Current use of unopposed estrogen and estrogen plus progestin and the risk of acute myocardial infarction among women with diabetes: the Northern California Kaiser Permanente Diabetes Registry, 1995-1998

Eligibility criteria for Menopausal Hormone Therapy (MHT): a position statement from a consortium of scientific societies for the use of MHT in women with medical conditions. MHT Eligibility Criteria Group

This project aims to develop eligibility criteria for menopausal hormone therapy (MHT). The tool should be similar to those already established for contraception A consortium of scientific societies coordinated by the Spanish Menopause Society met to formulate recommendations for the use of MHT by women with medical conditions based on the best available evidence. The project was developed in two phases. As a first step, we conducted 14 systematic reviews and 32 metanalyses on the safety of MHT (in nine areas: age, time of menopause onset, treatment duration, women with thrombotic risk, women with a personal history of cardiovascular disease, women with metabolic syndrome, women with gastrointestinal diseases, survivors of breast cancer or of other cancers, and women who smoke) and on the most relevant pharmacological interactions with MHT. These systematic reviews and metanalyses helped inform a structured process in which a panel of experts defined the eligibility criteria according to a specific framework, which facilitated the discussion and development process. To unify the proposal, the following eligibility criteria have been defined in accordance with the WHO international nomenclature for the different alternatives for MHT (category 1, no restriction on the use of MHT; category 2, the benefits outweigh the risks; category 3, the risks generally outweigh the benefits; category 4, MHT should not be used). Quality was classified as high, moderate, low or very low, based on several factors (including risk of bias, inaccuracy, inconsistency, lack of directionality and publication bias). When no direct evidence was identified, but plausibility, clinical experience or indirect evidence were available, "Expert opinion" was categorized. For the first time, a set of eligibility criteria, based on clinical evidence and developed according to the most rigorous methodological tools, has been defined. This will provide health professionals with a powerful decision-making tool that can be used to manage menopausal symptoms.

Management of Cardiovascular Risk in Perimenopausal Women with Diabetes

Cardiovascular disease is the primary cause of mortality in women and men with diabetes. Due to age and worsening of risk factors over the menopausal transition, risk of coronary heart disease events increases in postmenopausal women with diabetes. Randomized studies have conflicted regarding the beneficial impact of estrogen therapy upon intermediate cardiovascular disease markers and events. Therefore, estrogen therapy is not currently recommended for indications other than symptom management. However, for women at low risk of adverse events, estrogen therapy can be used to minimize menopausal symptoms. The risk of adverse events can be estimated using risk engines for the calculation of cardiovascular risk and breast cancer risk in conjunction with screening tools such as mammography. Use of estrogen therapy, statins, and anti-platelet agents can be guided by such calculators particularly for younger women with diabetes. Risk management remains focused upon lifestyle behaviors and achieving optimal levels of cardiovascular risk factors, including lipids, glucose, and blood pressure. Use of pharmacologic therapies to address these risk factors, particularly specific hypoglycemic agents, may provide some additional benefit for risk prevention. The minimal benefit for women with limited life expectancy and risk of complications with intensive therapy should also be considered.

Estrogen Therapy and Ischemic Stroke in Women with Diabetes Aged Over 55 Years: A Nation-Wide Prospective Population-Based Study in Taiwan

This study explores the possible association between the risk of ischemic stroke and conjugated equine estrogen (CEE) use in women who are over 55 years old and have diabetes. Data from the National Health Insurance system of Taiwan were used to identify 428 women over 55 years old with diabetes who used CEE (0.625 mg daily) from 2003 to 2009. For comparison, 21026 women with diabetes who were from the same cohort and did not use estrogen were used as a control group, excluding patients with previous ischemic stroke at the baseline. The propensity score method was used to identify a 1:3 ratio for the matched cohort (n = 1284). Covariates used for propensity score-matching included age and comorbidities. Cox’s proportional hazard model was applied to estimate the relationship between CEE use and ischemic stroke. The overall incidence of ischemic stroke was significantly lower in patients using CEE than in the control group (0.9% compared with 3.0%, p = 0.016). Further analyses using Cox’s proportional hazard model revealed that after adjusting for age, comorbidities, socioeconomic status, urbanization, and other medications associated with ischemic stroke, a lower risk was present in patients with CEE use (hazard ratio: 0.34; 95% confidence interval: 0.12–0.97). Time of menopause could not be identified because of the nature of the database. CEE might decrease the risk of ischemic stroke in women with diabetes aged over 55 years, according to this population-based study.

Mechanisms of estrogen protection in diabetes and metabolic disease

Until menopause, women are largely protected against several metabolic disorders, implicating a role for sex hormones. Adiposity and insulin resistance are fundamental features in the pathogenesis of type 2 diabetes mellitus. Emerging data suggest that sex-steroid hormones and adipocyte-derived hormones and cytokines could be associated with type 2 diabetes risk and that some of these novel markers can exhibit a sexual dimorphism with regard to this risk. Evidence suggests that the female hormone, 17β-estradiol protects insulin production and prevents diabetes. Although 17β-estradiol acts primarily via two distinct estrogen receptors (ERs), ERα and ERβ, it appears that ERα protects β-cell survival, whereas ERβ reduces ERα function and provokes β-cell apoptosis. Accordingly, use of menopausal hormone therapy has been shown to reduce diabetes incidence and weight gain. Recent findings that benefits of menopausal hormone therapy might not outweigh the risks in some women do not negate the importance of identifying mechanisms by which 17β-estradiol attenuates the development and progression of metabolic disease. This could lay the ground to the design of pharmacological treatments for the prevention of menopause-associated metabolic disorders that are safer and more efficacious than current hormone-based regimens.

Coronary Heart Disease in Postmenopausal Women with Type II Diabetes Mellitus and the Impact of Estrogen Replacement Therapy: A Narrative Review

Coronary heart disease is the main cause of death in postmenopausal women (PMW); moreover its mortality exceeds those for breast cancer in women at all ages. Type II diabetes mellitus is a major cardiovascular risk factor and there is some evidence that the risk conferred by diabetes is greater in women than in men. It was established that the deficiency of endogenous estrogens promotes the atherosclerosis process. However, the impact of estrogen replacement therapy (ERT) on cardiovascular prevention remains controversial. Some authors strongly recommend it, whereas others revealed a concerning trend toward harm. This review tries to underlines the different components of cardiovascular risk in diabetic PMW and to define the place of ERT.

Gender-specific care of diabetes

Diabetic men have benefited in the last 30 years from a significant improvement in total and cardiovascular mortality, whereas diabetic women have had no improvement at all. Moreover, recent research focused on the role of sex hormones in glucose homeostasis, and might account for different pathophysiologic mechanisms in the development of diabetes-related complications. Thus, care of diabetic women is a challenge that requires particular attention. The available data regarding gender-specific care of diabetes mellitus are uneven, rich in some domains but very poor in others. The large prospective trials performed in the last 20 years have assumed that the natural history of diabetes mellitus in men and women, as well as the efficiency of glucose-lowering therapies and management of hyperglycemic-related complications, could be attributable without distinction to men and women. We propose in this paper to analyze the published medical literature according to the specific management of diabetes mellitus in women, and to try to distinguish some particular features. We found important distinctions between diabetic men and women regarding the patterns of abnormalities of glucose regulation, epidemiology, development of diabetes-related complications, ischemic heart disease, morbidity and mortality, impact of cardiovascular risk factors, development of the metabolic syndrome, depression and osteoporosis, as well as the impact of lifestyle modifications or primary and secondary preventions on cardiovascular risk factors, and finally medical therapeutics. Moreover, special considerations were given to some particular aspects of the medical life in diabetic women, such as the features of gestational diabetes mellitus and the management of pregnancy in pregestational diabetic women, use of contraception, hormone-replacement therapy and polycystic ovary syndrome.

Maternal exposure to angiotensin converting enzyme inhibitors in the first trimester and risk of malformations in offspring: a retrospective cohort study

OBJECTIVE

To examine a reported association between use of angiotensin converting enzyme (ACE) inhibitors during the first trimester and risk of malformations in offspring.

DESIGN

A population based, retrospective cohort study linking automated clinical and pharmacy databases including comprehensive electronic medical records.

PARTICIPANTS

Pregnant women and their live born offspring (465,754 mother-infant pairs) in the Kaiser Permanente Northern California region from 1995 to 2008.

MAIN OUTCOME MEASURE

Congenital malformation in live births.

RESULTS

The prevalence of ACE inhibitor use in the first trimester only was 0.9/1000, and the use of other antihypertensive medications was 2.4/1000. After adjustment for maternal age, ethnicity, parity, and obesity, use of ACE inhibitors during the first trimester only seemed to be associated with increased risk of congenital heart defects in offspring compared with normal controls (those with neither hypertension nor use of any antihypertensives during pregnancy) (15/381 (3.9%) v 6232/400,021 (1.6%) cases, odds ratio 1.54 (95% confidence interval 0.90 to 2.62)). A similar association was observed for use of other antihypertensives (28/1090 (2.6%) cases of congenital heart defects, odds ratio 1.52 (1.04 to 2.21)). However, compared with hypertension controls (those with a diagnosis of hypertension but without use of antihypertensives) (708/29,735 (2.4%) cases of congenital heart defects), neither use of ACE inhibitors or of other antihypertensives in the first trimester was associated with increased congenital heart defects risk (odds ratios 1.14 (0.65 to 1.98) and 1.12 (0.76 to 1.64) respectively).

CONCLUSIONS

Maternal use of ACE inhibitors in the first trimester has a risk profile similar to the use of other antihypertensives regarding malformations in live born offspring. The apparent increased risk of malformations associated with use of ACE inhibitors (and other antihypertensives) in the first trimester is likely due to the underlying hypertension rather than the medications.

A "window of opportunity:" the reduction of coronary heart disease and total mortality with menopausal therapies is age- and time-dependent

The totality of data indicates that the "window of opportunity" for reducing coronary heart disease (CHD) and overall mortality is initiation of hormone therapy (HT) within 6 years of menopause and/or before 60 years of age. Reduction of CHD risk and overall mortality with prolonged HT use in this subgroup of women is consistent across randomized controlled trials and observational studies. As such, HT use for 5 to 30 years in postmenopausal women who initiate HT in their 50s substantially increases quality-adjusted life-years (QALYs) by 1.5 QALYs and is highly cost-effective at $2438 per QALY gained. Cumulated randomized controlled trial results indicate a consistency along with observational data that young postmenopausal women with menopausal symptoms who use HT for long periods of time have lower rates of CHD and overall mortality than comparable postmenopausal women who do not use HT.

Emerging role of estrogen in the control of cardiometabolic disease

Menopause is associated with an increased risk of cardiovascular and metabolic disease that is partly independent of aging. This increased risk is largely due to postmenopausal estrogen loss. Estrogen improves insulin sensitivity and ss-cell function. This is consistent with the increased risk of diabetes after menopause and the finding that menopausal hormone therapy (MHT) lowers the incidence of diabetes. Experimental data suggest that estrogen has anti-atherosclerotic and pro-thrombotic properties. This is consistent with observational and interventional studies suggesting that MHT reduces the risk of cardiovascular disease if initiated early in women with a low-risk profile, but might increase risk in older women and/or those with other risk factors (e.g. dyslipidemia). Future research focusing on improving prevention of cardiometabolic disease through MHT may help to identify agents with higher tissue- and estrogen receptor-isoform specificity than currently used hormones.

Gender-specific care of diabetes mellitus: particular considerations in the management of diabetic women

In the past 30 years, the all-cause mortality and cardiovascular mortality rates for women with diabetes mellitus (DM), in contrast to men, have not declined. Furthermore, the difference between all-cause mortality rates in women with DM and those without DM has more than doubled. This urgently needs addressing. This review will analyse published medical literature relating to the specific management of DM in women and try to identify areas where gender affects care. We have identified specific gender differences in the pathophysiology of glucose homeostasis disorder, diabetes-related complications and any female gender-specific features of women with diabetes, such as contraception and the menopause. These gender-specific features of DM may offer a route to improved care for women and new therapeutic possibilities.

Postmenopausal hormone therapy and cardiovascular disease in perspective

The totality of data indicate that the window of opportunity for reducing mortality and coronary heart disease is initiation of hormone therapy (HT) within 6 years of menopause and/or by 60 years of age and continued for 6 years or more. Additionally, the risks of HT are rare (<1/1000) especially in younger postmenopausal women and comparable with other primary prevention therapies. In fact, as randomized controlled trial results accumulate, the more they look like the consistent observational data. These studies showed that young postmenopausal women with menopausal symptoms who use HT for long periods of time have lower rates of mortality and coronary heart disease than comparable postmenopausal women who do not use HT.

Estrogen and progestogen use in postmenopausal women: July 2008 position statement of The North American Menopause Society

OBJECTIVE

: To update for both clinicians and the lay public the evidence-based position statement published by The North American Menopause Society (NAMS) in March 2007 regarding its recommendations for menopausal hormone therapy (HT) for postmenopausal women, with consideration for the therapeutic benefit-risk ratio at various times through menopause and beyond.

DESIGN

: An Advisory Panel of clinicians and researchers expert in the field of women's health was enlisted to review the March 2007 NAMS position statement, evaluate new evidence through an evidence-based analysis, and reach consensus on recommendations. The Panel's recommendations were reviewed and approved by the NAMS Board of Trustees as an official NAMS position statement. The document was provided to other interested organizations to seek their endorsement.

RESULTS

: Current evidence supports a consensus regarding the role of HT in postmenopausal women, when potential therapeutic benefits and risks around the time of menopause are considered. This paper lists all these areas along with explanatory comments. Conclusions that vary from the 2007 position statement are highlighted. Addenda include a discussion of risk concepts, a new component not included in the 2007 paper, and a recommended list of areas for future HT research. A suggested reading list of key references is also provided.

CONCLUSIONS

: Recent data support the initiation of HT around the time of menopause to treat menopause-related symptoms; to treat or reduce the risk of certain disorders, such as osteoporosis or fractures in select postmenopausal women; or both. The benefit-risk ratio for menopausal HT is favorable close to menopause but decreases with aging and with time since menopause in previously untreated women.

Adipose tissue, insulin resistance and low-grade inflammation: implications for atherogenesis and the cardiovascular harm of estrogen plus progestogen therapy

OBJECTIVE

To summarize recent findings providing mechanistic insight into why the relative presence of central to peripheral fat mass is a critical determinant of atherogenesis and why postmenopausal women with android obesity represent a risk population with increased susceptibility to the cardiovascular harm of estrogen plus progestin therapy (EPT).

METHODS

Review of own research and related literature in PubMed.

RESULTS

In postmenopausal women, android obesity characterized by excessive upper-body combined with relatively poorly developed lower-body fat mass is frequently associated with insulin resistance, low-grade inflammation, and early atherosclerosis. Underlying mechanisms involve disequilibrium between proinflammatory cytokines (high interleukin-6/C-reactive protein) and the anti-inflammatory adipokine (low adiponectin). Recent findings point out that women with abnormal glucose tolerance, a metabolic alteration closely linked to android adiposity, respond with increases in low-grade inflammation and accelerated atherogenesis to EPT that collectively may promote acute complications. We recently pointed out that a progestin could exert a dose-dependent inhibitory effect on circulating adiponectin. Thus, when EPT is prescribed to women with android obesity, further decreases in the protective adiponectin pool may become critical and act as a promoter of thromboembolic complications via its effects on plaque formation and stability. Since android obesity is associated with the highest levels of free estradiol, women with this phenotype might not be trivial candidates for EPT.

CONCLUSIONS

The herein summarized findings shed light on important interactions between sex steroids and body fat mass, with functional implications for cardiovascular risk. Since previous trials have not optimized the dose of the progestin for its effect on circulating adiponectin, utmost caution should be exercised in the prescription of available estrogen plus progestin therapies to women with android obesity and/or symptoms of the insulin resistance syndrome.

Hormone therapy and cardiovascular disease

As in other Western countries, cardiovascular disease (CVD) is the leading cause of death among women in Taiwan, exceeding the mortality from cervical or breast cancer. Women generally present with CVD after menopause and later than men, since menopause-related estrogen deficiency has been considered to be associated with an increased risk for CVD. Thus, coronary artery diseases and stroke are the two main contributors of mortality among postmenopausal women. Observational studies have reported a reduction in coronary artery disease risk after hormone therapy (HT) ranging from 31-44%. However, recent randomized controlled trials that evaluated the effect of HT on primary and secondary CVD prevention have questioned the efficacy of HT, despite confirming the lipid-lowering effect of estrogen. However, a cluster of factors are responsible for the genesis and progression of CVD. Until we further evaluate their specific actions and how these different factors interact, the issue related to HT and cardiovascular risk will remain unsettled. Since these studies have contributed to our understanding of the benefits and risks associated with HT, HT use should be individualized after consideration of the condition of each postmenopausal patient. Ideally, the efficacy of different preparations and dosages of HT in postmenopausal women who are at risk of CVD, before atheromatous lesions have developed, should be investigated.

Effects of low-dose continuous combined hormone replacement therapy on glucose homeostasis and markers of cardiovascular risk in women with type 2 diabetes

BACKGROUND

Low-dose hormone replacement therapy (HRT) has attracted interest for the treatment of postmenopausal symptoms in diabetes because of concerns about increased risk of coronary heart disease (CHD) and stroke with conventional HRT containing conjugated equine oestrogens (CEEs) and medroxyprogesterone acetate (MPA).

OBJECTIVES

We assessed the effects on glucose homeostasis and cardiovascular risk factors of continuous oral 17beta oestradiol (1 mg) and norethisterone (0.5 mg) in postmenopausal women with type 2 diabetes.

DESIGN

Double-blind, randomized placebo-controlled trial.

ASSESSMENTS

Hyperinsulinaemic isoglycaemic clamp and cardiovascular risk factors were assessed before and after 3 months of treatment.

RESULTS

Twenty-eight women completed the study. HRT decreased fasting glucose compared with placebo [-9.4% with HRT vs.+2.3% for placebo, 95% confidence interval (CI) -23.2 to -0.3] and total cholesterol (-13.7 vs.+1.0%, 95% CI -22.4 to -3.1%) No significant effect was seen on metabolic clearance rate of glucose, glycated haemoglobin (HbA1c), triglycerides, high density lipoprotein (HDL)-cholesterol or C-reactive protein (CRP).

CONCLUSIONS

In women with type 2 diabetes, low-dose HRT decreased fasting glucose and total cholesterol without detectable adverse effects on glucose clearance, triglycerides and CRP as reported with conventional HRT.

[Hormone replacement therapy for internal risk patients]

Using hormone replacement therapy (HRT), absolute and relative contradictions have to be considered, which are primarily classified according to a "worst case" scenario on the assumption of group effects, in order to satisfy forensic demands. However, in patients with severe complaints it make sense to apply HRT even at increased risk. To minimize the risk, a differentiated choice of the preparation especially in terms of progestin component and application mode is feasible apart from a general dose reduction. For internal risk patients, transdermal estradiol in a patch or gel and neutral progestins like progesterone and dydrogesterone or combination patches for a completely transdermal HRT are to be preferred. In the Women's Health Initiative, a study investigating a population strongly burdened with cardiovascular risks, the most important risks were venous thromboses and strokes, in old age also myocardial infarctions. In this context, the risk groups with diabetes, hypertension and dyslipoproteinemia as well as smokers in general are of particular importance. Other common internal risk groups comprise women with thyroid and hepatobiliary diseases. Rare but prognostically important diseases such as porphyria and lupus erythematosus are considered as relative contraindications. The available data on these risk groups are described and practical recommendations are given.

Conventional-dose hormone therapy (HT) and tibolone, but not low-dose HT and raloxifene, increase markers of activated coagulation

OBJECTIVES

Hormone therapy (HT) is associated with a modest, but significantly increased risk for arterial and venous thromboembolism. We have compared the effects of estrogen, tibolone, and raloxifene on relevant markers of coagulation activation and investigated whether there is a dose-response relationship of oral HT.

METHODS

Randomized, open-label, comparative study of 202 healthy women who were assigned to receive treatment for 12 weeks with either low-dose hormone therapy containing 1 mg 17beta-estradiol + 0.5 mg norethisterone acetate (NETA) (n=50), conventional-dose HT containing 2 mg 17beta-estradiol and 1 mg NETA (n=50), 2.5 mg tibolone (n=51), or 60 mg raloxifene (n=51).

RESULTS

The groups were comparable with regard to demographic characteristics and laboratory variables at baseline. D-dimer increased markedly in the conventional-dose HT group, but remained unchanged in the low-dose HT group. Tibolone was associated with a medium increase, whereas raloxifene was associated with a decrease in D-dimer levels. Changes in prothrombin fragment 1 + 2 showed a similar pattern for all four groups, whereas no significant differences in changes of thrombin-antithrombin complex were observed.

CONCLUSIONS

Our data suggest that low-dose HT is associated with less activation of coagulation than conventional-dose HT. This finding may be of clinical importance since randomized clinical trials showing increased risk of thrombosis have utilized conventional-dose HT.

Hormone replacement therapy and risk of acute myocardial infarction : a review of the literature

Many animal studies and studies on intermediate clinical endpoints have shown hormone replacement therapy (HRT) to be associated with both favourable and unfavourable cardiovascular effects. We reviewed the literature regarding HRT and the distinct endpoint of acute myocardial infarction (AMI) in peri- and postmenopausal women. Searches of the MEDLINE and EMBASE databases were conducted. Fifty papers were identified as eligible for inclusion: eight randomised controlled trials, 18 cohort studies, 23 case-control studies and one case-control and cohort study. The single large primary prevention randomised controlled trial on HRT and the risk of AMI in generally healthy women (Women's Health Initiative trial) reported a small yet significantly increased risk of AMI in postmenopausal women receiving combined HRT. This contrasts with a large number of observational studies that suggested a protective effect, although in many of these studies the results were not statistically significant. Inconclusive evidence on the effect of duration of use does not support the notion that a possible protective association is causal. Detection bias and residual confounding are alternative explanations for the associations observed in the randomised controlled trial and observational studies. No studies on groups of women with existing cardiovascular disease or with diabetes mellitus, including the only large secondary prevention trial (Heart and Estrogen/Progestin Replacement Study), reported a significant change in AMI risk between HRT users and non-users. There is insufficient evidence to suggest that HRT is associated with a change in the risk of AMI in the majority of women. However, certain subgroups of women with specific genetic polymorphisms may be more susceptible to a change in the risk of AMI with HRT use.

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.

Hormone therapy in the WHI era

The announcement in July 2002 in the media of the results of the combined continuous hormone treatment arm of the Women's Health Initiative (WHI) had a profound effect on perceptions about hormone therapy among the lay public and the medical profession. Careful scrutiny of the announcement and the subsequent publications leads to the conclusion that the widespread fear of hormone therapy that was generated was not supported by the facts. WHI was not designed to be, nor can it be, interpreted as a randomised controlled trial of menopausal hormone therapy--rather, it was a trial of chronic disease prevention, particularly aimed at the possible cardiovascular benefits of a specific combination hormone therapy in postmenopausal women. The results, which were consistent with existing data, did not and do not warrant any major change in the previously established guidelines for the use of hormone therapy. Tibolone has emerged as an alternative treatment for menopausal symptoms, but its long-term benefits and risks have yet to be documented.

Consequences of menopause in women with diabetes mellitus - a clinical problem

Human life was prolonged by 30 years in the past century, with the result that about 40% of a woman's life falls within the postmenopausal period. The consequences, both early and remote, in the form of cardiovascular disease, osteoporosis and neoplastic disease are most pronounced in women suffering from one of the most common diseases, i.e., diabetes mellitus and the metabolic syndrome preceding it. These patients are problematic for physicians, and for this reason a study of diagnostic and therapeutic management was undertaken on the basis of our own experience as well as examination based on evidence-based medicine. Prior to making therapeutic decisions it is necessary to determine cardiovascular, thromboembolic and breast cancer risk factors. Hormonal therapy may be helpful in young postmenopausal women who are free of risk factors, and its composition and route of administration are significant considerations. Women with risk factors and who are more than 10 years after menopause should be administered alternative therapy depending on the diagnosed pathology.

Bridging advanced glycation end product, receptor for advanced glycation end product and nitric oxide with hormonal replacement/estrogen therapy in healthy versus diabetic postmenopausal women: A perspective

Cardiovascular diseases (CVD) are the most significant cause of death in postmenopausal women. The loss of estrogen biosynthesis with advanced age is suggested as one of the major causes of higher CVD in postmenopausal women. While some studies show beneficial effects of estrogen therapy (ET)/hormonal replacement therapy (HRT) in the cardiovascular system of healthy postmenopausal women, similar studies in diabetic counterparts contradict these findings. In particular, ET/HRT in diabetic postmenopausal women results in a seemingly detrimental effect on the cardiovascular system. In this review, the comparative role of estrogens is discussed in the context of CVD in both healthy and diabetic postmenopausal women in regard to the synthesis or expression of proinflammatory molecules like advanced glycation end products (AGEs), receptor for advanced glycation end products (RAGEs), inducible nitric oxide synthases (iNOS) and the anti-inflammatory endothelial nitric oxide synthases (eNOS). The interaction of AGE-RAGE signaling with molecular nitric oxide (NO) may determine the level of reactive oxygen species (ROS) and influence the overall redox status of the vascular microenvironment that may further determine the ultimate outcome of the effects of estrogens on the CVD in healthy versus diabetic women.

Effects of postmenopausal hormone therapy every day and every other day on lipid levels according to difference in body mass index

OBJECTIVE

The objective of this study was to determine the effects of postmenopausal estrogen and progestogen therapy (EPT) every day and every other day on lipid levels, particularly triglyceride (TG) levels, according to difference in body mass index (BMI).

DESIGN

Ninety-nine postmenopausal women (mean age, 53.9 +/- 5.6 years; mean BMI, 22.8 +/- 2.8 kg/m) were randomly treated with EPT every other day or every day for 1 year. Fifty women received oral administration of 0.625 mg of conjugated equine estrogen (CEE) and 2.5 mg of medroxyprogesterone acetate (MPA) every other day, and 49 women received oral administration of 0.625 mg of CEE and 2.5 mg of MPA every day. Blood samples were collected at baseline and after 1 year of therapy for measurement of fasting TG, total cholesterol, high-density lipoprotein-cholesterol (HDL-C), and apolipoproteins. Data from 88 of the 99 postmenopausal women were used for analysis.

RESULTS

In women whose BMI was 25 kg/m or higher, TG levels during EPT every day increased by 26.8%, while TG levels during EPT every other day decreased by 12.3%. There was a significant (P < 0.05) difference between percentage changes in TG during EPT every day and every other day. In women whose BMI was less than 25 kg/m, TG levels during EPT every day increased by 21.7%, while during EPT every other day TG levels did not change. The mean levels of estradiol during EPT every day in women whose BMI was less than 25 kg/m and in women whose BMI was 25 kg/m or higher were 28.5 and 38.7 pg/mL, respectively, the difference between these levels was significant (P < 0.01). On the other hand, there was no significant difference between levels of estradiol during EPT every other day in these two BMI groups.

CONCLUSIONS

Triglyceride levels during EPT every day with conventional doses of CEE and MPA increased more in overweight and obese postmenopausal women in association with increased estrogen levels.

The therapeutic role of estrogens in postmenopausal women

This article reviews the history and present use of estrogens for the treatment of menopausal symptoms. It includes management of several different cases, including a review of all estrogens and estrogen/progestin preparations available in the United States.

Hormone Therapy and Selective Estrogen Receptor Modulators for Prevention of Coronary Heart Disease in Postmenopausal Women

Coronary heart disease is the leading cause of morbidity and mortality in women older than the age of 50 in the United States today. Traditional cardiovascular risk factors (hyperlipidemia, glucose intolerance, and hypertension) are more clearly associated with significant cardiovascular risk after menopause. The increased incidence of cardiovascular events in postmenopausal women and the evidence that cardiovascular disease on average manifests a decade later in women compared with men suggests that estrogen deficiency may predispose women to a higher cardiovascular risk. Numerous biologic mechanisms have been proposed that relate use of hormone therapy (HT) to improved lipid profiles, insulin sensitivity, and vascular reactivity. Early observational trials in the last 2 decades showed a significant decrease in cardiovascular events. Recently published randomized clinical trial results, however, have led to uncertainty about the earlier established cardiovascular benefits of HT. To complicate issues further, alternative estrogenlike compounds, selective estrogen receptor modulators, are being introduced that appear to convey similar cardiovascular benefit and notably less cancer risk than HT. The newly released randomized trials on hormone and nonhormonal agents are reviewed.

Effects of low-dose continuous combined HRT on vascular function in women with type 2 diabetes

BACKGROUND

Improvement in vascular endothelial function is widley cited as a beneficial effect of hormone replacement therapy (HRT). Women with type 2 diabetes (T2DM) are at increased cardiovascular risk and have impaired endothelial function. Any benefits of HRT on endothelial function in this group are of particular interest.

OBJECTIVES

We assessed effects on vascular function of oral 17beta oestradiol (1 mg) and norethisterone (0.5 mg) in postmenopausal women with T2DM.

DESIGN

Double-blind, randomised, placebo-controlled trial.

ASSESSMENTS

Twenty-eight women had pulse wave velocity (PWV) and adhesion molecules VCAM-1 and ICAM-1 assessed before and after three months' treatment. Twenty-four women also had gluteal fat biopsy for assessment of resistance vessel function (using wire myography).

RESULTS

HRT did not affect PWV, VCAM-1, ICAM-1 or carbachol response. Effects of L-NAME and indomethacin on carbachol sensitivity were similar in both groups.

CONCLUSIONS

This HRT preparation had no detectable effect on these measures of endothelial function in women with T2DM.

Novel associations between bioavailable estradiol and adipokines in elderly women with different phenotypes of obesity: implications for atherogenesis

BACKGROUND

Peripheral adiposity confers protection against diabetes and atherosclerosis in elderly women. The underlying mechanisms, however, remain to be elucidated.

METHODS AND RESULTS

On the basis on dual-energy X-ray absorptiometry measurements of central fat mass (CFM) and peripheral fat mass (PFM), we identified 290 elderly women with distinct forms of body fat distribution (lean, peripheral obesity, central obesity, or general obesity). Study parameters were plasma tumor necrosis factor-alpha, interleukin (IL)-6, adiponectin, estradiol, sex hormone-binding globulin, insulin resistance, and aortic calcification, graded on lateral radiography. In peripherally and generally obese women, plasma estradiol and insulin resistance were significantly lower, whereas sex hormone-binding globulin and adiponectin were significantly higher compared with centrally obese women independent of age, body mass index, total fat mass, and smoking habits (all P<0.05). After adjustment for these confounders, IL-6 in centrally obese women was comparable with that seen in generally obese (similar high CFM%) but significantly higher than in peripherally obese women and lean women (low CFM%). Atherosclerosis was less severe in generally obese (2.5+/-0.3) compared with centrally obese women (5.0+/-0.7, P=0.001). In multiple regression analysis, total fat mass, body fat distribution, insulin resistance, estradiol, current smoking, treated hyperlipidemia, and treated hypertension contributed independently to the variation of aortic calcification (R=0.55, SEE=3.60, P<0.001).

CONCLUSIONS

Abundant presence of PFM in generally obese women is associated with increased plasma adiponectin and higher insulin sensitivity, which could explain the apparent protection against the atherogenic effects of IL-6 derived from CFM. Low peripheral exposure to estradiol appears to be a sine qua non of maintained adiponectin secretion from PFM.

Estrogens, lipoproteins, and cardiovascular risk factors: an update following the randomized placebo-controlled trials of hormone-replacement therapy

PURPOSE OF REVIEW

The effects of hormone-replacement therapy on cardiovascular risk factors are examined. In an attempt to explain the results of recent randomized controlled trials in which no benefit of hormone-replacement therapy for postmenopausal women has been observed,

RECENT FINDINGS

Changes in lipoproteins in response to hormone-replacement therapy have now been analysed for both primary and secondary prevention studies. In none of the large randomized controlled trials was there any effect of hormone-induced changes in low-density lipoprotein, high-density lipoprotein, or triglyceride on clinical outcome. Further detailed studies of lipoprotein metabolism have not revealed any adverse effect of hormone-replacement therapy. Recent analysis of the Heart Estrogen/Progestin-Replacement Study data suggests hormone-replacement therapy reduces the risk of developing diabetes. The effect of hormone-replacement therapy on inflammatory markers and on flow-mediated dilatation is largely beneficial, although the effect on flow-mediated dilatation is modulated according to endothelial function, which is adversely affected by known risk factors, including age and presence of atherosclerosis. In this respect the work on polymorphisms of estrogen receptor-alpha may in due course help to define those women who would benefit most from use of estrogen. Crucially, oral but not transdermal hormone-replacement therapy increases activated protein C resistance independently of the presence of factor V Leiden. This effect increases the risk of venous thromboembolic events, which is reflected in the results of a hospital case control study of thromboembolism.

SUMMARY

Despite the outcome of the hormone-replacement therapy trials, recent work has confirmed the putative antiatherogenic effects of hormone-replacement therapy on lipoprotein metabolism. Metabolic differences of route of administration of estrogen, particularly on haemostatic variables, may explain this clinical paradox, which continues to be an important research area.

Should Progestins Be Blamed for the Failure of Hormone Replacement Therapy to Reduce Cardiovascular Events in Randomized Controlled Trials?

Many observational studies and experimental and animal studies have demonstrated that estrogen replacement therapy (ERT) or hormone replacement therapy (HRT) (estrogen plus progestin) significantly reduces the risk of coronary heart disease. Nonetheless, recent randomized controlled trials demonstrated some trends toward an increased risk of cardiovascular events rather than a reduction of risk. Recently, both the HRT and ERT arms of the Women’s Health Initiative (WHI) study were terminated early because of an increased/no incidence of invasive breast cancer, increased incidence of stroke, and increased trend/no protective effects of cardiovascular disease. We discuss the controversial effects of HRT and ERT on cardiovascular system and provide a hypothesis that the failure of HRT and ERT in reducing the risk of cardiovascular events in postmenopausal women might be because of the stage of their atherosclerosis at the time of initiation of HRT or ERT.

[Hormone therapy in menopause. A current update]

While the use of hormone replacement therapy (HRT) for prophylactic indications such as cardiovascular disease, osteoporosis, and Alzheimer's disease was increasingly propagated during the 1990s, recent studies have reported no risk reduction for women after myocardial infarction (HERS) or women from a mixed population with an average age of 63 years (Women's Health Initiative [WHI] Study). The results of the latter study even suggest an increased risk for cardiovascular events and breast cancer with previous or ongoing combined oral estrogen plus progestin. A final risk-benefit assessment for estrogen monotherapy will only be possible after the ongoing part of the WHI Study has been evaluated, expected in 2005. As effects, side effects, and contraindications for HRT in postmenopausal women are better known, the need for individualized risk assessment and the definition of therapeutic goals increases. Since the WHI Study did not address the risk-benefit ratio for women with perimenopausal complaints or osteoporosis or with lower dose hormone preparations commonly used in Germany, there is an urgent need to answer these open questions with large confirmative studies.

Preventing cardiovascular events in patients with diabetes mellitus

Diabetes mellitus and obesity are becoming increasingly prevalent in the United States. Patients with diabetes are 2 to 3 times more likely to develop cardiovascular disease (CVD) than are individuals without diabetes, but proper diabetes management and metabolic control can reduce this risk. Nonpharmacologic interventions, such as diet and exercise, can help to reduce weight and control insulin resistance, blood glucose levels, and lipid abnormalities, thereby lowering the risk of adverse cardiovascular outcomes. However, diet and exercise can provide particular challenges for the patient with diabetes. Antiobesity drugs, such as sibutramine and orlistat, can help individuals with diabetes lose weight and can have some effect on metabolic control. Alcohol use and hormone replacement therapy are still controversial topics with regard to reducing the risk of CVD. Smoking is known to be particularly dangerous for those with diabetes, and it is important for health care providers to help their patients stop smoking. Early and aggressive intervention in treating risk factors can reduce the risk of developing diabetes and prevent CVD in the patient with diabetes.

Effect of Lower Dosage of Oral Conjugated Equine Estrogen on Inflammatory Markers and Endothelial Function in Healthy Postmenopausal Women

Objective— Although oral estrogen replacement therapy (ERT) in postmenopausal women improves endothelial function, it also increases plasma C-reactive protein (CRP) and interleukin-6 (IL-6) concentration. The proinflammatory effect of oral ERT may explain the increased risk of coronary heart disease (CHD) associated with this treatment. Recent observational studies have demonstrated that a lower dose of oral estrogen reduces the risk for CHD. The purpose of the present study was to investigate the effects of low-dose oral estrogen on vascular inflammatory markers and endothelium-dependent vasodilation in postmenopausal women.

Methods and Results— Postmenopausal women were randomized into 3 groups to receive no treatment (n=14) or oral conjugated equine estrogen (CEE) at a dosage of 0.625 mg (n=15) or 0.3125 mg (n=15) daily for 3 months. CEE at a dosage of 0.625 mg resulted in significant increases in plasma concentrations of CRP from 690.9±749.5 to 1541.9±1608.0 ng/mL, serum amyloid A from 6.12±4.15 to 8.25±4.40 μg/mL, and IL-6 from 1.45±0.73 to 2.35±1.16 pg/mL. In contrast, CEE at a dosage of 0.3125 mg had no effect on these inflammatory markers. Both dosages of estrogen significantly decreased E-selectin concentration, whereas the concentrations of intercellular and vascular cell adhesion molecules remained unchanged. In both CEE groups, flow-mediated vasodilation in the brachial artery was increased significantly, whereas nitroglycerine-induced vasodilation was unaltered.

Conclusions— Oral CEE at a low dose of 0.3125 mg in postmenopausal women eliminated the adverse effects of high-dosage oral CEE on vascular inflammatory markers in addition to preserving the favorable effects of estrogen on cell adhesion molecules and endothelial function.

Metabolic, inflammatory and haemostatic effects of a low-dose continuous combined HRT in women with type 2 diabetes: potentially safer with respect to vascular risk?

BACKGROUND

Conventional hormone replacement therapy (HRT) containing conjugated equine oestrogen (CEE) and medroxyprogesterone acetate (MPA) increases triglyceride, C-reactive protein (CRP) and coagulation Factor VII concentrations, potentially explaining their increased coronary heart disease (CHD) and stroke risk.

OBJECTIVE

To assess the metabolic effects of a continuous combined HRT containing 1 mg oestradiol and 0.5 mg norethisterone or matching placebo.

DESIGN

Double-blind, randomized placebo-controlled trial.

PATIENTS

Fifty women with type 2 diabetes.

MEASUREMENTS

Classical and novel risk factors for vascular disease.

RESULTS

Triglyceride concentration was not altered (P = 0.31, change in active arm relative to placebo) and low-density lipoprotein (LDL) cholesterol concentration declined 13% (P = 0.018). IL-6 concentration (mean difference -1.42 pg/ml, 95% CI: -2-55 to -0-29 IU/dl, P = 0.015), Factor VII (-32 IU/dl, -43 to -21 IU/l, P < 0.001) and tissue plasminogen activator antigen (by 13%, P = 0.005) concentrations fell, but CRP was not significantly altered (P = 0.62). Fasting glucose (P = 0.026) also declined significantly, but there are no significant effects on HBA1c, Factor IX or APC resistance.

CONCLUSIONS

HRT containing 1 mg oestradiol and 0.5 mg norethisterone may avoid the adverse metabolic effects potentially implicated in the elevated CHD and stroke risk induced by conventional higher dose HRT. This type of preparation may therefore be more suitable than conventional HRT for women at elevated CHD risk such as those with type 2 diabetes. Large randomized controlled trials of such low dose preparations, powered for cardiovascular end points, are now needed.

Association between estrogen receptor alpha gene variation and cardiovascular disease

CONTEXT

Estrogen and related hormone therapies activate estrogen receptors, which in turn regulate genes for several cardiovascular disease (CVD) risk factors. Relatively little is known, however, about the impact of genetic variation in estrogen receptor alpha (ESR1) on CVD risk.

OBJECTIVE

To investigate whether the ESR1 c.454-397T>C polymorphism is associated with CVD risk.

DESIGN, SETTING, AND PARTICIPANTS

Prospective study of 1739 unrelated men and women from the population-based offspring cohort of the Framingham Heart Study, who were followed up from 1971 to 1998.

MAIN OUTCOME MEASURES

Total atherosclerotic CVD events, defined as recognized or unrecognized myocardial infarction (MI), angina pectoris, coronary insufficiency, intermittent claudication, coronary heart disease death, or atherothrombotic stroke (n = 178); major atherosclerotic CVD, defined as recognized acute MI, coronary insufficiency, coronary heart disease death, or atherothrombotic stroke (n = 83); and recognized acute MI (n = 59).

RESULTS

Twenty percent of participants (n = 352) were homozygous for the ESR1 c.454-397C allele. After adjustment for covariates (age, sex, body mass index, hypertension, diabetes mellitus, total cholesterol, high-density lipoprotein cholesterol, and cigarette smoking), the CC genotype was significantly associated with major atherosclerotic CVD, with an odds ratio of 2.0 (95% confidence interval [CI], 1.3-3.2; P =.004) compared with individuals with the CT or TT genotypes. Participants with the CC genotype had 3.0-fold greater odds of MI (95% CI, 1.7-5.2; P<.001) compared with those with the CT or TT genotype. The results remained significant when analyses were restricted to men; too few women had events to study them separately.

CONCLUSIONS

Individuals with the common ESR1 c.454-397CC genotype have a substantial increase in risk of MI. Whether ESR1 c.454-397T>C is causally related to MI risk or in linkage disequilibrium with 1 or more causal variants remains to be determined. These findings support the importance of estrogen receptors in CVD susceptibility, especially in men. Estrogen receptor variation also has potential to explain recent conflicting data regarding the effects of hormone therapy on CVD susceptibility in women.

Fortschritte in der Prävention des Typ-2-Diabetes

Type 2 diabetes mellitus is a major health problem associated with excess morbidity and mortality. Defects in the action and/or secretion of insulin are the two major abnormalities leading to development of glucose intolerance. Any intervention in the impaired glucose tolerance phase that reduces resistance to insulin or protects the beta-cells, or both, should prevent or delay progression to diabetes. The natural history of type 2 diabetes includes a preceding period of impaired glucose tolerance (IGT)/impaired fasting glucose (IFG) which provides an opportunity for targeted intervention within large communities. As the prevalence of this metabolic disorder is rapidly increasing and current treatment fails to stabilise the disease in most patients, prevention should be considered as a key objective in the near future. Lifestyle intervention studies have consistently shown that quite modest changes can reduce the progression from IGT to diabetes by 50-60%. The Diabetes Prevention Program (DPP) randomised trial has shown that a combined program of weight loss, improvement of diet and increase of physical exercise lowers the risk for development of type 2 diabetes by 58% compared with placebo. It may, however, not be possible to translate these successful findings to larger cohorts or maintain the lifestyle changes longer term. This has lead to consideration of pharmacotherapy. Benefits have been found for metformin, acarbose and troglitazone. Treatment with metformin was less effective than lifestyle modifications, resulting in an average reduction of risk for development of type 2 diabetes by 31% compared with placebo. Similarly, acarbose in the STOP-NIDDM trial reduced the risk of developing type 2 diabetes in patients with IGT by 25%. Remarkably, cardiovascular event rates, in particular myocardial infarction, were significantly reduced when acarbose was used instead of placebo in subjects with glucose intolerance. The ACE inhibitors captopril (CAPPP) or ramipril (HOPE) and the Angiotensin-II receptor antagonist losartan (LIFE) have been shown to reduce the appearance of diabetes by one third when given to patients with hypertension. Since many hypertensive patients are insulin-resistant and have an increased risk in developing type 2 diabetes, the protective effect of these classes of antihypertensive drugs might be explained by their antiinsulin-resistance effects.

Estrogen therapy and risk of cardiovascular events among women with type 2 diabetes

OBJECTIVE

To evaluate the association between estrogen therapy and cardiovascular disease risk among women with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A retrospective, case-cohort study was conducted among 6017 women aged 45-80 years with type 2 diabetes from 1 January 1986 to 31 December 1992 at the Group Health Cooperative in Washington state. Cardiovascular outcomes, including nonfatal myocardial infarction (n = 215), coronary revascularization (n = 253), and cardiovascular deaths (n = 229), were ascertained through 31 December 1998. Use of estrogen and progestin was derived from automated pharmacy records and modeled as a time-dependent variable. Median follow-up was 6.8 years. Multivariable-adjusted relative risk (RR) and 95% CI were calculated using Cox proportional hazard models for case-cohort analyses.

RESULTS

Current use of estrogen with (RR 0.43, 95% CI 0.22-0.85) or without (0.48, 0.30-0.78) progestin was associated with a decreased risk of cardiovascular events compared with never having used estrogen. Risk of cardiovascular events associated with a first episode of estrogen use (with or without progestin) of <25 months' duration (1.12, 0.49-2.54), first episode of use >or=25 months' duration (0.32, 0.06-1.70), and current use that was not the first episode of use (0.42, 0.42-0.67) indicated that recent initiation was not associated with an increase or decrease in risk.

CONCLUSIONS

These results show an association of estrogen therapy, with or without progestin, with decreased risk of cardiovascular events among women with type 2 diabetes. This association should be further investigated in large randomized, controlled trials.

Effect of lower dose of oral conjugated equine estrogen on size and oxidative susceptibility of low-density lipoprotein particles in postmenopausal women

BACKGROUND

Estrogen replacement therapy (ERT) has an antioxidant effect that opposes the oxidation of LDL. Oral ERT-induced increases in plasma triglyceride, however, are associated with decreased LDL size, which may counteract this antioxidant effect. Because lower doses of oral estrogen do not affect plasma triglyceride concentrations, LDL size might not change, and the antioxidant effect of estrogen might be preserved. We investigated whether a lower dose of oral estrogen could eliminate the adverse effects of high-dose oral ERT on the size and oxidative susceptibility of LDL in postmenopausal women.

METHODS AND RESULTS

Postmenopausal women received no treatment or were treated with oral conjugated equine estrogen (CEE) 0.625 or 0.3125 mg/d for 3 months. CEE at a dose of 0.625 mg/d significantly increased plasma triglyceride concentrations and decreased LDL diameter, but the concentrations of LDL-derived thiobarbituric acid reactive substances (TBARS) and lag time for conjugated diene formation did not change. In contrast, 0.3125 mg of CEE did not affect plasma triglyceride concentrations or LDL diameter and significantly decreased LDL-derived TBARS concentrations and significantly prolonged LDL lag time. Estrogen-induced changes in LDL diameter correlated negatively with changes in plasma triglyceride (r=-0.44, P<0.01) and LDL-derived TBARS (r=-0.57, P<0.001) but positively with changes in LDL lag time (r=0.42, P<0.01).

CONCLUSIONS

Because oral CEE at a dose of 0.3125 mg/d does not elevate plasma triglyceride, resulting in unchanged size of LDL particles that are resistant to oxidation, the antioxidant effect of estrogen can be preserved.