Current status of estrogen therapy for the menopause

Sexuality in Perimenopausal and Postmenopausal Women

This article reviews psychosocial and biological aspects of the effects of menopause on sexuality. Sexuality is conceptualized as having multiple dimensions including desire, arousal, and orgasm. Population studies have revealed that postmenopausal status is associated with decline in these components of sexual functioning. While it is probable that psychological response to menopause affects sexual functioning, little research has addressed this issue. Considerable research has addressed the possible relationship between sexuality and menopausal hormone changes. Some research shows that low estrogen levels are associated with diminished sexual response and that estrogen replacement produces enhanced sexual response. Other studies, however, do not show this. Testosterone level is more clearly related to at least some measures of sexuality. Issues for future research are discussed.

Diagnosis and treatment of endometriosis

Endometriosis is a chronic and progressive disease that affects approximately 10% of women of reproductive age. Its aetiology remains unknown, however, factors such as retrograde menstruation, heredity, impaired immune function and environmental toxins have been implicated. Laparoscopy is still considered the mainstay for diagnosis, however non-invasive diagnostic methods such as transvaginal ultrasound and MRI may also be complementary. Treatment should be individualised and current treatment options include medical treatment and surgery, however, disease recurrence is common following treatment. Hormonal therapy induces atrophy of endometriotic lesions. Conservative surgery may be successful in removing visible lesions, however in cases of severe or incapacitating illness, removal of the uterus and ovaries may be necessary. In such cases, extreme care must be taken to remove all traces of disease. Experimental treatments for endometriosis show promising preliminary results and include GnRH antagonists, aromatase inhibitors, selective oestrogen receptor modulators and mifepristone.

In vitro pro- and antioxidant properties of estrogens

The pro- and antioxidant properties of estrogens are subject of debate. The apparent discrepancy is largely caused by the chemical heterogeneity in the estrogen family and by their concentration and the environment in which they are found. To gain some insight into this debate, we determined whether estradiol (E(2)), estrone (E(1)), the 2-, 4- and 16alpha-hydroxyestrogens and also the 2- and 4-methoxyestrogens are: (1) good electron-donors; (2) capable of O(2) consumption and DNA strand break induction; (3) capable of inhibiting lipid peroxidation in vitro. E(2), E(1) and 16alpha-hydroxyestrone (16alpha-OHE(1)) were not pro-oxidants and were rather weak antioxidants, while the 2- and 4-hydroxyestrogens demonstrated both properties inducing DNA strand breaks damage as well as inhibiting lipid peroxidation. The 4-hydroxyestrogens consumed O(2) and induced DNA strand breaks to a level approximately 2.5-fold higher than the 2-hydroxyestrogens, but these hydroxyestrogens exhibited similar antioxidant capacity, as measured by inhibition of lipid peroxidation. The 4-methoxyestrogens cannot induce oxidative damage to DNA but can inhibit lipid peroxidation, although being less potent than the 2-methoxyestrogens and the 2- and 4-hydroxyestrogens. The 2-methoxyestrogens were both potent electron donors and inhibitors of lipid peroxidation. Although 2-methoxyestrogens cannot generate superoxide in vitro, they may also be considered pro-oxidants in vivo.

Endometriosis: an overview of the disease and its treatment

OBJECTIVE

To review endometriosis, its etiology, clinical presentation, and current management options.

DATA SOURCES

Published articles identified through MEDLINE (1966-2000) using the search term "endometriosis" and the additional terms "etiology" and "treatment." Additional articles were identified from the bibliographies of the retrieved articles.

DATA SYNTHESIS

Endometriosis, a disease that affects the physical health and emotional well-being of many women of reproductive age, is defined as the presence of endometrial tissue outside its normal location in the uterus. The disease ranges in severity from mild to severe, and patients may be asymptomatic or experience severe and potentially incapacitating symptoms, such as dysmenorrhea, dyspareunia, and infertility. The diagnosis can be confirmed only by direct visualization using laparoscopy and biopsy. The risk of endometriosis is increased in women who have an affected first-degree relative or who have shorter menstrual cycle lengths, longer duration of menstrual flow, and low parity. The etiology of endometriosis is not yet fully understand, but may involve retrograde menstruation, hereditary factors, and impaired immune function. Treatment should be individualized for each patient, taking into account the therapeutic goals, the extent of disease, symptomatology, and the woman's age and overall health. Treatment options include expectant management, hormonal therapies to suppress ovarian steroidogenesis and induce endometrial atrophy, and surgery to remove visible lesions or, as a last resort, the uterus and ovaries.

CONCLUSION

Although the precise etiology of endometriosis remains a mystery, treatment options have improved considerably in recent years. Pharmacists are well positioned to identify women with unexplained pelvic pain or infertility that may be indicative of endometriosis and refer them to their physicians for further evaluation. Pharmacists also can play an important role in counseling patients about the safe and effective use of the various treatments for this disease and strategies to recognize and reduce adverse effects.

Composição corpórea, distribuição de gordura e metabolismo de repouso em mulheres histerectomizadas no climatério: há diferenças de acordo com a forma da administração do estrogênio?

As mulheres no climatério sofrem inúmeras alterações metabólicas, cardiovasculares e de composição corporal. A terapêutica de reposição hormonal (TRH) vem alcançando importância na atualidade, tornando-se quase um consenso que a mulher após a menopausa deve receber hormônios, pelos benefícios que trazem para a saúde, tais como prevenção de doenças coronarianas e osteoporose. A forma de administração de estrogênios influi em uma série de parâmetros metabólicos; é sabido, por exemplo, que a administração oral provoca uma elevação no hormônio de crescimento (GH) e uma diminuição do IGFI: quanto à forma (transdérmica), os estudos ainda não são conclusivos quanto aos níveis do GH e IGFI. Por outro lado, o GH e o IGFI podem agir de maneiras diferentes no metabolismo lipídico, ósseo e na distribuição de gordura corpórea. O objetivo deste trabalho foi estudar as variações da distribuição visceral de gordura nas diferentes formas de administração estrogênica e, particularmente, verificar se a forma de administração do hormônio altera a quantidade de gordura visceral. Foram estudadas 33 mulheres no climatério, histerectomizadas, divididas em 3 grupos: 1) 13 pacientes recebendo estrogênio eqüino conjugado 0,625mg via oral diariamente; 2) 10 pacientes recebendo 17b estradiol TTS 50 2x/semana via transdérmica e; 3) 10 pacientes recebendo placebo. Estas pacientes foram submetidas: a) análise da composição corporal pelos métodos de bioimpedância (RJL 101-A) e densitometria óssea e corpórea (DEXA); b) análise da distribuição de gordura, particularmente de adiposidade visceral, pela tomografia computadorizada abdominal e; c) medida do metabolismo de repouso pelo calorímetro DELTA-TRAC. Foram ainda feitas dosagens laboratoriais de colesterol total e frações, triglicérides e glicemia aos 0,6 e 12 meses. Não observamos diferenças estatística significativas nos parâmetros estudados em nenhum dos 3 grupos (placebo, estrógeno oral e estrogênio transdérmico), embora notamos tendência a maior ganho de peso nos grupos com estrógenos e tendência a maior ganho de massa magra no grupo com estrogênio transdérmico.

Knowledge of menopause and hormone replacement therapy use in low-income urban women

Hormone replacement therapy (HRT) can have significant long-term health benefits in postmenopausal women, yet rates of HRT use are low, especially in low-income urban women. Previous research has revealed that knowledge of menopause is a key predictor of HRT use in this population. A descriptive cross-sectional survey of 215 perimenopausal and postmenopausal low-income urban women was carried out to characterize knowledge of menopause and HRT and factors associated with knowledge level. Sociodemographic characteristics, patterns of HRT use, and knowledge about menopause and HRT were collected through a structured interview. Results revealed a general lack of knowledge about menopause and HRT, particularly relative to heart disease and the role of HRT in prevention. Major independent predictors of increased knowledge (R2 = 0.31) were having talked with a healthcare provider about HRT, having at least a high school education, and being less than 60 years of age. These findings emphasize the key role of providers in educating this vulnerable population about menopause and HRT and the potential subsequent impact on HRT use.

Mammographic changes in postmenopausal women on hormonal replacement therapy

The purpose of this study was to investigate the extent of the effects of hormonal replacement therapy (HRT) on the mammographic breast pattern in postmenopausal women. In a hospital-based study mammographic examinations of 81 postmenopausal women were evaluated retrospectively, before and after 1-2 years of treatment with oestrogens or a combination of oestrogens and progestagens. Each individual mammographic film was examined separately, and the glandular tissue was classified according to a modified Wolfe classification. In a screening-centre-based study two consecutive mammograms, with a 2-year interval, of 645 women, of whom 70 were using some kind of hormone therapy, were evaluated retrospectively. In the hospital-based study 31 % of patients treated with combination HRT showed an increase in fibroglandular tissue compared with only 8.7 % in the group treated with oestrogens alone. The difference was statistically significant (p = 0.046). In the screening-based study 14.3 % of the women using hormonal therapy showed an increase, whereas in the non-users no increase was found (p = 1.24 x 10(-10)). After beginning HRT many women (between 14 and 25 % in our experience) can be expected to undergo a mammographically detectable increase in fibroglandular tissue. Radiologists should be aware of the aetiology of such changes, and can obtain information on HRT most conveniently by having the technologist routinely question each patient.

Salmon calcitonin nasal spray : An effective alternative to estrogen therapy in select postmenopausal women

The efficacy and safety of estrogen replacement therapy (ERT) and salmon calcitonin in the treatment of postmenopausal osteoporosis are reviewed with special consideration given to patients for whom ERT, the primary antiresorptive therapy for osteoporosis, is not indicated, tolerable, or is refused. The various formulations of estrogen and salmon calcitonin, for which the nasal spray formulation was recently approved for use in the United States, are reviewed in depth with reference to dose ranges, side effects, and convenience. Data regarding increases in bone mineral density (BMD) produced by each agent are presented. Specifically, the range of increases in BMD induced by ERT and salmon calcitonin are comparable. Given the substantial public health consequences of postmenopausal osteoporosis and osteoporotic fractures, the primary care physician is increasingly faced with the need to educated and recruit postmenopausal patients to appropriate therapy with the optimal agent for that particular patient. In the many patients who are unable or unwilling to accept, initiate, and comply with prescribed ERT, alternative therapeutic options are necessary Based on the established safety profile of salmon calcitonin, ease of administration, an uncomplicated dosing regimen, no reported drug interactions, and the lack of uterine bleeding associated with ERT or gastrointestinal adverse effects of other agents used to treat osteoporosis, salmon calcitonin nasal spray is an appropriate alternative approach for the treatment of postmenopausal bone loss.

Hormone replacement therapy and osteoporosis

Restoration of the osteoporotic skeleton is difficult. Factors that may aggravate the bone loss or increase the risk of fractures should be eliminated. The physician may then decide whether the patient is a candidate for one of the treatments which either stop further bone loss or increase the bone mass. The decision should be based on a variety of factors and be taken together with the patient.

Effect of 17 alpha-dihydroequilin sulfate, a conjugated equine estrogen, and ethynylestradiol on atherosclerosis in cholesterol-fed rabbits

The effect of 17 alpha-dihydroequilin sulfate (DHES), a water-soluble estrogen of conjugated estrogens (Premarin), and ethynylestradiol (EE), a commonly used estrogen found in many oral contraceptives, on the development of atherosclerosis was studied in rabbits fed an atherogenic diet (0.2% cholesterol) for 24 weeks. Ten animals were given 15 micrograms. kg-1.d-1 EE, 10 received 3.8 mg.kg-1.d-1 of DHES, and the remaining 10 sham-ovariectomized and 10 ovariectomized animals served as cholesterol-fed controls. These doses were chosen to have similar estrogenic potency. Plasma cholesterol concentrations increased to about 900 mg/dL and did not differ among the experimental groups. After 24 weeks, plasma beta-VLDL and HDL cholesterol concentrations were the same for all cholesterol-fed groups, while LDL cholesterol was significantly higher in the two estrogen-treated groups. In spite of this, both EE and DHES significantly reduced atherosclerosis by 35% in the aortic arch and 75% to 80% in the thoracic and abdominal aorta. The reduction in atherosclerosis was seen in animals with a wide range (400 to 1400 mg/dL) of plasma cholesterol concentrations and was independent of lipoprotein profile. beta-VLDL isolated from estrogen-treated animals was not significantly different from control beta-VLDL in its ability to stimulate cholesterol accumulation in THP-1 macrophages in culture. This suggests that the protective effect of estrogens on the development of atherosclerosis is not mediated by qualitative differences in beta-VLDL that affect uptake by macrophages. The results of this study extend our knowledge of the range of estrogens that reduce atherosclerosis. Given the lack of effect on plasma lipid and lipoprotein concentrations, these data are consistent with the conclusion that estrogens exert some of this beneficial effect directly at the level of the arterial wall by influencing certain key components in the pathogenesis of atherosclerosis.

Continuous combined piperazine oestrone sulphate and medroxyprogesterone acetate hormone replacement therapy--a study of bleeding pattern, endometrial response, serum lipid and bone density changes

This pilot study was conducted to establish the optimum oral dosage of medroxyprogesterone acetate (Provera) given daily in combination with a fixed dose of piperazine oestrone sulphate (Ogen), as hormone replacement therapy. A group of 32 nonhysterectomized, symptomatic menopausal women were randomly allocated to receive piperazine oestrone sulphate 1.25 mg daily and medroxyprogesterone acetate 2.5 mg, 5 mg or 10 mg daily for a 2-year period. This was an open study and the patients were reviewed at 3-monthly intervals for 2 years. Vaginal bleeding was reported by 58% of patients after the first 3 months of treatment. There was a gradual decline in the reported incidence of bleeding over the following 6 months particularly by women in the 5 mg and 10 mg Provera group. Only 10% of patients were still recording slight bleeding in the 10 mg group at 12 months. By 24 months all the women in the 5 mg and 10 mg Provera groups had ceased bleeding. There were 2 patients in the 2.5 mg Provera group with persistent proliferative endometrium at 24 months. All the remaining patients had atrophic endometrium. There was no significant difference in serum lipid changes between the 3 groups, but there was an overall reduction in total cholesterol, triglycerides and low density lipoprotein cholesterol in all women. There was no significant difference in bone mineral density changes between the groups over the 2-year period. Endometrial protection with increased incidence of amenorrhoea, without significant adverse effects, was seen with the use of 5 mg and 10 mg of provera.

The gynecologist and the prevention of cardiovascular disease

This article reviews current concepts regarding the prevention of cardiovascular disease for women, with particular attention to modifiable risk factors. The background describes the magnitude of the problem, assesses the quality of the data with respect to risk factor reduction, and emphasizes several important concepts. Changes at menopause, states of endocrine aberration, and benefits and risks of hormone substitution need to be understood in conjunction with all other potentially modifiable and nonmodifiable cardiovascular risk factors. Primary care physicians have a window of opportunity to prevent this number one women's health problem. Integrating behavior modification is the key to prevention as part of the regular gynecologic visit.

Bleeding pattern and climacteric symptoms during different sequential combined HRT regimens in current use

Four sequential combined oestrogen and progestogen regimens were compared in terms of bleeding pattern and relief of climacteric symptoms. Treatment was with either 2 mg 17 beta-oestradiol with 1 mg norethisterone acetate [E2 + NETA]; 2 mg oestradiol valerate with 75 micrograms levonorgestrel [E2V + LNG]; 2 mg oestradiol valerate with 10 mg medroxyprogesterone acetate [E2V + MPA]; or 1.5 mg 17 beta-oestradiol with 150 micrograms desogestrel [E2 + DG]. A placebo-controlled study lasting 12-24 months was completed by 143 healthy early postmenopausal women. Bleeding lengths were not substantially different; in all regimens the majority of women were bleeding for 3-6 days. Bleeding onset showed differences when related to the 11th day of progestogen addition; in the regimen with E2V + LNG, 21% of the women women were bleeding before the 11th day of progestogen addition 26% on, and 53% after that day. In the regimen with E2V + MPA, 56% of the women were bleeding before the 11th day, 28% on, and 17% after that day, whereas in the regimen with E2 + DG, 15% of the women were bleeding before the 11th day, 5% on, and 80% after that day. All regimens reduced climacteric symptoms to the same extent. Breast tenderness occurred in all the regimens, except in the E2 + DG. Conclusively, the differences between the responses to treatment were not conspicuous. However, our data indicate that one regimen (E2 + DG) resulted in optimal bleeding control, optimal effect on climacteric symptoms, and no production of breast tenderness.

The gynecologist and cardiovascular disease: a window of opportunity for prevention

OBJECTIVE

We present current concepts and assess the quality of information available for the prevention of cardiovascular disease in women.

METHODS

This article reviews research bearing on the prevention of cardiovascular disease in women, with particular attention to modifiable risk factors. We describe the magnitude of the problem and assess the quality of the data with respect to the classic risk factors. The concept is emphasized that changes at menopause, states of endocrine aberration, and benefits and risks of hormone substitution and oral contraception must be understood in conjunction with all other potentially modifiable and nonmodifiable risk factors.

CONCLUSIONS

Primary care physicians, especially obstetrician/gynecologists, have a pivotal role to play in the reduction of this disease. Behavior modification is the key to integrating prevention into the regular annual visit.

Biological and endocrinological insights into the possible breast cancer risk from menopausal estrogen replacement therapy

The question of whether estrogen therapy increases the risk of breast cancer is reviewed. Despite more than 60 epidemiological studies and several meta-analyses over a five-decade period, there is no consensus about the answer. At present, the majority of investigators agree that short-term or medium-term therapy (less than 10 years) poses no measurable risk; some, but not all, investigators feel that there is a modest risk with long-term therapy (more than 15 years). Even this semi-consensus is clouded by the startling and clear-cut finding of the largest ever epidemiological study, the Nurses Surveillance Study, that a small increase in risk with estrogen therapy occurred only in women who also ingested alcohol, itself a known risk factor for breast cancer; women who did not ingest alcohol were at no increased risk. Because virtually none of the other epidemiological studies has controlled for alcohol ingestion, the conclusions of all of them are placed in doubt. To try to shed light on this problem, the 60-year-old studies of Lacassagne et al. on the induction of breast cancer in mice by estrogens were reviewed. They found that the magnitude and timing of the inducing effect of estrogen depended on the spontaneous breast cancer incidence in the mouse strain studied: in no-incidence strains, no cancer was induced; in high-incidence strains, induction was rapid and universal; in low-incidence strains, only a low percentage of animals had cancer induced, and it required prolonged estrogen administration.(ABSTRACT TRUNCATED AT 250 WORDS)

Hormonal replacement therapy: analysis of clinical strategies used by residents

The authors investigated strategies employed by resident physicians to decide whether to prescribe hormonal replacement therapy (HRT) for menopausal women, a matter of continuing clinical controversy. Verbal protocols were obtained from 21 residents in three specialties as they responded to 12 brief case descriptions. The cases incorporated three levels of cancer risk and two levels of osteoporosis risk in a 3 x 2 factorial design with two replications in each cell. Substantial variation in willingness to prescribe HRT was observed. By clustering subjects with relatively similar approaches to the problem, three treatment strategies were formulated that accounted for the decisions of 20 subjects. Each strategy is a simplified representation of the conflicting considerations in this clinical dilemma that facilitates rapid decision making. The differences between these representations and formal decision-analytic models help to explain why observed clinical decisions were inconsistent with expected utility maximization.

Stress fractures in ballet dancers

We surveyed 54 female dancers in two professional ballet companies. A total of 27 fractures were reported in 17 dancers. Metatarsal fractures were the most common (63%), followed by fractures of the tibia (22%) and spine (7%). Dancers who danced greater than 5 hours per day were significantly more likely to have a stress fracture than those dancing less than 5 hours per day. Dancers in the stress fracture group also had a significantly longer duration of amenorrhea than those in the group with no stress fractures. No significant difference was found between the dancers who had stress fractures and those who did not with regard to any of the other variables examined. These data suggest that prolonged amenorrheic intervals and heavy training schedules may predispose ballet dancers to stress fractures. Of the 17 dancers with stress fractures, only 1 had neither of these risk factors.

Effects of long-term treatment with estradiol or clomiphene citrate on bone maintenance, and pituitary and uterine weights in ovariectomized rats

Long-term estrogen replacement therapy in postmenopausal women can bring relief to hot flushes and reduce loss of bone mass due to osteoporosis, however, such treatment often can cause uterine hyperplasia and other undesirable effects. This study compared changes in bone mineral content (BMC), uterine weight, pituitary weight and pituitary gonadotropin content in the ovariectomized rat model following treatment with estradiol (E2) or two levels of clomiphene citrate (CC), an estrogen agonist/antagonist. Groups (n = 8-12) of adult ovariectomized (OVX) rat were implanted with E2 pellets (5 micrograms/day) or injected subcutaneously with CC at 1 mg/kg body wt (CC-1) or 5 mg/kg body wt (CC-5) twice weekly for 12 months. Placebo implanted OVX and intact (INT) female rats served as negative and positive controls, respectively. Following treatment, the uterus, pituitary gland and right femur were collected from each animal. E2 treatment increased (P less than 0.05) uterine weight compared to all other treatment groups, while both CC doses increased uterine weight over the OVX group only (E2, 0.24 +/- 0.03; INT, 0.14 +/- 0.01; CC-1, 0.06 +/- 0.01; CC-5, 0.07 +/- 0.01; and OVX, 0.02 +/- 0.01 g per 100 g body wt). Pituitary weight was increased 15-fold (P less than 0.05) by E2 treatment over all other treatment groups (E2, 65.7 +/- 13.9; INT, 4.0 +/- 0.5; CC-1, 3.3 +/- 0.03; CC-5, 2.7 +/- 0.02; and OVX, 2.9 +/- 0.02 mg per 100 g body wt). Both E2 and CC treatments reduced pituitary luteinizing hormone and follicle stimulating hormone content (micrograms/pit) to INT levels and were lower (P less than 0.05) than OVX levels. Mean BMC of E2, CC-1- or CC-5-treated rats was greater (P less than 0.05) than that of either the INT or OVX groups, while INT animals had a higher BMC compared to OVX animals (E2, 0.027 +/- 0.003; CC-1, 0.026 +/- 0.001; CC-5, 0.028 +/- 0.001; INT, 0.021 +/- 0.001; and OVX, 0.017 +/- 0.001 g/cm per 100 g body wt). These data indicate that CC has the potential to reduce bone mineral loss without causing other undesirable effects, including uterine hyperstimulation, and thus needs to be further investigated.

Women's use of information regarding hormone replacement therapy

For perimenopausal women, an important decision is whether or not to use hormone replacement therapy (HRT). The decision is complex because HRT involves judgment in weighing gains and losses related to physiological risk. Gains involve relief of hot flashes and prevention of osteoporosis; losses include cancer mortality and side effects of medication. A policy-capturing study of 283 perimenopausal women showed that the factor of most frequent concern was relief of hot flashes. Cluster analyses identified four major groups. Group 4 had an n of 9 and the lowest R2, making interpretation of data questionable. The largest group responded to hot flashes alone; the second to hot flashes and osteoporosis; and the third to hot flashes, somewhat to osteoporosis, but also to side effects of estrogen/progestin therapy. Results indicate nursing interventions should anticipate differences in women's concerns and tailor counseling appropriately.

Secretory pattern of growth hormone regulates steroid sulfatase activity in rat liver

Steroid sulfatase activity was quantified in liver microsomes from hypophysectomized adult female rats treated with estradiol and continuous or intermittent human growth hormone (hGH). Hypophysectomy clearly enhanced sulfatase activity as compared to intact female rats. Normal female values were completely restored by continuous infusion of hGH (1.4 i.u./kg/day). Neither the same dose of hGH given as two daily injections nor estrogen replacement therapy had any effect. It is concluded that liver microsome sulfatase activity in the non-pregnant rat is regulated by the sexually dimorphic secretory pattern of GH.

Carbohydrate metabolism during hormonal substitution therapy

Oestrogens and progestogens are known to influence glucose tolerance. Impairment of glucose tolerance is seen in particular among users of progestogens with androgenic properties. Dydrogesterone is frequently used as the progestogen adjunct during oestrogen substitution therapy for the management of climacteric complaints in post-menopausal women. However, no detailed data have been published concerning its effects on carbohydrate metabolism. In this study, 20 healthy post-menopausal women received equine oestrogens at a dose of 0.625 mg/day for 2 mth, following which dydrogesterone was added cyclically (20 mg/day for 12 days/mth) over a period of 6 mth. Oral glucose tolerance tests were performed before and after each treatment regimen. In relation to the concentrations observed after oestrogen was given alone, dydrogesterone induced only a small increase in blood insulin values which was not statistically significant. The effect was similar to that produced by endogenous progesterone, which is known to be of no clinical significance.

The risk of breast cancer after estrogen and estrogen-progestin replacement

To examine the risk of breast cancer after noncontraceptive treatment with estrogen, we conducted a prospective study of 23,244 women 35 years of age or older who had had estrogen prescriptions filled in the Uppsala region of Sweden. During the follow-up period (mean, 5.7 years) breast cancer developed in 253 women. Compared with other women in the same region, the women in the estrogen cohort had an overall relative risk of breast cancer of 1.1 (95 percent confidence interval, 1.0 to 1.3). The relative risk increased with the duration of estrogen treatment (P = 0.002), reaching 1.7 after nine years (95 percent confidence interval, 1.1 to 2.7). Estradiol (used in 56 percent of the treatment periods in the cohort) was associated with a 1.8-fold increase in risk after more than six years of treatment (95 percent confidence interval, 0.7 to 4.6). No increase in risk was found after the use of conjugated estrogens (used in 22 percent of the treatment periods) or other types, mainly estriols (used in 22 percent of the treatment periods). Although the numbers of women were smaller, the risk of breast cancer was highest among the women who took estrogen and progestin in combination for extended periods. The relative risk was 4.4 (95 percent confidence interval, 0.9 to 22.4) in women who used only this combination for more than six years. Among women who had previously used estrogens alone, the relative risk after three years or more of use of the combination regimen was 2.3 (95 percent confidence interval, 0.7 to 7.8). We conclude that in this cohort, long-term perimenopausal treatment with estrogens (or at least estradiol compounds) seems to be associated with a slightly increased risk of breast cancer, which is not prevented and may even be increased by the addition of progestins.

Growth hormone and somatomedin C during post-menopausal replacement therapy with oestrogen alone and in combination with an antioestrogen

Serum concentrations of growth hormone (GH) and somatomedin C were monitored in 14 women during post-menopausal replacement therapy with oestrogen alone and in combination with a specific antioestrogen. During 3 mth of treatment with ethinyl oestradiol (10 micrograms daily), the mean serum GH level rose from 2.8 +/- 0.78 mU/l (mean +/- S.E.M.) to 6.5 +/- 0.39 mU/l, whereas the concentration of somatomedin C fell from 22.4 +/- 0.89 to 15.4 +/- 0.43 nM. These changes during unopposed oestrogen treatment were clearly reversed by the addition of tamoxifen (20 mg daily), following which GH concentrations fell to pre-treatment levels. It is suggested that oestrogens inhibit somatomedin C production in the liver and that GH secretion may play an important role in regard to certain liver effects induced by oral oestrogen therapy.

Effects of estrogen and growth hormone on steroid sulfatase activity and estrogen binding in rat liver

It is now well established that the activity of certain liver enzymes displays sex differences and that administration of human growth hormone to male rats alters the liver metabolism in a "female" direction. In this work we studied steroid sulfatase activity and binding of estradiol-17 beta in livers from intact rats and found a sex difference, with considerably higher enzyme activity in male as compared to female liver tissue. Continuous infusion of native and recombinant human growth hormone and estradiol-17 beta to male rats reduced sulfatase activity to "female" levels. A specific binding of estradiol-17 beta with receptor properties was found in the rat livers, but the concentration of binding sites did not change after administration of growth hormone or estradiol in this group of intact animals. Our data confirm previous reports that continuous administration of human growth hormone "feminize" liver metabolism, and since estradiol was found to have an identical effect on sulfatase activity it is suggested that the effect of estradiol-17 beta in this respect may be indirect, mediated via an altered secretory pattern of rat growth hormone.

Changes in the bone and liver isoenzymes of alkaline phosphatase in postmenopausal women being treated with norethisterone

The effects of norethisterone therapy on alkaline phosphatase isoenzyme activities were studied in a group of postmenopausal women. There was a significant fall in total alkaline phosphatase activity after 8 wk which was still in evidence after 24 wk. Both bone and liver alkaline phosphatase isoenzyme activities were decreased during the first 16 wk on treatment, but after 24 wk only the bone phosphatase activity was significantly lower than the pretreatment level. The other biochemical indices of bone metabolism and liver function were also measured during the study. The results indicate that bone specific alkaline phosphatase activity is a more sensitive index of bone activity than total alkaline phosphatase and that monitoring of total activity may in some instances be misleading.

Characteristics of menopausal women seeking assistance

Using a questionnaire approach, we have determined the demographic, social, and clinical characteristics of the first 100 participants attending our menopause clinic. Of the respondents, 79% reported onset of significant physical symptoms and 63% significant emotional symptoms during the menopause. Among the participants, 65% had varying degrees of depression as determined by the Zung self-rating depression scale. This seemed to be more prevalent in patients with previous pelvic operations. Only half the women were on a regimen of estrogen replacement therapy, and most were receiving estrogen in an unopposed fashion. In our menopause clinic, more than half the women were over their ideal body weight, which is in contrast to the popular misconception that only thin women develop menopausal symptoms. Data from our patients suggest the need for multidisciplinary menopause clinics to adequately address the physical and emotional problems of menopausal women.

Steroid-sensitive proteins, growth hormone and somatomedin C in prostatic cancer: effects of parenteral and oral estrogen therapy

The effects of parenteral and parenteral plus oral estrogen therapy on the serum levels of sex hormone binding globulin (SHBG), pregnancy-associated alpha 2-macroglobulin (alpha 2-PAG), growth hormone (GH), and somatomedin C (SmC) were studied in 26 patients with prostatic cancer. Intramuscular polyestradiol phosphate treatment, yielding a mean serum level of estradiol-17 beta of 1,446 pM and a mean testosterone level of 4.5 nM, had no significant effects on alpha 2-PAG, GH, and SmC and increased SHBG levels only marginally. Combined treatment with intramuscular polyestradiol phosphate and oral ethinyl estradiol greatly increased SHBG and alpha 2-PAG levels and caused elevated GH and decreased SmC levels. The route of estrogen administration is probably of major importance for the hormonal effects on hepatic activity as reflected by SHBG and alpha 2-PAG levels. Bypassing the portal circulation might be advantageous with respect to liver-related side effects of estrogen therapy. GH and SmC might act as mediators of estrogen effects on the human liver.

The influence of short-term estrogen replacement therapy (ERT) on the blood pressure and daily urinary catecholamine excretion in a small group of post-menopausal women

The blood pressure and daily urinary catecholamine excretion were examined in nineteen non-smoking post-menopausal women, receiving estrogen replacement therapy for a period of 4 months. The estrogens administered consisted of 17 beta-estradiol combined with estriol and norethisterone acetate administered sequentially (Trisequens, Novo, Denmark). Before the institution of treatment, the blood pressure and urinary catecholamine excretion were normal. After a period of 4 months, no change in blood pressure was observed. However, a marked and significant increase in daily urinary catecholamine excretion was noticed (72.3 +/- 18.96 micrograms/day to 102.0 +/- 26.0 micrograms: p less than 0.01). The pathogenetic implications of this increase are discussed.

Endometrial response in post-menopausal women during treatment with percutaneous 17 beta-oestradiol opposed by oral progesterone

Two groups of post-menopausal women were followed up during cyclic replacement therapy with percutaneous 17 beta-oestradiol 3 mg daily opposed by the sequential addition of either 200 mg or 300 mg oral micronised progesterone. Endometrial biopsies were performed before treatment was started and again during the sixth treatment cycle immediately before the progesterone period (days 9-10) and at the end of the progesterone period (days 19-21). Conventional histopathological analyses and morphometric analyses of glandular epithelial cells and nuclei and stromal cell nuclei were carried out. The mean profile area of glandular cell nuclei was the most sensitive marker for the oestrogenic effect; this increased by about 100% during treatment. The relative endometrial gland volume increased from 8 +/- 1% to 22 +/- 2%. Slight secretory changes were observed, but only 13 of the 32 women had regular withdrawal bleeding. It was concluded that the doses of progesterone used may have been too low, or the duration of treatment too short.

Effect of guanfacine, an alpha-adrenergic agonist, on menopausal flushing

The effect of guanfacine (0.5 mg/day), an alpha-adrenergic agonist, on menopausal flushing, was studied in a double-blind, placebo-controlled crossover study in 11 patients. Both guanfacine and placebo significantly decreased the total number of flushes from baseline values. There was, however, no significant difference between placebo and guanfacine. Larger doses of guanfacine may be required to exert a therapeutic effect similar to that reported in the literature with the alpha-adrenergic agents, clonidine and alpha-methyldopa.

Oestrogen-progestogen replacement therapy changes body composition in early post-menopausal women

Changes in body composition were investigated in a group of 136 post-menopausal women treated for at least 1 yr with combined oestrogen-progestogen therapy at three different doses, or a placebo. The body composition changes were evaluated using the urinary creatinine excretion rate as an indicator of lean body mass, and the changes in daily creatinine excretion were related to the changes in serum oestradiol and oestrone. The urinary creatinine excretion rate was significantly increased (P less than 0.001) in the group receiving high-dose hormones, and the urinary creatinine/body weight ratio was significantly increased (P less than 0.05) in all treated groups as compared with the placebo-group. The body weight remained unchanged in all groups. The relationships between the changes in daily creatinine excretion and the changes in serum oestradiol and serum oestrone were both significant (P less than 0.05). The present study suggests that high-dose post-menopausal hormone therapy changes the body composition by increasing the muscle mass and that, since the body weight remains unchanged, a proportionate decrease in the fat mass seems to occur.

Endocrine impact of pure estradiol replacement in postmenopausal women: alterations in anterior pituitary hormone release and circulating sex steroid hormone concentrations

Thirteen healthy postmenopausal volunteers were studied under basal conditions and at intervals (days 1, 5, 10, and 30) after intravaginal placement of a polysiloxane ring impregnated with 400 mg of estradiol. Mean serum estradiol concentrations rose 26-fold with a twofold increase in serum estrone concentrations. Serum delta 4-androstenedione, dehydroepiandrosterone sulfate, and total testosterone did not change, but absolute and percent free testosterone concentrations declined significantly by day 5. Concurrently, serum concentrations of immunoactive follicle-stimulating hormone declined progressively, while serum luteinizing hormone and free alpha-subunit concentrations exhibited a biphasic pattern of suppression. Serum levels of prolactin increased monophasically and those of growth hormone, somatomedin C, and thyroid-stimulating hormone did not change.

Climacteric complaints as influenced by progestogens

A general assessment of the usefulness of progestogens in the treatment of climacteric complaints is made, based on evidence from the literature. The effects of progestogens in regard to vasomotor and mental symptoms are considered separately.

Estrogen use and cardiovascular disease

In general, epidemiologic data from case-control and cohort studies have suggested that postmenopausal estrogen use confers a moderate degree of protection from coronary artery disease. The authors report reductions in all-cause mortality rates and in mortality rates for acute myocardial infarction among estrogen replacement users in comparison with never-users. It is calculated that even a small decline in the mortality rate for coronary artery disease among estrogen users would have a major impact on the overall risk/benefit ratio associated with estrogen use.

Comparison of physicians' decisions regarding estrogen replacement therapy for menopausal women and decisions derived from a decision analytic model

Decisions regarding estrogen replacement therapy were obtained from 50 physicians for 12 cases representing menopausal women with systematically varying levels of cancer risk, fracture risk, and symptom severity. Their decisions were compared with a decision analytic model for which each physician provided needed quantities--subjective probabilities, utilities of various outcomes, and weightings of the importance of the outcome categories. The majority of observed decisions were not to treat. By contrast, the decision analysis based on physician-provided estimates indicated that the optimal strategy was either to treat or a toss-up. Sensitivity analysis showed that these conclusions would hold over all possible utilities, over all plausible probabilities of cancer, and so long as symptom relief and fracture prevention were also considered as treatment objectives. The increased probability of early detection of cancer by regular follow-up was systematically incorporated into the decision analysis but apparently neglected in unaided clinical judgment, which follows the principle of minimizing the most important risk, regardless of its probability.

Idiopathic resorption of teeth. A report of three cases

External resorption of teeth is a condition typically associated with etiologic factors within the adjacent alveolar bone, such as chronic periapical or periodontal infections, neoplasms, erupting permanent teeth, orthodontic movement, or trauma to the jaws. When none of these causes are present, resorption of teeth at the cementoenamel junction has been termed "idiopathic resorption of teeth." Three cases of idiopathic resorption of teeth are reported, the literature on previous cases is reviewed, and hypotheses as to causes and a new theory are postulated regarding the possible mechanism for osteoclastic resorption of teeth.

Occult, high-risk endometrial cancer

In a series of 173 consecutive patients with endometrial cancer treated by a fixed protocol 62 tumors (36%) appear "estrogen independent," i.e. there is no history of estrogen ingestion and no recognized risk factors such as obesity or diabetes mellitus. A high proportion of these tumors are of advanced stage and grade. Prognosis is poorer and mortality higher than for "estrogen-dependent" tumors. Twenty-two tumors were truly occult (no spontaneous vaginal bleeding). Factors which identify this high-risk group are described and the reasons for delay in diagnosis discussed. Spread by intraperitoneal dissemination is considered a major factor in the poorer prognosis. Cytology of peritoneal washings is a useful diagnostic and prognostic aid. An estrogen provocation test is suggested as a means of earlier recognition which could reduce mortality in this group.

Subfractions of high-density lipoprotein cholesterol during estrogen replacement therapy: a comparison between progestogens and natural progesterone

Subfractions of high-density lipoprotein cholesterol and its apolipoproteins were followed up in 58 postmenopausal women during three cycles of unopposed estrogen replacement therapy with 2 mg of estradiol valerate daily. During the last 10 days of the following three cycles the women received sequential addition of either 250 micrograms of levonorgestrel, 10 mg of medroxyprogesterone acetate, or 200 mg of natural micronized progesterone. Both progestogens significantly decreased total high-density lipoprotein cholesterol as well as subfraction 2 of high-density lipoprotein. Data suggest that doses and relative biologic activity of 19-norsteroids and 17-hydroxyprogesterone derivatives are more important for their metabolic effects than are qualitative differences. Natural progesterone had no apparent influence on high-density lipoprotein cholesterol or its subfractions and may develop into an attractive alternative to synthetic progestogens.

Endometrial carcinogenesis and its relation to oestrogens

The epidemiological evidence suggesting an association between the administration of exogenous oestrogens and an increased risk of developing endometrial adenocarcinoma is critically reviewed and it is concluded that the case for oestrogens being a cause of endometrial cancer is proven. The benefits flowing from preventing postmenopausal osteoporosis by oestrogen replacement therapy are assessed and contrasted with the danger to life posed by endometrial adenocarcinoma: it is pointed out that the type of neoplasm developing in patients taking oestrogens is well differentiated, nonaggressive and easily cured, the survival rate being very high. The addition of progestational agents to the therapeutic regime may prevent the development of endometrial carcinoma but could introduce a risk of cardiovascular disease.

Bone mineral content of amenorrheic and eumenorrheic athletes

This study was designed to determine whether the hypoestrogenic status of 14 amenorrheic athletes was associated with a decrease in regional bone mass relative to that of 14 of their eumenorrheic peers. The two groups of athletes were matched for age, height, weight, sport, and training regimens. Bone mass was measured by dual-photon and single-photon absorptiometry at the lumbar vertebrae (L1 to L4) and at two sites on the radius. Vertebral mineral density was significantly lower in the amenorrheic group (mean, 1.12 g per square centimeter) than in the eumenorrheic group (mean, 1.30 g per square centimeter). There was no significant difference at either radial site. Radioimmunoassay confirmed a lower mean estradiol concentration (amenorrheic group, 38.58 pg per milliliter; eumenorrheic group, 106.99 pg per milliliter) and progesterone peak (amenorrheic group, 1.25 ng per milliliter; eumenorrheic group, 12.75 ng per milliliter) in the amenorrheic women, in four venous samples drawn at seven-day intervals. A three-day dietary history showed no significant differences in nutritional intake, including calcium with and without supplements. The two groups were similar in percentage of body fat, age at menarche, years of athletic participation, and frequency and duration of training but differed in number of miles run per week (amenorrheic group, 41.8 miles [67.3 km]; eumenorrheic group, 24.9 miles [40.1 km]). We conclude that the amenorrhea that is observed in female athletes may be accompanied by a decrease in mineral density of the lumbar vertebrae.

Estrogen replacement therapy. Universal remedy for the postmenopausal woman?

The menopausal woman is in a state of estrogen deficiency that induces a variety of metabolic, structural, and symptomatic disturbances. Indications for estrogen replacement therapy include vasomotor symptoms, psychosomatic complaints, urogenital atrophy, prevention of osteoporosis, and prevention of coronary heart disease. Potential risks of therapy include development of endometrial and breast cancer. The incidence of both can be decreased with combination estrogen-progestin therapy. Future research efforts should be directed toward identifying the postmenopausal woman at increased risk for osteoporosis and/or coronary heart disease.