Controversial issues in climacteric medicine II. Hormone replacement therapy and cancer

The management of menopausal symptoms in women following treatment for cancer at a specialist menopause service

OBJECTIVE

The aim of this study was to identify prescribing patterns at a specialist menopause service in a central London teaching hospital for women following treatment for a malignancy.

STUDY DESIGN

This was a prospective cohort study with data collected over a seven-month period from December 2019 to June 2020. All women reviewed at the specialist menopause services following treatment of a malignancy, BRCA carriers and Lynch syndrome were included in the study, with management options divided into three categories: hormonal, non-hormonal and no treatment.

MAIN OUTCOME MEASURES

The primary outcome of this study was to identify prescribing patterns for all women reviewed following a diagnosis of a malignancy, as well as those with genetic mutations necessitating risk-reducing prophylactic bilateral salpingo-oopherectomy (BSO).

RESULTS

Altogether 71 women were included in this study, with the majority of women post management of a non-gynaecological malignancy (51/71, 72%), of which breast cancer was the most common (37/71, 52%). While non-hormonal treatment was the most popular among those treated for breast cancer, for all other malignancies, hormonal treatment was more widespread. Fourteen women also had genetic mutations, with all of these women commencing hormonal treatment post risk reducing surgery.

CONCLUSION

With the exception of those with a history of hormone-sensitive breast cancer, the use of hormonal treatment for menopausal symptoms remained widespread. While this was a relatively small study, the need for long-term follow-up across specialist menopause services, to assess the risk of recurrence is vital.

Resveratrol treatment delays growth plate fusion and improves bone growth in female rabbits

Trans-resveratrol (RES), naturally produced by many plants, has a structure similar to synthetic estrogen diethylstilbestrol, but any effect on bone growth has not yet been clarified. Pre-pubertal ovary-intact New Zealand white rabbits received daily oral administration of either vehicle (control) or RES (200 mg/kg) until growth plate fusion occurred. Bone growth and growth plate size were longitudinally monitored by X-ray imaging, while at the endpoint, bone length was assessed by a digital caliper. In addition, pubertal ovariectomized (OVX) rabbits were treated with vehicle, RES or estradiol cypionate (positive control) for 7 or 10 weeks and fetal rat metatarsal bones were cultured in vitro with RES (0.03 µM-50 µM) and followed for up to 19 days. In ovary-intact rabbits, sixteen-week treatment with RES increased tibiae and vertebrae bone growth and subsequently improved final length. In OVX rabbits, RES delayed fusion of the distal tibia, distal femur and proximal tibia epiphyses and femur length and vertebral bone growth increased when compared with controls. Histomorphometrical analysis showed that RES-treated OVX rabbits had a wider distal femur growth plate, enlarged resting zone, increased number/size of hypertrophic chondrocytes, increased height of the hypertrophic zone, and suppressed chondrocyte expression of VEGF and laminin. In cultured fetal rat metatarsal bones, RES stimulated growth at 0.3 µM while at higher concentrations (10 μM and 50 μM) growth was inhibited. We conclude that RES has the potential to improve longitudinal bone growth. The effect was associated with a delay of growth plate fusion resulting in increased final length. These effects were accompanied by a profound suppression of VEGF and laminin expression suggesting that impairment of growth plate vascularization might be an underlying mechanism.

Genetic regulation of the growth plate

The epiphyseal growth plate consists of a layer of cartilage present only during the growth period and vanishes soon after puberty in long bones. It is divided to three well-defined zones, from epiphyses; resting, proliferative, and hypertrophic zones. Chondrocyte proliferation and differentiation and subsequent bone formation in this cartilage are controlled by various endocrine, autocrine, and paracrine factors which finally results into elimination of the cartilaginous tissue and promotion of the epiphyseal fusion. As chondrocytes differentiate from round, quiescent, and single structure to flatten and proliferative and then large and terminally differentiated, they experience changes in their gene expression pattern which allow them to transform from cartilaginous tissue to bone. This review summarizes the literature in this area and shortly describes different factors that affect growth plate cartilage both at the local and systemic levels. This may eventually help us to develop new treatment strategies of different growth disorders.

Hormone use and lung cancer incidence: the Rancho Bernardo cohort study

OBJECTIVE

This study examines the association of hormone use and lung cancer among women.

METHODS

This is a prospective study of 2,861 women aged 31 to 79 years from the Rancho Bernardo cohort. After enrollment in 1972 to 1974, women were followed up for 31 years for morbidity and mortality. Incident lung cancer was based on self-report or death certificates. Diagnosis was validated from the California Cancer Registry for cases that occurred after 1988. Cox proportional hazard models were used to estimate the adjusted association of hormone use and lung cancer.

RESULTS

During the 31-year follow-up, 87 women developed lung cancer. There was no association between hormone use and lung cancer (hazard ratio, 1.13; 95% CI, 0.73-1.73). Stratification by age 55 years (proxy for menopause status) showed divergent results. In women 55 years and older, lung cancer risk was 1.58 (95% CI, 0.95-2.53), whereas in women younger than 55 years, lung cancer risk was 0.44 (95% CI, 0.16-1.23). The confidence intervals for both groups contained the null value.

CONCLUSIONS

Although not statistically significant, our results from a long follow-up suggest that postmenopausal women on hormone therapy may have an increased risk of lung cancer, whereas younger women do not.

Estrogenic activity of diarylheptanoids from Curcuma comosa Roxb. Requires metabolic activation

Curcuma comosa Roxb. has traditionally been used as a dietary supplement for health promotion in peri- and postmenopausal women in Thailand. We investigated the estrogenic activity of 7 naturally occurring diarylheptanoids from the extracts of C. comosa both in vitro and in vivo. A yeast recombinant system containing human estrogen receptor alpha, coactivator TIF2 and a beta-galactosidase reporter gene was used to determine estrogenic activity of diarylheptanoids metabolically activated with rat liver S9-fraction prior to the assay. The most potent compound was (3R)-1,7-diphenyl-(4E,6E)-4,6-heptadien-3-ol, with a relative potency of 4% compared to 17beta-estradiol. The metabolic activation of diarylheptanoids markedly enhanced their efficiency. The chemical structure required for estrogenic activity of diarylheptanoids was the presence of a keto group at C3 and absence of hydroxyl moiety in ring B. Only diarylheptanoids showing full estrogenic efficiency in vitro were able to elicit uterotrophic activity of in immature ovariectomized rat. This is the first evidence for in vivo estrogenic activity of diarylheptanoids from C. comosa. This novel class of natural phytoestrogens has the potential to be developed for use as dietary supplement in the treatment of menopausal symptoms.

Fructooligosaccharide and soy isoflavone suppress colonic aberrant crypt foci and cyclooxygenase-2 expression in dimethylhydrazine-treated rats

This study investigated the inhibitory effects of soy isoflavones and fructooligosaccharide (FOS) on colon carcinogenesis. Sprague-Dawley male rats were injected with 1,2-dimethylhydrazine (DMH) and given experimental diets that contained 0%, 3%, 6%, or 9% FOS with or without soy isoflavones (1,000 mg/kg of diet). After 12 weeks, colonic aberrant crypt foci (ACF) formation, cyclooxygenase-2 (COX-2) expression, and fecal bile acid profiles were determined. The numbers of ACF, the numbers of ACF containing four or more crypts per focus of colonic mucosa, and the levels of COX-2 protein in the colonic epithelial tissues were significantly decreased in a dose-dependent manner in the FOS-fed, DMH-treated rats (P < .001), as compared to the DMH-treated control rats. Soy isoflavones significantly decreased the number of ACF with four or more aberrant crypts per focus (P < .001) and the amount of COX-2 protein (P < .01), independently of the effect of the oligosaccharide. The highest suppression of ACF formation was obtained with soy isoflavones combined with >or=6% FOS. No significant relationship was found between the dosage of FOS or soy isoflavones and the concentration of fecal secondary bile acid. We conclude that the combination of FOS and soy isoflavones inhibits colonic ACF formation and reduces COX-2 expression in DMH-treated rats.

Enhanced estrogenic responses and sensitivity to azoxymethane following dietary soy isoflavone supplementation in older female rats

Soy isoflavones are popular supplements among middle-aged and older women based on their potential protection against cancer and their use as alternative hormone replacement therapy. The purpose of this study was to investigate the effects of dietary soy isoflavones on early stage colon cancer in various ages of female rats. Young (1month), mature (11month) and old (22month) female Fisher 344 rats were fed either the control diet or a diet containing 0.4% soy isoflavone isolate for 1week, injected once with 20mg/kg azoxymethane (AOM) and maintained on the diets for another 15weeks. The concentration of isoflavones in the diet was 2g/kgdiet, composed of 1.2g/kg genistin, 0.7g/kg daidzin and 0.1g/kg other isoflavones including glycitin, acetylgenistin, acetyldaidzin, genistein, daidzein, and glycitein. There was no difference over all ages in the development of preneoplastic colonic aberrant crypt foci between rats fed the soy compared to the control diet, indicating that the soy diet did not provide protection against early stage colonic carcinogenesis. On the contrary, several adverse effects of soy supplementation in female AOM-treated rats were observed. Soy-supplemented rats had greater weight loss and a slower recovery of body weight following the AOM injection compared to rats fed the control diet and these changes increased with age. Five of the 21 rats fed the soy supplement died before the end of the experiment while all animals on the control diet survived to term. The density of normal crypts lining the colonic mucosa was reduced in rats fed the soy compared to control diet, indicating gastrointestinal damage. Uterine weights, serum estradiol and serum isoflavone levels were increased in mature and old female rats fed the soy-supplemented diets compared to age-matched controls, suggesting an increasing estrogenic response with age to isoflavone supplementation. These adverse effects of soy isoflavones in aged female animals need further examination because women, and particularly older women, are the prime target population for consumption of soy supplements.

Gonadotropin-releasing hormone receptor expression in endometrial stromal sarcomas: an immunohistochemical study

Gonadotropin-releasing hormone and its receptors have been identified in several human malignancies. We evaluated gonadotropin-releasing hormone receptor expression in 30 primary and recurrent endometrial stromal sarcomas. Archival formalin-fixed and paraffin-embedded material was analyzed immunohistochemically with antisera to gonadotropin-releasing hormone receptor type I and gonadotropin-releasing hormone receptor type II using the peroxidase-antiperoxidase method. Gonadotropin-releasing hormone receptor types I and II were demonstrated in most primary endometrial stromal sarcomas in varying intensity and percentage (range, 10-100%). The staining pattern was either diffuse cytoplasmic or granular/vesicular in perinuclear distribution. Recurrences stained stronger than primary tumors. The demonstration of gonadotropin-releasing hormone receptors I and II expression in endometrial stromal sarcomas may be a rationale for a clinical study of gonadotropin-releasing hormone analogs in the treatment of women with endometrial stromal sarcomas.

Psychological factors associated with sleep disturbance among perimenopausal women

The complex nature of sleep among perimenopausal women warrants a biopsychosocial conceptualization; however, research on the psychological factors that contribute to the increased prevalence of poor sleep quality during this time is limited. We conducted a survey study of perimenopausal women (N = 168) to investigate the relations among nocturnal hot flashes, mood, dysfunctional beliefs and attitudes about sleep (DBAS), and subjective sleep quality. Self-report ratings of depressive symptoms, trait anxiety, hot flashes, and DBAS significantly correlated with poor sleep quality. Ratings on the DBAS Scale-Short Form mediated the relations both between nocturnal hot flashes and sleep quality and between mood and sleep quality. The interplay between physiological and psychological mechanisms among perimenopausal women is highlighted.

Hormone replacement therapy and endometrial, ovarian and colorectal cancer

Sex-steroid-related tumours in women are represented by breast cancer and endometrial cancer, but a possible relationship may exist between sex steroids and both ovarian and colon cancer. Unopposed oestrogen therapy is known to increase the risk of endometrial cancer and is appropriate only for hysterectomized women. In women with an intact uterus, an appropriate combination of oestrogen and progestin does not appear to increase-and may even decrease-the risk of endometrial cancer. Current users of HRT seem to benefit from a reduced risk for colon cancer. As for epithelial ovarian cancer, the present data are very conflicting. The association between replacement hormones and this malignancy seems to be stronger for unopposed oestrogen than for oestrogen-progestin treatment. Data available at the moment do not allow discriminating for dose, routes of administration, bioavailability and tissue effects of different compounds so that it is inappropriate to consider all forms of HRT jointly. The future of HRT in post-menopausal women lies in the individualization of the therapy based upon personal risk factors and characteristics.