Long-term compliance with estrogen replacement therapy in surgical postmenopausal women: benefits to bone and analysis of factors associated with discontinuation

The effect of icariin on bone metabolism and its potential clinical application

Osteoporosis is a bone disease characterized by reduced bone mass, which leads to increased risk of bone fractures, and poses a significant risk to public health, especially in the elderly population. The traditional Chinese medicinal herb Epimedii has been utilized for centuries to treat bone fracture and bone loss. Icariin is a prenylated flavonol glycoside isolated from Epimedium herb, and has been shown to be the main bioactive component. This review provides a comprehensive survey of previous studies on icariin, including its structure and function, effect on bone metabolism, and potential for clinical application. These studies show that icariin promotes bone formation by stimulating osteogenic differentiation of BMSCs (bone marrow-derived mesenchymal stem cells), while inhibiting osteoclastogenic differentiation and the bone resorption activity of osteoclasts. Furthermore, icariin has been shown to be more potent than other flavonoid compounds in promoting osteogenic differentiation and maturation of osteoblasts. A 24-month randomized double-blind placebo-controlled clinical trial reported that icariin was effective in preventing postmenopausal osteoporosis with relatively low side effects. In conclusion, icariin may represent a class of flavonoids with bone-promoting activity, which could be used as potential treatment of postmenopausal osteoporosis.

RAZOR: A Phase II Open Randomized Trial of Screening Plus Goserelin and Raloxifene Versus Screening Alone in Premenopausal Women at Increased Risk of Breast Cancer

Background: Ovarian suppression in premenopausal women is known to reduce breast cancer risk. This study aimed to assess uptake and compliance with ovarian suppression using the luteinizing hormone releasing hormone (LHRH) analogue, goserelin, with add-back raloxifene, as a potential regimen for breast cancer prevention.Methods: Women at ≥30% lifetime risk breast cancer were approached and randomized to mammographic screening alone (C-Control) or screening in addition to monthly subcutaneous injections of 3.6 mg goserelin and continuous 60 mg raloxifene daily orally (T-Treated) for 2 years. The primary endpoint was therapy adherence. Secondary endpoints were toxicity/quality of life, change in bone density, and mammographic density.Results: A total of 75/950 (7.9%) women approached agreed to randomization. In the T-arm, 20 of 38 (52%) of women completed the 2-year period of study compared with the C-arm (27/37, 73.0%). Dropouts were related to toxicity but also the wish to have established risk-reducing procedures and proven chemoprevention. As relatively few women completed the study, data are limited, but those in the T-arm reported significant increases in toxicity and sexual problems, no change in anxiety, and less cancer worry. Lumbar spine bone density declined by 7.0% and visually assessed mammographic density by 4.7% over the 2-year treatment period.Conclusions: Uptake is somewhat lower than comparable studies with tamoxifen for prevention with higher dropout rates. Raloxifene may preserve bone density, but reduction in mammographic density reversed after treatment was completed.Impact: This study indicates that breast cancer risk reduction may be possible using LHRH agonists, but reducing toxicity and preventing bone changes would make this a more attractive option. Cancer Epidemiol Biomarkers Prev; 27(1); 58-66. ©2017 AACR.

Estrogens, inflammation and cognition

The effects of estrogens are pleiotropic, affecting multiple bodily systems. Changes from the body's natural fluctuating levels of estrogens, through surgical removal of the ovaries, natural menopause, or the administration of exogenous estrogens to menopausal women have been independently linked to an altered immune profile, and changes to cognitive processes. Here, we propose that inflammation may mediate the relationship between low levels of estrogens and cognitive decline. In order to determine what is known about this connection, we review the literature on the cognitive effects of decreased estrogens due to oophorectomy or natural menopause, decreased estrogens' role on inflammation--both peripherally and in the brain--and the relationship between inflammation and cognition. While this review demonstrates that much is unknown about the intersection between estrogens, cognition, inflammation, we propose that there is an important interaction between these literatures.

A comprehensive approach to the identification and management of the BRCA patient

As the testing criteria for BRCA expand, we are identifying a greater number of young women at significant risk for breast and ovarian cancer. Fortunately, there is strong evidence to support risk reduction from mastectomy and oophorectomy. However, these surgeries come with significant psychological and physical health consequences. For breast cancer, screening with mammogram and magnetic resonance imaging may be a reasonable approach for a woman who does not desire surgery. However, there is no evidence to suggest any efficacy in screening for ovarian cancer, and women electing to not undergo surgery must have a detailed discussion with their physician regarding the risks and benefits of different management strategies. As more women are electing to undergo surgical risk reduction, providers must also be able to counsel and care for these women who will face unique health challenges after surgical menopause at a young age. A review of the current evidence behind management of the BRCA woman follows, with a focus on areas of controversy and current research.

Potential health benefits of continuous LNG-IUS combined with parenteral ERT for seamless menopausal transition and beyond--a commentary based on clinical experience

OBJECTIVE

To comment on the acceptability and potential health benefits of the continuous use of the levonorgestrel-releasing intrauterine system (LNG-IUS), combined with estrogen substitution, for seamless transition through the menopause, in women with climacteric symptoms.

DESIGN AND METHOD

Evaluation of the recent hormone replacement therapy literature and the acceptability of the combined parenteral estrogen and intrauterine LNG-IUS regimen in a group of approximately 100 women, above 48 years of age, using LNG-IUS for contraception, who developed climacteric symptoms requiring estrogen substitution.

MAIN OUTCOME MEASURES

acceptability and continued use of the method for the treatment of climacteric symptoms and for prevention.

RESULTS

The combination of intrauterine progestogen delivery to suppress the endometrium, in combination with systemic estrogen, is highly acceptable resulting in a high continuation of use due to the absence of side effects and erratic bleeding in the large majority of women.

CONCLUSION

The study suggests that parenteral estrogen replacement therapy combined with intrauterine progestogen delivery for endometrial suppression in the perimenopause is highly practical and beneficial, providing enhanced quality of life. There are strong arguments to categorize the regimen as probably the most effective, safest and best accepted route resulting in high patient compliance as well as potentially providing maximal benefits for peri- and postmenopausal women.

BRCA carriers, prophylactic salpingo-oophorectomy and menopause: clinical management considerations and recommendations

Women who inherit a mutation in either the BRCA1 or BRCA2 gene have greatly elevated lifetime risks of ovarian cancer, fallopian tube cancer and breast cancer. Preventive surgical removal of the ovaries and fallopian tubes (salpingo-oophorectomy) is recommended to these women, often prior to natural menopause, to prevent cancer. The ensuing hormone deprivation may impact on health and quality of life. Most of these women experience menopausal symptoms shortly after surgery; however, there may also be longer term consequences that are less well understood. In this review, we highlight recent studies that examine the implications of salpingo-oophorectomy on health and quality of life in BRCA-positive women and we discuss the care of women following prophylactic surgery.

Treatment for the menopause in Central America: use, knowledge, perceptions and attitudes among urban living middle-aged women

BACKGROUND

Data on social and personal aspects of Central America are lacking in relation to hormone therapy (HT) and other treatments for the menopause.

OBJECTIVE

To gain information regarding the treatment of the menopause (HT/alternative): use, knowledge, perceptions and attitudes among middle-aged Central American women.

METHODS

A total of 720 urban living women (35-65 years) from six Central American countries (Guatemala, El Salvador, Honduras, Nicaragua, Costa Rica and Panama) were surveyed with a structured questionnaire that included socio-demographic data and information regarding the menopause and its treatment.

RESULTS

Participating countries displayed significant socio-demographic differences. Forty-one percent of all women were postmenopausal and 5.8% had no education at all. Knowledge regarding menopausal treatment options varied; while 27.2% (196/720) indicated HT as an option a higher rate (36.3%) either did not respond or answered not knowing anything. HT use for the whole sample was rather low 2.7% with differences seen among countries. 13.8% (27/196) indicated to have been on HT but abandoned treatment because of medical indication (51.9%), undesired side effects (29.6%) and costs (11.1%). While more than 50% considered HT served to replace hormones a smaller percentage (<14%) referred HT as bad for health, reduces cancer risk or has many side effects. 9.3% (67/720) acknowledged the existence of phytoestrogens as a menopausal treatment option, considering them as natural estrogens and good for health in 38.8% and 25.4%, respectively.

CONCLUSIONS

HT use in this mid-aged series was rather low in which the demography of Central America may be related factors. Education to women and physicians should be encouraged.

Hormone therapy for the management of the menopause in Ecuador: perception, use and knowledge among middle-aged women

BACKGROUND

There is scant data on social and personal aspects related to the use of menopausal hormone therapy (HT) in Latin America.

OBJECTIVES

To obtain information regarding menopausal HT, i.e. use, perception, level and sources of knowledge, and to determine factors affecting several of these issues among middle-aged women of Guayaquil, Ecuador.

DESIGN

A total of 349 women (nursing staff), aged 40 years or more, were included in the present cross-sectional study. Participants completed a structured questionnaire including details related to HT and the reasons for not using it, as well as demographic and psychosocial data.

RESULTS

Only 50.1% of women considered HT beneficial. Current and former HT use was low (1.7% and 14.3%, respectively) and mean HT duration among former users was short (mean +/- standard deviation: 1.0 +/- 1.4 years). Women responded that the main reasons for not using HT were being asymptomatic (49.0%), non-established menopause (30.4%) and physician's advice (27.2%). Only 28.9% of women considered having enough information regarding HT, whereas a high percentage (93.1%) indicated willingness to participate in educational sessions addressing this issue. For most of the women the main sources of information were physicians, educational sessions and television. Logistic regression analysis determined that women with lower income and HT information did not consider HT beneficial at a higher rate than their counterparts. Premenopausal women and those with lower income were more prone to never HT use. Age and professional level were found to be confounding factors.

CONCLUSIONS

HT use in this population was low; hormonal status, economic income and level of HT information determined its use and benefit awareness.

Guidance for the management of breast cancer treatment-induced bone loss: a consensus position statement from a UK Expert Group

In postmenopausal women, the use of aromatase inhibitors increases bone turnover and induces bone loss at sites rich in trabecular bone at an average rate of 1-3% per year leading to an increase in fracture incidence compared to that seen during tamoxifen use. The bone loss is much more marked in young women with treatment-induced ovarian suppression followed by aromatase inhibitor therapy (average 7-8% per annum). Pre-treatment with tamoxifen for 2-5 years may reduce the clinical significance of the adverse bone effects associated with aromatase inhibitors, particularly if this leads to a shortening in the duration of exposure to an aromatase inhibitor. However, skeletal status should still be assessed at the commencement of aromatase inhibitor therapy. The rate of bone loss in women who experience a premature menopause before the age of 45 or are receiving ovarian suppression therapy is accelerated by the concomitant use of aromatase inhibitors. These patients are considered to be at high risk of clinically important bone loss and should have a baseline dual energy X-ray absorptiometry (DXA) assessment of bone mineral density (BMD). Randomised clinical trials in postmenopausal women indicate that bisphosphonates prevent the bone loss and accelerated bone turnover associated with aromatase inhibitor therapy and are a promising strategy for the prevention and treatment of osteoporosis in this setting. Treatment initiation recommendations are based on a combination of risk factors for osteoporotic fracture and BMD levels. Bisphosphonates, along with a healthy lifestyle and adequate intake of calcium and vitamin D are the treatments of choice to prevent bone loss. Due to the rate of bone loss associated with breast cancer treatments, and uncertainties about the interaction between aromatase inhibitor use and BMD for fracture risk, the threshold for intervention has been set at a higher level than that generally recommended for postmenopausal osteoporosis. Management recommendations have been summarised in two algorithms, one for women experiencing a premature menopause and the other for postmenopausal women requiring adjuvant aromatase inhibitor therapy.

Epimedium-derived phytoestrogen flavonoids exert beneficial effect on preventing bone loss in late postmenopausal women: a 24-month randomized, double-blind and placebo-controlled trial

Epimedium brevicornum maxim, a nonleguminous medicinal plant, has been found to be rich in phytoestrogen flavonoids. Results from a 24-month randomized double-blind placebo-controlled clinical trial showed that Epimedium-derived phytoestrogen flavonoids were able to exert beneficial effects on preventing bone loss in late postmenopausal women, without resulting in a detectable hyperplasia effect on the endometrium.

INTRODUCTION

We performed a 24-mo randomized double-blind placebo-controlled clinical trial for evaluating the effect of the Epimedium-derived phytoestrogen flavonoids (EPFs) on BMD, bone turnover biochemical markers, serum estradiol, and endometrial thickness in postmenopausal women.

MATERIALS AND METHODS

One hundred healthy late postmenopausal women, with a natural menopausal history within 10 approximately 18 yr and with a BMD T-score at the lumbar spine between -2 and -2.5 SD, were randomized into EPF treatment group (n = 50; a daily dose of 60 mg Icariin, 15 mg Daidzein, and 3 mg Genistein) or placebo control group (n = 50). All participants received 300 mg element calcium daily. BMD, bone turnover biochemical markers, serum estradiol, and endometrial thickness were measured at baseline and 12 and 24 mo after intervention.

RESULTS

Eighty-five participants completed the trial. The patterns of BMD changes were significantly different between the EPF treatment group and placebo control group by repeated-measures ANOVA (p = 0.045 for interaction between time and group at femoral neck; p = 0.006 for interaction between time and group at lumbar spine). BMD was found with a decreased tendency in the placebo control group at 12 (femoral neck: -1.4%, p = 0.104; lumbar spine: -1.7%, p = 0.019) and 24 mo (femoral neck: -1.8%, p = 0.048; lumbar spine: -2.4%, p = 0.002), whereas EPF treatment maintained BMD at 12 (femoral neck: 1.1%, p = 0.285; lumbar spine:1.0%, p = 0.158) and 24 mo (femoral neck: 1.6%, p = 0.148; lumbar spine: 1.3%, p = 0.091). The difference in lumbar spine between the two groups was significant at both 12 (p = 0.044) and 24 mo (p = 0.006), whereas the difference in the femoral neck was marginal at 12 mo (p = 0.061) and significant at 24 mo (p = 0.008). Levels of bone biochemical markers did not change in the placebo control group. In contrast, EPF intervention significantly decreased levels of deoxypyrdinoline at 12 (-43%, p = 0.000) and 24 mo (-39%, p = 0.000), except for osteocalcin at 12 (5.6%, p = 0.530) and 24 mo (10.7%, p = 0.267). A significant difference in deoxypyrdinoline between the two groups was found at both 12 (p = 0.000) and 24 mo (p = 0.001). Furthermore, neither serum estradiol nor endometrial thickness was found to be changed in either groups during the clinical trial.

CONCLUSIONS

EPFs exert a beneficial effect on preventing bone loss in late postmenopausal women without resulting in a detectable hyperplasia effect on the endometrium.

Spanish post-menopausal women's viewpoints on hormone therapy

OBJECTIVE

The purpose of this study was to identify women's socio-demographic and climacteric factors, as well as other variables related to health care, associated with the prescription of the treatment during menopause and to investigate the prevalence of certain conditioning factors in early discontinuation in women aged 40-65 years in a population of post-menopausal women in Spain.

STUDY DESIGN

Cross-sectional survey.

SETTING

Four of the most inhabited cities in Spain (Madrid, Barcelona, Seville and Valencia).

POPULATION

A total of 270 symptomatic post-menopausal women.

METHODS

A personal interview with a semi-structured questionnaire specifically designed to collect information on treatments for climacteric-related complaints.

MAIN OUTCOME MEASURES

The reasons for HRT, the evaluation of alternative therapies, the reasons for choosing one therapy or another and reasons for discontinuation.

RESULTS

Of all the subjects included, 180 were still taking any type of treatment and 90 were former HRT users or had never used HRT. Among the latter, 43% of women expressed fear of the side effects and 38% gave the risk of breast cancer as the main reason for not using HRT. Of them, 58% receive phytoestrogens. Media and negative data from medical journals influenced this attitude in 67% of the women. On the other hand, only 9.4% of HRT users were reluctant to receive the therapy and the main reasons for maintaining HRT were its efficacy against climacteric symptoms, medical prescription and life quality.

CONCLUSIONS

Side effects and fear of cancer were the most common reasons for not using HRT; and medical prescription, symptomatic improvement and quality of life were the main reasons for using it. Negative data from journals have an important effect on women's attitudes to HRT.

The prescription of hormone replacement therapy in Spain: Differences between general practitioners and gynaecologists

OBJECTIVES

The purpose of this study was to determine the frequency with which hormone replacement therapy (HRT) was prescribed and to identify physician-related factors associated with the prescription of HRT in Spain.

STUDY DESIGN

A descriptive cross-sectional survey based on a personal interview with a structured questionnaire was conducted in April 2005 with physicians aged 25-65 years. A total of 2700 doctors were asked to participate in this prospective study (1350 GY and 1350 GP). This number included 270 gynaecologists (GY group) and 270 general practitioners (GP group).

RESULTS

Only 10% of gynaecologists and 19.4% of GPs had never prescribed HRT. The reasons given for not prescribing HRT were adverse effects and the fear of cancer among GPs and adverse effects and social alarm in the GY group. Phytoestrogens were the most commonly used alternative; however, GPs were more willing to use antidepressants and benzodiazepines than GYs. The frequency of HRT prescription in symptomatic women was significantly higher among GYs. The main reasons for prescribing HRT were climacteric complaints and improvement in life quality for GYs and, climacteric complaints and the prevention of osteoporosis for GPs. Seventy-eight percent of GYs prescribing hormones referred a high degree of satisfaction with HRT, whereas only 50% of GPs expressed a similar attitude.

CONCLUSIONS

Concern for HRT prescription in Spain is high. Adverse effects and the fear of cancer are negative conditioning factors in the prescription of HRT, whereas climacteric complaints, quality of life and the prevention of osteoporosis are positive conditioning factors. GYs are more willing to use HRT than GPs. This contrast may reflect the indecision of GPs regarding the preventive value of HRT.

Available medical choices for the management of menopause

The age at which menopause occurs is a critical factor in the magnitude of its consequences. Most of the medium-to-long-term effects of oestrogen deprivation depend on their duration. The timing of the last menstruation is therefore important, but hypoestrogenic amenorrhoea during the reproductive age is also a relevant factor in the evaluation of individual risks. In recent years, moving post-menopausal women from the lowest point of ovarian hypofunction has been the most important motivation for developing guidelines for the hormonal management of menopause. However, recent data suggest that this may be associated with an unacceptable increase in morbidity in a number of women. Concerns about long-term hormone replacement therapy (HRT) at menopause have recently enhanced interest in a group of molecules that act on the oestrogen receptor with selective effects, known as selective oestrogen receptor modulators (SERMs). Of these, Raloxifene has been approved for the treatment and prevention of osteoporosis, and exhibits a pattern of actions particularly well matched to the needs and concerns of post-menopausal women. Further studies on SERMs may open up new vistas in patient-specific management of post-menopausal health. Finally, debates on the specific health consequences of menopause deal mainly with the risk of chronic disease. Gynaecologists and other health professionals would be advised to develop intervention strategies at menopause according to the continuum of a woman's life, beginning at the post-menarche and extending into later life.

The effects of phytoestrogen isoflavones on bone density in women: a double-blind, randomized, placebo-controlled trial

BACKGROUND

Isoflavone phytoestrogen therapy has been proposed as a natural alternative to hormone replacement therapy (HRT). HRT has a beneficial effect on bone, but few trials in humans have investigated the effects of isoflavones on bone.

OBJECTIVE

The objective of the study was to determine the effect on bone density of a red clover-derived isoflavone supplement that provided a daily dose of 26 mg biochanin A, 16 mg formononetin, 1 mg genistein, and 0.5 mg daidzein for 1 y. Effects on biochemical markers of bone turnover and body composition were also studied.

DESIGN

Women aged 49-65 y (n = 205) were enrolled in a double-blind, randomized, placebo-controlled trial; 177 completed the trial. Bone density, body composition, bone turnover markers, and diet were measured at baseline and after 12 mo.

RESULTS

Loss of lumbar spine bone mineral content and bone mineral density was significantly (P = 0.04 and P = 0.03, respectively) lower in the women taking the isoflavone supplement than in those taking the placebo. There were no significant treatment effects on hip bone mineral content or bone mineral density, markers of bone resorption, or body composition, but bone formation markers were significantly increased (P = 0.04 and P = 0.01 for bone-specific alkaline phosphatase and N-propeptide of collagen type I, respectively) in the intervention group compared with placebo in postmenopausal women. Interactions between treatment group and menopausal status with respect to changes in other outcomes were not significant.

CONCLUSION

These data suggest that, through attenuation of bone loss, isoflavones have a potentially protective effect on the lumbar spine in women.

Hysterectomy and oophorectomy are unrelated to bone loss in older women

OBJECTIVE

The relation of hysterectomy and oophorectomy to change in bone mineral density (BMD) was examined in older women using and not using estrogen replacement therapy (ERT).

METHODS

Women aged 60-80 years from the Rancho Bernardo Study attended clinic visits in 1988-1991 and 1992-1995 when hysterectomy and oophorectomy were ascertained, ERT use was validated and spine and hip BMD was assessed at both visits with DEXA. Women were either current ERT users or nonusers at both visits.

RESULTS

Among these 447 women, average age was 71 (S.D.=9.0); average years postmenopause was 24.7 (S.D.=10.9). Overall, 122 had a hysterectomy with ovarian conservation and 91 had a hysterectomy with bilateral oophorectomy; 41% reported current ERT use for an average duration of 19.1 years (S.D.=10.8). Hysterectomized women were 2.3 times more likely to report ERT use than intact women (P<0.001). Comparisons adjusted for age, obesity, and age at menopause but not for ERT use showed hysterectomized women had less bone loss per year at the hip than intact women (P<0.05). However, this difference was explained by ERT; after adjustment for ERT, mean hip bone loss per year was -0.57% for intact women, -0.42% for hysterectomized women with ovarian conservation and -0.32% for bilaterally oophorectomized women (P's>0.10). There were no differences by hysterectomy or oophorectomy in bone loss at the spine or femoral neck. For all sites, women using ERT had higher BMD at both visits than nonusers (P's<0.001). Stratification by ERT showed that within users and nonusers, there were no differences in BMD or bone loss at any site by hysterectomy or oophorectomy.

CONCLUSIONS

There are no long term effects of hysterectomy and bilateral oophorectomy on bone loss. Women who use ERT have better BMD than nonusers.

[Compliance with hormone replacement therapy in menopausal women: results of a two-year prospective French study comparing transdermal treatment with fixed oral combination therapy]

OBJECTIVES

To evaluate rates of continuation with hormone replacement therapy (HRT) at 2 years in 2 cohorts of female patients, one of which was treated with a set combination of oral oestradiol valerate and medroxyprogesterone acetate and the other with percutaneous 17 beta-oestradiol gel combined with an oral progestogen selected by the prescribing doctor.

PATIENTS AND METHODS

A prospective, randomised, open study, including 885 patients followed for 2 years whose 477 were in the oral HRT cohort and 408 were in the dermal cohort. Randomisation was done by group with prescription of the selected HRT for the cohort. The 2 treatment groups were compared using chi(2) tests and Fisher's exact test for qualitative variables, Student's t test or Wilcoxon's test for qualitative variables and Kaplan-Meier survival curves for continuation of HRT, with comparisons using the log-rank test. The prognostic value of baseline parameters on subsequent continuation of HRT was studied using the Cox model (Wald test, odds ratio). RESULTS; Among the 885 treated patients, 711 received the HRT assigned to their cohort (382 in the oral HRT cohort, 329 in the dermal HRT cohort). After 2 years, 77.9% of the patients in the oral HRT cohort and 73.4% of the patients in the dermal HRT cohort were continuing to take their prescribed HRT (P = 0. 076): 37.9% of patients in the oral HRT cohort and 20.2% of patients in the dermal HRT cohort (P < 0.001) continued taking their treatment without any modification.

CONCLUSION

Although there was no significant difference in the level of compliance in the 2 groups, it is nonetheless worth noting that the HRT compliance with a sequential fixed estroprogestogen combination was, in this trial, at least equal to that with the free combination of a transdermal estrogen and a progestogen whose nature, dosage and sequence duration are selected by the prescriber. On the other hand, treatment modifications occurred more frequently in the cutaneous HRT group, which is logical as free combination affords to adapt the treatment to each patient.

Performance and acceptability of intrauterine release of levonorgestrel with a miniature delivery system for hormonal substitution therapy, contraception and treatment in peri and postmenopausal women

OBJECTIVE

To evaluate the performance and acceptability of a novel intrauterine drug delivery system, FibroPlant-levonorgestrel (LNG), delivering approximately 14 microg per day. SUBJECT AND DESIGNS: A 1-year prospective clinical trial in 141 peri and postmenopausal women, including women with heavy or postmenopausal bleeding and women needing contraception. The majority received percutaneous 17beta-estradiol (Oestrogel), 1.5 mg daily. Clinical results and ultrasonographic effects were evaluated.

RESULTS

Eighty-three insertions were done in perimenopausal women and 58 in postmenopausal women followed-up for 8-38 months. Fifty-two perimenopausal (64%) and virtually 100% of the postmenopausal women developed amenorrhoea, with occasional slight spotting. Eleven women with heavy bleeding, five of them with single or multiple intramural and subserosal fibroids of 3-6 cm or more, were all successfully treated, except one. There were no pregnancies.

CONCLUSION

This study of 1432 women-months of use suggests that the frameless FibroPlant-LNG IUS is safe, well tolerated and effective in suppressing the endometrium during EST. The fact that the IUS also acts as a contraceptive, and significantly reduces menstrual bleeding, as demonstrated in earlier studies, is of added importance.

Secreting ovarian tumors may protect women from osteoporosis

OBJECTIVE

It is well known that ovarian steroids modulate bone turnover. Conditions associated with low levels of these hormones, such as menopause, hypogonadism, and others, have been related to osteopenia or osteoporosis. On the other hand, hyperandrogenism in premenopausal women, mainly in polycystic ovarian syndrome, has been reported to have a protective effect on bone mass. However, data regarding how bone mass is affected by neoformative processes in which steroids are increased are not as well documented. Our aim was to study the effect of secreting ovarian tumors on bone mass.

METHODS

A total of 14 patients were referred to our hospital because of endocrine ovarian tumors. Steroid levels were measured prior to and after surgery. Bone mineral density (BMD) by DEXA was assessed at inclusion in all cases. Additionally, in 7 women bone measurement was repeated after 1-year follow-up. The setting was a tertiary hospital.

RESULTS

All patients showed increased levels of testosterone, androstenedione, and free testosterone prior to surgery. BMD was also in the normal-upper range or over normal in all of them. As expected in the subjects with a second DEXA a decrease in bone mass was noted.

CONCLUSION

Steroid secreting ovarian tumors increase bone mass and thus may protect women from later osteoporosis.

Pathophysiology and treatment of hot flashes

Hot flashes affect about three fourths of postmenopausal women and are one of the most common health problems in this demographic group. Dysfunction of central thermoregulatory centers caused by changes in estrogen levels at the time of menopause has long been postulated to be the cause of hot flashes. Treatment should begin with a careful patient history, with specific attention to the frequency and severity of hot flashes and their effect on the individual's function. For mild symptoms that do not interfere with sleep or daily function, behavioral changes in conjunction with vitamin E (800 IU/d) use is a reasonable initial approach. For more severe symptoms, the next step is to determine whether there is a contraindication or a personal reservation to estrogen replacement therapy. For women who are able and willing to use estrogen, it will successfully relieve symptoms by about 80% to 90%. In patients with a history of breast or uterine cancer, treatment with the progestational agent megesterol acetate appears to be a safe alternative that also decreases hot flashes by approximately 80%. For women unwilling or unable to use hormone therapy, one of the newer antidepressant agents can be prescribed. Venlafaxine decreases hot flashes by about 60%. Gabapentin is another drug that appears promising as therapy for women unable or unwilling to use estrogen, and the results of ongoing trials to determine its efficacy are eagerly awaited. The use of clonidine, methyldopa, and belladonna should be discouraged because of their modest efficacy and adverse effects.

Use of hormone replacement therapy among Chilean women: a comparison between socioeconomic levels

OBJECTIVE

To compare the use of hormone replacement therapy (HRT) among Chilean women according to their socioeconomic level.

METHODS

A total of 540 women between 50 and 79 years of age were interviewed in Santiago, Chile. Women were allocated into two groups (H, high; L, low), according to their socioeconomic status.

RESULTS

Each group consisted of 270 women. The mean age and percentage of menopausal women were similar in both groups. Of the interviewed women, 47% had taken HRT at some time; marked differences between the two groups were observed (L, 15%; H, 79%; < 0.0001). In group H, the percentage of women who had been advised about HRT was close to 88%, whereas, in group L, the percentage was only 24%. Among the women who were informed about HRT, 83% ( = 253) had used it at some time. The percentage of women who used HRT for >2 years was similar in both groups. The main reason for not taking HRT in group H was fear of adverse effects, whereas the main reason for not taking it in group L was the lack of medical advice.

CONCLUSIONS

The percentage of women in the low socioeconomic group who use HRT is low. Medical advice is fundamental to increasing HRT use in this group.

Hot flashes: aetiology and management

Menopause, an event often accompanied by symptoms such as hot flashes, can have a significant impact on a woman's quality of life. A majority of women will experience hot flashes at some point in their life, given a normal life span. Despite multiple theories, the exact pathophysiology of hot flashes is not yet known. Many types of treatment options exist for women with hot flashes, from hormonal and nonhormonal pharmacological therapies to nonpharmacological interventions. Choosing the best treatment option for specific women involves knowledge of the risks and benefits of each treatment. Hormones (estrogen and/or progesterone, or tibolone alone) are still the most effective option available, resulting in an 80 to 90% reduction in hot flashes. The best nonhormonal treatment to date is in the class of newer antidepressants that comprises various selective reuptake inhibitors; for example, venlafaxine provides about a 60% reduction in hot flashes. This article provides evidence-based information about available treatment options for hot flash management, with special consideration of populations such as breast cancer survivors.

Development of a miniature, low-dose, frameless intrauterine levonorgestrel-releasing system for contraception and treatment: a review of initial clinical experience

A low-dose levonorgestrel (LNG)-releasing intrauterine system (IUS) (FibroPlant) has been clinically developed since 1997 for endometrial suppression during hormone replacement therapy in peri- and postmenopausal women, for the treatment of menorrhagia in women with normal uteri or with uterine fibroids, for contraception, for the treatment of endometrial hyperplasia, and for alleviating primary and secondary dysmenorrhoea. Results of preliminary studies confirm the promising nature of this all-round drug delivery system. The low dose of LNG released accounts for the low hormonal side-effect rate and virtual absence of amenorrhoea in premenopausal women. The system has not yet been evaluated in tamoxifen users (to protect the endometrium), or in women with rectovaginal endometriosis. However, early indications suggest that the system will also be suitable for these indications. The frameless drug delivery support of this LNG-releasing IUS has been optimized to reduce the size of the foreign body and to maximize tolerance and continuation of use while simultaneously providing for the maximum duration of action.