lund area (WHILA) study--an overview

The Women's Health in the Lund Area (WHILA) study invited all women (n=10,766) living in the Lund area of Southern Sweden by 1995, who were born between 1935 and 1945. The health screening program included a postal validated questionnaire concerning medical history, drug treatment, family history of diabetes and hypertension, menopausal status, smoking and alcohol habits, education, household, and working status, physical activity, quality of life as well as subjective physical and mental symptoms. The screening consisted of a routine physical examination with standardized blood pressure measurements, bone densitometry and an extended laboratory examination. A link with the mammography registry was established. Based on menopausal status, the population was divided in three subgroups; premenopausal (PM), postmenopausal with hormone replacement therapy (PMT), and postmenopausal without hormone replacement therapy (PM0). Menopause was defined as a bleed-free interval of at least 12 months. Of 10,766 women, 6917 (64.2%) had complete data sets. A number of observational analyses were carried out based on the screening data at baseline, to be followed by long-term follow-up analyses based on national register linkages that are currently being started.

Recent research in stress, coping and women's health

PURPOSE OF REVIEW

To highlight recent publications in the area of stress and coping, with specific reference to women's physical health status.

RECENT FINDINGS

The transactional model of stress and coping continues to be the mainstay of research in this area. Several longitudinal studies have demonstrated that stress appraisal and resultant coping responses affect health outcome and health-related quality of life in women. In addition to problem-focused coping, women often use distraction methods, seeking social support and faith or religious coping. Psychological interventions in chronic medical conditions need to move beyond education and incorporate more cognitive behavioral components, at the same time addressing women's specific needs.

SUMMARY

Coping behaviors in response to the negative threat appraisal of a chronic or severe medical illness serve to reduce psychological distress. However, it is still not clear how they impact at the physiological level. In addition, coping responses, which enhance positive effects and promote health-related quality of life, merit greater attention from researchers. There is a need for more gender comparative research to improve health outcomes in men and women.

Cardiovascular disease and periodontitis: an update on the associations and risk

BACKGROUND

Associations between periodontitis and cardiovascular diseases have been recognized.

MATERIAL AND METHODS

New literature since the last European Workshop on Periodontology has been reviewed.

RESULTS

The lack of reliable epidemiological data on disease prevalence makes an assessment of the associations and risks between periodontitis and cardiovascular diseases difficult. Two recent meta-analysis reports have identified associations between periodontitis and cardiovascular diseases (odds ratios: 1.1-2.2). Different surrogate markers for both disease entities, including serum biomarkers, have been investigated. Brachial artery flow-mediated dilatation, and carotid intima media thickness have in some studies been linked to periodontitis. Studies are needed to confirm early results of improvements of such surrogate markers following periodontal therapy. While intensive periodontal therapy may enhance inflammatory responses and impair vascular functions, studies are needed to assess the outcome of periodontal therapies in subjects with confirmed cardiovascular conditions. Tooth eradication may also reduce the systemic inflammatory burden of individuals with severe periodontitis. The role of confounders remain unclear.

CONCLUSIONS

Periodontitis may contribute to cardiovascular disease and stroke in susceptible subjects. Properly powered longitudinal case-control and intervention trials are needed to identify how periodontitis and periodontal interventions may have an impact on cardiovascular diseases.

Hormone replacement therapy use and plasma levels of sex hormones in the Norwegian Women and Cancer postgenome cohort - a cross-sectional analysis

Background

Hormone replacement therapy use (HRT) is associated with increased breast cancer risk. Our primary objective was to explore hormone levels in plasma according to HRT use, body mass index (BMI) and menopausal status. A secondary objective was to validate self-reported questionnaire information on menstruation and HRT use in the Norwegian Women and Cancer postgenome cohort (NOWAC).

Methods

We conducted a cross-sectional study of sex hormone levels among 445 women aged 48–62 who answered an eight-page questionnaire in 2004 and agreed to donate a blood sample. The samples were drawn at the women's local general physician's offices in the spring of 2005 and sent by mail to NOWAC, Tromsø, together with a two-page questionnaire. Plasma levels of sex hormones and Sex Hormone Binding Globulin (SHBG) were measured by immunometry. 20 samples were excluded, leaving 425 hormone measurements.

Results

20% of postmenopausal women were HRT users. The plasma levels of estradiol (E₂) increased with an increased E₂ dose, and use of systemic E₂-containing HRT suppressed the level of Follicle Stimulating Hormone (FSH). SHBG levels increased mainly among users of oral E₂ preparations. Vaginal E₂ application did not influence hormone levels. There was no difference in BMI between HRT users and non-users. Increased BMI was associated with increased E₂ and decreased FSH and SHBG levels among non-users. Menopausal status defined by the two-page questionnaire showed 92% sensitivity (95% CI 89–96%) and 73% specificity (95% CI 64–82%), while the eight-page questionnaire showed 88% sensitivity (95% CI 84–92%) and 87% specificity (95% CI 80–94%). Current HRT use showed 100% specificity and 88% of the HRT-users had plasma E₂ levels above the 95% CI of non-users.

Conclusion

Users of systemic E₂-containing HRT preparations have plasma E₂ and FSH levels comparable to premenopausal women. BMI has an influence on hormone levels among non-users. NOWAC questionnaires provide valid information on current HRT use and menopausal status among Norwegian women who are between 48 and 62 years old.