The mythology of hormone replacement therapy

Gonadal Hormone Substitution in People with Prader-Labhart-Willi Syndrome: An International Prader-Willi Syndrome Organisation Survey

BACKGROUND

Prader-Labhart-Willi syndrome (PWS) is a rare genetic disorder characterized by intellectual disability, behavioural problems, hypothalamic dysfunction, and specific dysmorphisms. Hypothalamic dysfunction causes growth hormone deficiency, dysregulation of energy balance, and hypogonadism. Although hypogonadism is prevalent in PWS, there are no clear guidelines for diagnosis and treatment. In particular, gonadal hormone substitution is a matter of debate due to concerns associated with the potentially induced aggressive behaviour, foremost in males, by sex steroids.

METHODS

In 2019, a workshop dedicated to hypogonadism was held prior to the 10th International PWS Organization Conference. In this context, we designed a questionnaire to assess "the current standard of care" of hypogonadism in children and adults with PWS, which was sent out to physicians caring for people with PWS worldwide.

RESULTS

Responses were received from a total of 24 centres located in 19 countries. Participating centres treat a total number of at least 1,000 children and adults with PWS. Responses showed limited consensus on who should be treated or at what age treatment should commence. Remarkably, very few behavioural problems were attributed to hormone substitution.

CONCLUSION

Based on our findings, we make recommendations to progress the knowledge on hypogonadism in PWS and improve daily practice.

Prader-Willi Syndrome and Hypogonadism: A Review Article

Prader-Labhart-Willi syndrome (PWS) is a rare genetic disorder characterized by intellectual disability, behavioural problems, hypothalamic dysfunction and specific dysmorphisms. Hypothalamic dysfunction causes dysregulation of energy balance and endocrine deficiencies, including hypogonadism. Although hypogonadism is prevalent in males and females with PWS, knowledge about this condition is limited. In this review, we outline the current knowledge on the clinical, biochemical, genetic and histological features of hypogonadism in PWS and its treatment. This was based on current literature and the proceedings and outcomes of the International PWS annual conference held in November 2019. We also present our expert opinion regarding the diagnosis, treatment, care and counselling of children and adults with PWS-associated hypogonadism. Finally, we highlight additional areas of interest related to this topic and make recommendations for future studies.

Estrogens and the skin

OBJECTIVE

A review of the medical literature concerning the effect of the menopause and its hormonal treatment on the skin.

METHODS

An extensive Medline and Pubmed internet search utilizing the key words: collagen, elastin, estrogen, hormone replacement therapy, skin and aging.

RESULTS

The literature review demonstrated a wide array of research ranging from basic science work to clinical implications of the effects of the menopause and its treatment on the skin.

CONCLUSION

Estrogen loss at menopause has a profound influence on skin. Estrogen treatment in postmenopausal women has been repeatedly shown to increase collagen content, dermal thickness and elasticity, and data on the effect of estrogen on skin water content are also promising. Further, physiologic studies on estrogen and wound healing suggest that hormone replacement therapy (HRT) may play a beneficial role in cutaneous injury repair. Results on the effect of HRT on other physiologic characteristics of skin, such as elastin content, sebaceous secretions, wrinkling and blood flow, are discordant. Given the responsiveness of skin to estrogen, the effects of HRT on aging skin require further examination, and careful molecular studies will likely clarify estrogen's effects at the cellular level.

Knowledge, attitudes and management strategies in Scandinavia concerning hormone replacement therapy: a comparison between gynecologists in Denmark, Norway and Sweden

OBJECTIVES

To describe and compare attitudes, knowledge and management strategies concerning the prescription of hormone replacement therapy (HRT) between gynecologists from three Scandinavian countries.

DESIGN AND METHODS

In a cross-sectional study gynecologists in Denmark (n=386), Norway (n=475) and Sweden (n=1323) were invited by letter to complete and return an enclosed questionnaire. Then 1653 of the 2184 (76%) contacted gynecologists completed and returned the questionnaire.

RESULTS

of the 1653 Scandinavian gynecologists, 42% offered HRT to all women provided there was no contraindication, while 58% recommended HRT to selected women after considering the advantages and disadvantages of HRT. In Norway and Sweden, the proportion of gynecologists routinely prescribing HRT for women without contraindications increased with age and in the oldest age group of gynecologists (>55 years) 49 and 56%, respectively, recommended HRT to all women. The gynecologists were unanimous in their choice of the type of HRT for perimenopausal women as 94% preferred cyclical or sequential combined (estrogen/progestogen) treatment or estrogen monotherapy (orally or transdermally) for hysterectomized women (95%). For postmenopausal women, 75% of the gynecologists offered continuous combined HRT while cyclical combined therapy was chosen by 15% of the gynecologists. No significant differences were found between physicians in the three countries regarding indications and contraindications to HRT.

CONCLUSIONS

Scandinavian gynecologists are generally well informed concerning HRT and liberally recommend HRT for women without contraindications.

Hormone replacement therapy and the skin

Estrogens have a profound influence on skin. The hypoestrogenism occurring after the menopause leads to measured deterioration in the skin. Estrogen receptors have been identified in the skin and the concentration of these receptors varies in the different parts of the body. Estrogen improves skin in more than one way, the collagen content and quality is improved, skin thickness is increased, while vascularisation is enhanced. The extracellular matrix responsible for the tone and appearance of the skin is also improved. It is not just the skin that shows an improvement with estrogen therapy but also skin appendages, such as hair. Estrogens have been shown to increase the hair follicle life cycle. Skin aging is not totally estrogen dependent because the ravages of age and the external environment play very important roles. The effects of estrogen on skin need further elucidation and with the emergence of newer techniques it is now possible to study more clearly the changes occurring at the cellular level. Estrogen replacement reverses the deleterious effect of estrogen deprivation on the skin, which is thus yet another organ that benefits from hormone replacement therapy.

Recurrent pain after hysterectomy and bilateral salpingo-oophorectomy for endometriosis: evaluation of laparoscopic excision of residual endometriosis

Endometriosis can represent with a variety of symptoms including pelvic pain, dyspareunia and pain with defaecation, up to several years after hysterectomy and bilateral salpingo-oophorectomy. This may occur when all endometriotic tissue is not excised at the time of the initial procedure. Although excision of endometriosis at this time would be preferable, we have found laparoscopic excision of residual endometriosis to be effective in relieving endometriosis associated pain.

Pregnancy and exogenous hormones in patients with cutaneous malignant melanoma

In this article, recent literature is reviewed with regard to possible hormonal influences on susceptibility to melanoma and prognosis once melanoma is developed. At the present time, there is little data to suggest that melanoma and pregnancy interact as far as prognosis is concerned for patients with stage 1 and stage 2 disease. Recent data have provided further reassurance that oral contraceptives are safe for patients who have had melanoma, and more data is required before a definitive statement can be made regarding hormone replacement therapy for women who have had stage 1 or 2 melanoma adequately treated.

5-Benzylidene 1,2-dihydrochromeno[3,4-f]quinolines, a novel class of nonsteroidal human progesterone receptor agonists

A novel series of nonsteroidal progestins, 5-benzylidene-1, 2-dihydrochromeno[3,4-f]quinolines (2), was discovered, and a preliminary structure-activity relationship study around the 5-benzylidene ring generated several potent human progesterone receptor agonists (compounds 8, 16). These new progestins showed biological activities (EC50 = 5.7 and 7.6 nM) similar to progesterone (EC50 = 2.9 nM) in the cotransfection assay with high efficacy (132% and 166%) and binding affinity (Ki = 0.66 and 0.83 nM) similar to medroxyprogesterone acetate (MPA) (Ki = 0.34 nM). A representative analogue, 8, demonstrated similar oral potency to MPA in the uterine wet weight/mammary gland morphology assay in ovariectomized rats.

Sex hormonal preparations and the liver

The long-term use of oral contraceptives (OCs) may be associated with an increased, though quite small, risk of certain types of liver disease: acute intrahepatic canalicular idiosyncratic cholestasis, benign hepatic tumors (hepatic adenoma, focal nodular hyperplasia, hemangiomas), hepatocellular carcinoma, peliosis hepatis, hepatic vein thrombosis, and portal vein thrombosis. Estrogens have lithogenic properties, as shown by a rise in biliary cholesterol secretion and cholesterol saturation index, yet no substantial increase in the risk of gallstones among estrogen users has been found. Hormone replacement therapy (HRT), given after oophorectomy or menopause, is not associated with clinically significant liver injury. Generally speaking, synthetic sex hormones should not be used in patients with acute and chronic liver disease. A trial of a low-dose estrogen can be instituted under close monitoring for adverse reactions and HRT preparations are not contraindicated in patients with chronic liver disease. Moreover, OCs and HRT can be prescribed quite safely following successful liver transplantation. The incidence of hepatic abnormalities in patients taking androgen hormones is very high. Liver adenomas, cholestasis, peliosis, nodular regenerative hyperplasia and, particularly, hepatocellular carcinoma may complicate long-term use of C17-substituted testosterone and anabolic steroids.