The long-term effects of low-dose 17β-estradiol and dydrogesterone hormone replacement therapy on 24-h ambulatory blood pressure in hypertensive postmenopausal women: a 1-year randomized, prospective study

The association of hormone therapy with blood pressure control in postmenopausal women with hypertension: a secondary analysis of the Women's Health Initiative clinical trials

OBJECTIVE

The objective of this study was to assess the effect of menopausal hormone therapy (HT) on blood pressure control in postmenopausal women with hypertension.

METHODS

The Women's Health Initiative HT clinical trials were double-blinded, randomized, placebo-controlled studies of women aged 50 to 79 years testing the effects of HT (conjugated equine estrogens [CEE, 0.625 mg/d] or CEE + medroxyprogesterone acetate [MPA; 2.5 mg/d]) on risks for coronary heart disease and invasive breast cancer, the primary outcomes for efficacy and safety, respectively. This secondary analysis of the Women's Health Initiative HT trials examined a subsample of 9,332 women with hypertension (reported ever taking pills to treat hypertension or were taking antihypertensive medication) at baseline. Blood pressure was measured at baseline and up to 10 annual follow-up visits during the planned study phase. Antihypertensive medications were inventoried at baseline and years 1, 3, 6, and 9 during the study, and self-reported during extended follow-up: 2009-2010 and 2012-2013, which occurred median of 13 and 16 years after randomization, respectively. The intervention effect was estimated through year 6. Cumulative follow-up included all visits.

RESULTS

Compared with placebo, CEE-alone had significantly ( P = 0.02) higher systolic blood pressure (SBP) by mean (95% confidene interval [CI]) = 0.9 (0.2-1.5) mm Hg during the intervention phase. For cumulative follow-up, the CEE arm was associated with increased SBP by mean (95% CI) = 0.8 (0.1-1.4) mm Hg ( P = 0.02). Furthermore, CEE + MPA relative to placebo was associated with increased SBP by mean (95% CI) = 1.8 (1.2-2.5) mm Hg during the intervention phase ( P < 0.001). For cumulative follow-up, the CEE + MPA arm was associated with increased SBP by mean (95% CI) = 1.6 (1.0-2.3) mm Hg ( P < 0.001). The mean number of antihypertensive medications taken at each follow-up visit did not differ between randomization groups during the intervention or long-term extended follow-up of 16 years.

CONCLUSION

There was a small but statistically significant increase in SBP in both CEE-alone and CEE + MPA arms compared with placebo during both the intervention and cumulative follow-up phases among postmenopausal women with hypertension at baseline. However, this increase in SBP was not associated with an increased antihypertensive medication use over time among women randomized to HT compared with placebo.

Puerarin enhances proliferation and osteoblastic differentiation of human bone marrow stromal cells via a nitric oxide/cyclic guanosine monophosphate signaling pathway

Puerarin, a major active isoflavone extracted from the Traditional Chinese Medicine Radix Puerariae, has been studied for its comprehensive biological effects. However, to date, its effect on bone formation and the underlying mechanism of action have not been well investigated. The present study investigated the effect of puerarin on cell proliferation and osteoblastic maturation in cultured human bone marrow stromal cells (hBMSC) in vitro. Puerarin (2.5-100 µM) increased hBMSC growth in a dose-dependent manner, as indicated by an MTT assay, and stimulated osteoblastic maturation as indicated by assessment of alkaline phosphatase (ALP) activity, as well as calcium deposition into the extracellular matrix detected by alizarin red S staining. Furthermore, polymerase chain reaction analysis showed that the expression of osteoblastic markers, including Runt-related transcription factor 2/core-binding factor alpha 1, osterix and osteocalcin, were increased in hBMSCs following incubation with puerarin. Further experiments indicated that puerarin increased the nitric oxide (NO) production and cyclic guanosine monophosphate (cGMP) content in hBMSCs. The effects of puerarin were mimicked by 17β-estrodiol (10(-8) M) and were abolished in the presence of estrogen receptor antagonist ICI182780 (10(-7) M). A NO synthase inhibitor, Nx-nitro-L-arginine methylester (6 x 10(-3) M), significantly attenuated puerarin-induced increases in NO production and cGMP content, in parallel with a reduction of cell proliferation and osteoblastic differentiation as well as the expression of osteoblastic markers. These results suggested that puerarin may prevent osteoporosis by exerting stimulatory effects on bone formation and the NO/cGMP pathway, which has an important role in puerarin-induced hBMSC proliferation and osteoblastic differentiation.

Does hormone therapy affect blood pressure changes in the Diabetes Prevention Program?

OBJECTIVE

This study aims to examine whether blood pressure reductions differ by estrogen use among overweight glucose-intolerant women.

METHODS

We conducted a secondary analysis of Diabetes Prevention Program postmenopausal participants who used oral estrogen with or without progestogen at baseline and 1-year follow-up (n = 324) versus those who did not use oral estrogen with or without progestogen at either time point (n = 382). Changes in systolic blood pressure (SBP) and diastolic blood pressure (DBP) were examined by randomization arm (intensive lifestyle change [ILS], metformin 850 mg twice daily, or placebo). Associations between changes in blood pressure and changes in sex hormone-binding globulin, estradiol, testosterone, and dehydroepiandrosterone were also examined.

RESULTS

Estrogen users and nonusers had similar prevalences of baseline hypertension (33% vs 34%, P = 0.82) and use of blood pressure medications at baseline (P = 0.25) and on follow-up (P = 0.10). Estrogen users and nonusers randomized to ILS had similar decreases in SBP (-3.3 vs -4.7 mm Hg, P = 0.45) and DBP (-3.1 vs -4.7 mm Hg, P = 0.16). Among estrogen users, women randomized to ILS had significant declines in SBP (P = 0.016) and DBP (P = 0.009) versus placebo. Among nonusers, women randomized to ILS had significant declines in DBP (P = 0.001) versus placebo, but declines in SBP were not significant (P = 0.11). Metformin was not associated with blood pressure reductions versus placebo regardless of estrogen therapy. Blood pressure changes were not associated with changes in sex hormones regardless of estrogen therapy.

CONCLUSIONS

Among overweight women with dysglycemia, the magnitude of blood pressure reductions after ILS is unrelated to postmenopausal estrogen use.

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.

Menopausal hormone therapy: examining cardiovascular and clinical impacts of treatment

Postmenopausal women have reduced levels of female sex hormones and this may play a significant role in the onset of cardiovascular disease. Menopausal hormone therapy (MHT), which is primarily prescribed for the treatment of perimenopausal symptoms, has been associated with risk of coronary heart disease, hypertension and stroke in women. This review will summarize the outcomes of observational studies and randomized clinical trials that have investigated the influence of MHT use on the cardiovascular system. In addition, it will explore how the timing of MHT prescription relative to menopause, dosage and route of administration may alter the impact of MHT on cardiovascular health.

Menopausal hormone therapy is associated with having high blood pressure in postmenopausal women: observational cohort study

BACKGROUND

The relationship between menopausal hormone therapy (MHT) and cardiovascular risk remains controversial, with a number of studies advocating the use of MHT in reducing risk of cardiovascular diseases, while others have shown it to increase risk. The aim of this study was to determine the association between menopausal hormone therapy and high blood pressure.

METHODS AND FINDINGS

A total of 43,405 postmenopausal women were included in the study. Baseline data for these women were sourced from the 45 and Up Study, Australia, a large scale study of healthy ageing. These women reported being postmenopausal, having an intact uterus, and had not been diagnosed with high blood pressure prior to menopause. Odds ratios for the association between MHT use and having high blood pressure were estimated using logistic regression, stratified by age (<56 years, 56-61 years, 62-70 years and over 71 years) and adjusted for demographic and lifestyle factors. MHT use was associated with higher odds of having high blood pressure: past menopausal hormone therapy use: <56 years (adjusted odds ratio 1.59, 99% confidence interval 1.15 to 2.20); 56-61 years (1.58, 1.31 to 1.90); 62-70 years (1.26, 1.10 to 1.44). Increased duration of hormone use was associated with higher odds of having high blood pressure, with the effect of hormone therapy use diminishing with increasing age.

CONCLUSIONS

Menopausal hormone therapy use is associated with significantly higher odds of having high blood pressure, and the odds increase with increased duration of use. High blood pressure should be conveyed as a health risk for people considering MHT use.

Women and heart disease

In the United States heart disease causes more than one-third of all deaths and most of these occur in women, not men, although women and health care professionals alike continue to view death from heart disease as a threat primarily to middle-aged men. The disparity between genders in the incidence of cardiovascular disease (CVD) may be the result of significant differences in both cardiovascular risk factors and presentation between men and women. This article reviews recent data regarding unique sex-specific characteristics of both risk for, and presentation of, CVD in women.

Burden of illness of hypertension among women using menopausal hormone therapy: a US perspective

OBJECTIVE

To estimate the burden of illness (BOI) of hypertension in a cohort of women receiving menopausal hormone therapy (HT).

METHODS

Patients with at least one prescription for menopausal HT were selected from the PharMetrics database during the period July 1, 2003, to June 30, 2005. Hormone therapy patients were divided into those with and without hypertension. The nonhypertensive cohort was propensity score-matched to the hypertensive cohort, controlling for patient demographics, overall comorbidities, and type of HT use. The BOI of hypertension in the menopausal HT cohort was defined as the difference in average annual total healthcare expenditures per person between the cohorts.

RESULTS

The prevalence of menopausal HT use was 9.75% among potentially eligible patients in this commercially insured sample. Hypertension was the most common comorbidity in the menopausal HT cohort, with a prevalence of 34%. Hormone therapy patients with hypertension (n = 106,729) had significantly higher average annual healthcare expenditures compared to matched HT patients without hypertension ($8908 vs. $5960 per person per year; difference of $2948; p < 0.001).

CONCLUSIONS

Hypertension is the most common comorbidity among menopausal HT users in the United States. The annual BOI of hypertension is both substantial and significant when compared to matched patients without hypertension, averaging $2948 per patient per year.

Cardiovascular disease in women

The rates of cardiovascular disease (CVD) have decreased significantly for men over the past few decades, but similar reductions have not occurred in women. Consequently, CVD remains the leading killer of women in the United States. Men usually develop heart disease earlier than women, but women develop heart disease more rapidly once menopause has occurred. A review of risk factors that are common between men and women demonstrates some notable sex-dependent differences. Many of these changes appear related to the hormonal changes that occur in menopause, such as the development of hypertension, changes in lipid concentrations, and central adiposity. In addition, diabetes is a more significant risk factor for CVD in women than men. Sociologic and physiologic factors need to be considered in treatment of risk factors, such as smoking, lack of exercise, obesity, and depression. Prevention is known to significantly reduce CVD risk, but new goals are being established for women as the sex-dependent differences have become apparent.

Low-dose transdermal hormone therapy does not interfere with the blood pressure of hypertensive menopausal women: a pilot study

OBJECTIVES

To determine the effects of low-dose transdermal hormone therapy (HT) on systolic (SBP) and diastolic (DBP) blood pressure (BP) evaluated by 24-h ambulatory blood pressure monitoring (ABPM) in hypertensive postmenopausal women.

METHODS

The study was conducted on 24 hypertensive postmenopausal women aged, on average, 54 years and under treatment with enalapril maleate (10-20 mg/day) combined or not with hydrochlorothiazide (25 mg/day). Thirteen women used a transdermal adhesive containing estradiol and norethisterone (25 and 125 mug active substance/day, respectively) and 11 did not receive HT. ABPM, lipid profile, and climacteric symptoms were evaluated before and 3 and 6 months after treatment.

RESULTS

After 3 and 6 months of follow-up, there was a statistically significant reduction of the Blatt-Kupperman menopausal index in the treated group (19.6+/-8.3 vs. 9.6+/-5.9 vs. 9.7+/-7.0; P=0.01). No significant difference in any of the ABPM variables (areas under the systolic and diastolic curves, mean SBP and DBP, SBP and DBP loads and wakefulness-sleep variation) or in the lipid profile was observed between or within groups at the three time points studied.

CONCLUSION

Low-dose transdermal HT administered for 6 months was effective in improving climacteric symptoms and did not change BP values or circadian pattern in postmenopausal women with mild-to-moderate arterial hypertension taking antihypertensive medications.