Update: Estrogen and Estrogen plus Progestin Therapy in the Care of Women at and after the Menopause

Dietary genistein and 17β-estradiol implants differentially influence locomotor and cognitive functions following transient focal ischemia in middle-aged ovariectomized rats at different lengths of estrogen deprivation

Genistein possesses estrogenic activity and has been considered a potential replacement for estrogen replacement therapy after menopause. In the current study, we investigated the neuroprotective effects of dietary genistein at varied lengths of estrogen deprivation in middle-aged ovariectomized Sprague-Dawley rats under ischemic conditions. Two weeks of treatment with dietary genistein at 42 mg/kg but not 17β-estradiol implants improved cognitive flexibility (Morris water maze test) after short-term estrogen deprivation (2 weeks) but not long-term estrogen deprivation (12 weeks). 17β-estradiol implants but not dietary genistein improved locomotor asymmetry (cylinder test) after long-term but not short-term estrogen deprivation. Dietary genistein but not 17β-estradiol implant improved early phase motor learning (rotarod test) after long-term estrogen deprivation. Neither 17β-estradiol implant nor dietary genistein reduced infarct size after either short-term or long-term estrogen deprivation. Genistein, however, reduced ionized calcium-binding adaptor molecule-1 (Iba1) expression, a marker of brain inflammation, at the ipsilateral side of stroke injury after short-term but not long-term estrogen deprivation. This study suggests that the neuroprotective effects of dietary genistein on motor and cognitive functions are distinctly influenced by the length of estrogen deprivation following focal ischemia. SIGNIFICANCE: There is an increasing postmenopausal population opting for homeopathic medicines for the management of menopausal symptoms due to the perceived distrust in estrogen use as hormone replacement. Basic and clinical studies support the notion that early, but not delayed, hormone replacement after menopause is beneficial. Furthermore, evidence suggests that delaying hormone replacement augments the detrimental, rather than the beneficial effects of estrogens. Because of the active consideration of soy isoflavones including genistein as alternatives to estrogen replacement, it is necessary to understand the ramifications of soy isoflavones use when their administration is begun at various times after menopause.

Incidence and Trend of Type I and II Endometrial Cancer in Women from Two Population-Based European Cancer Registries (1998-2012)

Endometrial cancer (EC) is the most frequent female genital tract cancer in Europe. This cohort study aimed to determine age-standardised incidence rates and long-term trends of type I and II endometrial cancer in women from population-based cancer registries in the Region of Murcia (Spain) and the Bas-Rhin area (France). Data of new cases of endometrial cancer between 1998 and 2012 were obtained from the Murcia and Bas-Rhin cancer registries. In that period, 3756 cases of endometrial cancer were recorded, with 3270 corresponding to type I EC and 486 corresponding to type II EC. The Bas-Rhin area presented higher age-adjusted incidence rates than those in the Region of Murcia for both type I EC (24.2 and 19.3 cases/100,000 person-years (py), respectively) and type II EC (4.4 and 2.3 cases/100,000 py, respectively). Joinpoint regression showed no changes in trends. In both populations, there was an increasing trend for both EC types, but the trend was steeper in the Region of Murcia and larger overall for type II EC. Finally, a significant increase was observed in the annual trend of type II EC. Further studies are warranted to determine the potential risk factors, and continued efforts are needed to improve the recording and monitoring of EC types.

Breast cancer risk and serum levels of per- and poly-fluoroalkyl substances: a case-control study nested in the California Teachers Study

BACKGROUND

Per- and poly- fluoroalkyl substances (PFASs) are a large family of synthetic chemicals, some of which are mammary toxicants and endocrine disruptors. Their potential as breast carcinogens is unclear. Our objective was to evaluate the risk of breast cancer associated with serum PFAS concentrations in a nested case-control study within the California Teachers Study.

METHODS

Participants were 902 women with invasive breast cancer (cases) and 858 with no such diagnosis (controls) who provided 10 mL of blood and were interviewed during 2011-2015, an average of 35 months after case diagnosis. PFASs were measured using automated online SPE-HPLC-MS/MS methods. Statistical analyses were restricted to six PFASs with detection frequencies ≥ 95%: PFOA (Perfluorooctanoic acid), PFNA (Perfluorononanoic acid), PFUnDA (Perfluoroundecanoic acid), PFHxS (Perfluorohexane sulfonic acid), PFOS (Perfluorooctane sulfonic acid), and MeFOSAA (2-(N-Methyl-perfluorooctane sulfonamido) acetic acid. Unconditional logistic regression was used to calculate adjusted odds ratios (ORs), estimating the breast cancer risk associated with each PFAS.

RESULTS

For all cases of invasive breast cancer, none of the adjusted ORs were statistically significant but marginally significant ORs < 1.0 were observed for PFUnDA and PFHxS (p-trend = 0.08). Adjusted ORs < 1.0 for PFUnDA and PFHxS were statistically significant (p ≤ 0.05) among the 107 cases with hormone-negative tumors but not the 743 with hormone-positive tumors.

CONCLUSION

Overall, these findings do not provide evidence that serum PFAS levels measured after diagnosis are related to breast cancer risk. The few inverse associations found may be due to chance or may be artifacts of study design. Future studies should incorporate information about genetic susceptibility, endogenous estrogen levels, and measurements of PFASs prior to diagnosis and treatment.

Association of coronary artery calcium with bone mineral density in postmenopausal women

OBJECTIVES

Atherosclerosis and osteoporosis (OP) are common diseases in elderly individuals and may share common pathogenetic mechanisms. The aim of this study was to investigate the association between bone mineral density (BMD) and coronary artery calcium (CAC) in postmenopausal women.

METHODS

In this cross-sectional study, 186 postmenopausal women 50-80 years of age were included. BMD of the spine and femoral neck was measured by dual-energy X-ray absorptiometry. The coronary artery calcium score (CACS) was measured by multidetector computed tomography.

RESULTS

The study included postmenopausal women aged 65.6±7.3 years, 109 of whom (58.6%) showed CAC. Thirty-three (17.7%) of the patients were found to have OP in the lumbar spine and 83 (44.6%) had osteopenia, whereas in the femoral neck, 26 patients (14.0%) had OP and 87 patients (46.8%) had osteopenia. The mean CACS was 57.6±108.3 in normal status, 89.7±143.5 in OP, and 156.4±256.9 in osteopenia at the spine (P<0.05). The mean CACS was 43.2±89.9 in normal status, 126.9±180.3 in OP, and 198.2±301.2 in osteopenia at the femoral neck (P<0.05). Multivariable logistic regression analysis showed that BMD was an independent marker for an increased risk of developing CAC in postmenopausal women. The multiple regression model showed that T-scores were the independent predictors of CACS.

CONCLUSION

BMD identified on images from dual-energy X-ray absorptiometry were strongly related to multidetector computed tomography measures of CAC. This low-cost, minimal radiation technique used widely for OP screening is a promising marker of generalized coronary atherosclerosis.

Hospitalization for pulmonary embolism associated with antecedent testosterone or estrogen therapy in patients found to have familial and acquired thrombophilia

BACKGROUND

In patients hospitalized over a 4 year period for pulmonary embolism (PE), we assessed relationships of testosterone (TT) and estrogen therapy (ET) anteceding PE in patients found to have familial-acquired thrombophilia.

METHODS

From 2011 through 2014, 347 patients were hospitalized in Cincinnati Mercy Hospitals with PE. Retrospective chart review was used to identify patients receiving TT or ET before PE; coagulation studies were done prospectively if necessary.

RESULTS

Preceding hospitalization for PE, 8 of 154 men (5 %) used TT, and 24 of 193 women (12 %) used ET. The median number of months from the initiation of TT or ET to development of PE was 7 months in men and 18 months in women. Of the 6 men having coagulation measures, all had ≥ 1 thrombophilia, and of the 18 women having measures of coagulation, 16 had ≥ 1 thrombophilia. The sensitivity of a previous history of thrombosis to predict PE was low, 25 % (2/8 men), 4 % (1/24 women).

CONCLUSIONS

Of 154 men hospitalized for PE, 8 (5 %) used TT, and of 193 women, 24 (12 %) used ET. Our data suggests that PE is an important complication of TT in men and ET in women, in part reflecting an interaction between familial and acquired thrombophilia and exogenous hormone use.

The role of hormones and aromatase inhibitors on breast tumor growth and general health in a postmenopausal mouse model

BACKGROUND

Breast cancer is the most frequently diagnosed cancer in women in the United States. Approximately 70% of breast cancers are diagnosed in postmenopausal women. Major clinical trials and experimental studies showed that aromatase inhibitors are effective against postmenopausal breast cancer. Despite their effectiveness in reducing tumor recurrence, aromatase inhibitors have adverse effects on the cardiovascular system and increase osteoporosis and bone fractures. Our study is aimed at investigating the role of natural steroid hormones on serum cardiovascular and bone resorption markers in an established mouse model mimicking postmenopausal breast cancer.

METHODS

Ovariectomized nude mice were transplanted with MCF-7 breast cancer cells constitutively expressing aromatase. The mice were treated with different combinations and doses of steroids, [estrogen (25 pg, 40 pg, 100 pg), progesterone (6 ng) and testosterone (50 ng)] along with dehydroepiandrostenedione (100 ug). Serum levels of HDL, LDL/VLDL, free and total cholesterol, total and bone specific alkaline phosphatase and triglycerides were analyzed after 5, 10 and 15 months.

RESULTS

Free cholesterol and LDL/VLDL levels in serum were reduced in groups mimicking estrous cycle and menstrual cycle hormones treatment. HDL cholesterol was increased in all the hormone treated groups except the estrous cycle-mimicking group. Bone specific alkaline phosphatase was decreased in menstrual cycle levels of estrogen and progesterone treatment.

CONCLUSIONS

All together our results show that use of natural hormones in appropriate combinations have beneficial effects on cardiac and bone toxicity, along with better tumor reduction than current treatments.

Pharmacology of conjugated equine estrogens: efficacy, safety and mechanism of action

Oral conjugated equine estrogens (CEE) are the most used estrogen formulation for postmenopausal hormone therapy either alone or in combination with a progestin. CEE is most commonly used for the management of early menopausal symptoms such as hot flashes, vaginitis, insomnia, and mood disturbances. Additionally, if used at the start of the menopausal phase (age 50-59 years), CEE prevents osteoporosis and may in some women reduce the risk of cardiovascular disease (CVD) and Alzheimer's disease (AD). There appears to be a common mechanism through which estrogens can protect against CVD and AD. CEE is a natural formulation of an extract prepared from pregnant mares' urine. The product monogram lists the presence of only 10 estrogens consisting of the classical estrogens, estrone and 17β-estradiol, and a group of unique ring B unsaturated estrogens such as equilin and equilenin. The ring B unsaturated estrogens are formed by an alternate steroidogenic pathway in which cholesterol is not an obligatory intermediate. Both the route of administration and structure of these estrogens play a role in the overall pharmacology of CEE. In contrast to 17β-estradiol, ring B unsaturated estrogens express their biological effects mainly mediated by the estrogen receptor β and not the estrogen receptor α. All estrogen components of CEE are antioxidants, and some ring B unsaturated estrogens have several fold greater antioxidant activity than estrone and 17β-estradiol. The cardioprotective and neuroprotective effects of CEE appear to be, to some extent, due to its ability to prevent the formation of oxidized LDL and HDL, and by inhibiting or modulating some of the key proteases involved in programmed cell death (apoptosis) induced by the excess neurotransmitter glutamate and other neurotoxins. Selective combinations of ring B unsaturated estrogens have the potential of being developed as novel therapeutic agents for the prevention of cardiovascular disease and Alzheimer's disease in both aging women and men. This article is part of a Special Issue entitled 'Menopause'.

Gender-specific association between the metabolic syndrome and arterial stiffness in 8,300 subjects

BACKGROUND

The objective of this study was to determine the sex-specific association between the metabolic syndrome (MetS) and arterial stiffness.

METHODS

In this cross-sectional study, 3981 women and 4319 men aged 20 to 79 years were analyzed. All participants underwent the measurement of waist circumference, blood pressure (BP), brachial-ankle pulse wave velocity (baPWV) and blood chemistry. baPWV levels were compared between men and women using the Mann-Whitney's U test. Subjects with or without MetS and its components or specific clusters of MetS components in the different sexes were compared by the Kruskal-Wallis test. Binary logistic regression analysis was performed to evaluate the relationship between baPWV and the MetS components.

RESULTS

Women had lower baPWV than men in young and middle-aged subjects (P < 0.001), but there was no difference in the elderly subjects. baPWV levels in women were higher than in men with MetS and its components except for high-density lipoprotein cholesterol (HDL-C; P < 0.01). The combination of elevated triglycerides, elevated BP and elevated fasting glucose (with obesity or low HDL-C) had a greater baPWV than the other clusters. All the metabolic variables were positively correlated with baPWV except for HDL-C negatively correlating in women (P < 0.001), whereas age, BP and fasting glucose were moderately associated with baPWV in men (P < 0.001). Among the MetS components, BP had the strongest association with baPWV.

CONCLUSIONS

The MetS and its components affect arterial stiffness more severely in women than in men. More importance to women with MetS should be given.

A meta-analysis of reference values of leptin concentration in healthy postmenopausal women

Objective

There are numerous reports about the leptin concentration (LC) in postmenopausal women (PW). Changes in LC can elicit different clinical outcomes. We systematically analyzed the LC in PW.

Methods

A search was conducted in original English-language studies published from 1994 to October 2012 in the following databases: Medline (78), Cochrane Center (123) Embase (505), Biological abstracts (108), Cochrane (53) and Science Finder Scholar (0). A meta-analysis was undertaken on the correction coefficient (r) between the serum LC and body mass index (BMI) for healthy PW across studies containing a dataset and sample size. Pre-analytical and analytical variations were examined. Pre-analytical variables included fasting status (FS) and sampling timing. Analytical variation comprised assay methodology, LC in those undertaking hormone replacement therapy (HRT) and those not having HRT as well as LC change according to age.

Results

Twenty-seven studies met the inclusion criteria. Eighteen studies detected LC in the morning in a FS, 15 studies denoted the r between leptin and the BMI. A combined r was counted for the 15 studies (r = 0.51 [95% confidence interval (CI), 0.46–0.54], P = 0.025), and if sampling collection was in the FSat morning, a combined r was form 10 studies (r = 0.54 [95% CI, 0.45–0.54], P = 0.299) and heterogeneity was diminished. LC did not change between HRT users and non-users in 7 studies. Five studies analyzed changes in LC according to age.

Conclusion

Based on all studies that investigated both LC and BMI, LC was positively correlated with the BMI. No studies established reference ranges according to the Clinical and Laboratory Standards Institute (CLSI) in healthy PW, and there was a wide variation in LC values. These differences suggest that caution should be used in the interpretation and comparison between studies.

Alzheimer's disease, dementia, mild cognitive impairment and the menopause: a 'window of opportunity'?

Alzheimer's disease (AD) is not an inevitable consequence of aging and may be modified by both adverse and protective factors. The pathological changes of AD commence in midlife and AD has a long preclinical phase that may be diagnosed by biomarkers in the cerebrospinal fluid and by brain MRI. New clinical criteria for the diagnosis of AD dementia and AD mild cognitive impairment (MCI) have been proposed. MCI and dementia are frequently the result of AD and cerebrovascular disease combined. Over the age of 85 years, MCI and dementia are more common in women than in men. Women with a surgical premature menopause have an increased risk of MCI and AD. Menopausal hormone therapy from the menopause to the age of 60 years, when any risks of menopausal hormone therapy are extremely small, may provide a 'window of opportunity' to reduce the risk of MCI and AD in later life. Many measures may help to prevent, delay or minimize AD in both women and men and should be actively encouraged.

Exposures to synthetic estrogens at different times during the life, and their effect on breast cancer risk

Women are using estrogens for many purposes, such as to prevent pregnancy or miscarriage, or to treat menopausal symptoms. Estrogens also have been used to treat breast cancer which seems puzzling, since there is convincing evidence to support a link between high lifetime estrogen exposure and increased breast cancer risk. In this review, we discuss the findings that maternal exposure to the synthetic estrogen diethylstilbestrol during pregnancy increases breast cancer risk in both exposed mothers and their daughters. In addition, we review data regarding the use of estrogens in oral contraceptives and as postmenopausal hormone therapy and discuss the opposing effects on breast cancer risk based upon timing of exposure. We place particular emphasis on studies investigating how maternal estrogenic exposures during pregnancy increase breast cancer risk among daughters. New data suggest that these exposures induce epigenetic modifications in the mammary gland and germ cells, thereby causing an inheritable increase in breast cancer risk for multiple generations.

Potential antiosteoporotic agents from plants: a comprehensive review

Osteoporosis is a major health hazard and is a disease of old age; it is a silent epidemic affecting more than 200 million people worldwide in recent years. Based on a large number of chemical and pharmacological research many plants and their compounds have been shown to possess antiosteoporosis activity. This paper reviews the medicinal plants displaying antiosteoporosis properties including their origin, active constituents, and pharmacological data. The plants reported here are the ones which are commonly used in traditional medical systems and have demonstrated clinical effectiveness against osteoporosis. Although many plants have the potential to prevent and treat osteoporosis, so far, only a fraction of these plants have been thoroughly investigated for their physiological and pharmacological properties including their mechanism of action. An attempt should be made to highlight plant species with possible antiosteoporosis properties and they should be investigated further to help with future drug development for treating this disease.

The effects of obesity on venous thromboembolism: A review

Obesity has emerged as a global health issue that is associated with wide spectrum of disorders, including coronary artery disease, diabetes mellitus, hypertension, stroke, and venous thromboembolism (VTE). VTE is one of the most common vascular disorders in the United States and Europe and is associated with significant mortality. Although the association between obesity and VTE appears to be moderate, obesity can interact with other environmental or genetic factors and pose a significantly greater risk of VTE among individuals who are obese and who are exposed simultaneously to several other risk factors for VTE. Therefore, identification of potential interactions between obesity and certain VTE risk factors might offer some critical points for VTE interventions and thus minimize VTE morbidity and mortality among patients who are obese. However, current obesity measurements have limitations and can introduce contradictory results in the outcome of obesity. To overcome these limitations, this review proposes several future directions and suggests some avenues for prevention of VTE associated with obesity as well.