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Porterfield L, Davis JW, Weller SC, Chen L, Wilkinson G. Does hormone therapy exacerbate other venous thromboembolism risk factors? Menopause 2024; 31:123-129. [PMID: 38270903 DOI: 10.1097/gme.0000000000002305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
OBJECTIVE Postmenopausal symptoms in women at higher risk for venous thromboembolism (VTE) due to comorbidities are often undertreated because of concerns that hormone therapy (HT) may increase VTE risk; however, it is unclear how much HT impacts risk of VTE when compared with other risk factors. METHODS This is a case-control study in a commercial claims database from 2007 to 2019. Women aged 50 to 64 years (n = 223,949) were classified as cases if they had an International Classification of Diseases code indicating an acute VTE plus a filled prescription for an anticoagulant, placement of intravascular vena cava filter, or death within 30 days of diagnosis. Controls were matched 10:1 to each case by index date and age. Risk factors and comorbidities present within the year before index were examined. Exposure was defined as a HT prescription within 60 days before index. RESULTS There were 20,359 VTE cases and 203,590 matched controls. A conditional logistic regression indicated that the greatest risks for VTE were from metastatic cancer (odds ratio [OR], 13.66; 95% CI, 12.64-14.75), hospitalization/surgery (OR, 8.51; 95% CI, 8.09-8.96), trauma (OR, 3.52; 95% CI, 3.32-3.73), comorbidity burden (OR, 3.51; 95% CI, 3.34-3.69), history of hypercoagulable condition (OR, 3.10; 95% CI, 2.87-3.36), and varicose veins (OR, 2.87; 95% CI, 2.56-3.22). Regarding hormone exposure, we observed ORs of 1.51 (95% CI, 1.43-1.60) for any recent hormone exposure; 1.13 (95% CI, 1.04-1.23; number needed to harm, 4,274) for unopposed estrogen menopausal HT; 1.23 (95% CI, 1.10-1.38; number needed to harm, 2,440) for combined menopausal HT; and 5.22 (95% CI, 4.67-5.84) for combined hormonal contraceptives compared with no recent HT exposure. CONCLUSIONS Hormone therapy exposure did not appear to adversely influence other risk factors, and exposure generally played a minor role in VTE risk. Contraceptives, however, were a strong risk factor.
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Affiliation(s)
| | - John W Davis
- Department of Population Health Science, School of Public and Population Health, University of Texas Medical Branch, Galveston, TX
| | - Susan C Weller
- Department of Population Health Science, School of Public and Population Health, University of Texas Medical Branch, Galveston, TX
| | - Lu Chen
- Department of Population Health Science, School of Public and Population Health, University of Texas Medical Branch, Galveston, TX
| | - Gregg Wilkinson
- Department of Population Health Science, School of Public and Population Health, University of Texas Medical Branch, Galveston, TX
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Bluming AZ, Hodis HN, Langer RD. 'Tis but a scratch: a critical review of the Women's Health Initiative evidence associating menopausal hormone therapy with the risk of breast cancer. Menopause 2023; 30:1241-1245. [PMID: 37847875 PMCID: PMC10758198 DOI: 10.1097/gme.0000000000002267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
ABSTRACT Use of menopausal hormone therapy (HT) fell precipitously after 2002, largely as a result of the Women's Health Initiative's report claiming that the combination of conjugated equine estrogen (CEE) and medroxyprogesterone acetate increased breast cancer risk and did not improve quality of life. More recently, Women's Health Initiative (WHI) publications acknowledge HT as the most effective treatment for managing menopausal vasomotor symptoms and report that CEE alone reduces the risk of breast cancer by 23% while reducing breast cancer death by 40%. Their sole remaining concern is a small increase in breast cancer incidence with CEE and medroxyprogesterone acetate (1 per 1,000 women per year) but with no increased risk of breast cancer mortality. This article closely examines evidence that calls even this claim of breast cancer risk into serious question, including the WHI's reporting of nonsignificant results as if they were meaningful, a misinterpretation of its own data, and the misleading assertion that the WHI's findings have reduced the incidence of breast cancer in the United States. A generation of women has been deprived of HT largely as a result of this widely publicized misinterpretation of the data. This article attempts to rectify this misunderstanding, with the goal of helping patients and physicians make informed joint decisions about the use of HT.
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Affiliation(s)
- Avrum Z. Bluming
- Department of Medicine, Keck School of Medicine, University of Southern California, San Diego, CA
| | - Howard N. Hodis
- Atherosclerosis Research Unit, Keck School of Medicine, University of Southern California, San Diego, CA
| | - Robert D. Langer
- Department of Family Medicine and Public Health, University of California, San Diego, CA
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3
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Bernaud VE, Koebele SV, Northup-Smith SN, Willeman MN, Barker C, Schatzki-Lumpkin A, Sanchez MV, Bimonte-Nelson HA. Evaluations of memory, anxiety, and the growth factor IGF-1R after post-surgical menopause treatment with a highly selective progestin. Behav Brain Res 2023; 448:114442. [PMID: 37085118 PMCID: PMC11105077 DOI: 10.1016/j.bbr.2023.114442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 04/16/2023] [Accepted: 04/18/2023] [Indexed: 04/23/2023]
Abstract
Progestogens are a key component of menopausal hormone therapies. While some progestogens can be detrimental to cognition, there is preclinical evidence that progestogens with a strong progesterone-receptor affinity benefit some molecular mechanisms believed to underlie cognitive function. Thus, a progestin that maximizes progesterone-receptor affinity and minimizes affinities to other receptors may be cognitively beneficial. We evaluated segesterone-acetate (SGA), a 19-norprogesterone derivative with a strong progesterone-receptor affinity and no androgenic or estrogenic-receptor activity, hypothesizing that it would enhance cognition. Middle-aged rats underwent Sham or Ovariectomy (Ovx) surgery followed by administration of medroxyprogesterone-acetate (MPA; used as a positive control as we have previously shown MPA-induced cognitive deficits), SGA (low or high dose), or vehicle (one Sham and one Ovx group). Spatial working and reference memory, delayed retention, and anxiety-like behavior were assessed, as were memory- and hormone- related protein assays within the frontal cortex, dorsal hippocampus, and entorhinal cortex. Low-dose SGA impaired spatial working memory, while high-dose SGA had a more extensive detrimental impact, negatively affecting spatial reference memory and delayed retention. Replicating previous findings, MPA impaired spatial reference memory and delayed retention. SGA, but not MPA, alleviated Ovx-induced anxiety-like behaviors. On two working memory measures, IGF-1R expression correlated with better working memory only in rats without hormone manipulation; any hormone manipulation or combination of hormone manipulations used herein altered this relationship. These findings suggest that SGA impairs spatial cognition after surgical menopause, and that surgical menopause with or without progestin administration disrupts relationships between a growth factor critical to neuroplasticity.
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Affiliation(s)
- Victoria E Bernaud
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA
| | - Stephanie V Koebele
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA
| | - Steven N Northup-Smith
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA
| | - Mari N Willeman
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA; TGen Institute, 445 N 5th St, Phoenix, AZ 85004, USA
| | - Charlotte Barker
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA
| | - Alex Schatzki-Lumpkin
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA
| | - Maria Valenzuela Sanchez
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA
| | - Heather A Bimonte-Nelson
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA.
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4
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Carter AE, Merriam S. Menopause. Med Clin North Am 2023; 107:199-212. [PMID: 36759091 DOI: 10.1016/j.mcna.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Menopause, which is defined as the point in time 12 months after a woman's final menstrual period, is marked by a decrease in estrogen and accompanying symptoms including vasomotor and genitourinary symptoms. Hormone therapy is the most effective treatment of vasomotor symptoms and is first-line in women with moderate-to-severe vasomotor symptoms who are early in the menopausal transition and do not have a contraindication. Nonhormonal pharmacologic and nonpharmacologic treatments are also available for the treatment of menopause-related symptoms for women who prefer to avoid hormones or who have a contraindication to hormone therapy.
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Affiliation(s)
- Andrea E Carter
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, 200 Lothrop Street, MUH W923, Pittsburgh, PA 15213, USA
| | - Sarah Merriam
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine and Veterans Affairs Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240, USA.
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5
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Li J, Wei Z, Wu J, Min K, Li X, Yao Y, Li Y, Zhang N, Shi A, Han J, Qiao C, Yang K. Trends in research related to menopausal hormone therapy from 2000 to 2021: A bibliometric analysis. Front Med (Lausanne) 2022; 9:952487. [DOI: 10.3389/fmed.2022.952487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 10/11/2022] [Indexed: 11/13/2022] Open
Abstract
We conducted the present bibliometric analysis to explore menopausal hormone therapy (MHT)-related research trends between 2000 and 2021. The Web of Science database was systematically searched from 2000 to 2021 to retrieve MHT-related publications. Visualization mapping and keyword cluster graphs were utilized to illustrate the research topics and hotpots. We included 11,616 MHT-related publications for this bibliometric analysis. The results showed that (1) MHT-related research had a very slow increase in the past 22 years, and the trend fluctuated. Sum of times cited and average citations per item had the same trend: a sharp decline from 2002 to 2003, and a rapid increase from 2003 to 2006, reaching the peak in 2006, then following a downward trend. The average H-index was 57, peaking in 2001; (2) the USA, the League of European Research Universities, and Dr. JoAann Manson from Harvard University contributed the most; (3) Menopause: The Journal of The North American Menopause Society had the most significant number of MHT-related publications; (4) the research hotpots primarily focused on MHT for treating menopausal symptoms and the impact of MHT on women’s health. According to previous studies, MHT was the most effective treatment for managing vasomotor symptoms of menopause, but results from the clinical trials and observational studies regarding MHT adverse events remain inconsistent. Mechanisms are fundamental when clinical studies give conflicting results. Therefore, future studies should focus on adverse events and their mechanisms.
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6
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Beltz AM. Hormonal contraceptive influences on cognition and psychopathology: Past methods, present inferences, and future directions. Front Neuroendocrinol 2022; 67:101037. [PMID: 36154817 DOI: 10.1016/j.yfrne.2022.101037] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 08/24/2022] [Accepted: 09/16/2022] [Indexed: 11/04/2022]
Abstract
In the last decade, there has been a remarkable surge in research on the neural and behavioral correlates of hormonal contraceptive use, particularly oral contraceptive use. Questions have evolved swiftly and notably, with studies no longer revealing if hormonal contraceptives matter for the brain and behavior, but rather how, when, and for whom they matter most. Paralleling this shift, the goal of this review is to move beyond an average synthesis of hormonal contraceptive influences on human cognition and psychopathology (and their neural substrates) in order to consider the nature and specificity of effects. Accompanied by an evaluation of study methods and informed by findings from animal models, this consideration uncovers promising areas of research in the next ten years, including potential activational and organizational effects of hormonal contraceptive use, individual differences in effects that matter for the wellbeing of unique individuals, and correlates of intrauterine device use.
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Affiliation(s)
- Adriene M Beltz
- University of Michigan, 2227 East Hall, 530 Church Street, Ann Abor, MI 48109, USA.
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8
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Introduction: Estrogen Reconsidered: Exploring the Evidence for Estrogen's Benefits and Risks. Cancer J 2022; 28:157-162. [PMID: 35594461 DOI: 10.1097/ppo.0000000000000602] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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9
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Abstract
Hormone therapy is the most effective treatment for menopause-related symptoms. Current evidence supports its use in young healthy postmenopausal women under the age of 60 years, and within 10 years of menopause, with benefits typically outweighing risks. However, decision making is more complex in the more common clinical scenario of a symptomatic woman with one or more chronic medical conditions that potentially alter the risk-benefit balance of hormone therapy use. In this review, we present the evidence relating to the use of hormone therapy in women with chronic medical conditions such as obesity, hypertension, dyslipidemia, diabetes, venous thromboembolism, and autoimmune diseases. We discuss the differences between oral and transdermal routes of administration of estrogen and the situations when one route might be preferred over another. We also review evidence regarding the effect of different progestogens, when available.
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Affiliation(s)
- Ekta Kapoor
- Center for Women’s Health, Mayo Clinic, 200 First St SW, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, USA
- Division of Endocrinology, Diabetes, Metabolism, & Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN, USA
| | - Juliana M. Kling
- Center for Women’s Health, Mayo Clinic, 200 First St SW, Rochester, MN, USA
- Division of Women’s Health Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Angie S. Lobo
- Center for Women’s Health, Mayo Clinic, 200 First St SW, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, USA
| | - Stephanie S. Faubion
- Center for Women’s Health, Mayo Clinic, 200 First St SW, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, USA
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10
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Flores VA, Pal L, Manson JE. Hormone Therapy in Menopause: Concepts, Controversies, and Approach to Treatment. Endocr Rev 2021; 42:720-752. [PMID: 33858012 DOI: 10.1210/endrev/bnab011] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Indexed: 12/22/2022]
Abstract
Hormone therapy (HT) is an effective treatment for menopausal symptoms, including vasomotor symptoms and genitourinary syndrome of menopause. Randomized trials also demonstrate positive effects on bone health, and age-stratified analyses indicate more favorable effects on coronary heart disease and all-cause mortality in younger women (close proximity to menopause) than in women more than a decade past menopause. In the absence of contraindications or other major comorbidities, recently menopausal women with moderate or severe symptoms are appropriate candidates for HT. The Women's Health Initiative (WHI) hormone therapy trials-estrogen and progestin trial and the estrogen-alone trial-clarified the benefits and risks of HT, including how the results differed by age. A key lesson from the WHI trials, which was unfortunately lost in the posttrial cacophony, was that the risk:benefit ratio and safety profile of HT differed markedly by clinical characteristics of the participants, especially age, time since menopause, and comorbidity status. In the present review of the WHI and other recent HT trials, we aim to provide readers with an improved understanding of the importance of the timing of HT initiation, type and route of administration, and of patient-specific considerations that should be weighed when prescribing HT.
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Affiliation(s)
- Valerie A Flores
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lubna Pal
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - JoAnn E Manson
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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11
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Abstract
This review focuses on the diagnosis and management of menopause, highlighting both hormonal and nonhormonal treatment options. In particular, the article focuses on recent data on the risks and benefits of hormone therapy to help clinicians better counsel their patients about decision making with regard to understanding and treating menopause symptoms.
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Affiliation(s)
- Melissa A McNeil
- University of Pittsburgh Medical School, Pittsburgh, Pennsylvania
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12
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Romani AMP. The controversy on the beneficial effect of phytoestrogens in diabetic treatment in postmenopausal women. Biochem Pharmacol 2021; 190:114619. [PMID: 34051210 DOI: 10.1016/j.bcp.2021.114619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 11/29/2022]
Abstract
Phytoestrogens have been identified as a natural, plant-based alternative to synthetically derived estrogens, to supplement the absence of endogenous estrogens in post-menopausal women, and attenuate the progression of pathologies and side-effects associated with menopause. The increased availability of these plant's derived compounds as diet or nutritional supplements makes their ingestion and consumption easier and more accessible as compared to pharmacological alternatives. Further, phytoestrogen intake has shown beneficial effects as estrogens alternatives in attenuating severe complications in diseases such as type 2 diabetes, metabolic syndrome, NAFLD, and obesity. However, in many cases phytoestrogen effectiveness remains largely circumstantial or just anecdotal as significant uncertainties on the relative abundance of different phytoestrogens in a given diet, the need for conversion to an active principle through the gut microbiome, the possibility of an effect threshold, the synergistic effect of different phytoestrogens possible due to different modality of actions still persist. The present article aims at highlighting the main issues and concerns plaguing the field as well as some of the possible causes of inconsistencies observed in the various nutritional and clinical studies attempted so far.
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Affiliation(s)
- Andrea M P Romani
- Dept. Physiology and Biophysics, School of Medicine, Case Western Reserve University, United States.
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13
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Abstract
Screening for osteoporosis in women can be based on age and weight, using the Osteoporosis Screening Tool for Asians and assessment for other risk factors such as early menopause, Chinese ethnicity and other secondary factors. Based on the resulting risk profile, women can be triaged to dual-energy X-ray absorptiometry (DEXA) scanning for definite diagnosis of osteoporosis. Treatment should be considered in women with previous fragility fractures, DEXA-diagnosed osteoporosis and high risk of fracture. Exercise improves muscle function, can help prevent falls and has moderate effects on improvements in bone mass. Women should ensure adequate calcium intake and vitamin D. Menopausal hormone therapy (MHT) effectively prevents osteoporosis and fractures, and should be encouraged in those aged < 50 years. For women aged < 60 years, MHT or tibolone can be considered, especially if they have vasomotor or genitourinary symptoms. Risedronate or bisphosphonates may then be reserved for those aged over 60 years.
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Affiliation(s)
- Eu-Leong Yong
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Susan Logan
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Affiliation(s)
- Cynthia A Stuenkel
- Department of Medicine, University of California, San Diego, School of Medicine, La Jolla
| | - JoAnn E Manson
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Kase NG, Gretz Friedman E, Brodman M, Kang C, Gallagher EJ, LeRoith D. The midlife transition and the risk of cardiovascular disease and cancer Part I: magnitude and mechanisms. Am J Obstet Gynecol 2020; 223:820-833. [PMID: 32497614 DOI: 10.1016/j.ajog.2020.05.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/09/2020] [Accepted: 05/28/2020] [Indexed: 12/20/2022]
Abstract
Heart disease and cancer are the leading causes of death in the United States. In women, the clinical appearance of both entities-coronary heart disease and cancer (breast, endometrium, and ovary)-escalate during the decades of the midlife transition encompassing the menopause. In addition to the impact of aging, during the interval between the age of 40 and 65 years, the pathophysiologic components of metabolic syndrome also emerge and accelerate. These include visceral adiposity (measured as waist circumference), hypertension, diabetes, and dyslipidemia. Osteoporosis, osteoarthritis, sarcopenia, depression, and even cognitive decline and dementia appear, and most, if not all, are considered functionally related. Two clinical reports confirm the interaction linking the emergence of disease: endometrial cancer and metabolic syndrome. One describes the discovery of unsuspected endometrial cancer in a large series of elective hysterectomies performed in aged and metabolically susceptible populations. The other is from the Women's Health Initiative Observational Study, which found a positive interaction between endometrial cancer and metabolic syndrome regardless of the presence or absence of visceral adiposity. Both provide additional statistical support for the long-suspected causal interaction among the parallel but variable occurrence of these common entities-visceral obesity, heart disease, diabetes, cancer, and the prevalence of metabolic syndrome. Therefore, 2 critical clinical questions require analysis and answers: 1: Why do chronic diseases of adulthood-metabolic, cardiovascular, endocrine-and, in women, cancers of the breast and endometrium (tissues and tumors replete with estrogen receptors) emerge and their incidence trajectories accelerate during the postmenopausal period when little or no endogenous estradiol is available, and yet the therapeutic application of estrogen stimulates their appearance? 2: To what extent should identification of these etiologic driving forces require modification of the gynecologist's responsibilities in the care of our patients in the postreproductive decades of the female life cycle? Part l of this 2-part set of "expert reviews" defines the dimensions, gravity, and interactive synergy of each clinical challenge gynecologists face while caring for their midlife (primarily postmenopausal) patients. It describes the clinically identifiable, potentially treatable, pathogenic mechanisms driving these threats to quality of life and longevity. Part 2 (accepted, American Journal of Obstetrics & Gynecology) identifies 7 objectives of successful clinical care, offers "triage" prioritization targets, and provides feasible opportunities for insertion of primary preventive care initiatives. To implement these goals, a reprogrammed, repurposed office visit is described.
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Affiliation(s)
- Nathan G Kase
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY; Division of Endocrinology, Diabetes, and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Elissa Gretz Friedman
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael Brodman
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Chifei Kang
- Division of Endocrinology, Diabetes, and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Emily J Gallagher
- Division of Endocrinology, Diabetes, and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Derek LeRoith
- Division of Endocrinology, Diabetes, and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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16
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Kase NG, Gretz Friedman E, Brodman M. The midlife transition and the risk of cardiovascular disease and cancer Part II: strategies to maximize quality of life and limit dysfunction and disease. Am J Obstet Gynecol 2020; 223:834-847.e2. [PMID: 32533929 DOI: 10.1016/j.ajog.2020.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/28/2020] [Accepted: 06/03/2020] [Indexed: 12/11/2022]
Abstract
Chronic dysfunction, disabilities, and complex diseases such as cardiovascular disease, diabetes mellitus type 2, osteoporosis and certain cancers, among other burdens, emerge and accelerate in midlife women. Previously in part l, we described the clinical and laboratory research findings that more readily explain and clarify the underlying pathogenetic mechanisms driving these clinical burdens, including new findings on how in particular visceral obesity and the emergence and acceleration of various components of metabolic syndrome-glucotoxicity and lipotoxicity-and a chronic systemic inflammatory state abetted by the loss of ovarian production of estradiol and the inevitable inroads of aging generate this spectrum of clinical problems. These research insights translate into opportunities for effective care strategies leading to prevention, amelioration, possible correction, and enhanced quality of life. To achieve these goals, updated detailed diagnostic, management, and therapeutic guidelines implemented by a reprogrammed and repurposed "menopause" office visit are described. A triage mechanism-when to refer to other specialists for further care-is emphasized. The previously polarized views of menopausal hormone therapy have narrowed significantly, leading to the construction of a more confident, unified, and wider clinical application. Accordingly, a menopausal hormone therapy program providing maximum benefit and minimum risk, accompanied by an algorithm for enhanced shared decision making, is included.
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Lin RJ, Wang T. Comparison of Fundamental Frequency in Postmenopausal Women Who Are Treated With Hormone Replacement Therapy vs Those Who Are Not: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg 2020; 146:1045-1053. [PMID: 32790826 DOI: 10.1001/jamaoto.2020.2174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Hormonal changes during menopause have been associated with significant changes in voice. Although hormone replacement therapy (HRT) is used primarily to manage systemic symptoms of menopause, its association with voice in postmenopausal women has not been adequately investigated by large-scale studies. Objective To compare fundamental frequency between postmenopausal women who used HRT and those who did not use HRT. Data Sources PubMed, Ovid MEDLINE, CINAHL, Cochrane EBM Reviews, and Embase were searched from 1946 to February 19, 2020. Study Selection Studies included in the final review were those in English that compared voice outcomes in postmenopausal women who were or were not receiving HRT for treatment of climacteric symptoms associated with menopause. Data Extraction and Synthesis The study was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data extraction was performed by 2 independent investigators. Study quality was assessed using a validated quality tool. Whenever possible, data were pooled using random-effects meta-analysis. Main Outcomes and Measures The primary outcome was the difference in speaking fundamental frequency (F0) between HRT users and nonusers. Subgroup analysis of the primary outcome was based on body mass index (BMI) using a cutoff value of 25. A BMI of 18.5 to 24.9 is considered normal, and a BMI of at least 25 is considered overweight. Secondary outcomes included other objective measurements of voice, including jitter and shimmer. Results A total of 937 records were screened, 18 full texts were assessed, and 11 studies were included in the final review. All 11 studies were case-control studies and were rated from fair to good quality based on the Newcastle-Ottawa Scale. A total of 5 studies including 154 participants who received HRT and 154 controls were used for meta-analysis. The mean (SD) F0 was 185.9 (8.6) Hz for HRT users compared with 174.6 (6.6) Hz for nonusers. Hormone replacement therapy was associated with a higher mean F0 by a difference of 11.85 Hz (95% CI, 7.35-16.36 Hz). Subgroup analysis showed that the change in F0 was significant in postmenopausal women with a normal body mass index (mean difference, 13.47 Hz; 95% CI, 8.48-18.46 Hz) but not in those with a high body mass index. Conclusions and Relevance Existing evidence suggests that HRT is associated with a higher F0 in postmenopausal women. The effectiveness of the treatment appeared to be more pronounced in women with a normal body mass index.
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Affiliation(s)
- R Jun Lin
- Department of Otolaryngology-Head & Neck Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Tianyue Wang
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
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18
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Stuenkel CA. Managing menopausal vasomotor symptoms in older women. Maturitas 2020; 143:36-40. [PMID: 33308634 DOI: 10.1016/j.maturitas.2020.08.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/07/2020] [Accepted: 08/12/2020] [Indexed: 11/18/2022]
Abstract
This review considers the persistent vasomotor symptoms (VMS) of menopause-hot flashes-from the perspective of older women. Although these symptoms are most prevalent in younger women during the menopause transition and recent postmenopausal years, emerging data, corroborated by clinical experience, support the observation that for some women, VMS can remain bothersome into advanced age. Most clinical guidance focuses on treating VMS in younger women because of the concerns of increasing cardiovascular disease (CVD) risks and possibly dementia when menopausal hormone therapies (MHT) are initiated at more advanced ages. Furthermore, recent studies into the physiology of VMS suggest a potential link with endothelial dysfunction and evidence of increased subclinical CVD and CVD events. Clinical trials have reported that older women with VMS have markedly increased CVD risk in response to oral MHT initiation compared with asymptomatic women. Nonhormonal treatment options are available for those who elect not to use, or are advised not to use, menopausal hormone therapies. As the global population ages, more research is needed to clarify the physiology of VMS in older women, suggest optimal approaches to enhance awareness of potential health risks of VMS, and recommend strategic management of VMS in older women, with the goal of promoting health and maintaining quality of life.
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Affiliation(s)
- Cynthia A Stuenkel
- Department of Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, School of Medicine La Jolla, CA, USA.
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19
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The Women's Health Initiative trials of menopausal hormone therapy: lessons learned. ACTA ACUST UNITED AC 2020; 27:918-928. [DOI: 10.1097/gme.0000000000001553] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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20
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Weng CH, Okawa ER, Roberts MB, Park SK, Umbricht CB, Manson JE, Eaton CB. Breast Cancer Risk in Postmenopausal Women with Medical History of Thyroid Disorder in the Women's Health Initiative. Thyroid 2020; 30:519-530. [PMID: 31918623 PMCID: PMC7187984 DOI: 10.1089/thy.2019.0426] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: The association between thyroid disorders and breast cancer remains controversial, in part, due to small cohort sizes and inconsistent findings. We investigated this association in postmenopausal women to determine whether hyper- or hypothyroidism is associated with the risk of developing breast cancer and to determine whether menopausal hormone therapy (MHT) further modifies the risk. Methods: We conducted a prospective cohort study of multiethnic U.S. postmenopausal women aged 50 to 79 years enrolled in both clinical trial and observational study arms between 1993 and 1998 and followed up through February 28, 2017. Development of invasive breast cancer after enrollment was recorded and a history of hyper- or hypothyroidism before the diagnosis of breast cancer was identified. The effect modification by MHT in both study arms was analyzed. All statistical tests were two sided. Results: Among a total of 134,122 women who were included in our study, 8137 participants developed invasive breast cancer during the follow-up period. There was a significant inverse association of invasive breast cancer among women with a history of hypothyroidism (hazard ratio [HR] 0.91, confidence interval [95% CI] 0.86-0.97) and among women who had taken levothyroxine [HR 0.89, 95% CI 0.82-0.96]. Evaluating effect modification by MHT use, the inverse association between hypothyroidism treated with thyroid replacement medications and breast cancer risk was strongest in non-MHT users [HR 0.80, 95% CI 0.69-0.93]. The results did not significantly differ by race/ethnicity. Although a history of hyperthyroidism was associated with an increased risk of invasive breast cancer [HR 1.11, 95% CI 0.91-1.35], this finding did not reach statistical significance. We did not see significant differences in the breast cancer Surveillance, Epidemiology, and End Results stages, histologic types, morphologic grades, or receptor status (estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2) according to thyroid disorder status. Conclusions: Compared with women with no history of thyroid disorder, hypothyroidism was associated with a lower risk of breast cancer. This was mainly seen among those who received thyroid replacement therapy and had never used MHT. Among the treatment options for hypothyroidism, levothyroxine had the strongest inverse association with breast cancer risk.
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Affiliation(s)
- Chien-Hsiang Weng
- Department of Family Medicine, Brown University Warren Alpert Medical School, Providence, Rhode Island
- Department of Family Medicine, Providence Community Health Centers, Providence, Rhode Island
- Address correspondence to: Chien-Hsiang Weng, MD, MPH, Department of Family Medicine, Brown University Warren Alpert Medical School, Bio Med Family Medicine, Box G-MHRI, Brown University, Providence, RI 02912
| | - Erin R. Okawa
- Division of Pediatric Endocrinology, Mattel Children's Hospital, University of California, Los Angeles, California
| | - Mary B. Roberts
- Center for Primary Care and Prevention, Brown University School of Public Health, Pawtucket, Rhode Island
| | - Sue K. Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Christopher B. Umbricht
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - JoAnn E. Manson
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Charles B. Eaton
- Department of Family Medicine, Brown University Warren Alpert Medical School, Providence, Rhode Island
- Center for Primary Care and Prevention, Brown University School of Public Health, Pawtucket, Rhode Island
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
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21
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Lewiecki EM, Bilezikian JP, Kagan R, Krakow D, McClung MR, Miller PD, Rush ET, Shuhart CR, Watts NB, Yu EW. Proceedings of the 2019 Santa Fe Bone Symposium: New Concepts in the Care of Osteoporosis and Rare Bone Diseases. J Clin Densitom 2020; 23:1-20. [PMID: 31685420 DOI: 10.1016/j.jocd.2019.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 09/24/2019] [Indexed: 02/08/2023]
Abstract
The 20th annual Santa Fe Bone Symposium was held August 9-10, 2019, in Santa Fe, New Mexico, USA. This is an annual meeting devoted to clinical applications of recent advances in skeletal research that impact the care of patients with osteoporosis, metabolic bone diseases, and inherited bone diseases. Participants included practicing and academic physicians, fellows, advanced practice providers, fracture liaison service (FLS) coordinators, clinical researchers, and bone density technologists. The symposium consisted of lectures, case presentations, and panel discussions, with an emphasis on learning through interaction of all attendees. Topics included new approaches in the use of anabolic agents for the treatment osteoporosis, a review of important events in skeletal health over the past year, new and emerging treatments for rare bone diseases, the use of genetic testing for bone diseases in clinical practice, medication-associated causes of osteoporosis, new concepts in the use of estrogen therapy for osteoporosis, new Official Positions of the International Society for Clinical Densitometry, skeletal consequences of bariatric surgery, and update on the progress and potential of Bone Health TeleECHO, a virtual community of practice using videoconferencing technology to link healthcare professionals for advancing the care of osteoporosis worldwide. Sessions on rare bone diseases were developed in collaboration with the Rare Bone Disease Alliance. Symposium premeetings included an FLS workshop by the National Osteoporosis Foundation and others devoted to the use of new therapeutic agents for the care of osteoporosis and related disorders.
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Affiliation(s)
- E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA.
| | - John P Bilezikian
- Columbia University College of Physicians and Surgeons, NYC, NY, USA
| | - Risa Kagan
- UCSF and Sutter East Bay Medical Foundation, Berkeley, CA, USA
| | - Deborah Krakow
- University of California Los Angeles, Los Angeles, CA, USA
| | - Michael R McClung
- Oregon Osteoporosis Center, Portland, OR, USA; Mary MacKillop Center for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Paul D Miller
- University of Colorado Health Sciences Center, Denver, CO, USA
| | - Eric T Rush
- University of Kansas Medical Center, Kansas City, MO, USA; Children's Mercy Hospital, Kansas City, MO, USA; University of Missouri - Kansas City, Kansas City, MO, USA
| | | | - Nelson B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA
| | - Elaine W Yu
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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22
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Estradiol/Progesterone (Bijuva) for Menopausal Vasomotor Symptoms. JAMA 2019; 322:1206-1207. [PMID: 31550026 DOI: 10.1001/jama.2019.10692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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