Effects of different progestogens on lipoproteins during postmenopausal replacement therapy

The effects of progesterones on blood lipids in hormone replacement therapy

The safety of progestogens as a class has drawn much attention after the publication of data from the Women’s Health Initiative (WHI) trial, particularly with respect to cardiovascular disease. Depending on the chemical structure, pharmacokinetics, receptor affinity and potency of action, progestogens have a divergent range of properties that may translate to very different clinical effects. The purpose of this review is to describe the role of varied progestogens in hormone replacement therapy (HRT), especially focusing on blood lipids, which are the most important parameters for assessing cardiovascular disease risk.

Toward a new concept of "natural balance" in oral estroprogestin contraception

The Pill has undergone many changes since its first appearance some 50 years ago. Key developments included the reduction of ethinylestradiol doses and the synthesis of new progestins in order to increase safety, compliance and efficiency. Low-dose combined oral contraceptives (COCs) are currently the preferred option for millions of women. Due to this widespread use, it has been argued that the safety of COCs should be even better, raising the threshold for excellence. Yet in spite of major improvements, there is still an associated risk of venous thromboembolism (VTE). The next step in COCs' evolution should take total estrogenicity and hepatic estro-androgenic balance into account. The focus on the estrogen component--which has not changed in 50 years--has yielded a new class of natural estrogen pills. Following the introduction of a first quadriphasic pill, a monophasic estradiol pill based on the concept of "natural balance" was subsequently made available. These recent achievements could represent a step forward in the evolution of COCs and pave the way for better safety.

Hormone replacement therapy in the geriatric patient: current state of the evidence and questions for the future. Estrogen, progesterone, testosterone, and thyroid hormone augmentation in geriatric clinical practice: part 1

This article presents an up-to-date review of the literature on hormone augmentation in the elderly to help primary care physicians better evaluate and utilize hormone replacement and optimization strategies to benefit their patients. The scientific literature suggests that hormone supplementation with estrogen, progesterone, testosterone, growth hormone, and thyroid hormone has the potential to improve quality of life and to prevent, or reverse, the many symptoms and conditions associated with aging, including fatigue, depression, weight gain,frailty, osteoporosis, loss of libido, and heart disease. Possible long-term side effects are also considered.

Clinical profile of contraceptive progestins

The term progestogen has been widely utilized to indicate the general class of agents that includes both progesterone and its synthetic analogs, whereas the term progestin refers only to synthetic progestational steroids. The development of progestins has been influenced in a major way by the search for orally active hormonal contraceptives, since it is likely that hormonal contraceptives will continue to utilize a progestin, the only possible alternative being represented by the utilization of antiprogestins. Synthetic progestogens in clinical use today belong to three main chemical families: progesterone derivatives (progesterone, retro-progesterone, 19-norprogesterone and 17alpha-hydroxyprogesterone); gonane and 19-nortestosterone derivatives (norethisterone, levonorgestrel, desogestrel, gestodene, norgestimate); a spironolactone derivative. Biological potency of progestogens varies depending on the end-point measured, usually ovulation inhibition and endometrial transformation; with both these tests, the most active compounds are all gonane derivatives, with a potency over a 100 times that of the natural hormone. When administered in adequate doses, a progestin inhibits fertility by inhibiting ovulation. This action is mainly exerted at the hypothalamic level where, physiologically, progesterone decreases the number of LH pulses. When progestogens are delivered directly to the uterine cavity, their action seems to be purely local. It has been amply proven that--even when administered in doses that do not constantly inhibit ovulation--a progestin can still remain effective as a contraceptive by acting at the level of the cervical mucus and, at least in part, of the endometrium. Progestogens utilized today differ largely in their pharmacokinetics. In general, after intake, these compounds are rapidly absorbed and distributed so that peak serum concentrations are reached between 1 and 4 h. Third-generation progestins (desogestrel, gestodene, norgestimate) have common characteristics: a higher affinity for progesterone receptors than their predecessors, a lower affinity for androgen receptors, a higher selectivity of action, a higher central inhibitory activity, a higher potency at the level of the endometrium, and an overall metabolic neutrality, in terms of effects on lipid and carbohydrate metabolism. In general, progestins can induce two types of adverse effects: changes in lipid metabolism and bleeding irregularities. Whereas the newer compounds seem to have overcome the first of these adverse effects, the second remains untouched: to this day, proper cycle control can only be achieved with combined hormonal contraceptives.

The influence of medroxyprogesterone acetate on the effects of transdermal oestradiol replacement therapy on plasma lipids

A prospective study was carried out on 82 healthy menopausal women to determine whether or not there is an attenuation of the cardioprotective effects of continuous transdermal oestradiol on plasma lipid and lipoprotein concentrations with the use of sequential oral medroxyprogesterone acetate. Group 1 comprised 51 hysterectomised women on transdermal oestradiol (50 microg daily). Group 2 included 31 women with an intact uterus on oestradiol (50 microg daily) and medroxyprogesterone acetate (10 mg daily for the first 12 days of each calendar month). Women maintained on 50 microg throughout 6 months (group 1: n = 29; group 2: n = 20) were reviewed for changes in plasma lipids and lipoproteins at the end of 6 months (group 1), and in the combined phase of treatment in the seventh month (group 2). In group 1, there was a reduction in the concentrations of total cholesterol (- 6.3%, P = 0.004) and LDL-cholesterol (- 6.1%, P = 0.05). In group 2, there were no significant changes in total cholesterol (- 4.8%, P = 0.23) and LDL-cholesterol (- 5.8%, P = 0.30). HDL-cholesterol levels did not change significantly with unopposed oestradiol (+ 3.8%, P = 0.30), or with additional medroxyprogesterone acetate (0%, P = 0.94). Serum triglyceride concentrations decreased significantly in both the groups (- 14.3%, P = 0.001, and- 12.8%, P = 0.006, respectively). There were no statistically significant differences in the changes in the respective plasma lipid parameters on comparing the two treatment groups (P > 0.4 for all comparisons, Student's t -tests). The plasma lipid and lipoprotein profile encountered at the end of 6 months, was also generally maintained in 24 women (group 1: n = 13; group 2: n = 11) who completed 1 year of the study. Transdermal oestradiol may be of particular clinical benefit for women with hypertriglyceridaemia. Medroxyprogesterone acetate did not exert a significantly adverse influence on plasma lipid and lipoprotein concentrations.

Hormone replacement therapy and cardiovascular disease: the case for a randomized controlled trial

The menopause is associated with an increased risk of developing cardiovascular disease. Oestrogen may influence various metabolic pathways which contribute to the pathogenesis of cardiovascular disease, and observational studies suggest that in postmenopausal women oral oestrogen replacement therapy confers some protection against coronary heart disease and to a lesser extent against stroke. What is not clear is the magnitude of the cardioprotective effect and the overall balance of long-term benefits and hazards. Research is also required to establish the relative effects of oestrogen replacement therapy and combined or opposed hormone replacement therapy (HRT) where progestogen is added to counter the proliferative action of oestrogen on the endometrium. A large randomized controlled trial is the only way to provide accurate estimates of the cardioprotective effect of HRT and of other long-term benefits and hazards. Feasibility studies undertaken through the UK Medical Research Council (MRC) General Practice Research Framework show that such a trial is acceptable to patients and their doctors. Recruitment and withdrawal rates indicate that a trial of sufficient size to show a 25% reduction in cardiovascular disease with 90% power at the 1% level would be feasible. The full trial is costly and it is proposed that the UK collaborates with other countries in a major international trial to complement the Women's Health Initiative trial in the USA. Feasibility studies in Europe are underway, the design and scientific rationale for the trial have been approved by the UK MRC and it is hoped that recruitment to the full-scale trial can begin soon.

Contraception today

Modern contraceptive methods represent more than a technical advance: they are the instrument of a true social revolution-the "first reproductive revolution" in the history of humanity, an achievement of the second part of the 20th century, when modern, effective methods became available. Today a great diversity of techniques have been made available and-thanks to them, fertility rates have decreased from 5.1 in 1950 to 3.7 in 1990. As a consequence, the growth of human population that had more than tripled, from 1.8 to more than 6 billion in just one century, is today being brought under control. At the turn of the millennium, all over the world, more than 600 million married women are using contraception, with nearly 500 million in developing countries. Among married women, contraceptive use rose in all but two developing countries surveyed more than once since 1990. Among unmarried, sexually active women, it grew in 21 of 25 countries recently surveyed. Hormonal contraception, the best known method, first made available as a daily pill, can today be administered through seven different routes: intramuscularly, intranasally, intrauterus, intravaginally, orally, subcutaneously, and transdermally. In the field of oral contraception, new strategies include further dose reduction, the synthesis of new active molecules, and new administration schedules. A new minipill (progestin-only preparation) containing desogestrel has been recently marketed in a number of countries and is capable of consistently inhibiting ovulation in most women. New contraceptive rings to be inserted in the vagina offer a novel approach by providing a sustained release of steroids and low failure rates. The transdermal route for delivering contraceptive steroids is now established via a contraceptive patch, a spray, or a gel. The intramuscular route has also seen new products with the marketing of improved monthly injectable preparations containing an estrogen and a progestin. After the first device capable of delivering progesterone directly into the uterus was withdrawn, a new system releasing locally 20 microg evonorgestrel is today marketed in a majority of countries with excellent contraceptive and therapeutic performance. Finally, several subcutaneously implanted systems have been developed: contraceptive "rods," where the polymeric matrix is mixed with the steroid and "capsules" made of a hollow polymer tube filled with free steroid crystals. New advances have also been made in nonhormonal intrauterine contraception with the development of "frameless" devices. The HIV/AIDS pandemic forced policy makers to look for ways to protect young people from sexually transmitted diseases as well as from untimely pregnancies. This led to the development of the so-called dual protection method, involving the use of a physical barrier (condom) as well as that of a second, highly effective contraceptive method. More complex is the situation with antifertility vaccines, still at a preliminary stage of development and unlikely to be in widespread use for years to come. Last, but not least, work is in progress to provide effective emergency contraception after an unprotected intercourse. Very promising in this area is the use of selective progesterone receptor modulators (antiprogestins).

The role of progestins in treating the pain of endometriosis

Progestins, synthetic progestational agents, have been used in the management of symptomatic endometriosis both as primary therapy and as an adjunct to surgical resection. A variety of oral agents have been employed in this regard with investigators demonstrating differing degrees of benefit. Unfortunately, due to the lack of large-scale, appropriately controlled, randomized trials, or dose-ranging studies, no single agent can be demonstrated to be truly efficacious. The lack of a standardized instrument to evaluate painful symptoms makes comparative analysis more difficult. Injectable administration of long-acting depot medroxyprogesterone acetate preparations intramuscularly or subcutaneously has been investigated in three randomized trials. The lower dose subcutaneous injection holds promise with an apparent reduction in side effects. Issues of reversible bone mineral density loss, breakthrough bleeding, and return of menses have not been completely resolved. Selective progesterone receptor modulators represent an intriguing alternative. These orally administered agents have been shown in preliminary investigations to be not only efficacious in reducing symptoms but also associated with minimal side effects. Further investigation of these agents is clearly required.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effects of Transdermal Estrogen Replacement Therapy on Cardiovascular Risk Factors

The prevalence of hypertension and cardiovascular disease increases dramatically after menopause in women, implicating estrogen as having a protective role in the cardiovascular system. However, recent large clinical trials have failed to show cardiovascular benefit, and have even demonstrated possible harmful effects, of opposed and unopposed estrogen in postmenopausal women. While these findings have led to a revision of guidelines such that they discourage the use of estrogen for primary or secondary prevention of heart disease in postmenopausal women, many investigators have attributed the negative results in clinical trials to several flaws in study design, including the older age of study participants and the initiation of estrogen late after menopause.Because almost all clinical trials use oral estrogen as the primary form of hormone supplementation, another question that has arisen is the importance of the route of estrogen administration with regards to the cardiovascular outcomes. During oral estrogen administration, the concentration of estradiol in the liver sinusoids is four to five times higher than that in the systemic circulation. This supraphysiologic concentration of estrogen in the liver can modulate the expression of many hepatic-derived proteins, which are not observed in premenopausal women. In contrast, transdermal estrogen delivers the hormone directly into the systemic circulation and, thus, avoids the first-pass hepatic effect.Although oral estrogen exerts a more favorable influence than transdermal estrogen on traditional cardiovascular risk factors such as high- and low-density lipoprotein-cholesterol levels, recent studies have indicated that oral estrogen adversely influences many emerging risk factors in ways that are not seen with transdermal estrogen. Oral estrogen significantly increases levels of acute-phase proteins such as C-reactive protein and serum amyloid A; procoagulant factors such as prothrombin fragments 1+2; and several key enzymes involved in plaque disruption, while transdermal estrogen does not have these adverse effects.Whether the advantages of transdermal estrogen with regards to these risk factors will translate into improved clinical outcomes remains to be determined. Two ongoing clinical trials, KEEPS (Kronos Early Estrogen Prevention Study) and ELITE (Early versus Late Intervention Trial with Estradiol) are likely to provide invaluable information regarding the role of oral versus transdermal estrogen in younger postmenopausal women.

Bleeding profiles and effects on the endometrium for women using a novel combination of transdermal oestradiol and natural progesterone cream as part of a continuous combined hormone replacement regime

OBJECTIVE

Many women are seeking alternatives to conventional forms of hormone replacement. This study evaluates the endometrial effects of natural progesterone cream used in conjunction with transdermal oestradiol.

DESIGN

Open plan study conducted over 48 weeks.

SETTING

Tertiary referral London teaching hospital.

POPULATION

Women at least two years postmenopausal.

METHODS

Women were recruited nationally. They applied 40 mg transdermal natural progesterone cream and 1 mg transdermal oestradiol daily.

MAIN OUTCOME MEASURES

Endometrial histology, assessed by pipelle endometrial biopsy, ultrasound assessment of endometrial thickness and bleeding diaries.

RESULTS

Fifty-four women were recruited of which 41 completed the study. Mean age was 57.4 years. Thirty-two percent of women had evidence of inadequate endometrial opposition (proliferative or hyperplastic) at the end of 48 weeks. At baseline, women had a mean endometrial thickness of 3.3 mm, which had significantly thickened to a mean of 5.3 mm by 24 weeks (P < 0.001). By 48 weeks, there was significantly greater increase in endometrial thickness from baseline in those women who displayed inadequate endometrial opposition, compared with those women who had adequate endometrial opposition (P= 0.004). At 24 weeks, 48% of women had remained entirely amenorrhoeic. By the end of the study, 35% of women had been entirely amenorrhoeic and 50% had had either no bleeding or spotting alone. The number of bleeding episodes did not reduce with time.

CONCLUSIONS

The dose of natural progesterone cream in this study was insufficient to fully attenuate the mitogenic effect of oestrogen on the endometrium. We would not recommend this combination of hormones to be used by postmenopausal women.

Progestogens of varying androgenicity and cardiovascular risk factors in postmenopausal women receiving oestrogen replacement therapy

OBJECTIVE

Medroxyprogesterone (MP) was used as the progestogen in randomized clinical trials of postmenopausal hormone replacement on cardiovascular risk. To attempt to understand the lack of benefit in these trials, we have examined the effects of MP and two other progestogens, the less androgenic desogestrel (DG) and the more androgenic norethisterone (NE), on cardiovascular risk factors against a background of oestrogen therapy.

DESIGN AND MEASUREMENTS

Thirty-four women were treated with conjugated equine oestrogens (CEE) 0.625 mg daily alone for 12 weeks, followed in random order by each of the three progestogens (DG 75 microg, MP 10 mg and NE 1 mg daily) given sequentially for three 12-week cycles while maintaining the same CEE treatment. We measured serum lipoproteins, paraoxonase activity, C-reactive protein (CRP), fibrinogen, fasting glucose and insulin levels at baseline, at the end of the oestrogen-only phase and at the end of each of the combined oestrogen and progestogen phases.

RESULTS

The addition of progestogens to CEE maintained the oestrogen-induced reduction in apolipoprotein B (apo B) and lipoprotein (a) [Lp(a)], and further lowered total cholesterol (P < 0.01) and fibrinogen (P < 0.001). CEE raised serum triglyceride (P < 0.001) and CRP (P < 0.01) concentrations, which reverted towards pre-oestrogen levels with progestogens. Progestogens significantly reduced high density lipoprotein (HDL) cholesterol (P < 0.05). NE was associated with the greatest reduction in HDL cholesterol and apo A1, but was most effective in preserving paraoxonase activity and reducing the potentially unfavourable oestrogen-induced increases in triglycerides and CRP.

CONCLUSION

Preconceptions that more androgenic progestogens necessarily have more unfavourable effects on cardiovascular risk factors may require revision.

Hypercholesterolemia and obesity in adult patients with hypopituitarism: a report of a nation-wide survey in Japan

Dyslipidemia and obesity are common in adult patients with hypopituitarism. Possible contributions of age, sex and hormone deficiencies to hypercholesterolemia and obesity in adult hypopituitary patients were analyzed in 1, 272 Japanese cases based on a database of a national survey on adult hypopituitarism. In patients on routine hormone replacement therapy, 30.5% of male and 40.7% of female subjects were considered hypercholesterolemic. In univariate analysis, hypercholesterolemia was more prevalent in female, aged, untreated Gn-deficient and TSH-deficient groups. In multivariate analysis, sex of female, age older than 40 yr and TSH deficiency were the independent contributing factors to hypercholesterolemia. Obesity (body mass index (BMI) > or = 25 kg/m2) was more prevalent in male, TSH-deficient and ADH-deficient groups. Severe obesity (BMI > or = 30) was observed in high prevalence in the youngest group. These findings suggest that hypercholesterolemia and obesity were prevalent in different age and gender groups in Japanese adult patients with hypopituitarism. Insufficient replacement of thyroid hormone and possibly gonadotropin deficiency might contribute to hypercholesterolemia. In contrast, hypothalamic dysfunction as well as hormone deficiencies might play roles in obesity in these patients.

Modulation by progestogens of the effects of oestrogen on hepatic endocrine function in postmenopausal women

OBJECTIVE

Oral but not transdermal oestrogen administration reduces IGF-I, and increases GH binding protein (GHBP) reflecting effects on hepatic endocrine function in postmenopausal women. As progestogens attenuate the effects of oestrogen on circulating lipid levels according to their androgenic properties, we have investigated the impact of progestogen types on the hepatic endocrine effects of oestrogen.

DESIGN

Four progestogens differing in androgenicity were co-administered in a monthly cyclical regimen in random order to postmenopausal women receiving either oral (n = 9, premarin 1.25 mg) or transdermal (n = 10, Estraderm 100 microg patches twice weekly). The four progestogens were cyproterone acetate (CA 5 mg, antiandrogenic), dydrogesterone (20 mg, neutral), medroxyprogesterone acetate (MPA 10 mg, mildly androgenic), norethisterone (2.5 mg, androgenic).

PATIENTS

Nineteen postmenopausal women (age 57 +/- 3 years, mean +/- SE) were studied.

MEASUREMENTS

The effects of oestrogen alone and the combined effects with each progestogen type on IGF-I, GHBP, SHBG, cholesterol, triglycerides and lipoprotein(a) were investigated.

RESULTS

Mean IGF-I fell while GHBP and SHBG levels increased with oral (P < 0.01) but not transdermal oestrogen administration. When the combined effects were examined, progestogens did not affect IGF-I, GHBP and SHBG during oral oestrogen treatment, while they significantly increased (P < 0.01) mean IGF-I levels during transdermal therapy. Among the progestogen types, only norethisterone prevented the fall in IGF-I induced by oral oestrogen. During transdermal therapy, MPA and norethisterone but not CA or dydrogesterone significantly increased (P < 0.005) IGF-I. The rise in GHBP induced by oral oestrogens tended to be lower during co-administration of MPA and norethisterone. The increase in SHBG induced by oral oestrogen was attenuated (P < 0.05) by norethisterone which was the only progestogen that lowered SHBG (P < 0.05) during transdermal oestrogen treatment. Mean IGF-I was higher (P < 0.001), GHBP and SHBG lower during co-administration of androgenic progestogens (MPA and norethisterone).

CONCLUSIONS

Oestrogen effects on IGF-I, GHBP and SHBG are dependent on the route of administration with progestogens having variable effects. Among the progestogen types, norethisterone, the most androgenic, had the greatest effect, particularly on IGF-I. Progestogens modulate the effects of oestrogen on hepatic endocrine function in relation to their intrinsic androgenic properties. The modulatory effects of progestogens on IGF-I during oestrogen therapy may have long-term implications for lean body mass.

Norethisterone acetate in combination with estrogen: effects on the skeleton and other organs. A review

This article is focused on the use of norethisterone acetate as progestogen in hormone replacement therapy. Emphasis is made on the fact that the primary reason for adding a progestogen to hormone replacement therapy is to protect the endometrium against hyperplasia. In this paper we review data that demonstrate that hormone replacement therapy that includes norethisterone acetate has positive effects on the postmenopausal bone metabolism and that it increases bone mass more than expected and more than treatment with alendronate. All available evidence is reviewed to show that norethisterone acetate, if given in the correct dosage, does not influence serum lipids and lipoproteins in any negative way. It is furthermore shown that norethisterone acetate seems to be superior compared to other progestogens to provide optimum bleeding control and endometrial protection. Also, hormone replacement therapy combinations with norethisterone acetate efficiently alleviate hot flushes. Hormone replacement therapy and the risk of breast cancer and the role of progestogens are discussed.

Efficacy of a new 7-day transdermal sequential estradiol/levonorgestrel patch in women

OBJECTIVE

To investigate the efficacy and tolerability of a new 7-day transdermal sequential estradiol/levonorgestrel patch (Fem7 Combi; Merck KGaA; Germany), versus placebo, as hormone replacement therapy in menopausal women.

METHODS

A multicentre, randomized, clinical study consisting of a 3-week screening phase, a 12-week double-blind, placebo-controlled treatment phase, and a 12-week open, follow-up phase. Women aged 40-65 years with an intact uterus and menopausal complaints were randomized to either 2 weeks of an estradiol mono patch (50 microg per 24 h) followed by 2 weeks of an estradiol/levonorgestrel combination patch (50 microg/10 microg per 24 h), or a placebo patch, for three 28-day cycles. Changes in the Kupperman Index and the frequency of hot flushes were assessed.

RESULTS

The sequential use of a 7-day estradiol patch and a 7-day estradiol/levonorgestrel patch was superior to placebo in reducing menopausal symptoms, and was well tolerated. At the end of the treatment phase, there was a statistically significant reduction in the Kupperman Index score versus placebo (P<0.0001), and a statistically significant difference between groups in the proportion of patients with a reduction in the number of hot flushes (at least 50% versus baseline). During the open follow-up phase, there was a marked reduction in the Kupperman Index score and the number of hot flushes for patients switched from placebo to active study medication. The active medication was effective throughout the 1-week application period.

CONCLUSIONS

The new 7-day transdermal sequential estradiol/levonorgestrel patch was well tolerated, providing rapid and effective relief of menopausal symptoms. The addition of low-dose levonorgestrel did not influence the beneficial effects of estradiol.

Estradiol and norgestimate: a review of their combined use as hormone replacement therapy in postmenopausal women

The focus of this review is hormone replacement therapy (HRT) with continuous administration of micronised, oral 17beta-estradiol 1 mg/day (herein referred to as continuous estradiol) plus micronised, oral norgestimate 90 microg/day administered for 3 days then withdrawn for 3 days in a 6-day repeating sequence (herein referred to as intermittent norgestimate). According to data from randomised, comparative trials of 1 year's duration, continuous estradiol 1 mg/day plus intermittent norgestimate 90 microg/day relieves climacteric symptoms (vasomotor symptoms and vulvovaginal atrophy) in postmenopausal women. Continuous estradiol 1 mg/day plus intermittent norgestimate 90 microg/day appeared as effective as estradiol 1 mg/day alone or continuous estradiol 2 mg/day plus continuous norethisterone acetate 1 mg/day in the treatment of postmenopausal women with vasomotor symptoms. Continuous estradiol 1 mg/day plus intermittent norgestimate 90 microg/day was as effective as continuous estradiol 1 mg/day in causing the maturation of vaginal epithelial cells. In a randomised, double-blind study, bone mineral density (BMD) increased to a significantly greater extent and the rate of bone turnover was slower in postmenopausal women treated with continuous oral estradiol 1 mg/day plus intermittent norgestimate 90 microg/day than in placebo-treated patients. Two randomised, double-blind studies indicated that the addition of norgestimate 90 microg/day to continuous estradiol 1 mg/day did not attenuate the beneficial effects of estradiol on lipid parameters. Continuous estradiol 1 mg/day plus intermittent norgestimate 90 microg/day was associated with increases in mean serum high density lipoprotein (HDL)-cholesterol levels and decreases in total cholesterol, low density lipoprotein (LDL)-cholesterol and lipoprotein (a) levels, compared with baseline. There was no statistically significant increase in triglyceride levels. In comparative trials, continuous oral estradiol 1 mg/day plus intermittent oral norgestimate 90 microg/day was well tolerated. Headache, breast pain or discomfort, abdominal pain or discomfort, uterine bleeding, dysmenorrhoea, oedema, nausea and depression were the most commonly reported adverse events. Continuous estradiol 1 mg/day plus intermittent oral norgestimate 90 microg/day was associated with a favourable uterine bleeding profile that improved over time. In a randomised trial, 80% of women were free from bleeding (irrespective of spotting) during month 12 of treatment. Norgestimate 90 microg/day was effective in protecting postmenopausal women against induction of endometrial hyperplasia by continuous estradiol 1 mg/day. In conclusion, data from a limited number of randomised studies indicate that HRT with continuous estradiol 1 mg/day plus intermittent norgestimate 90 microg/day is effective in relieving climacteric symptoms, increasing BMD and slowing the rate of bone turnover in postmenopausal women. This HRT regimen is well tolerated and is associated with a similar incidence of adverse events to that reported in recipients of continuous estradiol 1 mg/day. The norgestimate component of the regimen provides good endometrial protection and is associated with a favourable bleeding profile. Long-term studies investigating the associated risk of breast cancer and thromboembolic events in recipients of continuous estradiol plus intermittent norgestimate are needed. In the meantime, continuous oral estradiol plus intermittent oral norgestimate can be regarded as an effective new option for HRT in postmenopausal women.

Glycaemic control and plasma lipoproteins in menopausal women with Type 2 diabetes treated with oral and transdermal combined hormone replacement therapy

AIMS

To compare the effect of a fixed combination of an oestrogen (17-beta oestradiol) with a cyclical progestagen (norethisterone) on glycaemic control, plasma lipoproteins and haemostatic factors in women with Type 2 diabetes.

METHODS

Oral and transdermal hormone replacement therapy (HRT) were compared to no HRT treatment in 33 postmenopausal women with Type 2 diabetes, in a 12-week randomised prospective open parallel group study.

RESULTS

In the 11 women who received 12 weeks of oral HRT, there was a significant fall in total cholesterol (5.9+/-1.0 (S.D.) to 4.7+/-1.0 mmol l(-1), P=0.005), low density lipoprotein cholesterol (3.44+/-0.89 to 2.77+/-0.92 mmol l(-1), P=0.005) and triglyceride values (median (range)), (2.46 (0.96-5.52) to 2.29 (1.00-3.87) mmol l(-1), P<0.05). Oral HRT improved glycated haemoglobin (HbA(1c)) (7.4+/-1.4 to 6.8+/-1.2%, P< or =0.005). Oral HRT additionally reduced the cell adhesion factor E-selectin (82+/-33 to 60+/-20 microg l(-1), P<0.01) and factor VII (143+/-25 to 109+/-24% pooled plasma activity, P<0.01). No improvement in any of these parameters, except E-selectin (65+/-19 to 58+/-18 microg l(-1), P<0.01), occurred in the nine women receiving transdermal HRT, and no improvement occurred in the 13 controls randomised to no treatment.

CONCLUSION

In women with Type 2 diabetes, cyclical oestrogen and progestagen taken orally for 12 weeks significantly improved glycaemic control and lipoprotein concentrations. These metabolic benefits were not apparent when a similar HRT preparation was administered transdermally.

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

OBJECTIVE

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

DESIGN

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

SETTING

Clinical trials centers, hospitals, menopause clinics.

PATIENT(S)

Healthy postmenopausal women.

INTERVENTION(S)

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

MAIN OUTCOME MEASURE(S)

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

RESULT(S)

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

CONCLUSION(S)

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

Serum lipids and arterial plaque load are altered independently with high-dose progesterone in hypercholesterolemic male rabbits

Antiatherogenic effects of sex steroids in premenopausal women are not well defined. Therefore, we employed an established rabbit model for atherosclerosis to study the effects of exogenous estrogen and a progesterone analogue (P) on serum lipids and aortic plaque load. Serum cholesterol (C) and triglyceride (T) levels and atherosclerotic plaque loads were compared in 5 groups of male New Zealand White rabbits fed a 12-week, C-rich diet: 1 control group (CG) and 4 groups treated with estriol (E), haloperidol (H), low-dose 17-hydroxyprogesterone (LDP), or high-dose 17-hydroxyprogesterone (HDP). Serum P was measured in the LDP and HDP groups. Serial histologic sections (15 each of 27 ascending aortas) were studied by light microscopy and computerized morphometric analysis. Plaque load is defined as the ratio of intimal area to medial area (I/M). Exogenous E (p<0.001), H (P = 0. 02), LDP and HDP (P<0.001, each) were found to be significantly associated with less aortic plaque load than controls. In a multivariate analysis, after controlling for the differences in serum C and T levels, HDP (p = 0.014) was found to be associated with less aortic plaque load than controls, and this association approached statistical significance in the E (p = 0.052) and H (p = 0.069) groups. These data suggest that the mechanism(s) involved with the antiatherogenic effect of HDP in this animal model is, or are, independent of an alteration in serum lipids.

Endometriosis: an overview of the disease and its treatment

OBJECTIVE

To review endometriosis, its etiology, clinical presentation, and current management options.

DATA SOURCES

Published articles identified through MEDLINE (1966-2000) using the search term "endometriosis" and the additional terms "etiology" and "treatment." Additional articles were identified from the bibliographies of the retrieved articles.

DATA SYNTHESIS

Endometriosis, a disease that affects the physical health and emotional well-being of many women of reproductive age, is defined as the presence of endometrial tissue outside its normal location in the uterus. The disease ranges in severity from mild to severe, and patients may be asymptomatic or experience severe and potentially incapacitating symptoms, such as dysmenorrhea, dyspareunia, and infertility. The diagnosis can be confirmed only by direct visualization using laparoscopy and biopsy. The risk of endometriosis is increased in women who have an affected first-degree relative or who have shorter menstrual cycle lengths, longer duration of menstrual flow, and low parity. The etiology of endometriosis is not yet fully understand, but may involve retrograde menstruation, hereditary factors, and impaired immune function. Treatment should be individualized for each patient, taking into account the therapeutic goals, the extent of disease, symptomatology, and the woman's age and overall health. Treatment options include expectant management, hormonal therapies to suppress ovarian steroidogenesis and induce endometrial atrophy, and surgery to remove visible lesions or, as a last resort, the uterus and ovaries.

CONCLUSION

Although the precise etiology of endometriosis remains a mystery, treatment options have improved considerably in recent years. Pharmacists are well positioned to identify women with unexplained pelvic pain or infertility that may be indicative of endometriosis and refer them to their physicians for further evaluation. Pharmacists also can play an important role in counseling patients about the safe and effective use of the various treatments for this disease and strategies to recognize and reduce adverse effects.

Piperazine oestrone sulphate and interrupted norethisterone: effects on the postmenopausal endometrium

OBJECTIVE

To assess the effects on the postmenopausal endometrium of two doses of oral piperazine oestrone sulphate and interrupted norethisterone in comparison with a continuously combined regimen and placebo.

DESIGN

A prospective randomised trial.

PARTICIPANTS

Two hundred healthy postmenopausal women.

METHODS

Random assignment to two years of treatment with alternating three-day cycles of 1.5 mg piperazine oestrone sulphate and 1.5 mg piperazine oestrone sulphate + 0.7 mg norethisterone (highEP), or alternating three-day cycles of 0.75 mg piperazine oestrone sulphate and 0.75 mg piperazine oestrone sulphate + 0.35 mg norethisterone (lowEP), or 2 mg 17 beta-oestradiol continuously combined with 1 mg norethisterone acetate (E2+NETA), or placebo.

MAIN OUTCOME MEASURES

Effect of treatment on endometrial histology, endometrial thickness, occurrence of uterine bleeding, endometrial oestrogen and progesterone receptor content, endometrial isocitrate dehydrogenase activity, and serum placental protein 14.

RESULTS

The incidence of bleeding declined with time. In the second treatment year, the women receiving lowEP reported on average 7.3 days of bleeding, highEP 16.7 days, and E2+NETA 11.2 days. Histological assessment of endometrial biopsies revealed an atrophic or slightly secretory endometrium. Serum placental protein 14 increased slightly, but was statistically highly significant, during treatment, but no cyclical variation was observed. Endometrial isocitrate dehydrogenase was low in all three hormone groups and the same low level of endometrial oestrogen receptor and progesterone receptor was found comparable to the level in the placebo group.

CONCLUSIONS

Histological and biochemical assessment of the endometrium showed that interrupted hormone replacement therapy induced the same pattern in endometrial parameters as continuous combined hormone replacement therapy.

Piperazine oestrone sulphate and interrupted norethisterone in postmenopausal women: effects on bone mass, lipoprotein metabolism, climacteric symptoms, and adverse effects

OBJECTIVE

To compare the effects of two doses of piperazine oestrone sulphate combined with interrupted norethisterone, with that of oestradiol continuously combined with norethisterone acetate, and with placebo, in postmenopausal women.

DESIGN

A prospective randomised trial.

PARTICIPANTS

Two hundred postmenopausal women.

SETTING

Monocentre study with expertise in osteoporosis.

METHODS

The participants were randomly assigned to two years of treatment with alternating three-day cycles of 1.5 mg of piperazine oestrone sulphate plus 0.7 mg of norethisterone (highEP), or alternating three-day cycles of 0.75 mg of piperaine oestrone sulphate plus 0.35 mg of norethisterone (lowEP), or 2 mg of 17beta-oestradiol continuously combined with 1 mg of norethisterone acetate (E2+NETA), or placebo.

MAIN OUTCOME MEASURES

Change in bone mineral density, lipoprotein metabolism, climacteric symptoms, and adverse effects.

RESULTS

One hundred and twenty-one women completed the study. Spinal bone mineral density was increased about 9% over two years by E2+NETA, about 6% by highEP, 4% by lowEP, but remained unchanged in the placebo group. The same pattern was seen in the hip and forearm. All hormone regimens decreased markers of bone turnover and alleviated climacteric symptoms. Serum lipoproteins decreased by about 10% in all hormone groups.

CONCLUSIONS

All hormone regimens studied prevented bone loss completely and lowered serum lipids.

Continuous combined hormone replacement therapy and its effects

The cessation of menstruation at the menopause is a great relief for most women. Hormone replacement therapy (HRT) in sequential regimens re-creates a monthly cycle and period-type bleeds, which are a major cause for dissatisfaction, especially for older, postmenopausal women. Continuous combined therapy aims to provide the benefits of HRT without cyclical bleeding.

Changes in normal lipid profile of menopausal women with combined hormone replacement therapy. Comparative clinical trial of two hormonal combinations (conjugated estrogens/medroxyprogesterone acetate versus estradiol valerate/cyproterone acetate)

OBJECTIVES

To compare the effect on plasma lipids of conjugated estrogens/medroxyprogesterone acetate (CE/MPA) and estradiol valerate/cyproterone acetate (EV/CPA) in healthy peri and postmenopausal women during 1 year.

METHODS

Multicentric, controlled, single blinded Phase III clinical trial. Women were randomized to two treatment groups: Group A (n = 49 women): CE 0.625 mg/day for 21 days and MPA 5 mg from day 12 to 21. Group B (n = 55 women): EV 2 mg/day for 21 days and CPA 1 mg from day 12 to 21. Total cholesterol (TC), high density cholesterol (HDL-C), low density cholesterol (LDL-C), triglycerides, aminotransferases and alkaline phosphatase were measured before starting therapy, and after 3, 6, 9 and 12 months of hormone replacement therapy (HRT). TC/HDL-C and LDL-C/HDL-C ratios were determined.

RESULTS

There were no changes in TC levels. HDL-C increased and LDL-C decreased significantly, with no differences between groups but within each group. Triglycerides increased significantly but remained within normal values, with no differences between groups. TC/HDL-C ratio showed a slight and steady decrease in both groups. LDL-C/HDL-C ratio decreased in both treatment groups.

CONCLUSION

Both cyclic sequential preparations used in HRT showed a favorable effect on plasma lipids in healthy peri and postmenopausal women, with an increase in HDL-C and a decrease in LDL-C levels, as well as in the LDL-C/HDL-C and TC/HDL-C ratios. Our study confirms the positive effect of estrogens on lipids, which does not seem to be adversely affected by the addition of progestogens derived from pregnanes.

Progestational effects of combinations of gestodene on the postmenopausal endometrium during hormone replacement therapy

OBJECTIVE

The aim of the study was to assess the dose-response effects on the postmenopausal endometrium of 3 sequential combined hormone replacement regimens and 1 continuous combined hormone replacement regimen of estradiol and gestodene.

STUDY DESIGN

In this 2-year double-blind, placebo-controlled study, 278 healthy postmenopausal women received either 2 mg estradiol sequentially combined with 50 microg or 25 microg gestodene, 1 mg estradiol sequentially or continuously combined with 25 microg gestodene, or placebo.

RESULTS

All 4 hormone treatment regimens produced a safe endometrial histologic appearance. The regimens that were based on the lower dose of 1 mg estradiol was associated with less uterine bleeding than were those that were based on 2 mg estradiol. For sequentially opposing the 2 mg dose of estradiol, the dose of 25 microg gestodene was less efficient in producing secretory activity than was the dose of 50 microg gestodene. The measurement of placental protein 14 in serum reflected the secretory transformation of the endometrial buildup.

CONCLUSION

The reduction in bleeding episodes associated with regimens with lower estradiol doses may lead to improved long-term therapy compliance by menopausal women. The potency of progestogens can be assessed by measuring the serum concentration of placental protein 14.

Update on androgenicity

The development of a new generation of progestins deemed less androgenic than their earlier counterparts has led to a number of misconceptions regarding their possible benefits in combination oral contraceptives. All combination oral contraceptives are beneficial for treating such androgenic conditions as acne and hirsutism. The only expressed androgenic effect of some first- and second-generation combined oral contraceptives are changes in plasma lipid and lipoprotein levels. However, the overall effect of today's low-dose oral contraceptives is largely lipid neutral, and human and monkey studies have shown that oral contraceptive use is associated with reduced, not increased, atherosclerosis rates. Myocardial infarction rates are not increased among oral contraceptive users, except among those who are heavy smokers.

Transdermal estrogen replacement therapy and plasma lipids in 693 French women

OBJECTIVES

The cardiovascular effects of transdermal estrogen are not so well established than those induced by oral estrogen. In a representative sample of French postmenopausal women, we assessed plasma lipid changes induced by transdermal 17 beta-estradiol.

METHODS

This cross-sectional study was carried out among the population sample of the third MONICA survey on cardiovascular risk factors. We selected 693 postmenopausal women according to the followed criteria; women with intact uterus and no menstruation for more than 12 months, women with bilateral oophorectomy, hysterectomized women older than 55 years and hysterectomized women who had followed hormone replacement therapy. We used multivariate linear regression models, taking into account confounding variables, to assess lipid changes induced by estrogen.

RESULTS

We compared 192 women currently taking transdermal 17 beta-estradiol (27 unopposed estrogen and 165 estrogen plus progestin) with 501 women without any hormonal treatment. After adjustment for living area, education level, income tax, smoking, alcohol consumption, physical activity, age and body mass index, transdermal estrogen replacement therapy (ERT) was significantly associated with lower levels of serum total cholesterol [6.10 (S.E., 0.11) vs 6.35 (0.09) mmol/l, P < 0.01], triglycerides [1.06 (0.06) vs 1.23 (0.05) mmol/l, P < 0.001], LDL-cholesterol [3.93 (0.11) vs 4.13 (0.09) mmol/l, P < 0.05], VLDL-cholesterol [0.48 (0.03) vs 0.56 (0.02) mmol/l, P < 0.001] and apolipoprotein B [1.20 (0.03) vs 1.26 (0.02) g/l, P < 0.01]. Levels did not differ significantly for HDL-cholesterol [1.68 (0.05) vs 1.66 (0.04) mmol/l] and apolipoprotein A1 [1.79 (0.03) vs 1.81 (0.02) g/l].

CONCLUSION

Transdermal ERT may confer a cardiovascular protection by lowering atherogenic lipoproteins.

The effects of different doses of medroxyprogesterone acetate on serum lipids, lipoprotein levels and atherogenic index in the menopausal period

The purpose of our study was to make a contribution to research in determining the least harmful progestogen dose for women who have not had their uterus removed. The study was an open comparative trial. The patients were consecutively assigned to two groups. The first group (n = 19) were given 0.625-mg conjugated equine estrogen plus 5-mg medroxyprogesterone acetate (MPA), and the second (n = 18) 0.625-mg conjugated equine estrogen plus 2.5-mg MPA. Serum total cholesterol (T-cholesterol), triglyceride, high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) levels plus LDL-C/HDL-C values (atherogenic index) were measured before the study and again after 6 and 12 months. These values were compared with ANOVA and postANOVA tests (Scheffe) within the groups and with unpaired t-test between the two groups. The triglyceride serum levels in the first group were decreased in the 12th month compared to baseline levels. In addition, LDL-C/HDL-C values were significantly decreased in the 6th month, but these values slightly increased in the following 6 months. In the second group, T-cholesterol, triglyceride, LDL-C and atherogenic index were decreased in the 12th month when compared to baseline levels within the groups. This decrease was statistically significant (p < 0.05). There was no significant difference between the two groups (p > 0.05). Hormone replacement therapy with continuous 0.625-mg conjugated equine estrogen and 2.5-mg MPA had a better effect on lipid profiles than 0.625-mg conjugated equine estrogens and 5-mg MPA after 12 months of treatment.

Norethindrone acetate enhances the antiatherogenic effect of 17beta-estradiol: a secondary prevention study of aortic atherosclerosis in ovariectomized cholesterol-fed rabbits

The influence of progestogens in combination with 17beta-estradiol (E2) on cardiovascular disease remains controversial. This study investigated the effect of norethindrone acetate (NETA) combined with E2 on aortic atherosclerosis. Eighty mature female rabbits were ovariectomized, then fed a cholesterol-rich diet (240 mg/d) for 14 weeks to induce aortic atherosclerosis. They were randomized to four equally large groups for the following 38-week intervention period. One group received placebo, another group oral E2 4 mg daily (E2), and the last two groups oral E2 4 mg daily combined with either NETA 1 mg (E2NETA1) or NETA 3 mg (E2NETA3). The cholesterol intake was reduced to a "maintenance" level of 80 mg/d during the intervention period. Total serum cholesterol and ultracentrifuged lipoproteins were analyzed enzymatically throughout the study. The cholesterol content in the aortic wall was 2.76+/-0.44 micromol/cm2 (mean+/-SEM) in the E2NETA1 group, 1.77+/-0.37 micromol/cm2 in the E2NETA3 group, 5.46+/-0.77 micromol/cm2 in the E2 group, and 7.20+/-0.94 micromol/cm2 in the placebo group (ANOVA P<0.0001). The difference (in the aortic cholesterol accumulation) between the E2 and each of the combined E2/NETA groups was statistically significant (P<0.01) but could only partly be explained by the differences in serum lipids and lipoproteins. In conclusion, NETA enhances the antiatherogenic effect of E2 in cholesterol-fed rabbits. This effect is only partially mediated through changes in serum lipids and lipoproteins.

The influence of transdermal oestradiol replacement therapy and medroxyprogesterone acetate on serum lipids and lipoproteins

AIMS

The objective of this study was to examine the effects of continuous transdermal oestradiol with or without sequential oral medroxyprogesterone acetate on serum lipids and lipoproteins in menopausal women.

METHODS

Sixty-two healthy menopausal women, attending at two menopause clinics in Western India, were recruited for this study over a period of 1 year. Group 1 included 38 hysterectomised women being treated with continuous transdermal oestradiol only (50 microg daily). Group 2 included 24 menopausal women with an intact uterus being treated with transdermal oestradiol (50 microg daily) and medroxyprogesterone acetate (10 mg daily for the first 12 days of each calendar month). Women maintained on 50 microg oestradiol throughout 6 months (group 1: n = 22; group 2: n = 16) were reviewed for changes in serum lipids and lipoproteins at the end of 6 months (group 1), and between days 8 and 12 of the seventh month (combined phase of treatment) (group 2).

RESULTS

In group 1, there was a small reduction in the concentrations of total cholesterol (-5.5%, P = 0.04) and a small but not significant reduction in LDL-cholesterol (-5.7%, P = 0.16). In group 2, there were no significant changes in total cholesterol (-4.2%, P = 0.43) and LDL-cholesterol (-3.9%, P = 0.57). HDL-cholesterol levels did not change significantly with unopposed transdermal oestradiol (+3.0%, P = 0.53), or with additional sequential medroxyprogesterone acetate (-3.8%, P = 0.32). Serum triglyceride concentrations decreased significantly in both the groups (-13.9%, P = 0.01, and -13.4%, P = 0.008, respectively). Serum lipid changes did not differ between the groups.

CONCLUSIONS

Transdermal oestrogen therapy appears to be of particular benefit for women with hypertriglyceridaemia. There were no significant adverse effects of medroxyprogesterone acetate on serum lipids and lipoproteins.

A comparative study of two levonorgestrel-containing hormone replacement therapy regimens of efficacy and tolerability variables

OBJECTIVE

To compare the effect of two sequential hormone replacement regimens differing in the dose of levonorgestrel on climacteric symptoms, bleeding pattern and lipid metabolism in postmenopausal women.

STUDY DESIGN

In a multicentre, randomized, double-blind, active-treatment-controlled study, 210 postmenopausal women were assessed at the end of treatment cycles 3 and 6. The high-levonorgestrel group was treated with 2 mg estradiol valerate (days 1-21) sequentially combined with 0.25 mg levonorgestrel (days 12-21). The low-levonorgestrel group received the same estrogen regimen (2 mg estradiol valerate, days 1-21), but levonorgestrel was administered sequentially in a dose of 0.15 mg during the last 12 days of the cycle (days 10-21). Statistical analysis by Student's t-test for dependent variables (measured values versus baseline) and independent variables (differences between groups), and the composite t-test method for comparison of both regimens with respect to efficacy, was performed.

RESULTS

Both groups were statistically comparable. The trial was completed by 137 subjects. Protocol violations occurred in 38 cases. Thirty-five subjects dropped out during the study, 21 of them because of adverse events. Both treatments were equally effective in the treatment of climacteric complaints. There were no clinically significant changes in body weight, blood pressure, haematological tests, and parameters of clinical chemistry. There was a tendency towards a reduction in bleeding intensity in both groups in the second half of the treatment period. The treatment for six cycles with both regimens significantly (P < 0.05) decreased plasma concentrations of triglycerides (significant in the low-levonorgestrel group only), high-density lipoprotein cholesterol, high-density lipoprotein-3-cholesterol, lipoprotein(a) and apolipoprotein A1. In parallel, the serum concentration of total cholesterol increased significantly in both treatment groups, whereas low-density lipoprotein cholesterol increased significantly in the high-levonorgestrel group only. The changes in high-density lipoprotein-2-cholesterol, and apolipoprotein B did not reach statistical significance.

CONCLUSIONS

It can be concluded that both sequential combined oral hormone replacement therapy (HRT) regimens were equivalent with respect to efficacy and tolerability in the treatment of women with climacteric complaints. The preparation with the lower dose of progestin showed a tendency towards a less unfavourable influence on the lipid profile.

Transdermal oestradiol gel in the treatment of the climacterium: a comparison with oral therapy

OBJECTIVE

To compare two doses of a transdermal oestradiol gel (Divigel/Sandrena) plus oral sequential medroxyprogesterone acetate (MPA) with oral oestradiol valerate plus oral sequential MPA (Divina/Dilena).

DESIGN

Two year, randomised, open-label, comparative study.

SETTING

Menopausal outpatient clinic in Helsinki.

SUBJECTS

Postmenopausal women with climacteric complaints or already using HRT.

INTERVENTIONS

(1) One gram gel containing 1 mg oestradiol for 3 months plus 20 mg oral MPA during the last 14 days; (2) 2 g gel containing 2 mg oestradiol for 21 days plus 10 mg oral MPA during the last 14 days; (3) 2 mg oestradiol valerate tablets for 3 weeks plus 10 mg oral MPA during the last 10 days. In all groups, each treatment period was followed by a 7-day medication-free interval.

MAIN OUTCOME MEASURES

Climacteric complaints, bleeding control, bone mineral density, biomarkers of bone metabolism, lipid profile, tolerability and safety.

RESULTS

With each preparation, climacteric complaints were significantly reduced and good bleeding control was obtained. In addition, maintenance of bone mineral density as well as a reduction of bone turnover was achieved in all groups. Lipid parameters showed no unfavourable changes. Continuation rates were similar in all groups with overall 74% of patients completing the first year, whereas 94% of patients who elected to continue completed the second year. Tolerability of the gel was good: only 1.7% of patients discontinued treatment due to skin irritation.

CONCLUSIONS

Transdermal oestradiol gel and oral oestradiol valerate tablets, used in combination with oral sequential MPA, are effective regimens of HRT in postmenopausal women. Transdermal oestradiol gel is an efficient, well-tolerated form of HRT.

Effects of transdermal oestrogen therapy in postmenopausal women: a comparative study of an oestradiol gel and an oestradiol delivering patch

OBJECTIVE

To compare the efficacy, safety and tolerability of an oestradiol gel (1.0 mg of oestradiol daily, Divigel/Sandrena) with those of an oestradiol delivering patch (delivering 50 micrograms oestradiol/24 h, Estraderm TTS) in hormone replacement therapy of postmenopausal women. Dydrogesterone tablets (Terolut), 10 mg daily for the first 12 days of every month, were used as the progestogen component of the therapy.

MAIN OUTCOME MEASURES

The effect of treatment on clinical symptoms and on endometrium, total body bone mineral density and lipid metabolism as well as the tolerability of the treatments with special emphasis on skin irritation and compliance were evaluated.

DESIGN

An open, randomised, controlled, parallel-group trial of 12 months' duration.

SETTING

The Medical Clinic of Kalevankatu, Helsinki, Finland.

PARTICIPANTS

One hundred twenty postmenopausal women were treated with transdermal oestradiol combined with dydrogesterone. In addition, 25 women without HRT served as a reference group for the bone mineral density measurements.

RESULTS

Both treatment regimens were equally effective in alleviating climacteric symptoms, preserving bone mineral density and were equally safe. A trend towards heavier bleeding was detected in patients treated with the oestradiol delivering patch. A statistically nonsignificant decrease of total cholesterol and triglyceride concentrations but no change in high-density lipoprotein cholesterol concentration was observed in both groups. The acceptability of the treatment was higher in the gel group (96.4%) than in the patch group (90.7%). Only two (3.3%) women using the oestradiol gel complained of skin irritation whereas 28 patients (46.7%, P < 0.001) using the oestradiol delivering patch reported this adverse effect.

CONCLUSIONS

Both the oestradiol gel and the oestradiol delivering patch are equally effective in hormone replacement therapy but the gel preparation is less irritative to the skin.

Differential effects of subcutaneous estrogen and progesterone on low-density lipoprotein size and susceptibility to oxidation in postmenopausal rhesus monkeys

OBJECTIVE

To study the differential effects of subcutaneous E2 alone or in combination with P on the susceptibility of low-density lipoprotein (LDL) cholesterol to oxidation in naturally postmenopausal diet-controlled rhesus monkeys.

DESIGN

Prospective, longitudinal controlled study.

SETTING

Oregon Health Sciences University, Portland, Oregon, and Oregon Regional Primate Research Center, Beaverton, Oregon.

PATIENT(S)

Five naturally postmenopausal rhesus monkeys.

INTERVENTION(S)

Estradiol was administered subcutaneously for the first 4 weeks, followed by E2 plus P for 4 weeks, followed by a third 4-week washout period.

MAIN OUTCOME MEASURE(S)

Changes in plasma lipoprotein levels and oxidation of LDL and serum concentrations of E2 and P.

RESULT(S)

Levels of LDL cholesterol fell after 4 weeks of treatment with E2, compared with baseline. The lag time to half maximal light absorbancy after 4 weeks of E2 treatment was significantly increased compared with baseline. The maximal absorbance values and the slope of the propagation phase after 4 weeks of treatment with E2 were decreased compared with baseline. After 4 weeks of combined E2 and P treatment, all values were comparable to baseline.

CONCLUSION(S)

These results suggest that subcutaneous E2 therapy appears to enhance LDL resistance to oxidation and that this effect is attenuated by the addition of the P.

A study on the effects of Norplant implantable contraceptive on lipid, lipoprotein, and apolipoprotein metabolism in Singaporean women

The Norplant subdermal implants system is rapidly becoming acceptable as a contraceptive system all over the world. Earlier studies in Singapore indicated that the implants do not appear directly contributory to cardiovascular risk. However, extraneous environmental effects could have contributed to the observed changes. In this study, when nonsteroid copper intrauterine device (IUD) users were used as control, we have shown that the findings are in concordance with the results of the earlier studies. There was a decrease in serum triglycerides, total cholesterol, and HDL and LDL cholesterol over the period of study. However, despite these changes the HDL cholesterol/total cholesterol ratio remained stable and was above 0.200. As regards apolipoprotein, there was generally a significant full in apolipoprotein AI, AII, and B. As a result, the apolipoprotein AI/AII ratio showed a significant decrease in the first 3 months before increasing close to its preinsertion value at 2 years. Similarly, the apolipoprotein AI/B ratio also stabilized at the end of 2 years. This study thus confirms our earlier findings that Norplant implants do not appear directly contributory to cardiovascular risk.

Impact of combined hormone replacement therapy on serum lipid metabolism: new aspects

The objective of this study was to evaluate the impact of combined estrogen-progestogen therapy on low density lipoprotein (LDL) particle size (determined by the LDL cholesterol/apolipoprotein B ratio). The prospective study was carried out on 139 healthy Danish early postmenopausal women. The subjects were randomized to placebo or to 2 mg estradiol valerate equivalents, either sequentially combined with 75 micrograms levonorgestrel, 10 mg medroxyprogesterone acetate (MPA), or 150 micrograms desogestrel, or continuously combined with 1 mg cyproterone acetate. LDL particle size was calculated before treatment and at nine-well-defined times during the subsequent 84 days. LDL particle size was reduced by all four treatments. This change was statistically significant for estradiol valerate combined with levonorgestrel and MPA (6.2 +/- 2.7% and 5.6 +/- 2.1% (mean +/- SEM), respectively; p < 0.05 for both, placebo-corrected). Estradiol valerate combined with MPA induced cyclic (progestogen-minus estrogen-related values) decreases (-6.3 +/- 2.6%; p < 0.05), and with levonorgestrel there were cyclic increases (5.1 +/- 2.7%; p = 0.067) in LDL particle size (placebo-corrected). In conclusion, combined estrogen-progestogen therapy causes a decrease in LDL particle size. A cyclic variation in LDL cholesterol/apolipoprotein B ratio was observed during sequential treatment.

Metabolic effect of two hormonal preparations in postmenopausal women

OBJECTIVES

To compare the metabolic and endocrinological effects of estradiol valerate/cyproterone acetate (EV/CPA) to a regimen of conjugated estrogens/medroxyprogesterone acetate (CE/MPA) in postmenopausal women.

METHODS

Lipid profile, endocrinological parameters, coagulation factors, renin and angiotensinogen were followed in postmenopausal women randomized to EV/CPA or CE/MPA during 12 cycles.

RESULTS

Following 12 cycles of treatment, total plasma cholesterol decreased more with EV/CPA than with CE/MPA. Low-density cholesterol decreased with EV/CPA while it increased with CE/MPA. High-density cholesterol remained fairly unchanged, and triglycerides increased significantly in both groups. Estradiol and estrone levels increased significantly more with EV/CPA than with CE/MPA while the sex-hormone-binding globulin increased more with CE/MPA. Follicle stimulating and luteinizing hormone levels also decreased significantly. Total testosterone and dihydroepiandrosterone sulfate remained stable. Total levothyroxine serum levels increased significantly, but thyroid stimulating hormone and triiodothyronine levels remained stable. Coagulation parameters also remained stable. Angiotensinogen increased, while plasma renin activity and blood pressure remained unchanged.

CONCLUSION

It is concluded that both EV/CPA and CE/MPA produce favourable metabolic effects. A better lipid profile, compatible with decreased cardiovascular risk, is observed with the EV/CPA regimen. Higher circulating estrogen levels may explain in part this observation.

Nonestrogen management of menopausal symptoms

Women who cannot or choose not to take estrogens do have alternatives; however, the options are few and unproven in longterm clinical trials with respect to safety and efficacy. Many available alternative treatments may alleviate the symptoms of the menopause, but do not convey long-term protection against osteoporosis and cardiovascular disease. This article reviews treatment alternatives to estrogen replacement therapy for symptomatic relief.

Comparative clinical evaluation of the effect on carbohydrate and lipid metabolism of two norethisterone-containing hormonal contraceptives: Mesigyna and TriNovum

The effect on carbohydrate and lipid metabolism of two hormonal contraceptive preparations containing norethisterone (commercially known as Mesigyna and TriNovum) was studied in a total of 60 women, before and after 6 months of treatment. Carbohydrate metabolism was evaluated by means of a euglycemic glucose clamp test; lipid metabolism was monitored by measuring total cholesterol, HDL-cholesterol, LDL-cholesterol, VLDL-cholesterol, and triglycerides. The two groups were properly matched with the exception of pretreatment levels of cholesterol and LDL-cholesterol. At the end of treatment, no difference was found within or between groups in fasting glucose and insulin levels and in glucose rate of disappearance. A significant increase in total cholesterol, HDL-cholesterol, and VLDL-cholesterol was found in both groups at the end of the treatment period; in addition, TriNovum caused a significant increase also in triglycerides. In conclusion, the safety of both preparations with regard to carbohydrate metabolism was confirmed using the most accurate method available; furthermore, changes in lipid metabolism were such as to have little clinical significance.

Differences in erythrocyte membrane cholesterol to phospholipids ratio in postmenopausal women with and without hormone replacement

OBJECTIVES

To investigate the changes in the cholesterol:phospholipids (C/PL) ratio of erythrocyte membrane in post-menopausal women with and without hormone replacement therapy (HRT).

STUDY DESIGN

A cross-sectional study including 83 patients divided into three groups according to HRT (group 1, no HRT (n = 52); group 2, combined HRT (n = 16); and group 3, estrogen-only therapy (n = 15)).

RESULTS

The C/PL ratio was lower in group 2 with respect to group 1 and group 3 (P = 0.03). No difference was found in erythrocyte membrane cholesterol between the three groups; however, the phospholipid concentration was higher in group 2 with respect to the other groups (P < 0.05). In the control group, C/PL values correlated positively with plasma LDL levels (P < 0.005) and negatively with HDL levels (P < 0.005).

CONCLUSIONS

From our data the addition of progestogens in HRT appears to decrease the C/PL of the erythrocyte membrane possibly resulting in a beneficial effect on rheological properties of erythrocyte membrane. The results of our study thus suggest additional benefits from supplementation of progestogens in HRT, in addition to prevention of estrogen dependent endometrial hyperplasia and adenocarcinoma.

Responses of HDL subclasses, Lp(A-I) and Lp(A-I:A-II) levels and lipolytic enzyme activities to continuous oral estrogen-progestin and transdermal estrogen with cyclic progestin regimens in postmenopausal women

Seventy postmenopausal women took part in the study. Subjects received either continuous oral 17 beta-estradiol 2 mg/day combined with norethisterone acetate 1 mg/day (E2/NETA, Kliogest) or transdermal treatment consisting of 28 day cycles with patches delivering 17 beta-estradiol 50 micrograms/day (Estraderm) combined with cyclic medroxyprogesterone acetate 10 mg/day (E2/MPA, Provera), on days 17-28. At baseline the serum lipid and lipoprotein concentrations, composition and concentrations of high density lipoprotein (HDL) subclasses, lipoprotein (Lp)(AI) and Lp(A-I:A-II) levels were comparable in the two groups. In the E2/NETA group, after 12 months hormone replacement therapy (HRT), the HDL2 cholesterol concentration decreased by 17% (P < 0.01) and the HDL3 cholesterol remained unchanged. The concentrations of HDL2b, HDL2a and HDL3a were reduced by 30, 26 and 15%, respectively, P < 0.001, and the cholesterol:triglyceride ratio decreased significantly in all HDL subclasses. Apolipoprotein (apo) A-I concentration decreased by 5% (P < 0.05), but apo A-II, Lp(A-I) and Lp(A-I:A-II) concentrations remained unchanged. In the E2/MPA group the HDL2 and HDL3 cholesterol levels were both reduced by 6% (P < 0.05) and the HDL3a, HDL3b and HDL3c concentrations decreased by 14, 12 and 17% during the E2/MPA phase compared with baseline (P < 0.01). No major changes in the composition of HDL subclasses occurred in the E2 MPA group during treatment. The apo A-I and Lp(A-I) levels were not changed, but apo A-II and Lp(A-I:A-II) concentrations decreased by 8 and 5%, P < 0.001 and P < 0.05, respectively. At 12 months the postheparin plasma hepatic lipase (HL) activity decreased only in the E2/NETA group (by 12%, P < 0.05). The cholesteryl ester transfer protein (CETP) activity was not affected by either HRT regimen. The results of our study show that the 2 HRT regimens have multiple effects on HDL particles and HRT induced changes in HDL are not associated with changes in activities of lipolytic enzymes or CETP.