Non-contraceptive estrogen use and the risk of gallstone disease in women

[Mineralocorticoid receptor antagonists: A new therapeutic option for diabetic kidney disease]

Diabetic kidney disease (DKD) and its associated cardiovascular morbidity represent a major complication in diabetic patients. Over the past two decades, several experimental studies have shown benefits of mineralocorticoid receptor (MR) antagonists on the cardiorenal outcomes in animal models of non-diabetic or diabetic kidney diseases. Here, we summarize the role of MR activation in promoting inflammatory and fibrotic mechanisms that contribute to DKD pathophysiology. We also review the key findings of two recent large clinical trials FIDELIO-DKD and FIGARO-DKD which showed for the first time a major benefit of the non-steroidal MR antagonist, finerenone, on renal and cardiac specific outcomes across the spectrum of DKD severity. We finally discuss the place of finerenone compared to other DKD therapeutic approaches.

Is the oral contraceptive or hormone replacement therapy a risk factor for cholelithiasis: A systematic review and meta-analysis

BACKGROUND

Association between exogenous estrogen intake and cholelithiasis risk has been reported in several epidemiological studies, including oral contraceptive (OC) and hormone replacement therapy (HRT), while the results were controversial. This study aimed to perform a comprehensive meta-analysis of this issue.

METHODS

PUBMED, EMBASE, and Cochrane library database were searched up to October 2016. Two reviewers independently extracted data from eligible studies, relative risks (RRs), and/or odds ratios (ORs) with 95% confidence intervals (95% CIs) for the highest versus lowest categories of intake were adopted. Either a fixed- or a random-effects model was adopted to estimate overall RRs or ORs. Besides, subgroup and publication bias analyses were applied to explain the heterogeneity. An original study was also conducted to verify our conclusion.

RESULTS

A total of 19 studies with approximately 556,620 participants were included in this meta-analysis. The pooled RR of cholelithiasis for the highest versus the lowest categories was 1.59 (95% CI: 1.44-1.75), indicating that exogenous estrogen was positive associated with the intake of exogenous estrogen. However, the pooled RR of OC intake and cholelithiasis risk was 1.19 (95% CI: 0.97-1.45), and the RR for HRT was 1.79 (95% CI: 1.61-2.00).

CONCLUSION

The HRT was positively associated with the cholelithiasis risk, and the OC will not increase the risk of cholelithiasis.

Gallbladder motility and the sex of the guinea pig

Progesterone (P), 17β‐estradiol (E2), and dihydrotestosterone (DHT) affect gallbladder motility. When gallbladders were taken from women and men, women had more estrogen and P receptors than men. Both P and E2 had an inhibitory effect upon gallbladder contractility in men and premenopausal and postmenopausal women. Similar findings have been reported in gallbladder strips from male and female guinea pigs. In the present study, there was no significant difference in the amount of E2‐, P‐, or DHT‐induced relaxation of CCK‐induced tension when the responses in gallbladder strips from male and female guinea pigs were compared. Three metabolites of P were used: 17‐hydroxyprogesterone (17‐P), 20α‐hydroxyprogesterone (20‐P), and 21‐hydroxyprogesterone (21‐P). There was no significant difference in the responses from strips from male and female guinea pigs. In order to determine if the effects of E2 and P were additive, strips from male animals were exposed to either E2 or P and the amount of relaxation recorded. After recovery, the strips were exposed to E2 or P in reverse order to ensure the order of treatment had no effect. Then, the strips were treated with both E2 and P simultaneously and the relaxation recorded. This procedure was repeated with strips from female guinea pigs. The effect of E2 and P was found to be additive; however, the response of the strips from each sex were not significantly different. It is concluded that the sex of the guinea pig has no significant effect on the response to the sex hormones used.

Variabilities of gallbladder contraction indices and a simple regression model for gallbladder and gastric emptying ratio

Introduction

The objective of this study was to assess the variabilities of gallbladder contraction indices (GBCI) and derive a predictive model for gallbladder and gastric motility.

Methods

The gallbladder volume and gastric antral measurements were obtained from 24 healthy male volunteers in preprandial and post-milk ingestion states. After preprandial measurement of the gallbladder volume and gastric antral area, each subject ingested 157 ml of full cream milk and 30 cl of ion -free water. In supine position, the gallbladder volume and the gastric antral area were obtained every five minutes for 40 minutes. For the gallbladder while only the 5 ^th, 10 ^th and 15 ^th measurement of gastric antral area were obtained. Gallbladder contraction indices were calculated and gastric emptying ratio obtained at the fifteenth minute is the indication of gastric motility. Statistical analyses were conducted using SPSS version 16.0 with p<0.05 as criterion of statistical significance.

Results

The GBCIs followed Gaussian response at some stages and did not at some other stages. The least variability occurred at the 35th measurement of GBCI. A cut- off value for the 35th minute GBCI value was established with the mean±2 SD (80.79±11.5%). Obvious gallbladder refilling was noted after 35minutes. A positive relationship was noted between gallbladder and gastric motilities.

Conclusion

With milk dilution, the variability of gall bladder motility is least at the 35th minute. A significant positive relationship between gastric emptying and gallbladder contraction index was also observed.

Menopausal hormone therapy and gallbladder disease: the Study of Health in Pomerania (SHIP)

OBJECTIVE

Several studies suggest that oral menopausal hormone therapy (MHT) is associated with an increased risk of gallbladder disease. It has been hypothesized that nonoral MHT may reduce the risk of cholelithiasis. The objective of the present study was to analyse the association between (1) use of life-time MHT (ever use) and gallbladder disease and (2) nonoral use of MHT and gallbladder disease.

DESIGN

Cross-sectional study using population-based data from the Study of Health in Pomerania (SHIP).

POPULATION

The study population included 994 postmenopausal women, aged 40-79 years. The subgroup of current oral and nonoral MHT users comprised 139 women.

METHODS AND MEASUREMENTS

Sociodemographic, medical and reproductive characteristics were based on computer-assisted personal interviews, and selected laboratory parameters were analysed. Gallbladder disease was defined by either a prior history of cholecystectomy or the presence of current sonographically diagnosed gallstones. Data analyses consisted of descriptive, bivariable and multivariable procedures. We performed Poisson regression with Huber/White standard errors to investigate the association between ever use, current nonoral use of MHT and gallbladder disease.

RESULTS

We found no significant association between ever use of MHT and gallbladder disease and sonographically diagnosed gallstones in fully adjusted analyses. Women who used MHT had a significantly higher risk for cholecystectomy compared to nonusers. There was no association between nonoral use of MHT and gallbladder disease.

CONCLUSIONS

Our analyses do not lend support to the hypothesis that use of MHT is associated with gallbladder disease.

Is there a link between oestrogen therapy and gallbladder disease?

Cholelithiasis is the most common form of benign gallbladder disease that results in major heath expenditure. Female sex hormones are causally related to cholesterol gallstone disease, which are more common in women than in men. The risk of development of cholelithiasis is further enhanced by the use of exogenous female sex hormones and by pregnancy. Oestrogens are used in oral contraceptives and in hormone replacement therapy (HRT). Oral contraceptives do not pose a greater risk for gallbladder disease. The findings from two randomised, controlled trials, the Heart and Oestrogen/Progestin Replacement Study and the Women's Health Initiative postmenopausal hormone trial, unequivocally confirm that oral oestrogen use in postmenopausal women is causally associated with gallbladder disease, and the magnitude of the effect is not influenced greatly by the presence or absence of progestins. A cautious approach should be observed when prescribing HRT. Women must be informed about the effect of oestrogen use on increased risk of benign gallbladder disease. HRT should be used in the lowest possible dose for the shortest possible time. Women harbouring asymptomatic gallstones should not receive oestrogens because of the possibility of developing cholecystitis.

Hormone replacement therapy in postmenopausal women

BACKGROUND

For many years, hormone replacement therapy (HRT) was considered an effective method of restoring the relative protection from coronary artery disease enjoyed by premenopausal women compared with men of similar age. This view has been supported by a substantial number of basic science and observational studies.

DATA SOURCES

Results of recent randomized controlled trials have seriously challenged the concept of the protective value of HRT by showing that rather than decreasing the risk of coronary artery disease, HRT actually appears to increase it. In addition, it increases the risk for breast cancer, stroke, venous thromboembolism, and cholecystitis.

RESULTS

Despite some benefits such as increased bone mineral density and decreased risk of fracture and colorectal cancer, these data suggest that the risks of HRT outweigh the benefits.

CONCLUSIONS

HRT is no longer routinely recommended for prevention of chronic disease. We present the current scientific data, benefits, risks, and consequent clinical recommendations regarding HRT use in postmenopausal women.

Alterations in gallbladder emptying and bile retention in the absence of changes in bile lithogenicity in postmenopausal women on hormone replacement therapy

The role of female sex hormones in the pathogenesis of gallstones is well established. Pregnancy, contraceptive use, estrogen replacement therapy in postmenopausal women, and estrogen therapy in men for the treatment of prostatic carcinoma have been found to be associated with increased risk of cholesterol gallstones. Alterations in gallbladder emptying and in bile lithogenicity in postmenopausal women receiving hormone replacement therapy (HRT) have not been studied to date. The present study was undertaken to study the effect of HRT on gallbladder emptying and bile lithogenicity. Sixteen postmenopausal women were included in the study. None of the patients had gallstone disease and none had received prokinetic drugs, such as, erythromycin, metoclopramide, domperidone or cisapride, aspirin, and nonsteroidal antiinflammatory drugs. Gallbladder emptying (n = 16), bile microscopy (n = 7), cholesterol saturation index (CSI) (n = 7), and nucleation time (n = 7) were studied before and 3 months after HRT (conjugated estrogen, 0.625 mg, + medroxyprogesterone acetate, 2.5 mg, everyday). Fasting and residual volumes increased (fasting volume, 18.2 +/- 2.2 mL pre-HRT vs 27.6 +/- 3.2 mL post-HRT, P = 0.0003; residual volume, 3.9 +/- 0.6 mL pre-HRT vs 10.3 +/- 2.0 mL post-HRT, P = 0.00009) and ejection fraction decreased (78.2 +/- 2.5% pre-HRT vs 62.2 +/- 3.8% post-HRT; P = 0.0017) after 3 months of HRT. There was no change in CSI (2.32 +/- 0.36 pre-HRT vs 2.60 +/- 0.51 post-HRT; P = NS) or in nucleation time (19.0 +/- 1.2 days pre-HRT vs 17.6 +/- 1.3 days post-HRT; P = NS). None of the bile samples either pre-HRT or post-HRT showed cholesterol monohydrate crystals. Though impairment of gallbladder emptying occurs in the short term with HRT in postmenopausal women, there is no change in CSI and nucleation time.

Association of obesity and type II diabetes mellitus as a risk factor for gallstones

Age, female sex, and obesity are well-known risk factors for gallstones; in contrast the possible role of type 2 diabetes mellitus (type-2 DM) is controversial. One reason for this discrepancy might be that type 2 DM is often accompanied by obesity. Therefore, the aim of this study was to evaluate the importance of obesity and of type 2 DM, separately and together, as risk factors for gallstones. In all, 203 obese patients with normal glucose tolerance (obese NGT), 446 obese patients with type 2 DM (obese type 2 DM), 269 lean patients with type 2 DM (lean type 2 DM) and 250 lean subjects with a normal glucose tolerance (lean NGT) were evaluated by ultrasonography for the presence of gallstones. At univariate analysis patients with gallstones (177) were older and were more frequently affected by both obesity and type 2 DM, and had higher triglycerides and fasting blood glucose levels. At multiple logistic regression analysis, only age and obesity, both in the presence or in absence of type 2 DM, were strongly associated with gallstones (P < 0.001); diabetes alone had a lower level of statistical significance (P = 0.07). These data suggest that obesity is a stronger risk factor for gallstones than type 2 DM.

Delay in gallbladder emptying during the perimenopausal period

A pilot study has ascribed an important role in gallbladder motility and emptying to the perimenopausal period. To assess the effect of this period on gallbladder emptying and cholelithogenesis, 25 women in the perimenopausal period without gallbladder disease were submitted to cholangiography and two ultrasound exams. The time for gallbladder emptying and the presence of cholelithiasis were assessed. All patients presented a delay in gallbladder emptying with no relationship to the pre- or postmenopausal period. This finding was not related to lithogenesis. Gallbladder emptying time is longer during the perimenopausal period.

Menopause: when hormone replacement therapy is not an option. Part I

Although the perimenopausal period is often experienced as a positive life transition, it is frequently accompanied by a variety of distressing physical and emotional sequelae. Hormone replacement therapy (HRT) has been hailed as the first-line treatment for many of these symptoms. A significant number of women, however, are unable to take exogenous hormones because of absolute or relative contraindications to therapy. Other women are unwilling to use this treatment for a variety of reasons, including reluctance to use unnatural exogenous hormones and fear of unknown risks of HRT. This two-part review discusses the physiology of menopause and its related symptoms, as well as the risks and benefits of both oral and non-oral routes of hormone administration. Self-help measures and alternative therapeutic options are recommended for the treatment of menopausal symptoms, which include vasomotor instability, urogenital atrophy, psychologic disturbances, and risk of osteoporosis and cardiovascular disease.

Postmenopausal hormone replacement therapy--clinical implications

The menopause is defined as cessation of menstruation, ending the fertile period. The hormonal changes are a decrease in progesterone level, followed by a marked decrease in estrogen production. Symptoms associated with these hormonal changes may advocate for hormonal replacement therapy. This review is based on the English-language literature on the effect of estrogen therapy and estrogen plus progestin therapy on postmenopausal women. The advantages of hormone replacement therapy are regulation of dysfunctional uterine bleeding, relief of hot flushes, and prevention of atrophic changes in the urogenital tract. Women at risk of osteoporosis will benefit from hormone replacement therapy. The treatment should start as soon after menopause as possible and it is possible that it should be maintained for life. The treatment may be supplemented with extra calcium intake, vitamin D, and maybe calcitonin. Physical activity should be promoted, and cigarette smoking reduced if possible. Women at risk of cardiovascular disease will also benefit from hormone replacement therapy. There is overwhelming evidence that hormone therapy will protect against both coronary heart disease and stroke, and there is no increased risk of venous thrombosis or hypertension. A disadvantage of hormone replacement therapy is an increased risk of forming gall-bladder stones and undergoing cholecystectomy. Unopposed estrogen therapy gives a higher incidence of endometrial cancer in women with an intact uterus, but the contribution of progestins for about 10 days every month excludes this risk. Breast cancer in relation to estrogen-progestogen therapy has been given much concern, and the problem is still not fully solved. If there is a risk, it is small, and only after prolonged use of estrogen (15-20 years). The decision whether or not to use hormone replacement therapy should, of course, be taken by the individual woman in question, but her decision should be based on the available scientific information. It is the opinion of the authors that the advantages of hormone replacement therapy far exceed the disadvantages. We suggest that every woman showing any signs of hormone deprivation should be treated with hormone replacement therapy. This includes women with subjective or objective vaso-motor symptoms, genito-urinary symptoms, women at risk of osteoporosis (fast bone losers), and women at risk of cardiovascular diseases.

Physicians' views on hormone therapy around and after menopause

Estrogens and progestins are commonly and increasingly used during and after menopause. We studied Finnish physicians' views of this hormone therapy based on their specialty. A questionnaire was sent to a stratified random sample of gynecologists, internists, general practitioners and nonspecialists (n = 500; response rate 74%). Reported prescription habits and opinions concerning benefits and harms of hormones were asked and compared to current literature. Combined therapy was much more popular than was estrogen alone. One fourth of the physicians said hormones should be preventively given to all or to all those at risk for osteoporosis. Long therapies were accepted by many and for our patient cases hormones were recommended much more commonly than were other medical therapies. Most considered prevention of osteoporosis to be a benefit of combined therapy, but opinions of other benefits and harms varied. Gynecologists had the most favourable opinions and most of them considered hormone therapy very useful; the other physicians' opinions were characterized by uncertainties about hormone therapy and its long term effects.

Hormone replacement therapy. Protection against the consequences of menopause

The time of menopause provides an excellent opportunity for physicians to educate their patients toward preventive care that involves life-style modification and disease screening. It is also the time to consider appropriate hormone replacement therapy. Most postmenopausal women are candidates for such therapy, which has beneficial effects on serum cholesterol levels and other cardiovascular risk factors and protects against osteoporosis, urogenital atrophy, and vasomotor symptoms. A small number of patients have specific risk factors for or contraindications to hormone replacement therapy. In general, however, hormone replacement therapy can be of great benefit to the expanding population of post-menopausal women.

Risk factors for gallstone formation in young Saudi women: A case control study

One hundred eighty-three young Saudi females (92 patients with gallstones, 91 controls) mean age and (SD), 30.2 (6.1) and 29.7 (6.4) years respectively were studied in detail for possible risk factors for gallstone formation. No statistically significant difference was found when the two groups were compared with regard to past history of jaundice. HBsAg carrier status, use of oral contraceptives, parity, diabetes mellitus, obesity (as Body Mass Index > 30), hypercholesterolemia and hypertriglyceridemia. However, it was noted that both groups were overweight; mean (SD) BMI of 27 (5.9) and 26.7 (6.8) for patients and controls respectively and both had high parity rates; mean and (SD) pregnancies of 4.7 (2.6) and 4.3 (2.9), respectively. Family history of gallstones in first degree relatives of patients was significant (.0027 < P < .01) more than in the controls (95% confidence interval of 3% to 23%). This may suggest a genetic or an environmental factor that strikes the balance toward gallstone formation in the obese and fertile young female population. A larger nationwide, population-based study is surely justified and needed.

Oral contraceptives and non-contraceptive oestrogens in the risk of gallstone disease requiring surgery

STUDY OBJECTIVE

The aim was to investigate the relationship between oral contraceptives, non-contraceptive oestrogens, and the risk of gallstone disease requiring surgery.

DESIGN

This was a hospital based case-control study carried out between 1987 and 1990. Main outcome measures were frequency of consumption of oral contraceptives and non-contraceptive oestrogens, and the corresponding multivariate relative risk estimates and 95% confidence intervals (CI) in relation to various measures of use of the preparations.

SETTING

A network including major teaching and general hospitals in the greater Milan area, northern Italy.

SUBJECTS

Subjects were 235 women with gallstones requiring surgery and 538 controls admitted for acute diseases, other than digestive or hormonal diseases or those potentially influencing the use of female hormone preparations.

MAIN RESULTS

For oral contraceptives, the relative risk for ever use was 0.8 with 95% CI 0.4 to 1.5. With reference to duration of use, the multivariate relative risk was 1.0 for less than two and 0.5 for two or more years of use. The relative risk was 1.7 (95% CI 0.6 to 4.7) in women who had last used the pill less than five years before diagnosis, but declined to 0.4 (95% CI 0.2 to 1.0) in those who had stopped more than five years before. With reference to oestrogen replacement treatment, the relative risk for ever use was 1.9 (95% CI 1.0 to 3.1). The relative risk, however, was not related to duration of use, since it was 1.8 for less than two and 1.5 for two or more years of use. Relative risk was higher for women who had last used non-contraceptive oestrogens 10 or more years before diagnosis (2.4) than for shorter periods since last use (1.3).

CONCLUSIONS

On a clinical and public health scale, oral contraceptives and non-contraceptive oestrogens are unlikely to have an important influence in the aetiology of gallbladder disease.

Risk factors for gallstone formation during rapid loss of weight

Risk factors for the development of gallstones during rapid weight loss were assessed in 457 subjects who entered a weight control program (520 kcal/day). Absence of gallstones in these subjects was documented by ultrasonography prior to entry into the study. Ultrasonography was performed again at 16 weeks on the subjects who remained in the study (N = 248). The incidence of gallstones by 16 weeks of rapid weight loss was 10.9% (27/248). Most factors associated with gallstones in the general population, eg, older age, female gender, parity, positive family history, etc, were not associated with gallstones in this population. The risk factors for developing gallstones included increased initial body mass index [weight (kg)/height (m)2], amount of body mass index loss, and serum triglyceride levels. The positive predictive value of these risk factors was 75%, but the sensitivity was only 12%. These observations indicate that risk factors for the development of gallstones during rapid weight loss are probably different from those in the general population. The factors identified by this study are useful in predicting patients at high risk for gallstones. However, since only a minority of gallstones that form can be predicted, further study is needed to identify additional factors that will improve our ability to predict gallstone formation.

The relationship between reproductive history and cholecystectomy in older women

We examined the relationship of reproductive history to cholecystectomy in a population-based sample of 1093 women aged 50 years and older. Number of pregnancies ranged from 0 to 13. Age and obesity were each significantly and independently associated with an increased risk of cholecystectomy. When adjusted for differences in age and obesity, those who had had five or more pregnancies had a significantly increased risk of cholecystectomy. We conclude that an increased risk of gallbladder disease may follow either obesity or multiple pregnancies. One possibly unifying hypothesis for the obesity and pregnancy association is sustained hyperestrogenemia.