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Morimont L, Didembourg M, Bouvy C, Jost M, Taziaux M, Oligschlager Y, van Rooijen M, Gaspard U, Foidart JM, Douxfils J. Low thrombin generation in postmenopausal women using estetrol. Climacteric 2024; 27:193-201. [PMID: 38241059 DOI: 10.1080/13697137.2023.2292066] [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] [Received: 10/18/2023] [Accepted: 12/01/2023] [Indexed: 03/13/2024]
Abstract
OBJECTIVE Estetrol (E4) represents a novel estrogen of interest to relieve vasomotor symptoms. E4 activates the nuclear estrogen receptor α (ERα) but antagonizes the estradiol ERα-dependent membrane-initiated steroid signaling pathway. The distinct pharmacological properties of E4 could explain its low impact on hemostasis. This study aimed to assess the effect of E4 on coagulation in postmenopausal women, using the thrombin generation assay (TGA). METHODS Data were collected from a multicenter, randomized, placebo-controlled, dose-finding study in postmenopausal women (NCT02834312). Oral E4 (2.5 mg, n = 42; 5 mg, n = 29; 10 mg, n = 34; or 15 mg, n = 32) or placebo (n = 31) was administered daily for 12 weeks. Thrombograms and TGA parameters were extracted for each subject at baseline and after 12 weeks of treatment. RESULTS After 12 weeks of treatment, all treatment groups showed a mean thrombogram (±95% confidence interval [CI] of the mean) within the reference ranges, that is, the 2.5th-97.5th percentile of all baseline thrombograms (n = 168), as well as for TGA parameters. CONCLUSIONS The intake of E4 15 mg for 12 weeks led to significant but not clinically relevant changes compared to baseline as the mean values (±95% CI of the mean) remained within reference ranges, demonstrating a neutral profile of this estrogen on hemostasis.
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Affiliation(s)
- L Morimont
- QUALIresearch, Qualiblood s.a, Namur, Belgium
- Clinical Pharmacology and Toxicology Research Unit (CPRU), Namur Research Institute for LIfe Sciences (NARILIS), Faculty of Medicine, University of Namur, Namur, Belgium
| | - M Didembourg
- Clinical Pharmacology and Toxicology Research Unit (CPRU), Namur Research Institute for LIfe Sciences (NARILIS), Faculty of Medicine, University of Namur, Namur, Belgium
| | - C Bouvy
- QUALIresearch, Qualiblood s.a, Namur, Belgium
| | - M Jost
- Estetra SRL, An affiliate Company of Mithra Pharmaceuticals, Liège, Belgium
| | - M Taziaux
- Estetra SRL, An affiliate Company of Mithra Pharmaceuticals, Liège, Belgium
| | - Y Oligschlager
- Estetra SRL, An affiliate Company of Mithra Pharmaceuticals, Liège, Belgium
| | - M van Rooijen
- Estetra SRL, An affiliate Company of Mithra Pharmaceuticals, Liège, Belgium
| | - U Gaspard
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - J-M Foidart
- Estetra SRL, An affiliate Company of Mithra Pharmaceuticals, Liège, Belgium
- Clinical Sciences Department, Faculty of Medicine, University of Liège, Liège, Belgium
| | - J Douxfils
- QUALIresearch, Qualiblood s.a, Namur, Belgium
- Clinical Pharmacology and Toxicology Research Unit (CPRU), Namur Research Institute for LIfe Sciences (NARILIS), Faculty of Medicine, University of Namur, Namur, Belgium
- Department of Biological Hematology, Centre Hospitalier Universitaire Clermont-Ferrand, Hôpital Estaing, Clermont-Ferrand, France
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2
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Gulamhusein N, Miranda KT, Ahmed SB, Leung AA, Tang KL, Adekanye J, Butalia S. Measurements of Postmenopausal Serum Estradiol Levels and Cardiovascular Events: A Systematic Review. CJC Open 2024; 6:347-354. [PMID: 38487048 PMCID: PMC10935696 DOI: 10.1016/j.cjco.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/13/2023] [Indexed: 03/17/2024] Open
Abstract
Background Cardiovascular disease (CVD) is the leading cause of death among female patients and its likelihood increases following menopause. However, whether estradiol levels are related to CVD remains unknown. We aimed to determine the association between serum estradiol levels and cardiovascular (CV) events in postmenopausal females. Methods Electronic databases (MEDLINE, Embase) were searched systematically from inception to October 2022. Studies were eligible for inclusion if they included the following: (i) postmenopausal females; (ii) examination of the association between total serum estradiol levels and CV events (CV mortality, CVD, coronary heart disease, myocardial infarction, stroke, venous thromboembolism, heart failure, and CV hospitalization); (iii) original data (randomized controlled trial, quasi-experimental, cohort, case-control, or cross-sectional study). A narrative synthesis was completed because the data were not amenable to meta-analysis. Results Of the 9026 citations retrieved, 8 articles were included, representing a total of 5635 women. The risk-of-bias was fair, and considerable heterogeneity was present. In those not using menopausal hormone therapy, 3 studies demonstrated mixed results between estradiol levels and risk of coronary heart disease, and 1 study showed that higher estradiol levels were associated with an increased risk of myocardial infarction. No significant associations were present between estradiol levels and the remaining events (ie, CV mortality, heart failure, CVD, and stroke). Conclusions The association between serum estradiol levels and CV events in postmenopausal females remains unclear. Further studies assessing this association are warranted, given the elevated CVD risk in this population.
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Affiliation(s)
- Nabilah Gulamhusein
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Keila Turino Miranda
- Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada
| | - Sofia B. Ahmed
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Kidney Disease Network, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, Calgary, Alberta, Canada
| | - Alexander A. Leung
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Karen L. Tang
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Joel Adekanye
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sonia Butalia
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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3
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Abouharb ALZ, Mehta S, Rathnayake H, Pandit H. Withholding of Hormone Replacement Therapy Prior to Total Joint Arthroplasty Surgery to Reduce the Risk of Postoperative Thromboembolic Events: Is It Justified?-A Systematic Review of Clinical Practice Guidelines. J Arthroplasty 2024; 39:541-548.e24. [PMID: 37634878 DOI: 10.1016/j.arth.2023.08.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Hormone replacement therapy (HRT), menopausal hormone therapy (MHT), and estrogen-containing medications are frequently withheld before elective lower limb arthroplasty, based on a perceived risk of venous thromboembolism (VTE). However, evidence linking HRT, MHT, and an increased VTE risk is equivocal. This systematic review evaluated the concordance of international clinical practice guidelines (CPGs) on the withholding of HRT or MHT. METHODS The PubMed, Google Scholar, Cochrane, and Ovid databases were searched for CPGs for the preoperative, perioperative, and postoperative management of patients on HRT and MHT undergoing elective lower limb arthroplasty. This was supplemented by an internet search. There were 7 international CPGs in English, from Europe and North America, published between January 2000 and February 2023 reviewed against the Appraisal of Guidelines for Research & Evaluation Instrument (AGREE-II) criteria, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. RESULTS The guidelines reviewed revealed a mixed picture on HRT or MHT withdrawal and use in arthroplasty, with some featuring detailed advice on the preoperative and postoperative management of HRT or MHT (Scottish Intercollegiate Guidelines Network), while others featured no guidance (American College of Chest Physicians). The evidence referenced in these guidelines highlighted studies showing HRT or MHT to play a limited role in increasing VTE risk, with most studies from the 1990s and 2000s. CONCLUSIONS Based on current evidence, non-estrogen-containing transdermal HRT or MHT should not be withheld in patients undergoing elective joint arthroplasty, though further evidence is required to justify withholding estrogen-containing forms.
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Affiliation(s)
- Alexander L Z Abouharb
- Leeds Teaching Hospitals NHS Trust, St. James's University Hospital, Leeds, West Yorkshire, United Kingdom; Imperial College London, Faculty of Medicine, St Mary's Hospital, London, United Kingdom
| | - Sachit Mehta
- Imperial College London, Faculty of Medicine, St Mary's Hospital, London, United Kingdom
| | - Hasithe Rathnayake
- Imperial College London, Faculty of Medicine, St Mary's Hospital, London, United Kingdom
| | - Hemant Pandit
- Leeds Teaching Hospitals NHS Trust, St. James's University Hospital, Leeds, West Yorkshire, United Kingdom; Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Chapel Allerton Hospital, Leeds, United Kingdom
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Rasouli B, Chubak J, Floyd JS, Psaty BM, Nguyen M, Walker RL, Wiggins KL, Logan RW, Danaei G. Combining high quality data with rigorous methods: emulation of a target trial using electronic health records and a nested case-control design. BMJ 2023; 383:e072346. [PMID: 38154827 DOI: 10.1136/bmj-2022-072346] [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: 12/30/2023]
Affiliation(s)
- Bahareh Rasouli
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA 02115, USA
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - James S Floyd
- Cardiovascular Health Research Unit, Departments of Medicine and Epidemiology, University of Washington, Seattle, WA, USA
| | - Bruce M Psaty
- Cardiovascular Health Research Unit, Departments of Medicine and Epidemiology, University of Washington, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Matthew Nguyen
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Rod L Walker
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Kerri L Wiggins
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Roger W Logan
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Goodarz Danaei
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA 02115, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
- CAUSALab, Harvard TH Chan School of Public Health, Boston, MA, USA
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5
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Mercer J, Bandy S, Tang H, Wenger B, Ryan L, Lee G, Lipscomb J. Gender-affirming pharmacotherapy and additional health considerations: A contemporary review. J Am Pharm Assoc (2003) 2023; 63:1669-1676.e1. [PMID: 37619851 DOI: 10.1016/j.japh.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/10/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Transgender and gender-diverse (TGD) individuals in the United States face health care disparities compounded with discrimination and limited access to necessary medical services. Gender-affirming interventions have been shown to mitigate gender dysphoria and psychiatric comorbidities, yet United States legislation limiting such interventions has increased. As medication experts, pharmacists can facilitate access to care and appropriate use of gender-affirming hormone therapy (GAHT) and educate other health care providers on best practices for caring for TGD individuals in a variety of settings. OBJECTIVES To provide pharmacists with a contemporary review of GAHT and associated medication-related concerns. METHODS We searched PubMed for articles published until December 2022. MeSH terms such as transgender, transsexual, gender diverse, gender variant, or gender nonconforming in combination with phrases like gender-affirming care, treatment, pharmacotherapy, or hormone therapy were used to capture desired articles. RESULTS Feminizing hormone therapy (FHT), such as estrogen and antiandrogen agents, increases female secondary sex characteristics while suppressing male secondary sex characteristics. Masculinizing hormone therapy (MHT) achieves male secondary sex characteristics and minimizes female secondary sex characteristics using testosterone. For both FHT and MHT, the choice of therapy and formulation ultimately involves the patient's treatment goals, preferences, and tolerability. GAHT has additional health considerations pertaining to renal drug dosing, fertility, cardiovascular, and cancer risks. Pharmacists may provide crucial guidance and education to both patients and health care providers regarding risks associated with GAHT. CONCLUSION Many pharmacists feel unprepared to help provide, manage, and optimize GAHT. For many TGD individuals, GAHT is medically necessary and a life-saving treatment. Therefore, pharmacists should be provided tools to close knowledge gaps and improve their ability to care for these patients. By offering a thorough updated overview of GAHT, pharmacists can gain confidence to provide appropriate care for this increasingly visible population.
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Douxfils J, Foidart JM, Gaspard U, Chatel G, Taziaux M, Jost M, Gérard C, Morimont L. Response to paper by Binkowska et al. Risk of venous thromboembolism during the use of oral estrogen-progestogen hormone therapies in light of most recent research findings. Commentary: Oestradiol is not the holy grail in the quest for the ideal oestrogen therapy. PRZEGLAD MENOPAUZALNY = MENOPAUSE REVIEW 2023; 22:117-119. [PMID: 37674929 PMCID: PMC10477764 DOI: 10.5114/pm.2023.128815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 09/08/2023]
Affiliation(s)
- Jonathan Douxfils
- Department of Pharmacy, Namur Research for Life Sciences, Namur Thrombosis and Hemostasis Center, University of Namur, Namur, Belgium
| | | | - Ulysse Gaspard
- Department of Gynecology, University of Liège, Liège, Belgium
| | | | | | - Maud Jost
- Mithra Pharmaceuticals, Liège, Belgium
| | | | - Laure Morimont
- Department of Pharmacy, Namur Research for Life Sciences, Namur Thrombosis and Hemostasis Center, University of Namur, Namur, Belgium
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7
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Douxfils J, Gaspard U, Taziaux M, Jost M, Bouvy C, Lobo RA, Utian WH, Foidart JM. Impact of estetrol (E4) on hemostasis, metabolism and bone turnover in postmenopausal women. Climacteric 2023; 26:55-63. [PMID: 36399023 DOI: 10.1080/13697137.2022.2139599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This study aimed to determine the effects of estetrol (E4) on hemostasis, lipids, carbohydrate metabolism and bone turnover in postmenopausal women. METHODS This study was a multicenter, randomized, double-blind placebo-controlled phase 2 trial. Participants (n = 180, age 43-64 years) received E4 2.5 mg, 5 mg, 10 mg and 15 mg or placebo once daily for 12 weeks. Changes from baseline at week 12 were evaluated versus placebo for hemostasis parameters, sex hormone binding globulin (SHBG), lipids, carbohydrate metabolism and bone markers. RESULTS Changes for hemostasis parameters were minimal with a small increase only in the normalized activated protein C sensitivity ratio in the E4 15 mg group versus placebo. SHBG increased in the E4 5 mg, 10 mg and 15 mg groups versus placebo. High-density lipoprotein cholesterol increased in all E4 groups; changes were not consistent for other lipids. Significant decreases versus placebo were seen for insulin resistance (E4 10 mg group), hemoglobin A1c (E4 15 mg group) and type 1 collagen C-terminal telopeptide (E4 10 mg and 15 mg groups). Small decreases in osteocalcin in the E4 5 mg, 10 mg and 15 mg groups were significant versus the increase observed in placebo. CONCLUSION E4 had limited impact on hemostasis and potentially beneficial effects on lipids, carbohydrate metabolism and bone turnover.
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Affiliation(s)
- J Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, University of Namur, Namur, Belgium.,QUALIblood s.a, Namur, Belgium
| | - U Gaspard
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - M Taziaux
- Estetra SRL, an affiliate company of Mithra Pharmaceuticals, Liège, Belgium
| | - M Jost
- Estetra SRL, an affiliate company of Mithra Pharmaceuticals, Liège, Belgium
| | - C Bouvy
- QUALIblood s.a, Namur, Belgium
| | - R A Lobo
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - W H Utian
- Case Western Reserve Medical School, Cleveland, OH, USA
| | - J-M Foidart
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium.,Estetra SRL, an affiliate company of Mithra Pharmaceuticals, Liège, Belgium
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8
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Graham S, Archer DF, Simon JA, Ohleth KM, Bernick B. Review of menopausal hormone therapy with estradiol and progesterone versus other estrogens and progestins. Gynecol Endocrinol 2022; 38:891-910. [PMID: 36075250 DOI: 10.1080/09513590.2022.2118254] [Citation(s) in RCA: 3] [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] [Indexed: 01/21/2023] Open
Abstract
Objective: The objective of the present document was to review/summarize reported outcomes compared between menopausal hormone therapy (MHT) containing estradiol (E2) versus other estrogens and MHT with progesterone (P4) versus progestins (defined as synthetic progestogens).Methods: PubMed and EMBASE were systematically searched through February 2021 for studies comparing oral E2 versus oral conjugated equine estrogens (CEE) or P4 versus progestins for endometrial outcomes, venous thromboembolism (VTE), cardiovascular outcomes, breast outcomes, cognition, and bone outcomes in postmenopausal women.Results: A total of 74 comparative publications were identified/summarized. Randomized studies suggested that P4 and progestins are likely equally effective in preventing endometrial hyperplasia/cancer when used at adequate doses. E2- versus CEE-based MHT had a similar or possibly better risk profile for VTE and cardiovascular outcomes, and P4- versus progestin-based MHT had a similar or possibly better profile for breast cancer and cardiovascular outcomes. E2 may potentially protect better against age-related cognitive decline and bone fractures versus CEE; P4 was similar or possibly better versus progestins for these outcomes. Limitations are that many studies were observational and some were not adequately powered for the reported outcomes.Conclusions: Evidence suggests a differential effect of MHT containing E2 or P4 and those containing CEE or progestins, with some evidence trending to a potentially better safety profile with E2 and/or P4.
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Affiliation(s)
| | - David F Archer
- Department of Obstetrics and Gynecology, Clinical Research Center, Eastern Virginia Medical School, Norfolk, VA
| | - James A Simon
- School of Medicine, George Washington University, Washington, DC
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Federici S, Goggi G, Quinton R, Giovanelli L, Persani L, Cangiano B, Bonomi M. New and Consolidated Therapeutic Options for Pubertal Induction in Hypogonadism: In-depth Review of the Literature. Endocr Rev 2022; 43:824-851. [PMID: 34864951 DOI: 10.1210/endrev/bnab043] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Indexed: 01/15/2023]
Abstract
Delayed puberty (DP) defines a retardation of onset/progression of sexual maturation beyond the expected age from either a lack/delay of the hypothalamo-pituitary-gonadal axis activation or a gonadal failure. DP usually gives rise to concern and uncertainty in patients and their families, potentially affecting their immediate psychosocial well-being and also creating longer term psychosexual sequelae. The most frequent form of DP in younger teenagers is self-limiting and may not need any intervention. Conversely, DP from hypogonadism requires prompt and specific treatment that we summarize in this review. Hormone therapy primarily targets genital maturation, development of secondary sexual characteristics, and the achievement of target height in line with genetic potential, but other key standards of care include body composition and bone mass. Finally, pubertal induction should promote psychosexual development and mitigate both short- and long-term impairments comprising low self-esteem, social withdrawal, depression, and psychosexual difficulties. Different therapeutic options for pubertal induction have been described for both males and females, but we lack the necessary larger randomized trials to define the best approaches for both sexes. We provide an in-depth and updated literature review regarding therapeutic options for inducing puberty in males and females, particularly focusing on recent therapeutic refinements that better encompass the heterogeneity of this population, and underlining key differences in therapeutic timing and goals. We also highlight persistent shortcomings in clinical practice, wherein strategies directed at "the child with delayed puberty of uncertain etiology" risk being misapplied to older adolescents likely to have permanent hypogonadism.
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Affiliation(s)
- Silvia Federici
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy.,Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Giovanni Goggi
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy.,Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Richard Quinton
- Department of Endocrinology, Diabetes & Metabolism, Newcastle-upon-Tyne Hospitals, Newcastle-upon-Tyne NE1 4LP, UK.,Translational & Clinical Research Institute, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne NE1 4EP, UK
| | - Luca Giovanelli
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy.,Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Luca Persani
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy.,Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Biagio Cangiano
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy.,Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Marco Bonomi
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy.,Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
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10
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Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, Ettner R, Fraser L, Goodman M, Green J, Hancock AB, Johnson TW, Karasic DH, Knudson GA, Leibowitz SF, Meyer-Bahlburg HFL, Monstrey SJ, Motmans J, Nahata L, Nieder TO, Reisner SL, Richards C, Schechter LS, Tangpricha V, Tishelman AC, Van Trotsenburg MAA, Winter S, Ducheny K, Adams NJ, Adrián TM, Allen LR, Azul D, Bagga H, Başar K, Bathory DS, Belinky JJ, Berg DR, Berli JU, Bluebond-Langner RO, Bouman MB, Bowers ML, Brassard PJ, Byrne J, Capitán L, Cargill CJ, Carswell JM, Chang SC, Chelvakumar G, Corneil T, Dalke KB, De Cuypere G, de Vries E, Den Heijer M, Devor AH, Dhejne C, D'Marco A, Edmiston EK, Edwards-Leeper L, Ehrbar R, Ehrensaft D, Eisfeld J, Elaut E, Erickson-Schroth L, Feldman JL, Fisher AD, Garcia MM, Gijs L, Green SE, Hall BP, Hardy TLD, Irwig MS, Jacobs LA, Janssen AC, Johnson K, Klink DT, Kreukels BPC, Kuper LE, Kvach EJ, Malouf MA, Massey R, Mazur T, McLachlan C, Morrison SD, Mosser SW, Neira PM, Nygren U, Oates JM, Obedin-Maliver J, Pagkalos G, Patton J, Phanuphak N, Rachlin K, Reed T, Rider GN, Ristori J, Robbins-Cherry S, Roberts SA, Rodriguez-Wallberg KA, Rosenthal SM, Sabir K, Safer JD, Scheim AI, Seal LJ, Sehoole TJ, Spencer K, St Amand C, Steensma TD, Strang JF, Taylor GB, Tilleman K, T'Sjoen GG, Vala LN, Van Mello NM, Veale JF, Vencill JA, Vincent B, Wesp LM, West MA, Arcelus J. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 23:S1-S259. [PMID: 36238954 PMCID: PMC9553112 DOI: 10.1080/26895269.2022.2100644] [Citation(s) in RCA: 531] [Impact Index Per Article: 265.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.
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Affiliation(s)
- E Coleman
- Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A E Radix
- Callen-Lorde Community Health Center, New York, NY, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - W P Bouman
- Nottingham Centre for Transgender Health, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - G R Brown
- James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
- James H. Quillen VAMC, Johnson City, TN, USA
| | - A L C de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M B Deutsch
- Department of Family & Community Medicine, University of California-San Francisco, San Francisco, CA, USA
- UCSF Gender Affirming Health Program, San Francisco, CA, USA
| | - R Ettner
- New Health Foundation Worldwide, Evanston, IL, USA
- Weiss Memorial Hospital, Chicago, IL, USA
| | - L Fraser
- Independent Practice, San Francisco, CA, USA
| | - M Goodman
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - J Green
- Independent Scholar, Vancouver, WA, USA
| | - A B Hancock
- The George Washington University, Washington, DC, USA
| | - T W Johnson
- Department of Anthropology, California State University, Chico, CA, USA
| | - D H Karasic
- University of California San Francisco, San Francisco, CA, USA
- Independent Practice at dankarasic.com
| | - G A Knudson
- University of British Columbia, Vancouver, Canada
- Vancouver Coastal Health, Vancouver, Canada
| | - S F Leibowitz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - H F L Meyer-Bahlburg
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University, New York, NY, USA
| | | | - J Motmans
- Transgender Infopunt, Ghent University Hospital, Gent, Belgium
- Centre for Research on Culture and Gender, Ghent University, Gent, Belgium
| | - L Nahata
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- Endocrinology and Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - T O Nieder
- University Medical Center Hamburg-Eppendorf, Interdisciplinary Transgender Health Care Center Hamburg, Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Hamburg, Germany
| | - S L Reisner
- Harvard Medical School, Boston, MA, USA
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - C Richards
- Regents University London, UK
- Tavistock and Portman NHS Foundation Trust, London, UK
| | | | - V Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - A C Tishelman
- Boston College, Department of Psychology and Neuroscience, Chestnut Hill, MA, USA
| | - M A A Van Trotsenburg
- Bureau GenderPRO, Vienna, Austria
- University Hospital Lilienfeld-St. Pölten, St. Pölten, Austria
| | - S Winter
- School of Population Health, Curtin University, Perth, WA, Australia
| | - K Ducheny
- Howard Brown Health, Chicago, IL, USA
| | - N J Adams
- University of Toronto, Ontario Institute for Studies in Education, Toronto, Canada
- Transgender Professional Association for Transgender Health (TPATH)
| | - T M Adrián
- Asamblea Nacional de Venezuela, Caracas, Venezuela
- Diverlex Diversidad e Igualdad a Través de la Ley, Caracas, Venezuela
| | - L R Allen
- University of Nevada, Las Vegas, NV, USA
| | - D Azul
- La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - H Bagga
- Monash Health Gender Clinic, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - K Başar
- Department of Psychiatry, Hacettepe University, Ankara, Turkey
| | - D S Bathory
- Independent Practice at Bathory International PLLC, Winston-Salem, NC, USA
| | - J J Belinky
- Durand Hospital, Guemes Clinic and Urological Center, Buenos Aires, Argentina
| | - D R Berg
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J U Berli
- Oregon Health & Science University, Portland, OR, USA
| | - R O Bluebond-Langner
- NYU Langone Health, New York, NY, USA
- Hansjörg Wyss Department of Plastic Surgery, New York, NY, USA
| | - M-B Bouman
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Plastic Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - M L Bowers
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mills-Peninsula Medical Center, Burlingame, CA, USA
| | - P J Brassard
- GrS Montreal, Complexe CMC, Montreal, Quebec, Canada
- Université de Montreal, Quebec, Canada
| | - J Byrne
- University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - L Capitán
- The Facialteam Group, Marbella International Hospital, Marbella, Spain
| | | | - J M Carswell
- Harvard Medical School, Boston, MA, USA
- Boston's Children's Hospital, Boston, MA, USA
| | - S C Chang
- Independent Practice, Oakland, CA, USA
| | - G Chelvakumar
- Nationwide Children's Hospital, Columbus, OH, USA
- The Ohio State University, College of Medicine, Columbus, OH, USA
| | - T Corneil
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada
| | - K B Dalke
- Penn State Health, PA, USA
- Penn State College of Medicine, Hershey, PA, USA
| | - G De Cuypere
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
| | - E de Vries
- Nelson Mandela University, Gqeberha, South Africa
- University of Cape Town, Cape Town, South Africa
| | - M Den Heijer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Endocrinology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - A H Devor
- University of Victoria, Victoria, BC, Canada
| | - C Dhejne
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - A D'Marco
- UCTRANS-United Caribbean Trans Network, Nassau, The Bahamas
- D M A R C O Organization, Nassau, The Bahamas
| | - E K Edmiston
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - L Edwards-Leeper
- Pacific University, Hillsboro, OR, USA
- Independent Practice, Beaverton, OR, USA
| | - R Ehrbar
- Whitman Walker Health, Washington, DC, USA
- Independent Practice, Maryland, USA
| | - D Ehrensaft
- University of California San Francisco, San Francisco, CA, USA
| | - J Eisfeld
- Transvisie, Utrecht, The Netherlands
| | - E Elaut
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Clinical Experimental and Health Psychology, Ghent University, Gent, Belgium
| | - L Erickson-Schroth
- The Jed Foundation, New York, NY, USA
- Hetrick-Martin Institute, New York, NY, USA
| | - J L Feldman
- Institute for Sexual and Gender Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A D Fisher
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | - M M Garcia
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Departments of Urology and Anatomy, University of California San Francisco, San Francisco, CA, USA
| | - L Gijs
- Institute of Family and Sexuality Studies, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | | | - B P Hall
- Duke University Medical Center, Durham, NC, USA
- Duke Adult Gender Medicine Clinic, Durham, NC, USA
| | - T L D Hardy
- Alberta Health Services, Edmonton, Alberta, Canada
- MacEwan University, Edmonton, Alberta, Canada
| | - M S Irwig
- Harvard Medical School, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - A C Janssen
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - K Johnson
- RMIT University, Melbourne, Australia
- University of Brighton, Brighton, UK
| | - D T Klink
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital, Gent, Belgium
- Division of Pediatric Endocrinology and Diabetes, ZNA Queen Paola Children's Hospital, Antwerp, Belgium
| | - B P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - L E Kuper
- Department of Psychiatry, Southwestern Medical Center, University of Texas, Dallas, TX, USA
- Department of Endocrinology, Children's Health, Dallas, TX, USA
| | - E J Kvach
- Denver Health, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - M A Malouf
- Malouf Counseling and Consulting, Baltimore, MD, USA
| | - R Massey
- WPATH Global Education Institute
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - T Mazur
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- John R. Oishei Children's Hospital, Buffalo, NY, USA
| | - C McLachlan
- Professional Association for Transgender Health, South Africa
- Gender DynamiX, Cape Town, South Africa
| | - S D Morrison
- Division of Plastic Surgery, Seattle Children's Hospital, Seattle, WA, USA
- Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - S W Mosser
- Gender Confirmation Center, San Francisco, CA, USA
- Saint Francis Memorial Hospital, San Francisco, CA, USA
| | - P M Neira
- Johns Hopkins Center for Transgender Health, Baltimore, MD, USA
- Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity, Baltimore, MD, USA
| | - U Nygren
- Division of Speech and Language Pathology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Speech and Language Pathology, Medical Unit, Karolinska University Hospital, Stockholm, Sweden
| | - J M Oates
- La Trobe University, Melbourne, Australia
- Melbourne Voice Analysis Centre, East Melbourne, Australia
| | - J Obedin-Maliver
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford, CA, USA
| | - G Pagkalos
- Independent PracticeThessaloniki, Greece
- Military Community Mental Health Center, 424 General Military Training Hospital, Thessaloniki, Greece
| | - J Patton
- Talkspace, New York, NY, USA
- CytiPsychological LLC, San Diego, CA, USA
| | - N Phanuphak
- Institute of HIV Research and Innovation, Bangkok, Thailand
| | - K Rachlin
- Independent Practice, New York, NY, USA
| | - T Reed
- Gender Identity Research and Education Society, Leatherhead, UK
| | - G N Rider
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J Ristori
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | | | - S A Roberts
- Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Boston's Children's Hospital, Boston, MA, USA
| | - K A Rodriguez-Wallberg
- Department of Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - S M Rosenthal
- Division of Pediatric Endocrinology, UCSF, San Francisco, CA, USA
- UCSF Child and Adolescent Gender Center
| | - K Sabir
- FtM Phoenix Group, Krasnodar Krai, Russia
| | - J D Safer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, USA
| | - A I Scheim
- Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
- Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Ontario, Canada
| | - L J Seal
- Tavistock and Portman NHS Foundation Trust, London, UK
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - K Spencer
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - C St Amand
- University of Houston, Houston, TX, USA
- Mayo Clinic, Rochester, MN, USA
| | - T D Steensma
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - J F Strang
- Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine, Washington, DC, USA
| | - G B Taylor
- Atrium Health Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Charlotte, NC, USA
| | - K Tilleman
- Department for Reproductive Medicine, Ghent University Hospital, Gent, Belgium
| | - G G T'Sjoen
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Endocrinology, Ghent University Hospital, Gent, Belgium
| | - L N Vala
- Independent Practice, Campbell, CA, USA
| | - N M Van Mello
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - J F Veale
- School of Psychology, University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - J A Vencill
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - B Vincent
- Trans Learning Partnership at https://spectra-london.org.uk/trans-learning-partnership, UK
| | - L M Wesp
- College of Nursing, University of Wisconsin MilwaukeeMilwaukee, WI, USA
- Health Connections Inc., Glendale, WI, USA
| | - M A West
- North Memorial Health Hospital, Robbinsdale, MN, USA
- University of Minnesota, Minneapolis, MN, USA
| | - J Arcelus
- School of Medicine, University of Nottingham, Nottingham, UK
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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11
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Booyens RM, Engelbrecht AM, Strauss L, Pretorius E. To clot, or not to clot: The dilemma of hormone treatment options for menopause. Thromb Res 2022; 218:99-111. [PMID: 36030662 DOI: 10.1016/j.thromres.2022.08.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/04/2022] [Accepted: 08/15/2022] [Indexed: 12/01/2022]
Abstract
Untreated menopause may have serious health implications, but treatments can have dangerous side effects. We evaluate menopausal symptoms as well as available treatments -the routes of administration and their effect on blood coagulation. Menopausal females may experience hot flushes, vulva- and vaginal atrophy and osteoporosis. Many treatments are available to relieve these symptoms such as Conjugated Equine Estrogen and bioidentical hormones. The routes of administration include oral and transdermal. Hormones that are administered orally undergo a hepatic first pass metabolism. The by-products have a lower efficacy and possibly enhanced side effects. Furthermore, hormone treatments influence the coagulation cascade through coagulation factors or their regulators. Increased coagulation poses a risk for venous thromboembolism. Currently a definite conclusion on whether the side effects from hormone treatments exceed the risk of untreated menopause cannot be made. However, a more individualised approach to hormone treatments may be the most feasible solution to this dilemma.
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Affiliation(s)
- Renata M Booyens
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch, South Africa
| | - Anna-Mart Engelbrecht
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch, South Africa
| | - Ledivia Strauss
- Functional Medicine Practice, A1 Polo Village Offices, Kliprug Minor Rd, Val De Vie Winelands Lifestyle Estate, 7646, South Africa
| | - Etheresia Pretorius
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch, South Africa.
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12
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Chang WC, Wang JH, Ding DC. Menopausal hormone therapy with conjugated equine estrogen is associated with a higher risk of hemorrhagic stroke than therapy with estradiol: a retrospective population-based cohort study. Maturitas 2022; 165:72-77. [PMID: 35933795 DOI: 10.1016/j.maturitas.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/18/2022] [Accepted: 07/13/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Several studies have shown that menopausal hormone therapy (MHT) reduces the risk of hemorrhagic stroke (HS), but there are no studies comparing the effect of different estrogen types (conjugated equine estrogen [CEE] and estradiol [E2]). METHODS This retrospective cohort study included menopausal women aged 40-65 years diagnosed between 2000 and 2016 who received MHT with oral CEE or E2 and were registered in Taiwan's National Health Insurance Research Database. The primary outcome was HS. Propensity score matching with menopausal age and comorbidities was performed. Cox proportional hazard regression models were used to calculate the incidence and hazard ratios (HRs) of HS. RESULTS A total of 14,586 pairs of women were included. The mean menopausal ages of the CEE and E2 groups were 50.45 ± 5.31 and 50.31 ± 4.99 years, respectively. After adjusting for age and comorbidities, the incidence of HS was 1.23-fold higher in women treated with CEE than in those treated with E2 (8.04 vs. 6.49/10,000 person-years), with an adjusted HR of 1.50 (95 % confidence interval [CI] 1.04-2.17). MHT with CEE initiated within 5 years of menopause was associated with a higher risk of HS than MHT with E2 (HR = 1.47, 95 % CI: 1.01-2.14). CONCLUSIONS In postmenopausal Taiwanese women, MHT with CEE was associated with an increased risk of HS compared to MHT with E2, a risk that women using CEE should discuss with their clinicians. Further large-scale investigations of this population are warranted.
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Affiliation(s)
- Wei-Chuan Chang
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Foundation, Tzu Chi University, Hualien, Taiwan
| | - Jen-Hung Wang
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Foundation, Tzu Chi University, Hualien, Taiwan
| | - Dah-Ching Ding
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Foundation, and Tzu Chi University, Hualien, Taiwan; Department of Obstetrics and Gynecology, College of Medicine, Tzu Chi University, Hualien, Taiwan.
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13
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LaVasseur C, Neukam S, Kartika T, Samuelson Bannow B, Shatzel J, DeLoughery TG. Hormonal therapies and venous thrombosis: Considerations for prevention and management. Res Pract Thromb Haemost 2022; 6:e12763. [PMID: 36032216 PMCID: PMC9399360 DOI: 10.1002/rth2.12763] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 04/12/2022] [Accepted: 05/21/2022] [Indexed: 11/18/2022] Open
Abstract
Background Venous thromboses are well‐established complications of hormonal therapy. Thrombosis risk is seen with both hormonal contraceptive agents and with hormone replacement therapy for menopause and gender transition. Over the past several decades, large epidemiological studies have helped better define these risks. Objectives To review and discuss the differences in thrombosis risk of the many of hormonal preparations available as well as their interaction with patient‐specific factors. Methods We conducted a narrative review of the available literature regarding venous thrombosis and hormonal therapies including for contraception, menopausal symptoms, and gender transition. Results Thrombosis risk with estrogen‐containing compounds increases with increasing systemic dose of estrogen. While progesterone‐only–containing products are not associated with thrombosis, when paired with estrogen in combined oral contraceptives, the formulation of progesterone does impact the risk. These components, along with patient‐specific factors, may influence the choice of hormonal preparation. For patients who develop thrombosis on hormonal treatment, anticoagulation is protective against future thrombosis. Duration of anticoagulation is dependent on ongoing and future hormone therapy choice. Finally, the optimal management of hormone therapy for individuals diagnosed with prothrombotic illnesses such as COVID‐19 remains unclear. Conclusions When contemplating hormonal contraception or hormone replacement therapy, clinicians must consider a variety of factors including hormone type, dose, route, personal and family history of thrombosis, and other prothrombotic risk factors to make informed, personalized decisions regarding the risk of venous thrombosis.
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Affiliation(s)
- Corinne LaVasseur
- Department of Medicine Oregon Health and Sciences University Portland Oregon USA
| | - Suvi Neukam
- Department of Medicine Oregon Health and Sciences University Portland Oregon USA.,Division of Internal Medicine Oregon Health and Sciences University Portland Oregon USA
| | - Thomas Kartika
- Division of Hematology-Oncology Oregon Health and Sciences University Portland Oregon USA
| | - Bethany Samuelson Bannow
- Department of Medicine Oregon Health and Sciences University Portland Oregon USA.,Division of Hematology-Oncology Oregon Health and Sciences University Portland Oregon USA.,The Hemophilia Center Oregon Health and Sciences University Portland Oregon USA
| | - Joseph Shatzel
- Department of Medicine Oregon Health and Sciences University Portland Oregon USA.,Division of Hematology-Oncology Oregon Health and Sciences University Portland Oregon USA
| | - Thomas G DeLoughery
- Department of Medicine Oregon Health and Sciences University Portland Oregon USA.,Division of Hematology-Oncology Oregon Health and Sciences University Portland Oregon USA.,Division of Laboratory Medicine, Department of Pathology Oregon Health and Sciences University Portland Oregon USA
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14
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Kalenga CZ, Hay JL, Boreskie KF, Duhamel TA, MacRae JM, Metcalfe A, Nerenberg KA, Robert M, Ahmed SB. The Association Between Route of Post-menopausal Estrogen Administration and Blood Pressure and Arterial Stiffness in Community-Dwelling Women. Front Cardiovasc Med 2022; 9:913609. [PMID: 35757351 PMCID: PMC9226418 DOI: 10.3389/fcvm.2022.913609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPostmenopausal hormone therapy (HT) is associated with increased cardiovascular risk. Although the route of estrogen administration may play a role in mediating risk, previous studies have not controlled for concomitant progestin use.ObjectiveTo investigate the association between the route of estrogen therapy (oral or non-oral) HT use, without concomitant progestin, and blood pressure and arterial stiffness in postmenopausal women.MethodsSystolic blood pressure [SBP], diastolic blood pressure [DBP]), arterial stiffness (aortic pulse wave velocity [aPWV] and augmentation index at 75 beats per minute [AIx]) were measured using a validated automated brachial cuff-based oscillometric approach (Mobil-O-Graph) in a community-dwelling sample of 328 women.ResultsFifty-five participants (16.8%) were ever users (current and past use) of estrogen-only HT (oral [n = 16], transdermal [n = 20], vaginal [n = 19]), and 223 were never HT users (control). Ever use of oral estrogen was associated with increased SBP and DBP (Oral: SBP: 137 ± 4 mmHg, DBP: 79 ± 2 mmHg) compared to use of non-oral estrogen (transdermal: SBP: 118 ± 2 mmHg, DBP: 73 ± 1 mmHg; p < 0.01 & p = 0.012, respectively; vaginal: SBP: 123 ± 2 mmHg DBP: 73 ± 2 mmHg; p = 0.02 & p = 0.01, respectively.) and controls (SBP: 124 ± 1 mmHg, DBP: 74 ± 1 mmHg, p = 0.03, p = 0.02, respectively) after adjustment for covariates. aPWV was higher in oral estrogen ever users (9.9 ± 1 m/s) compared to non-oral estrogen (transdermal: 8.6 ± 0.3 m/s, p < 0.01; vaginal: 8.8 ± 0.7 m/s, p = 0.03) and controls (8.9 ± 0.5 m/s, p = 0.03) but these associations were no longer significant after adjustment for covariates. AIx was higher in oral estrogen (29 ± 2 %) compared to non-oral estrogen (transdermal: 16 ± 2 %; vaginal: 22 ± 1.7 %) but this association was no longer significant after adjustment for covariates (p = 0.92 vs. non-oral; p = 0.74 vs. control).ConclusionEver use of oral estrogen was associated with increased SBP and DBP compared to non-oral estrogen use and no use. Given the cardiovascular risk associated with both menopause and increased blood pressure, further studies are required exploring the potential benefits of non-oral estrogen in postmenopausal women.
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Affiliation(s)
- Cindy Z. Kalenga
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Jacqueline L. Hay
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB, Canada
- Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Winnipeg, MB, Canada
| | - Kevin F. Boreskie
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB, Canada
- Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Winnipeg, MB, Canada
| | - Todd A. Duhamel
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB, Canada
- Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Winnipeg, MB, Canada
| | - Jennifer M. MacRae
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
- Alberta Kidney Disease Network, Calgary, AB, Canada
| | - Amy Metcalfe
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Kara A. Nerenberg
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Magali Robert
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Sofia B. Ahmed
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
- Alberta Kidney Disease Network, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- *Correspondence: Sofia B. Ahmed
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15
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Abstract
Pediatric endocrinologists often evaluate and treat youth with delayed puberty. Stereotypically, these patients are 14-year-old young men who present due to lack of pubertal development. Concerns about stature are often present, arising from gradual shifts to lower height percentiles on the population-based, cross-sectional curves. Fathers and/or mothers may have also experienced later than average pubertal onset. In this review, we will discuss a practical clinical approach to the evaluation and management of youth with delayed puberty, including the differential diagnosis and key aspects of evaluation and management informed by recent review of the existing literature. We will also discuss scenarios that pose additional clinical challenges, including: (1) the young woman whose case poses questions regarding how presentation and approach differs for females vs males; (2) the 14-year-old female or 16-year-old young man who highlight the need to reconsider the most likely diagnoses, including whether idiopathic delayed puberty can still be considered constitutional delay of growth and puberty at such late ages; and finally (3) the 12- to 13-year-old whose presentation raises questions about whether age cutoffs for the diagnosis and treatment of delayed puberty should be adjusted downward to coincide with the earlier onset of puberty in the general population.
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Affiliation(s)
- Jennifer Harrington
- Division of Endocrinology, Women's and Children's Health Network, North Adelaide, 5006, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, 5000, Australia
| | - Mark R Palmert
- Division of Endocrinology, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada
- Departments of Pediatrics and Physiology, University of Toronto, Toronto, Ontario, M5S 1A8, Canada
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Blondon M, Bodmer A, Thouvenin L, Lecompte T, Righini M, Fontana P, Casini A. Differential impact of tamoxifen and aromatase inhibitors on thrombin generation: the prospective HEMOBREAST cohort. Blood Adv 2022; 6:2884-2892. [PMID: 35086148 PMCID: PMC9092409 DOI: 10.1182/bloodadvances.2021006623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/19/2022] [Indexed: 11/20/2022] Open
Abstract
Tamoxifen and aromatase inhibitors (AIs) are potent antitumoral agents against breast cancer. Tamoxifen increases the risk of venous thromboembolism (VTE), but the influence of AIs on the risk of VTE remains unclear. To inform clinical decisions, we evaluated associations of tamoxifen or AIs with changes of surrogate hemostatic biomarkers. This prospective cohort included 107 women with localized breast cancer starting tamoxifen (n = 42) or an AI (n = 65). Thrombin generation (CAT) its sensitivity to thrombomodulin (TM) or activated protein C (APC), and specific coagulation parameters, were measured before and 10-16 weeks after initiation of treatmen Compared with baseline, endogenous thrombin potential and thrombin peak increased in tamoxifen users (+86 nM × min; 95% confidence interval [CI], 30-142; and +33 nM; 95% CI, 21-45) but not in AI users (n = 65; +44 nM × min; 95% CI, -4 to 93; and +7 nM; 95% CI, -3 to 17). Normalized TM sensitivity ratios increased with tamoxifen (+0.26; 95% CI, 0.19-0.33y) but not with AI (+0.02; 95% CI, -0.03 to 0.07). Plasma levels of fibrinogen, antithrombin, protein C, and Tissue Factor Pathway Inhibitor decreased, and free protein S increased with tamoxifen but not with AIs. The observed shift toward increased coagulability associated with tamoxifen is in line with its known increased risk of VTE. In contrast, AIs do not appear to impact hemostasis, suggesting a lack of associated VTE risk. The trial was registered at www.clinicaltrials.gov as #NCT03381963.
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Affiliation(s)
| | - Alexandre Bodmer
- Department of Oncology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Laure Thouvenin
- Department of Oncology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Sex Differences in Cardiovascular Diseases: A Matter of Estrogens, Ceramides, and Sphingosine 1-Phosphate. Int J Mol Sci 2022; 23:ijms23074009. [PMID: 35409368 PMCID: PMC8999971 DOI: 10.3390/ijms23074009] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 12/30/2022] Open
Abstract
The medical community recognizes sex-related differences in pathophysiology and cardiovascular disease outcomes (CVD), culminating with heart failure. In general, pre-menopausal women tend to have a better prognosis than men. Explaining why this occurs is not a simple matter. For decades, sex hormones like estrogens (Es) have been identified as one of the leading factors driving these sex differences. Indeed, Es seem protective in women as their decline, during and after menopause, coincides with an increased CV risk and HF development. However, clinical trials demonstrated that E replacement in post-menopause women results in adverse cardiac events and increased risk of breast cancer. Thus, a deeper understanding of E-related mechanisms is needed to provide a vital gateway toward better CVD prevention and treatment in women. Of note, sphingolipids (SLs) and their metabolism are strictly related to E activities. Among the SLs, ceramide and sphingosine 1-phosphate play essential roles in mammalian physiology, particularly in the CV system, and appear differently modulated in males and females. In keeping with this view, here we explore the most recent experimental and clinical observations about the role of E and SL metabolism, emphasizing how these factors impact the CV system.
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Hashemzadeh M, Haseefa F, Peyton L, Park S, Movahed MR. The effects of estrogen and hormone replacement therapy on platelet activity: a review. AMERICAN JOURNAL OF BLOOD RESEARCH 2022; 12:33-42. [PMID: 35291255 PMCID: PMC8918702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/24/2022] [Indexed: 06/14/2023]
Abstract
Many studies have shown that an increase in cardiovascular disease in women is related to hormonal changes occurring particularly after menopause with increasing age. While the results of large clinical trials reporting no benefit of hormone replacement therapy (HRT) in cardiovascular disease have been known for some time, there is an increasing body of knowledge regarding the various mechanisms by which estrogen modulates platelet function that could in part explain the higher cardiovascular risk occurring in postmenopausal women and potential benefits of HRT on cardiovascular health. Our review summarizes our current knowledge regarding the effect of endogenous and exogenous estrogen on platelet activity, which can help researchers design future studies. We collected information from 21 peer-reviewed articles published from 1993 to 2021. Studies have indicated that postmenopausal women have higher platelet activity than premenopausal women, which can increase the risk of thrombo-embolic events and cardiovascular disease. Although some studies have reported pro-thrombotic effects of estrogen replacement therapy such as increased platelet activation and adhesion, other studies demonstrated decreased platelet aggregation by inhibiting GP IIb/IIIa receptor expression. This is mediated by estrogen receptors on the platelet membrane in a non-genomic manner and suggests an opportunity for the usage of estrogen replacement therapy with subtle changes in the formulation and route, particularly if started early after menopause. The effect of estrogen on platelet activity is promising as an important factor in reducing the risk of cardiovascular events, warranting further investigation.
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Affiliation(s)
- Mehrnoosh Hashemzadeh
- University of Arizona, College of MedicinePhoenix, AZ, USA
- Pima CollegeTucson, AZ, USA
| | | | - Lee Peyton
- Pima CollegeTucson, AZ, USA
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic College of Medicine and ScienceRochester, MN, USA
| | - Shery Park
- Pima CollegeTucson, AZ, USA
- University of ArizonaTucson, AZ, USA
| | - Mohammed Reza Movahed
- University of Arizona, College of MedicinePhoenix, AZ, USA
- University of ArizonaTucson, AZ, USA
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19
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Voutsadaki K, Matalliotakis M, Ladomenou F. Hypogonadism in adolescent girls: treatment and long-term effects. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022317. [PMID: 36300209 PMCID: PMC9686158 DOI: 10.23750/abm.v93i5.13719] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/08/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND AIM Hypogonadism in adolescent females presents as delayed puberty or primary amenorrhea. Constitutional delay of growth and puberty, hypogonadotropic hypogonadism and hypergonadotropic hypogonadism represent the principal differential diagnosis of delayed puberty. Girls with hypogonadism require hormone replacement therapy to initiate and sustain puberty. We aimed to provide a brief review concerning treatment for female adolescents with hypogonadism and further to focus on current data regarding long-term effects of therapy. METHODS The published studies and articles of the international literature were used regarding the approach to adolescent girls with hypogonadism. RESULTS The aim of therapy is the development of secondary sexual characteristics and achievement of target height, body composition and bone mass, to promote psychosexual health and, finally, to maximize the potential for fertility. Hypogonadal females need long-term HRT, so it is of great importance to fully define risks and benefits of therapy. CONCLUSIONS The optimal pubertal induction in women contains both estrogens and progesterone regimens. Different therapeutic options have been described over the years in the literature, but larger randomized trials are required in order to define the ideal approach. The latest acquisitions in the field seem to propose that transdermal 17β-estradiol and micronized progesterone present the most physiological formulations available for this purpose. Further studies and follow up are needed concerning the long-term effects of HRT in adolescents.
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Affiliation(s)
- Kleanthi Voutsadaki
- Department of Pediatrics, Venizeleion General Hospital Heraklion, Crete, Greece
| | - Michail Matalliotakis
- Obstetrics and Gynecology Department of Venizeleion General Hospital Heraklion, Crete, Greece
| | - Fani Ladomenou
- Department of Pediatrics, Venizeleion General Hospital Heraklion, Crete, Greece
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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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21
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McGlacken-Byrne SM, Conway GS. Premature ovarian insufficiency. Best Pract Res Clin Obstet Gynaecol 2021; 81:98-110. [PMID: 34924261 DOI: 10.1016/j.bpobgyn.2021.09.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 09/18/2021] [Indexed: 11/17/2022]
Abstract
The natural lifespan of the ovary is occasionally interrupted by pathological processes; some are known, but many are unknown. Premature ovarian insufficiency (POI) can be a devastating diagnosis for an adolescent or for someone who has yet to start a family. Common causes of POI include genetic and chromosomal defects, autoimmune damage, and cancer treatments. Knowledge of the pathogenesis of this condition and an awareness of contemporary hormone replacement and fertility options are required to design a multidisciplinary therapeutic approach comprising reproductive medicine, endocrinology, clinical psychology, and assisted fertility expertise.
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Affiliation(s)
| | - Gerard S Conway
- Institute for Women's Health, University College London, London, UK.
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22
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Blondon M, Timmons AK, Baraff AJ, Floyd JS, Harrington LB, Korpak AM, Smith NL. Comparative venous thromboembolic safety of oral and transdermal postmenopausal hormone therapies among women Veterans. Menopause 2021; 28:1125-1129. [PMID: 34313612 PMCID: PMC8478712 DOI: 10.1097/gme.0000000000001823] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Hormone therapy (HT) is used by menopausal women to treat vasomotor symptoms. Venous thromboembolism (VTE) is an important risk of HT use, and more knowledge on the comparative safety of different estrogenic compounds is useful for women who use HT for these symptoms. The objective was to compare the risk of VTE among users of oral conjugated equine estrogen (CEE), oral estradiol (E2), and transdermal E2, in a cohort of women veterans. METHODS This retrospective cohort study included all women veterans aged 40 to 89 years, using CEE or E2, without prior VTE, between 2003 and 2011. All incident VTE events were adjudicated. Time-to-event analyses using a time-varying HT exposure evaluated the relative VTE risk between estrogen subtypes, with adjustment for age, race, and body mass index, with stratification for prevalent versus incident use of HT. RESULTS Among 51,571 users of HT (74.5% CEE, 12.6% oral, and 12.9% transdermal E2 at cohort entry), with a mean age of 54.0 years, the incidence of VTE was 1.9/1,000 person-years. Compared with CEE use, in the multivariable regression model, there was no difference in the risk of incident VTE associated with oral E2 use (hazard ratio 0.96, 95% CI 0.64-1.46) or with transdermal E2 use (hazard ratio 0.95, 95% CI 0.60-1.49). Results were unchanged when restricting to incident users of HT. CONCLUSIONS Among women veterans, the risk of VTE was similar in users of oral CEE, oral E2, and transdermal E2. These findings do not confirm the previously observed greater safety of transdermal and oral E2 over CEE.
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Affiliation(s)
- Marc Blondon
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Andrew K. Timmons
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA, USA
| | - Aaron J. Baraff
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA, USA
| | - James S. Floyd
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Laura B. Harrington
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Anna M. Korpak
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA, USA
| | - Nicholas L. Smith
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
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Abstract
The aim of the study is to present the problem of functional hypothalamic amenorrhea, taking into account any disease and treatment, diagnosis, and consequences of this disease. We searched PubMed (MEDLINE) and included 38 original and review articles concerning functional hypothalamic amenorrhea. Functional hypothalamic amenorrhea is the most common cause of secondary amenorrhea in women of childbearing age. It is a reversible disorder caused by stress related to weight loss, excessive exercise and/or traumatic mental experiences. The basis of functional hypothalamic amenorrhea is hormonal, based on impaired pulsatile GnRH secretion in the hypothalamus, then decreased secretion of gonadotropins, and, consequently, impaired hormonal function of the ovaries. This disorder leads to hypoestrogenism, manifested by a disturbance of the menstrual cycle in the form of amenorrhea, leading to anovulation. Prolonged state of hypoestrogenism can be very detrimental to general health, leading to many harmful short- and long-term consequences. Treatment of functional hypothalamic amenorrhea should be started as soon as possible, and it should primarily involve lifestyle modification. Only then should pharmacological treatment be applied. Importantly, treatment is most often long-term, but it results in recovery for the majority of patients. Effective therapy, based on multidirectional action, can protect patients from numerous negative impacts on fertility, cardiovascular system and bone health, as well as reducing mental morbidity.
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24
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Khialani D, Vasan S, Cushman M, Dahm AEA, Sandset PM, Rossouw J, van Hylckama Vlieg A. Venous thrombosis with oral postmenopausal hormone therapy: Roles of activated protein C resistance and tissue factor pathway inhibitor. J Thromb Haemost 2021; 19:1729-1737. [PMID: 33774921 DOI: 10.1111/jth.15319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 03/02/2021] [Accepted: 03/15/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Oral postmenopausal hormone therapy (HT) increases the risk of venous thrombosis (VT). We postulated that activated protein C (APC) resistance induced by HT is one of the mechanisms causing VT, and also assessed the role of one of the main determinants of APC resistance (i.e., tissue factor pathway inhibitor [TFPI]). METHODS We performed a nested case-control study embedded within two Women's Health Initiative hormone trials. Women were randomized to hormone therapy or placebo. Biomarkers were measured at baseline and after 1 year in 217 cases and 817 controls. RESULTS Increased APC resistance and decreased TFPI at baseline were associated with VT (odds ratio 1.20-2.06). However, women with such prothrombotic profile at baseline did not have further increased risk of VT when randomized to HT compared with placebo. Although there was no change in APC resistance or TFPI in placebo group after 1 year, HT group showed prothrombotic changes in the biomarkers (i.e., an increase in APC resistance) (mean [standard deviation] 0.39 [0.54]) and decrease in TFPI (-0.21 [0.50]: free TFPI, -0.24 [0.22]: TFPI activity -0.22 [0.20]: total TFPI). However, HT induced prothrombotic change in biomarkers did not increase risk of VT. CONCLUSION Women with prothrombotic levels of APC resistance and TFPI at baseline were not at increased risk of VT when randomized to HT compared with placebo. This suggests that testing for these biomarkers before starting HT is not required. HT led to prothrombotic change in these biomarkers after one year, but this did not relate to increased risk of VT.
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Affiliation(s)
- Deeksha Khialani
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sowmya Vasan
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Anders Erik Astrup Dahm
- Department of Haematology, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Per Morten Sandset
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - Jacques Rossouw
- National Heart, Lung, and Blood Institute, Bethesda, MD, USA
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25
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Chang WC, Wang JH, Ding DC. Conjugated equine estrogen used in postmenopausal women associated with a higher risk of stroke than estradiol. Sci Rep 2021; 11:10801. [PMID: 34031535 PMCID: PMC8144437 DOI: 10.1038/s41598-021-90357-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 05/10/2021] [Indexed: 02/04/2023] Open
Abstract
This study aimed to evaluate the risk of ischemic stroke (IS) in hormone therapy (HT) with oral conjugated equine estrogen (CEE) and estradiol (E2) in postmenopausal women in Taiwan. A retrospective cohort study was conducted using the Taiwan National Health Insurance Research Database, a population-based healthcare claims dataset. Eligible women, aged 40-65 years, who received HT with E2 and CEE orally were enrolled. The primary outcome was IS. Propensity score matching with menopausal age and comorbidities was used. Cox proportional hazard regression models were used to calculate the incidence and hazard ratios (HRs) for IS. The mean menopausal ages of the E2 and CEE groups were 50.31 ± 4.99 and 50.45 ± 5.31 years, respectively. After adjusting for age and comorbidities, the incidence of IS was 1.17-fold higher in the women treated with CEE than in those treated with E2 (4.24 vs. 3.61/1000 person-years), with an adjusted HR (aHR) of 1.23 (95% confidence interval [CI] 1.05-1.44). Moreover, HT with CEE initiated within 5 years of menopause had a higher HR than E2 (aHR = 1.20; 95% CI 1.02-1.42). In conclusion, HT with oral CEE might be associated with a higher risk of IS than E2 in postmenopausal Taiwanese women. The use of HT with CEE should be cautioned with the risk of IS.
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Affiliation(s)
- Wei-Chuan Chang
- grid.411824.a0000 0004 0622 7222Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Foundation, and Tzu Chi University, Hualien, Taiwan
| | - Jen-Hung Wang
- grid.411824.a0000 0004 0622 7222Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Foundation, and Tzu Chi University, Hualien, Taiwan
| | - Dah-Ching Ding
- grid.411824.a0000 0004 0622 7222Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi General Hospital, Buddhist Tzu Chi Foundation, and Tzu Chi University, No. 707, Chung-Yang Rd., Sec. 3, Hualien, Taiwan, ROC ,grid.411824.a0000 0004 0622 7222Department of Obstetrics and Gynecology, College of Medicine, Tzu Chi University, Hualien, Taiwan
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26
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Gosset A, Robin G, Letombe B, Pouillès JM, Trémollieres F. [Menopause hormone treatment in practice. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2021; 49:358-372. [PMID: 33757922 DOI: 10.1016/j.gofs.2021.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Menopause Hormonal Treatment (MHT) was initially developed to correct the climacteric symptoms induced by postmenopausal estrogen deficiency. In non-hysterectomized women, MHT combines estrogens and a progestogen, the latter opposing the negative impact of estrogen on endometrial proliferation. In France, and contrary to the USA and Northern European countries, MHT mainly combines 17β-estradiol, which is the physiological estrogen produced by the ovary, and progesterone or its derivative, dihydrogesterone. France has been a pioneer in the development of cutaneous administration routes (gel or transdermal patch) for estradiol, allowing better metabolic tolerance and a reduction of the risk of venous thromboembolism compared to the oral route. The choice of the doses as well as the treatment regimen is underpinned by tolerance as well as acceptance and compliance. The risk of breast cancer, which is one of the main risks of MHT, is higher with estro-progestogen combinations than with estrogens alone ; the preferential use of progesterone or dihydrogesterone being likely to limit the excess risk of breast cancer associated with MHT at least for duration of treatment of less than 5 to 7 years. The question of the optimal duration of MHT remains an issue and must take into account the initial indication of treatment as well as the benefit-risk balance, which is specific to each woman. Continuation of MHT is conditioned by the benefit-risk balance, which must be evaluated regularly, but also by the evolution of symptoms when MHT is stopped as well as menopause-related health risks or induced by MHT. After stopping MHT, it is necessary to maintain a medical follow-up to be adapted to the clinical situation of each woman and in particular, her cardiovascular and gynecological risk factors.
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Affiliation(s)
- A Gosset
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule-de-Viguier, CHU de Toulouse, 330, avenue de Grande-Bretagne, TSA 70034, 31059 Toulouse cedex 9, France
| | - G Robin
- Service de gynécologie médicale, orthogénie et sexologie-UF de gynécologie endocrinienne, CHU Jeanne-de-Flandres, Lille, France
| | - B Letombe
- Service de gynécologie médicale, orthogénie et sexologie-UF de gynécologie endocrinienne, CHU Jeanne-de-Flandres, Lille, France
| | - J-M Pouillès
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule-de-Viguier, CHU de Toulouse, 330, avenue de Grande-Bretagne, TSA 70034, 31059 Toulouse cedex 9, France
| | - F Trémollieres
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule-de-Viguier, CHU de Toulouse, 330, avenue de Grande-Bretagne, TSA 70034, 31059 Toulouse cedex 9, France; Inserm U1048-I2MC-équipe 9, université Toulouse III Paul-Sabatier, Toulouse, France.
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27
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Hugon-Rodin J, Perol S, Plu-Bureau G. [Menopause and risk of thromboembolic events. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2021; 49:455-461. [PMID: 33757918 DOI: 10.1016/j.gofs.2021.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The incidence of venous thromboembolism (VTE) increases with age with an annual incidence of 1.25/1000 women in the 40-59 age group. Menopausal hormone therapy (MHT) may also increase the risk of VTE. This risk must be assessed during the first consultation before initiating MHT and assess each renewal of the MHT. MHT with oral estrogen combined (or not) with progestin increases the risk of VTE by about 70%. Using transdermal estrogen does not appear to increase the risk of VTE in women. VTE risk appears to be modulated by the type of progestin combined in MHT. The risk of VTE associated with MHT with transdermal estradiol appears to be safe in women using micronised progesterone and pregnane derivatives and higher in women using norpregnane derivatives . To limit the risk of VTE associated with MHT, transdermal estradiol use is recommended. In women at risk of VTE, MHT with oral estrogen is contraindicated. MHT with transdermal estradiol associated (or not) with micronised progesterone or dydrogesterone may be used in women with low or moderate risk of VTE.
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Affiliation(s)
- J Hugon-Rodin
- Service de gynécologie, groupe hospitalier Paris Saint-Joseph, Paris, France; Inserm U 1153, Épidémiologie obstétricale, périnatale et pédiatrique, Centre de recherche en épidémiologie et statistiques, Paris, France
| | - S Perol
- Service de gynécologie obstétrique, unité de gynécologie médicale, hôpital Port-Royal-Cochin, Paris, France; Université de Paris, Paris, France
| | - G Plu-Bureau
- Service de gynécologie obstétrique, unité de gynécologie médicale, hôpital Port-Royal-Cochin, Paris, France; Université de Paris, Paris, France; Inserm U 1153, Épidémiologie obstétricale, périnatale et pédiatrique, Centre de recherche en épidémiologie et statistiques, Paris, France.
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28
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Lambrinoudaki I, Paschou SA, Lumsden MA, Faubion S, Makrakis E, Kalantaridou S, Panay N. Premature ovarian insufficiency: a toolkit for the primary care physician. Climacteric 2021; 24:425-437. [PMID: 33434082 DOI: 10.1080/13697137.2020.1859246] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Premature ovarian insufficiency (POI) refers to the loss of ovarian activity before the age of 40 years, which leads to hypoestrogenism and amenorrhea. The diagnosis of POI in a young woman has potentially life-changing physical and emotional consequences for both the patient and her family. Therefore, it is very important that the diagnosis is correct and that it is made in a timely manner. Unfortunately, the diagnosis and therefore the effective treatment of POI are often delayed, which underlines the need for education of the broad medical community on the issue. A panel of menopause experts reviewed and critically appraised the literature, and present: (1) the diagnostic approach to POI, (2) the investigation of the etiology of this condition, (3) the therapeutic strategy regarding both hormone replacement therapy and fertility, and (4) the long-term follow-up and management for ensuring quality of life, as well as urogenital, cardiovascular, bone and mental health. The ultimate goal of this article is to provide a complete toolkit for the primary care physician to have easy access to all the information needed for the optimal management of women with POI, in the context of evidence-based and personalized medicine.HIGHLIGHTSPremature ovarian insufficiency occurs in 1% of the female population of reproductive age, yet the diagnosis is often delayed, with severe physical and emotional consequences for the patient.Primary care physicians should be aware of the possibility of premature ovarian insufficiency in young women presenting with menstrual irregularity.Prompt initiation of hormone replacement therapy ensures quality of life and prevents osteoporosis and cardiovascular disease.Women seeking fertility should be referred to specialists to discuss assisted reproduction options.
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Affiliation(s)
- I Lambrinoudaki
- 2nd Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - S A Paschou
- 2nd Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - M A Lumsden
- Gynaecology and Medical Education, University of Glasgow, Glasgow, UK
| | - S Faubion
- Mayo Clinic Center for Women's Health, Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - E Makrakis
- 3rd Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - S Kalantaridou
- 3rd Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - N Panay
- Queen Charlotte's & Chelsea and Chelsea and Westminster Hospitals, Imperial College, London, UK
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Premature ovarian insufficiency: A toolkit for the primary care physician. Maturitas 2021; 147:53-63. [PMID: 33451805 DOI: 10.1016/j.maturitas.2020.11.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 11/14/2020] [Indexed: 12/17/2022]
Abstract
Premature ovarian insufficiency (POI) refers to the loss of ovarian activity before the age of 40 years, which leads to hypoestrogenism and amenorrhoea. The diagnosis of POI in a young woman has potentially life-changing physical and emotional consequences for both the patient and her family. Therefore, it is very important that the diagnosis is correct and that it is made in a timely manner. Unfortunately, the diagnosis and therefore the effective treatment of POI are often delayed, which underlines the need for education of the broad medical community on the issue. A panel of menopause experts reviewed and critically appraised the literature, and present: 1) the diagnostic approach to POI, 2) the investigation of the etiology of this condition, 3) the therapeutic strategy regarding both hormone replacement therapy (HRT) and fertility and 4) the long-term follow-up and management for ensuring quality of life, as well as urogenital, cardiovascular, bone and mental health. The ultimate goal is to provide a complete toolkit for the primary care physician to have easy access to all the information needed for the optimal management of women with POI, in the context of evidence-based and personalized medicine.
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Archer DF, Bernick BA, Mirkin S. A combined, bioidentical, oral, 17β-estradiol and progesterone capsule for the treatment of moderate to severe vasomotor symptoms due to menopause. Expert Rev Clin Pharmacol 2019; 12:729-739. [DOI: 10.1080/17512433.2019.1637731] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- David F. Archer
- Clinical Research Center, Eastern Virginia Medical School, Norfolk, VA, USA
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Dodda BR, Bondi CD, Hasan M, Clafshenkel WP, Gallagher KM, Kotlarczyk MP, Sethi S, Buszko E, Latimer JJ, Cline JM, Witt-Enderby PA, Davis VL. Co-administering Melatonin With an Estradiol-Progesterone Menopausal Hormone Therapy Represses Mammary Cancer Development in a Mouse Model of HER2-Positive Breast Cancer. Front Oncol 2019; 9:525. [PMID: 31355130 PMCID: PMC6636553 DOI: 10.3389/fonc.2019.00525] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/30/2019] [Indexed: 12/20/2022] Open
Abstract
Melatonin has numerous anti-cancer properties reported to influence cancer initiation, promotion, and metastasis. With the need for effective hormone therapies (HT) to treat menopausal symptoms without increasing breast cancer risk, co-administration of nocturnal melatonin with a natural, low-dose HT was evaluated in mice that develop primary and metastatic mammary cancer. Individually, melatonin (MEL) and estradiol-progesterone therapy (EPT) did not significantly affect mammary cancer development through age 14 months, but, when combined, the melatonin-estradiol-progesterone therapy (MEPT) significantly repressed tumor formation. This repression was due to effects on tumor incidence, but not latency. These results demonstrate that melatonin and the HT cooperate to decrease the mammary cancer risk. Melatonin and EPT also cooperate to alter the balance of the progesterone receptor (PR) isoforms by significantly increasing PRA protein expression only in MEPT mammary glands. Melatonin significantly suppressed amphiregulin transcripts in MEL and MEPT mammary glands, suggesting that amphiregulin together with the higher PRA:PRB balance and other factors may contribute to reducing cancer development in MEPT mice. Melatonin supplementation influenced mammary morphology by increasing tertiary branching in the mouse mammary glands and differentiation in human mammary epithelial cell cultures. Uterine weight in the luteal phase was elevated after long-term exposure to EPT, but not to MEPT, indicating that melatonin supplementation may reduce estrogen-induced uterine stimulation. Melatonin supplementation significantly decreased the incidence of grossly-detected lung metastases in MEL mice, suggesting that melatonin delays the formation of metastatic lesions and/or decreases aggressiveness in this model of HER2+ breast cancer. Mammary tumor development was similar in EPT and MEPT mice until age 8.6 months, but after 8.6 months, only MEPT continued to suppress cancer development. These data suggest that melatonin supplementation has a negligible effect in young MEPT mice, but is required in older mice to inhibit tumor formation. Since melatonin binding was significantly decreased in older mammary glands, irrespective of treatment, melatonin supplementation may overcome reduced melatonin responsiveness in the aged MEPT mice. Since melatonin levels are known to decline near menopause, nocturnal melatonin supplementation may also be needed in aging women to cooperate with HT to decrease breast cancer risk.
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Affiliation(s)
- Balasunder R Dodda
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States
| | - Corry D Bondi
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States
| | - Mahmud Hasan
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States
| | - William P Clafshenkel
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States
| | - Katie M Gallagher
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States
| | - Mary P Kotlarczyk
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States
| | - Shalini Sethi
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States
| | - Ethan Buszko
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States
| | - Jean J Latimer
- UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, United States
| | - J Mark Cline
- Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Paula A Witt-Enderby
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States.,UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, United States
| | - Vicki L Davis
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States
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Best practices in care for menopausal patients: 16 years after the Women's Health Initiative. J Am Assoc Nurse Pract 2019; 31:420-427. [PMID: 30908403 DOI: 10.1097/jxx.0000000000000186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Women's Health Initiative (WHI) was a large, randomized clinical trial funded by the National Institutes of Health to determine whether menopause hormone therapy (MHT) prevented heart disease, breast and colorectal cancer, and osteoporotic fractures in postmenopausal women. Two WHI trials were stopped early, and the findings had a profound effect on the clinical practice guidelines related to postmenopausal health. This article provides an overview of the WHI MHT clinical trials and findings, discusses the early stoppage of the trials and subsequent implications, and details the current nomenclature and treatment options for women transitioning through menopause in light of the WHI. This study is based on a comprehensive literature review and an education activity developed by the American Association of Nurse Practitioners. To best serve patients and individualize therapy, clinicians must provide the best estimate of potential risks or benefits to the individual patient. It is important to balance evidence of symptom relief with long-term risks and benefits that fit the patient's characteristics of family and personal health history. Armed with evidence to support various hormonal and non-hormonal options, well-informed clinicians can counsel women about MHT and potentially avoid negative impact on quality of life.
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Podzolkov VI, Bragina AE, Podzolkovа NM. Menopausal hormone therapy and heart disease prevention: desired or valid? КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2019. [DOI: 10.15829/1728-8800-2019-3-94-106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Cardiovascular diseases are the main cause of death for women in older age groups. For many decades, specialists have tried to prevent their development by the use of estrogen. The review of the literature presents current data on the effect of menopausal hormone therapy (MHT) on the risk of cardiovascular complications. The results of the main randomized clinical and observational studies in this area, conducted over several decades, are discussed. We described the concept of “window of opportunities”, in accordance with which an improvement in cardiovascular prognosis can be expected only at the onset of MHT in women under the age of 60 years in early postmenopause (menopause duration <10 years). There are experimental and clinical data explaining the different effects of estrogen on the cardiovascular prognosis in women of various age groups and different duration of postmenopause. The recommendations given in the review on the use of MHT are based on modern international guidelines.
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Affiliation(s)
| | - A. E. Bragina
- I. M. Sechenov First Moscow State Medical University
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Equilin in conjugated equine estrogen increases monocyte-endothelial adhesion via NF-κB signaling. PLoS One 2019; 14:e0211462. [PMID: 30699196 PMCID: PMC6353580 DOI: 10.1371/journal.pone.0211462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 01/15/2019] [Indexed: 11/19/2022] Open
Abstract
The adhesion of monocytes to endothelial cells, which is mediated by adhesion molecules, plays a crucial role in the onset of atherosclerosis. Conjugated equine estrogen, which is widely used for estrogen-replacement therapy, contains both estrone sulfate and various nonhuman estrogens, including equilin. To investigate the association between various estrogen types and atherosclerosis risk, we examined their effect on adhesion-molecule expression in human umbilical vein endothelial cells (HUVECs). In estrogen-treated HUVECs, the mRNA and protein expression levels of adhesion molecules were quantified by real-time polymerase chain reaction and enzyme immunoassay. Additionally, a flow-chamber system was used to assess the effects of estrogens on the adherence of U937 monocytoid cells to HUVECs. Equilin, but not 17β-estradiol (E2) or other types of estrogen, significantly increased the mRNA (P < 0.01) and protein (P < 0.05) expression of the adhesion molecules E-selectin and intercellular adhesion molecule-1 as compared with levels in controls. Equilin treatment increased the adherence of U937 monocytoid cells to HUVECs relative to the that in the control (P < 0.05), decreased estrogen receptor (ER)β expression, and increased the expression of proteins involved in nuclear factor kappa-B (NF-κB) activation relative to levels in controls. Furthermore, the accumulation of NF-κB subunit p65 in HUVEC nuclei was promoted by equilin treatment. By contrast, E2 treatment neither increased the number of adhered monocytoid cells to HUVECs nor altered the expression of ERβ or NF-κB-activating proteins. Our findings suggest that in terms of the adhesion of monocytes at the onset of atherosclerosis, E2 may be preferable for estrogen-replacement therapy. Further studies comparing equilin treatment with that of E2 are needed to investigate their differential impacts on atherosclerosis.
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Swee DS, Javaid U, Quinton R. Estrogen Replacement in Young Hypogonadal Women-Transferrable Lessons From the Literature Related to the Care of Young Women With Premature Ovarian Failure and Transgender Women. Front Endocrinol (Lausanne) 2019; 10:685. [PMID: 31681164 PMCID: PMC6798086 DOI: 10.3389/fendo.2019.00685] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 09/20/2019] [Indexed: 11/22/2022] Open
Affiliation(s)
- Du Soon Swee
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
- *Correspondence: Du Soon Swee
| | - Usman Javaid
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Richard Quinton
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
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Thaung Zaw JJ, Howe PRC, Wong RHX. Postmenopausal health interventions: Time to move on from the Women's Health Initiative? Ageing Res Rev 2018; 48:79-86. [PMID: 30355506 DOI: 10.1016/j.arr.2018.10.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/25/2018] [Accepted: 10/17/2018] [Indexed: 11/15/2022]
Abstract
Menopause is a critical period during which, without timely interventions, increased risks of cardiovascular and metabolic diseases, osteoporosis, sexual dysfunction and premature cognitive decline will contribute to diminished quality-of-life in women. Hormone therapy (HT) used to be the standard of care for managing vasomotor symptoms and prevention of chronic diseases until publication of the Women's Health Initiative (WHI) in 2002. Concerned about risks highlighted in WHI publications, many symptomatic women promptly ceased HT which resulted in increased vasomotor symptoms, osteoporosis-related-fractures and insomnia. Data from post-hoc WHI analyses and newer clinical trials consistently show reductions in coronary heart disease and mortality when estrogen therapy is initiated soon after menopause, whereas administration in later years and/or in combination with progesterone carries increased risks. However, no validated primary preventive strategies are available for younger postmenopausal women (<60 years), highlighting the need to re-evaluate the use of estrogen alone for which the risk-benefit balance appears positive. In contrast, in older women (>60 years), risks associated with oral HT exceed benefits; however transdermal estrogen may offer a safer alternative and should be further evaluated. Alternative therapies such as phytoestrogens and non-hormonal prescriptions may be beneficial for older women or those who are unsuitable for HT. Long-term head-to-head comparisons of HT with alternative interventions are warranted to confirm their efficacy for chronic disease prevention.
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Affiliation(s)
- Jay Jay Thaung Zaw
- Clinical Nutrition Research Centre, School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, 2308, Australia
| | - Peter Ranald Charles Howe
- Clinical Nutrition Research Centre, School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, 2308, Australia; University of Southern Queensland, Institute for Resilient Regions, Springfield Central, Queensland, 4300, Australia
| | - Rachel Heloise Xiwen Wong
- Clinical Nutrition Research Centre, School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, 2308, Australia; University of Southern Queensland, Institute for Resilient Regions, Springfield Central, Queensland, 4300, Australia.
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Speth RC, D'Ambra M, Ji H, Sandberg K. A heartfelt message, estrogen replacement therapy: use it or lose it. Am J Physiol Heart Circ Physiol 2018; 315:H1765-H1778. [PMID: 30216118 PMCID: PMC6336974 DOI: 10.1152/ajpheart.00041.2018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 09/04/2018] [Accepted: 09/04/2018] [Indexed: 12/24/2022]
Abstract
The issue of cardiovascular and cognitive health in women is complex. During the premenopausal phase of life, women have healthy blood pressure levels that are lower than those of age-matched men, and they have less cardiovascular disease. However, in the postmenopausal stage of life, blood pressure in women increases, and they are increasingly susceptible to cardiovascular disease, cognitive impairments, and dementia, exceeding the incidence in men. The major difference between pre- and postmenopausal women is the loss of estrogen. Thus, it seemed logical that postmenopausal estrogen replacement therapy, with or without progestin, generally referred to as menopausal hormone treatment (MHT), would prevent these adverse sequelae. However, despite initially promising results, a major randomized clinical trial refuted the benefits of MHT, leading to its falling from favor. However, reappraisal of this study in the framework of a "critical window," or "timing hypothesis," has changed our perspective on the benefit-to-risk ratio of MHT, and this review discusses the historical, current, and future approaches to MHT.
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Affiliation(s)
- Robert C Speth
- College of Pharmacy, Nova Southeastern University , Fort Lauderdale, Florida
- Department of Pharmacology and Physiology, College of Medicine, Georgetown University , Washington, District of Columbia
| | | | - Hong Ji
- Center for the Study of Sex Differences in Health, Aging and Disease, Georgetown University , Washington, District of Columbia
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Abstract
Vasomotor symptoms are the most common manifestation of the menopause transition and postmenopausal phases of reproductive life. They interfere not only in quality of life, but also contribute to sleep and mood disturbances that potentially compromise home and work effectiveness. Treatment options include hormone therapy (HT), nonhormonal prescription drugs, mind body and behavior therapies, and over-the-counter preparations. Evidence confirms that HT is the most effective option. The initial reticence to prescribe HT immediately following publication of the Women's Health Initiative has been replaced by clear guidelines for confidently identifying women for whom this therapy will be safe.
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39
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Increased cardiac and stroke death risk in the first year after discontinuation of postmenopausal hormone therapy. Menopause 2018; 25:375-379. [DOI: 10.1097/gme.0000000000001023] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Cushman M, Larson JC, Rosendaal FR, Heckbert SR, Curb JD, Phillips LS, Baird AE, Eaton CB, Stafford RS. Biomarkers, menopausal hormone therapy and risk of venous thrombosis: The Women's Health Initiative. Res Pract Thromb Haemost 2018; 2:310-319. [PMID: 30046733 PMCID: PMC5974918 DOI: 10.1002/rth2.12100] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 03/05/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Oral menopausal hormone therapy causes venous thrombosis but whether biomarkers of thrombosis risk can identify women at risk is unknown. METHODS We completed a nested case control study in the two Women's Health Initiative hormone trials; 27 347 women aged 50-79 were randomized to hormone therapy (conjugated equine estrogen with or without medroxyprogesterone acetate) or placebo. With 4 years follow-up, biomarkers were measured using stored baseline samples prior to starting treatment, and one-year later, in 215 women who developed thrombosis and 867 controls. RESULTS Overall, lower protein C and free protein S, and higher D-dimer, prothrombin fragment 1.2 and plasmin-antiplasmin complex were associated with risk of future thrombosis with odds ratios ranging from 1.9 to 3.2. Compared to women with normal biomarkers assigned to placebo, the risk of thrombosis with hormone therapy was increased among women with abnormal biomarkers, especially elevated D-dimer, elevated plasmin-antiplasmin, and low free protein S; the largest association was for D-dimer: odds ratio 6.0 (95% CI 3.6-9.8). Differences in associations by hormone use were not significant on the multiplicative scale. Considering a multi-marker score of eight biomarkers, women with three or more abnormal biomarkers had 15.5-fold increased odds of VT (95% CI 6.8-35.1). One-year changes in biomarkers were not robustly associated with subsequent thrombosis risk. CONCLUSION Abnormal levels of biomarkers of thrombosis risk identified women at increased risk of future venous thrombosis with oral menopausal hormone therapy. Findings support the potential for clinical use of D-dimer testing in advance of hormone therapy prescription.
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Affiliation(s)
- Mary Cushman
- Department of MedicineLarner College of MedicineUniversity of VermontBurlingtonVTUSA
| | - Joseph C. Larson
- Public Health Sciences DivisionFred Hutchinson Cancer Research CenterSeattleWAUSA
| | - Frits R. Rosendaal
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Susan R. Heckbert
- Department of EpidemiologyCardiovascular Health Research UnitUniversity of WashingtonSeattleWAUSA
| | - J. David Curb
- Department of Geriatric MedicineUniversity of HawaiiHonoluluHIUSA
| | - Lawrence S. Phillips
- Atlanta VA Medical CenterDecaturGAUSA
- Division of Endocrinology and MetabolismEmory University School of MedicineAtlantaGAUSA
| | - Alison E. Baird
- Department of NeurologyState University of New York Downstate Medical CenterBrooklynNYUSA
| | - Charles B. Eaton
- Department of Family MedicineAlpert Medical SchoolBrown UniversityProvidenceRIUSA
- Department of EpidemiologySchool of Public HealthBrown UniversityProvidenceRIUSA
| | - Randall S. Stafford
- Program on Prevention Outcomes and PracticesStanford Prevention Research CenterStanford UniversityPalo AltoCAUSA
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Scarabin PY. Progestogens and venous thromboembolism in menopausal women: an updated oral versus transdermal estrogen meta-analysis. Climacteric 2018; 21:341-345. [PMID: 29570359 DOI: 10.1080/13697137.2018.1446931] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Postmenopausal hormone therapy (HT) is a modifiable risk factor for venous thromboembolism (VTE). While the route of estrogen administration is now well recognized as an important determinant of VTE risk, there is also increasing evidence that progestogens may modulate the estrogen-related VTE risk. This review updates previous meta-analyses of VTE risk in HT users, focusing on the route of estrogen administration, hormonal regimen and progestogen type. Among women using estrogen-only preparations, oral but not transdermal preparations increased VTE risk (relative risk (RR) 1.48, 95% confidence interval (CI) 1.39-1.58; RR 0.97, 95% CI 0.87-1.09, respectively). In women using opposed estrogen, results were highly heterogeneous due to important differences between the molecules of progestogen. In transdermal estrogen users, there was no change in VTE risk in women using micronized progesterone (RR 0.93, 95% CI 0.65-1.33), whereas norpregnane derivatives were associated with increased VTE risk (RR 2.42, 95% CI 1.84-3.18). Among women using opposed oral estrogen, there was higher VTE risk in women using medroxyprogesterone acetate (RR 2.77, 95% CI 2.33-3.30) than in those using other progestins. These clinical findings, together with consistent biological data, emphasize the safety advantage of transdermal estrogen combined with progesterone and support the current evidence-based recommendations on HT, especially in women at high VTE risk.
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Affiliation(s)
- P-Y Scarabin
- a Université Paris-Saclay, Université Paris-Sud, UVSQ, Centre de Recherche en Epidémiologie et Santé des Populations , INSERM UMRS1018 Villejuif , France
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Ding XH, Wang Y, Cui B, Qin J, Zhang JH, Rao RS, Yu SY, Zhao XH, Huang L. Acute Mountain Sickness Is Associated With a High Ratio of Endogenous Testosterone to Estradiol After High-Altitude Exposure at 3,700 m in Young Chinese Men. Front Physiol 2018; 9:1949. [PMID: 30740062 PMCID: PMC6355701 DOI: 10.3389/fphys.2018.01949] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 12/22/2018] [Indexed: 12/12/2022] Open
Abstract
Background: A large proportion of populations suffer from acute mountain sickness (AMS) after exposure at high altitude. AMS is closely related with age and gender implying that the sex hormones may play critical roles in AMS. Our observational study aimed to identify the association between the endogenous testosterone (T), estradiol (E2) and AMS. Methods: A total of 113 subjects were recruited in 2012. The participants were evaluated at 500 m and after acute (1 day) and short-term (7 days) high-altitude exposure at 3,700 m. The subjects also completed a case report form questionnaire and underwent blood pressure measurements and an echocardiography examination. The red blood cell (RBC) count, Hb concentration ([Hb]), hematocrit (HCT), E2, T, and erythropoietin (EPO) were measured. Results: Upon acute high-altitude exposure, E2 and EPO were significantly lower in AMS+ group, and T/E2 and stroke volume were higher. On the 1st day, AMS score correlated positively with the T/E2 ratio while it negatively correlated with E2. After 7 days at 3,700 m, the AMS+ subjects had higher erythropoietic parameters: EPO, T, and T/E2 were significantly higher in the AMS+ group. [Hb], RBC count, HCT, EPO, T and T/E2 were also correlated with AMS score. EPO, HCT, and the RBC count were also correlated with T/E2. Regression analyses indicated that T/E2 significantly correlated to AMS score and T/E2 on the 1st day was an independent predictor for AMS on the 7th day. Conclusion: AMS was correlated with T/E2 ratio and EPO. After short-term exposure, higher T/E2 may contribute to AMS together with EPO via erythropoiesis. Furthermore, T/E2 level at high altitude in the early stage was an independent predictor for AMS in the latter stage.
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Affiliation(s)
- Xiao-Han Ding
- Department of Health Care and Geriatrics, Lanzhou General Hospital of Lanzhou Military Region, Lanzhou, China
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Yanchun Wang
- Department of Health Care and Geriatrics, Lanzhou General Hospital of Lanzhou Military Region, Lanzhou, China
| | - Bin Cui
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jun Qin
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Ji-Hang Zhang
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Rong-Sheng Rao
- Department of Ultrasonography, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shi-Yong Yu
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Xiao-Hui Zhao
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Lan Huang
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- *Correspondence: Lan Huang,
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Postmenopausal hormone therapy and risk of stroke: A pooled analysis of data from population-based cohort studies. PLoS Med 2017; 14:e1002445. [PMID: 29149179 PMCID: PMC5693286 DOI: 10.1371/journal.pmed.1002445] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 10/17/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Recent research indicates a favourable influence of postmenopausal hormone therapy (HT) if initiated early, but not late, on subclinical atherosclerosis. However, the clinical relevance of timing of HT initiation for hard end points such as stroke remains to be determined. Further, no previous research has considered the timing of initiation of HT in relation to haemorrhagic stroke risk. The importance of the route of administration, type, active ingredient, and duration of HT for stroke risk is also unclear. We aimed to assess the association between HT and risk of stroke, considering the timing of initiation, route of administration, type, active ingredient, and duration of HT. METHODS AND FINDINGS Data on HT use reported by the participants in 5 population-based Swedish cohort studies, with baseline investigations performed during the period 1987-2002, were combined in this observational study. In total, 88,914 postmenopausal women who reported data on HT use and had no previous cardiovascular disease diagnosis were included. Incident events of stroke (ischaemic, haemorrhagic, or unspecified) and haemorrhagic stroke were identified from national population registers. Laplace regression was employed to assess crude and multivariable-adjusted associations between HT and stroke risk by estimating percentile differences (PDs) with 95% confidence intervals (CIs). The fifth and first PDs were calculated for stroke and haemorrhagic stroke, respectively. Crude models were adjusted for age at baseline only. The final adjusted models included age at baseline, level of education, smoking status, body mass index, level of physical activity, and age at menopause onset. Additional variables evaluated for potential confounding were type of menopause, parity, use of oral contraceptives, alcohol consumption, hypertension, dyslipidaemia, diabetes, family history of cardiovascular disease, and cohort. During a median follow-up of 14.3 years, 6,371 first-time stroke events were recorded; of these, 1,080 were haemorrhagic. Following multivariable adjustment, early initiation (<5 years since menopause onset) of HT was associated with a longer stroke-free period than never use (fifth PD, 1.00 years; 95% CI 0.42 to 1.57), but there was no significant extension to the time period free of haemorrhagic stroke (first PD, 1.52 years; 95% CI -0.32 to 3.37). When considering timing as a continuous variable, the stroke-free and the haemorrhagic stroke-free periods were maximal if HT was initiated approximately 0-5 years from the onset of menopause. If single conjugated equine oestrogen HT was used, late initiation of HT was associated with a shorter stroke-free (fifth PD, -4.41 years; 95% CI -7.14 to -1.68) and haemorrhagic stroke-free (first PD, -9.51 years; 95% CI -12.77 to -6.24) period than never use. Combined HT when initiated late was significantly associated with a shorter haemorrhagic stroke-free period (first PD, -1.97 years; 95% CI -3.81 to -0.13), but not with a shorter stroke-free period (fifth PD, -1.21 years; 95% CI -3.11 to 0.68) than never use. Given the observational nature of this study, the possibility of uncontrolled confounding cannot be excluded. Further, immortal time bias, also related to the observational design, cannot be ruled out. CONCLUSIONS When initiated early in relation to menopause onset, HT was not associated with increased risk of incident stroke, regardless of the route of administration, type of HT, active ingredient, and duration. Generally, these findings held also for haemorrhagic stroke. Our results suggest that the initiation of HT 0-5 years after menopause onset, as compared to never use, is associated with a decreased risk of stroke and haemorrhagic stroke. Late initiation was associated with elevated risks of stroke and haemorrhagic stroke when conjugated equine oestrogen was used as single therapy. Late initiation of combined HT was associated with haemorrhagic stroke risk.
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Pickar JH, Archer DF, Kagan R, Pinkerton JV, Taylor HS. Safety and benefit considerations for menopausal hormone therapy. Expert Opin Drug Saf 2017; 16:941-954. [DOI: 10.1080/14740338.2017.1343298] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- James H Pickar
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, USA
| | - David F Archer
- Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Risa Kagan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco and East Bay Physicians Medical Group, Sutter East Bay Medical Foundation, Berkeley, CA, USA
| | - JoAnn V Pinkerton
- Department of Obstetrics and Gynecology, University of Virginia Health System, Charlottesville, VA, USA
| | - Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
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Araujo PX, Costa TJ, Echem C, Aparecida de Oliveira M, Santos-Eichler RA, Colli LG, Jiménez-Altayó F, Vila E, Akamine EH, Dantas AP, Ceravolo GS, de Carvalho MHC. Treatment with Standard and Low Dose of Conjugated Equine Estrogen Differentially Modulates Estrogen Receptor Expression and Response to Angiotensin II in Mesenteric Venular Bed of Surgically Postmenopausal Hypertensive Rats. J Pharmacol Exp Ther 2017; 362:98-107. [DOI: 10.1124/jpet.117.240465] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 04/21/2017] [Indexed: 01/03/2023] Open
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Mikkola TS, Savolainen-Peltonen H, Venetkoski M, Ylikorkala O. New evidence for cardiac benefit of postmenopausal hormone therapy. Climacteric 2017; 20:5-10. [DOI: 10.1080/13697137.2016.1262839] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- T. S. Mikkola
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - H. Savolainen-Peltonen
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - M. Venetkoski
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - O. Ylikorkala
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Harrington LB, Marck BT, Wiggins KL, McKnight B, Heckbert SR, Woods NF, LaCroix AZ, Blondon M, Psaty BM, Rosendaal FR, Matsumoto AM, Smith NL. Cross-sectional association of endogenous steroid hormone, sex hormone-binding globulin, and precursor steroid levels with hemostatic factor levels in postmenopausal women. J Thromb Haemost 2017; 15:80-90. [PMID: 27797446 PMCID: PMC5280337 DOI: 10.1111/jth.13554] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Indexed: 11/27/2022]
Abstract
Essentials Endogenous hormone levels' influence on hemostatic factor levels is not fully characterized. We tested for associations of endogenous hormone with hemostatic factor levels in postmenopause. Estrone levels were inversely associated with the natural anticoagulant, protein S antigen. Dehydroepiandrosterone sulfate levels were inversely associated with thrombin generation. SUMMARY Background Oral use of exogenous estrogen/progestin alters hemostatic factor levels. The influence of endogenous hormones on these levels is incompletely characterized. Objectives Our study aimed to test whether, among postmenopausal women, high levels of estradiol (E2), estrone (E1), testosterone (T), dehydroepiandrosterone sulfate (DHEAS), dehydroepiandrosterone (DHEA), and androstenedione, and low levels of sex hormone-binding globulin (SHBG), are positively associated with measures of thrombin generation (TG), a normalized activated protein C sensitivity ratio (nAPCsr), and factor VII activity (FVIIc), and negatively associated with antithrombin activity (ATc) and total protein S antigen (PSAg). Methods This Heart and Vascular Health study cross-sectional analysis included 131 postmenopausal women without a prior venous thrombosis who were not currently using hormone therapy. Adjusted mean differences in TG, nAPCsr, FVIIc, ATc and PSAg levels associated with differences in hormone levels were estimated using multiple linear regression. We measured E2, E1, total T, DHEAS, DHEA and androstenedione levels by mass spectrometry, SHBG levels by immunoassay, and calculated the level of free T. Results One picogram per milliliter higher E1 levels were associated with 0.24% lower PSAg levels (95% Confidence Interval [CI]: -0.35, -0.12) and 1 μg mL-1 higher DHEAS levels were associated with 40.8 nm lower TG peak values (95% CI: -59.5, -22.2) and 140.7 nm×min lower TG endogenous thrombin potential (ETP) (95% CI: -212.1, -69.4). After multiple comparisons correction, there was no evidence for other associations. Conclusions As hypothesized, higher E1 levels were associated with lower levels of the natural anticoagulant PSAg. Contrary to hypotheses, higher DHEAS levels were associated with differences in TG peak and ETP that suggest less generation of thrombin.
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Affiliation(s)
- Laura B. Harrington
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Brett T. Marck
- Geriatric Research, Education and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Kerri L. Wiggins
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Barbara McKnight
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Susan R. Heckbert
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Group Health Research Institute, Seattle, WA, USA
| | - Nancy F. Woods
- School of Nursing, University of Washington, Seattle, WA, USA
| | - Andrea Z. LaCroix
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Group Health Research Institute, Seattle, WA, USA
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, USA
| | - Marc Blondon
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Division of Angiology and Haemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Bruce M. Psaty
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Group Health Research Institute, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Frits R. Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alvin M. Matsumoto
- Geriatric Research, Education and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
- Division of Gerontology & Geriatric Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Nicholas L. Smith
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Group Health Research Institute, Seattle, WA, USA
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA, USA
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Gawlik A, Hankus M, Such K, Drosdzol-Cop A, Madej P, Borkowska M, Zachurzok A, Malecka-Tendera E. Hypogonadism and Sex Steroid Replacement Therapy in Girls with Turner Syndrome. J Pediatr Adolesc Gynecol 2016; 29:542-550. [PMID: 27018757 DOI: 10.1016/j.jpag.2016.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 03/06/2016] [Accepted: 03/09/2016] [Indexed: 12/28/2022]
Abstract
Turner syndrome is the most common example of hypergonadotropic hypogonadism resulting from gonadal dysgenesis. Most patients present delayed, or even absent, puberty. Premature ovarian failure can be expected even if spontaneous menarche occurs. Laboratory markers of gonadal dysgenesis are well known. The choice of optimal hormone replacement therapy in children and adolescents remains controversial, particularly regarding the age at which therapy should be initiated, and the dose and route of estrogen administration. On the basis of a review of the literature, we present the most acceptable schedule of sex steroid replacement therapy in younger patients with Turner syndrome.
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Affiliation(s)
- Aneta Gawlik
- Department of Pediatrics and Pediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland; Department of Pediatrics, Pediatric Endocrinology and Diabetes, Upper-Silesian Pediatric Health Center, Katowice, Poland.
| | - Magdalena Hankus
- Department of Pediatrics, Pediatric Endocrinology and Diabetes, Upper-Silesian Pediatric Health Center, Katowice, Poland
| | - Kamila Such
- Medical Students' Scientific Association, Katowice, Poland
| | | | - Paweł Madej
- Department of Endocrinological Gynecology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | | | - Agnieszka Zachurzok
- Department of Pediatrics and Pediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland; Department of Pediatrics, Pediatric Endocrinology and Diabetes, Upper-Silesian Pediatric Health Center, Katowice, Poland
| | - Ewa Malecka-Tendera
- Department of Pediatrics and Pediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland; Department of Pediatrics, Pediatric Endocrinology and Diabetes, Upper-Silesian Pediatric Health Center, Katowice, Poland
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Crous-Bou M, Harrington LB, Kabrhel C. Environmental and Genetic Risk Factors Associated with Venous Thromboembolism. Semin Thromb Hemost 2016; 42:808-820. [PMID: 27764878 DOI: 10.1055/s-0036-1592333] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Venous thromboembolism (VTE) includes deep vein thrombosis and pulmonary embolism, and a combination of environmental and genetic risk factors contributes to VTE risk. Within environmental risk factors, some are provoking (e.g., cancer, surgery, trauma or fracture, immobilization, pregnancy and the postpartum period, long-distance travel, hospitalization, catheterization, and acute infection) and others are nonprovoking (e.g., age, sex, race/ethnicity, body mass index and obesity, oral contraceptive or hormone therapy use, corticosteroid use, statin use, diet, physical activity, sedentary time, and air pollution). Additionally, VTE has a strong genetic basis, with approximately 50 to 60% of the variance in VTE incidence attributed to genetic effects. Some genetic susceptibility variants that contribute to risk have been identified in candidate genes, mostly related to the clotting system and responsible for inherited hypercoagulable states (e.g., factor V Leiden, prothrombin, fibrinogen gamma, or blood group non-O). Other susceptibility single-nucleotide polymorphisms have been identified from genome-wide association studies, such as the two new loci in TSPAN15 (rs78707713) and SCL44A2 (rs2288904) genes. Risk factors are not always associated with VTE in isolation; however, and an understanding of how environmental and genetic factors interact may provide insight into the pathophysiology of VTE, possibly identifying opportunities for targeted prevention and treatment.
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Affiliation(s)
- Marta Crous-Bou
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laura B Harrington
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Boston, Massachusetts
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Tuomikoski P, Salomaa V, Havulinna A, Airaksinen J, Ketonen M, Koukkunen H, Ukkola O, Kesäniemi YA, Lyytinen H, Ylikorkala O, Mikkola TS. Decreased mortality risk due to first acute coronary syndrome in women with postmenopausal hormone therapy use. Maturitas 2016; 94:106-109. [PMID: 27823727 DOI: 10.1016/j.maturitas.2016.09.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/26/2016] [Accepted: 09/27/2016] [Indexed: 01/15/2023]
Abstract
OBJECTIVES The role of postmenopausal hormone therapy (HT) in the incidence of acute coronary syndrome (ACS) has been studied extensively, but less is known of the impact of HT on the mortality risk due to an ACS. STUDY DESIGN AND MAIN OUTCOME MEASURES We extracted from a population-based ACS register, FINAMI, 7258 postmenopausal women with the first ACS. These data were combined with HT use data from the National Drug Reimbursement Register; 625 patients (9%) had used various HT regimens. The death risks due to ACS before admission to hospital, 2-28, or 29-365days after the incident ACS were compared between HT users and non-users with logistic regression analyses. RESULTS In all follow-up time points, the ACS death risks in HT ever-users were smaller compared to non-users. Of women with HT ever use, 42% died within one year as compared with 52% of non-users (OR 0.62, p<0.001). Most deaths (84%) occurred within 28days after the ACS, and in this group 36% of women with ever use of HT (OR 0.73, p=0.002) and 30% of women with ≥5year HT use (OR 0.54, p<0.001) died as compared to 43% of the non-users. Age ≤60 or >60 years at the HT initiation was accompanied with similar reductions in ACS mortality risk. CONCLUSIONS Postmenopausal HT use is accompanied with reduced mortality risk after primary ACS.
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Affiliation(s)
- Pauliina Tuomikoski
- University of Helsinki and Helsinki University Hospital, Department of Obstetrics and Gynecology, 00029 Helsinki, Finland
| | - Veikko Salomaa
- THL-National Institute for Health and Welfare, PO BOX 30, 00271 Helsinki, Finland
| | - Aki Havulinna
- THL-National Institute for Health and Welfare, PO BOX 30, 00271 Helsinki, Finland
| | - Juhani Airaksinen
- Heart Center, Turku University Hospital and Department of Clinical Medicine, University of Turku, Turku, Finland
| | | | | | - Olavi Ukkola
- Research Institute of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Y Antero Kesäniemi
- Research Institute of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Heli Lyytinen
- University of Helsinki and Helsinki University Hospital, Department of Obstetrics and Gynecology, 00029 Helsinki, Finland
| | - Olavi Ylikorkala
- University of Helsinki and Helsinki University Hospital, Department of Obstetrics and Gynecology, 00029 Helsinki, Finland
| | - Tomi S Mikkola
- University of Helsinki and Helsinki University Hospital, Department of Obstetrics and Gynecology, 00029 Helsinki, Finland; Folkhälsan Research Center, Biomedicum, 00029 Helsinki, Finland.
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