Side-effects of hormone replacement therapy and influence on pattern of use among women aged 45-64 years. The Norwegian Women and Cancer (NOWAC) study 1997

Effects of stellate ganglion block on perimenopausal hot flashes: a randomized controlled trial

Background

Hot flashes are common symptoms afflicting perimenopausal women. A stellate ganglion block (SGB) is believed to be an effective treatment for hot flashes; however, more evidence is needed to evaluate its safety and efficacy in relieving perimenopausal hot flashes.

Objective

To investigate the efficacy and safety of SGB for the treatment of perimenopausal hot flashes.

Methods

A randomized controlled trial was conducted at Shanxi Bethune Hospital. Forty perimenopausal women with hot flashes were recruited from April 2022 to November 2022 and randomly assigned to receive either 6 consecutive SGB treatments or 6 consecutive saline placebo treatments. The primary outcome was the change in hot flash symptom score from baseline to 12 weeks after treatment. The secondary outcomes were the change in hot flash symptom score from baseline to 12 weeks after treatment and the post-treatment Kupperman Index (KI) and Pittsburgh Sleep Quality Index (PSQI) scores.

Results

Of the 40 randomized subjects, 35 completed the study. All the variables were significantly improved. During 12 weeks of follow-up, the hot flash scores, Kupperman Menopause Scale scores, and Pittsburgh Sleep Quality Scale scores decreased significantly. Two subjects in the SGB treatment group experienced transient hoarseness, and the incidence of related adverse events was 10%. No related adverse events occurred in the control group.

Conclusion

Compared to the control treatment, SGB treatment was a safe and effective nonhormone replacement therapy that significantly relieved perimenopausal hot flashes and effectively improved sleep quality. Additional studies are needed to assess the long-term efficacy of this therapy.

17β-estradiol inhibits human umbilical vascular endothelial cell senescence by regulating autophagy via p53

Vascular endothelial cell (VEC) senescence is an initiating factor in numerous cardiovascular diseases. Recent studies showed that 17β-estradiol (17β-E2), an estrogen with numerous biological activities such as inhibition of atherosclerosis, protects VECs from senescence. However, the effects of 17β-E2 on human umbilical VECs (HUVECs) remain unknown. This study investigated the anti-senescent effect of 17β-E2 on HUVECs and explored the underlying mechanism with respect to autophagy and p53 activity. First, rapamycin and 3-methyladenine were used to clarify the relationship between autophagy and senescence in HUVECs, and an inverse relationship was demonstrated. Next, the effect of 17β-E2 on H₂O₂-induced senescence of HUVECs was examined. Increased autophagy induced by 17β-E2 inhibited H₂O₂-induced senescence of HUVECs, increased cell viability, and maintained HUVEC morphology. 17β-E2 pre-treatment also decreased cell cycle arrest, decreased the dephosphorylation of Rb, decreased the production of ET-1, and increased the production of NO. Most importantly, 17β-E2 pre-treatment increased autophagy by activating p53 and its downstream effector p53-upregulated modulator of apoptosis (PUMA). Overall, our data indicate the critical role of autophagy in the anti-senescent effect of 17β-E2 on HUVECs.

Phytoestrogens for menopausal vasomotor symptoms

BACKGROUND

Vasomotor symptoms, such as hot flushes and night sweats, are very common during the menopausal transition. Hormone therapy has traditionally been used as a highly effective treatment, but concerns about increased risk of some chronic diseases have markedly increased the interest of women in alternative treatments. Some of the most popular of these treatments are foods or supplements enriched with phytoestrogens-plant-derived chemicals that have estrogenic action.

OBJECTIVES

To assess the efficacy, safety and acceptability of food products, extracts and dietary supplements containing high levels of phytoestrogens when compared with no treatment, placebo or hormone therapy for the amelioration of vasomotor menopausal symptoms (such as hot flushes and night sweats) in perimenopausal and postmenopausal women.

SEARCH METHODS

Searches targeted the following electronic databases: the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of randomised trials (29 July 2013), the Cochrane Register of Controlled Trials (CENTRAL; 29 July 2013), MEDLINE (inception to 29 July 2013), EMBASE (inception to 29 July 2013), AMED (1985 to 29 July 2013), PsycINFO (inception to 29 July 2013) and CINAHL (inception to 29 July 2013). Attempts were made to access grey literature by sending letters to pharmaceutical companies and performing searches of ongoing trial registers. Reference lists of included trials were also searched.

SELECTION CRITERIA

Studies were included if they were randomised, included perimenopausal or postmenopausal participants with vasomotor symptoms (hot flushes or night sweats), lasted at least 12 weeks and provided interventions such as foods or supplements with high levels of phytoestrogens (not combined with other herbal treatments). Trials that included women who had breast cancer or a history of breast cancer were excluded.

DATA COLLECTION AND ANALYSIS

Selection of trials, extraction of data and assessment of quality were undertaken by at least two review authors. Most trials were too dissimilar for their results to be combined in a meta-analysis, so these findings are provided in narrative 'Summary of results' tables. Studies were grouped into broad categories: dietary soy, soy extracts, red clover extracts, genistein extracts and other types of phytoestrogens. Five trials used Promensil, a red clover extract; results of these trials were combined in a meta-analysis, and summary effect measures were calculated.

MAIN RESULTS

A total of 43 randomised controlled trials (4,364 participants) were included in this review. Very few trials provided data suitable for inclusion in a meta-analysis. Among the five trials that yielded data assessing the daily frequency of hot flushes suitable for pooling, no significant difference overall was noted in the incidence of hot flushes between participants taking Promensil (a red clover extract) and those given placebo (mean difference (MD) -0.93, 95% confidence interval (CI) -1.95 to 0.10, I(2) = 31%). No evidence indicated a difference in percentage reduction in hot flushes in two trials between Promensil and placebo (MD 20.15, 95% CI -12.08 to 52.38, I(2) = 82%). Four trials that were not combined in meta-analyses suggested that extracts with high (> 30 mg/d) levels of genistein consistently reduced the frequency of hot flushes. Individual results from the remaining trials were compared in broad subgroups such as dietary soy, soy extracts and other types of phytoestrogens that could not be combined. Some of these trials found that phytoestrogen treatments alleviated the frequency and severity of hot flushes and night sweats when compared with placebo, but many trials were small and were determined to be at high risk of bias. A strong placebo effect was noted in most trials, with a reduction in frequency ranging from 1% to 59% with placebo. No indication suggested that discrepant results were due to the amount of isoflavone in the active treatment arm, the severity of vasomotor symptoms or trial quality factors. Also, no evidence indicated that these treatments caused oestrogenic stimulation of the endometrium or the vagina or other adverse effects when used for up to two years.

AUTHORS' CONCLUSIONS

No conclusive evidence shows that phytoestrogen supplements effectively reduce the frequency or severity of hot flushes and night sweats in perimenopausal or postmenopausal women, although benefits derived from concentrates of genistein should be further investigated.

Are progestins really necessary as part of a combined HRT regimen?

For many years it has been perceived wisdom that hormone replacement therapy for women with a uterus should include a progestin to prevent the proliferative effects of estrogen on the endometrium and endometrial cancer. But, with the reports from the Women's Health Initiative (WHI) and Million Women Study indicating that such regimens are associated with an increased risk of breast cancer, whereas unopposed estrogen may not increase this risk, or even reduce it, it is pertinent to reassess the merits of adding a progestin. In addition, the suggestion from the WHI that the effects of estrogen and progestins are a 'class effect' are clearly inaccurate, as there is particular evidence from the French E3N cohort studies of differential effects of progestins, with progesterone and dydrogesterone additions showing no increase in risk of breast cancer. The data are presented but an answer to the posed question remains unclear and as usual dependent on the circumstances and views of each individual woman and her medical adviser.

Hormone replacement therapy is associated with gastro-oesophageal reflux disease: a retrospective cohort study

Background

Oestrogen and progestogen have the potential to influence gastro-intestinal motility; both are key components of hormone replacement therapy (HRT). Results of observational studies in women taking HRT rely on self-reporting of gastro-oesophageal symptoms and the aetiology of gastro-oesophageal reflux disease (GORD) remains unclear. This study investigated the association between HRT and GORD in menopausal women using validated general practice records.

Methods

51,182 menopausal women were identified using the UK General Practice Research Database between 1995–2004. Of these, 8,831 were matched with and without hormone use. Odds ratios (ORs) were calculated for GORD and proton-pump inhibitor (PPI) use in hormone and non-hormone users, adjusting for age, co-morbidities, and co-pharmacy.

Results

In unadjusted analysis, all forms of hormone use (oestrogen-only, tibolone, combined HRT and progestogen) were statistically significantly associated with GORD. In adjusted models, this association remained statistically significant for oestrogen-only treatment (OR 1.49; 1.18–1.89). Unadjusted analysis showed a statistically significant association between PPI use and oestrogen-only and combined HRT treatment. When adjusted for covariates, oestrogen-only treatment was significant (OR 1.34; 95% CI 1.03–1.74). Findings from the adjusted model demonstrated the greater use of PPI by progestogen users (OR 1.50; 1.01–2.22).

Conclusions

This first large cohort study of the association between GORD and HRT found a statistically significant association between oestrogen-only hormone and GORD and PPI use. This should be further investigated using prospective follow-up to validate the strength of association and describe its clinical significance.

Ultra low dose continuous combined hormone replacement therapy with 0.5mg 17beta-oestradiol and 2.5mg dydrogesterone: protection of the endometrium and amenorrhoea rate

OBJECTIVES AND STUDY DESIGN

The aim of this open, multicentre study was to demonstrate the endometrial safety and assess the bleeding pattern of ultra low dose continuous combined hormone replacement therapy with 0.5 mg 17beta-oestradiol and 2.5 mg dydrogesterone in 446 healthy, non-hysterectomised, postmenopausal women with symptoms of oestrogen deficiency.

MAIN OUTCOME MEASURE

Aspiration endometrial biopsies were performed at baseline and after 1 year of treatment to assess the incidence of endometrial hyperplasia or a more serious endometrial outcome.

RESULTS

The only adverse endometrial outcome at the end of the study was one case of simple hyperplasia. This gives an overall incidence of 0.27% (95% CI: 0.01-1.48%) in the per protocol sample (n=395). The overall rate of amenorrhoea in the full sample (n=446) was 68% and 14% had only one or two bleeding/spotting episodes. The rate of amenorrhoea in months 10-12 (n=413) was 88%. The number of bleeding/spotting days per cycle fell during the study. The mean number of bleeding/spotting days was 5.8 and the mean number of days without bleeding was 358.2. Spotting alone was the most prevalent bleeding intensity, whilst heavy bleeding was rare.

CONCLUSIONS

In conclusion, 2.5 mg dydrogesterone continuously combined with 0.5 mg 17beta-oestradiol effectively protects the endometrium in postmenopausal women in accordance with the guidelines of the Committee for Medicinal Products for Human Use (CHMP). It has a favourable amenorrhoea rate and is well tolerated by the majority of women.

Estimating mean sojourn time and screening sensitivity using questionnaire data on time since previous screening

OBJECTIVES

Mean sojourn time (MST) and screening test sensitivity (STS), is usually estimated by Markov models using incidence data from the first screening round and the interval between screening examinations. However, several screening programmes do not have full registration of cancers submerging after screening, and increased use of opportunistic screening over time can raise questions regarding the quality of interval cancer registration. Methods/settings Based on the earlier used Markov model, formulas for expected number of cases given time since former screening activity was developed. Using questionnaire data for 336,533 women in the Norwegian Breast Cancer Screening Programme (NBCSP), mean square regression estimates of MST and STS were calculated.

RESULTS

In contrast to the previously used method, the new approach gave satisfactory model fit. MST was estimated to 5.6 years for women aged 50-59 years, and 6.9 years for women aged 60-69 years, and STS was estimated to 55% and 60%, respectively. Attempts to add separate parameters for breast cancer incidence without screening, or previous STS, resulted in wide confidence intervals if estimated separately, and non-identifiably if combined.

CONCLUSION

Previously published results of long MST and low screen test sensitivity were confirmed with the new approach. Questionnaire data on time since previous screening can be used to estimate MST and STS, but the approach is sensitive to relaxing the assumptions regarding the expected breast cancer incidence without screening and constant STS over time.

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.

Advances in hormone replacement therapy: weight benefits of drospirenone, a 17alpha-spirolactone-derived progestogen

Hormone replacement therapy (HRT) remains the most effective treatment for menopausal symptom relief, and may provide cardiovascular benefits in younger women initiating treatment soon after menopause. However, large surveys indicate that many symptomatic women refuse or discontinue HRT prematurely owing to fear of weight gain. A continuous combined HRT containing 17beta-estradiol (E(2)) 1 mg plus drospirenone (DRSP) 2 mg is effective in relieving menopausal symptoms and preventing postmenopausal osteoporosis. DRSP is a unique synthetic progestogen with a pharmacological profile similar to that of natural progesterone, including antialdosterone activity, a property not exhibited by other synthetic progestogens. DRSP can therefore reduce estrogen-related sodium and water retention in postmenopausal women receiving HRT via the renin-angiotensin-aldosterone system, which regulates sodium and water balance. This may translate into weight benefits. Pooled data from two placebo-controlled clinical trials (n = 333) indicated statistically significant weight loss of -1.5 kg at 6 and 12 months in postmenopausal women receiving E(2)/DRSP vs. placebo (p < 0.001). In a third randomized controlled trial (n = 1147), women receiving E(2)/DRSP maintained or lost weight, whereas weight increases were observed in women receiving E(2) monotherapy (p < 0.0125). E(2)/DRSP could help maintain or even slightly decrease body weight during treatment, potentially improving HRT acceptance and compliance.

Phytoestrogens for vasomotor menopausal symptoms

BACKGROUND

Vasomotor symptoms, such as hot flushes and night sweats, are very common during the menopausal transition. Hormone replacement therapy has traditionally been used as a very effective treatment but concerns over increased risks of some chronic diseases have markedly increased the interest of women in alternatives. Some of the most popular of these are treatments based on foods or supplements enriched with phytoestrogens, plant-derived chemicals that have oestrogenic action.

OBJECTIVES

To assess the efficacy, safety and acceptability of foods and supplements based on high levels of phytoestrogens for reducing hot flushes and night sweats in postmenopausal women.

SEARCH STRATEGY

Searches were undertaken of the following electronic databases: the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of randomised trials, Cochrane Register of Controlled Trials (CENTRAL) (March 2007), MEDLINE (1966 to March 2007), EMBASE (1980 to March 2007), AMED (1985 to March 2007), PsycINFO (1986 to March 2007) and CINAHL (1982 to March 2007). Attempts were made to access grey literature by letters to pharmaceutical companies and searches of ongoing trial registers. Reference lists of included trials were also searched.

SELECTION CRITERIA

Studies were included if they were randomised, had peri- or postmenopausal participants with vasomotor symptoms, a duration of at least 12 weeks and where the intervention was a food or supplement with high levels of phytoestrogens (and not combined with other herbal treatments). Trials of women who had breast cancer or a history of breast cancer were excluded.

DATA COLLECTION AND ANALYSIS

Selection of trials, data extraction and quality assessment were undertaken by at least two authors. Most of the trials were too dissimilar to combine in meta-analysis and their results are provided in table format. Studies were grouped into broad categories: dietary soy, soy extracts, red clover extracts and other types of phytoestrogen. Five trials used Promensil, a red clover extract; these trials were combined in a meta-analysis and summary effect measures were calculated.

MAIN RESULTS

Thirty trials comparing phytoestrogens with control met the inclusion criteria. Very few trials had data suitable for combining in meta-analysis. Of the five trials with data suitable for pooling that assessed daily frequency of hot flushes, there was no significant difference overall in the frequency of hot flushes between Promensil (a red clover extract) and placebo (WMD=-0.6, 95% CI -1.8 to 0.6). There was no evidence of a difference in percentage reduction in hot flushes in two trials between Promensil and placebo (WMD=20.2, 95% CI -12.1 to 52.4). Individual results from the remaining trials were compared. Some of the trials found that phytoestrogen treatments alleviated the frequency and severity of hot flushes and night sweats when compared to placebo but many of the trials were of low quality and were underpowered. There was a strong placebo effect in most trials with a reduction in frequency ranging from 1% to 59% with placebo. There was no indication that the discrepant results were due to the amount of isoflavone in the active treatment arm, the severity of vasomotor symptoms or trial quality factors. There was also no evidence that the treatments caused oestrogenic stimulation of the endometrium (an adverse effect) when used for up to two years.

AUTHORS' CONCLUSIONS

There is no evidence of effectiveness in the alleviation of menopausal symptoms with the use of phytoestrogen treatments.

Body composition during treatment with conjugated estrogens with and without medroxyprogesterone acetate: analysis of the women's Health, Osteoporosis, Progestin, Estrogen (HOPE) trial

OBJECTIVE

The objective of the study was to determine the effects of several doses of conjugated estrogens (CE) and CE plus medroxyprogesterone acetate (MPA) on body composition (BC).

STUDY DESIGN

This was a randomized, double-blind, placebo-controlled substudy of the Women's Health, Osteoporosis, Progestin, Estrogen (HOPE) trial. Healthy women (n = 822, 1-4 years after menopause) were randomly assigned to receive the following treatments daily for 2 years: CE, 0.625 mg; CE, 0.625 mg, and MPA, 2.5 mg; CE, 0.45 mg; CE, 0.45 mg, and MPA, 2.5 mg; CE, 0.45 mg, and MPA, 1.5 mg; CE, 0.3 mg; CE, 0.3 mg, and MPA, 1.5 mg; or placebo. Body weight (BW) was assessed every 3-4 cycles and fat body mass (FBM), lean body mass (LBM), and percent body fat (PBF) at cycles 6, 13, 19, and 26.

RESULTS

In the placebo group, BW, FBM, and PBF increased at each visit during the study. Changes in these parameters were smaller in the active groups. These effects were independent of CE dose and the presence of MPA. Changes in LBM were small and comparable across groups.

CONCLUSION

Treatment with CE or CE and MPA for up to 2 years does not affect BC.

Advances in hormone replacement therapy with drospirenone, a unique progestogen with aldosterone receptor antagonism

Unlike other currently available progestogens, drospirenone (DRSP) has a pharmacological profile, which closely mimics that of endogenous progesterone, most notably potent anti-aldosterone and anti-androgenic effects. Consequently, DRSP, when combined with 17beta-estradiol (E2) as hormone replacement therapy (HRT), offsets E2-related water and sodium retention by blocking the mineralocorticoid receptor. This review evaluates the potential benefits offered by DRSP as the progestin component of HRT with respect to its anti-aldosterone activity, which translates into positive effects on body weight and blood pressure in clinical trials of continuous, combined E2/DRSP in post-menopausal women. In a 1-year, large-scale, randomised, controlled trial, E2 1 mg/DRSP 2 mg significantly decreased mean body weight by 1.2 kg versus baseline (P<0.001), whereas patients receiving E2 1 mg gained weight. E2 1 mg/DRSP 2 mg also significantly lowered mean systolic blood pressure (SBP) by 9.0 mmHg from baseline (P<0.05) versus 3.7 mmHg in the E2 1 mg group (P=0.220) in a sub-group of hypertensive women. In addition, E2/DRSP was not associated with hyperkalaemia (potassium > or =5.5 meq/L) irrespective of concomitant use of ACE inhibitors, angiotensin II receptor antagonists or non-steroidal anti-inflammatory drugs, and co-morbid diabetes mellitus. In summary, as well as effectively treating climacteric symptoms, DRSP 2 mg combined with E2 1 mg has shown positive effects on body weight and blood pressure in clinical trials, most likely due to DRSP's anti-aldosterone properties. This combination may therefore offer an alternative therapeutic option with additional benefits beyond current HRT agents for symptomatic post-menopausal women.

Gynaecological health care utilization and use of sex hormones–the study of Health in Pomerania

BACKGROUND

In Germany, there is a lack of population-based data related to the use of gynaecological health care services. The objectives of our analyses utilizing a population-based cross-sectional survey conducted in one geographically defined area [Study of Health in Pomerania (SHIP)] are to assess the prevalences of: (i) attendance of gynaecological outpatient facilities and of (cervical) cancer screening; (ii) gynaecological and breast surgery; (iii) use of oral contraceptives (OC) and menopausal hormone therapy (MHT).

METHODS

We analysed socio-demographic factors, reproductive history, gynaecological service utilization, and use of sex hormones in 2186 women aged 20-79 years. We used standard statistics and sex- and age group-specific weighting factors to reflect characteristics of the population of Western Pomerania.

RESULTS

Approximately 43% of women reported surgical procedures. Participation in cancer screening at least once was reported by 78% of women (lifetime prevalence). Two-thirds of women stated ever use of OC, 28% (aged >40 years) ever use of MHT.

CONCLUSIONS

Women in Western Pomerania reported a high life-time use of both OC and MHT. The use of cervical cancer screening exceeded the national average. Women had an almost 50% risk of undergoing gynaecological, breast or obstetric surgery. The high use of MHT and surgical procedures calls for efforts regarding continuing medical education and health care policy actions.