HRT in the early menopause: scientific evidence and common perceptions

Hormone replacement therapy for women with type 1 diabetes mellitus

BACKGROUND

There is conflicting information about the impact of the menopause on glycaemic control amongst women with type 1 diabetes. Some menopausal women with type 1 diabetes are treated with hormone replacement therapy (HRT) but the effects of this treatment have, to date, not been established.

OBJECTIVES

To assess the effects of HRT for women with type 1 diabetes mellitus.

SEARCH METHODS

We searched The Cochrane Library, MEDLINE, EMBASE, CINAHL and PsycINFO from their inception to June 2012. The last search was run for all databases on 18 June 2012.

SELECTION CRITERIA

We selected randomised controlled trials or controlled clinical trials that involved peri- or postmenopausal women with type 1 diabetes undergoing HRT as an intervention.

DATA COLLECTION AND ANALYSIS

Two researchers independently applied the inclusion criteria to the identified studies and assessed risk of bias. Disagreements were resolved by discussion or by intervention by a third party. Descriptive analysis was conducted for the review.

MAIN RESULTS

Ninety-two publications were screened. No studies met the inclusion criteria exclusively but one study that included both type 1 and type 2 diabetes participants was considered. This randomised clinical trial (RCT) compared HRT (N = 27) with placebo (N = 29) over 12 months. The outcome measures were cardiovascular risk factors, including lipid profile, glycaemic control, blood pressure and body weight. No significant differences between placebo and HTR were detected. Patient-important outcomes like all-cause mortality, cardiovascular disease, diabetic complications or health-related quality of life were not investigated.

AUTHORS' CONCLUSIONS

There is a lack of evidence around the use of HRT in women with type 1 diabetes. The one study that has been undertaken in this area is underpowered. More RCTs are required in the area to examine the impact of HRT on glycaemic control and cardiovascular outcomes.

The effects of heuristic cues, motivation, and ability on systematic processing of information about breast cancer environmental factors

The heuristic systematic model is used to investigate how ability, motivation, and heuristic message cues predict knowledge scores for individuals receiving messages written for different literacy levels about 3 environmental risk factors for breast cancer. The 3 risk factors were the roles of genetics, progesterone, and ingesting perfluorooctanoic acid in breast cancer risk. In this study, more than 4,000 women participated in an online survey. The results showed support for the hypotheses that ability (measured as education, number of science courses, and confidence in scientific ability) predict knowledge gain and that those individuals who presented with the lower literacy level message had significantly higher knowledge scores across all 3 message topics. There was little support for motivation or heuristic cues as direct predictors of knowledge gain across the 3 message topics, although they served as moderators for the perfluorooctanoic acid topic. The authors provide implications for health communication practitioners.

Risk-Benefit Analysis of Combination vs. Unopposed HRT in Post-Menopausal Women

Many trials on the use of hormone replacement therapy (HRT) have provided contradictory results on its risks and benefits in post-menopausal women. The use of HRT declined globally following publication of the first data from the Women’s Health Initiative (WHI) trial in 2002, with the revelation that there was an increased risk of breast cancer and coronary heart disease (CHD) in postmenopausal women taking HRT. Following this, other leading studies published results that were consistent with these findings, which reduced enthusiasm for HRT use. However, recent publications from the International Menopause Society indicate that HRT is the first-line and most effective treatment for menopausal symptoms. Moreover, when the full results of the WHI trial were subsequently published, it appeared that HRT may confer benefits for CHD prevention below age 60. The statements from the British Menopause Society and the International Menopause Society (IMS) published in 2008 also supported this opinion. These revelations renew interest in HRT use. This paper analyzes the effects of combination versus unopposed HRT on osteoporosis, breast and CHD, endometrial cancer induction, venous thromboembolic disease, lipids and lipoproteins, neuroprotection, and cognitive function in post-menopausal women.

Cardiovascular risk factors in women and the role of sex hormones

Despite certain success in the recent years, the problem of cardiovascular disease (CVD) in women remains one of the greatest challenges of the 21st century. Its social and economic burden will continue to increase, due to increasing proportion of older women in the population. Recently, cardiologists have been focusing on menopause as a specific CVD risk factor in women. At the same time, other conditions, also increasing CVD risk, such as certain pregnancy complications and premature menopause, have not received enough attention. Hormone replacement therapy (HRT) remains the first-line treatment and the most effective strategy in young women with estrogen deficiency and postmenopausal women with menopausal symptoms. HRT effectiveness and safety is based on its timely start, low dose, and individually appropriate combination of estrogens and progestins. Interdisciplinary approach is essential for early identification of high-risk women, since lifestyle modification recommendations, diagnostic procedures, and, if needed, an active therapeutic intervention could reduce future CVD incidence in these women.

Benzothiophene Selective Estrogen Receptor Modulators Provide Neuroprotection by a novel GPR30-dependent Mechanism

The clinical benzothiophene SERM (BT-SERM), raloxifene, was compared with estrogens in protection of primary rat neurons against oxygen-glucose deprivation (OGD). Structure-activity relationships for neuroprotection were determined for a family of BT-SERMs displaying a spectrum of ERα and ERβ binding affinity and agonist/antagonist activity, leading to discovery of a neuroprotective pharmacophore, present in the clinically relevant SERMS, raloxifene and desmethylarzoxifene (DMA), for which submicromolar potency was observed for neuroprotection. BT-SERM neuroprotection did not correlate with binding to ER nor classical ER activity, however, both the neuroprotective SERMs and estrogens were shown, using pharmacological probes, to activate the same kinase signaling cascades. The antiestrogen ICI 182,780 inhibited the actions of estrogens, but not those of BT-SERMs, whereas antagonism of the G-protein coupled receptor, GPR30, was effective for both SERMs and estrogens. Since SERMs have antioxidant activity, ER-independent mechanisms were studied using the classical phenolic antioxidants, BHT and Trolox, and the Nrf2-dependent cytoprotective electrophile, sulforaphane. However, neuroprotection by these agents was not sensitive to GPR30 antagonism. Collectively, these data indicate that the activity of neuroprotective BT-SERMs is GPR30-dependent and ER-independent and not mediated by antioxidant effects. Comparison of novel BT-SERM derivatives and analogs identified a neuroprotective pharmacophore of potential use in design of novel neuroprotective agents with a spectrum of ER activity.

On the need to clarify and disseminate contemporary knowledge of hormone therapy initiated near menopause

The dramatic change in opinion on postmenopausal hormone therapy (HT) following initial reports from the Women's Health Initiative (WHI) came about as the 'baby boom' generation of women created the largest population of newly menopausal women in history. That trial of conjugated equine estrogen (CEE) plus medroxyprogesterone acetate (MPA) focused on outcomes in women starting HT a decade or more after menopause. Yet clinical practice has focused on initiation near menopause. Recent findings in the limited numbers of younger menopausal women in the WHI CEE + MPA trial, and findings in the CEE-only trial, suggest that age at initiating HT strongly influences outcomes, and that benefits greatly exceed risk for most women who start within 10 years of menopause. Findings in other cohorts support this view. Benefits are both short (vasomotor, dyspareunia) and long term (bone health, possible coronary risk reduction). Not all postmenopausal women have indications for HT, but, even if the fraction is one-third, the numbers affected are staggering. Low-dose and non-oral regimens, and other compounds, were introduced in the wake of the WHI. Emerging evidence suggests that these may further reduce risk in some population subgroups. The demonizing of HT may already have caused a burden of chronic disease that could have been mitigated or delayed. It is time for action to re-establish appropriate clinical context based on this emerging evidence, to reverse the inappropriate broad generalization of the WHI findings to younger menopausal women, and to support outcomes studies of current regimens in younger menopausal women.

Urogenital disorders associated with oestrogen deficiency: the role of promestriene as topical oestrogen therapy

Urogenital disorders associated with oestrogen deficiency affect many women throughout menopausal transition. Symptoms such as vaginal dryness, burning, pruritus, dyspareunia, urinary tract urgency/frequency and incontinence have a significant impact on the individual's quality of life. For younger and healthy menopausal women, systemic oestrogen replacement may improve both vasomotor and urogenital symptoms and will be the treatment of choice. However, a proportion of women on systemic therapy still experience symptoms associated with urogenital atrophy, and patients with oestrogen-dependent cancers may be at risk from systemic oestrogen replacement. For women with mainly urogenital symptoms, local oestrogen is a logical choice and it is often more effective than systemic hormone replacement therapy. Generally speaking, there are no contraindications to local therapy. In terms of which topical preparation to use, a wide range of products are available. Promestriene is an analogue of oestradiol which is minimally absorbed and it has been shown to be effective in reversing atrophic changes caused by oestrogen deficiency in women undergoing natural or surgically induced menopause. Given the absence of systemic activity, promestriene may be a good choice in women requiring purely locally oestrogen, and those who have survived, or who are at risk of breast cancer and who have severe vulvo-vaginal symptoms.

Revisiting estrogen: efficacy and safety for postmenopausal bone health

The rapid decline in endogenous estrogen production that occurs during menopause is associated with significant bone loss and increased risk for fragility fracture. While hormone therapy (HT) is an effective means to re-establish endogenous estrogen levels and reduce the risk of future fracture, its use can be accompanied by undesirable side effects such as stroke and breast cancer. In this paper, we revisit the issue of whether HT can be both safe and effective for the prevention of postmenopausal bone loss by examining standard and alternative doses and formulations of HT. The aim of this paper is to continue the dialogue regarding the benefits and controversies of HT with the goal of encouraging the dissemination of-up-to date evidence that may influence how HT is viewed and prescribed.

Estrogen and angiotensin interaction in the substantia nigra. Relevance to postmenopausal Parkinson's disease

Epidemiological studies have reported that the incidence of Parkinson's disease (PD) is higher in postmenopausal than in premenopausal women of similar age. Several laboratory observations have revealed that estrogen has protective effects against dopaminergic toxins. The mechanism by which estrogen protects dopaminergic neurons has not been clarified, although estrogen-induced attenuation of the neuroinflammatory response plays a major role. We have recently shown that activation of the nigral renin-angiotensin system (RAS), via type 1 (AT1) receptors, leads to NADPH complex and microglial activation and induces dopaminergic neuron death. In the present study we investigated the effect of ovariectomy and estrogen replacement on the nigral RAS and on dopaminergic degeneration induced by intrastriatal injection of 6-OHDA. We observed a marked loss of dopaminergic neurons in ovariectomized rats treated with 6-OHDA, which was significantly reduced by estrogen replacement or treatment with the AT1 receptor antagonist candesartan. We also observed that estrogen replacement induces significant downregulation of the activity of the angiotensin converting enzyme as well as downregulation of AT1 receptors, upregulation of AT2 receptors and downregulation of the NADPH complex activity in the substantia nigra in comparison with ovariectomized rats. The present results suggest that estrogen-induced down-regulation of RAS and NADPH activity may be associated with the reduced risk of PD in premenopausal women, and increased risk in conditions causing early reduction in endogenous estrogen, and that manipulation of brain RAS system may be an efficient approach for the prevention or coadjutant treatment of PD in estrogen-deficient women.

Hormone replacement therapy advertising: sense and nonsense on the web pages of the best-selling pharmaceuticals in Spain

BACKGROUND

The balance of the benefits and risks of long term use of hormone replacement therapy (HRT) have been a matter of debate for decades. In Europe, HRT requires medical prescription and its advertising is only permitted when aimed at health professionals (direct to consumer advertising is allowed in some non European countries). The objective of this study is to analyse the appropriateness and quality of Internet advertising about HRT in Spain.

METHODS

A search was carried out on the Internet (January 2009) using the eight best-selling HRT drugs in Spain. The brand name of each drug was entered into Google's search engine. The web sites appearing on the first page of results and the corresponding companies were analysed using the European Code of Good Practice as the reference point.

RESULTS

Five corporate web pages: none of them included bibliographic references or measures to ensure that the advertising was only accessible by health professionals. Regarding non-corporate web pages (n = 27): 41% did not include the company name or address, 44% made no distinction between patient and health professional information, 7% contained bibliographic references, 26% provided unspecific information for the use of HRT for osteoporosis and 19% included menstrual cycle regulation or boosting feminity as an indication. Two online pharmacies sold HRT drugs which could be bought online in Spain, did not include the name or contact details of the registered company, nor did they stipulate the need for a medical prescription or differentiate between patient and health professional information.

CONCLUSIONS

Even though pharmaceutical companies have committed themselves to compliance with codes of good practice, deficiencies were observed regarding the identification, information and promotion of HRT medications on their web pages. Unaffected by legislation, non-corporate web pages are an ideal place for indirect HRT advertising, but they often contain misleading information. HRT can be bought online from Spain, without a medical consultation or prescription constituting a serious issue for public health. In our information society, it is the right and obligation of public health bodies to ensure that such information is not misleading.

Coronary heart disease in postmenopausal recipients of estrogen plus progestin therapy: does the increased risk ever disappear? A randomized trial

BACKGROUND

Estrogen plus progestin therapy increases the risk for coronary heart disease (CHD) in postmenopausal women. However, this increased risk might be limited to the first years of use and to women who start therapy late in menopause.

OBJECTIVE

To estimate the effect of continuous estrogen plus progestin therapy on CHD risk over time and stratified by years since menopause.

DESIGN

Women's Health Initiative randomized, double-blinded, placebo-controlled trial. (ClinicalTrials.gov registration number: NCT00000611)

SETTING

40 U.S. clinical centers.

PATIENTS

16 608 postmenopausal women with an intact uterus at baseline from 1993 to 1998.

INTERVENTION

Conjugated equine estrogens, 0.625 mg/d, plus medroxyprogesterone acetate, 2.5 mg/d, or placebo.

MEASUREMENTS

Adherence-adjusted hazard ratios and CHD-free survival curves estimated through inverse probability weighting.

RESULTS

Compared with no use of hormone therapy, the hazard ratio for continuous use of estrogen plus progestin therapy was 2.36 (95% CI, 1.55 to 3.62) for the first 2 years and 1.69 (CI, 0.98 to 2.89) for the first 8 years. For women within 10 years after menopause, the hazard ratios were 1.29 (CI, 0.52 to 3.18) for the first 2 years and 0.64 (CI, 0.21 to 1.99) for the first 8 years, and the CHD-free survival curves for continuous use and no use of estrogen plus progestin crossed at about 6 years (CI, 2 years to 10 years).

LIMITATION

The analysis may not have fully adjusted for joint determinants of adherence and CHD risk. Sample sizes for some subgroup analyses were small.

CONCLUSION

No suggestion of a decreased risk for CHD was found within the first 2 years of estrogen plus progestin use, including in women who initiated therapy within 10 years after menopause. A possible cardioprotective effect in these women who initiated therapy closer to menopause became apparent only after 6 years of use.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute.

A longitudinal study of the effect of genistein on bone in two different murine models of diminished estrogen-producing capacity

This experiment was designed to assess the capacity of dietary genistein (GEN), to attenuate bone loss in ovariectomized (OVX) and ovary-intact VCD-treated mice. Pretreatment of mice with 4-vinylcyclohexene diepoxide (VCD) gradually and selectively destroys ovarian follicles whilst leaving ovarian androgen-producing cells largely intact. VCD induces a perimenopause-like condition prior to the onset of reproductive acyclicity. Sixteen-week-old C57BL/6J mice were randomized to five treatment groups: sham(SHM), OVX, SHM + VCD, OVX + GEN, and SHM + VCD + GEN. In vivo, blood samples were drawn for hormone and isoflavone analyses, estrous cycles were monitored, and X-ray imaging was performed to assess changes in bone parameters. Following sacrifice, ovaries were assessed histologically, bone microarchitecture was evaluated via microcomputed tomography, and bone mechanical properties were measured. Some effects of GEN were observed in OVX mice, but GEN effects were not able to be evaluated in VCD-treated mice due to the subtle diminution of bone during the 4 months of this experiment.

Hormone replacement therapy and cardiovascular disease revisited

Controversy still rages about whether hormone replacement therapy (HRT) confers cardiovascular benefit or harm. There is a wealth of biological evidence that estrogen has a beneficial effect, supporting a large body of epidemiological evidence demonstrating reduction in coronary events with HRT. A large randomized placebo-controlled clinical trial of preventive strategies for coronary heart disease (CHD) in postmenopausal women, the Women's Health Initiative (WHI), included HRT arms. The published preliminary findings of this trial showed a significant increase in coronary events, stroke, venous thromboembolism and breast cancer with estrogen–progestogen, leading to the conclusion that HRT was unsafe to use other than for short-term relief of menopausal symptoms. But subsequent publications of the more complete data from WHI have shown no significant increase in CHD, and a tendency to a reduction in those initiating HRT below age 60 years. This is important because other therapeutic strategies for the primary prevention of CHD, such as aspirin and statins, are not of proven benefit in women, in contrast to men. Subsequent WHI findings have not shown a clear increase in breast cancer, and any potential increase from HRT is similar to that seen with many lifestyle factors and other commonly used medications. The preliminary WHI results do not reflect accurately true benefits and risks, and HRT should remain a potential preventive treatment for CHD.