Reappraising 21 years of the WHI study: Putting the findings in context for clinical practice

Targeting the CD39/CD73 pathway: New insights into cardiac fibrosis and inflammation in female cardiac surgery patients

Women undergoing cardiac surgery suffer from worse outcomes than their male counterparts. The reasons for this disparity are multifactorial, but the loss of the protective effects of estrogen likely plays a role. Estrogen acts on the CD39/CD73 purine pathway, and loss of estrogen effects may contribute to the increased inflammation seen in post-menopausal women. We aimed to compare CD39/CD73 expression and downstream fibrosis, and inflammation in men and women undergoing cardiac surgery and then used an ovariectomy/high fat diet mouse model to approximate women who present for cardiac surgery to test therapeutics. We found decreased CD39 and CD73 in women compared to men, which was associated with increased fibrosis. Apyrase supplementation (a CD39 mimetic) improved ejection fraction and decreased E/e'. Increased CD73 function (via dipyridamole) decreased fibrosis. This study demonstrates the importance of purinergic dysfunction in cardiovascular disease in women and presents two potential therapeutics to improve cardiac health via manipulation of purine pathways.

PD-E2: a nano-scaled delivery for estradiol to decrease uterus damage and increase bone mineral density

It is well known that a specific application of 17β-estradiol (E2) is in hormone replacement therapy (HRT), but it is capable of inducing uterine gland cysts. However, the concentration of E2 that causes uterine gland cysts and bone loss remains unknown. To better understand this, we used an ovariectomized (OVX) mouse as the animal model and administered poly-α,β-DL-aspartyl-Lys-coupled E2 (PD-E2) as the bone targeting agent. HPLC-FT-MS analysis showed that the amounts of E2 in the uterus and the femurs of the OVX mice treated with 2.3 μmol kg-1 per day of E2 were 0.62 ± 0.15 ng g-1 and 0.31 ± 0.09 ng g-1, respectively, while the amounts of E2 in the uterus and the femurs of the OVX mice treated with 10 nmol kg-1 per day of PD-E2 were 0 ± 0 ng g-1 and 1.11 ± 0.27 ng g-1, respectively. The data suggested that if the amount of E2 in the uterus was equal to 0.62 ± 0.15 ng g-1, the uterine gland will form cysts, and if the amount of E2 in the femurs was less than 0.31 ± 0.09 ng g-1, the bone loss will be significant. Furthermore, the nano-scaled PD-E2 agent reported in this study provides an innovative strategy for HRT.

Update on Menopause Hormone Therapy; Current Indications and Unanswered Questions

OBJECTIVE

To provide clinicians involved in managing menopause with a summary of current evidence surrounding menopause hormone therapy (MHT).

DESIGN

The authors evaluate and synthesize existing pooled evidence relating to MHT's clinical indications, efficacy, and safety and explore the limitations of existing data.

PATIENTS

The review focuses on MHT-related outcomes in women with natural-timed menopause captured within observational studies, RCTs, and pooled data from pivotal meta-analyses and reviews.

MEASUREMENTS

Available published data are scrutinized. Available evidence and notably lacking data from women not adequately represented in published MHT trials, such as those with socioeconomic adversity, significant comorbidities, and minority ethnic backgrounds, are highlighted and deliberated.

RESULTS

The impact of MHT differs significantly between demographics. Current consensus recommendations for MHT emphasize the importance of tailoring type, route, dose, and duration of therapy to individual needs and risk/benefit ratio through shared decision-making. MHT impact can change over time. Current MHT data support its benefits for treating menopause symptoms and a potential window of opportunity in midlife to benefit skeletal health. Limitations of current evidence highlight menopause health inequalities and underscores the need for further research.

CONCLUSIONS

This review recommends tailored use of MHT for well-defined indications, recognizing its value for menopause symptom relief and skeletal benefits for many midlife women. MHT may be used as long as benefits outweigh risks, through shared decision-making. There is insufficient clinical evidence to support the long-term use of MHT in some contemporary cohorts of women accessing MHT in clinical practice.

Real-world evaluation of treatment utilization by women experiencing vasomotor symptoms associated with menopause in the United States and Europe: Findings from the REALISE study

OBJECTIVES

Despite the profound impact of menopausal symptoms on women, treatment utilization is low, and many seek alternative therapies. The REALISE study aimed to evaluate the treatment landscape - that is, pharmacological treatment, lifestyle changes (LC), and use of over-the-counter (OTC) products - for women from six high-income countries experiencing vasomotor symptoms (VMS) and receiving healthcare.

STUDY DESIGN

Analysis of a secondary dataset, the Adelphi Real World Disease Specific Programme™, a large, cross-sectional, point-in-time survey conducted in the United States and five European countries (February-October 2020). Physicians provided demographic, clinical, and treatment data; women were stratified by VMS severity (mild; moderate-severe) and presence of concomitant sleep/mood symptoms. Women completed forms on VMS severity, concomitant symptoms, LC, and OTC product use. Two subgroups were identified: VMS-only and VMS + sleep/mood.

MAIN OUTCOME MEASURES

Prescription treatment, LC, and OTC product utilization.

RESULTS

Physicians (n = 233) provided data on 1767 women; 825 (46.7 %) completed a self-completion form. Physicians rated 60 % of women with moderate-severe VMS, of whom 709 (66.8 %) were currently prescribed pharmacological treatment; 27.1 % had never been prescribed. Hormone therapy was most frequently prescribed in the moderate-severe group (overall, 49.8 %; VMS-only, 57.4 %; VMS + sleep/mood, 47.3 %), followed by serotonergic antidepressants (15.7 %; 9.7 %; 17.6 %, respectively). Most women (78.3 %) with moderate-severe VMS adopted LC, and 57.6 % used at least one OTC product for VMS relief.

CONCLUSIONS

Nearly a third of women with moderate-severe VMS had never received treatment despite access to healthcare. This, combined with the prevalent use of LC/OTC products, suggests an unmet need for new treatment options to manage VMS and concomitant sleep/mood symptoms.

Clinical challenges and considerations in pharmacotherapy of osteoporosis due to menopause

INTRODUCTION

Osteoporosis is a chronic systemic skeletal disorder characterized by compromised bone strength and an increased risk of fracture, with a high prevalence worldwide. It is associated with a negative quality of life and an increased morbidity and mortality. Postmenopausal women are more prone to develop osteoporosis, and many of them will suffer at least one fragility fracture along their lifetime.

AREAS COVERED

This review starts by summarizing the pathogenesis of postmenopausal osteoporosis (PMO), with focus on the estrogen deficiency-associated bone loss. It continues with the current PMO diagnostic and fracture risk prediction tools, and it finally addresses management of PMO. All the efficacy and safety profiles of the current and future osteoporosis medications are reviewed. Furthermore, strategies to optimize the long-term disease management are discussed. For this review, only publications in English language were selected. References were extracted from PubMed, Embase, and Medline.

EXPERT OPINION

PMO disease management is far from being ideal. Educational and communication programs with the goal of improving disease knowledge and awareness, as well as reducing the health-care gap, should be implemented. In addition, most effective sequential prevention and treatment strategies should be initiated from the early menopause.

Menopausal Hormone Therapy, an Ever-Present Topic: A Pilot Survey about Women's Experience and Medical Doctors' Approach

Background and Objective: Menopause can be associated with many clinical manifestations: vasomotor symptoms, urogenital problems, and additional psychological disturbances, such as anxiety, mood changes, and sleep alterations. The prolonged lack of hormones also increases the risk of long-term consequences. Hormone Replacement Treatment (HRT) in menopause consists of the administration of estrogen, alone or associated to progesterone, to relieve these uncomfortable disturbances and to prevent the onset of other pathologic conditions. The aim of this study is to examine the prevalence of HRT use in a sample of menopausal women and their experience with menopause and HRT. This study also investigates the knowledge of general practitioners (GPs) and gynecologists about HRT and its prescription. Materials and Methods: We conducted a cross-sectional population survey on 126 women of 50-59 years in an industrial city in the North of Italy, Vercelli (Novara), in Eastern Piedmont. We also presented a questionnaire on the topic to 54 medical doctors (GPs and gynecologists) of the same area. Results: The prevalence of HRT use in our sample was 11.9%. In total, a good percentage of the users affirmed to be satisfied with HRT. Additionally, a minority of women reported being ideally against the use of replacement hormones, were advised against using HRT by doctors, and did not use it because of the fear of side effects. We found a positive association between patient education, health care attitude, and HRT usage. A significant number of women knew about HRT from the media, and most of them were not informed by a health professional. Despite this, the interviewed doctors considered their knowledge about HRT as 'good' and would recommend HRT: only 5.6% would not prescribe it. Conclusions: Our results highlight the need for information about HRT among patients and health professionals, along with the need for more effective communication, evaluation, and suggestion of treatment.

Not All Maca Is Created Equal: A Review of Colors, Nutrition, Phytochemicals, and Clinical Uses

Maca (Lepidium meyenii, Lepidium peruvianum) is part of the Brassicaceae family and grows at high altitudes in the Peruvian Andes mountain range (3500-5000 m). Historically, it has been used as a nutrient-dense food and for its medicinal properties, primarily in enhancing energy and fertility. Scientific research has validated these traditional uses and other clinical applications by elucidating maca's mechanisms of action, nutrition, and phytochemical content. However, research over the last twenty years has identified up to seventeen different colors (phenotypes) of maca. The color, hypocotyl size, growing location, cultivation, and post-harvest processing methods can have a significant effect on the nutrition content, phytochemical profile, and clinical application. Yet, research differentiating the colors of maca and clinical applications remains limited. In this review, research on the nutrition, phytochemicals, and various colors of maca, including black, red, yellow (predominant colors), purple, gray (lesser-known colors), and any combination of colors, including proprietary formulations, will be discussed based on available preclinical and clinical trials. The gaps, deficiencies, and conflicts in the studies will be detailed, along with quality, safety, and efficacy criteria, highlighting the need for future research to specify all these factors of the maca used in publications.

The evolving perspective of menopause management in the United Kingdom

BACKGROUND

The use of menopausal hormone therapy (MHT) was significantly reduced following the publication of the Women's Health Initiative study results and has remained low ever since. However, from 2015 onwards, the UK has seen a substantial increase in MHT prescribing compared to other European countries.

OBJECTIVES

To evaluate the factors contributing to the shift in women's and healthcare professionals' (HCPs) perception of MHT in the United Kingdom and to provide learning points for other European countries.

DESIGN

An exploratory, descriptive and qualitative study.

METHODS

An interactive virtual panel discussion in which seven UK-based HCPs with a special interest in the menopause discussed the evolution of its management in the United Kingdom.

RESULTS

In the last 8 years, there has been a substantial increase in MHT prescriptions in the United Kingdom due to improved menopause awareness and acceptance of MHT. Accessibility to accurate, scientific, information and guidance from respected institutions is one of the main drivers of this change. Social media has increased that reach with 'influencers' empowering women to seek help. Women are demanding access to menopause health care so that they can receive holistic and individualized treatment based on their clinical conditions and needs. Standardized education of HCPs is an essential pillar to provide appropriate and equitable care to menopausal women and to guarantee safe prescribing of MHT. Furthermore, up to date and factually correct menopausal education would benefit all the population.

CONCLUSIONS

Publication of new scientific data reporting a more favourable benefit/risk ratio with MHT, production of national guidance and an increased awareness via social media have led to the significant rise in MHT prescribing and improvement of menopause care in the United Kingdom. The lessons learned may benefit other European countries.

Revisiting Estrogen for the Treatment of Endocrine-Resistant Breast Cancer: Novel Therapeutic Approaches

Estrogen receptor (ER)-positive breast cancer is the most common subtype, representing 70-75% of all breast cancers. Several ER-targeted drugs commonly used include the selective estrogen receptor modulator (SERM), tamoxifen (TAM), aromatase inhibitors (AIs) and selective estrogen receptor degraders (SERDs). Through different mechanisms of action, all three drug classes reduce estrogen receptor signaling. Inevitably, resistance occurs, resulting in disease progression. The counterintuitive action of estrogen to inhibit ER-positive breast cancer was first observed over 80 years ago. High-dose estrogen and diethylstilbestrol (DES) were used to treat metastatic breast cancer accompanied by harsh side effects until the approval of TAM in the 1970s. After the development of TAM, randomized trials comparing TAM to estrogen found similar or slightly inferior efficacy but much better tolerability. After decades of research, it was learned that estrogen induces tumor regression only after a period of long-term estrogen deprivation, and the mechanisms of tumor regression were described. Despite the long history of breast cancer treatment with estrogen, this therapeutic modality is now revitalized due to the development of novel estrogenic compounds with improved side effect profiles, newly discovered predictive biomarkers, the development of non-estrogen small molecules and new combination therapeutic approaches.