A randomised comparison of the effects of oral versus transdermal 17beta-oestradiol, each combined with sequential oral norethisterone acetate, on serum lipoprotein levels

Effects of transdermal versus oral hormone replacement therapy in postmenopause: a systematic review

PURPOSE

To summarize available evidence comparing the transdermal and the oral administration routes of hormone replacement therapy (HRT) in postmenopausal women.

METHODS

We performed a systematic review of the literature on multiple databases between January 1990 and December 2021. We included randomized controlled trials and observational studies comparing the transdermal and oral administration routes of estrogens for HRT in postmenopausal women regarding at least one of the outcomes of interest: cardiovascular risk, venous thromboembolism (VTE), lipid metabolism, carbohydrate metabolism, bone mineral density (BMD), and risk of pre-malignant and malignant endometrial lesions, or breast cancer.

RESULTS

The systematic literature search identified a total of 1369 manuscripts, of which 51 were included. Most studies were observational and of good quality, whereas the majority of randomized controlled trials presented a high or medium risk of bias. Oral and transdermal administration routes are similar regarding BMD, glucose metabolism, and lipid profile improvements, as well as do not appear different regarding breast cancer, endometrial disease, and cardiovascular risk. Identified literature provides clear evidence only for the VTE risk, which is higher with the oral administration route.

CONCLUSIONS

Available evidence comparing the transdermal and oral administration routes for HRT is limited and of low quality, recommending further investigations. VTE risk can be considered the clearest and strongest clinical difference between the two administration routes, supporting the transdermal HRT as safer than the oral administration route.

Evolution of postmenopausal hormone therapy between 2002 and 2009

OBJECTIVE

The results of the Women's Health Initiative led to a sharp decline in postmenopausal hormone therapy use. Subsequently, treatment guidelines were revised to recommend hormone therapy at the lowest effective dose for the shortest possible duration. The objective of this analysis was to assess trends in nationwide hormone therapy prescription claims from 2002 to 2009.

METHODS

This study was a retrospective database analyses of pharmacy claims from MedImpact Healthcare Systems Inc. Data from women with claims for oral or transdermal hormone therapy were analyzed to assess trends in hormone therapy claims, including route of administration, dose, and physician specialty.

RESULTS

By the end of 2002, the total number of hormone therapy claims dropped approximately 30% from 2002 second quarter claims. This trend continued during the next 7 years, and by 2009, hormone therapy claims were reduced by more than 70%. The proportion of low-dose oral claims rose fourfold, whereas the proportion of standard/high-dose claims decreased 30%. The proportion of claims for transdermal formulations more than doubled, and the proportion of claims for low-dose transdermal hormone therapy increased 10-fold. Although reductions in overall claims, routes of administration, and dose categories were similar between physician specialties, obstetrician/ gynecologists prescribed transdermal hormone therapy nearly twice as often as all other types of providers.

CONCLUSIONS

Since the publication of the Women's Health Initiative results, there has been a sustained decrease in hormone therapy claims. The proportional use of low-dose oral and transdermal formulations has increased, but as of 2009, claims for these formulations accounted for approximately one in four total hormone therapy claims.

Early, but not late onset estrogen replacement therapy prevents oxidative stress and metabolic alterations caused by ovariectomy

AIMS

The usefulness of estrogen replacement therapy (ERT) in preventing oxidative stress associated with menopause is controversial. We aimed to study if there is a critical time window for effective treatment of the effects of ovariectomy with estrogens at the molecular, metabolic, and cellular level.

RESULTS

Our main finding is that early, but not late onset of ERT prevents an ovariectomy-associated increase in mitochondrial hydrogen peroxide levels, oxidative damage to lipids and proteins, and a decrease in glutathione peroxidase and catalase activity in rats. This may be due to a change in the estrogen receptor (ER) expression profile: ovariectomy increases the ER α/β ratio and immediate estrogen replacement prevents it. Positron emission tomography analysis shows that ovariectomy decreases the brain glucose uptake in vivo and that estrogen administration is beneficial, but only if administered immediately after deprivation. Ovariectomy decreases GLUT-1 and 3 glucose transporters in the brain, and only early onset estrogen administration prevents it. Plasma from rats treated with estrogens immediately after ovariectomy show similar metabolomics profiles as controls.

INNOVATION

We provide molecular basis for the recommendation of early onset ERT and explain its lack of effectiveness if a significant time period elapses after ovariectomy and probably after the onset of menopause.

CONCLUSION

Only early, but not late onset administration of estrogens after ovariectomy has beneficial effects at molecular levels on oxidative stress, brain glucose uptake, and metabolomic profiles.

Evolution of postmenopausal hormone therapy between 2002 and 2009

OBJECTIVE

The results of the Women's Health Initiative led to a sharp decline in postmenopausal hormone therapy use. Subsequently, treatment guidelines were revised to recommend hormone therapy at the lowest effective dose for the shortest possible duration. The objective of this analysis was to assess trends in nationwide hormone therapy prescription claims from 2002 to 2009.

METHODS

This study was a retrospective database analyses of pharmacy claims from MedImpact Healthcare Systems Inc. Data from women with claims for oral or transdermal hormone therapy were analyzed to assess trends in hormone therapy claims, including route of administration, dose, and physician specialty.

RESULTS

By the end of 2002, the total number of hormone therapy claims dropped approximately 30% from 2002 second quarter claims. This trend continued during the next 7 years, and by 2009, hormone therapy claims were reduced by more than 70%. The proportion of low--dose oral claims rose fourfold, whereas the proportion of standard/high-dose claims decreased 30%. The proportion of claims for transdermal formulations more than doubled, and the proportion of claims for low-dose transdermal hormone therapy increased 10-fold. Although reductions in overall claims, routes of administration, and dose categories were similar between physician specialties, obstetrician/gynecologists prescribed transdermal hormone therapy nearly twice as often as all other types of providers.

CONCLUSIONS

Since the publication of the Women's Health Initiative results, there has been a sustained decrease in hormone therapy claims. The proportional use of low-dose oral and transdermal formulations has increased, but as of 2009, claims for these formulations accounted for approximately one in four total hormone therapy claims.

A review of transdermal nonpatch estrogen therapy for the management of menopausal symptoms

During the transition into menopause, women may experience a wide range of symptoms that negatively impact quality of life. The vasomotor symptoms (VMS) of hot flushes and night sweats are common and vary widely in frequency and severity. The treatment of menopause-associated VMS is a frequently encountered clinical challenge, with the goal of tailoring treatment for each individual woman's needs. Estrogen therapy is the most effective treatment for menopausal VMS. Current guidelines suggest that estrogen therapy be prescribed at the lowest effective dose for the shortest duration of time. Transdermal estrogen therapy has dominated the menopause prescribing practice in Europe for decades; however, in the United States, oral estrogen therapy is most commonly prescribed. Transdermal estrogen therapy can be prescribed at considerably lower doses than oral therapy yet has similar efficacy on the symptoms of menopause. Emerging research demonstrates transdermal estrogen, particularly 17beta-estradiol, may have the potential for fewer health risks than oral estrogen therapy. This review article discusses the spectrum of menopausal symptoms, addresses prevailing issues in the treatment of menopause, elaborates on the risks and benefits of oral and transdermal hormone therapies, and focuses on five nonpatch transdermal estradiol therapies currently available in the United States.

Timing and duration of menopausal hormone treatment may affect cardiovascular outcomes

Largely on the basis of the first publication of findings of net harm with menopausal hormone treatment in the Women's Health Initiative (WHI) hormone trials, current Food and Drug Administration recommendations limit menopausal hormone treatment to the "…shortest duration consistent with treatment goals…," with goals generally taken to mean relief of menopausal symptoms and maximal duration as approximately 5 years. The WHI finding of net harm was due largely to the absence of beneficial effects on coronary heart disease incidence rates. Published analyses of WHI data by age or time since menopause find that excess coronary heart disease risk with menopausal hormone treatment is confined to more remotely menopausal or older women, with younger women showing nonsignificant trends toward benefit (the "timing hypothesis"). Moreover, a recently published reexamination of data from the WHI Estrogen plus Progestin trial suggests that reduced coronary heart disease risk may appear only after 5 to 6 years of treatment. Consistent with this finding, risk ratios for coronary heart disease were calculated as 1.08 (95% confidence interval, 0.86-1.36) in years 1 to 6 and as 0.46 (confidence interval, 0.28-0.78) in years 7 to 8+ in the WHI Estrogen Alone trial. Previous studies also support the beneficial effects of menopausal hormone treatment after prolonged exposure. Thus, current analyses do not support a generalized recommendation for short duration of menopausal hormone treatment. Rather, they suggest that current Food and Drug Administration practice guidelines should be reconsidered to allow individualized care based on risk:benefit considerations. New research is urgently needed evaluating influences of timing, duration, dose, route of administration, and agents on menopausal hormone treatment-related risks and benefits to better understand how to optimize recommendations for individual patients.

Using basic science to design a clinical trial: baseline characteristics of women enrolled in the Kronos Early Estrogen Prevention Study (KEEPS)

Observational and epidemiological studies suggest that menopausal hormone therapy (MHT) reduces cardiovascular disease (CVD) risk. However, results from prospective trials showed neutral or adverse effects most likely due to differences in participant demographics, such as age, timing of initiation of treatment, and preexisting cardiovascular disease, which reflected in part the lack of basic science information on mechanisms of action of hormones on the vasculature at the time clinical trials were designed. The Kronos Early Estrogen Replacement Study (KEEPS) is a prospective, randomized, controlled trial designed, using findings from basic science studies, to test the hypothesis that MHT when initiated early in menopause reduces progression of atherosclerosis. KEEPS participants are younger, healthier, and within 3 years of menopause thus matching more closely demographics of women in prior observational and epidemiological studies than women in the Women's Health Initiative hormone trials. KEEPS will provide information relevant to the critical timing hypothesis for MHT use in reducing risk for CVD.

Effects of non-oral postmenopausal hormone therapy on markers of cardiovascular risk: a systematic review

OBJECTIVE

To review the effects of non-oral administration of postmenopausal hormone therapy (HT) on risk markers for atherosclerotic and venous thromboembolic disease.Non-oral postmenopausal HT appears not to increase venous thromboembolic risk, whereas the effect on coronary heart disease risk is less clear.

DESIGN

Systematic review of literature obtained from MEDLINE, EMBASE, and CENTRAL databases from 1980 until and including April 2006. Terms for "postmenopausal hormone therapy" and for "non-oral administration" were combined in the search.

SETTING

Randomized clinical trials.

PATIENT(S)

Postmenopausal women, both healthy and with established cardiovascular disease or specified cardiovascular risk factors

INTERVENTION(S)

Non-oral HT (e.g., transdermal or intranasal) compared with oral HT or no treatment/placebo.

MAIN OUTCOME MEASURE(S)

Lipoprotein(a), homocysteine, C-reactive protein (CRP), cell adhesion molecules, markers of endothelial dysfunction, coagulation, and fibrinolysis.

RESULT(S)

Seventy-two studies investigating either transdermal or intranasal administration were included. For non-oral HT, decreases in lipoprotein(a), cell adhesion molecules, and factor VII generally were significant, resistance to activated protein C (APCr) was slightly increased, and other markers including CRP and homocysteine did not change. Compared with oral HT, changes in CRP and APCr were smaller, changes in cell adhesion molecules and some fibrinolytic parameters tended to be smaller, whereas changes in other factors including lipoprotein(a) and homocysteine did not differ.

CONCLUSION(S)

Potentially unfavorable changes seen with oral HT on two important markers, CRP and APCr, are substantially smaller with non-oral HT. Non-oral HT has minor effects on the other cardiovascular risk markers studied. Therefore, compared with oral HT, non-oral HT appears be safer with respect to atherosclerotic and venous thromboembolic disease risk.

Is the estrogen controversy over? Deconstructing the Women's Health Initiative study: a critical evaluation of the evidence

The Women's Health Initiative (WHI) hormone trials have been widely interpreted as demonstrating that combined menopausal hormone therapy (HT) fails to protect against-and may increase-cardiovascular disease (CVD), stroke, and dementia in menopausal women, regardless of whether initiated early in the menopause or later. This conclusion does not agree with results of large epidemiological studies showing protection by HT and by estrogen replacement alone (ET) against CVD and dementia. One possible reason for this inconsistency is that the epidemiologic data are confounded by "healthy user bias." Another possible explanation is that most women in the observational studies initiated ET or HT at or near the menopausal transition, at which point there is little or no arterial injury, whereas, in the WHI studies, older women, averaging approximately 12 years postmenopausal, many of whom would have had significant asymptomatic atherosclerosis, were treated. Substantial data demonstrate atheropreventive effects of estrogen before vascular damage occurs, whereas adverse effects of oral estrogen on thrombosis and inflammation may predominate once complex atheromas are present. Similarly, the excess of dementia observed in older WHI women treated with oral conjugated estrogen could be due to cerebral thromboses (multi-infarct dementia). Given the uncertain relevance of the WHI (and other published randomized clinical trials) to initiation of HT in perimenopausal women, and its subsequent continuation for atheroprevention, new trials will be needed to resolve whether early intervention with estrogen may prevent CVD and/or dementia. The Kronos Early Estrogen Prevention Study (KEEPS), which began in mid-2005, is a randomized, controlled multicenter trial of HT in recently menopausal women. It will examine surrogate end points as well as risk factors for atherosclerosis.

Hormone replacement therapy and the cardiovascular system lessons learned and unanswered questions

Cardiovascular disease is the leading cause of death among women in the U.S., exceeding breast cancer mortality in women of all ages. Women present with cardiovascular disease a decade after men, and this has been attributed to the protective effect of female ovarian sex hormones that is lost after menopause. Animal and observational studies have shown beneficial effects of hormone therapy when it is initiated early in the perimenopausal period or before the development of significant atherosclerosis. However, randomized, placebo-controlled trials in older women have not shown any benefit in either primary prevention or secondary prevention of cardiovascular events, with a concerning trend toward harm. This review outlines the lessons learned from the basic science, animal, observational, and randomized trials, and then summarizes yet-unanswered questions of hormone therapy and cardiovascular risk.

Oral oestrogen and combined oestrogen/progestogen therapy versus placebo for hot flushes

BACKGROUND

Hot flushes and night sweats are common symptoms experienced by menopausal women. Hormone therapy (HT), containing oestrogens alone or oestrogens together with progestogens in a cyclic or continuous regimen, is often recommended for their alleviation.

OBJECTIVES

To examine the effect of oral HT compared to placebo on these vasomotor symptoms and the risk of early onset side-effects.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders Group and Subfertility Group trials register (searched May 2002). This register is based on regular searches of MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, the handsearching of 20 relevant journals and conference proceedings, and searches of several key grey literature sources. We also contacted all relevant pharmaceutical companies, The Journal of the International Menopause Society and Climacteric.

SELECTION CRITERIA

Double-blind, randomised, placebo-controlled trials of oral HT for at least three months duration.

DATA COLLECTION AND ANALYSIS

Study quality and outcome data were assessed independently. Random effects models were considered appropriate due to the variety of trial methodologies. The meta-analyses were explored for sensitivity to trial quality and therapy duration. Symptom frequency and severity were assessed separately, together with withdrawals and side-effects. Frequency data were analysed using the Weighted Mean Difference (WMD) between treatment and placebo outcomes. For severity data, odds ratios were estimated from the proportional odds model. From 115 references originally identified, 24 trials meeting the selection criteria were included in the review. Study participants totaled 3,329. Trial duration ranged from three months to three years.

MAIN RESULTS

There was a significant reduction in the weekly hot flush frequency for HT compared to placebo (WMD -17.92, 95% CI -22.86 to -12.99). This was equivalent to a 75% reduction in frequency (95% CI 64.3 to 82.3) for HT relative to placebo. Symptom severity was also significantly reduced compared to placebo (OR 0.13, 95% CI 0.07 to 0.23). Withdrawal for lack of efficacy occurred significantly more often on placebo therapy (OR 10.51, 95% CI 5.00 to 22.09). Withdrawal for adverse events, commonly breast tenderness, oedema, joint pain and psychological symptoms, was not significantly increased (OR 1.25, 95% CI 0.83 to 1.90), although the occurrence of any adverse events was significantly increased for HT (OR 1.41, 95% CI 1.00 to 1.99). In women who were randomised to placebo treatment, a 57.7% (95% CI 45.1 to 67.7) reduction in hot flushes was observed between baseline and end of study.

REVIEWERS' CONCLUSIONS

Oral HT is highly effective in alleviating hot flushes and night sweats. Therapies purported to reduce such symptoms must be assessed in blinded trials against a placebo or a validated therapy because of the large placebo effect seen in well conducted randomised controlled trials, and also because during menopause symptoms may fluctuate and after menopause symptoms often decline. Withdrawals due to side-effects were only marginally increased in the HT groups despite the inability to tailor HT in these fixed dose trials. Comparisons of hormonal doses, product types or regimens require analysis of trials with these specific "within study" comparisons.

Is the WHI relevant to HRT started in the perimenopause?

The Women's Health Initiative (WHI) hormone replacement therapy (HRT) estrogen plus progestin (E+P) and estrogen-only arms are part of a large NIH-sponsored randomized controlled trial (RCT). Both arms were terminated prematurely after 5 and 8 yr, respectively. The E+P arm showed non-statistically significant increased incidences of cardiovascular events and breast cancer, whereas the E-only arm did not. Both arms showed an increased rate of thromboembolic events and stroke. Both arms showed protection against fractures and with protection against colon cancer only in the E+P arm. These results have been widely generalized as indicating a negative risk/benefit ratio for HRT in menopausal women. The WHI results are at odds with results of large epidemiological studies that showed protection against cardiovascular disease. Although the latter data are, in part, confounded by a "healthy user bias," much of the inconsistency may be explained by the fact that women in the latter studies initiated HRT at the menopausal transition, whereas the WHI trial was conducted in older women (mean age 63.3), who were, on average, approx 12 yr postmenopausal. In addition, older trials included women on either unopposed estrogen therapy (ERT) or cyclic HRT regimens. Whatever other forces may have been at work, observational and experimental evidence supports the conclusion that estrogen's atheropreventive effects predominate early, in the absence of vulnerable plaque to be ruptured or thrombotic episodes propagated by narrowed lumens and intravascular turbulence. On the contrary, age-related adverse effects of HRT may prevail once complex atheromas and luminal narrowing/irregularity are established. It is known that prevalence of subclinical "at-risk" atherosclerotic lesions increases in women during the first 5-10 yr after menopause. Furthermore, animal and clinical evidence supports the use of lower doses of estrogen than were employed in the WHI in older/longer postmenopausal women.

The lipid and clinical effects of sequential transdermal estradiol and estradiol/norethisterone acetate in 674 women

OBJECTIVE

To measure lipid changes induced by patches delivering continuous estradiol (E(2)) and sequential norethisterone acetate (NETA) in a large population of symptomatic menopausal women, compared with a non-symptomatic control group.

PATIENTS AND METHODS

A total of 748 women recruited in 42 different hospital services and clinics in Spain were invited to participate in a prospective, open, controlled study for 48 weeks. Six hundred and seventy-four women were evaluated in the treatment group, and 74 in the control group. Treatment consisted of patches delivering 0.05 mg/day E(2) for the first 14 days of the cycle, and 0.05 mg/day E(2) plus 0.25 mg/day NETA for another 14 days.

RESULTS

Use of patches led to a slight, but significant decrease of 1.3% and 0.9% in concentrations of total cholesterol and low-density lipoprotein cholesterol (LDL-C), respectively. A substantial 37.0% decrease in triglycerides concentration was observed in treated women. The treatment effectively reduced climacteric symptoms (Kupperman index) for the duration of the study. Compliance was acceptable, with 489 (72.6%) women completing the study. Adverse events were reported by 137 (20.3%) women.

CONCLUSIONS

Transdermal administration of E(2) and sequential NETA for a period of 48 weeks (twelve 28-day cycles) was associated with beneficial changes, albeit of differing magnitudes, in the concentration of total cholesterol, LDL-C and triglycerides. This protective lipid profile, together with satisfactory clinical efficacy and acceptable safety and compliance, makes this system a good alternative in hormone replacement therapy.

The relevance of the Women's Health Initiative results on combined hormone replacement therapy in clinical practice

The results of the Women's Health Initiative's (WHI) large prospective randomized controlled study on the benefits and risks of combined hormone replacement therapy (HRT) have been reported earlier than expected, due to the findings of a small excess in cases of breast cancer, myocardial infarction, cerebrovascular accident, and venous thrombosis, in conjunction with a slight diminution of the number of cases of bone fracture and colon cancer. These results were obtained in a population of women with a mean age of 63 +/- 7 years, many of whom were already presenting relative risks of diseases at randomization. The results provide the best evidence available at present on HRT for prevention of heart disease, and indicate that combined HRT is not indicated for this purpose in the studied population, thus contradicting the reported beneficial effects of HRT on coronary heart disease (CHD) in previous observational studies. Some comments need to be made, particularly with regard to the relevance of the WHI study results to the traditional use of HRT at the beginning of menopause. The results, obtained from a population having a wide age range (50 to 79 years), with only 33% being between the ages of 50 and 59, taking 0.625 mg/day conjugated equine estrogens combined with 2.5 mg/day medroxyprogesterone acetate or placebo, are presented without stratification according to the various decades. Further, 73.9% of the women never took HRT before entering the study; rather, they began HRT several years after menopause. Thus, the age distribution and late start of HRT in the women in the WHI study do not correspond to the traditional use of HRT. The studied population presented numerous risks of diseases related to aging, in particular cardiovascular disease. Except for venous thrombosis, the confidence intervals for outcomes are near the limit of statistical significance, which disappears after adjustment. The accrual of breast cancer cases appearing during the fourth year of observation is similar to that found in previous studies, and remains inferior to the increases related to lifestyle factors reported in other studies. The overall results are being applied to women aged 50 to 60 without specific data for this age group, who are usually considered to be at no or low risk for the traditional use of HRT. There are no data to compare the various formulations actually approved as class labelling (estrogens or estradiol associated or not with a progestin or natural progesterone by the oral or transdermal route) in the various outcomes of the WHI study. Results of the ongoing WHI study on estrogen alone will have to be considered when they become available. The results of the WHI study do not put into question the validity of prescribing combined HRT in early menopause. They are likely to modify somewhat the recommendations of published consensus cautioning the use of HRT. HRT remains an effective and safe intervention when it is prescribed to palliate the signs and symptoms related to estrogen deficiency, mainly in women soon after menopause, but also in women presenting risk factors for osteoporosis but without actual risk factors of cardiovascular disease and without a family history of breast cancer. New mid-term and long-term randomized studies need to be conducted on women starting various formulations of HRT before the age of 60, to evaluate their impact on risk factors and events of cardiovascular disease.

Different effects of oral contraceptives containing levonorgestrel or desogestrel on plasma lipoproteins and coagulation factor VII

OBJECTIVE

The objective of the study was to compare the effects of two different combined oral contraceptives on levels of plasma lipoproteins and coagulation factor VII.

STUDY DESIGN

A prospective randomized crossover study was undertaken. Thirty-five women were treated with combined oral contraceptives containing the same amount of ethinyl estradiol and either levonorgestrel or desogestrel. Levels of plasma lipoproteins and factor VII were determined before and after 2 months of treatment with each preparation.

RESULTS

Levels of high-density lipoprotein cholesterol were increased significantly with treatment with ethinyl estradiol/desogestrel when compared with baseline and treatment with ethinyl estradiol/levonorgestrel. A significant rise in plasma triglyceride levels was obtained with both preparations, although the increase was more pronounced with ethinyl estradiol/desogestrel. Plasma concentrations of factor VII mass concentration and activated factor VII were increased significantly only with ethinyl estradiol/desogestrel.

CONCLUSION

The rise in concentrations of high-density lipoprotein cholesterol may be advantageous, whereas the combined elevations of plasma triglyceride and factor VII levels obtained with ethinyl estradiol/desogestrel may reflect a hypercoagulable state.

Effects of postmenopausal hormone replacement therapy on lipid, lipoprotein, and apolipoprotein (a) concentrations: analysis of studies published from 1974-2000

OBJECTIVE

To establish reference estimates of the effects of different hormone replacement therapy (HRT) regimens on lipid and lipoprotein levels.

DESIGN

Review and pooled analysis of prospective studies published up until the year 2000.

SETTING

Clinical trials centers, hospitals, menopause clinics.

PATIENT(S)

Healthy postmenopausal women.

INTERVENTION(S)

Estrogen alone, estrogen plus progestogen, tibolone, or raloxifene in the treatment of menopausal symptoms.

MAIN OUTCOME MEASURE(S)

Serum high- and low-density lipoprotein (HDL and LDL) cholesterol, total cholesterol, triglycerides, and lipoprotein (a).

RESULT(S)

Two-hundred forty-eight studies provided information on the effects of 42 different HRT regimens. All estrogen alone regimens raised HDL cholesterol and lowered LDL and total cholesterol. Oral estrogens raised triglycerides. Transdermal estradiol 17-beta lowered triglycerides. Progestogens had little effect on estrogen-induced reductions in LDL and total cholesterol. Estrogen-induced increases in HDL and triglycerides were opposed according to type of progestogen, in the order from least to greatest effect: dydrogesterone and medrogestone, progesterone, cyproterone acetate, medroxyprogesterone acetate, transdermal norethindrone acetate, norgestrel, and oral norethindrone acetate. Tibolone decreased HDL cholesterol and triglyceride levels. Raloxifene reduced LDL cholesterol levels. In 41 studies of 20 different formulations, HRT generally lowered lipoprotein (a).

CONCLUSION(S)

Route of estrogen administration and type of progestogen determined differential effects of HRT on lipid and lipoprotein levels. Future work will focus on the interpretation of the clinical significance of these changes.

Lipoprotein(a) changes during natural menstrual cycle and ovarian stimulation with recombinant and highly purified urinary FSH

This prospective, randomized, controlled study compared the effects of recombinant human FSH (r-hFSH) and highly purified urinary FSH (u-hFSH HP) on lipoprotein(a) [Lp(a)] concentrations in women undergoing ovarian stimulation. Fifty infertile women were randomly allocated into two equally sized treatment groups (n = 25 per group). Thirty normal ovulation women were recruited as controls. The infertile women received u-hFSH or r-hFSH 150 IU/day starting on cycle day 2. From cycle day 6 the dose was adjusted according to ovarian response. Human chorionic gonadotrophin 10,000 IU was administered once there was at least one follicle > or =18 mm in diameter. The luteal phase was supported with progesterone 50 mg/day for at least 15 days. Repeated measurements of Lp(a) concentrations were performed during both stimulated and natural cycles. A significant increase in luteal phase Lp(a) concentrations was detected in the stimulated cycles, whereas no significant changes in serum Lp(a) concentrations were observed during natural cycles. There were no significant differences between the urinary and recombinant FSH effects on serum Lp(a). The luteal Lp(a) increase was transitory because after 1 month Lp(a) concentrations returned to baseline values if pregnancy failed to occur; in pregnant women persistent increased Lp(a) concentrations were found at the 8th week. The percentage changes in serum Lp(a) were positively correlated with the luteal progesterone increase (r = 0.40, P < 0.05), but not with follicular or luteal oestradiol increase. The women with low baseline Lp(a) (< or =5 mg/dl) had a greater increase of the Lp(a) concentrations at midluteal phase than women with baseline Lp(a) >5 mg/dl. In conclusion, the recombinant or urinary hFSH administration does not directly influence Lp(a) concentrations. The luteal Lp(a) increase in stimulated cycles is not related to gonadotrophin treatment per se, but appears to be related to the high luteal progesterone concentrations, physiologically or pharmacologically determined. Our results also suggest that the sensitivity to the progesterone changes could be related to apolipoprotein(a) phenotype.

Oral oestrogen replacement therapy versus placebo for hot flushes

BACKGROUND

Hot flushes and night sweats are common symptoms experienced by menopausal women. Hormone replacement therapy (HRT), containing oestrogens alone or oestrogens together with progestogens in a cyclic or continuous regimen, is often recommended for their alleviation.

OBJECTIVES

To examine the effect of oral HRT compared to placebo on these vasomotor symptoms and the risk of early onset side-effects.

SEARCH STRATEGY

As developed by the Menstrual Disorders Group and Subfertility group of the Cochrane Collaboration.

SELECTION CRITERIA

Double-blind, randomised, placebo-controlled trials of oral HRT therapy for at least three months duration.

DATA COLLECTION AND ANALYSIS

Study quality and outcome data were assessed independently. Random effects models were considered appropriate due to the variety of trial methodologies. The meta-analyses were explored for sensitivity to trial quality and therapy duration. Symptom frequency and severity were assessed separately, together with withdrawals and side-effects. Frequency data were analysed using the Weighted Mean Difference (WMD) between treatment and placebo outcomes. For severity data, odds ratios were estimated from the proportional odds model. From 99 references originally identified, 21 trials meeting the selection criteria were included in the review. Study participants totalled 2,511. Trial duration ranged from three months to three years.

MAIN RESULTS

There was a significant reduction in the weekly hot flush frequency for HRT compared to placebo (WMD -17.46, 95% CI -24.72, -10.21). This was equivalent to a 77% reduction in frequency (95% CI 58.2, 87.5) for HRT relative to placebo. Symptom severity was also significantly reduced compared to placebo (OR 0.13, 95% CI 0.08, 0.22). Withdrawal for lack of efficacy occurred significantly more often on placebo therapy (OR 17.25, 95% CI 8.23, 36.15). Withdrawal for adverse events, commonly breast tenderness, oedema, joint pain and psychological symptoms, was not significantly increased for HRT therapy (OR 1.38, 95% CI 0.87, 2.21). In women who were randomised to placebo treatment, a 50.8% (95% CI 41.7, 58.5) reduction in hot flushes was observed between baseline and end of study.

REVIEWER'S CONCLUSIONS

Oral HRT is highly effective in alleviating hot flushes and night sweats. Therapies purported to reduce such symptoms must be assessed in blinded trials against a placebo or a validated therapy. Withdrawals due to side-effects were only marginally increased in the HRT groups despite the inability to tailor HRT in these fixed dose trials. Comparisons of hormonal doses, product types or regimens require analysis of trials with these specific "within study" comparisons.