A review of the relationships between endogenous sex steroids and incident ischemic stroke and coronary heart disease events

Sex Hormones and Cardiovascular Disease in Relation to Menopause

Natural menopause is defined as the cessation of menstruation among women who have not undergone hysterectomy or bilateral oophorectomy. The implications of menopause management are particularly important with the aging of the population and increasing awareness of the importance of midlife risk upon longevity. Our understanding of the relationships between reproductive milestones and cardiovascular disease continues to evolve particularly regarding shared determinants of health.

Validation of a GC- and LC-MS/MS based method for the quantification of 22 estrogens and its application to human plasma

In epidemiological studies, blood levels of 17β-estradiol (E2) are associated with hormone-dependent diseases. The lack of specific methods impedes studies on the role of E2 metabolites and their conjugates in the etiology of hormone-dependent diseases. Stable-isotope dilution tandem mass spectrometry methods (coupled to gas chromatography and liquid chromatography systems) for the analysis of 22 endogenous estrogens, including both oxidative metabolites, as well as sulfates and glucuronides, was validated and the method applied to plasma of women with no breast cancer. No changes in estrogen profile during sample cleanup were observed and values for limit of detection (7fmol/ml - 2 pmol/ml), accuracies (80-122%) as well as intra- and inter-day precision (below 28%) at levels near the limit of quantification were acceptable. In human plasma only seven estrogens were detected and estrone conjugates contributed most to the estrogen profile.

Analgesic use and circulating estrogens, androgens, and their metabolites in the Women's Health Initiative Observational Study

Though studies have observed inverse associations between use of analgesics (aspirin, non-aspirin nonsteroidal anti-inflammatory drugs [NSAIDs], and acetaminophen) and the risk of several cancers, the potential biological mechanisms underlying these associations are unclear. We investigated the relationship between analgesic use and serum concentrations of estrogens, androgens, and their metabolites among postmenopausal women to provide insights on whether analgesic use might influence endogenous hormone levels, which could in turn influence hormone-related cancer risk. The study included 1,860 postmenopausal women from two case-control studies nested within the Women's Health Initiative Observational Study. Analgesic use was reported at study baseline. Fifteen estrogens and estrogen metabolites and twelve androgens and androgen metabolites were quantified in baseline serum by liquid chromatography-tandem mass spectrometry. Linear regression with inverse probability weighting, stratified by menopausal hormone therapy (MHT) use, was used to estimate adjusted geometric mean concentrations of each hormone by analgesic use. Among women not currently using MHT (n=951), low-dose aspirin (<100 mg) use was associated with a higher serum concentration of estrone, estradiol, and 2,4, and 16 hydroxylated metabolites. Use of regular-dose aspirin ( {greater than or equal to} 100 mg), non-aspirin NSAIDs, and acetaminophen were not associated with serum concentrations of estrogens, androgens, or their metabolites. This study highlights the importance of examining aspirin use by dose and suggests that low-dose aspirin may influence endogenous estrogen concentrations.

Associations of Physician Characteristics with Sex Difference in Ischemic Heart Disease Incidence among Patients Living with Type 2 Diabetes in Taiwan

(1) Background: Certain non-biological factors are suspected to explain the reduced sex difference in cardiovascular risk after diabetes. This study aimed to assess whether physician characteristics may account for such reduced sex difference. (2) Methods: Totally 10,105 type 2 diabetes patients (including 4962 men and 5143 women) were selected from Taiwan’s National Health Insurance claim data. The three-year period following the first day of clinical visit for type 2 diabetes in 2000 was set as the baseline period. The follow-up was made from the first day after baseline period to date of ischemic heart disease (IHD) incidence or censoring. Cox regression model was used to estimate hazard ratios (HRs) of IHD in relation to physician’s characteristics. (3) Results: The incidence of IHD for men and women was estimated at 17.47 and 15.96 per 1000 person-years, respectively. After controlling for socio-demographic variables and co-morbidity, male patients experienced a significantly higher HR than females for IHD (1.16, 95% Confidence Interval (CI) 1.04 to 1.29). Further adjustment for treatment adherence/continuity and physician characteristics resulted in essentially the same results. (4) Conclusions: Our study provides little support for the notation that physician characteristics may contribute to the reduced sex difference in IHD incidence in patients with type 2 diabetes.

Sex steroids and markers of micro- and macrovascular damage among women and men from the general population

AIMS

The contribution of sex hormones to micro- and macrovascular damage might differ among women and men. In particular, little is known about the association between sex hormones and small vessel disease. Therefore, we examined the association of total oestradiol, total testosterone, free-androgen index (FAI), dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), and androstenedione levels with micro- and macrovascular diseases.

METHODS AND RESULTS

This cross-sectional study included 2950 women and 2495 men from the population-based Rotterdam Study. As proxy of microvascular damage, we measured diameters of retinal arterioles and venules. Markers of macrovascular damage included carotid intima-media thickness and carotid plaque, coronary artery calcification (CAC), and peripheral artery disease. Linear and logistic regression models were used and adjusted for age, cardiovascular risk factors, and years since menopause. Associations with microvasculature: In women, total testosterone [mean difference per 1-unit increase in natural-log transformed total testosterone (95% confidence interval, CI): 2.59 (0.08-5.09)] and androstenedione [4.88 (1.82-7.95)] and in men DHEAS [2.80 (0.23-5.37)] and androstenedione [5.83 (2.19-9.46)] were associated with larger venular caliber. Associations with markers of large vessel disease: In women, higher total testosterone [-0.29 (-0.56 to -0.03)], FAI [-0.33 (-0.56 to -0.10)], and androstenedione levels [-0.33 (-0.64 to -0.02)] were associated with lower CAC burden and FAI [odds ratio (95% CI): 0.82 (0.71-0.94)] was associated with lower prevalence of plaque.

CONCLUSION

A more androgenic profile was associated with more microvascular damage in both women and men. Among women, however, higher androgen levels were also associated with less macrovascular damage. Our findings suggest that androgens might have distinct effects on the vasculature, depending on the vascular bed and stages of the atherosclerosis process.

Endogenous testosterone does not improve prediction of incident cardiovascular disease in a community-based cohort of adult men: results from the Tehran Lipid and Glucose Study

Introduction: To explore the predictive value of testosterone added to the Framingham Risk Score (FRS) for cardiovascular disease (CVD).Methods: Among 816 men, 30-70 years/old, without prevalent CVD, from a community-based cohort (Tehran Lipid and Glucose Study), we assessed the predictive value of testosterone with incident CVD, using three multivariate Cox proportional-hazards models. Model I: FRS variables; model II: Model I plus total testosterone; model III: Model II plus Systolic blood pressure (SBP) * total testosterone (the best fit interaction-term between testosterone and FRS variables). Discriminations and goodness-of-fit were assessed by the C-statistic and the approach of Grønnesby, respectively. p Value <.05 was significant.Results: During 12 years of follow-up, 121 CVD events occurred. In all models, age, treated SBP, smoking, and diabetes were associated with increased CVD (p values <.05). Neither testosterone (models II and III), nor SBP * testosterone (model III) were associated with CVD (p values >.05). The C-statistics for models I, II, and III were 0.819, 0.820, and 0.821, respectively, indicating no significant improvement in the discrimination power. The models' goodness-of-fit did not improve compared with the FRS.Conclusion: Testosterone could not add to the predictive value of FRS for CVD in men, either directly, or through interactions with FRS variables.

Implantable Nanosensors for Human Steroid Hormone Sensing In Vivo Using a Self-Templating Corona Phase Molecular Recognition

Dynamic measurements of steroid hormones in vivo are critical, but steroid sensing is currently limited by the availability of specific molecular recognition elements due to the chemical similarity of these hormones. In this work, a new, self-templating synthetic approach is applied using corona phase molecular recognition (CoPhMoRe) targeting the steroid family of molecules to produce near infrared fluorescent, implantable sensors. A key limitation of CoPhMoRe has been its reliance on library generation for sensor screening. This problem is addressed with a self-templating strategy of polymer design, using the examples of progesterone and cortisol sensing based on a styrene and acrylic acid copolymer library augmented with an acrylated steroid. The pendant steroid attached to the corona backbone is shown to self-template the phase, providing a unique CoPhMoRE design strategy with high efficacy. The resulting sensors exhibit excellent stability and reversibility upon repeated analyte cycling. It is shown that molecular recognition using such constructs is viable even in vivo after sensor implantation into a murine model by employing a poly (ethylene glycol) diacrylate (PEGDA) hydrogel and porous cellulose interface to limit nonspecific absorption. The results demonstrate that CoPhMoRe templating is sufficiently robust to enable a new class of continuous, in vivo biosensors.

Gonadal hormones and stroke risk: PCOS as a case study

It is well known that stroke incidence and outcome is sex-dependent and influenced by age and gonadal hormones. In post-menopausal and/or aged females, declining estrogen levels increases stroke risk. However, women who experience early menopause also have an increase in stroke risk. This suggests that, regardless of age, gonadal hormones regulate stroke risk and severity. This review discusses prolonged gonadal hormone dysfunction in a common female endocrine disorder known as polycystic ovarian syndrome, PCOS, and the associated increased risk of stroke due to resulting hyperandrogenism and metabolic comorbidities.

ADTRP regulates TFPI expression via transcription factor POU1F1 involved in coronary artery disease

Genomic variants in both ADTRP and TFPI genes are associated with risk of coronary artery disease (CAD). ADTRP regulates TFPI expression and endothelial cell functions involved in the initiation of atherosclerotic CAD. ADTRP also specifies primitive myelopoiesis and definitive hematopoiesis by upregulating TFPI expression. However, the underlying molecular mechanism is unknown. Here we show that transcription factor POU1F1 is the key by which ADTRP regulates TFPI expression. Luciferase reporter assays, chromatin-immunoprecipitation (ChIP) and electrophoretic mobility shift assay (EMSA) in combination with analysis of large and small deletions of the TFPI promoter/regulatory region were used to identify the molecular mechanism by which ADTRP regulates TFPI expression. Genetic association was assessed using case-control association analysis and phenome-wide association analysis (PhenGWA). ADTRP regulates TFPI expression at the transcription level in a dose-dependent manner. The ADTRP-response element was localized to a 50 bp region between -806 bp and -756 bp upstream of TFPI transcription start site, which contains a binding site for POU1F1. Deletion of POU1F1-binding site or knockdown of POU1F1 expression abolished ADTRP-mediated transcription of TFPI. ChIP and EMSA demonstrated that POU1F1 binds to the ADTRP response element. Genetic analysis identified significant association between POU1F1 variants and risk of CAD. PhenGWA identified other phenotypic traits associated with the ADTRP-POU1F1-TFPI axis such as lymphocyte count (ADTRP), waist circumference (TFPI), and standing height (POU1F1). These data identify POU1F1 as a transcription factor that regulates TFPI transcription in response to ADTRP, and link POU1F1 variants to risk of CAD for the first time.

Sex differences in stroke

Sex disparities within the field of stroke, including subarachnoid hemorrhages (SAHs), have been in focus during the last 2 decades. It is clear that stroke incidence is higher in men, and also that men have their first stroke earlier than women. On the other hand, women have more severe strokes, mainly because cardioembolic strokes are more common in women. This leads to higher case fatality and worse functional outcome in women. It has often been pointed out that women more often have nontraditional stroke symptoms, and therefore may seek medical help later. After discharge from the hospital, female stroke survivors live alone in many cases and are dependent on external care. Therefore, these women frequently rate their quality of life (QoL) lower than men do. Female spouses more often provide help to their male stroke survivors than the reverse, and they accept a heavier burden. These caregivers are at high risk for depression, low QoL, and low psychologic wellbeing. SAH is a special form of stroke, often caused by a ruptured aneurysm. It is about 20% more common in women. The case fatality is high, but does not differ between the sexes.

A Pilot Study to Assess Kidney Functions and Toxic Dimethyl-arginines as Risk Biomarkers in Women with Low Vitamin D Levels

Background

Although vitamin D in not a traditional marker for cardiovascular and renal diseases, several studies have proposed a correlation between vitamin D deficiency and these diseases due to the effect of vitamin D on endothelial function. Asymmetric and symmetric dimethyl arginine (ADMA and SDMA, respectively) are endogenous markers of endothelial dysfunction, and are considered as future markers for the assessment of cardiovascular and renal diseases. The present study investigated the association of kidney function tests (urea and creatinine) and dimethylarginine toxins (ADMA and SDMA) in women with vitamin D insufficiency or deficiency. Indeed, sex hormones (estrogen and testosterone) were analyzed in the participants.

Methods

Women were divided into two groups: premenopausal women (younger than 50 years) and postmenopausal women (older than 50 years). Urea, creatinine, estrogen, testosterone, ADMA, and SDMA levels were analyzed when vitamin D level was deficient or insufficient in the participants.

Results

The premenopausal women group showed no significant correlations between dimethylarginine toxins and renal failure tests or sex hormones. In the elderly (postmenstrual) women group, only SDMA was significantly correlated with urea and creatinine, while both ADMA and SDMA were not correlated with sex hormones.

Conclusions

Although ADMA and SDMA are promising candidates of endothelial dysfunction and are increased in menopause and aging, no direct link between ADMA and further progression of renal failure was observed in women with low vitamin D levels. In contrast, a possible direct correlation between SDMA and renal dysfunction was noticed, but only in an age-dependent manner.

Prazosin protects myocardial cells against anoxia-reoxygenation injury via the extracellular signal‑regulated kinase signaling pathway

Ischemic heart disease (including coronary arterial atherosclerosis, or vascular cavity stenosis or occlusion) remains the leading cause of disease-associated mortality worldwide. Prazosin, a receptor blocker of postsynaptic adrenaline, is essential in expanding peripheral arteries, which decreases peripheral vascular resistance, and regulates anti-hypertensive action. However, the mechanisms underlying the effects of prazosin have not been fully elucidated. The aim of the present study was to investigate the protective effects of prazosin on myocardial cells against anoxia-reoxygenation injury in a mouse model. The regulatory effects of prazosin on blood lipid levels and blood pressure were investigated in experimental mice. Furthermore, inflammation responses and oxidative stress in myocardial cells were analyzed in mice treated with prazosin. Apoptotic myocardial cells were investigated in experimental mice treated with prazosin. In addition, apoptotic gene expression levels were evaluated in myocardial cells. Extracellular signal-regulated kinase (ERK) expression and phosphorylation was investigated in myocardial cells in mice with anoxia-reoxygenation injury following prazosin treatment. The activity and expression levels of nuclear factor of activated T cells (NF-AT), activator protein 1 (AP-1) and necrosis factor (NF)-κB were observed in myocardial cells. Furthermore, histological analyses were performed to investigate the benefits of prazosin treatment on anoxia-reoxygenation injury. The results of the present study identified that prazosin decreased the expression levels of inflammatory factors, interleukin (IL)-6, tumor necrosis factor (TNF)-α, IL-10 and IL-1 in the serum of mice exhibiting hypoxia/reoxygenation injury. Oxidative stress was observed to be improved and the apoptosis rate was decreased in myocardial cells in anoxia-reoxygenation injury model mice treated with prazosin. ERK expression and phosphorylation was upregulated, and expression levels of NF-AT, AP-1 and NF-κB were downregulated in the myocardial cells of mice treated with prazosin. Blood lipid levels and blood pressure of the anoxia-reoxygenation injury model mice were markedly improved following treatment with prazosin. Histological analysis indicated that the area, circumference fragmentation and segmentation of myocardial cells were significantly improved following prazosin treatment. Thus, these results indicate that prazosin treatment decreases inflammation responses, oxidative stress, and apoptosis of myocardial cells via regulation of the ERK signaling pathway. The findings indicate that prazosin may present as a potential therapeutic agent for the treatment of hypoxia/reoxygenation injury.

Gaps, limitations and new insights on endogenous estrogen and follicle stimulating hormone as related to risk of cardiovascular disease in women traversing the menopause: A narrative review

While it is known that estrogen protects heart health in women prior to menopause, its role after menopause and during the menopause transition is far less apparent. Previous reviews summarizing the literature on the impact of endogenous estrogen on risk of cardiovascular disease (CVD) have focused on postmenopausal women and have not come to a clear conclusion. No previous review has summarized the associations between follicle stimulating hormone (FSH), a proxy measure of the menopause transition, and CVD risk. The main purpose of this narrative review is to highlight gaps and limitations in the literature on endogenous estrogen and FSH as related to CVD risk. Future directions are addressed in light of recent findings in the field. When studying the relationship of estrogen to cardiovascular risk, it is critical to separate endogenously produced estrogen from exogenously administered estrogen. Moreover, other reproductive hormones such as FSH should be assessed, since growing evidence suggests a potential contribution of this hormone. Evaluation of estrogen changes over time allows a separation of women based on their hormone trajectories. These individual trajectories correlate with subclinical CVD and thus indicate that it is much more important to observe a woman over time rather than ascribe risk to a single determination at a single time point. As women progress through menopause and the ovary stops producing estradiol, the nature of the relationship between estrogens and subclinical CVD markers also appears to undergo a switch. Studies are needed to examine the midlife course of endogenous estradiol, FSH and CVD risk. These studies should also consider other hormones, including androgens, with an eye towards helping women modify their cardiovascular risk in midlife, when prevention is most likely possible.

Anti-Müllerian Hormone Trajectories Are Associated With Cardiovascular Disease in Women: Results From the Doetinchem Cohort Study

BACKGROUND

Earlier age at menopause is widely considered to be associated with an increased risk of cardiovascular disease. However, the underlying mechanisms of this relationship remain undetermined. Indications suggest that anti-Müllerian hormone (AMH), an ovarian reserve marker, plays a physiological role outside of the reproductive system. Therefore, we investigated whether longitudinal AMH decline trajectories are associated with an increased risk of cardiovascular disease (CVD) occurrence.

METHODS

This study included 3108 female participants between 20 and 60 years of age at baseline of the population-based Doetinchem Cohort. Participants completed ≥1 of 5 consecutive quinquennial visits between 1987 and 2010, resulting in a total follow-up time of 20 years. AMH was measured in 8507 stored plasma samples. Information on total CVD, stroke, and coronary heart disease was obtained through a hospital discharge registry linkage. The association of AMH trajectories with CVD was quantified with joint modeling, with adjustment for age, smoking, oral contraceptive use, body mass index, menopausal status, postmenopausal hormone therapy use, diastolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, and glucose levels.

RESULTS

By the end of follow-up, 8.2% of the women had suffered from CVD, 4.9% had suffered from coronary heart disease, and 2.6% had experienced a stroke. After adjustment, each ng/mL lower _logAMH level was associated with a 21% higher risk of CVD (hazard ratio, 1.21; 95% confidence interval, 1.07-1.36) and a 26% higher risk of coronary heart disease (hazard ratio, 1.25; 95% confidence interval, 1.08-1.46). Each additional ng/mL/year decrease of _logAMH was associated with a significantly higher risk of CVD (hazard ratio, 1.46; 95% confidence interval, 1.14-1.87) and coronary heart disease (hazard ratio, 1.56; 95% confidence interval, 1.15-2.12). No association between AMH and stroke was found.

CONCLUSIONS

These results indicate that AMH trajectories in women are independently associated with CVD risk. Therefore, we postulate that the decline of circulating AMH levels may be part of the pathophysiology of the increased cardiovascular risk of earlier menopause. Confirmation of this association and elucidation of its underlying mechanisms are needed to place these results in a clinical perspective.

Use of antimüllerian hormone to predict the menopausal transition in HIV-infected women

BACKGROUND

HIV infection has been associated with early menopausal onset, which may have adverse long-term health consequences. Antimüllerian hormone, a biomarker of ovarian reserve and gonadal aging, is reduced in HIV-infected women.

OBJECTIVE

We sought to assess the relationship of antimüllerian hormone to age of menopause onset in HIV-infected women.

STUDY DESIGN

We used antimüllerian hormone levels measured in plasma in 2461 HIV-infected participants from the Women's Interagency HIV Study to model the age at final menstrual period. Multivariable normal mixture models for censored data were used to identify factors associated with age at final menstrual period.

RESULTS

Higher antimüllerian hormone at age 40 years was associated with later age at final menstrual period, even after multivariable adjustment for smoking, CD4 cell count, plasma HIV RNA, hepatitis C infection, and history of clinical AIDS. Each doubling of antimüllerian hormone was associated with a 1.5-year increase in the age at final menstrual period. Median age at final menstrual period ranged from 45 years for those in the 10th percentile of antimüllerian hormone to 52 years for those in the 90th percentile. Other factors independently associated with earlier age at final menstrual period included smoking, hepatitis C infection, higher HIV RNA levels, and history of clinical AIDS.

CONCLUSION

Antimüllerian hormone is highly predictive of age at final menstrual period in HIV-infected women. Measuring antimüllerian hormone in HIV-infected women may enable clinicians to predict risk of early menopause, and potentially implement individualized treatment plans to prevent menopause-related comorbidities and to aid in interpretation of symptoms.

Serum vitamin D and sex hormones levels in men and women: The Multi-Ethnic Study of Atherosclerosis (MESA)

INTRODUCTION

25-hydroxyvitamin D [25(OH)D] deficiency has been associated with low testosterone levels in men, but there are conflicting reports of its associations with sex hormones in women. Less is known about whether these associations are independent of adiposity and lifestyle factors, and whether they differ by race/ethnicity.

AIM

To examine associations of 25(OH)D concentrations with sex hormone levels.

METHODS

Cross-sectional analysis of 3017 men and 2929 women in a multi-ethnic cohort.

MAIN OUTCOME MEASURES

Testosterone, estradiol, dehydroepiandrosterone (DHEA), sex hormone binding globulin (SHBG), and free testosterone.

RESULTS

The mean (SD) levels of 25(OH)D in men and women were 25.7(10.4) and 26.1(12.0)ng/ml, respectively. In men, after adjusting for demographic and lifestyle variables, a 10ng/ml [25nmol/L] decrease in 25(OH)D was associated with an average difference of -0.70nmol/L (95%CI -1.36, -0.05) in SHBG and 0.02 percent (0.01, 0.04) in free testosterone, but was not associated with low total testosterone level (<10.41nmol/L). In women, a 10ng/ml decrease in 25(OH)D levels was associated with an average difference of -0.01nmol/L (-0.01, -0.00) for estradiol, -8.29nmol/L (-10.13, -6.45) for SHBG, 0.06 percent (0.04, 0.07) for free testosterone, and 0.40nmol/L (0.19, 0.62) for DHEA. There was no significant interaction by race/ethnicity.

CONCLUSIONS

Lower 25(OH)D concentrations were associated with lower SHBG levels and higher free testosterone levels in both men and women, and lower estradiol and higher DHEA levels in women, independent of adiposity and lifestyle. We observed no significant association of 25(OH)D with total testosterone in men. Future studies are needed to determine whether vitamin D supplementation influences sex hormone levels.

Cohort profile: Women's Healthy Ageing Project (WHAP) - a longitudinal prospective study of Australian women since 1990

Background

The cohort was commenced to examine women’s health from midlife (45–55 years) before the menopausal transition and into ageing.

Methods

Randomised selection and assessment of 2,001 women living in the Melbourne metropolitan area was conducted by the Roy Morgan Centre in 1990/91. Of the 779 women who met the entry criteria for the longitudinal follow-up (aged 45–55 years, menstruating, having a uterus and at least one ovary and not taking hormone therapy) 438 agreed to be seen annually across the menopausal transition from 1992 to 1999. Longitudinal prospective follow-up since 2000 has continued intermittently (2002/03, 2004/05, 2012/13, 2014/15). Data collection has included fasting biomarkers in each year since 1992, clinical assessment, lifestyle and quality of life data, physical measures and validated questionnaire data. Participants have consented to data linkage and, to date, mammogram and BioGrid data have been accessed. Biobank storage including serum, deoxyribonucleic acid (DNA) storage and PAXgene tubes are maintained.

Discussion

The WHAP has contributed to over 200 published research findings, several books, and book chapters in a variety of areas, including: health and wellbeing; mental and cognitive health; bone health; lifestyle, vascular risk and prevention; women’s health and hormonal transition; and cross-cultural research.

With all participants now aged over 70 years, the cohort is ideally placed to answer key questions of healthy ageing in women. With more than 25 years of longitudinal prospective follow-up this Australian dataset is unique in its duration, breadth and detail of measures including clinical review and specialized disease-specific testing and biomarkers. Ongoing follow-up into older ages for this long-running cohort will enable the association between mid to late-life factors and healthy ageing to be determined. This is particularly valuable for the examination of chronic diseases which have a 20–30 year prodrome and to provide knowledge on multiple morbidities. The dataset has a unique opportunity to improve our understanding of temporal relationships and the interactions between risk factors and comorbidities.

Electronic supplementary material

The online version of this article (doi:10.1186/s40695-016-0018-y) contains supplementary material, which is available to authorized users.

Androgen Deprivation Therapy and the Incidence of Inflammatory Bowel Disease in Patients With Prostate Cancer

Androgen deprivation therapy (ADT) is the mainstay treatment for advanced prostate cancer. By lowering androgen levels, ADT inhibits the progression of prostate cancer, but it may also affect gut autoimmunity. We investigated the association between ADT and the incidence of inflammatory bowel disease using a cohort of 31,842 men newly diagnosed with prostate cancer between 1988 and 2014, identified in the United Kingdom Clinical Practice Research Datalink. Exposure to ADT was treated as a time-varying variable and lagged by 1 year to account for diagnostic delays, with nonuse as the reference category. During 133,018 person-years of follow-up, 48 men were newly diagnosed with ulcerative colitis (incidence rate (IR) = 36/100,000 person-years (PY)) and 12 were diagnosed with Crohn's disease (IR = 9/100,000 PY). In Cox proportional hazards models, ADT was associated with a decreased risk of ulcerative colitis (IR = 24/100,000 PY vs. IR = 50/100,000 PY; hazard ratio = 0.52, 95% confidence interval: 0.28, 0.99) and a nonsignificant decreased risk of Crohn's disease (hazard ratio = 0.38, 95% confidence interval: 0.11, 1.37). These findings indicate that the use of ADT may be associated with intestinal autoimmunity. Further research is warranted to replicate these findings and assess their clinical significance.

Testosterone and cardiac mass and function in men with type 1 diabetes in the Epidemiology of Diabetes Interventions and Complications Study (EDIC)

OBJECTIVE

Low testosterone concentrations have been reported to be associated with increased risk of congestive heart failure, but the mechanisms are unclear. Our objective was to examine the relationship between endogenous testosterone and measures of cardiac mass and function among men with type 1 diabetes.

DESIGN

Secondary analysis of a prospective observational study.

PARTICIPANTS

Men (n = 508) in the Epidemiology of Diabetes Interventions and Complications (EDIC) study, the observational follow-up of the Diabetes Control and Complications Trial (DCCT).

MEASUREMENTS

Testosterone assessed by liquid chromatography mass spectrometry at EDIC year 10 and cardiac magnetic resonance imaging (CMR) measures at EDIC years 14/15. Linear regression models were used to assess the relationship between testosterone, sex hormone binding globulin (SHBG) and left ventricular (LV) mass, volume, ejection fraction and cardiac index before and after adjustment for age, randomization arm, alcohol and cigarette use, macroalbuminuria, haemoglobin A1c, insulin dose, body mass index, lipids, blood pressure, use of antihypertensive medications and microvascular complications.

RESULTS

In fully adjusted models, total testosterone concentrations were significantly associated with LV mass (P = 0·014), end-diastolic volume (P = 0·002), end-systolic volume (P = 0·012) and stroke volume (P = 0·022), but not measures of LV function after adjustment for cardiac risk factors. Bioavailable testosterone was associated with LV mass, but not volume or function, while SHBG was associated with volume, but not mass or function.

CONCLUSIONS

Among men with type 1 diabetes, higher total testosterone was associated with higher LV mass and volume, but not with function. The clinical significance of this association remains to be established.

Testosterone Concentrations and Cardiovascular Autonomic Neuropathy in Men with Type 1 Diabetes in the Epidemiology of Diabetes Interventions and Complications Study (EDIC)

INTRODUCTION

Previous studies have reported that lower testosterone concentrations are associated with cardiovascular autonomic neuropathy (CAN), a risk factor for cardiovascular events. However, no studies have examined this relationship in men with type 1 diabetes, who are at high risk for CAN.

AIM

The aim of this study was to examine the associations between testosterone concentrations and measures of CAN in a large, well-characterized cohort of men with type 1 diabetes.

METHODS

We conducted an analysis of men in the Diabetes Control and Complications Trial (DCCT), a randomized trial of intensive glucose control, and its observational follow-up the Epidemiology of Diabetes Intervention and Complications (EDIC) Study. Testosterone was measured by liquid chromatography mass spectrometry in stored samples from EDIC follow-up years 10 and 17. Regression models were used to assess the cross-sectional relationships between testosterone and CAN measures.

MAIN OUTCOME MEASURES

The main CAN measure from EDIC follow-up year 17 was a standardized composite of R-R variation with paced breathing < 15, or R-R variation 15-20 combined with either a Valsalva ratio ≤ 1.5 or a decrease in diastolic blood pressure > 10 mm Hg upon standing. Continuous R-R variation and Valsalva ratio were secondary outcomes.

RESULTS

Lower total and bioavailable testosterone concentrations at follow-up years 10 and 17 were not associated with the presence of CAN at year 17. In analyses using Valsalva ratio as a continuous measure, higher total (P = 0.01) and bioavailable testosterone concentrations (P = 0.005) were associated with a higher (more favorable) Valsalva ratio after adjustment for covariates including age, body mass index, smoking status, hypertension, and glycemia.

CONCLUSIONS

Testosterone levels are not associated with CAN among men with type 1 diabetes. Although testosterone is associated with a higher Valsalva ratio, a more favorable indicator, the clinical significance of this association is not known.

Sex-specific differential in risk of diabetes-related macrovascular outcomes

Reports from recent studies suggest that diabetes confers a higher risk of cardiovascular disease in women compared to men. Larger studies, including meta-analyses, report that women with diabetes have a 44 % greater risk of incident coronary heart disease and a 27 % greater risk of incident stroke compared to men with diabetes. In this article, we summarize results from longitudinal studies that examine sex differences in risk factors for and rates of macrovascular complications from diabetes. We also discuss possible mechanisms for increased cardiovascular risk associated with diabetes in women compared to men, including the clustering of hypertension, obesity, and elevated triglycerides, the possible contribution of hormonal differences, and sex differences in the prescription of and adherence to pharmacologic treatment. In conclusion, diabetes is associated with a slightly higher risk of cardiovascular disease in women compared to men. Future studies should further explore the reasons underlying imperfect use of medications that lower cardiovascular risk in both women and men with diabetes.