Molecular portrait of the progestagenic and estrogenic actions of tibolone: behavior of cellular networks in response to tibolone

Estrogenic regulation of skeletal muscle proteome: a study of premenopausal women and postmenopausal MZ cotwins discordant for hormonal therapy

Female middle age is characterized by a decline in skeletal muscle mass and performance, predisposing women to sarcopenia, functional limitations, and metabolic dysfunction as they age. Menopausal loss of ovarian function leading to low circulating level of 17β‐estradiol has been suggested as a contributing factor to aging‐related muscle deterioration. However, the underlying molecular mechanisms remain largely unknown and thus far androgens have been considered as a major anabolic hormone for skeletal muscle. We utilized muscle samples from 24 pre‐ and postmenopausal women to establish proteome‐wide profiles, associated with the difference in age (30–34 years old vs. 54–62 years old), menopausal status (premenopausal vs. postmenopausal), and use of hormone replacement therapy (HRT; user vs. nonuser). None of the premenopausal women used hormonal medication while the postmenopausal women were monozygotic (MZ) cotwin pairs of whom the other sister was current HRT user or the other had never used HRT. Label‐free proteomic analyses resulted in the quantification of 797 muscle proteins of which 145 proteins were for the first time associated with female aging using proteomics. Furthermore, we identified 17β‐estradiol as a potential upstream regulator of the observed differences in muscle energy pathways. These findings pinpoint the underlying molecular mechanisms of the metabolic dysfunction accruing upon menopause, thus having implications for understanding the complex functional interactions between female reproductive hormones and health.

Levels of Tibolone and Estradiol and their Nonsulfated and Sulfated Metabolites in Serum, Myometrium, and Vagina of Postmenopausal Women Following Treatment for 21 Days With Tibolone, Estradiol, or Estradiol Plus Medroxyprogestrone Acetate

Tibolone has estrogenic effects on the vagina but not on the uterus. To explain this, levels of tibolone and estradiol and their metabolites were determined in serum, myometrium, and vagina. Thirty-four postmenopausal women with uterine prolapse received either no treatment, tibolone, E(2) or E(2) + medroxyprogesterone acetate (MPA) for 21 days, or a single dose of tibolone. Twenty +/- 6 hours after administration, >98% of the 3-hydroxytibolone metabolites in serum and tissues were disulfated. Of the unconjugated metabolites, the estrogenic 3alpha-hydroxytibolone predominated in serum, whereas the progestagenic/ androgenic Delta(4)-tibolone predominated in myometrium and vagina. Levels of disulfated metabolites in serum and tissues were higher (3- to 5-fold) after multiple dosing than after a single dose. Tissue:serum ratios were <1, except for Delta(4)-tibolone. In all groups, E(2) tissue levels were higher than serum levels; the percentage of serum E(1)S was >90%. Tibolone did not affect endogenous E(1), E(2), or E(1)S levels in serum, but in myometrium and vagina, E(1) levels were significantly higher and E(1)S levels tended to be lower than in controls. Serum and tissue levels of endogenous and exogenous E(1), E(2), and E(1)S were markedly increased 20 hours after E(2) or E(2) + MPA; the percentage of E(1)S and tissue:serum ratios were not affected. MPA had no effect on the degree of sulfation of E(1). Compared with serum, tissue levels of E(2) were high in all groups; absolute E(2) levels in control and tibolone groups were much lower than in the E(2) groups. Tibolone metabolite patterns are different in serum, myometrium, and vagina.

Progestagenic Effects of Tibolone are Target Gene—Specific In Human Endometrial Cells

OBJECTIVES

Tibolone (Tib) exhibits progestagenic activities in addition to its tissue-specific estrogenic activities. The purpose of the current study was to determine the progestagenic actions of Tib and its metabolites using target genes known to be regulated by progestins in human endometrial glandular and stromal cells.

METHODS

Human endometrial glandular and stromal cells were isolated from endometrial tissue fragments and separately incubated with Tib and its metabolites. Real-time polymerase chain reaction (PCR) was used to determine the mRNA content of 17betahydroxy steroid dehydrogenase (17betaHSD, type 2) and sulfotransferase (SULT1E1) in endometrial glandular cells, and prolactin (PRL) and insulin-like growth factor binding protein-1 (IGFBP1) in endometrial stromal cells.

RESULTS

In glandular cells, Tib and Delta4-tibolone (Delta4Tib) significantly increased the content of 17betaHSD and SULT1E1 mRNA. In stromal cells, Tib and Delta4Tib increased PRL mRNA ( approximately 30% of the capacity compared to progesterone) and had little effect on IGFBP1 mRNA. Anti-progestin, RU486, reversed the induction of SULT1E1 and PRL by progesterone or Tib. Also, the two 3 hydroxyl tobolone metabolites, especially 3betaOHTib, showed some progestagenic effects.

CONCLUSIONS

The data showed that Tib and Delta4Tib exhibited clear progestagenic effects in endometrial glandular cells by inducing 17betaHSD and SULT1E1, while in stromal cells the response was weaker in the induction of PRL and had little effect on IGFBP1. In addition, the 3betaOHTib metabolite expressed progestagenic activity. These disparate effects in two types of cells may be beneficial for maintaining endometrial cells in a quiescent state.

Estradiol and progesterone exhibit similar patterns of hepatic gene expression regulation in the bovine model

Female sex steroid hormones, estradiol-17β (E2-17β) and progesterone (P4) regulate reproductive function and gene expression in a broad range of tissues. Given the central role of the liver in regulating homeostasis including steroid hormone metabolism, we sought to understand how E2-17β and P4 interact to affect global gene expression in liver. Ovariectomized cows (n = 8) were randomly assigned to 4 treatment groups applied in a replicated Latin Square design: 1) No hormone supplementation, 2) E2-17β treatment (ear implant), 3) P4 treatment (intravaginal inserts), and 4) E2-17β combined with P4. After 14 d of treatment, liver biopsies were collected, allowing 28 d intervals between periods. Changes in gene expression in the liver biopsies were monitored using bovine-specific arrays. Treatment with E2-17β altered expression of 479 genes, P4 472 genes, and combined treatment significantly altered expression of 468 genes. In total, 578 genes exhibited altered expression including a remarkable number (346 genes) that responded similarly to E2-17β, P4, or combined treatment. Additional evidence for similar gene expression actions of E2-17ß and/or P4 were: principal component analysis placed almost every treatment array at a substantial distance from controls; Venn diagrams indicated overall treatment effects for most regulated genes; clustering analysis indicated the two major clusters had all treatments up-regulating (172 genes) or down-regulating (173 genes) expression. Thus, unexpectedly, common biological pathways were regulated by E2-17β and/or P4 in liver. This indicates that the mechanism of action of these steroid hormones in the liver might be either indirect or might occur through non-genomic pathways. This unusual pattern of gene expression in response to steroid hormones is consistent with the idea that there are classical and non-classical tissue-specific responses to steroid hormone actions. Future studies are needed to elucidate putative mechanism(s) responsible for overlapping actions of E2-17β and P4 on the liver transcriptome.

In silico pathway analysis: the final frontier towards completely rational drug design

Pathway and network analyses are rapidly becoming the mainstream tools for functional interpretation of high-throughput data and for drug discovery. Current scientific literature has plenty of examples on how pathway analysis tools are used across all steps of drug development pipeline. Pathway and network analyses already enable rational selection of drug targets based on the knowledge about disease biology. Pathway analysis tools are also popular for the analysis of drug action and validation of drug efficacy and toxicity. This article overviews current achievements of pathway analysis and suggests future directions for its application in drug development such as rational design of combinatorial therapy and personalized medicine.

The estrogenic component of tibolone reduces adiposity in female aromatase knockout mice

OBJECTIVE

To explore the effects of tibolone on adiposity in the absence of aromatase and determine which of the hormonal properties of tibolone are exerting these effects.

METHODS

In this study, vehicle; tibolone; estrogenic (ethinyl estradiol [EE]), progestogenic (ORG2058), or androgenic (dihydrotestosterone) compounds; or a combination of ORG2058 + EE was administered to 6-month-old ovariectomized aromatase knockout (ArKO) mice for a period of 6 weeks.

RESULTS

In response to tibolone or EE-alone treatments, omental adipose tissue and infrarenal adipose tissue weights were significantly reduced (P = 0.004 and P = 0.01; P = 0.009 and P = 0.014, respectively) compared with those in ovariectomized and vehicle-treated ArKO mice. In contrast, adipose tissue weight tended to increase after ORG2058-alone treatment. Furthermore, EE in the presence of ORG2058 (ORG2058 + EE group) results in little effect on adiposity when compared with that in ovariectomized and vehicle-treated ArKO mice, showing that ORG2058 can negate the effect of EE. Dihydrotestosterone treatment did not have an impact on adipose tissue mass. Adipocyte volume and numbers followed the same treatment trends.

CONCLUSIONS

In summary, our study in the ArKO mouse has confirmed the efficacy of tibolone as a hormone therapy to reduce adipose tissue accumulation after menopause and also shows that aromatization of tibolone is not required to elicit these estrogenic effects.

Effects of tibolone metabolites on human endometrial cell lines in co-culture

In human endometrium, cell proliferation is regulated by ovarian steroids through heterotypic interactions between stromal and epithelial cells populating this tissue. The authors test the proliferative effects of tibolone and its metabolites using endometrial co-cultures that mimic the normal proliferative response to hormones. They found that both the Delta(4)-tibolone metabolite and the pure progestin ORG2058 counteract estradiol-driven epithelial cell proliferation. Surprisingly, the estrogen receptor binding 3-hydroxyl-metabolites of tibolone also counteracted estradiol-driven proliferation. Inhibition of proliferation by 3beta-OH-tibolone was abrogated by low doses of the progesterone receptor antagonist mifepristone. This suggests that 3beta-OH-tibolone is converted to a progestagenic metabolite. The authors found that the stromal cells used in the co-cultures express high levels of the ketosteroid dehydrogenase AKR1C2, which is able to oxidize 3beta-OH-tibolone back to tibolone. Thus, the unexpected progestagenic effect of 3beta-OH-tibolone in these co-cultures may be due to metabolic activity present in the stromal cells of the co-cultures.

Hormone control and expression of androgen receptor coregulator MAGE-11 in human endometrium during the window of receptivity to embryo implantation

The androgen receptor (AR) is a ligand-activated transcription factor of the male and female reproductive tracts whose activity is modulated by coregulator binding. We recently identified melanoma antigen gene protein-11 (MAGE-11) of the MAGEA gene family that functions as an AR coregulator by binding the AR N-terminal FXXLF motif. Here we report that MAGE-11 is expressed in a temporal fashion in endometrium of normally cycling women. Highest levels of MAGE-11 mRNA and protein occur in the mid-secretory stage, coincident with the window of uterine receptivity to embryo implantation. Studies in human endometrial cell lines together with the hormone profile of the menstrual cycle and pattern of estrogen receptor-alpha expression in cycling endometrium suggest the rise in MAGE-11 mRNA results from down-regulation by estradiol during the proliferative phase and up-regulation by cyclic AMP signaling in the early and mid-secretory stage. In agreement with its coregulatory function, MAGE-11 localizes with AR in glandular epithelial cell nuclei in the mid-secretory stage. The increase in AR protein in the mid-secretory endometrium without an increase in AR mRNA suggests MAGE-11 stabilizes AR in glandular epithelial cell nuclei. This was supported by expression studies at low androgen levels indicating AR stabilization by MAGE-11 dependent on the AR N-terminal transactivation domain. The results suggest that MAGE-11 functions as a coregulator that increases AR transcriptional activity during the establishment of uterine receptivity in the human female.

Pathway analysis software as a tool for drug target selection, prioritization and validation of drug mechanism

One of the major challenges of drug discovery today is the poor understanding of the detailed molecular mechanisms underlying both disease progression and drug action. Insufficient drug specificity and side effects are often discovered during the late stages of drug development, sometimes after the drug is released on the market. These discoveries result in a high target attrition rate, a slow drug design pipeline and high development costs. Recent advances in systems biology and pathway analysis can help make true rational design a reality through the integration of experimental observations with underlying cellular regulation and metabolic networks. It should enable the formulation of better and more informed testable hypotheses with regard to the most efficient target candidates. In this article, the authors overview the broad and heterogeneous field of molecular interaction databases and pathway analysis tools, and the challenges existing in the field. The authors describe and classify different approaches for data acquisition, storage and navigation, give a detailed description of the integrative technology behind the Pathway Studio software solution, and present a comparison with other integrative pathway analysis platforms suitable for drug discovery tasks.

Comparative profiling of the gene expression for estrogen responsiveness in cultured human cell lines

It is important to know the difference as well as the similarity in estrogen responsiveness among cell lines for understanding the effects of estrogenic chemicals. Here, using 120 estrogen responsive genes, we examined comparative expression profiles between the profile in breast cancer MCF-7 cells treated with 17beta-estradiol and the profiles in other cell lines derived from breast (T-47D and HBC-4 cells), endometrium (Ishikawa cells) and kidney (RXF-631L cells) treated with estrogenic chemicals. First, comparative profiling between MCF-7 and T-47D cells showed similar (correlation coefficient or R value=0.49-0.87) profiles for all chemicals examined: 17beta-estradiol, estrone, estriol, diethylstilbestrol, bisphenol A, nonylphenol and genistein. The analysis using other cell lines indicated that significant correlations to the profile in MCF-7 cells treated with 17beta-estradiol were observed for the profiles in Ishikawa cells treated with 17beta-estradiol, diethylstilbestrol and bisphenol A, and HBC-4 cells treated with 17beta-estradiol. The profiles for diethylstilbestrol and bisphenol A in HBC-4 cells and all three chemicals in RXF-631L cells did not show significant correlation with those in MCF-7 cells. Hierarchical cluster analysis revealed that there are cell-specific responses to estrogenic chemicals (T-47D and HBC-4 cells for example). Correlation analysis using six (proliferation, transcription, transport, enzymes, signaling and others) functionally-categorized gene groups indicated that the genes related to enzymes showed greater correlations for all chemicals tested in T-47D cells and some chemicals in Ishikawa and HBC-4 cells while those related to transcription contributed to variations.

Molecular analysis of human endometrium: short-term tibolone signaling differs significantly from estrogen and estrogen + progestagen signaling

Tibolone, a tissue-selective compound with a combination of estrogenic, progestagenic, and androgenic properties, is used as an alternative for estrogen or estrogen plus progesterone hormone therapy for the treatment of symptoms associated with menopause and osteoporosis. The current study compares the endometrial gene expression profiles after short-term (21 days) treatment with tibolone to the profiles after treatment with estradiol-only (E₂) and E₂ + medroxyprogesterone acetate (E₂ + MPA) in healthy postmenopausal women undergoing hysterectomy for endometrial prolapse. The impact of E₂ treatment on endometrial gene expression (799 genes) was much higher than the effect of tibolone (173 genes) or E₂ + MPA treatment (174 genes). Furthermore, endometrial gene expression profiles after tibolone treatment show a weak similarity to the profiles after E₂ treatment (overlap 72 genes) and even less profile similarity to E₂ + MPA treatment (overlap 17 genes). Interestingly, 95 tibolone-specific genes were identified. Translation of profile similarity into biological processes and pathways showed that ER-mediated downstream processes, such as cell cycle and cell proliferation, are not affected by E2 + MPA, slightly by tibolone, but are significantly affected by E₂. In conclusion, tibolone treatment results in a tibolone-specific gene expression profile in the human endometrium, which shares only limited resemblance to E₂ and even less resemblance to E2 + MPA induced profiles.

Regulation of SULT1E1 expression in Ishikawa adenocarcinoma cells by tibolone

Tibolone is used therapeutically as a hormone replacement agent and has beneficial effects on osteoporosis and hot flushes as well as libido in post-menopausal women without stimulatory effects in the breast and endometrium. The lack of effect in the endometrium is due in part to the tissue specific sulfation of tibolone and its active metabolites in endometrial tissues. Tibolone is metabolized into 3alpha-OH and 3beta-OH tibolone as well as the Delta4-isomer. Tibolone and the Delta4-isomer bind and activate progesterone and androgen receptors whereas 3alpha-OH and 3beta-OH tibolone activate the estrogen receptors. Human endometrium and Ishikawa endometrial adenocarcinoma cells express SULT1E1 that efficiently sulfates both 3-OH tibolone metabolites and has trace activity with tibolone but no activity with the Delta4-isomer. Treatment of Ishikawa cells with all four tibolone compounds resulted in the induction of SULT1E1 activity similar to the induction by progesterone. The induction of SULT1E1 was inhibited by RU486 indicating a role for the progesterone receptor. Sulfation of the tibolone compounds by Ishikawa cells and Ishikawa cells expressing physiological levels of SULT1E1 activity resulted in the sulfation of tibolone and the 3-OH metabolites but not Delta4-tibolone. These results indicate that the lack of endometrial stimulation involves induction of SULT1E1 and the selective sulfation and inactivation of the estrogenic 3-OH tibolones and interconversion of the tibolone metabolites to generate the progestagenic non-sulfated Delta4-isomer.

Endometrial cancer patients and tibolone: A matched case–control study

OBJECTIVE

To evaluate whether tibolone had adverse effects on the prognosis of endometrial cancer patients.

METHODS

In this retrospective matched case-control study, out of 396 patients with endometrial cancer from January 1997 to December 2002, 68 patients who underwent complete surgical staging were identified as tibolone users (cases). For each case, one control as tibolone non-user was matched for stage and grade of disease, in this order of priority (ratio users: non-users, 1:1).

RESULTS

There were no significant differences in age (p = 0.11), stage (p = 1.00), grade (p = 0.96) and treatment modality (p = 0.55) between two arms. The mean duration of follow-up for tibolone users and tibolone non-users is 48.0 months and 54.4 months, respectively (p = 0.12). In tibolone users, a total of four patients recurred and two out of four patients died of disease. In tibolone non-users, there were three recurrences and all of three patients died of disease. There were no significant differences in disease free survival (p = 0.52) and overall survival (p = 0.61) between two arms. And there was no significant difference in disease free survival according to the duration of tibolone use (p = 0.14).

CONCLUSION

There was no evidence that tibolone had adverse effects on the disease free survival and overall survival of endometrial cancer patients. So, tibolone could be used in these patients.

Histological and immunohistochemical evaluation of postmenopausal endometrium after 3 weeks of treatment with tibolone, estrogen only, or estrogen plus progestagen

OBJECTIVE

To evaluate histological and immunohistochemical parameters of short-term (21 days) tibolone, estrogen-only, and estrogen+progestagen treatment in the human postmenopausal endometrium.

DESIGN

An observational, open, nonrandomized, controlled study.

SETTING

Three collaborating centers: Amphia Hospital in Breda, Albert Schweitzer Hospital in Dordrecht, Erasmus Medical Center in Rotterdam, the Netherlands.

PATIENT(S)

Thirty healthy, postmenopausal women.

INTERVENTION(S)

Control group (n = 9), no hormonal treatment; tibolone group (n = 8), patients were treated with 2.5 mg of tibolone (administered orally) every day, starting 21 days before surgery; estrogen group (n = 7), patients were treated with 2 mg of E(2) (Zumenon, administered orally; Zambon, Amerfoort; The Netherlands) every day, starting 21 days before surgery; estrogen+progestagen group (n = 6), patients were treated with 2 mg of E(2) (Zumenon, administered orally) and 5 mg of medroxyprogesterone acetate (administered orally) every day, starting 21 days before surgery.

MAIN OUTCOME MEASURE(S)

Uterine tissues were collected, and two pathologists independently assessed histology. Immunohistochemical parameters measured were estrogen receptor alpha, progesterone receptor A/B, Hoxa10, Ki67, and Bcl-2.

RESULT(S)

On the basis of a number of histological and immunohistochemical parameters measured after 21 days of treatment, it was observed that tibolone displays clearly less stimulation (proliferation) of the human postmenopausal endometrium than estrogen at the beginning of a treatment, but the stimulation is higher than with estrogen+progestagen.

CONCLUSION(S)

Short-term (21 days) tibolone treatment results in a small stimulation of proliferation of the endometrium, and because long-term treatment with tibolone has been demonstrated to lead to an atrophic endometrium, it may be concluded that the stimulatory effect, as observed in this study, is transient in nature. It is hypothesized that tibolone first displays a more estrogenic mode of action, which over time, is counterbalanced by the induction of its progestagenic properties.

Tibolone and its metabolites inhibit invasion of human mammary carcinoma cells in vitro

Tibolone is used in postmenopausal women to alleviate menopausal symptoms and to prevent osteoporosis, but it does not stimulate the endometrium and the breast. Up to date, little data are available on the effect of tibolone on breast cancer initiation and progression.

OBJECTIVE

In the present in vitro study, we investigated the effect of tibolone and its metabolites (3alpha-OH tibolone, 3beta-OH tibolone, the Delta4 isomer and the sulphated isoform) on invasion of human breast cancer cells.

METHODS

The effect on invasion was evaluated in the chick heart invasion assay using MCF-7/6 cells and in the collagen type I invasion assay using T47-D cells. Furthermore, the compounds were tested in aggregation and migration assays.

RESULTS

We observed that, at a concentration of 100 microM, tibolone and its 3beta-OH metabolite possess anti-invasive activities in the two different invasion assays. However, this was neither due to effects on cell-cell adhesion nor on motility. In an attempt to probe the mechanism underlying the anti-invasive effect, we found that pro-MMP-9 release was markedly reduced in the supernatant of MCF-7/6 breast cancer cells treated with tibolone, 3alpha-OH tibolone and the Delta4 isomer but, interestingly, not with the sulphated metabolite.

CONCLUSION

We conclude that tibolone and its 3beta-OH metabolite have an anti-invasive effect on the tested breast cancer cell lines in vitro. This effect on invasion is not correlated with an effect on cell-cell adhesion or motility but coincides with a decreased release of pro-MMP-9 in the medium.

Effect of misoprostol on bone mineral density in women with postmenopausal osteoporosis

OBJECTIVE

To evaluate the effect of misoprostol on bone mineral density in postmenopausal women.

MATERIALS AND METHODS

The study was performed in a randomized controlled prospective manner in 90 women with menopause at Süleymaniye Maternity and Women's Diseases Teaching and Research Hospital between January and December 2003. Cases were divided into three groups each consisting of 30 women who were in menopause for at least 1 year and had t-scores less than -1 by dual energy X-ray densitometry (DEXA). Group I was treated with misoprostol and calcium, Group II received tibolone and calcium and Group III was given calcium only and considered as control group. In all patients, bone mineral density in L1-L4 vertebrae, femur neck and Ward triangle were measured by DEXA and t and z scores were calculated.

RESULTS

All groups were similar demographically. Bone mineral density in L1-L4 vertebrae, femur neck and Ward triangle in the group treated with misoprostol, increased by 5, 8.1 and 3.6%, respectively. In the tibolone group, bone mineral density in L1-L4 vertebrae, femur neck and Ward triangle increased by 8.3, 5.3 and 7.8%, respectively. There was not a significant difference in t and z-scores and bone mineral density measurements between misoprostol and tibolon groups.

CONCLUSION

Misoprostol may be an alternative treatment for patients with osteopenia and osteoporosis who are not suitable for hormone replacement therapy.

The role of hormones for the treatment of endometrial hyperplasia and endometrial cancer

PURPOSE OF REVIEW

Hormone therapy has been palliative for advanced/ recurrent endometrial cancer. High remission rates are seen in well-selected stage I, grade 1 endometrial cancer of young women using hormone therapy (usually progestins) as fertility-preserving treatment. Many other hormones, such as gonadotropin-releasing hormone analogs (GnRHa), selective estrogen receptor modulators, aromatase inhibitors, intrauterine progestins, and others are potential modalities. This review updates the recent publications in this area.

RECENT FINDINGS

Two reports investigating different scheduling of tamoxifen and progestins indicated that tamoxifen may be a valuable adjunct to progestin therapy. GnRHa has been used adjunctively to tamoxifen as second-line hormone therapy for fertility sparing after progestin failed. Aromatase inhibitors have shown their potential in treating endometrial cancer and endometrial hyperplasia as single agent or in combination with progestins. Intrauterine progestins seem efficacious in treating endometrial hyperplasia; its applications on endometrial cancer patients, however, have been limited to postmenopausal women with poor surgical risk.

SUMMARY

Translational research based on molecular mechanisms is mandatory to a more appropriate utilization of hormone therapy. The role of dose, scheduling, route of administration of progestins as well as the addition of other hormonal agents should be further explored by well designed randomized controlled trials.