Hormone replacement therapy and cardioprotection: a new dawn? A statement of the Study Group on Cardiovascular Disease in Women of the Italian Society of Cardiology on hormone replacement therapy in postmenopausal women

A Potential Involvement of Anandamide in the Modulation of HO/NOS Systems: Women, Menopause, and "Medical Cannabinoids"

Endocannabinoids and their receptors are present in the cardiovascular system; however, their actions under different pathological conditions remain controversial. The aim of our study was to examine the effects of anandamide (AEA) on heme oxygenase (HO) and nitric oxide synthase (NOS) systems in an estrogen-depleted rat model. Sham-operated (SO) and surgically induced estrogen-deficient (OVX) female Wistar rats were used. During a two-week period, a group of OVX rats received 0.1 mg/kg estrogen (E₂) per os, while AEA-induced alterations were analyzed after two weeks of AEA treatment at the dose of 1.0 mg/kg. At the end of the experiment, cardiac activity and expression of HO and NOS enzymes, content of cannabinoid 1 receptor, as well as concentrations of transient potential vanilloid 1 (TRPV1) and calcitonin gene-related peptide (CGRP) were measured. Our results show that estrogen withdrawal caused a significant decrease in both NOS and HO systems, and a similar tendency was observed regarding the TRPV1/CGRP pathway. Two weeks of either AEA or E₂ treatment restored the adverse changes; however, the combined administration of these two molecules did not result in a further improvement. In light of the potential relationship between AEA and HO/NOS systems, AEA-induced upregulation of HO/NOS enzymes may be a therapeutic strategy in estrogen-deficient conditions.

A Cross-sectional Study on the Relationship Between Homocysteine and Lipid Profiles Among Chinese Population from Hunan

Previous studies have explored the relationship between homocystein (Hcy) and lipid profiles. However, the results from these studies have been inconsistent. The current study investigated the correlation between Hcy and lipid profiles in Chinese community-based population. The participants were composed of 4012 Chinese people aged 30-92 years old, who were recruited from rural and urban communities in the Hunan Province. Non-parametric test and logistic regression were used to examine the distribution of Hcy and lipid profiles (triglyceride [TG], total cholesterol [TC], low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C]) and the relationship between them. The median age of subjects was 54.50 years old, and 40.98% were male. Median Hcy was 13.20 μmol/L, and 35.39% had hyperhomocysteinemia (HHcy). Median TG was 1.51 mmol/L, TC was 4.77 mmol/L, LDL-C was 2.62 mmol/L, and HDL-C was 1.27 mmol/L. In multivariable logistic regression analysis, HHcy was associated with high levels of TG (OR_male = 2.240, p < 0.001; OR_female = 2.539, p < 0.001), TC (OR_male = 2.237, p < 0.001; OR_female = 2.202, p < 0.001), and LDL-C (OR_male = 1.413, p = 0.010; OR_female = 1.617, p < 0.001) in the different sexes population and low level of HDL-C in females (OR = 1.326, p = 0.023) after adjusting for confounders. HHcy was independently associated with an increasing risk of low HDL-C among females. The regression analysis showed that HHcy was also associated with hypertriglyceridemia, hypercholesterolemia, and high level of LDL-C in males and females from Chinese community-based population, which provides a basis for the treatment and prevention of abnormal lipid metabolism.

Is Extra Virgin Olive Oil an Ally for Women's and Men's Cardiovascular Health?

Noncommunicable diseases are long-lasting and slowly progressive and are the leading causes of death and disability. They include cardiovascular diseases (CVD) and diabetes mellitus (DM) that are rising worldwide, with CVD being the leading cause of death in developed countries. Thus, there is a need to find new preventive and therapeutic approaches. Polyphenols seem to have cardioprotective properties; among them, polyphenols and/or minor polar compounds of extra virgin olive oil (EVOO) are attracting special interest. In consideration of numerous sex differences present in CVD and DM, in this narrative review, we applied "gender glasses." Globally, it emerges that olive oil and its derivatives exert some anti-inflammatory and antioxidant effects, modulate glucose metabolism, and ameliorate endothelial dysfunction. However, as in prescription drugs, also in this case there is an important gender bias because the majority of the preclinical studies are performed on male animals, and the sex of donors of cells is not often known; thus a sex/gender bias characterizes preclinical research. There are numerous clinical studies that seem to suggest the benefits of EVOO and its derivatives in CVD; however, these studies have numerous limitations, presenting also a considerable heterogeneity across the interventions. Among limitations, one of the most relevant in the era of personalized medicine, is the non-attention versus women that are few and, also when they are enrolled, sex analysis is lacking. Therefore, in our opinion, it is time to perform more long, extensive and lessheterogeneous trials enrolling both women and men.

On the role of skin in the regulation of local and systemic steroidogenic activities

The mammalian skin is a heterogeneous organ/tissue covering our body, showing regional variations and endowed with neuroendocrine activities. The latter is represented by its ability to produce and respond to neurotransmitters, neuropeptides, hormones and neurohormones, of which expression and phenotypic activities can be modified by ultraviolet radiation, chemical and physical factors, as well as by cytokines. The neuroendocrine contribution to the responses of skin to stress is served, in part, by local synthesis of all elements of the hypothalamo-pituitary-adrenal axis. Skin with subcutis can also be classified as a steroidogenic tissue because it expresses the enzyme, CYP11A1, which initiates steroid synthesis by converting cholesterol to pregnenolone, as in other steroidogenic tissues. Pregnenolone, or steroidal precursors from the circulation, are further transformed in the skin to corticosteroids or sex hormones. Furthermore, in the skin CYP11A1 acts on 7-dehydrocholesterol with production of 7-dehydropregnolone, which can be further metabolized to other Δ7steroids, which after exposure to UVB undergo photochemical transformation to vitamin D like compounds with a short side chain. Vitamin D and lumisterol, produced in the skin after exposure to UVB, are also metabolized by CYP11A1 to several hydroxyderivatives. Vitamin D hydroxyderivatives generated by action of CYP11A1 are biologically active and are subject to further hydroxylations by CYP27B1, CYP27A1 and CP24A. Establishment of which intermediates are produced in the epidermis in vivo and whether they circulate on the systemic level represent a future research challenge. In summary, skin is a neuroendocrine organ endowed with steroid/secosteroidogenic activities.

Prognostic role of heart rate in patients referred for coronary angiography: age and sex differences

OBJECTIVE To evaluate the predictive value of resting heart rate (RHR) for cardiac and total mortality in a large population of patients referred for coronary angiography with an extended follow-up, stratified in four subpopulations according to gender and age (50th percentile corresponding to 67 years).

METHODS

We studied 3559 subjects (2603 males, age: 66 ± 11 years, mean ± SD), obtaining patient data from the Institute electronic databank which saves demographic, clinical, instrumental and follow-up data of patients admitted to our department.

RESULTS

During a mean follow-up period of 35 ± 25 months, 296 (8%) patients died; there were 173 (5%) cardiac deaths. In female patients irrespective of age, RHR (≥ 76 bpm, 75th percentile) did not appear predictive for cardiac death. In females, RHR was predictive for overall mortality after multivariate adjustment only in those aged ≥ 67 years (hazard ratio (HR) 1.7, 95% confidence interval (CI) 1-2.8, p ≤ 0.05). In male patients aged < 67 years, RHR remained as an independent predictive factor for overall mortality at the multivariate analysis (HR 2.5, 95% CI 1.5-4.2, p < 0.001), and as an independent predictor for both cardiac mortality (HR 1.8, 95% CI 1.2-2.7, p < 0.01) and total mortality (HR 1.6, 95% CI 1.2-2.3, p < 0.01) in male patients over 67 years.

CONCLUSION

The current study suggests that the prognostic importance of RHR may differ according to the patient's gender and age, suggesting significant differences in cardiovascular physiopathology between female and male patients.

Changes in fertility and hormone replacement therapy in kidney disease

Infertility is common among men and women with CKD and fertility is usually restored with successful kidney transplantation. There are many causes of infertility in those on dialysis, including sexual dysfunction and impaired spermatogenesis and ovulation resulting from an altered hormonal milieu. There is little information about infertility in CKD, but it is clear that ESRD results in low rates of pregnancy in women. Early reports of increased pregnancy rates in women on nocturnal hemodialysis suggest that this modality may improve the abnormal reproductive hormonal milieu of ESRD; small studies of men on dialysis also suggest this. Just as the specific causes of infertility in men and women with CKD/ESRD are unknown, we also lack information about the appropriateness of hormone replacement in these patients. This paper reviews these linked issues, pointing out the lack of data upon which to base clinical decision-making about these quality-of-life issues in our CKD/ESRD patients.

Calcitriol restores renovascular function in estrogen-deficient rats through downregulation of cyclooxygenase-2 and the thromboxane-prostanoid receptor

Cardiovascular risks increase in postmenopausal women. While vitamin D is supplemented for osteoporosis, it is not known whether it protects renal arterial function during estrogen deficiency. Here we measured changes in renovascular reactivity induced by ovariectomy in rats and examined whether calcitriol, the most active form of vitamin D, was able to correct such changes. The impairment of endothelium-dependent relaxation in renal arteries from ovariectomized rats was effectively reversed by long-term calcitriol treatment. It was also corrected by acute exposure to cyclooxygenase-2 (COX-2) inhibitors and a thromboxane-prostanoid receptor antagonist, respectively. Calcitriol normalized the overexpression of COX-2 and thromboxane-prostanoid receptors in intralobal renal artery segments and aortic endothelial cells isolated from ovariectomized rats. In vitro exposure of the arterial segments to calcitriol for 12 h improved relaxation and downregulated thromboxane-prostanoid receptors. The attenuated nitric oxide production in ovariectomized rat aortic endothelial cells was restored following a 12-h treatment with calcitriol, COX-2 inhibition, or thromboxane-prostanoid receptor antagonism. Thus, impaired endothelium-dependent renal artery relaxation in ovariectomized rats is mediated largely through increased activity and expression of COX-2 and the thromboxane-prostanoid receptor. Calcitriol restores endothelial function through downregulating both signaling proteins during estrogen deficiency.

Characteristics of the Aging Skin

SIGNIFICANCE

Although most researches into the changes in skin with age focus on the unwelcome aesthetic aspects of the aging skin, skin deterioration with age is more than a merely cosmetic problem. Although mortality from skin disease is primarily restricted to melanoma, dermatological disorders are ubiquitous in older people with a significant impact on quality of life. The structural and functional deterioration of the skin that occurs with age has numerous clinical presentations, ranging from benign but potentially excruciating disorders like pruritus to the more threatening carcinomas and melanomas.

RECENT ADVANCES

The degenerative changes that occur in the aging skin are increasingly understood at both the molecular and cellular level, facilitating a deeper understanding of the structural and functional deterioration that these changes produce.

CRITICAL ISSUES

A loss of both function and structural stability in skin proceeds unavoidably as individuals age, which is the result of both intrinsic and extrinsic processes, which contribute simultaneously to a progressive loss of skin integrity. Intrinsic aging proceeds at a genetically determined pace, primarily caused by the buildup of damaging products of cellular metabolism as well as an increasing biological aging of the cells. Estrogen levels strongly influence skin integrity in women as well; falling levels in midlife, therefore, produce premature aging as compared with similarly aged men. Extrinsic insults from the environment add to the dermatological signs of aging.

FUTURE DIRECTIONS

A deeper understanding of the physiological basis of skin aging will facilitate progress in the treatment of the unwelcome sequelae of aging skin, both cosmetic and pathogenic.

Age- and Gender-Normalized Coronary Incidence and Mortality Risks in Primary and Secondary Prevention

Epidemiologic differences in ischemic heart disease incidence between women and men remain largely unexplained. The reasons of women’s “protection” against coronary artery disease (CAD) are not still clear. However, there are subsets more likely to die of a first myocardial infarction. The purpose of this review is to underline different treatment strategies between genders and describe the role of classical and novel factors defined to evaluate CAD risk and mortality, aimed at assessing applicability and relevance for primary and secondary prevention. Women and men present different age-related risk patterns: it should be important to understand whether standard factors may index CAD risk, including mortality, in different ways and/or whether specific factors might be targeted gender-wise. Take home messages include: HDL-cholesterol levels, higher in pre-menopausal women than in men, are more strictly related to CAD. The same is true for high triglycerides and Lp(a). HDL-cholesterol levels are inversely related to incidence and mortality. In primary prevention the role of statins is not completely ascertained in women although in secondary prevention these agents are equally effective in both genders. Weight and glycemic control are effective to reduce cardiovascular disease (CVD) mortality in women from middle to older age. Blood pressure is strongly and directly related to CVD mortality, from middle to older age, particularly in diabetic and over weighted women. Kidney dysfunction, defined using UAE and eGFR predicts primary CVD incidence and risk in both genders. In secondary prediction, kidney dysfunction predicts sudden death in women in conjunction with left ventricular ejection fraction evaluation. Serum uric acid does not differentiate gender-related CVD incidences, although it increases with age. Age-related differences between genders have been related to loss of ovarian function traditionally and to lower iron stores more recently. QT interval, physiologically longer in women than men, may be an index of arrhythmic risk in patients with mitral valve prolapse and increased circulating levels of catecholamines. However, there are no large population-based studies to assess this. In conjunction with novel parameters, such as inflammatory markers and reproductive hormones, classical risk score in women may be implemented in the future.

Hormone replacement therapy: relation to homocysteine and prooxidant-antioxidant status in healthy postmenopausal women

OBJECTIVES

Studies have consistently shown a lower cardiovascular risk in women who received postmenopausal hormone replacement therapy (HRT).

DESIGN AND METHODS

In this study, the effects of HRT were investigated on plasma total homocysteine (tHcy) and the oxidant-antioxidant status in postmenopausal women. 35 of postmenopausal receiving (2 mg estrodiol valerate + 1 mg cyproterone acetate) HRT group, the remaining 25 received orally placebo (NHRT group).

RESULTS

There was no significant change in plasma tHcy levels between HRT and NHRT groups. Malondialdehyde (MDA) and total thiol (t-SH) correlated significantly with tHcy (0.388 and 0.478, respectively) content, and there was a significant negative correlation between E2 level and glutathione transferase (GST) activity (-0.425) in HRT group. Superoxide dismutase (SOD) and HDL-C correlated significantly with t-SH level (0.339 and 0.336, respectively) in plasma after HRT.

CONCLUSION

Our results show that HRT is beneficial in the protection against oxidative damage, and prevents atherosclerotic complications.

Determinants of oxidative stress related to gender: relevance of age and smoking habit

BACKGROUND

Magnitude and major causes of oxidative stress may be different between sexes, although limitedly addressed in clinical studies with controversial results. The present study aimed to determine whether any gender-related difference exists concerning oxidative stress in a population of 332 subjects of both sexes, in a wide age range, with and without cigarette smoking habit.

METHODS

The Oxidative-INDEX was calculated after evaluation of serum hydroperoxides (ROMs) and total antioxidant capacity (OXY) by means of commercial kits (d-ROMs and Oxy-adsorbent Tests, Diacron, Italy) subtracting the OXY standardized variable from the ROMs standardized variable.

RESULTS

The Oxidative-INDEX resulted higher in women with respect to men (p<0.001), in smokers (p<0.01) than in non-smokers, and correlated with cigarette number (p<0.01), age (p<0.001), and post-menopausal status (p<0.001). The multivariate analysis identified age, high blood pressure, and smoking habit as factors independently associated with the Oxidative-INDEX in men, whereas cigarette smoking and age represented the independent risk factors for an elevated oxidative stress status in women.

CONCLUSIONS

Gender-based differences in oxidative stress levels may provide a biochemical basis for the epidemiologic differences in the disease susceptibility between sexes, and suggest different strategies for risk assessment, diagnosis, and treatment specifically targeted to men and women.

Menopausal hormone therapy: what we know now

OVERVIEW

This article describes the findings and limitations of the major research thus far on hormone therapy, particularly that of the Women's Health Initiative; examines practice recommendations; clarifies common terminology related to menopause and hormone therapy; and provides the implications for nurses. This is part one of a four-part series on postmenopausal health.

KEYWORDS

bioidentical hormones, combined estrogen and progestogen therapy, estrogen, estrogen therapy, hormone therapy, menopause, menopausal transition, postmenopause, progestin, progestogen, women's health, Women's Health Initiative.

Gender differences in the cardiovascular effects of sex hormones

Over the last decade, compelling evidence supports the idea that the different impact of cardiovascular disease (CVD) and the differences in vascular biology in men and women may be, at least in part, related to the cardiovascular and metabolic effects of sex steroid hormones. Indeed, androgens and oestrogens influence a multitude of vascular biological processes and their cardiovascular effects are multifaceted. While in women the effects of androgens mainly depend upon oestrogens' levels and, ultimately, upon the estradiol/testosterone ratio, the effects of androgens in men mostly relate to their aromatization into oestrogens. Oestrogens exert potential beneficial effects on the cardiovascular system in both sexes. In women, the effect of oestrogens, alone or in association with progestins, has been widely investigated, but data obtained from older patient populations have lead the medical community and the general public to misleading conclusions. Growing evidence supports the 'timing hypothesis', which suggests that oestrogen/hormone replacement therapy may increase CVD risk if started late after menopause, but produce beneficial cardiovascular effects in younger postmenopausal women. Because in men adequate interventional studies with testosterone are lacking, specific investigations should be performed.

Effects of menopause and tibolone on different cardiovascular biomarkers in healthy women

BACKGROUND AND AIM

The effects of tibolone on cardiovascular risk is not yet fully understood today. We designed this study to assess the effect of the menopausal status and tibolone treatment (2.5 mg/day for 3 months) on different biomarkers of cardiovascular risk in healthy women.

METHODS

Blood arterial pressure were measured, and blood samples collected for glucose, lipid profile (total cholesterol, high density lipoproteins, HDL, low density lipoproteins, and triglycerides), inflammatory (C-reactive protein, Interleukin-6, IL-6, tumor necrosis factor alpha, TNF alpha) and oxidative stress (hydroperoxides and antioxidant capacity) evaluation in 15 premenopausal (mean age: 30 +/- 4 years) and 15 postmenopausal (mean age: 52 +/- 3, mean time from menopause 1.4 +/- 0.4 years) women before and after tibolone treatment.

RESULTS

The menopausal status is associated with increased systolic and diastolic pressure (p<0.05), higher IL-6 (p<0.05) and TNF alpha (p<0.01), and lower antioxidants (p<0.01). However, blood pressure (p<0.05), glucose (p<0.05), TNF alpha (p<0.05) and HDL (p<0.05) fell after tibolone, which did not significantly affect levels of the other biochemical parameters.

CONCLUSIONS

As menopause is associated with increased blood pressure, inflammation and oxidative stress, tibolone restores blood pressure and has beneficial effect on inflammation and glycemia without worsening oxidative stress, although it also reduces HDL levels. Such modifications should be taken into account when tailoring menopausal therapies to specific requirements of each woman.

The effect of hormone therapy and tibolone on serum CD40L and ADAM-8 in healthy post-menopausal women

BACKGROUND/AIM

The role of neutrophils and platelets in atherothrombotic disease is well established. The aim of our study was to investigate the effect of HT and tibolone on the soluble markers of neutrophil and platelet activation, "a disentigrin and metalloproteinase domain" (ADAM-8) and CD40 ligand (CD40L) respectively, in healthy post-menopausal women.

SUBJECTS AND METHODS

One hundred and six healthy post-menopausal women were randomly allocated to: estradiol plus drospirenone (E₂/DSP), E₂ hemihydrate 1 mg plus norethisterone acetate (E₂/NETA) 0.5 mg, and tibolone 2.5 mg. Serum ADAM-8 and CD40L were measured at baseline and at 6 months.

RESULTS

Baseline values of ADAM-8 and CD40L were similar between groups. No significant correlation was revealed between ADAM-8 or CD40L and parameters related to cardiovascular risk factors in each group. No significant changes were observed between baseline values and values at 6 months (E₂/DSP group: ADAM-8: 267.4±71.3 pg/ml vs 270.7±42.8 pg/ml, p=0.86, CD40L: 6.43±3.13 vs 6.79±2.70 ng/ml, p=0.67), (E₂/NETA group: ADAM-8: 308.3±64.3 vs 294.7±57.7 pg/ml, p=0.40, CD40L: 9.68±2.81 vs 8.59±5.13 ng/ml, p=0.51), (tibolone group: ADAM-8: 307.5±87.5 vs 289±48.1 pg/ml, p=0.48, CD40L: 9.46±4.30 vs 9.26±4.60 ng/ml, p=0.99).

CONCLUSIONS

Our study has not revealed an association between estrogen plus progestin treatment or tibolone on serum ADAM-8 and CD40L levels in healthy post-menopausal women. Larger prospective studies are needed to further investigate the effect of low-dose HT or tibolone on serum markers of neutrophil and platelet activation.

Oxidative status and cardiovascular risk in women: Keeping pink at heart

Although cardiovascular disease (CVD) has always been perceived as a pathology regarding essentially males, incidence and death from cardiovascular events dramatically increase after menopause in women. Obviously, while many aspects of CVD are similar in both sexes, it is now clear that there are significant differences as well. Exploration of these gender-related differences in CVD might provide a basis for the development of new strategies in the management of patients with CVD from a gender point of view. In particular, a growing amount of data suggested the possible major role of oxidative stress in female patients and the possibility to integrate this new biomarker in future study evaluating CVD risk in women.

Questioning the cardioprotective action of hormone replacement therapy in postmenopausal women

This article comments on the point of view by Rosano et al. and outlines that the only indications for hormone replacement therapy, at the lowest effective dose for the shortest possible time, should be limited to younger, recently menopausal women who are not at high risk for cardiovascular disease and with unsustainable menopausal symptoms, without any illusory attempt to prevent chronic diseases.

Gender differences in the cardiovascular effect of sex hormones

The higher incidence of cardiovascular disease in men than in women of similar age, and the menopause-associated increase in cardiovascular disease in women, has led to speculation that gender-related differences in sex hormones have a key role in the development and evolution of cardiovascular disease. Compelling data have indicated that sex differences in vascular biology are determined not only by gender-related differences in sex steroid levels, but also by gender-specific tissue and cellular differences that mediate sex-specific responses. In this Review, we describe the sex-specific effects of estrogen and testosterone on cardiovascular risk, direct vascular effects of these sex hormones, and how these effects influence development of atherosclerosis. Cardiovascular effects of exogenous hormone administration are also discussed. Importantly, evidence has indicated that estrogens alone or in combination with progestins in postmenopausal women increase cardiovascular risk if started late after menopause, but that it possibly has beneficial cardiovascular effects in younger postmenopausal women, although data on long-term testosterone therapy are lacking. Hormone therapy should not be considered solely for primary prevention or treatment of cardiovascular disease at this time.