Hormone replacement therapy, cancer, controversies, and women's health: historical, epidemiological, biological, clinical, and advocacy perspectives

Ethics and Academic Discourse, Scientific Integrity, Uncertainty, and Disinformation in Medicine: An American College of Physicians Position Paper

Respect for the scientific process and a diversity of views; open discourse and debate based on principles of ethics, best available evidence, and scientific inquiry and integrity; and an understanding of evidence gaps and uncertainty and how to communicate about them are important values in the advancement of science and the practice of medicine. Physicians often must make decisions about their recommendations to patients in the face of scarce or conflicting data. Are these characteristics of medicine and science widely understood and effectively communicated among members of the profession and to patients and the public? Issues of scientific integrity are longstanding, but COVID-19 brought them to the forefront, in an environment that was sometimes characterized by communication missteps as guidance came and went-or changed-quickly. Today, is open debate flourishing? Have some debates shed more heat than light? Are people losing confidence in science and medicine? In health care institutions? The American College of Physicians explores these issues and offers guidance in this position paper.

Risks and benefits of hormone therapy after menopause for cognitive decline and dementia: A conceptual review

OBJECTIVE

The effects on the brain of hormone therapy after the onset of menopause remain uncertain. The effects may be beneficial, neutral, or harmful. We provide a conceptual review of the evidence.

METHODS

We 1) provide a brief history of the evidence, 2) discuss some of the interpretations of the evidence, 3) discuss the importance of age at menopause, type of menopause, and presence of vasomotor symptoms, and 4) provide some clinical recommendations.

RESULTS

The evidence and the beliefs about hormone therapy and dementia have changed over the last 30 years or more. Five recent observation studies suggested that hormone therapy is associated with an increased risk of dementia, and the association appears not to change with the timing of initiation of therapy. These harmful associations may be explained by a causal effect of hormone therapy on the brain or by several confounding mechanisms. We suggest that the use of hormone therapy should be customized for different subgroups of women. It may be important to subgroup women based on age at onset of menopause, type of menopause, and presence or absence of vasomotor symptoms. In addition, the effects may vary by type, dose, route, and duration of administration of estrogens and by the concurrent use of progestogens.

DISCUSSION

The relation of hormone therapy with the risk of dementia is complex. Hormone therapy may have beneficial, neutral, or harmful effects on the brain. Hormone therapy should be guided by the clinical characteristics of the women being treated.

Is Hormone Replacement Therapy a Risk Factor or a Therapeutic Option for Alzheimer's Disease?

Alzheimer's disease (AD) is a progressive neurodegenerative disorder that accounts for more than half of all dementia cases in the elderly. Interestingly, the clinical manifestations of AD disproportionately affect women, comprising two thirds of all AD cases. Although the underlying mechanisms for these sex differences are not fully elucidated, evidence suggests a link between menopause and a higher risk of developing AD, highlighting the critical role of decreased estrogen levels in AD pathogenesis. The focus of this review is to evaluate clinical and observational studies in women, which have investigated the impact of estrogens on cognition or attempted to answer the prevailing question regarding the use of hormone replacement therapy (HRT) as a preventive or therapeutic option for AD. The articles were retrieved through a systematic review of the databases: OVID, SCOPUS, and PubMed (keywords "memory", "dementia," "cognition," "Alzheimer's disease", "estrogen", "estradiol", "hormone therapy" and "hormone replacement therapy" and by searching reference sections from identified studies and review articles). This review presents the relevant literature available on the topic and discusses the mechanisms, effects, and hypotheses that contribute to the conflicting findings of HRT in the prevention and treatment of age-related cognitive deficits and AD. The literature suggests that estrogens have a clear role in modulating dementia risk, with reliable evidence showing that HRT can have both a beneficial and a deleterious effect. Importantly, recommendation for the use of HRT should consider the age of initiation and baseline characteristics, such as genotype and cardiovascular health, as well as the dosage, formulation, and duration of treatment until the risk factors that modulate the effects of HRT can be more thoroughly investigated or progress in the development of alternative treatments can be made.

Clusters of high-risk, low-risk, and temporal trends of breast and cervical cancer-related mortality in São Paulo, Brazil, during 2000-2016

PURPOSE

Studying breast and cervical cancers in space and time and verifying divergences of different territorially established socioeconomic profiles.

METHODS

Ecological study using spatial scanning (with socioeconomic characterization), space-time, and spatial variation of temporal trends, in order to identify significant clusters of high- and low-risk or temporal trends, of deaths from breast cancer and cervical cancer, in the city of São Paulo, Brazil, during 2000-2016.

RESULTS

High-risk spatial clusters were identified in the central areas, and low-risk clusters were identified in the peripheral areas, which were associated with better and worse socioeconomic conditions, respectively. As for cervical cancer, the pattern was the opposite. High-risk space-time clusters occurred in the early years of the study, whereas low-risk clusters occurred in the most recent years. For breast cancer, the central areas showed a temporal trend of decreasing mortality and the peripheral areas showed an increasing trend. While for cervical cancer, in general, the temporal trend was for the identified clusters to fall.

CONCLUSIONS

It is expected that this study will provide insights for the formulation of public policies to implement prevention and control measures, in order to reduce mortality and inequalities related to breast and cervical cancers.

Hormone Replacement Therapy and the Incidence of Nonarteritic Anterior Ischemic Optic Neuropathy: a Nationwide Population-Based Study (2009-2018)

PURPOSE

This study aimed to assess the association between hormone replacement therapy (HRT) and the prevalence of nonarteritic anterior ischemic optic neuropathy (NAION) in menopausal women using national data from the entire Korean population.

METHODS

The health screening data of 1,381,605 women between 40 and 90 years of age collected by the National Health Insurance Service (NHIS) of Korea between January 1, 2009, and December 31, 2018, were retrospectively reviewed. Before data analysis, the potential cofounders were adjusted for among all participants. Based on HRT use and its duration (classified into four groups), the hazard ratio (HR) and 95% confidence interval (CI) of NAION development were calculated via a Cox proportional hazards regression analysis using the nonuser group as a reference.

RESULTS

Overall, 7824 NAION diagnoses were made during the mean follow-up of 8.22 years (standard deviation: 1.09 years) in 1,381,605 post-menopausal women. NAION was more common in the HRT group than in the non-HRT group (HR [95% CI]: 1.268 [1.197-1.344]). Furthermore, the risk of NAION increased along with increased HRT duration (p < 0.0001). In the multivariate analysis, the adjusted HRs of the < 2-year HRT group, the 2-5-year HRT group, and the ≥ 5-year HRT group were 1.19 (95% CI: 1.10-1.28), 1.3 (95% CI: 1.17-1.45), and 1.473 (95% CI: 1.31-1.65), respectively. Compared to women younger than 65 years, the HR of HRT for NAION was significantly higher than that of women older than 65 years (p < 0.0001).

CONCLUSION

Our population-based cohort study found that HRT was significantly associated with increased incidence of NAION. The incidence of NAION also increased with the duration of HRT.

Serum Uric Acid and Hyperuricemia Associate with Coronary Artery Disease among Postmenopausal Women

Background

Serum uric acid (SUA) levels has been considered a possible risk factor for coronary artery disease (CAD) for many years. Since SUA levels are greatly affected by medications, diet, and metabolism, the association between SUA and CAD has been controversial for centuries. While, the state of hyperuricemia (HUA) has been proven to have a negative impact on CAD in previous studies, there are still few clinical and epidemiological studies of HUA in CAD. In particular, evidence of this association is limited in postmenopausal women. This study explored the influence of SUA levels and HUA on CAD in this demographic group.

Methods

In total, 5435 postmenopausal women were allocated to either a non-CAD group (n = 2021) or a CAD group (n = 3414). Regression analyses, including generalized linear models (GLM), correlation analysis, comparison between stratified groups, and analysis by use of diuretics were carried out on data obtained in this study.

Results

SUA and HUA were found to associate significantly with CAD by univariate logistic regression analysis. In addition, GLM showed nonlinear response of CAD probability with increasing level of SUA. In multivariate analysis, we found that SUA and HUA were independently related to CAD. Correlation analysis showed that SUA and HUA both correlated positively with CAD (p < 0.001). By comparing the stratified age groups, we found that the differences among the age groups were significant (p < 0.05).

Conclusions

SUA and HUA were shown to be independently associated with CAD among postmenopausal women.

Like mother, like daughter, like granddaughter… Transgenerational ignorance engendered by a defective reproductive health technology

From 1941, the synthetic oestrogen diethylstilbestrol (DES) was administered to millions of women around the world to prevent miscarriages. In 1971, a clear and direct link was shown between taking DES during pregnancy and its subsequent long-term morbid effects on offspring. In the last 50 years, the list of side effects of in-utero exposure to DES has grown to include cancer, infertility, significant prematurity and urogenital malformation, amongst others. Based on qualitative sociological research conducted between 2010 and 2013, compiling archives, judicial documents and 108 interviews, this article illustrates a continuous production of ignorance in France. By focusing on DES as a reproductive health technology, three aspects are stressed. First, in terms of recognition of adverse effects, despite DES being identified as a prototype for other technologies such as the contraceptive pill or hormone replacement therapy, there remained a strong reluctance to import knowledge from the USA on its dangers and risks. Second, there was indifference to transgenerational side effects: even when the most visible effects of DES were finally acknowledged, there was a lack of consideration of the health of descendants; an inability to deem the knowledge of these repercussions as emancipatory or potentially empowering for the offspring. Third, regarding the health care of DES daughters, an important propensity to undone science is highlighted, with notable indifference to the risks of hormonalization of the female body, even on the part of activists. Thus, decades after it was last given to pregnant women, the shadow of DES still lingers as a failed reproductive health technology.

Benefits of Black Cohosh (Cimicifuga racemosa) for Women Health: An Up-Close and In-Depth Review

Women’s health is an imminent concern worldwide, but it remains an ignored segment of research in most developing countries, and is yet to take the center stage in even developed nations. Some exclusive female health concerns revolve around both pathological and physiological aspects. These gender-specific maladies include breast, cervical, and ovarian cancers, and physiological concerns such as menopause and osteoporosis, which are often coexistent. Recently, women’s health issues, including postmenopausal syndrome, have attracted the attention of researchers and practitioners alike, opening newer pharmaceutical research and clinical avenues. Although not counted as a disease, postmenopausal syndrome (PMS) is a female health phenomenon underpinned by hormonal depletion. Enhanced life expectancy in women has added to their suffering, and pharmacological interventions are needed. Amongst the available treatment modalities, the use of numerous botanicals has emerged as an efficient health management tool for women. Cimicifuga racemosa (CR or Black Cohosh) is a plant/herb which has been traditionally exploited and extensively used by women. This review is an attempt to compile and provide a summary of the importance of CR in complementary and alternative therapies for the improvement of various disorders related to women, such as menopausal syndrome, mammary cancer, and osteoporosis. It aims to systematically highlight the bioactive constituents, pharmacology, pharmacokinetics, therapeutic potentials, quality control processes, chromatographic techniques, and possible mechanisms of action of clinically effective phytomedicine for women’s health. Various clinical trials and patents relating to CR and women’s health have been collated. Furthermore, the plant and its related products have been considered from a regulatory perspective to reveal its commercial feasibility. The present review summarizes the existing data on CR focusing on women’s health, which can help to introduce this traditional phytomedicine to the world and provide some reference for future drug development.

Gender aspects in cardiooncology

BACKGROUND

Cardiooncology is a relatively new subspeciality, investigating the side effects of cytoreductive therapies on the cardiovascular (CV) system. Gender differences are well known in oncological and CV diseases, but are less elucidated in cardiooncological collectives.

METHODS

Five hundred and fifty-one patients (278 male, 273 female) with diagnosed cancer who underwent regular cardiological surveillance were enrolled in the 'MAnnheim Registry for CardioOncology' and followed over a median of 41 (95% confidence interval: 40-43) months.

RESULTS

Female patients were younger at the time of first cancer diagnosis [median 60 (range 50-70) vs. 66 (55-75), P = 0.0004], while the most common tumour was breast cancer (49.8%). Hyperlipidaemia was more often present in female patients (37% vs. 25%, P = 0.001). Male patients had a higher cancer susceptibility than female patients. They suffered more often from hypertension (51% vs. 67%, P = 0.0002) or diabetes (14% vs. 21%, P = 0.02) and revealed more often vitamin D deficiency [(U/l) median 26.0 (range 17-38) vs. 16 (9-25), P = 0.002] and anaemia [(g/dl) median 11.8 (range 10.4-12.9) vs. 11.7 (9.6-13.6), P = 0.51]. During follow-up, 140 patients died (male 77, female 63; P = 0.21). An increased mortality rate was observed in male patients (11.4% vs. 14%, P = 0.89), with even higher mortality rates of up to 18.9% vs. 7.7% (P = 0.02) considering tumours that can affect both sexes compared.

CONCLUSIONS

Although female patients were younger at the time of first cancer diagnosis, male patients had both higher cancer susceptibility and an increased mortality risk. Concomitant CV diseases were more common in male patients.

The Triangulation WIthin a STudy (TWIST) framework for causal inference within pharmacogenetic research

In this paper we review the methodological underpinnings of the general pharmacogenetic approach for uncovering genetically-driven treatment effect heterogeneity. This typically utilises only individuals who are treated and relies on fairly strong baseline assumptions to estimate what we term the ‘genetically moderated treatment effect’ (GMTE). When these assumptions are seriously violated, we show that a robust but less efficient estimate of the GMTE that incorporates information on the population of untreated individuals can instead be used. In cases of partial violation, we clarify when Mendelian randomization and a modified confounder adjustment method can also yield consistent estimates for the GMTE. A decision framework is then described to decide when a particular estimation strategy is most appropriate and how specific estimators can be combined to further improve efficiency. Triangulation of evidence from different data sources, each with their inherent biases and limitations, is becoming a well established principle for strengthening causal analysis. We call our framework ‘Triangulation WIthin a STudy’ (TWIST)’ in order to emphasise that an analysis in this spirit is also possible within a single data set, using causal estimates that are approximately uncorrelated, but reliant on different sets of assumptions. We illustrate these approaches by re-analysing primary-care-linked UK Biobank data relating to CYP2C19 genetic variants, Clopidogrel use and stroke risk, and data relating to APOE genetic variants, statin use and Coronary Artery Disease.

Understanding how much a specific treatment’s effect is moderated by common genetic variation is an important public health question. If a person’s genetics means they will experience a much reduced treatment effect, as measured with respect to a particular health outcome, then they could be switched to an alternative therapy. When assessing the impact of such a switch at the population level, it is typical to only use data on those who are treated with the said drug. However, this analysis is compromised if genetic variants exist which moderate the treatment effect and affect the outcome through alternative pathways. In this paper we describe an extended analysis framework to estimating the ‘genetically moderated treatment effect’ (GMTE) that incorporates information on both treated and untreated individuals. With this larger set of information we show that four analysis approaches for estimating the GMTE are possible. Each one relies on a different set of assumptions to work correctly and provides estimates that are largely uncorrelated with one another. Our paper describes a decision framework for triangulating the findings from these four approaches in order to provide a more robust basis for decision making in public health.

Effect of liquiritin on neuroendocrine-immune network in menopausal rat model

PURPOSE

The aim of the study was to investigate the effect of liquiritin on neuroendocrine-immune network in menopausal rat model.

METHODS

Liquiritin groups were respectively given liquiritin suspension at the dose of 80, 40, and 20 mg/kg, once a day for continuous 30 days after the removal of bilateral ovaries to induce the menopausal rat model. Behavioral experiments were conducted and the organs were weighed for the viscera index. The content of estradiol (E₂ ) and follicle-stimulating hormone (FSH) in the serum and 5-hydroxytryptamine (5-HT) and norepinephrine (NE) in hypothalamus were assayed by enzyme linked immunosorbent assay kits. Morphological changes of uterus and adrenal gland were observed by hematoxylin-eosin (HE) staining and estrogen receptor (ER) expression of uterus and spleen were determined by immunohistochemical staining.

RESULTS

For the nervous system, liquiritin relieved menopausal depression and up-regulated the levels of 5-HT and NE in hypothalamus; for the endocrine system, it raised the concentrations of E₂ and FSH in serum, relieved the histological changes of uterus and adrenal gland and increased the expression of ER in uterus; for the immune system, it increased the thymus index and the expression of ER in spleen.

CONCLUSIONS

Liquiritin improved menopausal syndrome in multiple ways by affecting the neuro-endocrine-immune network.

Stem Cell Paracrine Signaling for Treatment of Premature Ovarian Insufficiency

Premature ovarian insufficiency is a common disorder affecting young women and represents the worst-case ovarian scenario due to the substantial impact on the reproductive lifespan of these patients. Due to the complexity of this condition, which is not fully understood, non-effective treatments have yet been established for these patients. Different experimental approaches are being explored and strategies based on stem cells deserve special attention. The regenerative and immunomodulatory properties of stem cells have been successfully tested in different tissues, including ovary. Numerous works point out to the efficacy of stem cells in POI treatment, and a wide range of clinical trials have been developed in order to prove safety and effectiveness of stem cells therapy-in diminished ovarian reserve and POI women. The main purpose of this review is to describe the state of the art of the treatment of POI involving stem cells, especially those that use mobilization of stem cells or paracrine signaling.

Association of genetically predicted testosterone with thromboembolism, heart failure, and myocardial infarction: mendelian randomisation study in UK Biobank

OBJECTIVE

To determine whether endogenous testosterone has a causal role in thromboembolism, heart failure, and myocardial infarction.

DESIGN

Two sample mendelian randomisation study using genetic variants as instrumental variables, randomly allocated at conception, to infer causality as additional randomised evidence.

SETTING

Reduction by Dutasteride of Prostate Cancer Events (REDUCE) randomised controlled trial, UK Biobank, and CARDIoGRAMplusC4D 1000 Genomes based genome wide association study.

PARTICIPANTS

3225 men of European ancestry aged 50-75 in REDUCE; 392 038 white British men and women aged 40-69 from the UK Biobank; and 171 875 participants of about 77% European descent, from CARDIoGRAMplusC4D 1000 Genomes based study for validation.

MAIN OUTCOME MEASURES

Thromboembolism, heart failure, and myocardial infarction based on self reports, hospital episodes, and death.

RESULTS

Of the UK Biobank participants, 13 691 had thromboembolism (6208 men, 7483 women), 1688 had heart failure (1186, 502), and 12 882 had myocardial infarction (10 136, 2746). In men, endogenous testosterone genetically predicted by variants in the JMJD1C gene region was positively associated with thromboembolism (odds ratio per unit increase in log transformed testosterone (nmol/L) 2.09, 95% confidence interval 1.27 to 3.46) and heart failure (7.81, 2.56 to 23.8), but not myocardial infarction (1.17, 0.78 to 1.75). Associations were less obvious in women. In the validation study, genetically predicted testosterone (based on JMJD1C gene region variants) was positively associated with myocardial infarction (1.37, 1.03 to 1.82). No excess heterogeneity was observed among genetic variants in their associations with the outcomes. However, testosterone genetically predicted by potentially pleiotropic variants in the SHBG gene region had no association with the outcomes.

CONCLUSIONS

Endogenous testosterone was positively associated with thromboembolism, heart failure, and myocardial infarction in men. Rates of these conditions are higher in men than women. Endogenous testosterone can be controlled with existing treatments and could be a modifiable risk factor for thromboembolism and heart failure.

Long-term relationships between screening rates, breast cancer characteristics, and overdiagnosis in US counties, 1975-2009

Effects of mammography screening in the general population are disputed. Screening rates differ greatly between US counties, providing a natural opportunity to investigate effects of screening. We compared mammography screening rates with the types and outcomes of breast cancers diagnosed in US counties. The county screening rate was defined as the proportion of women age ≥40 with ≥1 mammogram in the past 2 years (range, 34-91%). Two periods were analyzed: 1975-2009 (612,941 breast cancer cases, 195 counties) and 1996-2009 (645,057 cases, 211-547 counties). Multiple signs of overdiagnosis were observed: First, breast cancer incidence increased as screening became common. Second, incidence stopped increasing once screening rates stabilized. Third, the increases in incidence were limited to age groups receiving screening. Fourth, the increases were larger in counties where screening became more common. Fifth, the increases were limited to small and early-stage breast cancers (which are consistent with overdiagnosis). Sixth, compensatory reductions in large and advanced-stage breast cancers were much smaller than the increases. Difference-in-differences regression analysis suggested 31% (95% CI: 28-34%) of breast cancers diagnosed in 1996-2009 were overdiagnosed. Screening rates correlated with increased incidence for all hormone receptor statuses, HER2 statuses, and grades. Reductions in breast cancer mortality during 1975-2009 were similar in screened and unscreened age groups. Overall, we found repeated signs that breast cancer overdiagnosis is widespread in the US, but the biological nature of overdiagnosed tumors remains unclear. Mortality benefits of screening, though they may be present and substantial, could not be detected at the population level.

The role of menopausal hormone therapy in women with or at risk of ovarian and breast cancers: Misconceptions and current directions

For women who are candidates for menopausal hormone therapy (MHT), estrogen can provide relief from symptomatic menopause, decrease rates of chronic illnesses, and improve health-related quality of life. However, confusion surrounds the evidence regarding the impact of exogenous estrogen and progesterone on the breast and ovary. Available data regarding the risks of MHT (estrogen and/or progestin) related to the development of breast and ovarian cancer are often inconsistent or incomplete. Modern molecular and genetic techniques have improved our understanding of the heterogeneity of breast and ovarian cancer. This enhanced understanding of the disease has impacted our understanding of carcinogenesis. Treatment options have evolved to be more targeted toward hormonal therapy for certain subtypes of disease, whereas cytotoxic chemotherapy remains the standard for other histological and molecular subtypes. The role of MHT in the breast and ovarian cancer survivor, as well as women who are at high risk for the development of hereditary breast and ovarian cancer, remains controversial despite evidence that this treatment can improve quality of life and survival outcomes. Through this article, we examine the evidence for and against the use of MHT with a focus on women who have or are at high risk for breast and ovarian cancer.

Computerized hybrid decision-making system for hormone replacement therapy in menopausal women

BACKGROUND

The diversity of the results of different hormone replacement therapy (HRT) protocols and the fuzziness of the conclusions have caused problems in routine clinical practice.

OBJECTIVE

To develop an intelligent decision-making system for HRT specifically is appropriate as we use the abbrevation HRT in the background section in menopausal women in order to assist physicians.

METHODS

This study consisted of 179 peri- and post-menopausal patients who were admitted to Hacettepe University Hospital (between 1996 and 2001) with various menopausal complaints. Database variables used in this study were age, height, weight, menopause duration, clinical condition, HRT duration, and the laboratory test results. Our newly developed multiple-centered fuzzy clustering (MCFC) algorithm was applied to the medical data set to differentiate patient groups. Finally, a hybrid intelligent decision-making system was developed by combining knowledge-based algorithms and the MCFC algorithm results.

RESULTS

We have used Fuzzy C-means, K-means, Hard C-means, similarity based clustering, and MCFC algorithms on the medical data set and have determined that the MCFC algorithm is the most appropriate algorithm for our medical model. We have defined 5 clusters and 16 cluster centers. A diagnostic phrase was assigned to each cluster center by the physician and these clusters together with knowledge-based algorithms were used for the decision-making system.

CONCLUSIONS

We have developed a computerized hybrid decision-making system recommending HRT to peri- and post-menopausal women in order to assist and protect physicians.

Hormone Therapy and Breast Cancer: Emerging Steroid Receptor Mechanisms

Although hormone therapy is widely used by millions of women to relieve symptoms of menopause, it has been associated with several side-effects such as coronary heart disease, stroke and increased invasive breast cancer risk. These side-effects have caused many women to seek alternatives to conventional hormone therapy, including the controversial custom-compounded bioidentical hormone therapy suggested to not increase breast cancer risk. Historically estrogens and the estrogen receptor were considered the principal factors promoting breast cancer development and progression, however, a role for other members of the steroid receptor family in breast cancer pathogenesis is now evident, with emerging studies revealing an interplay between some steroid receptors. In this review, we discuss examples of hormone therapy used for the relief of menopausal symptoms, highlighting the distinction between conventional hormone therapy and custom-compounded bioidentical hormone therapy. Moreover, we highlight the fact that not all hormones have been evaluated for an association with increased breast cancer risk. We also summarize the current knowledge regarding the role of steroid receptors in mediating the carcinogenic effects of hormones used in menopausal hormone therapy, with special emphasis on the influence of the interplay or crosstalk between steroid receptors. Unraveling the intertwined nature of steroid hormone receptor signaling pathways in breast cancer biology is of utmost importance, considering that breast cancer is the most prevalent cancer among women worldwide. Moreover, understanding these mechanisms may reveal novel prevention or treatment options, and lead to the development of new hormone therapies that does not cause increased breast cancer risk.

The tale wagged by the DAG: broadening the scope of causal inference and explanation for epidemiology

'Causal inference', in 21st century epidemiology, has notably come to stand for a specific approach, one focused primarily on counterfactual and potential outcome reasoning and using particular representations, such as directed acyclic graphs (DAGs) and Bayesian causal nets. In this essay, we suggest that in epidemiology no one causal approach should drive the questions asked or delimit what counts as useful evidence. Robust causal inference instead comprises a complex narrative, created by scientists appraising, from diverse perspectives, different strands of evidence produced by myriad methods. DAGs can of course be useful, but should not alone wag the causal tale. To make our case, we first address key conceptual issues, after which we offer several concrete examples illustrating how the newly favoured methods, despite their strengths, can also: (i) limit who and what may be deemed a 'cause', thereby narrowing the scope of the field; and (ii) lead to erroneous causal inference, especially if key biological and social assumptions about parameters are poorly conceived, thereby potentially causing harm. As an alternative, we propose that the field of epidemiology consider judicious use of the broad and flexible framework of 'inference to the best explanation', an approach perhaps best developed by Peter Lipton, a philosopher of science who frequently employed epidemiologically relevant examples. This stance requires not only that we be open to being pluralists about both causation and evidence but also that we rise to the challenge of forging explanations that, in Lipton's words, aspire to 'scope, precision, mechanism, unification and simplicity'.

A comparative characterization of estrogens used in hormone therapy via estrogen receptor (ER)-α and -β

Conventional hormone therapy (HT) containing estrogens such as ethinylestradiol (EE) have been associated with an increased risk of breast cancer and cardiovascular disease resulting in women seeking safer alternatives that are claimed to have fewer health risks. One such alternative gaining popularity, is custom-compounded bioidentical (b)HT formulations containing bioidentical estradiol (bE₂) and estriol (bE₃). However, the preparation of these custom-compounded estrogens is not regulated, and depending on the route of synthesis, steroid mixtures with differing activities may be produced. Thus, an investigation into the activities of estrogens prepared by custom-compounded pharmacies is warranted. The aim of this study was therefore to directly compare the pharmacological properties of bE₂ and bE₃ of unknown purity relative to commercially available, pure E₂, E₃ and estrone (E₁) standards as well as synthetic EE used in conventional HT via the human estrogen receptor (ER)-α and -β. We determined precise equilibrium dissociation constants (K_d or K_i values) and showed that bE₂ and bE₃ display similar binding affinities to the E₂ and E₃ standards, while EE had a higher affinity for ERα, and E₁ a lower affinity for ERβ. Furthermore, all the estrogens display similar agonist efficacies, but not potencies, for transactivation on a minimal ERE-containing promoter via the individual ER subtypes. Although E₂ and E₃ were equally efficacious and potent on the endogenous ERE-containing pS2 promoter in the MCF-7 BUS breast cancer cell line co-expressing ERα and ERβ, E₁ was less efficacious and potent than E₂. This study is the first to demonstrate that the bioidentical estrogens, commercially available estrogen standards and synthetic EE are full agonists for transrepression on both minimal and endogenous NFκB-containing promoters. Moreover, we showed that these estrogens all increase proliferation and anchorage-independent growth of MCF-7 BUS cells to a similar extent, suggesting that custom-compounded bHT may in fact not be a safer alternative to conventional HT. Furthermore, our results showing that E₃ and E₁ are not weak estrogens, and that E₃ does not antagonize the activity of E₂, suggest that the rationale behind the use of E₃ and E₁ in custom-compounded bHT formulations should be readdressed. Taken together, the results indicating that there is mostly no difference between the custom-compounded bioidentical estrogens, commercially available estrogen standards and synthetic EE, at concentrations reflecting serum levels in women using estrogen-containing HT, suggest that there is no clear advantage in choosing bHT above conventional HT.

Evidence reversal-when new evidence contradicts current claims: a systematic overview review of definitions and terms

OBJECTIVE

To explore the terminology and definitions surrounding the phenomenon of evidence reversal (ER)-which occurs when an existing claim is tested and the original evidence is contradicted by new and stronger evidence.

STUDY DESIGN AND SETTING

For this systematic overview review, multiple medical and gray literature databases were systematically searched from inception to 2016 as well as hand searches of relevant journals, websites, blogs, article bibliographies, citing articles, and related articles. All reviews directly and indirectly defining ER were included and rated for quality using AMSTAR.

RESULTS

A total of 87 articles met the inclusion criteria. Fifty unique sets of terms related to ER were identified: nine described the phenomenon of reversal; 17 described the consequences of reversal; 20 described targets; four described potential predictors of reversal.

CONCLUSION

ER has only recently become a topic of formal exploration. There are many terms that relate to the concept of reversal, which fall into the categories of phenomenon, consequences, targets, and potential predictors of reversal. Consensus should be reached on which terms are most appropriate such that subject headings can be developed and cohesion can be brought to this emerging field of meta-research. (PROSPERO Registration number: CRD42014013768).

Why women choose compounded bioidentical hormone therapy: lessons from a qualitative study of menopausal decision-making

BACKGROUND

In recent years, compounded bioidentical hormone therapy (CBHT) has emerged as a popular alternative to manufactured, FDA approved hormone therapy (HT)-despite concerns within the medical community and the availability of new FDA approved "bioidentical" products. This study aims to characterize the motivations for using CBHT in a U.S. sample of ordinary midlife women.

METHODS

We analyze data collected from 21 current and former users of CBHT who participated in a larger qualitative study of menopausal decision-making among U.S. women. Interviews and focus groups were audio-recorded, transcribed verbatim, and analyzed thematically using an iterative inductive and deductive process.

RESULTS

Although women's individual motivations varied, two overarching themes emerged: "push motivations" that drove women away from conventional HT and from alternative therapies, and "pull motivations" that attracted women to CBHT. Push motivations focused on (1) fear and uncertainty about the safety of conventional HT, (2) an aversion to conjugated estrogens in particular, and (3) and overarching distrust of a medical system perceived as dismissive of their concerns and overly reliant on pharmaceuticals. Participants also voiced dissatisfaction with the effectiveness of herbal and soy supplements. Participants were attracted to CBHT because they perceive it to be (1) effective in managing menopausal symptoms, (2) safer than conventional HT, (3) tailored to their individual bodies and needs, and (4) accompanied by enhanced clinical care and attention.

CONCLUSIONS

This study finds that women draw upon a range of "push" and "pull" motivations in their decision to use CBHT. Importantly, we find that women are not only seeking alternatives to conventional pharmaceuticals, but alternatives to conventional care where their menopausal experience is solicited, their treatment goals are heard, and they are engaged as agents in managing their own menopause. The significance of this finding goes beyond understanding why women choose CBHT. Women making menopause treatment decisions of all kinds would benefit from greater shared decision-making in the clinical context in which they are explicitly invited to share their experiences, priorities, and preferences. This would also provide an opportunity for clinicians to discuss the pros and cons of conventional HT, CBHT, and other approaches to managing menopause.

Phytoestrogen-Rich Natural Preparation for Treatment of Climacteric Syndrome and Atherosclerosis Prevention in Perimenopausal Women

The present study evaluated the risks and benefits of phytoestrogen treatment in healthy perimenopausal women in relation to the dynamics of climacteric syndrome and progression of atherosclerosis. Study participants were treated with placebo or phytoestrogen-rich natural preparation Karinat based on grape (Vitis vinifera) seeds, green tea (Camellia sinensis) leaves, hop (Hunulus lupulus) cone powder and garlic (Allium sativum) powder. The dynamics of climacteric syndrome was evaluated by Kupperman Index and Utian Quality of Life Scale. Atherosclerosis progression was evaluated by measuring carotid intima-media thickness. Significant changes of climacteric syndrome's severity in both Karinat and placebo groups (p = 0.005 and p = 0.001) were obtained after 24 months of follow-up. Detailed analysis of Kupperman Index suggested that Karinat possessed a significant effect on nervousness (p = 0.010), weakness (p = 0.020) and formication (p = 0.010). A significant improvement of medical (p = 0.070) and emotional (p = 0.060) components of Kupperman Index and Utian Quality of Life Scale was also observed in Karinat group. However, difference in carotid intima-media thickness between the two groups was not statistically significant at follow-up. A slight positive effect of phytoestrogens on climacteric syndrome manifestations was demonstrated in this study. Karinat can be used for alleviation of climacteric syndrome and cardiovascular disease prevention in perimenopausal women. Copyright © 2017 John Wiley & Sons, Ltd.

Testosterona, desejo sexual e conflito de interesse: periódicos biomédicos como espaços privilegiados de expansão do mercado de medicamentos

Resumo Este artigo focaliza a articulação entre pesquisa biomédica e indústria farmacêutica com base nos estudos da tecnociência. Abordamos o caso do medicamento Intrinsa – adesivo de testosterona, cujo propósito é o aumento do desejo sexual em mulheres – examinando artigos que relatam resultados de ensaios clínicos, publicados em periódicos científicos. Buscamos demonstrar como a população visada pelos ensaios clínicos foi paulatinamente expandida de modo a englobar um número cada vez maior de mulheres, o que pressupôs rearranjos na maneira de definir as disfunções para as quais o medicamento seria indicado e as possíveis causas subjacentes. Foi possível identificar três caminhos de ampliação do mercado para o Intrinsa: o primeiro baseou-se na alteração do status de menopausa. A terapia com testosterona passou a ser vinculada também ao envelhecimento (incluindo, portanto, a pré-menopausa e a menopausa “natural”) e não mais exclusivamente à menopausa cirúrgica; o segundo focalizou a dissociação entre o uso do Intrinsa e a terapia com estrógenos; o terceiro buscou vincular o medicamento ao aumento de “bem-estar”.

A proposed World Council on Epidemiology and Causation: summary of feedback and considerations in an international workshop

Rigorous evaluation of associations in epidemiology is essential, especially given big data, data mining, and hypothesis-free analyses. There is a precedent in making judgments on associations in the monographs of the International Agency for Research on Cancer; however, only the carcinogenic effects of exposures are examined. The idea of a World Council of Epidemiology and Causality to undertake rigorous, independent, comprehensive examination of associations has been debated, including in a workshop at the International Epidemiology Association's 20^th World Congress of Epidemiology, 2014. The objective of the workshop was both to, briefly, debate the idea and set out further questions and next steps. The principal conclusion from feedback including from the workshop is that the World Council of Epidemiology and Causality idea, notwithstanding challenges, has promise and deserves more debate. The preferred model is for a small independent body working closely with relevant partners with a distributed approach to tasks. Recommendations are contextualized in contemporary approaches in causal thinking in epidemiology.

The utility of medico-legal databases for public health research: a systematic review of peer-reviewed publications using the National Coronial Information System

BACKGROUND

Medico-legal death investigations are a recognised data source for public health endeavours and its accessibility has increased following the development of electronic data systems. Despite time and cost savings, the strengths and limitations of this method and impact on research findings remain untested. This study examines this issue using the National Coronial Information System (NCIS).

METHODS

PubMed, ProQuest and Informit were searched to identify publications where the NCIS was used as a data source for research published during the period 2000-2014. A descriptive analysis was performed to describe the frequency and characteristics of the publications identified. A content analysis was performed to identify the nature and impact of strengths and limitations of the NCIS as reported by researchers.

RESULTS

Of the 106 publications included, 30 reported strengths and limitations, 37 reported limitations only, seven reported strengths only and 32 reported neither. The impact of the reported strengths of the NCIS was described in 14 publications, whilst 46 publications discussed the impacts of limitations. The NCIS was reported to be a reliable source of quality, detailed information with comprehensive coverage of deaths of interest, making it a powerful injury surveillance tool. Despite these strengths, researchers reported that open cases and missing information created the potential for selection and reporting biases and may preclude the identification and control of confounders.

CONCLUSIONS

To ensure research results are valid and inform health policy, it is essential to consider and seek to overcome the limitations of data sources that may have an impact on results.

Naringin protects human adipose-derived mesenchymal stem cells against hydrogen peroxide-induced inhibition of osteogenic differentiation

Extensive evidence indicates that oxidative stress plays a pivotal role in the development of osteoporosis. We show that naringin, a natural antioxidant and anti-inflammatory compound, effectively protects human adipose-derived mesenchymal stem cells (hADMSCs) against hydrogen peroxide (H2O2)-induced inhibition of osteogenic differentiation. Naringin increased viability of hAMDSCs and attenuated H2O2-induced cytotoxicity. Naringin also reversed H2O2-induced oxidative stress. Oxidative stress induced by H2O2 inhibits osteogenic differentiation by decreasing alkaline phosphatase (ALP) activity, calcium content and mRNA expression levels of osteogenesis marker genes RUNX2 and OSX in hADMSCs. However, addition of naringin leads to a significant recovery, suggesting the protective effects of naringin against H2O2-induced inhibition of osteogenic differentiation. Furthermore, the H2O2-induced decrease of protein expressions of β-catenin and clyclin D1, two important transcriptional regulators of Wnt-signaling, was successfully rescued by naringin treatment. Also, in the presence of Wnt inhibitor DKK-1, naringin is no longer effective in stimulating ALP activity, increasing calcium content and mRNA expression levels of RUNX2 and OSX in H2O2-exposed hADMSCs. These data clearly demonstrates that naringin protects hADMSCs against oxidative stress-induced inhibition of osteogenic differentiation, which may involve Wnt signaling pathway. Our work suggests that naringin may be a useful addition to the treatment armamentarium for osteoporosis and activation of Wnt signaling may represent attractive therapeutic strategy for the treatment of degenerative disease of bone tissue.

Bioidentical hormones, menopausal women, and the lure of the "natural" in U.S. anti-aging medicine

In 2002, the Women's Health Initiative, a large-scale study of the safety of hormone replacement therapy (HRT) for women conducted in the United States, released results suggesting that use of postmenopausal HRT increased women's risks of stroke and breast cancer. In the years that followed, as rates of HRT prescription fell, another hormonal therapy rose in its wake: bioidentical hormone replacement therapy (BHRT). Anti-aging clinicians, the primary prescribers of BHRT, tout it as a safe and effective alternative to treat menopausal symptoms and, moreover, as a preventative therapy for age-related diseases and ailments. Through in-depth interviews with 31 U.S.-based anti-aging clinicians and 25 female anti-aging patients, we analyze attitudes towards BHRT. We illustrate how these attitudes reveal broader contemporary values, discourses, and discomforts with menopause, aging, and biomedicine. The attraction to and promise of BHRT is rooted in the idea that it is a "natural" therapy. BHRT is given both biomedical and embodied legitimacy by clinicians and patients because of its purported ability to become part of the body's "natural" processes. The normative assumption that "natural" is inherently "good" not only places BHRT beyond reproach, but transforms its use into a health benefit. The clinical approach of anti-aging providers also plays a role by validating patients' embodied experiences and offering a "holistic" solution to their symptoms, which anti-aging patients see as a striking contrast to their experiences with conventional biomedical health care. The perceived virtues of BHRT shed light on the rhetoric of anti-aging medicine and a deeply complicated relationship between conventional biomedicine, hormonal technologies, and women's bodies.

The irreducibility of value-freedom to theory assessment

The current ideal of value-freedom holds non-cognitive values to be illegitimate in theory appraisal but legitimate in earlier stages of the research process, for example, when affecting the selection of topics or the generation of hypotheses. Respective decisions are often considered as part of a context of discovery and as irrelevant for the justification and assessment of theories. I will argue that this premise of an epistemic independence of theory appraisal, though often taken for granted, is false. Due to the possibility of value-laden blind spots, decisions in discovery can have an indirect impact on theory assessment that the value-free ideal cannot deal with. This argument is illustrated by a case study from women's health research, namely the assessment of hormone replacement therapy as a prevention of coronary heart diseases. In consequence, the epistemic trustworthiness of science is promoted more by a pluralism of non-cognitive values than by their exclusion; and a normative philosophy of science needs to enlarge its focus to include the context of discovery as well as the social conditions of science.

Gender bias in clinical research, pharmaceutical marketing, and the prescription of drugs

This thesis is part of the studies of gender bias in health which together with the paradigm of evidence-based medicine shares the empirical assumption that there are inaccuracies in medical practice, in addition to a lack of rigour and transparency. It worked with the distinction between the concepts of sex and gender and between the concepts of sex-related differences and gender inequalities, in terms of applying a gender perspective in the study design and the subsequent analysis. This PhD review presents the research process conducted in Spain, which can provide an example for future research. Study I described a review of 58 clinical trials (CTs) of etoricoxib to assess its compliance with the Recommendations of Evaluation of Gender Differences in the Clinical Evaluation of Drugs. In Study II, key informants from professions related to different areas in drug development and pharmacovigilance held a working meeting to reach a consensus document on recommendations for the study and evaluation of gender differences in CTs in Spain. In Study III, the websites of the eight best-selling hormone replacement therapy drugs in Spain on Google first page of results were analysed. In Study IV, a logistic regression analysis was performed to compare analgesic prescription by sex in regions with a higher or lower Gender Development Index (GDI) than the Spanish average. Gender biases identified in this thesis limited the legitimacy of medicine, which is not based on the best possible evidence. The results also demonstrate the existence of inequalities between men and women that are not due merely to biological differences, but are gender inequalities stemming from the social differences that exist between both sexes.

Effects of naringin on the proliferation and osteogenic differentiation of human amniotic fluid-derived stem cells

Human amniotic fluid-derived stem cells (hAFSCs) are a novel cell source for generating osteogenic cells to treat bone diseases. Effective induction of osteogenic differentiation from hAFSCs is critical to fulfil their therapeutic potential. In this study, naringin, the main active compound of Rhizoma drynariae (a Chinese herbal medicine), was used to stimulate the proliferation and osteogenic differentiation of hAFSCs. The results showed that naringin enhanced the proliferation and alkaline phosphatase activity (ALP) of hAFSCs in a dose-dependent manner in the range 1-100 µg/ml, while an inhibition effect was observed at 200 µg/ml. Consistently, the calcium content also increased with naringin concentration up to 100 µg/ml. The enhanced osteogenic differentiation of hAFSCs by naringin was further confirmed by the dose-dependent upregulation of marker genes, including osteopontin (OPN) and Collagen I from RT-PCR analysis. The increased osteoprotegerin (OPG) expression and minimal expression of receptor activator of nuclear factor-κB ligand (RANKL) suggested that naringin also inhibited osteoclastogenesis of hAFSCs. In addition, the gene expressions of bone morphogenetic protein 4 (BMP4), runt-related transcription factor 2 (RUNX2), β-catenin and Cyclin D1 also increased significantly, indicating that naringin promotes the osteogenesis of hAFSCs via the BMP and Wnt-β-catenin signalling pathways. These results suggested that naringin can be used to upregulate the osteogenic differentiation of hAFSCs, which could provide an attractive and promising treatment for bone disorders. Copyright © 2014 John Wiley & Sons, Ltd.

Postmenopausal hormone therapy is not associated with risk of all-cause dementia and Alzheimer's disease

The relationship of postmenopausal hormone therapy with all-cause dementia and Alzheimer's disease dementia has been controversial. Given continued interest in the role of hormone therapy in chronic disease prevention and the emergence of more prospective studies, we conducted a systematic review to identify all epidemiologic studies meeting prespecified criteria reporting on postmenopausal hormone therapy use and risk of Alzheimer's disease or dementia. A systematic search of Medline and Embase through December 31, 2012, returned 15 articles meeting our criteria. Our meta-analysis of any versus never use did not support the hypothesis that hormone therapy reduces risk of Alzheimer's disease (summary estimate = 0.88, 95% confidence interval: 0.66, 1.16). Exclusion of trial findings did not change this estimate. There were not enough all-cause dementia results for a separate meta-analysis, but when we combined all-cause dementia results (n = 3) with Alzheimer's disease results (n = 7), the summary estimate remained null (summary estimate = 0.94, 95% confidence interval: 0.71, 1.26). The limited explorations of timing of use-both duration and early initiation-did not yield consistent findings. Our findings support current recommendations that hormone therapy should not be used for dementia prevention. We discuss trends in hormone therapy research that could explain our novel findings and highlight areas where additional data are needed.

History, biology, and health inequities: emergent embodied phenotypes and the illustrative case of the breast cancer estrogen receptor

How we think about biology--in historical, ecological, and societal context--matters for framing causes of and solutions to health inequities. Drawing on new insights from ecological evolutionary developmental biology and ecosocial theory, I question dominant gene-centric and ultimately static approaches to conceptualizing biology, using the example of the breast cancer estrogen receptor (ER). Analyzed in terms of its 4 histories--societal, individual (life course), tumor (cellular pathology), and evolutionary--the ER is revealed as a flexible characteristic of cells, tumors, individuals, and populations, with magnitudes of health inequities tellingly changing over time. This example suggests our science will likely be better served by conceptualizing disease and its biomarkers, along with changing magnitudes of health inequities, as embodied history--that is, emergent embodied phenotype, not innate biology.

Lifestyle risk management--a qualitative analysis of women's descriptions of taking hormone therapy following surgically induced menopause

AIM

This article is a report of a study that examined how women describe their decisions in relation to the use of menopausal hormone therapy following surgical menopause.

BACKGROUND

Women who have had a surgically induced menopause generally experience more intense menopausal symptoms than natural menopause and are regularly prescribed menopausal hormone therapy. Since 2002 the risks associated with this therapy have been widely reported.

METHOD

This study is a qualitative analysis of semi-structured interviews between March and May 2009 with 30 participants who had experienced surgical menopause and were, or had in the past, taken menopausal hormone therapy. This was a community sample recruited in Christchurch, New Zealand. A risk management theoretical approach underpinned the analysis.

FINDINGS

The womens' descriptions of managing the risks associated with menopausal therapy fell into two main themes: Life has to go on and Waiting for someone to tell me. All these women had either made an active decision to continue on treatment because of the impact of menopausal symptoms or took their doctor's advice to continue. A less dominant theme but one that was also evident was Relying on my body to get me through in which the women had decided to discontinue treatment because they regarded it as unnatural.

CONCLUSION

The study provided insights into how women utilize an experiential reasoning process to manage the health and lifestyle risks associated with taking menopausal hormone therapy. Nurses need to be aware of how this process influences women's reasoning processes when working with women following surgical menopause.

Breast cancer incidence trends in Norway--explained by hormone therapy or mammographic screening?

A decline in breast cancer incidence has been observed in several countries after 2002. Reduced use of menopausal hormonal therapy (HT), as a consequence of the publication of results from the Women's Health Initiative, has been argued to be the main reason. In Norway, the governmentally funded Norwegian Breast Cancer Screening Program (NBCSP) was implemented during the same time period as the increased use of HT. This study investigated trends in breast cancer incidence by use of HT and introduction of the screening program. We obtained rates of breast cancer from the Cancer Registry of Norway and sales data of HT preparations from the Norwegian Institute of Public Health. Mammography rates were estimated from published reports. Breast cancer incidence rates increased steadily from 1956 to the end of the 20th century, particularly in women aged 55-69 during 1996-2002 residing in the counties where the NBCSP was first introduced. The rates declined after 2002-2003. HT use increased in 1987-2001, peaking around year 2000. In particular, sales of combined estrogen and progestogen preparations declined after 2002. Among women aged 55-59, rates of hormone receptor positive breast cancers peaked in 2000-2003. No such trend was seen in other age groups. In conclusion, the interpretation of breast cancer incidence trends in Norway from 1987 to 2009 is complicated because the NBCSP was introduced during a period with increasing HT use. Both factors likely contributed to the observed trends, and the role of each may vary across age groups.

Osteoprotective effects of Fructus Ligustri Lucidi aqueous extract in aged ovariectomized rats

Background

Fructus Ligustri Lucidi (FLL) is a commonly used herb for treating bone disorders in Chinese medicine. The present study investigates the anti-osteoporotic activity of FLL aqueous extract in the model of postmenopausal bone loss in aged ovariectomized (OVX) female rats.

Methods

After eight weeks of treatment of FLL or water, the lumbar spine was scanned by peripheral quantitative computed tomography (pQCT). Effects of FLL water extract on osteogenic and adipogenic differentiations in rat mesenchymal stem cells (MSCs) were assessed by biochemical methods and staining.

Results

FLL aqueous extract significantly inhibited bone mineral density (BMD) loss in total, trabecular and cortical bones without affecting body weight and uterus wet weight. FLL extract significantly promoted osteogenesis and suppressed adipogenesis in MSCs as indicated by the elevated alkaline phosphatase activity, calcium deposition levels and decreased adipocyte number in a dose-dependent manner without cytotoxic effects. Real-time PCR analysis revealed significant increase of osteoprotegerin (OPG)-to-receptor activator for nuclear factor-κB ligand (RANKL) mRNA, indicating a decrease in osteoclastogenesis.

Conclusion

The present study demonstrates the osteoprotective effects of FLL aqueous extract on aged OVX rats, stimulation of osteogenesis, inhibition of adipogenesis and osteoclastogenesis in MSCs.

Estrogens of multiple classes and their role in mental health disease mechanisms

Gender and sex hormones can influence a variety of mental health states, including mood, cognitive development and function, and vulnerability to neurodegenerative diseases and brain damage. Functions of neuronal cells may be altered by estrogens depending upon the availability of different physiological estrogenic ligands; these ligands and their effects vary with life stages, the genetic or postgenetic regulation of receptor levels in specific tissues, or the intercession of competing nonphysiological ligands (either intentional or unintentional, beneficial to health or not). Here we review evidence for how different estrogens (physiological and environmental/dietary), acting via different estrogen receptor subtypes residing in alternative subcellular locations, influence brain functions and behavior. We also discuss the families of receptors and transporters for monoamine neurotransmitters and how they may interact with the estrogenic signaling pathways.

Hormone replacement therapy advertising: sense and nonsense on the web pages of the best-selling pharmaceuticals in Spain

BACKGROUND

The balance of the benefits and risks of long term use of hormone replacement therapy (HRT) have been a matter of debate for decades. In Europe, HRT requires medical prescription and its advertising is only permitted when aimed at health professionals (direct to consumer advertising is allowed in some non European countries). The objective of this study is to analyse the appropriateness and quality of Internet advertising about HRT in Spain.

METHODS

A search was carried out on the Internet (January 2009) using the eight best-selling HRT drugs in Spain. The brand name of each drug was entered into Google's search engine. The web sites appearing on the first page of results and the corresponding companies were analysed using the European Code of Good Practice as the reference point.

RESULTS

Five corporate web pages: none of them included bibliographic references or measures to ensure that the advertising was only accessible by health professionals. Regarding non-corporate web pages (n = 27): 41% did not include the company name or address, 44% made no distinction between patient and health professional information, 7% contained bibliographic references, 26% provided unspecific information for the use of HRT for osteoporosis and 19% included menstrual cycle regulation or boosting feminity as an indication. Two online pharmacies sold HRT drugs which could be bought online in Spain, did not include the name or contact details of the registered company, nor did they stipulate the need for a medical prescription or differentiate between patient and health professional information.

CONCLUSIONS

Even though pharmaceutical companies have committed themselves to compliance with codes of good practice, deficiencies were observed regarding the identification, information and promotion of HRT medications on their web pages. Unaffected by legislation, non-corporate web pages are an ideal place for indirect HRT advertising, but they often contain misleading information. HRT can be bought online from Spain, without a medical consultation or prescription constituting a serious issue for public health. In our information society, it is the right and obligation of public health bodies to ensure that such information is not misleading.

Decline in US breast cancer rates after the Women's Health Initiative: socioeconomic and racial/ethnic differentials

OBJECTIVES

We investigated whether there were socioeconomic and racial/ethnic disparities in recent reported declines in overall US breast cancer incidence rates attributed to post-2002 declines in hormone therapy use following publication of the Women's Health Initiative study.

METHODS

We analyzed 1992-2005 US breast cancer incidence data from the US Surveillance, Epidemiology and End Result (SEER) 13 Registries Database, stratified by race/ethnicity, county income level, age, and estrogen receptor (ER) status.

RESULTS

As we hypothesized, between 1992 and 2005, the temporal pattern of rising and then falling US breast cancer incidence rates occurred only among White non-Hispanic women who lived in high-income counties, were aged 50 years and older, and had ER-positive tumors. No such trends were evident--regardless of county income level, ER status, or age--among Black non-Hispanic, Asian/Pacific Islander, Hispanic, or-where numbers were sufficient to conduct meaningful analyses-American Indian/Alaska Native women.

CONCLUSIONS

The recent decline in US breast cancer incidence was not equally beneficial to all women, but instead mirrored the social patterning of hormone therapy use. Joint information on socioeconomic resources and race/ethnicity is vital for correctly understanding disease distribution, including that of breast cancer.

Recent breast cancer incidence trends according to hormone therapy use: the California Teachers Study cohort

INTRODUCTION

Recent, international declines in breast cancer incidence are unprecedented, and the causes remain controversial. Few data sources can address breast cancer incidence trends according to pertinent characteristics like hormone therapy use history.

METHODS

We used the prospective California Teachers Study to evaluate changes in self-reported use of menopausal hormone therapy (HT) between 1995 to 1996 and 2005 to 2006 and age-adjusted breast cancer incidence among 74,647 participants aged 50 years or older. Breast cancer occurrence was determined by linkage with the California Cancer Registry.

RESULTS

During 517,286 woman years of follow up, 565 in situ and 2,668 invasive breast cancers were diagnosed. In situ breast cancer incidence rates in this population did not change significantly from 2000 to 2002 to 2003 to 2005, whereas rates of invasive breast cancer declined significantly by 26.0% from 528.0 (95% confidence intervals (CI) = 491.1, 564.9) per 100,000 women in 2000 to 2002 to 390.6 (95% CI = 355.6, 425.7) in 2003 to 2005. The decline in invasive breast cancer incidence rates was restricted to estrogen receptor-positive tumors. In 1996 to 1999 and 2000 to 2002 invasive breast cancer incidence was higher for women who reported current HT use especially estrogen-progestin (EP) use at baseline than for never or past users; but by 2003 to 2005 rates were comparable between these groups. For women who were taking EP in 2001 to 2002,75% of whom had stopped use by 2005 to 2006, incidence had declined 30.6% by 2003 to 2005 (P = 0.001); whereas incidence did not change significantly for those who never took HT (P = 0.33).

CONCLUSIONS

Few data resources can examine prospectively individual HT use and breast cancer diagnosis. Stable in situ breast cancer rates imply consistent levels of screening and suggest recent declines in invasive breast cancer to be explained predominantly by changes in HT use.

Seven mistakes and potential solutions in epidemiology, including a call for a World Council of Epidemiology and Causality

All sciences make mistakes, and epidemiology is no exception. I have chosen 7 illustrative mistakes and derived 7 solutions to avoid them. The mistakes (Roman numerals denoting solutions) are:

1. Failing to provide the context and definitions of study populations. (I Describe the study population in detail)

2. Insufficient attention to evaluation of error. (II Don't pretend error does not exist.)

3. Not demonstrating comparisons are like-for-like. (III Start with detailed comparisons of groups.)

4. Either overstatement or understatement of the case for causality. (IV Never say this design cannot contribute to causality or imply causality is ensured by your design.)

5. Not providing both absolute and relative summary measures. (V Give numbers, rates and comparative measures, and adjust summary measures such as odds ratios appropriately.)

6. In intervention studies not demonstrating general health benefits. (VI Ensure general benefits (mortality/morbidity) before recommending application of cause-specific findings.)

7. Failure to utilise study data to benefit populations. (VII Establish a World Council on Epidemiology to help infer causality from associations and apply the work internationally.)

Analysis of these and other common mistakes is needed to benefit from the increasing discovery of associations that will be multiplying as data mining, linkage, and large-scale scale epidemiology become commonplace.

Theorizing social context: rethinking behavioral theory

Major behavioral theories focus on proximal influences on behavior that are considered to be predominantly cognitive characteristics of the individual largely uninfluenced by social context. Social ecological models integrate multiple levels of influence on health behavior and are noted for emphasizing the interdependence of environmental settings and life domains. This theory-based article explains how social context is conceptualized in the social sciences and how the social science conceptualization differs from and can broaden the analytic approach to health behavior. The authors use qualitative data from the Behavioral Constructs and Culture in Cancer Screening study to illustrate our conceptualization of social context. We conclude that the incorporation into health behavior theory of a multidimensional socioculturally oriented, theoretical approach to social context is critical to understand and redress health disparities in multicultural societies like the United States.