Aortic hemodynamics in postmenopausal women following cessation of hormone therapy

Effects of menopausal hormone therapy on ambulatory blood pressure and arterial stiffness in postmenopausal Korean women with grade 1 hypertension: a randomized, placebo-controlled trial

Background

Estrogen therapy in early menopausal women decreases the risk of coronary heart disease and parenteral, but not oral, estrogen is reported to reduce blood pressure (BP). Progestogens are typically added to estrogens to prevent unopposed endometrial stimulation. The effects of progestogen on BP have been less well studied to date. This study was conducted to explore the impacts of micronized progesterone (MP4) combined with percutaneous estradiol gel (PEG) on hemodynamics in postmenopausal Korean women with grade 1 hypertension.

Methods

Fifty-two postmenopausal women (aged 49–75 years) with systolic BP (SBP) of 140–160 mmHg or diastolic BP (DBP) of 90–100 mmHg were randomly assigned for 12 weeks to placebo (n = 16), estrogen therapy (ET) (n = 19) with PEG (0.1 %, 1 g./d), or estrogen + progestogen therapy (EPT, n = 17) with PEG and MP4 (100 mg/d). The primary endpoint was ambulatory BP and the secondary endpoints were arterial stiffness as brachial–ankle pulse-wave velocity (baPWV) and aortic parameters on applanation tonometry.

Results

One woman in the ET group dropped out, so 51 participants were finally analyzed. Outcome measures for ambulatory BP and arterial stiffness were not different between groups. Within-group comparisons showed that EPT significantly decreased daytime heart rate and baPWV: the changes from baseline (mean ± standard deviation) were − 2.5 ± 5.7 bpm (P = 0.03) and − 0.6 ± 1.4 m/s (P = 0.04), respectively. After adjusting for baseline, linear regression analysis revealed a significant difference in the relationship between baseline and 12-week baPWV among groups (P = 0.02). The relationship was significantly different between placebo and ET (P = 0.03) and EPT (P = 0.01), respectively, but not between ET and EPT. Additionally, pooled results of active treatments disclosed that SBP, DBP, PWV, and augmentation index at the aorta were significantly reduced relative to baseline.

Conclusions

There was no difference in ambulatory BP between ET and EPT in postmenopausal Korean women with grade 1 hypertension. Further, ET and EPT similarly decreased baPWV from baseline as compared with placebo. MP4 might not adversely influence estrogen effects on ambulatory BP and arterial stiffness.

Trial registration

Clinical Research Information Registry, KCT0005405, Registered 22 September 2020 - Retrospectively registered, https://cris.nih.go.kr/cris/search/detailSearch.do?all_type=Y&search_page=L&pageSize=10&page=1&seq=17608&search_lang=E.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40885-021-00175-1.

Evaluating daily profile of central aortic pressure and reflected pulse wave parameters in climacteric women

Introduction

Structural and functional changes of the vascular wall in women occur already at the very early stages of reproductive aging. An emergence of applanation tonometry made it possible to evaluate arterial stiffness and central hemodynamic parameters non-invasively, which considerably expanded the information that had been provided previously by invasive methods used for studying these parameters during cardiac catheterization. Whereas a few studies have assessed central aortic pressure (CAP) parameters and reflected pulse wave in women at different phases of their reproductive aging, none investigated the daily profile of CAP and reflected pulse wave parameters in women undergoing different stages of the menopause. Background: assessment of the daily variability in CAP and daily profile of amplification and augmentation of pulse blood pressure (PBP) in women at different menopause phases.

Methods

The study involved 384 climacteric women. The first group included 168 women undergoing perimenopause, the second group comprised of 216 women in their early postmenopausal stage. A 24-h blood pressure (BP) monitoring in the brachial artery and aorta (BPLab® Vasotens® system, Petr Telegin LLC, Russia) was performed via the measurements of the following indicators: systolic blood pressure (SBP), pulse blood pressure (PBP), central aortic systolic pressure (CASP), central aortic pulse pressure (CAPP), aortic augmentation index (AIxao), and pulse pressure amplification (PPA).

Results

When investigating PPA values in the brachial artery and aorta, we detected smaller amplification and higher aortic augmentation index at night than in daytime, which reflected a disproportionately higher CAP level during night hours. This pattern was more pronounced in postmenopausal women. We calculated the logistic regression equation (adjusted R² = 0.49, log-likelihood = − 50.3, chi-square (19) = 97.6, p < 0.001), in which dependent variable was represented by the menopausal status, whereas body mass index with all indicators of a 24-h BP monitoring represented independent variables. In this model, two indicators (body mass index and AIxao) were, independently of each other, associated significantly with the menopause phases. Differences among women at various climacteric phases in terms of remaining indicators of a 24-h BP monitoring, apparently, matched the differences in their body mass index values.

Conclusion

Rising CAP, in combination with declining PPA and augmenting reflected pulse wave amplitude, may be associated with an increased risk of cardiovascular complications.

Integrative cardiovascular control in women: Regulation of blood pressure, body temperature, and cerebrovascular responsiveness

Over the past several decades, it has become increasingly clear that women have distinct cardiovascular profiles compared to men. In this review, our goal is to provide an overview of the literature regarding the influences of female sex and reproductive hormones (primarily estradiol) on mechanisms of cardiovascular control relevant to regulation of blood pressure, body temperature, and cerebral blood flow. Young women tend to have lower resting blood pressure compared with men. This sex difference is reversed at menopause, when women develop higher sympathetic nerve activity and the risk of systemic hypertension increases sharply as postmenopausal women age. Vascular responses to thermal stress, including cutaneous vasodilation and vasoconstriction, are also affected by reproductive hormones in women, where estradiol appears to promote vasodilation and heat dissipation. The influence of reproductive hormones on cerebral blood flow and sex differences in the ability of the cerebral vasculature to increase its blood flow (cerebrovascular reactivity) are relatively new areas of investigation. Sex and hormonal influences on integrative blood flow regulation have further implications during challenges to physiological homeostasis, including exercise. We propose that increasing awareness of these sex-specific mechanisms is important for optimizing health care and promotion of wellness in women across the life span.

Lessons from KEEPS: the Kronos Early Estrogen Prevention Study

The Kronos Early Estrogen Prevention Study (KEEPS) was a randomized, double-blind, placebo-controlled trial designed to determine the effects of hormone treatments (menopausal hormone treatments [MHTs]) on the progression of carotid intima-medial thickness (CIMT) in recently menopausal women. Participants less than 3 years from menopause and without a history of overt cardiovascular disease (CVD), defined as no clinical CVD events and coronary artery calcium < 50 Agatston units, received either oral conjugated equine estrogens (0.45 mg/day) or transdermal 17β-estradiol (50 µg/day), both with progesterone (200 mg/day for 12 days/month), or placebo pills and patches for 4 years. Although MHT did not decrease the age-related increase in CIMT, KEEPS provided other important insights about MHT effects. Both MHTs versus placebo reduced the severity of menopausal symptoms and maintained bone density, but differed in efficacy regarding mood/anxiety, sleep, sexual function, and deposition of β-amyloid in the brain. Additionally, genetic variants in enzymes for metabolism and uptake of estrogen affected the efficacy of MHT for some aspects of symptom relief. KEEPS provides important information for use of MHT in clinical practice, including type, dose, and mode of delivery of MHT recently after menopause, and how genetic variants in hormone metabolism may affect MHT efficacy on specific outcomes.

Aortic hemodynamics in postmenopausal women following cessation of hormone therapy

Central (aortic) blood pressure and aortic pulse wave characteristics are measures of cardiovascular health, predictive of cardiovascular mortality. Previous studies have compared aortic hemodynamics in women who do and do not take menopausal hormone therapy, but characteristics of these parameters following cessation of treatment have not been defined. Therefore, the purpose of this study was to define aortic pulse wave characteristics in postmenopausal women with and without a history of menopausal hormone therapy use. Pulse wave analysis was conducted on 67 women who had participated in the randomized, double‐blind, placebo‐controlled Kronos Early Estrogen Prevention Study (KEEPS), 3 years subsequent to the four‐year treatment period. Treatment was oral conjugated equine estrogen (0.45 mg/day; n = 18); transdermal 17β‐estradiol (50 μg/day; n = 23) each with oral micronized progesterone (Prometrium 200 mg); and placebo pills and patch (n = 26). At post‐treatment, median age (60 years) and body mass index (27 kg/m²) did not differ across prior treatment assignment. Aortic blood pressures (median systolic 115 mm Hg and diastolic 76 mm Hg) and augmentation index (median 33%) did not differ among women across prior treatment assignment. These results suggest that these doses and formulations of menopausal hormone therapy had no long‐term effects on central vascular function 3 years after cessation of treatment.