Postmenopause hormone treatment in women with NIDDM or impaired glucose tolerance: the MEDIA randomized clinical trial

Effects of Transdermal 17β-Estradiol + Norethisterone Acetate on Cardiovascular Disease Risk Factors in Postmenopausal Women: A Meta-analysis of Data From Randomized, Controlled Trials

PURPOSE

To date, no study has demonstrated the role of transdermal 17β-estradiol + norethisterone acetate on all of the risk factors for cardiovascular disease in postmenopausal women. To overcome this knowledge gap, a systematic review and meta-analysis were conducted to determine the effects of this combination treatment on BMI, body weight, waist/hip ratio, fibrinogen, factor VII, lipoprotein(a), fasting blood sugar, insulin, HbA1c, TG, LDL-C, HDL-C, and TC in postmenopausal women.

METHODS

PubMed/Medline, SCOPUS, Web of Science, Embase, and Google Scholar were searched for relevant articles published between the inception of each database and April 6, 2023. The sample size and mean (SD) were used to calculate overall effect size using a random-effects model.

FINDINGS

A total of 10 articles with 14 arms were included in the meta-analysis. On pooled analysis of effect size, fibrinogen (weighted mean difference [WMD], -0.18 g/L; 95% CI, -0.25 to -0.10), factor VII (WMD, -9.58; 95% CI, -12.51 to -6.64), LDL-C (WMD, -13.09 mg/dL; 95% CI, -18.48 to -7.71), and TC (WMD, -12.61 mg/dL; 95% CI, -18.11 to -7.12) were significantly affected with the use of transdermal 17β-estradiol + norethisterone acetate (all, P < 0.001), but effects on lipoprotein(a), TG, HDL-C, fasting blood sugar, insulin, HbA1c, BMI, body weight, and waist/hip ratio were not significant.

IMPLICATIONS

Based on the findings from the present systematic review and meta-analysis, it was concluded that transdermal administration of 17β-estradiol + norethisterone acetate had beneficial impacts on fibrinogen, factor VII, LDL-C, and TC, suggesting a possible application in the reduction of cardiovascular disease risk.

The effect of 17beta-estradiol plus norethisterone acetate on anthropometric indices: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Little evidence exists on the effect of 17beta-estradiol plus norethisterone acetate on all the anthropometric indices. Hence, this systematic review and meta-analysis of Randomized Controlled Trials was conducted to give an evidence-based report on the effect of 17beta-estradiol plus norethisterone acetate on anthropometric indices.

METHODS

The literature search was executed in databases including PubMed/Medline, Web of Science, Scopus, Embase, and Google Scholar to recognize clinical trials that examined the influence of 17beta-estradiol plus norethisterone acetate on obesity indices from database inception to Jan 2023.

RESULTS

Combined findings were generated from 20 eligible articles. The meta-analysis showed that body weight (Weighted Mean Difference (WMD): -0.47 kg, 95% CI: -1.32, 0.37, p = 0.274), body fat (WMD: 0.16 kg, 95% CI: -1.26, 1.59, p = 0.821), WHR (WMD: 0.001 kg, 95% CI: -0.006, 1.15, p = 0.872), and LBM (WMD: -0.02 kg, 95% CI: -1.19, 1.15, p = 0.970) were not modified in DHEA group compared to the control, but BMI levels were significantly reduced in 17beta-estradiol plus norethisterone acetate group (WMD: -0.15 kg/m2, 95% CI: -0.30, -0.008, p = 0.039). Moreover, based on intervention duration (months), a more significant reduction in BMI was found in trials that were performed on studies with ˃3 months duration (WMD: -0.176 kg/m2) than studies with ≤ 3 months (WMD: 0.05 kg/m2).

CONCLUSION

Administration of 17beta-estradiol plus norethisterone acetate for more than 3 months results in a decrease in BMI, which helps to reduce cardiovascular disease risk.

Eligibility criteria for Menopausal Hormone Therapy (MHT): a position statement from a consortium of scientific societies for the use of MHT in women with medical conditions. MHT Eligibility Criteria Group

This project aims to develop eligibility criteria for menopausal hormone therapy (MHT). The tool should be similar to those already established for contraception A consortium of scientific societies coordinated by the Spanish Menopause Society met to formulate recommendations for the use of MHT by women with medical conditions based on the best available evidence. The project was developed in two phases. As a first step, we conducted 14 systematic reviews and 32 metanalyses on the safety of MHT (in nine areas: age, time of menopause onset, treatment duration, women with thrombotic risk, women with a personal history of cardiovascular disease, women with metabolic syndrome, women with gastrointestinal diseases, survivors of breast cancer or of other cancers, and women who smoke) and on the most relevant pharmacological interactions with MHT. These systematic reviews and metanalyses helped inform a structured process in which a panel of experts defined the eligibility criteria according to a specific framework, which facilitated the discussion and development process. To unify the proposal, the following eligibility criteria have been defined in accordance with the WHO international nomenclature for the different alternatives for MHT (category 1, no restriction on the use of MHT; category 2, the benefits outweigh the risks; category 3, the risks generally outweigh the benefits; category 4, MHT should not be used). Quality was classified as high, moderate, low or very low, based on several factors (including risk of bias, inaccuracy, inconsistency, lack of directionality and publication bias). When no direct evidence was identified, but plausibility, clinical experience or indirect evidence were available, "Expert opinion" was categorized. For the first time, a set of eligibility criteria, based on clinical evidence and developed according to the most rigorous methodological tools, has been defined. This will provide health professionals with a powerful decision-making tool that can be used to manage menopausal symptoms.

Transdermal estrogen therapy in menopausal women at increased risk for thrombotic events: a scoping review

IMPORTANCE AND OBJECTIVE

It is estimated that over 45% of women in the United States are menopausal. Many of these women suffer from vasomotor symptoms of menopause, for which the gold standard treatment is menopause hormone therapy (MHT). However, MHT use has been controversial since the Women's Health Initiative (WHI) study in 2001. Transdermal MHT has been shown to be effective for treatment of vasomotor symptoms and does not increase the risk of venous thromboembolism (VTE) when used in healthy postmenopausal women. However, there is little data on its safety in women at increased risk for VTE such as women with prior VTE, increased body mass index, thrombophilia, tobacco use, autoimmune disease, chronic inflammatory disorders, recent surgery, trauma, or immobilization. This scoping review of the literature provides clinicians with an overview of the evidence on the risk profile of transdermal MHT use in these postmenopausal women at increased risk of VTE.

METHODS

We searched all published studies from 2000 to 2020 and included 13 primary articles on transdermal MHT use in postmenopausal women at increased risk of VTE.

DISCUSSION AND CONCLUSION

In women with prior VTE, two studies found a decrease in coagulability and no increased risk of recurrent VTE with transdermal MHT use. In women with increased body mass index, three studies found no increased VTE risk in transdermal MHT users. In women with prothrombotic genetic polymorphisms, three studies found minimal to no increased VTE risk in transdermal MHT users. In women with various proinflammatory comorbidities, five studies found an improved thrombotic profile and no increased VTE risk with transdermal MHT use. This scoping review provides data regarding the safety of transdermal MHT use in postmenopausal women with risk factors for VTE, and clinicians should have risk versus benefit discussions with each patient regarding its use.

Menopause, hormone therapy and diabetes

Over the past three decades, the prevalence of diabetes has increased four-fold. Coupled with the global obesity epidemic and aging of the world's population, a perfect metabolic storm is brewing. The influence of menopause and exogenous estrogen and progestogens must be included in this equation. In this review, criteria for diagnosing diabetes and recommendations for screening are described. The reported effects of menopause on diabetes risk in healthy women are reviewed as well as the relationship between established diabetes and the timing of menopause. The effects of menopausal hormone therapies (MHT) on glucose control in women with diabetes and the effect of MHT on diabetes risk in menopausal women without diabetes are described. Evidence-based strategies to prevent diabetes in midlife women are highlighted. The augmenting effect of diabetes on chronic health concerns of aging women, such as cardiovascular disease, osteoporosis, and cancer, along with current recommendations for screening and prevention are presented. Given the current demographics of today's world, the content of this review may apply to as many as one-third of the average practitioner's postmenopausal patient population.

Menopausa e síndrome metabólica

A incidência de doença cardiovascular aumenta consideravelmente após a menopausa. Um dos motivos para o crescente risco cardiovascular parece ser determinado pela síndrome metabólica, da qual todos os componentes (obesidade visceral, dislipidemia, hipertensão arterial e distúrbio do metabolismo glicídico) se associam à maior incidência de coronariopatia. Após a menopausa, a síndrome metabólica é mais prevalente do que na pré-menopausa, podendo ter importante papel na ocorrência de infarto do miocárdio e outras morbidades ateroscleróticas e cardiovasculares. A obesidade, componente primordial da síndrome metabólica, se associa ainda ao aumento da incidência de câncer de mama, endométrio, intestino, esôfago e rim. O tratamento da síndrome metabólica se baseia na mudança de hábitos de vida e, quando necessário, no emprego de medicação dirigida aos seus componentes. Na presença de sintomas de síndrome do climatério, a terapia hormonal, quando indicada, concorrerá também para a melhora da síndrome metabólica.

Influence of menopause on diabetes and diabetes risk

Many postmenopausal women live with diabetes mellitus; however, little information is available about how the changes that occur around the time of menopause might uniquely affect management of diabetes mellitus in this population. Although the weight gain that commonly occurs during the menopausal transition is largely attributable to aging rather than the transition itself, changes in body composition have been independently associated with menopausal status. These changes in body composition have, in turn, been associated with alterations in insulin sensitivity and glucose metabolism in postmenopausal women. Hormone therapy seems to have neutral or beneficial effects on the adverse changes in body composition associated with menopause. Whether menopausal status independently influences diabetes risk remains controversial. Nevertheless, consistent findings from large clinical trials suggest that postmenopausal hormone therapy decreases the risk of developing diabetes mellitus. Similarly, many studies suggest that postmenopausal hormone therapy has neutral or beneficial effects on glycemic control among women already diagnosed as having diabetes mellitus. Future studies are needed to elucidate the mechanisms that underlie these relationships and to determine how these observations should influence recommendations for the care of postmenopausal women with diabetes mellitus.

Hemostatic markers in healthy postmenopausal women during intranasal and oral hormone therapy

OBJECTIVE

To study changes in the hemostatic balance during intranasal compared with oral administration of 17beta-estradiol (E2) and norethisterone (NET) or NET acetate in postmenopausal women. A wide range of markers of coagulation and fibrinolysis associated with coronary artery disease was tested.

DESIGN

In a two-center, randomized, double-blind, comparative trial, 90 healthy postmenopausal women (aged 56.6 +/- 4.7 y) received daily continuous combined hormone therapy, either E2/NET 175 microg/275 mug intranasally as a spray (n = 47) or E2/NET acetate 1 mg/0.5 mg orally as a capsule (n = 43) for 1 year. Hemostatic markers were measured in blood samples taken at baseline and after 12, 24, and 52 weeks of treatment.

RESULTS

After 52 weeks of treatment, changes in the intranasal group in markers of coagulation-fibrinogen (-1.3%), factor VII activity (-14.0%), and prothrombin fragment 1 + 2 (+5.8%)-were significantly less (P < 0.05) than the changes in the oral group for these parameters (-6.5%, -20.3%, and +19.0%, respectively). Changes in activated factor VII did not differ between the groups. Neither group showed significant changes in thrombin-antithrombin complex. In the intranasal group, decreases in markers of fibrinolysis-tissue-type plasminogen activator (-10.4%) and plasminogen activator inhibitor-1 antigen (-13.8%)-were significantly less (P < 0.05) than the decreases in the oral group (-17.8% and -38.0%, respectively). A decrease in plasminogen activator inhibitor-1 activity and increases in D-dimer and plasmin-alpha2-antiplasmin complex did not differ between the groups. No differences were found between the groups in homocysteine, which overall was unaltered in both groups.

CONCLUSIONS

During intranasal E2/NET therapy, changes in the coagulatory and fibrinolytic markers were to some extent less than those observed during oral therapy.

Effects of non-oral postmenopausal hormone therapy on markers of cardiovascular risk: a systematic review

OBJECTIVE

To review the effects of non-oral administration of postmenopausal hormone therapy (HT) on risk markers for atherosclerotic and venous thromboembolic disease.Non-oral postmenopausal HT appears not to increase venous thromboembolic risk, whereas the effect on coronary heart disease risk is less clear.

DESIGN

Systematic review of literature obtained from MEDLINE, EMBASE, and CENTRAL databases from 1980 until and including April 2006. Terms for "postmenopausal hormone therapy" and for "non-oral administration" were combined in the search.

SETTING

Randomized clinical trials.

PATIENT(S)

Postmenopausal women, both healthy and with established cardiovascular disease or specified cardiovascular risk factors

INTERVENTION(S)

Non-oral HT (e.g., transdermal or intranasal) compared with oral HT or no treatment/placebo.

MAIN OUTCOME MEASURE(S)

Lipoprotein(a), homocysteine, C-reactive protein (CRP), cell adhesion molecules, markers of endothelial dysfunction, coagulation, and fibrinolysis.

RESULT(S)

Seventy-two studies investigating either transdermal or intranasal administration were included. For non-oral HT, decreases in lipoprotein(a), cell adhesion molecules, and factor VII generally were significant, resistance to activated protein C (APCr) was slightly increased, and other markers including CRP and homocysteine did not change. Compared with oral HT, changes in CRP and APCr were smaller, changes in cell adhesion molecules and some fibrinolytic parameters tended to be smaller, whereas changes in other factors including lipoprotein(a) and homocysteine did not differ.

CONCLUSION(S)

Potentially unfavorable changes seen with oral HT on two important markers, CRP and APCr, are substantially smaller with non-oral HT. Non-oral HT has minor effects on the other cardiovascular risk markers studied. Therefore, compared with oral HT, non-oral HT appears be safer with respect to atherosclerotic and venous thromboembolic disease risk.

The complex role of estrogens in inflammation

There is still an unresolved paradox with respect to the immunomodulating role of estrogens. On one side, we recognize inhibition of bone resorption and suppression of inflammation in several animal models of chronic inflammatory diseases. On the other hand, we realize the immunosupportive role of estrogens in trauma/sepsis and the proinflammatory effects in some chronic autoimmune diseases in humans. This review examines possible causes for this paradox. This review delineates how the effects of estrogens are dependent on criteria such as: 1) the immune stimulus (foreign antigens or autoantigens) and subsequent antigen-specific immune responses (e.g., T cell inhibited by estrogens vs. activation of B cell); 2) the cell types involved during different phases of the disease; 3) the target organ with its specific microenvironment; 4) timing of 17beta-estradiol administration in relation to the disease course (and the reproductive status of a woman); 5) the concentration of estrogens; 6) the variability in expression of estrogen receptor alpha and beta depending on the microenvironment and the cell type; and 7) intracellular metabolism of estrogens leading to important biologically active metabolites with quite different anti- and proinflammatory function. Also mentioned are systemic supersystems such as the hypothalamic-pituitary-adrenal axis, the sensory nervous system, and the sympathetic nervous system and how they are influenced by estrogens. This review reinforces the concept that estrogens have antiinflammatory but also proinflammatory roles depending on above-mentioned criteria. It also explains that a uniform concept as to the action of estrogens cannot be found for all inflammatory diseases due to the enormous variable responses of immune and repair systems.

Effects of low-dose continuous combined hormone replacement therapy on glucose homeostasis and markers of cardiovascular risk in women with type 2 diabetes

BACKGROUND

Low-dose hormone replacement therapy (HRT) has attracted interest for the treatment of postmenopausal symptoms in diabetes because of concerns about increased risk of coronary heart disease (CHD) and stroke with conventional HRT containing conjugated equine oestrogens (CEEs) and medroxyprogesterone acetate (MPA).

OBJECTIVES

We assessed the effects on glucose homeostasis and cardiovascular risk factors of continuous oral 17beta oestradiol (1 mg) and norethisterone (0.5 mg) in postmenopausal women with type 2 diabetes.

DESIGN

Double-blind, randomized placebo-controlled trial.

ASSESSMENTS

Hyperinsulinaemic isoglycaemic clamp and cardiovascular risk factors were assessed before and after 3 months of treatment.

RESULTS

Twenty-eight women completed the study. HRT decreased fasting glucose compared with placebo [-9.4% with HRT vs.+2.3% for placebo, 95% confidence interval (CI) -23.2 to -0.3] and total cholesterol (-13.7 vs.+1.0%, 95% CI -22.4 to -3.1%) No significant effect was seen on metabolic clearance rate of glucose, glycated haemoglobin (HbA1c), triglycerides, high density lipoprotein (HDL)-cholesterol or C-reactive protein (CRP).

CONCLUSIONS

In women with type 2 diabetes, low-dose HRT decreased fasting glucose and total cholesterol without detectable adverse effects on glucose clearance, triglycerides and CRP as reported with conventional HRT.

Meta-analysis: effect of hormone-replacement therapy on components of the metabolic syndrome in postmenopausal women

AIM

To quantify the effects of hormone-replacement therapy (HRT) on components of the metabolic syndrome in postmenopausal women.

METHODS

Comprehensive searches of electronic databases were performed from April 1966 to October 2004. We included randomized controlled trials that were of at least 8 weeks duration and evaluated the effect of HRT on metabolic, inflammatory or thrombotic components. Insulin resistance was calculated by homeostasis model assessment (HOMA-IR). Subgroup analysis evaluated the effects for transdermal and oral treatment and for diabetic and non-diabetic women.

RESULTS

Pooled results of 107 trials showed that HRT reduced abdominal fat [-6.8% (CI, -11.8 to -1.9%)], HOMA-IR [-12.9% (CI, -17.1 to -8.6%)] and new-onset diabetes [relative risk 0.7 (CI, 0.6-0.9)] in women without diabetes. In women with diabetes, HRT reduced fasting glucose [-11.5% (CI, -18.0 to -5.1%)] and HOMA-IR [-35.8% (CI, -51.7 to -19.8%)]. HRT also reduced low-density lipoprotein/high-density lipoprotein cholesterol ratio [-15.7% (CI, -18.0 to -13.5%)], lipoprotein(a) [Lp(a)] [-25.0% [CI, -32.9 to -17.1%)], mean blood pressure [-1.7% (CI, -2.9 to -0.5%)], E-selectin [-17.3% (CI, -22.4 to -12.1%)], fibrinogen [-5.5% (CI, -7.8 to -3.2%)] and plasminogen activator inhibitor-1 [-25.1% (CI, -33.6 to -15.5%)]. Oral agents produced larger beneficial effects than transdermal agents, but increased C-reactive protein (CRP) [37.6% (CI, 17.4-61.3%)] and decreased protein S [-8.6% CI, -13.1 to -4.1%)], while transdermal agents had no effect.

CONCLUSIONS

HRT reduces abdominal obesity, insulin resistance, new-onset diabetes, lipids, blood pressure, adhesion molecules and procoagulant factors in women without diabetes and reduced insulin resistance and fasting glucose in women with diabetes. Oral agents adversely affected CRP and protein S, while transdermal agents had no effects.

Influence of hormone replacement therapy in postmenopausal women with type 2 diabetes and hyperlipidemia on lipid and glucose metabolism

Introduction. Hormone replacement therapy (HRT) is less frequently prescribed to postmenopausal women with diabetes type 2 who have poor lipid status despite well known favorable effect of HRT on lipid levels. Objective. The aim of this study was to assess the effect of oral HRT in postmenopausal women with type 2 diabetes and hyperlipidemia. Method. Continuously combined HRT, estradiol 2mg + norethisterone acetate 1mg was given to 30 women with diabetes type 2 and hyperlipidemia and two control groups of postmenopausal women (30 with hyperlipidemia only and 30 healthy women) over a 6-month period. Total cholesterol (t- HOL), triglycerides, LDL-cholesterol, HDL-cholesterol, glycosylated hemoglobin A1c (HbA1c) were evaluated in 3-month intervals. Fasting and postprandial glucose levels were evaluated monthly. Results. HRT significantly decreased levels of t-HOL (?2 Friedman=11.712; p<0.01) and LDL-c (?2 Friedman=10.403; p<0.01) in postmenopausal women with type 2 diabetes. However, the effect was more pronounced in two control groups. Triglycerides (?2 Friedman=5.400; p?0.05) and HDL-c (?2 Friedman=1.113; p>0.05) did not change in postmenopausal women with type 2 diabetes. Six month of oral HRT significantly decreased HbA1c (F=44.693; p<0.01). Fasting and postprandial glycemia was decreased but not significantly (?2 Friedman=6.527; p>0.05). Conclusion. Six-month application of HRT is effective in lowering the lipid levels and HbA1c in postmenopausal women with type 2 diabetes. However, target lipid levels were not achieved.

Relation between hormone replacement therapy and ischaemic heart disease in women: prospective observational study

OBJECTIVE

To investigate the risk of ischaemic heart disease and myocardial infarction among women using hormone replacement therapy, especially the potential modifying effect of cardiovascular risk factors.

DESIGN

Prospective observational study.

SETTING

Denmark.

PARTICIPANTS

19 898 nurses aged 45 and over completing a questionnaire on lifestyle and use of hormone replacement therapy in 1993.

MAIN OUTCOME MEASURES

All cases of death and incident cases of ischaemic heart disease and myocardial infarction until the end of 1998.

RESULTS

Current users of hormone replacement therapy smoked more, consumed more alcohol, had lower self rated health, but were slimmer and had a lower prevalence of diabetes than never users. In current users compared with never users, hormone replacement therapy had no protective effect on ischaemic heart disease (hazard ratio 1.2, 0.9 to 1.7) or myocardial infarction (1.0, 0.6 to 1.7), whereas current users with diabetes had an increased risk of death (3.2, 1.4 to 7.5), ischaemic heart disease (4.2, 1.4 to 12.5), and myocardial infarction (9.2, 2.0 to 41.4) compared with never users with diabetes.

CONCLUSION

Hormone replacement therapy showed no protective effect on ischaemic heart disease, but there was a significantly increased risk of death from all causes and ischaemic heart disease among women with diabetes.