Effects of 1-year treatment with ipriflavone on bone in postmenopausal women with low bone mass

Isoflavone intervention and its impact on bone mineral density in postmenopausal women: a systematic review and meta-analysis of randomized controlled trials

Due to estrogen deficiency, postmenopausal women may suffer from an imbalance in bone metabolism that leads to bone fractures. Isoflavones, a type of phytoestrogen, have been suggested to improve bone metabolism and increase bone mass. Therefore, isoflavones are increasingly recognized as a promising natural alternative to hormone replacement therapy for postmenopausal women who face a heightened risk of osteoporosis and are susceptible to bone fractures.

PURPOSE

This study aimed to evaluate the efficacy of isoflavone interventions on bone mineral density (BMD) in postmenopausal women by means of systematic review and meta-analysis.

METHODS

The electronic database searches were performed on PubMed, Embase, Scopus, and Cochrane Library databases, covering literature up to April 20, 2023. A random-effects model was used to obtain the main effect estimates, with a mean difference (MD) and its 95% confidence interval (CI) as the effect size summary. The risk of bias assessment was conducted using the Risk of Bias 2 (RoB2) tool.

RESULTS

A total of 63 randomized controlled trials comparing isoflavone interventions (n = 4,754) and placebo (n = 4,272) were included. The results indicated that isoflavone interventions significantly improved BMD at the lumbar spine (MD = 0.0175 g/cm2; 95% CI, 0.0088 to 0.0263, P < 0.0001), femoral neck (MD = 0.0172 g/cm2; 95% CI, 0.0046 to 0.0298, P = 0.0073), and distal radius (MD = 0.0138 g/cm2; 95% CI, 0.0077 to 0.0198, P < 0.0001) in postmenopausal women. Subgroup analysis showed that the isoflavone intervention was effective for improving BMD when the duration was ≥ 12 months and when the intervention contained genistein of at least 50 mg/day.

CONCLUSION

This systematic review and meta-analysis suggests that isoflavone interventions, especially those containing genistein of at least 50 mg/day, can effectively enhance BMD in postmenopausal women.

The Effects of Polyphenols on Bone Metabolism in Postmenopausal Women: Systematic Review and Meta-Analysis of Randomized Control Trials

Osteoporosis is a condition favored by the postmenopausal decline in estrogen levels and worsened by oxidative stress (OS). Polyphenols are natural compounds abundantly found in fruits and vegetables, and they exert antioxidant and hormonal effects that could be useful in osteoporosis prevention, as suggested by epidemiological studies showing a lower incidence of fractures in individuals consuming polyphenol-rich diets. The aim of our meta-analysis is to evaluate the effects of polyphenols on bone mineral density (BMD, primary endpoint) and bone turnover markers (BTMs, secondary endpoint) in postmenopausal women. Twenty-one randomized control trials (RCTs) were included in our analysis after in-depth search on PubMed, EMBASE, and Scopus databases. We found that supplementation with polyphenols for 3-36 months exerted no statically significant effects on BMD measured at lumbar spine (sMD: 0.21, 95% CI [-0.08 to 0.51], p = 0.16), femoral neck (sMD: 0.16, 95% CI [-0.23 to 0.55], p = 0.42), total hip (sMD: 0.05, 95% CI [-0.14 to 0.24], p = 0.61), and whole body (sMD: -0.12, 95% CI [-0.42 to 0.17], p = 0.41). Subgroup analysis based on treatment duration showed no statistical significance, but a significant effect on lumbar BMD emerged when studies with duration of 24 months or greater were analyzed separately. On the other hand, we found a significantly slight increase in bone-specific alkaline phosphatase (BALP) levels (sMD: 1.27, 95% CI [1.13 to 1.42], p < 0.0001) and a decrease in pyridinoline (PD) levels (sMD: -0.58, 95% CI [-0.77 to -0.39], p < 0.0001). High heterogeneity among studies and unclear risk of bias in one third of the included studies emerged. A subgroup analysis showed similar effects for different duration of treatment and models of dual-energy X-ray absorptiometry (DXA) scanner. More robust evidence is needed before recommending the prescription of polyphenols in clinical practice.

Phytoestrogens

Phytoestrogens are defined as naturally occurring compounds found in plants that are structurally and functionally similar to 17-ß oestradiol or that produce oestrogenic effects. They are diphenolic in structure and are most commonly found in cereals, legumes and grasses. There have been numerous classes identified, the mostly highly investigated being isoflavones and lignans. Isoflavones are attenuated oestrogens. They behave both in vivo and in vitro as agonists and antagonists. Genistein and daidzein are found in high concentrations in soy beans and soy products. Their relative potencies as compared to oestradiol are low but they exhibit equivalent levels of bioactivity when tested in high concentrations. Lignans are found in oilseeds, cereals and berries. The main urinary lignans are enterolactone and enterodiol. Most phytoestrogens are modified by gut flora from glycoside precursors to a compound with oestrogenic properties.

A high dietary intake of phytoestrogens was first noted to be associated with decreased incidences of certain diseases. This epidemiological data was obtained primarily from studying Asian populations. Soy consumption is highest in Japan, where urinary levels of phytoestrogen metabolites are extremely high and there are lower rates of so-called ‘Western’ diseases, including breast, endometrial, colon cancers as well as atherosclerotic disease. Research to date has focused on the antiproliferative potential of phytoestrogens, primarily genistein both in vitro and in vivo. Their role in the relief of menopausal symptoms, their hypocholesterolaemic effects and bone resorption protection have been investigated to some extent with promising results. A brief overview of the background of, and the research into, phytoestrogens will be provided in this article.

Antimutagenic activity of ipriflavone against the DNA-damage induced by cyclophosphamide in mice

In the present study we evaluated the potential of ipriflavone against the cytotoxic and mutagenic effects induced by cyclophosphamide chemotherapeutic agent in bone marrow cells of mice, using the micronucleus assay in vivo on cells of bone marrow. The study was performed following three protocols: pre-treatment, simultaneous treatment and post treatment. The results demonstrated that ipriflavone has a protective effect against mutagenicity induced by cyclophosphamide in the pre-treatment and post-treatment and against the cytotoxicity in all treatments. There was variation between the genders in some of the experimental groups. To evaluate their possible mechanisms of action, it was performed the DPPH assay, which showed no ability to donate hydrogens, suggesting that it acts through other mechanisms. Due to its ability to prevent chromosomal damage, ipriflavone is likely to open an interest field concerning its possible the use in clinical applications.

Soy isoflavones in the management of postmenopausal osteoporosis

This is a review article designed to address the effects of soy isoflavones on bone metabolism in postmenopausal women and their place in the prevention and treatment of postmenopausal osteoporosis. Soy isoflavones are natural products that could be used as an alternative to menopausal hormone therapy because they are structurally and functionally related to 17beta-estradiol. In vitro and animal studies have shown that they act in multiple ways to exert their bone-supporting effects. They act on both osteoblasts and osteoclasts through genomic and nongenomic pathways. Epidemiological studies and clinical trials suggest that soy isoflavones have beneficial effects on bone mineral density, bone turnover markers, and bone mechanical strength in postmenopausal women. However, there are conflicting results related to differences in study design, estrogen status of the body, metabolism of isoflavones among individuals, and other dietary factors. The long-term safety of soy isoflavone supplements remains to be demonstrated.

Phytoestrogen derivatives differentially inhibit arterial neointimal proliferation in a mouse model

Neointimal proliferation is a key element in atherosclerotic plaque formation and in arterial restenosis following angioplasty. Estrogen-like compounds, including naturally occurring plant phytoestrogens, are known to alter the extent of neointimal proliferation. This study investigates the anti-atherogenic/restenotic effect of several synthetic metabolites of isoflavone phytoestrogens (dihydrodaidzein, tetrahydrodaidzein and dehydroequol) (Novogen, Sydney, Australia). Acute neointimal proliferation was induced in the iliac artery of cholesterol-fed mice, by mechanically damaging the endothelium. Phytoestrogens were administered orally for 4 weeks and the damaged arteries harvested. Intimal area, as a percentage of the iliac artery wall area, was measured. Dihydrodaidzein significantly halved the intimal response (intima approximately 25% of wall area; p < 0.01) compared with placebo diet-fed mice (intima approximately 50% of wall area), while tetrahydrodaidzein and dehydroequol showed no inhibitory effects. Immunohistochemistry demonstrated that alpha-actin-positive vascular smooth muscle cells were the major cell type in the proliferating neointima. A single layer of endothelium covered the thickened intima by 4 weeks. Thus, a specific phytoestrogen isoflavone compound (dihydrodaidzein) can selectively inhibit neointimal proliferation, either by inhibition of vascular smooth muscle cell migration and proliferation, and/or by enhancing endothelial proliferation and function, and inhibition of endothelial apoptosis.

DT56a stimulates creatine kinase specific activity in vascular tissues of rats

The novel natural product DT56a (Secure Pharmaceuticals, Yavne, Israel), derived from soybean, has been shown to relieve menopausal vasomotor symptoms and increase in bone mineral density with no effect on sex steroid hormone levels or endometrial thickness. In single injection, like 17beta-estradiol (E2), DT56a stimulated bone, cartilage and uterus in immature or ovariectomized female rats, by measuring the changes in the specific activity of the BB isozyme of creatine kinase (CK). When administered in multiple oral doses, DT56a stimulated skeletal tissues similarly to E2 but not uterine CK. The selective estrogen receptor modulator raloxifene blocked the stimulation of CK by either DT56a or by E2 in all tissues tested. In the present study we measured the effects of DT56a on vascular tissues i.e. aorta (Ao) and the left ventricle of the heart (Lv). Both types of animals responded to either single or multiple administration of DT56a like to E2. In the Ao from both animals and in the Lv from ovariectomized rats, raloxifene completely blocked CK activity induced by DT56a, whereas in the Lv of immature female rats the inhibition was partial. Our experimental findings suggest that DT56a acts as estrogen; it has beneficial effects not only on skeletal tissues, but also on vascular tissues, however contrary to estrogen DT56a, did not affect the uterus. These findings suggest that DT56a--which has similar beneficial effects on vascular tissues like that of E2--is probably mediated via common receptor(s).

DT56a (Tofupill/Femarelle) selectively stimulates creatine kinase specific activity in skeletal tissues of rats but not in the uterus

The novel natural product DT56a (Tofupill/Femarelle), derived from soybean, has been shown to relieve menopausal vasomotor symptoms and to increase bone mineral density with no effect on sex steroid hormone levels or endometrial thickness. In the present study, we compared the effects of DT56a and estradiol-17beta (E2) on bone and cartilage (Ep) of immature or ovariectomized female rats, by measuring the changes in the specific activity of the BB isozyme of creatine kinase (CK). Single short-term injection of high doses of DT56a induced estrogenic activity in bones and uterus similar to that of E2. When administered in multiple oral doses, DT56a stimulated skeletal tissues similarly to E2, but whereas E2 increased CK specific activity in the uterus, DT56a did not. The selective estrogen receptor modulator (SERM) raloxifene (Ral) blocked the stimulation of CK by either DT56a or by E2 in all tissues tested. Our findings suggest that DT56a acts as a selective estrogen receptor modulator stimulating skeletal tissues without affecting the uterus. The effect of DT56a on other systems, such as the vascular and the central nervous system, are currently under investigation.

Use of alternative and complementary medicine in menopause

OBJECTIVES

To review the clinical evidence available for the treatment of menopausal symptoms with alternative and complementary medicine.

METHODS

The MEDLINE, PREMEDLINE and COCHRANE electronic databases for the years 1980-2002 were searched for articles concerning soy products, black cohosh, dong quai, acupuncture, ginseng and evening primrose oil. Studies pertaining to menopausal vasomotor symptoms, lipid profiles and bone mineral densities of postmenopausal women were included. The data from clinical trials were reviewed.

RESULTS

Soy isoflavones slightly decrease total cholesterol and LDL levels. The clinical significance of this small change is yet to be determined. The synthetic isoflavone derivative ipriflavone increases bone mineral density in healthy peri- and postmenopausal women with moderate bone mineral densities. Although earlier reports have claimed that soy is beneficial for the improvement of vasomotor symptoms, recent data do not support this claim. There are insufficient data on the other alternative therapies for treating menopausal symptoms at this time.

CONCLUSION

Alternative and complementary medicine may play a role in the management of menopause, however, well-designed large studies are still needed.

Use of alternative therapies in menopause

Hormone replacement therapy has traditionally been used to treat the accompanying symptoms of oestrogen deficiency in menopause. However, not all women can, or prefer to, receive this treatment and alternatives should be considered to reduce the increased risk of osteoporosis and heart disease in menopausal women. This chapter reviews the current literature on the efficacy of phyto-oestrogens in preventing cardiovascular disease, various cancers and osteoporosis, as well as treating the vasomotor and other menopause-related symptoms. Select herbal therapies, as well as selective oestrogen receptor modulators, are also considered.

Complementary therapies for reducing the risk of osteoporosis in patients receiving luteinizing hormone-releasing hormone treatment/orchiectomy for prostate cancer: a review and assessment of the need for more research

Osteoporosis in women has received a substantial amount of attention, but its impact in men is also significant and noteworthy. Those men who benefit from treatment for prostate cancer with androgen deprivation therapy (ADT) may also be at a higher risk for osteoporosis. Pharmacologic approaches to reduce this risk have received some attention. For example, agents such as bisphosphonates, estrogen receptor-binding drugs (diethylstilbestrol, tamoxifen, and raloxifene), calcitonin, and fluoride are some of the more promising interventions that have been previously outlined. In addition, statin drugs, or hepatic 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, have recently been hypothesized to lower osteoporosis risk. However, complementary therapies, which may also have an impact on reducing osteoporosis risk, have not received attention. Dietary and supplemental calcium and vitamin D have been shown, in some preliminary investigations, to maintain bone density in women and men. Numerous healthy and affordable dietary sources of this mineral and vitamin exist, and large intakes can be realistically achieved through proper education. Similarly, the supplemental dosages required to impact risk have been moderate, appear to be safe, are of low cost, and thus may provide an additional route for reducing risk, especially if these interventions are initiated at the start of medical treatment. More studies in men receiving ADT are needed because the existing work has mostly focused on men without castrate levels of male hormone. Additionally, many studies with conventional and nonconventional agents have only focused on individuals with baseline osteoporosis, rather than normal bone mineral densities or osteopenia. Other promising complementary therapies, such as weight-bearing exercise and abstaining from smoking, may also be of benefit. Newer estrogenic-type supplements (eg, ipriflavone) appear interesting and have some preliminary data, but more research is desperately required to determine their actual impact and potential for adverse effects (such as lymphocytopenia from a recent trial). Simple, inexpensive, and potentially effective dietary and supplemental approaches to reduce the risk of osteoporosis in men exist, and they should be discussed with patients. Whether these approaches effectively reduce the risk of osteoporosis in men receiving androgen ablation remains to be determined. The possibility is intriguing, and future research is needed. In the meantime, it is important to keep in mind that these complementary approaches are, at the very least, an integral part of the conventional options used today to the reduce the risk of osteoporosis in men and women.

Genistein, daidzein and glycitein inhibit growth and DNA synthesis of aortic smooth muscle cells from stroke-prone spontaneously hypertensive rats

Recent studies have reported that estrogen replacement therapy (ERT) reduces the risk of cardiovascular diseases in postmenopausal women. However, mechanisms responsible for this effect are not yet completely understood, and ERT is associated with carcinogenic side effects in women and feminizing effects in men. Because soybean isoflavones, a group of natural phytoestrogens, have only weak estrogenic activity and are not known to have side effects such as carcinogenesis and feminization, we evaluated the effects of genistein, daidzein and glycitein on the growth and DNA synthesis of aortic smooth muscle cells (SMC) from stroke-prone spontaneously hypertensive rats (SHRSP). SMC were cultured in dishes and proliferated on 10% dextran-coated charcoal/fetal bovine serum, and then treated with 0.1-30 micromol/L of genistein, daidzein or glycitein to investigate cell proliferation (cell number) and DNA synthesis (cell proliferation ELISA system), respectively. We also studied their effects on platelet-derived growth factor (PDGF)-BB (20 microg/L)-induced SMC proliferation. Soybean isoflavones inhibited proliferation and DNA synthesis of SMC from SHRSP in a concentration-dependent manner. Inhibition was significant at 3 micromol/L of genistein and 10 micromol/L of both daidzein and glycitein. For significant inhibition of PDGF-BB-induced SMC proliferation, concentrations as low as 0.1 micromol/L of each isoflavone were effective. These isoflavones, with their inhibitory effects on natural and PDGF-BB-induced SMC proliferation, may be useful in attenuatating such proliferation, a basic mechanism involved in atherosclerotic vascular change, thereby preventing atherosclerotic cardiovascular diseases.

Phytoestrogens as hormone replacement therapy: an evidence-based approach

Postmenopausal women have sought nonestrogen alternatives to hormone replacement in order to avoid possible risks and side effects of the therapy. Selective estrogen receptor modulators have been developed to tailor therapy to a specific risk/benefit profile that will best fit the patient. More women have looked to phytoestrogens, such as the isoflavones found in the soy plant, to tailor their menopausal therapy in a "natural" way. This review examines the evidence regarding the risks and benefits of isoflavones as hormone replacement therapy. Controlled trials have shown a reduction in postmenopausal hot flashes when subjects' diets were supplemented with soy. There is less evidence for a benefit in vaginal dryness symptoms. Furthermore, dietary supplementation also appears to lower total and low-density lipoprotein cholesterol in hypercholesterolemic subjects. A synthetic isoflavone, ipriflavone, has been shown in controlled trials to prevent postmenopausal bone loss, though there is much less evidence that soy isoflavones will accomplish this goal. Finally, although unopposed estrogen replacement may promote breast and endometrial cancer, there is no evidence that phytoestrogens will do the same. In contrast, great interest has been taken in the potential cancer-protective effects of phytoestrogens, though prospective evidence in postmenopausal women is not available. Although data regarding the use of isoflavone extracts are incomplete, dietary supplementation with soy foods appears to be a safe and possibly beneficial option for postmenopausal women.

Soyfoods, soybean isoflavones, and bone health: a brief overview

Soyfoods have received considerable attention during the past 5 years for their role in disease prevention, especially in relation to heart disease, osteoporosis, and cancer. However, limited research also suggests that soy protein favorably affects renal function. Much of the research interest in soy is aimed at establishing the physiological effects of isoflavones. Isoflavones are diphenolic compounds that have a very limited distribution in nature. Soybeans and soyfoods are, for practical purposes, the only nutritionally relevant dietary sources of isoflavones. Isoflavones are weak estrogens in that they bind to estrogen receptors, but they also have important nonhormonal properties as well. Initial speculation that soyfoods, and in particular isoflavones, might promote bone health was based on the estrogenic properties of isoflavones and the similarity in structure between isoflavones and the osteoporosis drug, ipriflavone, which is a synthetic isoflavone. In ovariectomized rodents, isoflavones retard bone loss almost as effectively as estrogen. Most research, but not all, also indicates that soyfoods rich in isoflavones favorably affect bone turnover and spinal bone mineral density in perimenopausal and postmenopausal women. However, studies conducted thus far have been of short duration and involved small numbers of subjects. Furthermore, no studies have actually examined the effect of soy feeding on fracture risk. Thus, although the data in general are encouraging, no firm conclusions can be drawn about the relationship between soy consumption and bone health. In addition to a possible direct effect of isoflavones on bone tissue, soy protein when substituted for animal protein may indirectly enhance bone strength. Several studies have found that in comparison with animal protein, soy protein decreases calcium excretion, a result of the lower sulfur amino acid content of soy protein. Although the high potassium content of soy is a consideration, the evidence clearly indicates that clinicians should consider recommending that their renal patients incorporate soyfoods into their diet.

Protein tyrosine kinase inhibitors increase cytosolic calcium and inhibit actin organization as resorbing activity in rat osteoclasts

Although there is evidence that protein tyrosine kinase inhibitors (PTKIs) suppress bone resorption activity, the mechanism of action of these compounds on osteoclastic bone resorption remains obscure. In the present study, we investigated the effect of PTKIs on cytosolic Ca(2+) concentration ([Ca(2+)](i)) and on the cytoskeleton in rat osteoclasts. The PTKIs, genistein and herbimycin A, reversibly elevated [Ca(2+)](i) measured by fura-2 microfluorimetry. The PTKI-induced increase was abolished by omission of extracellular Ca(2+), but was not attenuated by depletion of Ca(2+) stores. The PTKI-induced increase was inhibited by addition of La(3+) and Ni(2+), but not abolished by dihydropyridine (DHP) Ca(2+) channel blockers. Genistin, an inactive analogue of genistein, had no effect on [Ca(2+)](i). In the cytoskeleton assay, genistein rapidly disrupted the actin ring formation that serves as a marker for the resorbing state of osteoclasts. Disruption of the actin ring formation was also diminished in Ca(2+)-free extracellular solution. These results suggest that PTKIs in rat osteoclasts elevate [Ca(2+)](i) via activation of a DHP-insensitive, nonspecific Ca(2+) entry pathway and disrupt the formation of actin rings, resulting in suppression of bone resorption activity. The regulation of this Ca(2+)-influx by PTKIs is likely to contribute to inhibition of bone resorption by these compounds.

Legumes and soybeans: overview of their nutritional profiles and health effects

Legumes play an important role in the traditional diets of many regions throughout the world. In contrast in Western countries beans tend to play only a minor dietary role despite the fact that they are low in fat and are excellent sources of protein, dietary fiber, and a variety of micronutrients and phytochemicals. Soybeans are unique among the legumes because they are a concentrated source of isoflavones. Isoflavones have weak estrogenic properties and the isoflavone genistein influences signal transduction. Soyfoods and isoflavones have received considerable attention for their potential role in preventing and treating cancer and osteoporosis. The low breast cancer mortality rates in Asian countries and the putative antiestrogenic effects of isoflavones have fueled speculation that soyfood intake reduces breast cancer risk. The available epidemiologic data are limited and only weakly supportive of this hypothesis, however, particularly for postmenopausal breast cancer. The data suggesting that soy or isoflavones may reduce the risk of prostate cancer are more encouraging. The weak estrogenic effects of isoflavones and the similarity in chemical structure between soybean isoflavones and the synthetic isoflavone ipriflavone, which was shown to increase bone mineral density in postmenopausal women, suggest that soy or isoflavones may reduce the risk of osteoporosis. Rodent studies tend to support this hypothesis, as do the limited preliminary data from humans. Given the nutrient profile and phytochemical contribution of beans, nutritionists should make a concerted effort to encourage the public to consume more beans in general and more soyfoods in particular.

Effect of ipriflavone on bone in elderly hemiplegic stroke patients with hypovitaminosis D

A significant reduction in bone mineral density occurs in stroke patients on the hemiplegic side, correlating with the degree of paralysis and vitamin D deficiency due to malnutrition, sunlight deprivation, and immobilization-induced hypercalcemia, and increases the risk of hip fracture. We evaluated the effect of ipriflavone and 1alpha-hydroxyvitamin D3 [1alpha(OH)D3; vitamin D3] administration on bone mineral density preservation as compared with untreated controls. In a randomized and prospective study of 103 patients with hemiplegia after stroke (the mean duration of illness was 4.8 yr), 68 (34 patients in each group) were given 600 mg ipriflavone or 1 microg vitamin D3 daily for 12 mo, whereas the remaining 35 patients received no drug. Bone mineral density on the hemiplegic side decreased by 1.4% in the ipriflavone group, 3.8% in the vitamin D3 group, and 5.4% in the control group (P < .0001, ipriflavone v vitamin D3 and control). At baseline, all three groups of patients showed a 25-hydroxyvitamin D insufficiency, increased serum ionized calcium, and low levels of 1, 25-dihydroxyvitamin D, suggesting immobilization-induced hypercalcemia and inhibition of renal synthesis of 1, 25-dihydroxyvitamin D. After treatment, the serum 1, 25-dihydroxyvitamin D level increased by 139.9% in the ipriflavone group and by 26.9% in the vitamin D3 group. Significant decreases in the serum ionized calcium and pyridinoline cross-linked carboxyterminal telopeptide of type I collagen, and increases in parathyroid hormone and bone Gla protein were observed in the ipriflavone group, whereas no changes occurred in the other two groups. One patient in the untreated group suffered a hip fracture, compared with none in the ipriflavone and vitamin D3 groups. These results suggest that ipriflavone is more efficacious than vitamin D3 in the prevention of decreased bone mineral density in hemiplegic stroke patients because it decreases serum calcium levels through inhibition of bone resorption and cause a subsequent increase in 1, 25-dihydroxyvitamin D concentration.

Phytoestrogens: the "natural" selective estrogen receptor modulators?

Phytoestrogens are diphenolic compounds that are present in several plants eaten by human beings. Soybeans and flaxseed are particularly abundant source of phytoestrogens. When ingested in relatively large amounts, phytoestrogens have been shown to have significant estrogen agonists/antagonists effects in animals and humans. There is epidemiological, laboratory and clinical evidence which indicates that phytoestrogens, like certain selective estrogen receptor mudulators, have an antiproliferative effect on the breast, and positive effects on the lipoprotein profile and bone density. They might also improve some of the climacteric symptoms. This evidence is critically reviewed, and the possible benefit of dietary intervention with phytoestrogen-rich food for woman's health is discussed.

Phytoestrogens and the menopause

Phytoestrogens are defined as naturally occurring plant compounds that are structurally and functionally similar to 17 beta-estradiol or that produce estrogenic effects. The commonest sources are cereals, legumes and grasses. Isoflavones are the most highly investigated subgroup of phytoestrogens. They are attenuated estrogens and behave both in vivo and in vitro as agonists and antagonists. The highest concentrations are found in soy beans and legumes. The relative potencies of isoflavones as compared to estradiol are small but they can exhibit bioactivity when tested in high concentrations. A high dietary intake of phytoestrogens was first noted to be associated with a decreased incidence of certain diseases. This epidemiological information was obtained primarily from studying Asian populations. Soy consumption is highest in Japan, where urinary levels of phytoestrogen metabolites are extremely high, and where there are lower rates of so-called 'Western' diseases, namely breast, endometrial, colon and prostatic cancers as well as atherosclerotic disease. These observations have prompted extensive research, which has demonstrated the varying degrees of estrogenicity of these phytoestrogen compounds. This article provides an epidemiological background to phytoestrogens, a brief description of their composition and biochemistry, and an overview of the literature to date on phytoestrogens with an emphasis on relief of menopausal symptoms.

Treatment of bone loss in oophorectomized women with a combination of ipriflavone and conjugated equine estrogen

OBJECTIVE

We previously reported that 0.625 mg/day of conjugated equine estrogen (CEE) could not prevent acute bone loss in the first year after oophorectomy. The effect of additional administration of ipriflavone on bone mineral density (BMD) and biochemical indices of bone remodeling were studied to investigate whether concurrent use of CEE and ipriflavone prevent acute bone loss in the early stages following surgical menopause.

METHODS

One-hundred and sixteen oophorectomized women were randomly divided into four groups according to treatment; group 1: placebo, n = 30; group 2: CEE (0.625 mg/day), n = 29; group 3: ipriflavone (600 mg/day), n = 30; group 4: CEE (0.625 mg/day) plus ipriflavone (600 mg/day), n = 27. Vertebral BMD was measured using dual energy X-ray absorptiometry (DEXA) and two biochemical indices of bone metabolism, urinary pyridinoline (Pyr) and serum intact human osteocalcin (hOC), were also measured before, 24 weeks, and 48 weeks after initiation of treatment.

RESULTS

BMD was reduced 48 weeks after treatment by 6.1, 3.9 and 5.1% in groups 1-3, respectively, but by only 1.2% in group 4. Pyr decreased by 49.5, 32.0 and 41.5% in groups 2-4, respectively. hOC also decreased by 45.2 and 21.6% in groups 2 and 4, but increased by 40.5% in group 3, suggesting an inhibitory action of CEE and ipriflavone on the turnover of bone metabolism and stimulatory action of ipriflavone on bone formation.

CONCLUSION

Concomitant use of ipriflavone with CEE from an early stage after oophorectomy inhibited bone loss and was considered to be effective in maintaining bone mass after oophorectomy.

Therapy for osteoporosis. Miscellaneous and experimental agents

None of the currently available medications for osteoporosis have demonstrated an ability to fully prevent the occurrence of new vertebral or peripheral osteoporotic fractures once the disease is established. Several new therapies, therefore, are currently being developed to optimize the risk/benefit ratio of osteoporosis treatment. This article discusses a number of treatments currently being considered, including anabolic steroids, growth hormone or insulin-like growth factors, ipriflavone, parathyroid peptides, and strontium. Several other compounds have been suggested recently for treatment of osteoporosis and other are at very early stages of their development. In addition to pharmacologic approaches to the treatment of osteoporosis, hip protectors also may reduce hip fractures.

Effects of combined low dose of the isoflavone derivative ipriflavone and estrogen replacement on bone mineral density and metabolism in postmenopausal women

OBJECTIVES

To assess the pattern of biochemical markers of bone metabolism and vertebral bone mineral density in early postmenopausal women treated with combined ipriflavone and low dose conjugated estrogens.

METHODS

Bone biochemical markers and vertebral bone density were evaluated in a longitudinal, comparative, 2 year study conducted in postmenopausal women treated with sole calcium supplementation (500 mg/day), or with either ipriflavone (IP) at the standard dose (600 mg/day) plus the same calcium dose, low dose conjugated estrogens (CE) (0.3 mg/day) plus calcium, or low dose IP (400 mg/day) plus low dose CE (0.3 mg/day) plus calcium. The results were analyzed by repeated measures analysis of variance, as appropriate.

RESULTS

No modifications of both urinary excretion of hydroxyproline and plasma osteocalcin levels were observed in calcium and in CE-treated women, while vertebral bone density significantly decreased (P < 0.0001) in both groups. In IP or IP + CE-treated women, plasma osteocalcin did not show any modification, while urinary hydroxyproline showed a significant (P < 0.05) decrease, that paralleled a significant (P < 0.05) increase in vertebral bone density.

CONCLUSION

Postmenopausal IP administration, at the standard dose of 600 mg/day, can prevent the increase in bone turnover and the decrease in bone density that follow ovarian failure. The same effect can be obtained with the combined administration of low dose (400 mg/day) IP with low dose (0.3 mg/day) CE.

Bone density changes in postmenopausal women with the administration of ipriflavone alone or in association with low-dose ERT

Ipriflavone is a synthetic flavonoid that has been shown to exert a direct inhibitory effect on osteoclastic activity and possibly stimulate the osteoblast activity in different experimental models. The aim of the present study was to evaluate the effects of either ipriflavone alone or ipriflavone plus low dose hormone replacement therapy (HRT) in the prevention of postmenopausal bone loss. Patients were randomly allocated to different treatment groups receiving calcium (500 mg/day, control group), continuous HRT (25 or 50 micrograms/day of transdermal 17 beta-estradiol) plus medrogestone 5 mg/day for 12 days/month, ipriflavone at the standard dose of 600 mg/day, or finally ipriflavone 600 mg/day plus 17 beta-estradiol 25 micrograms/day plus medrogestone 5 mg/day for 12 days/month. No significant differences in basal levels of biochemical markers of bone turnover or in basal bone mineral density (BMD) values were evident in the different groups. In the control group after 12 months, spine BMD showed a significant (p < 0.05) 3.41% decrease. The pattern of BMD modification was significantly different from controls in the high dose HRT group (+1.84%), the ipriflavone group (+0.11%), and the combined ipriflavone/HRT group (-0.22%). Conversely, the BMD pattern in the low dose HRT group (-0.55%) was similar to that observed in controls. Thus, present results confirm that ipriflavone and 50 micrograms/day of transdermal 17 beta-estradiol are effective measures in the prevention of postmenopausal osteopenia. A lower transdermal estrogen dose is unable to increase the antiresorptive effect of ipriflavone and did not exert any further action in the prevention of postmenopausal osteopenia.

Effect of chronic treatment with ipriflavone in postmenopausal women with low bone mass

We present the results of two multicenter, double-blind, placebo-controlled, 2-year studies to evaluate the efficacy and tolerability of ipriflavone in postmenopausal women (PMW) with low bone mass. 453 PMW (aged 50-65 years) with a vertebral (VMD) or radial (RMD) mineral density value 1 SD lower compared with age-matched controls, were randomly selected to receive oral ipriflavone (200 mg T.I.D. at meals) or matching placebo, plus 1 g oral calcium daily. Vertebral (study A, by dual X-ray absorptiometry-DXA) and radial (study B, by dual photon absorptiometry-DPA) bone density, serum bone Gla-protein (BGP), and urinary hydroxyproline/creatinine (HOP/Cr) were measured every 6 months. In both studies, the Valid Completers (VC) analysis showed a maintenance of bone mass in ipriflavone-treated women, whereas in the placebo group, bone mineral density (BMD) was significantly decreased. The final outcome was a bone-sparing effect of 1.6% in study A, and of 3.5% in study B after 2 years. The Intention to Treat (ITT) analysis confirmed the decrease in the placebo group, with no changes in ipriflavone-treated women. A significant (P < 0.05) between-treatment difference was found in both studies. Biochemical markers of bone turnover decreased in patients treated with ipriflavone, thus suggesting a reduction of bone turnover rate. Twenty-six women treated with ipriflavone and 28 receiving the placebo dropped out because of side effects, mainly gastrointestinal. The compliance to the oral long-term treatment was good. The results of these studies show that ipriflavone is able to prevent both axial and peripheral bone loss in PMW with low bone mass, and is well tolerated.

Ipriflavone prevents radial bone loss in postmenopausal women with low bone mass over 2 years

Two hundred and fifty-five postmenopausal women with distal forearm bone mineral density (BMD) 1 SD below the mean value for normal age-matched postmenopausal subjects were randomly allocated to a 2-year treatment with oral ipriflavone (200 mg t.i.d) or a matched placebo, according to a double-masked, parallel group design. All patients also received a 1 g/day calcium supplement. Distal radius BMD and bone metabolism markers were measured at baseline, and every 6 months. Blood haematology and chemistry and physical parameters were monitored at the same time. One hundred and ninety-six patients completed 2 years of treatment. BMD changes from baseline were analysed according to valid completers (VC) and intention to treat (ITT) analyses. In both cases radial BMD was maintained in patients treated with ipriflavone while in decrease in those receiving the placebo, the between-treatment difference being significant at year 1 and year 2. Urinary hydroxyproline/creatinine levels were decreased in the ipriflavone-treated group and increased in the placebo group, with a significant between-treatment difference. Adverse reactions, mainly gastrointestinal, occurred to a similar extent in the two treatment groups.

Design for an ipriflavone multicenter European fracture study

In order to investigate the efficacy of ipriflavone (i.p.) on the prevention of vertebral fractures and the effect on bone mineral density (BMD) in women with postmenopausal osteoporosis, a large multicentric European study was designed and is presently ongoing. Included in the study were 460 Caucasian, nonobese postmenopausal women aged > 45 and < 75 years, menopaused for at least 12 months. Inclusion was on the basis of a lumbar bone mineral density (BMD) lower than 2 SD compared with healthy women aged 50 years, corresponding to values below 0.860 g/cm2 (antero-posterior measurement) by Hologic QDR 1000. Women with prevalent vertebral fractures were excluded as well as those presenting secondary osteoporosis or having been treated with medications that could affect bone metabolism. This study was designed as a 3-year, double-blind, placebo-controlled, parallel group study that randomized the women to the oral administration of either 3 x 200 mg/day of i.p. or placebo. All patients received a daily supplement of 500 mg calcium. The primary purpose of the study was to evaluate the efficacy of i.p. in preventing vertebral nontraumatic fractures. Fracture is defined here as a > or = 20% decrease in any anterior, central, or posterior T4-L4 vertebral height. Blinded vertebral X-ray readings and vertebral morphometry have been centralized in an independent Center, with standardized evaluation of two experts. Power calculations have been based on the hypothesis that 21% of placebo-treated patients would fracture within 3 years and that treatment with i.p. would lead to a 50% reduction in the incidence of fracture. Statistical tests have been designed to have a power of 80%, with a type I error equal to 5%. Secondary endpoints were changes in vertebral, radial, and femoral BMD. Centralized controls on 100% BMD scans would ensure the good quality of BMD readings. This study should verify the hypothesis that i.p. significantly decreases the risk of vertebral fracture in postmenopausal, osteoporotic women.

Miscellaneous and experimental agents

Current therapeutic approaches to postmenopausal bone loss or established osteoporosis vary widely among the different regions of the world. Because no treatment of osteoporosis has unequivocally demonstrated full prevention of the appearance or the recurrence of axial or peripheral fractures so far, many investigational compounds are being developed. Anabolic steroids act mainly as inhibitors of bone resorption with very few, if any, effects on bone formation. Because of the high occurrence of signs of virilization and the weak effects on bone structure, the risk/benefit ratio in osteoporosis should be considered at least problematic. If ongoing large-scale trials confirm the expected benefits of estrogen antagonist/agonists on the skeleton and confirm no cardiovascular risk to postmenopausal women with optimal uterine safety, these substances are likely to become the most prominent alternative to hormonal replacement therapy after the menopause. Additional studies are requested to evaluate the potential benefit of growth hormone or insulin-like growth factors in treatment of osteoporosis. Ipriflavone acts predominantly as an inhibitor of bone resorption. To confirm the efficacy of ipriflavone on the prevention of vertebral fractures and its effects on bone mineral density in women with postmenopausal established osteoporosis, a large multicentric European study is being conducted. Treatment with parathyroid peptides induces a significant gain in bone mass, mainly in the axial skeleton. Long-term studies that compare peptides, doses, and regimes are needed to better understand the exact position of parathyroid peptides as treatment of osteoporosis. Prolonged administration of strontium to postmenopausal osteoporotic women resulted in a decoupling between bone resorption and formation that yielded a significant increase in the lumbar spine bone mineral density of treated subjects. In the view of these promising results and of the excellent tolerance of strontium during preliminary trials, additional investigations of this compound in prevention and treatment of osteoporosis should be promptly initiated. Several other compounds have been punctually suggested for treatment of osteoporosis or are at very early stages of development. Finally, besides pharmacologic approaches to the treatment of osteoporosis, hip fractures may also be reduced by the use of hip protectors.

Natural and synthetic isoflavones in the prevention and treatment of chronic diseases

The evidence that natural isoflavones protect against several chronic diseases is both observational and experimental. In humans, epidemiologic findings clearly show a higher incidence of some common types of cancer (i.e., breast, prostate, and colon) and of coronary heart diseases in Western populations exposed to limited amounts of soybean isoflavones (i.e., genistein, daidzein) in the diet. Further evidence for cancer and cardiac protection and antiatherogenic effects resulting from soybean isoflavones administration has been noted in various experimental animal models. Isoflavones may also prevent postmenopausal bone loss and osteoporosis. In fact, genistein has been reported to be as active as estrogens in maintaining bone mass in ovariectomized rats. Moreover, the synthetic isoflavone derivative ipriflavone is able to reduce bone loss in various types of animal models of experimental osteoporosis providing a rationale on its use in the prevention and treatment of postmenopausal and senile osteoporosis in humans. The mechanism through which isoflavones may exert the above-mentioned effects seems to depend, at least in part, on their mixed estrogen agonist-antagonist properties. An alternative hypothetical mechanism could derive from other biochemical actions of isoflavones such as inhibition of enzymatic activity, in particular protein kinases, or activation of an "orphan" receptor distinct from the estrogen type I receptor.

Ipriflavone inhibits bone resorption in intact and ovariectomized rats

The aim of this study was to investigate the possible inhibitory effect of ipriflavone on bone resorption in rats. For this purpose, 10-week-old, intact and ovariectomized (OVX) rats, prelabeled from birth with [3H]-tetracycline, were used. Bone resorption was monitored by measuring the urinary excretion of [3H]. The animals were fed a purified diet devoid of naturally occurring flavonoids. In the intact rats, the daily meal was given either as a single portion or divided into four portions, a procedure known to lead by itself to a decrease in bone resorption. Ipriflavone, given 7 days after OVX at the dose of 400 mg/kg B.W. daily mixed with the food, led within 2-3 days to a significant decrease in bone resorption equivalent to that of 27.2 micrograms/kg s.c. of 17 beta-estradiol. The inhibition was sustained for the length of the experiment, up to 21 days. Ipriflavone given 7 days before OVX prevented the increase in bone resorption induced by castration, the effect being dose-dependent between 50 and 400 mg/kg B.W. In contrast to 17 beta-estradiol, a 5-week treatment with ipriflavone failed to prevent the OVX-induced uterine atrophy. Significant inhibition of bone resorption was also seen in intact animals, provided they rapidly ingested the daily meal. Actually, the decrease in bone resorption induced by portioning the daily food masked the inhibitory effect of ipriflavone in intact animals. In conclusion, ipriflavone can decrease bone resorption in both intact and OVX animals given a purified diet as a single daily meal. In the OVX model, ipriflavone mimics the osteoprotective effect of estrogen. However, the lack of a uterotropic effect suggests that the compound can discriminate between bone and reproductive tissues.

Current and potential future drug treatments for osteoporosis

There has been a major interest in the drug treatment of osteoporosis and an increase in the number of drugs available in most countries. The ideal drug (one which increases or restores bone density and trabecular connectivity) is still not available. However, in patients with relatively preserved trabecular connectivity and moderately reduced bone density, several agents have shown substantial clinical benefit. Oestrogens are still the mainstay of drug treatment, but the risks of breast cancer versus the cardiovascular and skeletal benefits with long term use have to be assessed in the individual. Newer tissue specific oestrogens show some promise in this respect. The bisphosphonates and possibly fluoride are likely to be the major alternatives to oestrogens in the medium term. The newer bisphosphonates, alendronate and in the future risedronate, are likely to supersede etidronate. Calcitriol probably has a limited role, confined to those patients in whom HRT or bisphosphonates are not appropriate. Calcium supplementation, or an increase in dietary intake if deficient, irrespective of which agent is used, is also of benefit. In older patients there is considerable support for using a combination of calcium and vitamin D. Whether combination treatment, for example oestrogens, bisphosphonates, and calcium together, will result in greater efficacy remains to be conclusively shown, but may be an attractive option in younger patients with higher bone turnover. Apart from fluoride, bone formation stimulators are unlikely to have a major role until the next century, although it may be possible to use growth factors as part of an ADFR regimen (A = activate remodelling, D = depress resorption, F = free formation, and R = repeat). This is still an important theoretical approach and needs further work with newer agents to see if increased efficacy can be found. In addition sequential treatment may be necessary in view of the limited time periods over which particular agents, such as intermittent fluoride (four years), have been examined, and this will have to be individually tailored. Other approaches include trying to increase peak bone mineral density, although influencing the young to prevent a disease that may not manifest itself for half a century is daunting.

Ipriflavone improves bone density and biomechanical properties of adult male rat bones

To assess the potential impact of ipriflavone on the biomechanical properties and mineral composition of bone, we administered two doses (200 or 400 mg/kg bw) of the drug orally to adult male rats for 1 month. Bone biomechanics were evaluated by vibration damping, an index of strain energy loss, and impact strength (the amount of energy required to fracture after a single impact). At the higher dose, ipriflavone significantly decreased vibration damping of rat femurs by 23.0 +/- 9.8% compared with control, vehicle-treated animals, suggesting a higher capacity to withstand dynamic stress. This result was confirmed by the impact strength studies showing that a higher energy (49.6 +/- 21.3% above control) was required to fracture femurs of rat treated with 400 mg/kg bw ipriflavone. The high dose of ipriflavone increased bone mineral density, assessed by both volume displacement and ash analysis (4.2% and 2.5% above controls, respectively). The relative content of calcium, phosphorus, and magnesium in the ashes was not different among the treated and untreated groups, indicating that no gross abnormalities in mineral composition of bone occurred after ipriflavone administration. Similarly, there were no differences in serum calcium and magnesium levels between treated and control animals at the end of the study, whereas lower circulating phosphorus levels were detected in the latter. Ipriflavone treatment was not associated with significant changes in serum alkaline phosphatase nor type I collagen telopeptide levels, two markers of bone turnover. In summary, 1-month treatment with ipriflavone increased bone density and improved the biomechanical properties of adult rat male bones without altering mineral composition.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevention of early postmenopausal bone loss using low doses of conjugated estrogens and the non-hormonal, bone-active drug ipriflavone

Hormone replacement therapy is the optimal therapeutic choice for postmenopausal syndrome. While low doses of estrogens (0.3 mg/day of conjugated estrogens) can counteract neurovegetative menopausal symptoms, higher doses (0.625 mg/day of conjugated estrogens) are required to prevent bone loss in postmenopausal women. Experimental and clinical studies have shown that ipriflavone, a non-hormonal isoflavone derivative, is effective in the prevention and treatment of postmenopausal osteoporosis. The aim of the present investigation was to evaluate the efficacy and tolerability of ipriflavone and very low doses of equine conjugated estrogens on bone loss in early postmenopausal women. Eighty-three healthy postmenopausal women (50.3 +/- 0.7 years) were enrolled for this 1-year multicenter study. All subjects were randomly allocated to receive: double placebo (n = 24; group A), placebo plus conjugated equine estrogens 0.30 mg/day (n = 31; group B) or conjugated equine estrogens 0.30 mg/day plus oral ipriflavone 200 mg tris in die at meals (n = 28; group C), according to a double-masked design. Among women who completed the treatment period (valid completers), those of group A showed a progressive decrease in forearm bone density (FBD; measured by dual photon absorptiometry) that reached 1.7% after 12 months. The women in group B maintained their FBD in the first 6 months of treatment but, at the end of the study, showed a bone loss of 1.4% compared with basal values. By contrast, women in group C showed a significant increase in FBD after 1 year of treatment (+5.6%; p < 0.01). Both valid completers and intention to treat analyses revealed a significant difference (p < 0.05) between group A and group C over the study period. None of the treatments produced significant changes of biochemical markers of bone turnover, while hot flushes and other climacteric symptoms were significantly reduced after the sixth month of treatment in women receiving estrogens. Adverse events were generally mild, and did not differ among the groups. The results of this study suggest that low doses of estrogens combined with ipriflavone could represent a new therapeutic approach to the treatment of the postmenopausal syndrome.