Effects of hormone replacement therapy on cardiovascular risk factors in postmenopausal women

Relationship between the phases of the menstrual cycle and the transversus abdominis muscle

[Purpose] This study investigated changes in the thickness of the transversus abdominis muscle at various stages of the menstrual cycle. [Subjects] The subjects were 15 young healthy females with regular menstrual cycles. [Methods] A regular menstrual cycle was defined as a 28-day cycle comprising 3 phases: the menstrual phase, the follicular phase, and the luteal phase. For the purpose of the study, measurements were taken at day 3 (menstrual phase), day 12 (follicular phase), and day 21 (luteal phase) of the cycle. An ultrasonic imaging diagnostic device (MyLab 25) and a linear expression probe were used for measurement of the transversus abdominis muscle. [Results] There were no significant differences in the variation rate of the thickness of the muscle at any phase of the menstrual cycle. [Conclusion] The results suggested that the sex hormones associated with the menstrual cycle do not affect the contractility or changes in the thickness of the transversus abdominis muscle. For the reasons stated above, there is little need to consider the menstrual cycle when measuring muscle thickness in physical therapy scenarios because the transversus abdominis muscle does not depend on the menstrual cycle.

Effects of the progestagen-only contraceptive implant Implanon on cardiovascular risk factors

OBJECTIVE

Epidemiological studies on the cardiovascular risk of progestagen-only contraceptives are rare. With the present study we aimed to investigate the effect of the low-dose etonogestrel-releasing contraceptive implant Implanon on cardiovascular risk factors, including markers of inflammation.

DESIGN

Longitudinal study.

SETTING

Family planning centre of a University Hospital.

SUBJECTS

Thirty-six healthy, nonsmoking women with regular cycles (n = 18 controls without hormonal contraception; n = 18 cases requesting the insertion of Implanon.

MEASUREMENTS

Blood samples for the determination of C-reactive protein (CRP), nitric oxide (NO), sex hormones and plasma lipids were taken in the early follicular phase of the cycle in both groups. A second sample was taken 12 weeks after Implanon insertion or in the controls during the early follicular phase of cycle 4.

RESULTS

Implanon treatment caused a 36% decrease in CRP (P < 0.06) and a significant decrease in high density lipoprotein (HDL) (P < 0.007), low density lipoprotein (LDL) (P < 0.001), cholesterol (P < 0.001), testosterone (P < 0.05) and SHBG (P < 0.002). Levels of NO, oestradiol and progesterone were not affected in either group. The cholesterol/HDL ratio did not change in Implanon carriers. There was a significant correlation between the cardiovascular risk factors CRP, cholesterol/HDL ratio and NO.

CONCLUSION

The progestagen-only implant Implanon does not exert a negative effect on the cardiovascular risk factors CRP, cholesterol/HDL ratio and NO. These results suggest that the use of a progestagen-only contraception does not increase cardiovascular risk factors in healthy young women.

Selective estrogen receptor modulators and risk for coronary heart disease

Coronary heart disease (CHD) is the leading cause of death in women in most countries. Atherosclerosis is the main biological process determining CHD. Clinical data support the notion that CHD is sensitive to estrogens, but debate exists concerning the effects of the hormone on atherosclerosis and its complications. Selective estrogen receptor modulators (SERMs) are compounds capable of binding the estrogen receptor to induce a functional profile distinct from estrogens. The possibility that SERMs may shift the estrogenic balance on cardiovascular risk towards a more beneficial profile has generated interest in recent years. There is considerable information on the effects of SERMs on distinct areas that are crucial in atherogenesis. The complexity derived from the diversity of variables affecting their mechanism of action plus the differences between compounds make it difficult to delineate one uniform trend for SERMs. The present picture, nonetheless, is one where SERMs seem less powerful than estrogens in atherosclerosis protection, but more gentle with advanced forms of the disease. The recent publication of the Raloxifene Use for The Heart (RUTH) study has confirmed a neutral effect for raloxifene. Prothrombotic states may favor occlusive thrombi at sites occupied by atheromatous plaques. Platelet activation has received attention as an important determinant of arterial thrombogenesis. Although still sparse, available evidence globally suggests neutral or beneficial effects for SERMs.

Hormone therapy and cardiovascular disease

As in other Western countries, cardiovascular disease (CVD) is the leading cause of death among women in Taiwan, exceeding the mortality from cervical or breast cancer. Women generally present with CVD after menopause and later than men, since menopause-related estrogen deficiency has been considered to be associated with an increased risk for CVD. Thus, coronary artery diseases and stroke are the two main contributors of mortality among postmenopausal women. Observational studies have reported a reduction in coronary artery disease risk after hormone therapy (HT) ranging from 31-44%. However, recent randomized controlled trials that evaluated the effect of HT on primary and secondary CVD prevention have questioned the efficacy of HT, despite confirming the lipid-lowering effect of estrogen. However, a cluster of factors are responsible for the genesis and progression of CVD. Until we further evaluate their specific actions and how these different factors interact, the issue related to HT and cardiovascular risk will remain unsettled. Since these studies have contributed to our understanding of the benefits and risks associated with HT, HT use should be individualized after consideration of the condition of each postmenopausal patient. Ideally, the efficacy of different preparations and dosages of HT in postmenopausal women who are at risk of CVD, before atheromatous lesions have developed, should be investigated.

Comparison of the effects of tibolone and estrogen therapy on hemostasis in surgical menopause: a randomized, double-blind, placebo-controlled study

OBJECTIVE

To examine the effects of unopposed estrogen (E) and tibolone therapy on coagulation and natural anticoagulant systems in surgical menopause.

DESIGN

A randomized, double-blind, placebo-controlled study.

SETTING

University hospital clinic in Turkey.

PATIENT(S)

Ninety healthy surgically postmenopausal women.

INTERVENTION(S)

Ninety surgically postmenopausal women were randomized into three groups: unopposed conjugated ET (0.625 mg/d, group 1), tibolone (2.5 mg/d, group 2), and identical tablets of placebo (group 3).

MAIN OUTCOME MEASURE(S)

Effects on parameters in the clotting cascade at baseline and after 24 weeks of treatment.

RESULT(S)

After 6 months, fibrinogen, lipoprotein (a), and factor VIIa were decreased, and activated partial thromboplastin time was increased significantly in the ET group compared with in the placebo group. However, tibolone significantly decreased only the serum levels of factor VIIa and factor IX and prolonged the activated partial thromboplastin time, compared with placebo group. In addition, conjugated ET caused a significantly greater decrease in serum fibrinogen level than did tibolone.

CONCLUSION(S)

Neither E nor tibolone therapy led to activation of coagulation in the surgically menopausal women. Both preparations changed the overall hemostatic balance to a more fibrinolytic state.

Effect of genetic variations in platelet glycoproteins Ibalpha and VI on the risk for coronary heart disease events in postmenopausal women taking hormone therapy

Millions of women still use postmenopausal hormone therapy (HT). We genotyped 2090 women in Heart and Estrogen/progestin Replacement Study for functional polymorphisms in GP1BA and GP6 and assessed the coronary heart disease (CHD) event rate over 5.8 years of follow-up. In patients receiving placebo, there was an increased CHD death/myocardial infarction (MI)/unstable angina (UA) event rate in carriers of the GP1BA -5C allele (adjusted [adj] P = .006). HT increased the hazard ratio (HR) of CHD events in patients with the GP1BA -5TT genotype by 16% and reduced the HR in patients with the TC+CC genotypes by 46% (adj interaction P < .001). HT reduced the HR in patients with the GP6 13254TT genotype by 17% but increased the HR in patients with the TC+CC genotypes by 35% (adj interaction P < .001). Furthermore, HT increased the HR of CHD events in patients with the GP1BA -5TT plus GP6 13254TC+CC genotypes by 57% and reduced the HR in patients with the GP1BA -5TC+CC plus GP6 13254TT genotypes by 55% (adj interaction P < .001). In postmenopausal women with established CHD, these polymorphisms of platelet genes were predictors of CHD events and significantly modified the effects of HT on CHD risk. It will be important to replicate these findings in other studies.

Differential effect of hormone therapy and tibolone on lipids, lipoproteins, and the atherogenic index of plasma

The aim of our study was to assess the effect of various regimens and doses of hormone therapy and tibolone on the Atherogenic Index of Plasma (AIP). A total of 519 postmenopausal women attending our menopause clinic were studied in a prospective design. Women with climacteric symptoms were randomly assigned to receive 1 of the following regimens: tibolone 2.5 mg, conjugated equine estrogens 0.625 mg plus medroxyprogesterone acetate 5 mg (CEE/MPA), 17beta-estradiol 2 mg plus norethisterone acetate 1 mg (E2/NETA), or 17beta-estradiol 1 mg plus norethisterone acetate 0.5 mg (low E2/NETA). Serum parameters were assessed at baseline and after 6 months and included total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, apolipoprotein A1 and apolipoprotein B. The AIP was assessed as the log (triglycerides [mmol/L]/HDL-C [mmol/L]). CEE/MPA treatment associated with lower mean LDL-C but higher mean triglyceride levels (-15.5 mg/dL +/- 3.6, P = 0.0001; 12.6 mg/dL +/- 4.8, P = 0.01). Furthermore, CEE/MPA treatment resulted in higher AIP levels (0.073 +/- 0.021, P = 0.001). On the contrary, both E2/NETA regimens and tibolone associated with lower mean triglyceride and HDL-C levels (E2/NETA, triglycerides: -9.8 mg/dL +/- 5.0, P = 0.049; HDL-C: -4.9 mg/dL +/- 1.8, P = 0.01, low E2/NETA triglycerides: -12.5 mg/dL +/- 4.1, P = 0.003; HDL-C: -4.7 mg/dL +/- 1.3, P = 0.001; tibolone, triglycerides: -21.9 mg/dL +/- 2.7, P = 0.0001; HDL-C: -12.7 mg/dL +/- 1.1, P = 0.0001). None of the 3 regimens had any effect on AIP. The effect of a particular regimen of hormone therapy on the lipid-lipoprotein profile differs depending on the parameter assessed. The use of unified markers such as AIP will be helpful in evaluating the overall effect of lipid-lipoprotein modulation on the cardiovascular system. In fact, the concurrent assessment of the therapy effect on both LDL-C and AIP may be more dependable in evaluating the cardiovascular impact of a given regimen.

The effect of hormone replacement therapy on the levels of serum lipids, apolipoprotein AI, apolipoprotein B and lipoprotein (a) in Turkish postmenopausal women

OBJECTIVES

Estrogen replacement therapy alters the lipid profiles favorably for delaying atherosclerosis in postmenopausal women. The effects of estrogen plus progesterone combination therapy on lipids are controversial. This study was designed to evaluate the effect of female sex hormones on lipids and lipoproteins and to clarify the influence of progesterone on the effect of estrogen in postmenopausal women.

METHODS

Of the 60 postmenopausal women admitted to our menopause clinic, 40 had intact uterus and received continuous 0.625 mg conjugated equine estrogen (CEE) plus 2.5 mg medroxyprogesterone acetate (MPA), whereas the remaining 20 were hysterectomized and received 0.625 mg CEE daily. To assess the alterations in lipids and lipoproteins during menopause, 45 healthy premenopausal women were investigated. Lipid and lipoprotein levels were assessed in each subject at baseline and at the 6th and 18th months of therapy.

RESULTS

In menopause, a shift towards more atherogenic lipid and lipoprotein profiles than those of the premenopausal state was found. Following 18 months of treatment, both regimens reduced total cholesterol (TC) levels as compared with the baseline (6.4 vs. 6.9% in the CEE/MPA and CEE groups, respectively). The CEE group had a more pronounced increase in high-density lipoprotein (HDL) cholesterol than the CEE/MPA group (10.3 vs. 8.8%, respectively). Both groups displayed reduced TC, low-density lipoprotein (LDL) cholesterol and apolipoprotein-B (ApoB) concentrations, whereas triglycerides increased, with a greater tendency to increase in the CEE/MPA group at the end of the trial. Also, the lipoprotein (a) [Lp(a)] levels decreased significantly (27.6 vs. 24.5% in the CEE/MPA and CEE groups, respectively). This decrease was more pronounced in subjects with a relatively higher basal Lp(a) concentration.

CONCLUSION

Both treatment regimens caused positive alterations in the lipid and lipoprotein profiles. This association might play a pivotal role in the postmenopausal increases in atherosclerotic diseases and cardioprotective effect of estrogen in postmenopausal women.

Comparison of effects of pravastatin and hormone therapy on soluble P-selectin and platelet P-selectin expression in postmenopausal hypercholesterolemic women

OBJECTIVE

Recent trials have suggested an adverse early effect on cardiovascular risk of hormone therapy (HT) in postmenopausal women, an effect which could be due to an increase in arterial thrombosis via platelet activation. We examined the effect of HT on platelet surface expression of P-selectin, a marker of platelet activation, and plasma levels of soluble P-selectin, also believed to be a marker of platelet activation, and compared these effects with pravastatin, a drug proven to reduce cardiovascular events and reported to decrease both platelet and soluble P-selectin.

METHODS

Surface expression of platelet P-selectin, soluble P-selectin and fasting lipids were measured at baseline and 6 months in a randomized, double-blind study of postmenopausal hypercholesterolemic women comparing low-dose combined HT (1mg estradiol + 0.5 mg norethisterone acetate; n = 26) with pravastatin (n = 24).

RESULTS

After adjusting for baseline levels, HT and pravastatin produced similar reductions in soluble P-selectin (p < 0.0001 for both). The percentage of platelets expressing P-selectin was also reduced by pravastatin (p = 0.025), but there was a trend to an increase in platelet P-selectin expression with HT (p = 0.13), and a significant difference between pravastatin and HT in the changes in platelet P-selectin (p < 0.002). No relationship was evident between changes in soluble or platelet P-selectin and changes in lipids with either treatment.

CONCLUSIONS

In postmenopausal hypercholesterolemic women, both pravastatin and HT reduced soluble P-selectin levels, but only pravastatin reduced P-selectin expression on the surface of platelets. An implication of these findings is that the reduction in soluble P-selectin by HT may occur by a non-platelet related mechanism.

Risk factors for high blood pressure in women attending menopause clinics in Italy

OBJECTIVE

We analysed risk factors for high blood pressure (BP) among women around menopause.

METHODS

Eligible women were consecutively attending first-level outpatient menopause clinics in Italy for general counseling or treatment of menopausal symptoms. During the visit BP was measured three times. The mean of second and third of the three diastolic BP values for women was >90mm of mercury and/or reporting any current pharmacological treatment for high BP were considered hypertensive. Out of 45,204 women who entered the study with information on blood pressure, 12,150 had high BP.

RESULTS

The odds ratios (OR) of high BP increased with age: in comparison with women aged <50 years, the multivariate OR were 1.44 (95% confidence interval (CI), 1.34-1.55), 1.61 (95% CI, 1.50-1.74) and 1.91 (95% CI, 1.77-2.06) in women aged 51-53, 54-57 and > or =58, respectively. Women with high BP were less educated than those without (OR education >12 versus <7 years, 0.79, 95% CI, 0.74-0.84). In comparison with women with a body mass index (BMI) <24, the multivariate ORs were 1.48 (95% CI, 1.39-1.57) and 2.56 (95% CI, 2.41-2.71) for women with BMI 24-26 and >26. In comparison with women reporting no regular physical activity, the multivariate OR of high BP was 0.93 (95% CI, 0.87-0.99) for women reporting regular activity. In comparison with peri-menopausal women, post-menopausal women were at increased risk (OR 1.14, 95% CI, 1.03-1.24) and the risk tended to increase with age at menopause. Current use of hormonal replacement therapy (HRT) was associated with a lower risk of high BP (OR 0.88, 95% CI, 0.84-0.94).

CONCLUSIONS

This large cross-sectional study suggests that, after taking into account the effect of age, post-menopausal women are at greater risk of high BP, but current HRT use slightly lowers the risk. Other determinants of high BP were low level of education, overweight, and low level of physical activity.

Cardiovascular disease: Screening and management of the a-symptomatic high-risk post-menopausal woman

Menopause-related oestrogen deficiency increases the risk of cardiovascular disease (CVD). The presence of abdominal obesity, dyslipidemia, hypertension, fasting hyperglycaemia or impaired glucose tolerance further aggravates the CVD risk imposed by menopause. A detailed personal history should be recorded, covering PCOS, gestational diabetes mellitus, alcohol intake and smoking, as well as a family history of cardiovascular disease. Screening of the a-symptomatic post-menopausal woman should include fasting lipid profile, plasma glucose and liver, renal and thyroid function tests. Serum low-density lipoprotein cholesterol (LDL-c)>130 mg/dL is associated with an increased risk of CVD. Levels of triglycerides (TG)>or=150 mg/dL and high-density lipoprotein cholesterol (HDL-c)<or=50 mg/dL coupled with an increase in small dense LDL and very low-density lipoprotein (VLDL) particles constitute the atherogenic dyslipidemia, which characterizes the metabolic syndrome. In women with previous VTE episodes, screening for thrombophilia is advisable, as well as an estimation of baseline homocysteine and C-reactive protein (CRP). Non-pharmacological intervention should be targeted towards smoking cessation, a low-salt, low-fat, high-fibre diet and increased physical activity.

The effect of hormone replacement therapy on Ca2+ mobilization and P-selectin (CD62P) expression in platelets examined under flow cytometry

A series of events, such as increase of cytoplasmic free calcium (Ca2+) and expression of P-selectin (CD62P), an adhesion molecule, on the platelet surface, are significant indicators of platelet activation. We have used flow cytometry to examine Ca2+ mobilization and CD62P expression in platelets in whole blood obtained in women prior to, and after, different forms of hormone replacement therapy. Thirty-two women completed a protocol consisting of two consecutive 1-month periods under oestradiol (E2), administered orally (2 mg/day) or transdermally (50 microg/day) in random order, followed by a 4-week transdermal sequential regime, in which, during the last 14 days, either progesterone (300 mg/day) or medroxyprogesterone acetate (5 mg/day) was added to the 50 microg/day E2, administered orally in random order. None of the hormonal combinations determined significant changes in Ca2+ mobilization or CD62P expression in non-stimulated platelets. However, stimulation of platelets with adenosine diphosphate, but not with thrombin, caused a significant increase in cytoplasmic Ca2+ concentration during treatment with transdermal E2 plus progesterone. Also when stimulating with thrombin, transdermal E2 was more active than oral E2 in increasing CD62P expression, a difference that was not reduced by the addition of progestogens. In conclusion, hormone replacement therapy only increased Ca2+ mobilization or CD62P expression in stimulated platelets, and then followed a varied pattern that was dependent on the stimulant and on the specific hormonal formulation.

Effect of hormone replacement therapy, tibolone and raloxifene on serum lipids, apolipoprotein A1, apolipoprotein B and lipoprotein(a) in Greek postmenopausal women

The aim of this study was to assess the effect of estrogen, two regimens of continuous combined hormone replacement therapy (HRT), tibolone and raloxffene on serum lipid, apolipoprotein A1 and B and lipoprotein(a) levels in Greek postmenopausal women. A total of 350 postmenopausal women were studied in a prospective open design. Women were assigned to one of the following regimens depending on the presence of risk factors for osteoporosis, dimacteric symptoms and an intact uterus: conjugated equine estrogen 0.625 mg (CEE, n = 34), continuous combined CEE 0.625 mg plus medroxyprogesterone acetate (MPA) 5 mg, (n = 80), continuous combined 17beta-estradiol 2 mg plus norethisterone acetate (NETA) 1 mg (n = 58), tibolone 2.5 mg (n = 83) and raloxifene HCl 60 mg (n = 50). Forty-five postmenopausal women with no indications for HRT served as controls. Total cholesterol (TC), low-density lipoprotein (LDL) cholestrol and high-density lipoprotein (HDL) cholesterol, triglyceride (TG), apolipoprotein A1 (ApoA1), apolipoprotein B (ApoB) and lipoprotein(a) (Lp(a)) levels were assessed in each subject at baseline, and at 6 and 12 months of therapy. All therapy regimens lowered TC levels compared to baseline (4.2-8.0% decrease). This effect was more prominent in the subgoup of women with high baseline TC levels (9.1-20.4% decrease). LDL cholesterol decreased significantly in CEE, CEE/MPA and raloxifene groups (-11.2%, -11.9% and -11.0%, respectively). Hypercholesterolemic women exhibited a steeper decrease in LDL cholesterol (10.6-27.8% in all therapy groups). TG levels increased significantly in the CEE and CEE/MPA groups (23.7% and 21.8%, respectively), while estradiol/NETA had no effect on TG levels. Tibolone decreased TG levels markedly, by 20.6%, while raloxifene had no TG-lowering effect. HDL cholesterol and ApoA1 were increased by CEE and CEE/MPA (HDL cholesterol, 7.4% and 11.8%, respectively; ApoA1, 17.8% and 7.9%, respectively) and decreased by tibolone (HDL cholesterol, -13.6%; and ApoA1, -9.9%). All therapy regimens except raloxifene lowered Lp(a) levels, with tibolone having the more pronounced effect (-13.2 to -29.0%). In conclusion, each therapy regimen had a diferent effect on lipid-lipoprotein levels, exerting favorable and unfavorable modifications. Hypercholesterolemic women seemed to benefit more from the cholesterol-lowering effect of estrogen replacement therapy/HRT. The choice for a particular regimen should be based on individual needs, indications and lipid-lipoprotein profile.

Estrogen, inflammation and cardiovascular risk in women: a critical appraisal

The widely shared enthusiasm about the cardioprotective potential of estrogenic compounds has come to an abrupt halt since randomized trials failed to show a cardiovascular risk reduction in postmenopausal women. This was unexpected because observational studies had strongly suggested that hormone replacement therapy would reduce the incidence of cardiovascular disease. Inflammatory activity is considered central in atherogenesis and atherosclerosis progression. Thus, parts of the striking discrepancy between observational and randomized data have been attributed to an estrogen-mediated adverse effect on inflammation. Here, we review the current clinical evidence with respect to the inflammation-modulating effects of different estrogenic compounds as one potential explanatory factor for these divergent findings. We conclude that it is still unclear whether estrogen-modulated inflammation is an important biological factor determining clinical outcome or a mere epiphenomenon.

Effects of estradiol alone or in combination with cyproterone acetate on carotid artery pulsatility index in postmenopausal women

OBJECTIVES

The incidence of cardiovascular disease (CVD) increases dramatically with the loss of ovarian function. Observational studies indicate that the risk of CVD may be reduced by up to 50% in postmenopausal women who take estrogen replacement therapy. Estrogen therapy reduces internal carotid artery pulsatility index (PI). The improvement in carotid PI following HRT has been proposed as a marker of the cardioprotective effect of estrogen therapy. Cyclical progesterone addition to ERT partially antagonizes the reduction on the carotid artery PI. As progesterone, androgens has been shown to decreases arterial vasodilatation and carotid PI. To our knowledge no information is available regarding the effect of CPA addition on the carotid artery PI in women taking estrogen replacement therapy.

METHODS

We recruited a total of 30 women in postmenopause for at least 12 months and were in good health. Fifteen women were postmenopausal following surgical bilateral oophorectomy for benign condition. Fifteen postmenopausal women received estradiol valerate for 21 days and CPA (1 mg) for 10 days for 3 months (Group E/CPA). Ovarectomized women (n=15) received estradiol hemihydrate (2 mg) for 3 months (Group E). The main factor investigated was PI, an indicator of impedence to blood flow down stream. Doppler US were performed before the start and at the end of the therapy.

RESULTS

The mean reductions respect to basal values were 11.5% in women treated with E and 10.8% in women treated with E/CPA. No significant difference was found between treatment values.

CONCLUSIONS

The results of the present study demonstrate that cyproterone acetate addition to E do non-antagonize the effect of estrogen on carotid artery PI. The present study demonstrate that both estradiol hemihydrate and estradiol valerate plus cyproterone acetate lead to similar improvement in carotid artery; through this mechanism both treatments could potentially reduce the incidence of cerebrovascular disease in postmenopausal women.

Managing cardiovascular risk reduction in elderly adults. By promoting and monitoring healthy lifestyle changes, health care providers can help older adults improve their cardiovascular health

Primary care practitioners must explore the most effective techniques for promoting cardiovascular risk reduction in older adults. Managing lifestyle modification risk factors, such as smoking cessation, obesity, sedentary lifestyle, and nutrition is discussed in this article. Other risk factor modification efforts, often not highlighted, include managing homocysteinemia, and sedentary behavior. These factors are presented as equally important modifiable coronary heart disease risks.

Serum lipids and apolipoproteins in Greek postmenopausal women: association with estrogen, estrogen-progestin, tibolone and raloxifene therapy

The aim of this study was to assess lipid and apolipoprotein levels in postmenopausal women taking various regimens of replacement therapy or no therapy. Seven hundred forty-eight postmenopausal women followed in the Menopause Clinic of the 2nd Department of Obstetrics and Gynecology, University of Athens, Aretaieion Hospital, were studied in a cross-sectional design. Women were either non-users of replacement therapy (no. = 511) or users of one of the following regimens: conjugated equine estrogen 0.625 mg (CEE, no. = 34), CEE 0.625 mg plus medroxyprogesterone acetate 5 mg (CEE/MPA, no. = 60), 17beta-estradiol 2 mg plus norethisterone acetate 1 mg (E2/NETA, no. = 44), tibolone 2.5 mg (no. = 84), raloxifene HCI 60 mg (no. = 51). Total cholesterol (TC), LDL-cholesterol (LDL-C) and HDL-cholesterol (HDL-C), triglycerides (TG), apolipoprotein A1 (ApoA1) and apolipoprotein B (ApoB) levels were assessed. Women were grouped according to replacement regimen and mean levels of lipid and apolipoproteins were compared between groups. Women in the raloxifene group were older and longer menopaused. After adjustment for age and duration of menopause, TG levels were significantly lower in the tibolone and E2/NETA groups (75 and 89.9 mg/dl, respectively) compared to non-users. TC was lower in all therapy groups, but the difference acquired significance only in the E2/NETA (207.8 mg/dl), compared to non-users (231.5 mg/dl). LDL-C levels were significantly lower in the CEE (133.8 mg/dl), CEE/MPA (130.4 mg/dl) and raloxifene group (129.9 mg/dl) compared to non-users (151.9 mg/dl). There was no difference in HDL-C levels between users and non-users (58.9 mg/dl) except for the tibolone group where HDL-C was significantly lower (48.6 mg/dl). ApoA1 levels were significantly higher in the CEE/MPA group (194.4 mg/dl) and significantly lower in the tibolone group (141.6 mg/dl) compared to non-users (170.4 mg/dl). No difference was detected between groups concerning ApoB levels. In conclusion, tibolone therapy is associated with lower TG levels as well as lower HDL and ApoA1 levels. ERT, continuous combined estrogen-progestin therapy (HRT) and raloxifene are associated with lower LDL-C levels. Among continuous combined HRT users, CEE/MPA is associated with higher ApoA1 levels, while E2/NETA with lower TG levels. Large prospective randomized studies are required to validate these results.

The effect of sodium monofluorophosphate therapy on lipid and lipoprotein metabolism in postmenopausal women

OBJECTIVE

To investigate the effect of a low dose of fluoride, combined with hormone replacement therapy (HRT) or alone, on serum lipids and lipoproteins in postmenopause.

STUDY DESIGN

One hundred and thirty-five healthy postmenopausal women were enrolled in this prospective study and randomly assigned to: (1) oral monofluorophosphate (MFP, 25 mg per day); or (2) HRT (a combination of oral conjugated estrogen 0.625 mg in conjunction with medroxyprogesterone acetate 5 mg daily); or (3) HRT + MFP; or (4) placebo, for 18 months. Serum lipid and lipoprotein levels were measured at enrollment and at the end of the study period.

RESULTS

Total cholesterol was not significantly different among groups, with a decrease in the HRT and the HRT + MFP groups (respectively, -7.8 and -7.9%), and a small increase in the MFP group (0.4%). LDL-C did not differ significantly in the groups, with a decrease in the HRT and HRT + MFP groups (respectively, -10.3 and -10.4%), and a slight increase in the MFP group (0.8%). TG decreased with -12 and 11.8% in the HRT and HRT + MFP groups (P = 0.052 and 0.055, respectively), but a slight increase was seen in the MFP group (1.4%). For HDL-C, both HRT and HRT+MFP groups showed a small increase (respectively, 3.5 and 3.6%), whereas MFP group showed a slight decrease (-0.9%, NS).

CONCLUSION

We conclude that long-term use of a low dose of fluoride had no significant adverse changes in the lipid and lipoprotein profile in postmenopause. It neither attenuated nor potentiated the effect of HRT on lipids and lipoproteins.

Effects of hormone replacement therapy on blood platelets

BACKGROUND

Hormone replacement therapy (HRT) increases the risk of cardiovascular morbidity in postmenopausal women under certain circumstances. Part of this effect may be the result of the influence of HRT on blood platelets. We studied the effect of short-term oral hormone replacement therapy (unopposed oestradiol or sequentially combined oestradiol and trimegestone or dydrogesterone) on platelet activation parameters in healthy postmenopausal women.

DESIGN

We designed a prospective, randomised, placebo-controlled 12-week study. Sixty healthy, normotensive, nonhysterectomised, postmenopausal women received daily micronised oestradiol (E2) 2 mg (n = 16), or 2 mg E2 daily sequentially combined with either trimegestone 0.5 mg daily (n = 14) or dydrogesterone 10 mg daily (n = 14), or placebo (n = 16). Data on platelet activation were collected at baseline and after 12 weeks of treatment using flow cytometry.

RESULTS

Twelve weeks of treatment with combined HRT was associated with an increase in platelet activation parameters P-selectin and glycoprotein 53 (by 17% and 14%, respectively, P = 0.04 vs. the placebo group for both comparisons), suggesting alpha granule and lysosome degranulation. E2 replacement therapy was associated with an increase in P-selectin labelling by 22% (P = 0.04 vs. the placebo group).

CONCLUSION

Short-term treatment with oestradiol or combined HRT increases the amount of circulating activated platelets as measured by flow cytometry. This could be a mechanism by which short-term HRT might increase the risk of thrombosis.

Combined oral estradiol valerate-norethisterone treatment over 3 years in postmenopausal women: effect on lipids, coagulation factors, haematology and biochemistry

OBJECTIVE

To determine the effect of continuous estradiol valerate 2 mg and norethisterone 0.7 mg daily as hormone replacement on lipid profiles, coagulation factors, haematology and biochemistry over 3 years.

METHODS

An open label trial with 107-133 postmenopausal women assessed pre-treatment and at annual visits with extensive lipid and coagulation profiles, and observation of circulatory adverse events. Standard haematology and biochemical profiles were also analysed. Results were compared at point of entry and at 36 months.

RESULTS

Total cholesterol (TC) and HDL and LDL fractions fell significantly (P=0.0001) and there was a significant decline in favourable ratios as well as a rise in VLDL mass (P=0.0001). Lipoprotein (a) (Lp(a)) decreased significantly (P=0.0053). Fibrinogen, free protein, prothrombin time and thrombin increased (P=0.0001) while platelets and KPTT were unchanged. Protein C, antithrombin III and total protein S decreased (P=0.0001) and there was a rise in the frequency of lupus anticoagulant positivity. Significant but small changes were seen in haematology and biochemical parameters although this did not raise safety issues and their clinical significance was uncertain.

CONCLUSION

The direction of lipid and coagulation factors move in competing ways, emphasising the complexity of metabolic change and making interpretation of outcome for venous and arterial thrombosis or atherosclerosis difficult to predict. Eight patients developed thromboembolic or ischaemic events over the 3 year period of this study but these patients had lipid changes normally considered beneficial to cardiovascular disease and coagulation changes not thought to be associated with thromboembolism. Decrease in lipoprotein 'a' levels might be an indicator of long-term decreases in atherosclerotic events.

Long-term effects of combined oral contraceptives on markers of endothelial function and lipids in healthy premenopausal women

The aim of this prospective cross-over study was to investigate the effect of two low-dosed oral contraceptives on markers of endothelial function and plasma lipids. Twelve healthy, nonsmoking women (mean age: 21.7 years) were recruited from the family planning clinic of the university hospital Zurich. For 6 months the participants received a treatment with two contraceptive pills containing 30 microg ethinyl estradiol/150 microg levonorgestrel (three cycles) and 30 microg ethinyl estradiol/75 microg gestodene (three cycles). Plasma levels of endothelin-1, nitric oxide, cholesterol, and HDL were measurement before and during treatment with both oral contraceptive treatments. No significant changes in the plasma levels of nitric oxide and endothelin-1, both important regulators of the vascular tone, were observed during oral contraceptive use. A significant negative correlation was found between nitric oxide and endothelin-1 and nitric oxide and cholesterol. There was a positive correlation between endothelin-1 and cholesterol. In conclusion, the investigated contraceptive pills did not cause major changes in circulating nitric oxide and endothelin-1 plasma levels.

Effects of estrogen-progestin and raloxifene therapy on nitric oxide, prostacyclin and endothelin-1 synthesis

This randomized double-blind study was conducted to investigate the effects of 17 beta-estradiol plus norethisterone acetate, and raloxifene, on nitric oxide (NO), prostacyclin (PGI2) and endothelin-1 (ET-1) serum levels in postmenopausal women. Treatment was initiated after a 28-50 day placebo period. Fourteen women were treated daily with 17 beta-estradiol 2 mg plus norethisterone acetate 1 mg (E2 + NETA), and 14 with raloxifene HCl 60 mg for a period of 6 months. Serum NO, PGI2 and ET-1 levels were estimated at baseline, after placebo, and at months 3 and 6. E2 + NETA decreased NO levels significantly, while raloxifene did not cause any appreciable change. Both regimens decreased PGI2 levels and ET-1 levels significantly. Finally, E2 + NETA and raloxifene increased the NO/ET-1 ratio by 61.4% and 81.1%, respectively. In conclusion, both regimens may exert a cardio-protective effect by decreasing ET-1 levels and increasing the NO/ET-1 ratio. In contrast, both regimens had a negative influence on PGI2 levels.

The influence of apo E phenotypes on the plasma triglycerides response to hormonal replacement therapy during the menopause

OBJECTIVE

To study the influence of apo E phenotype in plasma lipids, especially in triglycerides levels, in menopausal women receiving hormonal replacement therapy (HRT).

METHODS

One hundred and ten postmenopausal women were studied. Plasma total cholesterol (TC), HDL-C and triglycerides (TG) were measured before and after 3 months of HRT and the apo E phenotype was determined. According to the apo E phenotype the sample was divided into three groups: E2/E3 (n=28), E3/E3 (n=96) and E4/E3 (n=25).

RESULTS

In the pre-treatment state, higher plasma levels of TC and TC/HDL-C ratio were observed in women with phenotype E3/E4 (P<0.0001 and P<0.02, respectively), while higher plasma TG levels were found in the apo E2/E3 group (P<0.0001). After HRT, women with phenotype E3/E4 showed higher levels of TC and TC/HDL-C ratio (P<0.0001 and P<0.006, respectively). The apo E2/E3 phenotype group showed increased levels of TG (P<0.0001). In the multivariant analysis the changes of TG after HRT were related to the type of treatment used (P<0.001), age (P=0.05) and the apo E phenotype (E2/E3).

CONCLUSION

Women with phenotype E2/E3 have higher plasma TG levels and show a significant post HRT increase compared with the other phenotypes. Other factors with a lower impact on TG levels are age and progestagen association.

Continuous versus cyclical transdermal oestrogen replacement therapy in postmenopausal women: effects on lipoprotein(a) and nitric oxide levels

The purpose of our study was to compare the effects of cyclical versus continuous transdermal oestrogen replacement therapy on lipoprotein (a) (Lp(a)) and nitric oxide levels. The patients were randomly assigned into two groups. The first group received transdermal 17-beta oestradiol 50 microg/day for 21 days and the second group the same treatment on a continuous basis. Medroxyprogesterone acetate (10 mg/day orally) was added between the 14th and 25th days to each group. Lipoprotein (a) and nitric oxide levels were measured before the study and after six months. These values were compared using the Wilcoxon rank test within the groups and the unpaired t-test between the groups. Lipoprotein (a) levels decreased significantly in each group at the sixth month (p < 0.05). When compared between the groups, the decrease of lipoprotein (a) levels in the second group was more prominent at the sixth month (p < 0.05). Nitric oxide levels increased in each group after six months (p < 0.05). No difference in nitric oxide levels was observed between the groups before and after the therapy (p > 0.05). Continuous transdermal estradiol had a better effect on lipoprotein (a) levels than cyclical therapy The seven day pause in the 21-day administration did not affect nitric oxide levels negatively after six months.

The mechanisms of thrombotic risk induced by hormone replacement therapy

OBJECTIVES

To review the available information on the action of hormones on the mechanisms involved in thrombotic risk.

RESULTS AND CONCLUSIONS

Thrombosis plays a crucial role in the genesis and progression of both coronary heart disease (CHD) and venous thromboembolic disease (VTED), the two main forms of cardiovascular disease. Two main determinants of the thromboembolic phenotype, hypercoagulable state and altered endothelium, accumulate much of the work performed on the influence of hormones on thrombosis. Information has accumulated mainly for oestrogens, but increasing evidences support a role for progestogens. The sensitivity of each of the three components of the hemostatic balance, the coagulation cascade, the anticoagulant system and fibrinolysis, to oestrogens has been widely examined in the literature. Functional tests suggest that HRT is accompanied by a procoagulant state. Much of the work has concentrated on changes induced on reputable indicators of risk for either CHD or VTED. Distinct indicators of increased coagulability, such as resistance to activated C protein, antithrombin or tissue factor pathway inhibitor have been selected for VTED, whereas factor VII, fibrinogen, and defective fibrinolysis, for CHD. Different states of genetic susceptibility have been involved in both forms of the disease. The status of health of endothelium, defines another scenario for attention in CHD. A long-term anti-atherogenic action of oestrogens, which may be associated with short-term risk in cases of atherosclerosis-induced endothelial dysfunction, may most adequately explain much of the clinical observation. In both CHD and VTED, the procoagulant changes initiate soon after HRT administration.

Effect of postmenopausal hormone replacement therapy on lipoprotein and homocysteine levels in Chinese women

Epidemiological studies have revealed that postmenopausal estrogen replacement therapy results in a marked reduction in the risk for cardiovascular diseases. In the present study, we evaluated plasma lipoprotein profile as well as homocysteine levels in 145 postmenopausal and premenopausal Chinese women living in Hong Kong. We also investigated the effect of hormone-replacement therapy (HRT) with estrogen or estrogen combined with progestin on plasma lipoprotein profile and homocysteine concentrations in those individuals. Postmenopausal women displayed significantly higher plasma levels of total cholesterol, LDL-cholesterol and apoB as well as higher plasma homocysteine levels than that of premenopausal women. HRT with either estrogen (17beta-estradiol or conjugated equine estrogen) alone or estrogen combined with progestin for 3.5-4.5 years significantly improved the lipoprotein profile in postmenopausal women by decreasing the levels of total cholesterol (12-20% reduction), LDL-cholesterol (26-29% reduction) and apoB (21-25% reduction). In women treated with 17beta-estradiol or conjugated equine estrogens their plasma levels of apoAl were significantly elevated (18% elevation) as compared to non-users. HRT also reduced plasma concentrations of homocysteine (13-15% reduction). In conclusion, we found that long-term HRT was associated with improvement in plasma lipoprotein profile and a reduction in homocysteine concentration in postmenopausal women. These results support the notion that the improvement of lipoprotein profile and a reduction in homocysteine concentration may contribute to the beneficial effect of HRT on cardiovascular risk.

Effects of hormone replacement on hemostasis in spontaneous menopause

OBJECTIVE

To examine the effects of continuous combined estrogen-progesterone replacement therapy on coagulation and natural anticoagulant systems in spontaneous menopause.

DESIGN

A randomized, double-blind, placebo-controlled study was conducted during a 6-month period to examine the effect of hormone replacement therapy (HRT) on blood coagulation parameters. One hundred-ten healthy postmenopausal women were randomized into two groups. Those in group 1 were given conjugated estrogen (0.625 mg/d, Premarin) and medroxyprogesterone acetate (5 mg/d, Farlutal), and those in group 2 were given identical tablets of placebo for 6 months. Serum levels of modified activated protein C resistance, antithrombin III, fibrinogen, factor VIIIa, factor VIII, factor IX, activated partial thromboplastin time, prothrombin time, thrombin time, and lipoprotein (a) were measured before and 6 months after the treatment and analyzed for changes in extrinsic and intrinsic coagulation parameters.

RESULTS

At the end of the 6-month period, fibrinogen, lipoprotein (a), and activated protein C resistance levels were decreased significantly in the HRT group compared with the control group. Antithrombin III levels were increased, indicating antithrombin activity. Activated partial thromboplastin time, as a measure for intrinsic coagulation cascade, was prolonged in concert with decreased intrinsic coagulation factors, factor VIII, and factor IX (p < 0.05). In the extrinsic coagulation system, prothrombin time was significantly increased, although factor VIIa level was not changed (p > 0.05).

CONCLUSION

Significant changes were observed in the coagulation parameters, which may further explain the cardioprotective effect of HRT.

Effects of postmenopausal hormone replacement therapy on lipid, lipoprotein, and apolipoprotein (a) concentrations: analysis of studies published from 1974-2000

OBJECTIVE

To establish reference estimates of the effects of different hormone replacement therapy (HRT) regimens on lipid and lipoprotein levels.

DESIGN

Review and pooled analysis of prospective studies published up until the year 2000.

SETTING

Clinical trials centers, hospitals, menopause clinics.

PATIENT(S)

Healthy postmenopausal women.

INTERVENTION(S)

Estrogen alone, estrogen plus progestogen, tibolone, or raloxifene in the treatment of menopausal symptoms.

MAIN OUTCOME MEASURE(S)

Serum high- and low-density lipoprotein (HDL and LDL) cholesterol, total cholesterol, triglycerides, and lipoprotein (a).

RESULT(S)

Two-hundred forty-eight studies provided information on the effects of 42 different HRT regimens. All estrogen alone regimens raised HDL cholesterol and lowered LDL and total cholesterol. Oral estrogens raised triglycerides. Transdermal estradiol 17-beta lowered triglycerides. Progestogens had little effect on estrogen-induced reductions in LDL and total cholesterol. Estrogen-induced increases in HDL and triglycerides were opposed according to type of progestogen, in the order from least to greatest effect: dydrogesterone and medrogestone, progesterone, cyproterone acetate, medroxyprogesterone acetate, transdermal norethindrone acetate, norgestrel, and oral norethindrone acetate. Tibolone decreased HDL cholesterol and triglyceride levels. Raloxifene reduced LDL cholesterol levels. In 41 studies of 20 different formulations, HRT generally lowered lipoprotein (a).

CONCLUSION(S)

Route of estrogen administration and type of progestogen determined differential effects of HRT on lipid and lipoprotein levels. Future work will focus on the interpretation of the clinical significance of these changes.

Estrogen replacement therapy is underutilized among postmenopausal women at high risk for coronary heart disease

Observational studies have found that estrogen replacement therapy (ERT) reduces the risk of coronary heart disease (CHD) in postmenopausal women. To determine the frequency of current use of ERT in an economically and racially diverse group of women at high risk for CHD, we examined the medical records of 393 women older than 40 who were admitted to the University of South Alabama Medical Center with symptoms suggestive of angina. Women in the study group were classified as African American or European American and data were examined for significant differences. Use of ERT was lower in African American women (11 of 111, 9.9%) than in European American women (26 of 152, 17.1%, odds ratio 1.9). Compared with the reported utilization of ERT in middle-class European American women, ERT is underutilized in this economically diverse group of women at high risk for coronary heart disease. In our population, European American women were twice as likely to be receiving ERT as African American women.

Phytoestrogens and cardiovascular health

Coronary artery disease is the leading overall cause of mortality for women and increases dramatically after menopause. Estrogen has many beneficial cardiovascular actions although concerns have been raised about its effects on the progression of breast and uterine neoplasms and its tendency to increase coagulability. Selective estrogen agonists may be superior to conventional estrogens. A dietary source of a partial estrogen agonist is the plant-based group of phytoestrogens, which include isoflavones, lignans and coumestans. Phytoestrogens have a similar structure to estradiol and have weak affinity for the estrogen receptor. Epidemiologic data indicate that women ingesting high amounts of phytoestrogens, particularly as isoflavones in soy products, have less cardiovascular disease, breast and uterine cancer and menopausal symptoms than those eating Western diets. Preclinical and clinical studies have found that isoflavones have lipid-lowering effects as well as the ability to inhibit low-density lipoprotein oxidation. They have been shown to normalize vascular reactivity in estrogen-deprived primates. Furthermore, phytoestrogens have antineoplastic effects with inhibition of cellular proliferation as well as angiogenesis, properties that could be protective against cancer development. Finally, menopausal symptoms and bone density may be favorably influenced by phytoestrogens. In summary, phytoestrogens, in the form of dietary isoflavones, represent a new area to explore in pursuit of nutritional approaches to cardiovascular protection.

Short-term hormone replacement therapy: reduced plasma levels of soluble adhesion molecules

BACKGROUND

Epidemiological data have suggested that the use of hormone replacement therapy (HRT) is associated with a decreased risk of cardiovascular disease. Vascular endothelium and adhesion molecules play an important role in the initiation and progression of atherosclerosis.

MATERIAL AND METHODS

Prospective, randomized, placebo-controlled 12-week study. Sixty healthy, normotensive postmenopausal women received either micronised oestradiol 2 mg alone (n = 16, E2 group), or sequentially combined with a progestagen; E2 + P groups trimegestone 0.5 mg (E2 + T, n = 14) or dydrogesterone 10 mg (E2 + D group, n = 14) or placebo (n = 16). Data were collected at baseline and at 4 and 12 weeks.

RESULTS

Twelve weeks of treatment with E2 or E2 + P was associated with a significant decrease in the plasma concentrations of soluble intercellular adhesion molecule-1 (sICAM-1), vascular cell adhesion molecule-1 (sVCAM-1), and thrombomodulin (sTM). The average decrease in these markers was about 9%. In women treated with trimegestone the decreases were larger than in those treated with dydrogesterone; for sICAM-1 (-15% vs. -2%; P < 0.0001), sVCAM-1 (-15% vs. +3%; P = 0. 003) and sTM (-9% vs. -4%; P = 0.11). Plasma levels of endothelin-1 (ET-1) decreased (by 13%) only in women treated with E2 + P. In the E2 group, flow-mediated, endothelium-dependent vasodilatation increased by 6 percentage points after 12 weeks (P = 0.07 vs. baseline, P = 0.02 vs. E2 + P, and P = 0.17 vs. placebo).

CONCLUSION

Short-term treatment with E2 or E2 + trimegestone reduces plasma levels of sICAM-1, sVCAM-1 and sTM. ET-1 decreased only in the E2 + P groups. Different types of progestagens may differentially affect sICAM-1, sVCAM-1 and sTM levels, which may be relevant for the choice of type HRT.

Postmenopausal hormone use for cardioprotection: what we know and what we must learn

Coronary heart disease is a highly prevalent and lethal illness for women, particularly in their menopausal years, a fact that fostered interest in hormone use for cardioprotection. Despite the compelling evidence of cardiovascular benefit of estrogen therapy and estrogen and progestin therapy in observational studies of postmenopausal women, and multiple biologically plausible mechanisms for estrogen benefit, precise clinical outcome information from prospective randomized controlled trials is lacking. The only such trial reported, the Heart and Estrogen/Progestin Replacement Study, not only failed to demonstrate cardioprotection, but showed an early adverse outcome in women with documented coronary heart disease who received daily conjugated equine estrogen and medroxy-progesterone acetate. Several large randomized clinical trials of hormone and selective estrogen receptor moderator therapy for primary and secondary prevention are currently underway.

Estrogen stimulates expression of adenine nucleotide translocator ANT1 messenger RNA in female rat hearts

The identification of estrogen-responsive genes in the heart, is necessary to understand estrogen-induced changes in cardiac function. Using Delta RNA fingerprinting, we demonstrate that a single injection of estradiol benzoate (50 microg, s.c.) revealed mRNA species that were elevated, down-regulated, or were unaffected in the heart tissue of ovariectomized female rats. One of the upregulated genes was identified, by cloning and sequencing, to have 95.8% (230/240) identity with the 3' end of the rat ant1 gene encoding the mitochondrial adenine nucleotide translocator, ANT1. Using the isolated ANT1 cDNA (280 bp) as a probe in Northern analysis, estrogen was shown to upregulate the expression of cardiac ANT1, by at least 3-fold in female rats, from as early as 1 h to as long as 24 h. In contrast, estrogen treatment had no effect on ANT1 expression in heart tissue from male rats. RNA yields were low in rat atria and no transcript was detectable by Northern analysis. Using primers specific to the known rat ANT1 gene, the estrogen upregulation of the cardiac ANT1 transcript in female rat was confirmed by reverse transcriptase-polymerase chain reaction (RT-PCR); a predicted product of 249 bp was obtained and this was stimulated by at least 3-fold upon estrogen treatment for 24 h.

Long-term effects of combined hormone replacement therapy on markers of endothelial function and inflammatory activity in healthy postmenopausal women

OBJECTIVE

To study the effects of combined hormone replacement therapy on markers of endothelial function and inflammatory activity.

DESIGN

Prospective, randomized, controlled study.

SETTING

Academic hospital.

PATIENT(S)

Healthy postmenopausal women with an intact uterus.

INTERVENTION(S)

For the first 12 months, the hormone replacement therapy group (n = 14) received oral E2, 1 mg daily, sequentially combined with 5 or 10 mg of dydrogesterone. Thereafter, they received oral E2, 2 mg daily, sequentially combined with 10 mg of dydrogesterone. The control group (n = 13) received no treatment. Data were collected at baseline and at 3, 12, and 15 months.

MAIN OUTCOME MEASURE(S)

Parameters of endothelial function and inflammatory activity.

RESULT(S)

During 12 months of follow-up, we observed decreases of 15% in plasma levels of endothelin-l, of 21% in soluble thrombomodulin, of 14% in von Willebrand factor, and of 12% in clottable fibrinogen in the hormone replacement therapy group compared with the control group. There was a 5% decrease in soluble E-selectin tevels. All significant changes were observed by 3 months and sustained after 15 months. Brachial artery flow-mediated vasodilatation and C-reactive protein levels did not change significantly.

CONCLUSION(S)

Long-term combined hormone replacement therapy with E2 and dydrogesterone in healthy women was associated with sustained improvement in some aspects of endothelial function and in clottable fibrinogen levels.