Effects of norethisterone acetate addition to estradiol in long term HRT

The role of ovarian hormones in the pathophysiology of perimenopausal sleep disturbances: A systematic review

Sleep disturbance is a common clinical concern throughout the menopausal transition. However, the pathophysiology and causes of these sleep disturbances remain poorly understood, making it challenging to provide appropriate therapy. Our goal was to i) review the literature about the influence of ovarian hormones on sleep in perimenopausal women, ii) summarize the potential underlying pathophysiology of menopausal sleep disturbances and iii) evaluate the implications of these findings for the therapeutic approach to sleep disturbances in the context of menopause. A systematic literature search using the databases Embase, MEDLINE and Cochrane Library was conducted. Keywords relating to ovarian hormones, sleep disturbances and menopause were used. Ultimately, 86 studies were included. Study Quality Assessment Tools of the National Institutes of Health were used for quality assessment. Results from good-quality studies demonstrated that the postmenopausal decline in estrogen and progesterone contributes to sleep disturbances in women and that timely treatment with estrogen and/or progesterone therapy improved overall sleep quality. Direct and indirect effects of both hormones acting in the central nervous system and periphery, as well as via secondary effects (e.g. reduction in vasomotor symptoms), can contribute to improvements in sleep. To strengthen external validity, studies examining neurobiological pathways are needed.

Transdermal hormone therapy: gels and patches

Hormone therapy (HT) in the climacteric has a number of beneficial effects including mitigation of climacteric symptoms and prevention of osteoporosis. Administration of HT via the transdermal route avoids hepatic first-pass metabolism and therefore the high plasma levels of estrogen metabolites that are associated with oral administration. Patch formulations have traditionally been the most common form of transdermal HT. However, as patches may be associated with local skin reactions, gel formulations have been developed in an attempt to improve acceptability and compliance with transdermal HT. Patch and gel formulations are equally as effective in treating climacteric symptoms and improving bone mineral density, and the effects are comparable to those achieved by oral HT.

The women's health in the Lund area (WHILA) study--an overview

The Women's Health in the Lund Area (WHILA) study invited all women (n=10,766) living in the Lund area of Southern Sweden by 1995, who were born between 1935 and 1945. The health screening program included a postal validated questionnaire concerning medical history, drug treatment, family history of diabetes and hypertension, menopausal status, smoking and alcohol habits, education, household, and working status, physical activity, quality of life as well as subjective physical and mental symptoms. The screening consisted of a routine physical examination with standardized blood pressure measurements, bone densitometry and an extended laboratory examination. A link with the mammography registry was established. Based on menopausal status, the population was divided in three subgroups; premenopausal (PM), postmenopausal with hormone replacement therapy (PMT), and postmenopausal without hormone replacement therapy (PM0). Menopause was defined as a bleed-free interval of at least 12 months. Of 10,766 women, 6917 (64.2%) had complete data sets. A number of observational analyses were carried out based on the screening data at baseline, to be followed by long-term follow-up analyses based on national register linkages that are currently being started.

Background factors influencing somatic and psychological symptoms in middle-age women with different hormonal status

OBJECTIVE

To analyse the influence of socio-demographic characteristics and environmental factors on self-reported somatic and psychological symptoms among middle-aged Swedish women.

METHODS

A total of 6917 women living in the Lund area of southern Sweden were participates of this study. They completed a generic questionnaire pertaining to socio-demographic characteristics, lifestyle factors and current health related problems. According to hormonal status, the participants were subdivided into three groups, i.e. premenopause, postmenopause and peri- or postmenopausal women with hormone replacement therapy (HRT).

RESULTS

By using multiple logistic regression models, a high risk for somatic symptoms was independently associated with unemployment, no exercise, unmarried, high body weight and diseases affecting the cardiovascular system as well as a history of cancer. Psychological symptoms were independently associated with higher educational level, unemployment, no exercise, unmarried, heavy smoking habits (> or =15 cig/day), weight gain and a history of cancer. In addition, the background factors seemed to have less impact on symptoms among women who used HRT.

CONCLUSION

Socio-demographic characteristics, lifestyle factors and concurrent health problems appear to have influences on the frequency and the number of somatic and psychological symptoms in middle-age women. Hormone replacement therapy seems to be able to counteract negative impacts caused by un-healthy lifestyle and other health problems.

Does hormone therapy increase allergic reactions and upper gastrointestinal problems? Results from a population-based study of Swedish woman. The women's health in the Lund area (WHILA) study

OBJECTIVES

To delineate the use of various drugs particularly pertaining to allergy and upper gastrointestinal problems in relation to hormone status in middle aged women.

METHODS

An analysis from a population-based study on women born between 1935 and 1945 and lived in the Lund area southern Sweden. Of 10,766 women, 6,917 provided complete data sets; in turn 5,673 were assessed for the use of medication in this study. Among the cohort, 9% of women were premenopausal (PM), 54% were postmenopausal without hormone replacement therapy (PM0) and 37% were current hormone replacement therapy users (PMT).

RESULTS

There were 7 (1.3%) women in PM, 11 (0.4%) in PM0 and 21 (1.0%) in PMT group who used loratadine regularly. There was a significant difference between the PM and PM0 groups and also between the PM0 and PMT groups in the use of loratadine (P < 0.05 ). Among 21 loratadine users in PMT group 4 (19%) used transdermal patches and 17 (81%) used oral HRT. The result for omeprazole use was as follows: 4 (0.8%) of PM group, 39 (1.3%) of PM0 group and 42 (2.0%) of PMT group. The use of omeprazole was significantly higher in the PMT group than in the PM (P = 0.05 ) and PM0 group (P < 0.05 ). There was no relation between the use of omeprazole and smoking or alcohol consumption.

CONCLUSIONS

Use of hormone replacement therapy seems to be related to a higher frequency of omeprazole and loratadine use, which implies that hormone replacement therapy, may be associated with more upper gastrointestinal symptoms as well as allergy.

Combined hormone therapy in postmenopausal women with features of metabolic syndrome. Results from a population-based study of Swedish women: Women’s Health in the Lund Area study

OBJECTIVE

To delineate the influence of hormone therapy (HT) on features of metabolic syndrome with special reference to the composition and mode of administration of three specific HT regimens, all containing estradiol (E2) + norethisterone.

DESIGN

The Women's Health in the Lund Area project screened all women (n = 10,766), born between 1935 and 1945. Complete data were obtained from 6,917 women. Those at or above defined cutoff limits were considered positively screened (n = 3,593) for metabolic syndrome. All of them were invited to undergo an oral glucose tolerance test; 2,923 women accepted. After excluding 200 women with impaired fasting glucose, 2,723 women were included in the present analysis. Serum lipids were determined by conventional standard methods at the department of clinical chemistry of Lund University Hospital.

RESULTS

According to World Health Organization criteria, 2,123 women had normal glucose tolerance and 600 women had impaired glucose tolerance (IGT). IGT was less common (P = 0.001) among users of a transdermal patch [CYC-TRANS; E2 50 microg + norethisterone acetate (NETA) 250microg] compared with the two-combined oral regimen [CON-O (continuous oral E2 2 mg + NETA 1 mg) + CYC-O (sequential oral E2 2 mg + NETA 1 mg)]. Furthermore, IGT was more common among CON-O users when compared with either the CYC-O + CYC-TRANS group (P = 0.002) or the CYC-TRANS only group (P = 0.001). There were no significant differences between CYC-O versus CYC-TRANS or CON-O. Serum levels of total cholesterol were higher in the CYC-TRANS group than in the combined CON-O + CYC-O group (P < 0.05); they also were higher (P = 0.05) when comparing the CYC-O + CYC-TRANS versus CON-O as well as higher in CYC-TRANS versus CON-O (P < 0.05). Serum high-density lipoprotein cholesterol levels were higher in the CYC-O (P = 0.001), CYC-TRANS (P < 0.05), and the CYC-O + CYC-TRANS (P = 0.001) groups when compared with the CON-O users. There were no differences in the mean age, blood pressure (systolic and diastolic), body mass index, waste-hip ratio, or the rate of cigarette and alcohol consumption between the different hormone regimens.

CONCLUSION

The risk of having a pathological glucose load was lower in transdermal versus oral users of HT. Transdermal HT could be regarded as first-line treatment in women at risk of developing diabetes.

Dose proportionality study of four doses of an estradiol transdermal system, Estradot®

OBJECTIVES

To establish dose proportionality among four doses of a new estradiol transdermal system (ETS), Estradot, in healthy postmenopausal women and to evaluate the wear and irritation properties of the ETS.

METHODS

In an open label, single-dose, randomized, four-period crossover study, healthy postmenopausal women, age range 44-64 years, wore four different sizes of Estradot, 2.5, 3.75, 5.0 and 10.0 cm(2) that were expected to release estradiol at 0.025, 0.0375, 0.05 and 0.10 mg/day, respectively. Each patch was worn for 84 h with a 7-day washout period between treatments. Blood samples were drawn prior to medication, then at various time points following patch application. Serum concentrations of estradiol and estrone were determined by validated gas chromatography/mass spectrometry (GS/MS) methods. Skin irritation, (erythema and edema), patch adherence and local skin reaction were assessed and recorded following patch removal. After removal, the patches were assayed for residual estradiol to estimate the apparent dose delivered.

RESULTS

The baseline-corrected, mean maximum serum estradiol concentrations (C(max)) for the 2.5, 3.75, 5.0 and 10.0 cm(2) patches were 24.0, 34.8, 50.1 and 96.0 pg/ml, respectively, and for estrone were 10.5, 15.2, 21.8 and 41.0 pg/ml, respectively. The four Estradot patches adhered well during the study. No significant skin irritation was observed with any of the four treatments.

CONCLUSIONS

The results indicate a dose proportional relationship of increased serum concentrations of estradiol with increasing size of the Estradot patches. The four doses of Estradot demonstrated good systemic and local skin tolerability.

Comparative bioequivalence studies with Estradot® and Menorest® transdermal systems

OBJECTIVES

To compare the relative bioavailability of Estradot, a small size, new generation estradiol transdermal system (ETS) to Menorest, in healthy postmenopausal women.

METHODS

In two open-label, single center, randomized, crossover, bioequivalence studies, healthy postmenopausal women aged 40-65 years received treatment with all the test regimens. In Study 1 (single-dose study), patients wore 5 cm(2) (50 microg/day), 10 cm(2) (100 microg/day) Estradot and 29 cm(2) (100 microg/day) Menorest for 84 h. In Study 2 (multiple-dose study), patients wore a regimen of four consecutive treatments with a 5 cm(2) (50 microg/day) new generation patch, Estradot and a 14.5 cm(2) (50 microg/day) patch, Menorest. Blood samples were drawn at various time-points in both studies. Estradiol and estrone serum levels were determined by gas chromatography/mass spectrometry or radioimmunoassay methods. Skin irritation (erythema and edema), patch adherence and local skin reaction were assessed following patch removal.

RESULTS

In Study 1, baseline-uncorrected C(max) for estradiol for Estradot 50 and 100 microg/day and Menorest 100 microg/day was 54.8, 106.2 and 101.6 pg/ml, respectively, and C(max) for estrone was 75.6, 97.0 and 98.3 pg/ml, respectively. In Study 2, the baseline-uncorrected mean maximum serum concentration (C(max)) for estradiol for Estradot 50 microg/day and Menorest 50 microg/day patches was 56.7 and 52.7 pg/ml, respectively, and C(max) for estrone was 41.7 and 41.3 pg/ml, respectively. No significant skin irritation was observed in either study, but Estradot caused less skin irritation than Menorest.

CONCLUSIONS

Estradot produced comparable serum concentrations of estradiol and estrone and caused less skin irritation than Menorest.

Effects of hormone replacement therapy on perceptual and cognitive event-related potentials in menopausal insomnia

The influence of a combined estrogen-progestin regimen (Climodien, Lafamme) on auditory event-related potentials (ERPs) was investigated in a double-blind, placebo-controlled, comparative, randomized 3-arm trial phase (Climodien 2/3=estradiol valerate 2 mg+the progestin dienogest 3 mg, EV=estradiol valerate 2 mg, and placebo), followed by an open-label phase in which all patients received Climodien 2/2 (estradiol valerate 2 mg+dienogest 2 mg). Both the double-blind and the open-label phase lasted 2 months. ERPs were recorded from 19 EEG leads in a two-tone odd-ball paradigm in 49 patients aged between 46 and 67 yr with the diagnosis of insomnia (G 47.0) related to postmenopausal syndrome (N 95.1). Climodien reduced standard N1 and target P300 latencies as compared to placebo, while EV did not affect N1 latency but similarly reduced P300 latency. Climodien increased N1, P2 and P300 amplitudes dose-dependently, predominantly at frontal leads. Estrogen alone had only minor effects on ERP amplitudes. The shortening of standard N1 latency and enhancement of N1 and P2 amplitudes indicates a positive effect of Climodien on perceptual processing, most likely due to vigilance improvements also observed in EEG mapping. Concerning target P300, it seems that estradiol is responsible for the improvement in stimulus evaluation time, as reflected by the shortening of the peak latency, while dienogest seems to account for the improvement in cognitive information processing capacity, whereby 3 mg induced a more pronounced augmentation of P300 amplitudes than 2 mg. Based on the spatial distribution of this increase, it can be speculated that Climodien mainly affects the more frontally distributed P3a subcomponent, which is associated with attention and orientation. Furthermore, the observed changes in ERP-components are consistent with recent studies showing significant positive effects of hormone replacement therapy on cholinergic functions. Thus, Climodien seems to be of interest in preventing cognitive decline and treating cognitive disorders in postmenopausal women. Indeed, there is increasing evidence of beneficial effects of estrogen in dementia. Our present findings suggest that the estrogen effects may be augmented by dienogest.

Evaluation of irritation and sensitisation of two 50 microg/day oestrogen patches

OBJECTIVES

To comparatively assess the irritation and sensitisation of the Estradot transdermal oestrogen patch, in healthy postmenopausal women, using the Menorest transdermal oestrogen patch, as a comparator.

METHODS

In an open-label, single-centre, randomised, active-treatment, within-patient controlled study, 208 healthy postmenopausal women, age range 40-70 years, received and completed simultaneous treatment with a 5 cm(2) (50 microg/day) oestradiol patch (Estradot) and a 14.5 cm(2) (50 microg/day) oestradiol patch (Menorest). The treatment was given for 72 h, then 96 h, for eight successive applications during an induction phase, and for 72 h during a challenge phase. There was a 14-day resting period between phases. Skin irritation (measured by erythema on a scale of 0-4), topical sensitisation, patch adherence and local skin reaction, were assessed and recorded immediately before or after removal of each patch, as appropriate.

RESULTS

Most patients experienced a significant difference in irritation with Menorest than with Estradot (P < 0.0001) at the end of the induction phase. Patch loss was also significantly higher for Menorest as compared to Estradot (P = 0.0253) at the end of the induction phase. Most incidences of erythema were classified as slight (score of 1), and there was no significant difference in the percentage of topical sensitisation, or in the incidence of local skin reactions between Estradot and Menorest. Patch loss was low for both systems.

CONCLUSIONS

Estradot demonstrates reduced skin irritation, superior adhesion and a lower rate of patch loss compared to Menorest.

Hormone replacement therapy and vigilance: double-blind, placebo-controlled EEG-mapping studies with an estrogen-progestogen combination (Climodien, Lafamme) versus estrogen alone in menopausal syndrome patients

The aim of the double-blind, placebo-controlled study was to investigate the effects of a continuous combined estrogen-progestogen treatment (Climodien, Lafamme) as compared with estrogen alone on vigilance in insomniac postmenopausal syndrome patients, objectified by EEG mapping.

METHODS

In a 3-arm, 2-month parallel group design phase, patients received a combination of estradiol valerate 2 mg and the novel progestogen dienogest 3 mg (Climodien 2/3) or estradiol valerate 2 mg alone or placebo. In a subsequent open-label phase, all patients received estradiol valerate 2 mg+dienogest 2 mg (Climodien 2/2). EEG mapping was carried out before and after the 2-month double-blind phase as well as after the 2-month open-label treatment.

RESULTS

As compared with placebo, Climodien 2/3 induced a marked and highly significant increase in absolute power in all frequency bands, specifically in alpha-2 activity. Moreover, a significant increase in relative alpha-2 power, a decrease in relative delta and beta power as well as an acceleration of the dominant frequency and of the delta and alpha centroids suggested a marked improvement in vigilance. In contrast, under estradiol valerate 2 mg alone, only a slight augmentation of alpha and attenuation of relative delta and beta power occurred, suggesting only a slight vigilance improvement as compared with placebo. Thus, dienogest 2 mg increased the estrogen effect, which was also confirmed by a statistical evaluation of the differences between Climodien 2/3 and estradiol valerate alone (augmentation of alpha-2, attenuation of relative beta, acceleration of the dominant frequency). Moreover, Climodien 2/2 also markedly increased alpha-2 power, decreased relative beta-2 power and accelerated the alpha centroid. Finally, comparing Climodien 2/3 with Climodien 2/2, there was even a dose-efficacy relation.

CONCLUSIONS

Estradiol valerate 2 mg improves vigilance slightly, thereby confirming previous findings. The additional administration of dienogest does not minimize the effect of estrogen, but on the contrary increases it, which makes the combination superior to both placebo and estradiol valerate alone. Vigilance improvement may be of great therapeutic benefit to menopausal syndrome patients at a time when increased adaptability is needed to adjust to increasing sexual, marital, occupational and social difficulties known to occur specifically in this period of life.

The role of ERT/HRT

Given the rapidly increasing number of women above 50 it is of pivotal importance to consider health issues related to gonadal hormone deficiency. The possibility of alleviating such symptoms by hormone replacement therapy (HRT) should be recognized by all physicians, not merely by gynaecologists. But which women should be given what therapy, and for how long? Due to the increased risk of endometrial cancer and bleeding problems when using oestrogen monotherapy, only women who have undergone hysterectomy could use this regimen unless treatment is aimed at amelioration of urogenital symptomatology only. In this case a vaginal administration of low-dose oestrogens is possible as such doses do not induce endometrial proliferation. In all other cases a combination of an oestrogen and a progestogen must be used. There are several options for doing so. During the early phase of the climacteric period when irregular and/or heavy vaginal bleeds are part of the symptomatology a cyclical therapy will often combat these problems. As women pass into the menopause a sequential regimen is often preferred until 1-3 years have elapsed since menopause. With advancing time since menopause women become more and more reluctant to experience monthly bleeds. In such cases a continuous combined regimen may be offered even though it cannot guarantee a bleed-free remedy.Non-oral, particularly transdermal, therapy is an alternative in women with co-existing morbidity such as migraine, diabetes, malfunction of the gastrointestinal tract and liver disease. Oral therapy is preferred particularly in women with elevated plasma levels of LDL-cholesterol, lipoprotein(a) or homocysteine. Oral therapy induces liver protein synthesis. This could be an advantage in cases with low plasma levels of sex hormone-binding globulin (SHBG) as low levels of SHBG may promote androgenic stigmata such as hirsutism and a lowering of the voice. However, in cases with too low an androgen influence the use of a non-oral therapy may counteract symtoms such as low libido.Tibolone could be used for the prevention (and treatment?) of osteoporosis but it will also mitigate the typical climacteric symptoms. Raloxifene is a fairly new type of drug which is classified as a selective oestrogen receptor modulator (SERM). It will reduce vertebral fractures to the same extent as bisphosphonates, albeit the increase in bone density is less. Raloxifene has no effect on climacteric symptoms. Its greatest benefit is a clear reduction of breast cancer in women, which is in contrast to HRT/ERT.There are insufficent data on tibolone and the incidence of breast cancer. Experimental data, however, are intriguing in suggesting less impact on the breast than conventional HRT/ERT.