Determinants of elevated blood pressure in women around menopause: results from a cross-sectional study in Italy

Are Any Changes in Carotid Intima–Media Thickness Associated with Cardiometabolic Risk Among Adult Bantu Central African Hypertensive Patients from Monkole and Biamba Marie Mutombo Hospitals?

Background

Several classic/traditional risk factors are associated with intima–media thickness (IMT), a novel risk of cardio metabolic risk (CMR) in the literature but not in Kinshasa, a megacity prone to CMR. Thus, the objective of this study was to evaluate potential correlations between inflammation, kidney function, psychological stress, hemodynamics, and changes in IMT.

Methods

This cross-sectional study was carried out between 2018 and 2021 within Monkole and Biamba Marie Mutombo Hospitals, respectively, and randomly selected from 10 health structures from East and West of Kinshasa, Capital of Democratic Republic Congo (DRC). A random sample of adult hypertensive Bantu Central Africans was examined after bivariate correlations and multiple linear regression.

Results

Out of 280 patients with 140 men and 140 women aged 62 ± 11 years, the mean carotid intima–media thickness (CIMT) was 1.06 ± 0.5 mm and 73% (n = 204) patients had uncontrolled hypertension. After controlling for confounders, 52.9% variations (R2) of CIMT were independently and significantly (P = 0.037) predicted by CRP, 24-hour proteinuria, urinary albumin/creatinine ratio, duration of hypertension, heart rate, hip circumference, and psychological stress with Equation Y = 0.717 + 0.87 × CRP + 0.02 × 24 H – proteinuria + 0.005 × urinary albumin/creatinine ratio + 0.05 × duration of hypertension + 0.001 × heart rate + 0.006 × hip circumference + 0.017 × psychological stress.

Conclusion

There is an urgent need to control inflammation, impaired renal function, cardiac rhythm, peripheral obesity, longer duration of hypertension management, and stress, which are emerging as specific novel determinants of the subclinical atherosclerosis for those Bantu Central African hypertensive patients.

Obesity-associated cardiovascular risk in women: hypertension and heart failure

The pathogenesis of obesity-associated cardiovascular diseases begins long prior to the presentation of a cardiovascular event. In both men and women, cardiovascular events, and their associated hospitalizations and mortality, are often clinically predisposed by the presentation of a chronic cardiovascular risk factor. Obesity increases the risk of cardiovascular diseases in both sexes, however, the clinical prevalence of obesity, as well as its contribution to crucial cardiovascular risk factors is dependent on sex. The mechanisms via which obesity leads to cardiovascular risk is also discrepant in women between their premenopausal, pregnancy and postmenopausal phases of life. Emerging data indicate that at all reproductive statuses and ages, the presentation of a cardiovascular event in obese women is strongly associated with hypertension and its subsequent chronic risk factor, heart failure with preserved ejection fraction (HFpEF). In addition, emerging evidence indicates that obesity increases the risk of both hypertension and heart failure in pregnancy. This review will summarize clinical and experimental data on the female-specific prevalence and mechanisms of hypertension and heart failure in women across reproductive stages and highlight the particular risks in pregnancy as well as emerging data in a high-risk ethnicity in women of African ancestry (AA).

The hypertensive potential of estrogen: An untold story

Cardiovascular disease (CVD) is the major cause of morbidity and mortality worldwide. The implication of estrogen in this disease has been extensively studied. While the vast majority of published research argue for a cardioprotective role of estrogen in vascular inflammation such as in atherosclerosis, the role of estrogen in hypertension remains far from being resolved. The vasorelaxant effect of estrogen has already been well-established. However, emerging evidence supports a vasoconstrictive potential of this hormone. It has been proposed that the microenvironment dictates the effect of estrogen-induced type 1 nitric oxide synthase-1 (nNOS) on vasotone. Indeed, depending on nNOS product, nitric oxide or superoxide, estrogen can induce vasodilation or vasoconstriction, respectively. In this review, we discuss the evidence supporting the vasorelaxant effects of estrogen, and the molecular players involved. Furthermore, we shed light on recent reports revealing a vasoconstrictive role of estrogen, and speculate on the underlying signaling pathways. In addition, we identify certain factors that can account for the discrepant estrogenic effects. This review emphasizes a yin-yang role of estrogen in regulating blood pressure.

Protective roles of estradiol against vascular oxidative stress in ovariectomized female rats exposed to normoxia or intermittent hypoxia

AIM

We tested the hypothesis that estradiol (E₂ ) reduces aortic oxidative stress and endothelial dysfunction in ovariectomized (OVX) female rats exposed to room air (RA) or chronic intermittent hypoxia (CIH).

METHODS

We used intact or OVX female rats treated with vehicle or E₂ (0.5 mg/kg/d) and exposed to RA or CIH (21%-10% O₂ , 10 cycles/h, 8 h/d) for 7 or 35 days, and measured the arterial pressure, heart rate and plasma endothelin-1 levels. We also measured in thoracic aortic samples, the activities of the pro-oxidant enzymes NADPH (NOX) and xanthine oxidase (XO), the antioxidant enzymes superoxide dismutase, catalase, glutathione peroxidase and the advanced oxidation protein products (AOPP-oxidative stress marker). Finally, we used aortic rings to assess the contractile response to phenylephrine and the vasodilatory response to acetylcholine.

RESULTS

After 7 or 35 days of CIH, E₂ supplementation reduced arterial pressure. E₂ reduced plasma endothelin-1 levels after 7 days of CIH, but not after 35 days. Ovariectomy, but not CIH for 7 days, increased aortic oxidative stress and E₂ treatment prevented this effect. Remarkably, in animals exposed to RA, this was achieved by a reduction in NOX and XO activities, but in animals exposed to CIH this was achieved by increased catalase activity. In OVX female rats exposed to CIH for 7 days, E₂ supplementation improved the NO-mediated vasodilation. After 35 days of CIH, enzymatic activities, AOPP and aortic reactivity were similar in all groups.

CONCLUSION

E₂ -based therapy could help prevent the vascular consequences of CIH in apneic women.

Hormone replacement therapy and prevention of chronic conditions

Nowadays, postmenopausal women are largely undertreated. Analysis of conflicting results among different studies suggests that hormone replacement therapy (HRT) can prevent osteoporosis and cardiovascular disease in symptomatic, early postmenopausal women. In fact, climacteric symptoms are related to an increased risk of chronic conditions, including hypertension and cardiovascular disease. Different scientific societies have pointed out that patient selection, timing of initiation, and the choice of the type and dose of HRT used are the major determinants of the ultimate effect of HRT on women's health and quality of life in selected women. HRT may prevent chronic conditions when started in symptomatic women before the age of 60 years or within 10 years of the onset of the menopause, taking into consideration the characteristics and risk profiles of each given woman. The bulk of scientific evidence from preclinical, clinical, epidemiological, and also randomized studies indicates that wisely selected HRT is generally useful and rarely dangerous. Following simple and well-established rules, HRT benefits outweigh all of the possible risks. Progestogen choice can make the difference in terms of cardiovascular disease benefits.

Impact of exercise on oocyte quality in the POLG mitochondrial DNA mutator mouse

The mtDNA 'mutator' mouse, also called the 'POLG' mouse, is a well-characterized model frequently used for studies of progeroid aging. Harboring a mutation in the proofreading domain of the mitochondrial polymerase, polymerase-γ (Polg), POLG mice acquire mtDNA mutations at an accelerated rate. This results in premature mitochondrial dysfunction and a systemic aging phenotype. Previous work has demonstrated that the progeroid phenotype in POLG is attenuated following endurance exercise, the only reported intervention to extend health span and lifespan of these mice. Herein, oocyte quality was evaluated in sedentary and exercised POLG mice. In mice homozygous for the Polg mutation, litter size is dramatically reduced as compared to heterozygous Polg mice. Following ovarian hyper-stimulation, oocytes were retrieved until 9 months of age in exercised and sedentary groups, with no oocytes ovulated thereafter. Although ovulated oocyte numbers were not impacted by exercise, we did find a modest improvement in both the ovarian follicle reserve and in oocyte quality based on meiotic spindle assembly, chromosomal segregation and mitochondrial distribution at 7 months of age in exercised POLG mice as compared to sedentary counterparts. Of note, analysis of mtDNA mutational load revealed no differences between exercised and sedentary groups. Collectively, these data indicate that exercise differentially influences somatic tissues of the POLG mouse as compared to oocytes, highlighting important mechanistic differences between mitochondrial regulatory mechanisms in the soma and the germline.

Left ventricular remodeling and arterial afterload in older women with uncontrolled and controlled hypertension

OBJECTIVE

The prevalence of hypertension increases with advancing age in women. Blood pressure control is more difficult to achieve in older women, and despite well-controlled blood pressure, the cardiovascular mortality remains high. However, the underlying mechanisms are not understood.

METHODS

Nineteen women with uncontrolled hypertension on drug treatment (70 ± 2 [SE] years, ambulatory awake blood pressure; 152 ± 2/84 ± 2 mm Hg), 19 with controlled hypertension (68 ± 1 years, 128 ± 2/71 ± 2 mm Hg), and 31 healthy normotensive women (68 ± 1 years, 127 ± 1/73 ± 1 mm Hg) were recruited. Participants were weaned from antihypertensive drugs and underwent 3 weeks of run-in before cardiac-vascular assessments. Left ventricular morphology was evaluated with cardiac magnetic resonance imaging. Arterial load and vascular stiffness were measured via ultrasound and applanation tonometry.

RESULTS

Left ventricular mass normalized by body surface area was not different between hypertension groups (uncontrolled vs controlled: 50.0 ± 1.7 vs 51.8 ± 2.3 g/m), but it was lower in the normotensive group (41.7 ± 0.9 g/m; one-way analysis of variance [ANOVA] P = 0.004). Likewise, central pulse wave velocity was not different between hypertension groups (11.5 ± 0.6 vs 11.1 ± 0.5 m/s) and lower in the normotensive group (9.1 ± 0.3 m/s; 1-way ANOVA P = 0.0001). Total peripheral resistance was greater in uncontrolled hypertension (HTN) compared with normotensive group (2051 ± 323 vs 1719 ± 380 dyns/cm), whereas controlled HTN group (1925 ± 527 dyns/cm) was not different to either groups.

CONCLUSION

Regardless of current blood pressure control, hypertensive older women exhibited increased cardiac mass and arterial stiffness compared with normotensives. Future large-scale longitudinal studies are warranted to directly investigate the mechanisms for the high cardiovascular mortality among older hypertensive women with well-controlled blood pressure.

Gender Differences in Epidemiology, Pathophysiology, and Treatment of Hypertension

PURPOSE OF REVIEW

This review aims to examine gender differences in both the epidemiology and pathophysiology of hypertension and to explore gender peculiarities on the effects of antihypertensive agents in decreasing BP and CV events.

RECENT FINDINGS

Men and women differ in prevalence, awareness, and control rate of hypertension in an age-dependent manner. Studies suggest that sex hormones changes play a pivotal role in the pathophysiology of hypertension in postmenopausal women. Estrogens influence the vascular system inducing vasodilatation, inhibiting vascular remodeling processes, and modulating the renin-angiotensin aldosterone system and the sympathetic system. This leads to a protective effect on arterial stiffness during reproductive age that is dramatically reversed after menopause. Data on the efficacy of antihypertensive therapy between genders are conflicting, and the underrepresentation of aged women in large clinical trials could influence the results. Therefore, further clinical research is needed to uncover potential gender differences in hypertension to promote the development of a gender-oriented approach to antihypertensive treatment.

Hypertension and age at onset of natural menopause in Korean postmenopausal women: Results from the Korea National Health and Nutrition Examination Survey (2008-2013)

OBJECTIVES

Menopause is a natural phenomenon of aging, although the timing and management of menopause can significantly affect a woman's quality of life. It is therefore important to identify measures to ensure a healthy menopause. We set out to investigate the association between hypertension and early menopause in Korean women.

STUDY DESIGN

This cross-sectional study was based on 2008-2013 data from the Korea National Health and Nutrition Examination Survey (KNHANES). Of the 53,829 participants surveyed, 13,584 women were selected. We analyzed the contents of the health interview, health examination, and nutrition survey.

MAIN OUTCOME MEASURE

The main outcome was defined based on hazard ratios (HR) to identify the effects of hypertension on age at onset of menopause.

RESULTS

Among postmenopausal women (n=6650), the mean age at onset of menopause was 50.4 years. Premenopausal hypertension was statistically significantly associated with age at menopause, oral contraceptive usage, household income, education level, occupation, marital status and smoking and drinking habits. With lower age at diagnosis of hypertension, HRs for menopause tended to be higher, and hypertension diagnosed before age 40 years conferred a statistically significantly higher HR (Model 1, HR=2.32, 95% CI=1.87-2.88; Model 2, HR=2.31, 95% CI=1.86-2.86; Model 3, HR=2.23, 95% CI=1.80-2.77; Model 4, HR=2.00, 95% CI=1.52-2.63).

CONCLUSION

Premature menopause is strongly associated with lifestyle factors, in combination with incomplete management of chronic diseases. Our findings support the hypothesis that younger age at diagnosis of hypertension is associated with younger age at onset of menopause in Korean women.

Modification of blood pressure in postmenopausal women: role of hormone replacement therapy

The rate of hypertension increases after menopause. Whether estrogen and progesterone deficiency associated with menopause play a role in determining a worst blood pressure (BP) control is still controversial. Also, studies dealing with the administration of estrogens or hormone therapy (HT) have reported conflicting evidence. In general it seems that, despite some negative data on subgroups of later postmenopausal women obtained with oral estrogens, in particular conjugated equine estrogens (CEE), most of the data indicate neutral or beneficial effects of estrogen or HT administration on BP control of both normotensive and hypertensive women. Data obtained with ambulatory BP monitoring and with transdermal estrogens are more convincing and concordant in defining positive effect on BP control of both normotensive and hypertensive postmenopausal women. Overall progestin adjunct does not hamper the effect of estrogens. Among progestins, drospirenone, a spironolactone-derived molecule, appears to be the molecule with the best antihypertensive properties.

Modified relaxation technique for treating hypertension in Thai postmenopausal women

Aim

To examine the effectiveness of a modified relaxation (MR) technique in reducing blood pressure levels in Thai postmenopausal women with mild hypertension, compared with a control group who received health education.

Methods

This is a 16-week, randomized, parallel, open-label, controlled trial in a menopausal clinic in a tertiary health care center in Northeastern Thailand. The intervention group received a 60-minute session of MR training and were encouraged to practice 15–20 minutes a day, at least 5 days a week. The control group received lifestyle education, including diet and exercise. The primary and secondary outcomes were systolic and diastolic blood pressure (SBP and DBP).

Results

Of 432 participants, 215 and 217 were randomly allocated to the MR and control groups, respectively. Of those, 167 participants in the MR group and 175 participants in the control group completed the study. The SBP was significantly more reduced in the MR group, with a mean of 2.1 mmHg (P < 0.001). There was no significant difference between groups on the changed DBP.

Conclusion

The MR technique may be effective in lowering SBP in Thai postmenopausal women visiting a menopause clinic. Its efficacy may be observed as soon as 4 weeks after start of treatment. Long-term and combined relaxation therapy and antihypertensive agents are warranted in a large cohort of this population. This trial is registered in clinicaltrials.gov (number NCT01429662).

Gender difference in association between low back pain and metabolic syndrome: locomotive syndrome and health outcome in Aizu cohort study (LOHAS)

STUDY DESIGN

Cross-sectional survey. OBJECTIVE.: To investigate the relationship between low back pain (LBP) and metabolic syndrome (Mets) in community-based Japanese subjects. SUMMARY OF BACKGROUND DATA.: Relatively few reports have demonstrated a relationship between general pain and Mets, and none have addressed the relationship between LBP and Mets.

METHODS

This study enrolled 2650 people from among residents aged 40 to 74 years in Tadami and Minamiaizu, Fukushima, Japan, who participated in health checkups conducted in 2008. LBP was defined as lower back pain continuing for more than 24 hours and severe enough to merit treatment, or it was based on clinical prediction rules from the clinical diagnosis support tool to identify patients with lumbar spinal stenosis. Mets was defined according to the Japanese criteria recommended by the Japanese Society of Internal Medicine. Prevalence of Mets was recorded for subjects with and without LBP. The relationship between LBP and Mets was investigated, using a generalized linear model. With LBP as the main explanatory variable and Mets as the outcome variable, risk ratios of Mets were calculated for men and women.

RESULTS

In this study, we analyzed a total of 1395 subjects. In men, the prevalence of Mets was 21.2% in those without LBP and 24.7% in those with LBP. In women, the prevalence of Mets was 12.4% in those without LBP and 23.7% in those with LBP. After adjusting for factors such as age, body mass index, occupational status, SF-36 mental health, and physical activity level, no relationship was noted between LBP and Mets in men. However, in women, the risk ratio for Mets in subjects with LBP compared with those without LBP was 1.5 (95% confidence interval, 1.0-2.1).

CONCLUSION

We observed a tendency toward higher prevalence of Mets among those with LBP than among those without it in women, but not in men.

Effects of estrogen plus progesterone on hemodynamic and vascular reactivity in hypertensive postmenopausal women

AIMS

To investigate the medium-term effects of estrogen plus progesterone therapy (EPT) on vascular reactivity, endothelial function and hemodynamic responses in 20 hypertensive postmenopausal women.

METHODS

This randomized, double-blind, cross-over, placebo-controlled study investigates the effect of 6 months of EPT (conjugated equine estrogen plus medroxyprogesterone). Blood pressure (office and ambulatory), heart rate and heart rate variability (HRV) were measured at baseline and following EPT/placebo treatment. In eight women, we used a wire-myograph to assess endothelial function and contractile response of subcutaneous arteries to transmural nerve stimulation (TNS) and exogenous noradrenaline.

RESULTS

EPT decreased vascular reactivity to cumulative TNS compared with baseline (p<0.01) and placebo (p<0.05). Moreover, EPT diminished sensitivity to exogenous noradrenaline (p<0.05). Although EPT reinforced response to acetylcholine, we observed no difference in maximal relaxation induced by substance P or acetylcholine. EPT did not affect ambulatory blood pressure, heart rate or HRV.

CONCLUSIONS

Oral combined medium-term EPT reduces adrenergic reactivity in subcutaneous arteries from treated hypertensive postmenopausal women. EPT might act postjunctionally at the adrenergic vascular receptor level. In the present study, EPT neither reduces sympathetic activity nor increases vagal tone, and thus does not support an effect on the central hemodynamic system.

Novel strategies and targets for the management of hypertension

Hypertension, as the sole or comorbid component of a constellation of disorders of the cardiovascular (CV) system, is present in over 90% of all patients with CV disease and affects nearly 74 million individuals in the United States. The number of medications available to treat hypertension has dramatically increased during the past 3 decades to some 50 medications as new targets involved in the normal regulation of blood pressure have been identified, resulting in the development of new agents in those classes with improved therapeutic profiles (e.g., renin-angiotensin-aldosterone system; RAAS). Despite these new agents, hypertension is not adequately managed in approximately 30% of patients, who are compliant with prescriptive therapeutics, suggesting that new agents and/or strategies to manage hypertension are still needed. Some of the newest classes of agents have targeted other components of the RAS, for example, the selective renin inhibitors, but recent advances in vascular biology have provided novel potential targets that may provide avenues for new agent development. These newer targets include downstream signaling participants in pathways involved in contraction, growth, hypertrophy, and relaxation. However, perhaps the most unique approach to the management of hypertension is a shift in strategy of using existing agents with respect to the time of day at which the agent is taken. This new strategy, termed "chronotherapy," has shown considerable promise in effectively managing hypertensive patients. Therefore, there remains great potential for future development of safe and effective agents and strategies to manage a disorder of the CV system of epidemic proportion.

The metabolic syndrome among postmenopausal women in Ecuador

BACKGROUND

The prevalence of the metabolic syndrome increases with age and after the onset of menopause, and may explain in part the apparent acceleration of cardiovascular disease in postmenopausal women.

OBJECTIVE

To determine the prevalence of metabolic syndrome and related risk determinants among postmenopausal women in Ecuador.

METHODS

Postmenopausal women >or=40 years of age, non-users of hormone therapy and with an intact uterus, were asked to participate in a metabolic syndrome screening and educational program at the Institute of Biomedicine of the Universidad Católica of Guayaquil, Ecuador. Sociodemographic data, waist circumference and blood pressure measurements were recorded, and a fasting blood sample obtained for serum glucose and lipid profile determinations. Woman were counseled and managed according to the results. Metabolic syndrome was defined in accordance with the criteria of the Third Adult Treatment Panel (ATP III).

RESULTS

Three hundred and twenty-five postmenopausal women entered the program. Mean (+/-standard deviation) age was 55.9 +/- 8.1 years, 53.5% of them were aged >or=54 years (median). The prevalence of metabolic syndrome, according to ATP III criteria, was 41.5%. Using the same criteria, 38.8%, 16.6%, 56.9% and 54.2% of the women presented with hypertension, diabetes, hypertriglyceridemia and abdominal obesity, respectively. More than 40% of women determined to have hypertension or diabetes lacked knowing so. Logistic regression analysis determined that age increased the risk of presenting hypertension and diabetes (odds ratio (95% confidence interval): 2.0 (1.2-3.2) and 1.6 (0.9-3.0), respectively, p < 0.05), entities which in turn duplicated the risk of having high triglyceride levels. Sedentary women with <5 years since menopause onset were at higher risk of having abdominal obesity, which was directly related to diabetes and hypertension.

CONCLUSIONS

In this postmenopausal Ecuadorian population the prevalence of the metabolic syndrome was high and its determinant factors related to age, time since menopause onset and sedentary habits. Because of the implications for cardiovascular risk, counseling programs directed toward high-risk populations should be encouraged.

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.

Sun exposure and age at natural menopause: A cross-sectional study in Turkish women

OBJECTIVES

In a cross-sectional study of 157 Turkish women attending outpatient clinics of a university hospital during April-May 2003, association between various subject characteristics and menopause timing was investigated.

METHODS

Characteristics were self-reported by women aged 45-60. Of the lifestyle factors, sun exposure, physical activity, food intake and dressing with headscarf were obtained as recalled average lifelong practices up to time of menopause. Cox proportional hazard modeling was used, censoring for hysterectomy, oopherectomy and HRT use.

RESULTS

Median age at natural menopause was 52 years. In multivariate analysis, earlier natural menopause was associated with low level of lifelong sun exposure (HR=6.381, 95% CI: 2.996-13.588, p< or =0.0001), heavy physical activity (HR=2.335, 95% CI: 1.305-4.177, p=0.0043), current calcium supplement use (HR=3.191, 95% CI: 1.361-7.485, p=0.0076), diagnosis of hypertension (HR=2.002, 95% CI: 1.186-3.378, p=0.0093), not owning a house (HR=3.002, 95% CI: 1.148-7.852, p=0.0250) and longer years on oral contraceptives (HR=1.085, 95% CI: 1.000-1.176, p=0.0487). Engagement in farming (HR=2.043, 95% CI: 1.056-3.952, p=0.0339), height (cm) (HR=0.953, 95% CI: 0.907-0.994, p=0.0279) and fish consumption (servings/week) (HR=0.600, 95% CI: 0.375-0.960, p=0.0331) were associated with age at menopause in univariate analysis only. For n=109 women who recalled whether maternal menopausal age was <50 or > or =50, sun exposure (HR=7.221, 95% CI: 2.971-17.547, p<0.0001) was a stronger predictor of age at natural menopause than maternal menopausal age (HR=2.882, 95% CI: 1.477-5.621, p=0.0019).

CONCLUSIONS

We identify some previously unrecognized correlates of age at natural menopause, namely self-reported lifelong sun exposure, lifelong physical activity, house-ownership, current use of calcium supplements, and lifelong fish consumption. These findings should be confirmed in larger studies.

Cardiovascular risk factors in middle-aged women and the association with use of hormone therapy: results from a population-based study of Swedish women. The Women's Health in the Lund Area (WHILA) Study

OBJECTIVE

Cardiovascular diseases in women are multifactorial. Women carry different risk factors compared to men and these specific risk factors need to be delineated, particularly in relation to the hormonal situation, and effects of diet and lifestyle.

METHODS

Out of the total cohort of 10,766 women born 1935-1945 living in the Lund area of southern Sweden, 6917 women completed a generic questionnaire and underwent a physical and laboratory assessment. According to hormonal status, 492 women were premenopausal (PM), 3600 were postmenopausal without hormone therapy (HT) (PM0) and 2816 were postmenopausal with ever-use of HT (PMT). Major cardiovascular risk factors as well as level of education, diet, and degree of physical activity were assessed in relation to hormonal status.

RESULTS

Compared to the PM0 group, the women in the PMT group had a higher level of education, more often worked full time, more often had sedentary work and lived a more regular life. They also had a lower rate of cigarette consumption, lower waist-to-hip ratio and lower body mass index than women in the PM0 group. The PMT group had lower levels of serum total cholesterol, low density lipoprotein cholesterol, high density lipoprotein cholesterol and triglycerides than the PM0 group and also had lower systolic and diastolic blood pressures, a lower prevalence of type II diabetes mellitus, of deep venous thrombosis and of coronary artery disease. Low-risk factors for cardiovascular disease and high level of education were still associated with HT, after adjustment by multiple logistic regression. Major risk factors for coronary heart disease were similar between the PM and the PMT groups.

CONCLUSION

Use of HT is accompanied by a lower risk profile for cardiovascular disease and also by several factors indicating a healthier lifestyle.

Use of hormone replacement therapy in Italian women aged 50-70 years

OBJECTIVES

The aim of the present cross-sectional analysis was to describe patterns and determinants of use of hormone replacement therapy (HRT) in a large sample of women attending mammographic screening.

METHODS

Between 1999 and 2001, 8533 women aged 50-70 years were recruited by 11 screening centres, and structured interviews were made collecting information on socio-demographic characteristics, lifestyle habits, medical and reproductive history (overall response rate 87%).

RESULTS

Current HRT use was reported by 6.9% of women (n=585), the average duration of use being 3.5 years; 13.2% were ever HRT users. Binomial and multinomial logistic regression (MLR) analyses showed that younger age, higher educational level, past mammographic examination and history of bilateral oophorectomy were the major predictors of current and ever HRT use. Current use was also more frequently reported by women who were thinner, nulliparae, had had induced menopause, had a later onset of menopause, with history of oral contraceptive use and hysterectomy without bilateral oophorectomy. By contrast, those who were diabetics or had positive history of cardiovascular disease were less likely to be current HRT users. No differences were found in HRT use according to marital status, type of occupation, menopausal status, smoking, history of breast cancer, hypercholesterolemia, hypertension and phlebitis.

CONCLUSIONS

Our results support previous findings indicating that HRT use in Italian women is uncommon and of short duration. Current HRT users were less likely than non-users to report several characteristics associated with higher mortality and morbidity, in accordance with the healthy-user phenomenon described in other countries.

Effect of hormone therapy on BP in normotensive and hypertensive postmenopausal women

High blood pressure (BP) ranks as the greatest risk factor for cardiovascular disease. The increased cardiovascular risk determined in recent interventional studies has led the health authorities in some countries to re-ignite the discussion about whether hypertension should be listed as a contraindication for hormone replacement therapy (HRT). We reviewed papers published since 1960 and listed in MEDLINE, EMBASE and Biosis, on studies that monitored the course of BP during HRT. We found that both primarily normotensive and hypertensive postmenopausal women actually run only a very low risk of BP increase during HRT, indeed, BP was often lowered. In one of our own studies 1397 hypertensive women with BP diastolic >95 mmHg received transdermal HRT regimens; BP was lowered by an average of 7 mmHg systolic and 9 mmHg diastolic. The results of the more recent 24-h ambulatory BP studies are particularly conclusive. At least 19 such studies have been performed, 13 placebo-controlled and 10 cross-over; 5 found no effect on BP and 14 studies demonstrated BP reductions. BP was lowered by treatment with transdermal estradiol in 11 of 13 studies and by oral estrogen in 4 of 11 studies. The effects were not consistent with regard to systolic or diastolic BP nor to action on day- and night-time BP. It cannot be ruled out that some women with a particular predisposition exhibit an abnormal reaction to the vasoactive effects of HRT, and there is a paucity of long-term data on risk populations, specifically on the progestogenic effects in patients with pre-existing arteriosclerotic lesions. In conclusion, the risk of developing hypertension during HRT is very low, but hormone therapy should always be appropriately indicated and during therapy BP should be checked regularly.

Health status of users of hormone replacement therapy by hysterectomy status in Western Australia

STUDY OBJECTIVES

To compare the demographic, behavioural, and biological correlates of use of hormone replacement therapy (HRT) in women with an intact uterus and women who have undergone hysterectomy.

DESIGN

Cross sectional analysis of data from the Busselton Health Study and the 1994 Healthway-National Heart Foundation Risk Factor Survey.

SETTING

Busselton and Perth, Western Australia, 1994.

PARTICIPANTS

2540 women aged 35-79 years.

MAIN OUTCOME MEASURES

Demographic, behavioural, and biological correlates of use of HRT by hysterectomy status.

RESULTS

In women with an intact uterus, after adjustment for age and place of residence, current use of HRT was significantly associated with having a professional level of occupation, ever use of alcohol, having a history of smoking, and a lower body mass index. Current users of HRT had significantly lower levels of total cholesterol and higher levels of triglycerides than non-users. In women who had undergone hysterectomy, the only non-biological characteristic associated with use of HRT was having a history of smoking. Current users of HRT had lower levels of systolic blood pressure, lower levels of LDL cholesterol, higher levels of HDL cholesterol, and higher levels of triglycerides. The association between use of HRT and participation in exercise, level of systolic blood pressure, level of HDL cholesterol, and total/HDL cholesterol ratio varied significantly by hysterectomy status. After adjustment for age and place of residence, the mean levels of systolic and diastolic blood pressure, body mass index, waist/hip ratio, LDL cholesterol, and total/HDL cholesterol ratio were highest in women who had undergone hysterectomy and were not using HRT.

CONCLUSIONS

Demographic/behavioural and biological correlates of use of HRT varied depending on hysterectomy status. Demographic and behavioural characteristics were more important as selection factors for use of HRT in women with an intact uterus than in women who had undergone hysterectomy. Women who had undergone hysterectomy and were not using HRT had a significantly worse profile for CHD than did women with an intact uterus. These results indicate that any bias in estimates of the protective effect of HRT on risk of CHD in observational studies is likely to depend on the prevalence of hysterectomy within the study population. Hysterectomy status needs to be taken into account in any studies that investigate the effect of HRT on risk of CHD.

Angiotensin II type 1 receptor blockade to control blood pressure in postmenopausal women: influence of hormone replacement therapy

BACKGROUND

Hypertension is twice as common in postmenopausal than in premenopausal women. This study evaluated the effectiveness of a blockade of the renin-angiotensin-aldosterone system (RAAS) with candesartan cilexetil (CC) to control blood pressure (BP) in hypertensive menopausal women, and the influence of hormone replacement therapy (HRT).

METHODS

This was designed as a prospective, open-label and non-comparative study. Included were 618 hypertensive menopausal women grade I/II according to the Sixth Report of the Joint National Committee (VI-JNC), with an average age 52+/-4.7 years (95% CI 52.3-53.0) and with a last menstrual period (LMP) at least one year before. BP was determined by measurement in four visits during six months of follow-up, according to the recommendations of the OMS/SIH. Optimal control of BP was considered as BP <140/90 mm Hg.

RESULTS

A statistically significant decrease in systolic (SBP; 19.9+/-11.2) and diastolic (DBP; 11.5+/-7.3) blood pressure mm Hg values was observed (P<0.01). The control of BP increased significantly over time to 61.2% (P<0.01). In multivariate analysis, only age was associated with control of BP (beta= -0.062; P=0.004). Of the women not controlled in the second visit, 12.5 mg of hydrochlorothiazide (HCTZ) were added to 31.5% (N=122), with 80% more BP control achieved in visit 3 than in the non-supplement group (OR=1.8; 95% CI 1.04-3.05; P<0.03). One hundred and three (16.7%) patients were receiving HRT for 2.01+/-2.23 years (95% CI 1.55-2.46). HRT did not affect the control of BP. No severe adverse reactions were reported.

CONCLUSIONS

Candesartan cilexetil significantly reduced SBP and DBP and increased control (61.2%) of BP in hypertensive menopausal women. Only age had an inverse association with control of BP. In this study, HRT did not affect the control of BP.

Resistive index of renal artery and blood pressure in postmenopausal women

Causal association between perimenopausal changes and symptoms and disease is commonly accepted even if not definitely explained. Resistive index (RI) of renal artery assessed by Doppler echography is related to renal function and systemic circulatory adaptation in patients with chronic renal failure and hypertension. Echocardiographic measurement of left ventricular myocardial mass (LVMM) is a useful tool for assessing effects of arterial hypertension on heart. Aim of the study was to assess RI in normotensive postmenopausal women and relationship, if any, with blood pressure and LVMM. We studied 28 normotensive, non-obese postmenopausal women, age 52.21 +/- 5.40 years, with normal creatinine clearance. Renal colour-Doppler echography was performed assessing intra-parenchimal renal artery mean velocity (mVRA) and intra-parenchimal RI [(peak systolic velocity - end diastolic velocity)/peak systolic velocity]. Echocardiography was performed as well. RI of intra-parenchimal renal artery is 0.67 +/- 0.05 and it shows correlations vs. diastolic blood pressure (r=0.41; P<0.03) and vs. mean BP (r=0.47; P<0.01). LVMM has correlation (r=0.41; P>0.03) with RI. Age, body weight, body mass index, menarche age, fertility years and postmenopausal years do not show correlation with RI. Heart rate, creatinine clearance, hemoglobin, serum albumin do not show any correlation with RI. Higher RI is associated with alcohol intake, liver steatosis, biliary gallstones and family history of diabetes mellitus, but not with postmenopausal years, unrespective of surgical or non-surgical menopause. Among echocardiographic measurements only LVMM is correlated with RI; mVRA does not show correlation. LVMM and BP do not show other independent correlation except that the one already reported vs. RI. RI, as a pathophysiological measurement whose increase preludes to arterial hypertension, could help to ascertain perimenopausal women at risk for arterial hypertension and left ventricular hypertrophy, but does not seem directly associated with the loss of ovarian function.

General and medical factors associated with hormone replacement therapy among women attending menopause clinics in Italy

OBJECTIVE

The objective of the study was to analyze medical and general factors associated with hormone replacement therapy (HRT) use in women attending a network of menopause clinics in Italy.

DESIGN

Between 1997 and 1999, we conducted a large cross-sectional study on the characteristics of women around menopause attending a network of first level outpatient menopause clinics for general counseling about menopause or treatment of menopausal symptoms. All women consecutively observed during the study period at the participating centers were eligible for the study. A total of 42,464 women (mean age 54 years) entered the study. The characteristics of women who had at some time used HRT were compared with those of women who were never users.

RESULTS

Of the 42,464 women considered, 4,909 (11.6%) reported having used HRT at some time. In comparison with premenopausal women, the odds ratio (OR) of HRT use was 2.1 and 4.0, respectively, in women with natural and surgical menopause; the frequency of use tends to be lower in women with later age at menopause. In comparison with women reporting primary school education, the OR was 1.4 in women with a secondary or university degree. In comparison with nulliparity, the OR of HRT use was 0.7 (95% confidence interval [CI] 0.6-0.7) in women with two or more births. HRT use was less frequent in women reporting a history of diabetes (OR 0.7, in comparison with women with no history, 95% CI 0.5-0.9) and cardiovascular diseases (OR 0.8, 95% CI 0.7-0.8) and more frequent in women with a history of osteopenia/osteoporosis (OR 1.2, 95% CI 1.0-1.5), but the latter finding was not statistically significant.

CONCLUSION

The results of the study indicate that HRT use is more common in this population in women of higher education with early age at menopause and with a history of osteoporosis/osteopenia and less frequent in women with a history of cardiovascular disease and diabetes.

Cross-sectional study of determinants of menopausal age and hormone replacement therapy use in Italian women

OBJECTIVE

The aim of the study was to analyze determinants of age at menopause and hormone replacement therapy (HRT) use. Women included were identified in a large cross-sectional study into epidemiology of the menopause among a sample of women visiting their general practitioners, conducted in Italy.

METHODS

Eligible women were identified among consecutive patients, aged 44-66 years, who visited their general practitioner for a general health check-up during the period May-November 1997. A total of 16,916 postmenopausal women were identified by 1123 general practitioners.

RESULTS

Overall, the mean age at menopause was 50.2 (SD 3.8) years. Ever-married women reported a slightly higher age at spontaneous menopause than that of never-married women. The finding was significant, but the difference was small. Smoking women reported a younger age at menopause. No clear association emerged between age at menopause, physical activity and body mass index (BMI). A total of 3515 women (20.8%) reported HRT ever-use; the mean duration of use was 3.6 years. HRT use was more frequent among women of higher socioeconomic status, those with a lower BMI and smokers. In particular, in comparison with women reporting a BMI of < 25 kg/m2, the odds ratio (OR) of HRT use was 0.7 (95% confidence interval (CI) 0.7-0.8) and 0.5 (95% CI 0.4-0.6), respectively, in women with a BMI of 25-28 kg/m2 and > or = 29 kg/m2. No association emerged between alcohol consumption, level of physical activity and HRT use. Diabetic women reported HRT use less frequently than non-diabetic women. Likewise, hypertensive women, and those with a history of cardiovascular disease, were less likely to be HRT users than those not reporting these conditions. Women with a diagnosis of osteoporosis/osteopenia reported HRT use more frequently.

CONCLUSION

This study, using a large dataset from an Italian population, has confirmed that smoking is related to age at menopause. It has also demonstrated that HRT is more frequently used by women of higher socioeconomic status, those with low BMI and smokers. Diabetes is associated with less frequent use of HRT; conversely, osteoporosis/osteopenia is associated with more frequent HRT use.