Hormone replacement therapy and cardiovascular risk: the cardiovascular physicians' viewpoint

Influence of hormone replacement therapy on proteomic pattern in serum of postmenopausal women

OBJECTIVES

Proteomics approaches to cardiovascular biology and disease hold the promise of identifying specific proteins and peptides or modification thereof to assist in the identification of novel biomarkers.

METHOD

By using surface-enhanced laser desorption and ionization time of flight mass spectroscopy (SELDI-TOF-MS) serum peptide and protein patterns were detected enabling to discriminate between postmenopausal women with and without hormone replacement therapy (HRT).

RESULTS

Serum of 13 HRT and 27 control subjects was analyzed and 42 peptides and proteins could be tentatively identified based on their molecular weight and binding characteristics on the chip surface. By using decision tree-based Biomarker Patternstrade mark Software classification and regression analysis a discriminatory function was developed allowing to distinguish between HRT women and controls correctly and, thus, yielding a sensitivity of 100% and a specificity of 100%. The results show that peptide and protein patterns have the potential to deliver novel biomarkers as well as pinpointing targets for improved treatment. The biomarkers obtained represent a promising tool to discriminate between HRT users and non-users.

CONCLUSION

According to a tentative identification of the markers by their molecular weight and binding characteristics, most of them appear to be part of the inflammation induced acute-phase response.

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

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

Hypopituitarism and atherosclerosis

In the last decade, retrospective cohort data has provided evidence of premature atherosclerosis in patients with hypopituitarism which may account for the recently observed increased death rate from vascular events in these patients. The exact mechanism(s) for such propensity to atherosclerotic vascular disease is not yet completely clear. It is possible that hormonal factors may be the initiating mechanisms with subsequent secondary metabolic abnormalities acting as risk factors for development of atherosclerosis. This seems to be more evident in female hypopituitary patients compared with their male counterparts. Female patients have higher frequency and more pronounced abnormalities of various risk factors as well as surrogate markers of early vascular disease. This may explain why morbidity and mortality in women is in excess of men in retrospective epidemiological studies. Addressing abnormal hormonal factors, especially in females, is a primary objective in managing these patients both in the clinical arena as well as in trials designed to reduce the risk of atherosclerotic vascular disease in these patients. While short-term growth hormone treatment may ameliorate some of the vascular risk factors and improve endothelial function, it remains to be shown whether this translates into long-term reduction in morbidity and mortality from vascular, especially cerebrovascular, disease.

Acute hazards to young children from residential pesticide exposures

OBJECTIVES

This study assessed acute hazards to young children from pesticides toxic enough to require child-resistant packaging.

METHODS

The names of pesticides meeting acute toxicity criteria were ascertained from the Environmental Protection Agency. Poison Control Center reports identified children younger than 6 years who were exposed to these pesticides. Toxicity category, medical outcome, sex, and age were examined.

RESULTS

A higher proportion of children with exposure to the more toxic products had serious medical outcomes. Children 2 years and younger were the predominant age group exposed.

CONCLUSIONS

Protective measures--substituting less lethal pesticides, reducing the concentration of the active ingredients, and improving packaging and storage--are recommended.

Menopausal hormones and breast cancer in a biracial population

OBJECTIVES

This study examined the association between menopausal hormones and breast cancer in a biracial population.

METHODS

Logistic regression was used to calculate odds ratios for breast cancer associated with hormone use among 397 cases and 425 controls, all menopausal women.

RESULTS

Odds ratios for ever use of hormones were 0.8 (95% confidence interval [CI] = 0.5, 1.2) for White women and 0.7 (95% CI = 0.4, 1.2) for Black women. Risk was not increased with longer duration of use or more recent use.

CONCLUSIONS

Breast cancer risk was not increased among White or Black women who used menopausal hormones, despite patterns of use varying considerably between races.

Effect of postmenopausal hormone therapy on lipoprotein(a) concentration. PEPI Investigators. Postmenopausal Estrogen/Progestin Interventions

BACKGROUND

Postmenopausal hormone therapy has been reported to decrease levels of lipoprotein (Lp)(a) in cross-sectional studies and small or short-term longitudinal studies. We report findings from a large, prospective, placebo-controlled clinical trial that allows a broad characterization of these effects for four regimens of hormone therapy.

METHODS AND RESULT

The Postmenopausal Estrogen/Progestin Interventions study was a 3-year, placebo-controlled, randomized clinical trial to assess the effect of hormone regimens on cardiovascular disease risk factors in postmenopausal women 45 to 65 years of age. The active regimens were conjugated equine estrogens therapy at 0.625 mg daily, alone or in combination with each of three regimens of progestational agents: medroxyprogesterone acetate (MPA) at 2.5 mg daily (ie, continuous MPA), MPA at 10 mg days 1 to 12 (ie, cyclical MPA), and micronized progesterone at 200 mg days 1 to 12. Plasma levels of Lp(a) were measured at baseline (n = 366), 12 months (n = 354), and 36 months (n = 342). Assignment to hormone therapy resulted in a 17% to 23% average drop in Lp(a) concentrations relative to placebo (P<.0001), which was maintained across 3 years of follow-up. No significant differences were observed among the four active arms. Changes in Lp(a) associated with hormone therapy were positively correlated with changes in LDL cholesterol, total cholesterol, apolipoprotein B, and fibrinogen levels and were similar across subgroups defined by age, weight, ethnicity, and prior hormone use.

CONCLUSIONS

Postmenopausal estrogen therapy, with or without concomitant progestin regimens, produces consistent and sustained reductions in plasma Lp(a) concentrations.

Prevention and treatment of osteoporosis: does the future belong to hormone replacement therapy?

Estrogen replacement therapy (ERT) after menopause prevents the development of osteoporosis and reduces the risk of fracture. Other potential benefits are cardioprotection--probably related to the effects of estrogen on lipid profile and fibrinogen levels--and a delay in the onset of Alzheimer's disease and perhaps amelioration of the disease. ERT, however, increases the risk of endometriosis and endometrial cancer unless given with a progestin for at least 10 days per menstrual cycle. It also results in a small but real increase in breast cancer. Alendronate, a bisphosphonate, is the first serious competitor of conjugated equine estrogen for the treatment of osteoporosis. Nearing FDA approval are so-called designer estrogens (e.g., raloxifene), which may selectively prevent osteoporosis with little or no effects on endometrial and breast tissue.

The menopause and the cardiovascular system

Combining the wealth of epidemiological, metabolic and recent mechanistic data, it would appear biologically plausible that HRT, either oestrogen alone or in combination with progestogen, is cardioprotective. Further research is required, as information is lacking on cardiovascular effects of HRT instigated at an older age. There is a need to identify cardiovascular benefit, indirect and/or direct, of combined oestrogen/progestogen therapy using randomized trials. The various progestogen types and doses also need to be investigated. Studies are also required to investigate the effect of HRT use in higher risk patients with established CVD. There is scant information on the effect of HRT on blood pressure of patients with hypertension. Cardiovascular risk factor profiles and incidence surveys need to be conducted in developing countries to characterize their female population and to identify the prevalence of CVD; this needs to be undertaken before widespread recommendations on CVD prevention and the role of HRT can be made. If HRT is to be used effectively in the future treatment of heart disease in women these questions need to be addressed. At present HRT is indicated for the relief of menopausal symptoms and the prevention of osteoporosis. In women without these indications, ORT may be recommended in those who have had a premature menopause, and possibly in those who have established CHD or who are at high risk of developing CHD. It is too early to suggest a blanket recommendation for the use of HRT in the treatment of the symptoms of women with established CVD, but HRT after the menopause may at least be safely used in the secondary prevention of CHD.