The menopause

The role of probiotics in vaginal health

Probiotics have been widely used in the treatment of intestinal diseases, but the effect of probiotics on female reproductive tract health is still controversial. Lactobacillus is the most abundant microorganism in the vagina, which is related to the vaginal mucosal barrier. Lactobacillus adheres to the vaginal epithelium and can competitively antagonize the colonization of pathogens. The factors produced by Lactobacillus, such as bacteriocin and hydrogen peroxide (H₂O₂), can inhibit the growth of pathogenic microorganisms and maintain the low pH environment of the vagina. Probiotics play an important role in maintaining the stability of vaginal microenvironment, improving immune defense and blocking the progression of cervical cancer. We review the research progress of probiotics represented by Lactobacillus in gynecological diseases such as human papilloma virus (HPV) infection, bacterial vaginosis (BV) and Genitourinary Syndrome of Menopause (GSM), so as to provide basis for further exerting the role of probiotics in women’s health.

Isoformononetin, a methoxydaidzein present in medicinal plants, reverses bone loss in osteopenic rats and exerts bone anabolic action by preventing osteoblast apoptosis

PURPOSE

Daidzein (Daid) has been implicated in bone health for its estrogen-'like' effects but low bioavailability, unfavorable metabolism and uterine estrogenicity impede its clinical potential. This study was aimed at assessing isoformononetin (Isoformo), a naturally occurring methoxydaidzein, for bone anabolic effect by overcoming the pitfalls associated with Daid.

METHODS

Sprague-Dawley ovariectomized (OVx) rats with established osteopenia were administered Isoformo, 17β-oestradiol (E2) or human parathyroid hormone. Efficacy was evaluated by bone microarchitecture using microcomputed tomography and determination of new bone formation by fluorescent labeling of bone. Osteoblast apoptosis was measured by co-labeling of bone sections with Runx-2 and TUNEL. Biochemical markers of bone metabolism were measured by ELISA. Plasma and bone marrow levels of Isoformo and Daid were determined by LC-MS-MS. Rat bone marrow stromal cells were harvested to study osteoblastic differentiation by Isoformo and Daid. New born rat pups were injected with Isoformo and Daid to study the effect of the compounds on the expression of osteogenic genes in the calvaria by real time PCR.

RESULTS

In osteopenic rats, Isoformo treatment restored trabecular microarchitecture, increased new bone formation, increased the serum osteogenic marker (procollagen N-terminal propeptide), decreased resorptive marker (urinary C-terminal teleopeptide of type I collagen) and diminished osteoblast apoptosis in bone. At the most effective osteogenic dose of Isoformo, plasma and bone marrow levels were comprised of ~90% Isoformo and the rest, Daid. Isoformo at the concentration reaching the bone marrow achieved out of its most effective oral dosing induced stromal cell mineralization and osteogenic gene expression in the calvaria of neonatal rats. Isoformo exhibited uterine safety.

CONCLUSIONS

Our study demonstrates that Isoformo reverses established osteopenia in adult OVx rats likely via its pro-survival effect on osteoblasts. Given its bone anabolic and anti-catabolic effects accompanied with safety at uterine level we propose its potential in the management of postmenopausal osteoporosis.

Engineered multilayer ovarian tissue that secretes sex steroids and peptide hormones in response to gonadotropins

Although hormone replacement therapy is an option for the loss of ovarian function, hormone delivery through pharmacological means results in various clinical complications. The present study was designed to deliver sex steroids by a functional construct fabricated using encapsulation techniques. Theca and granulosa cells isolated from ovaries of 21-day old rats were encapsulated in multilayer alginate microcapsules to recapitulate the native follicular structure. Cells encapsulated in two other schemes were used as controls to assess the importance of the multilayer structure. The endocrine functions of the encapsulated cells were assessed in vitro for a period of 30 days. Encapsulated cells showed sustained viability during long-term in vitro culture with those encapsulated in multilayer capsules secreting significantly higher and sustained concentrations of 17 β-estradiol (E(2)) than the two other encapsulation schemes (p < 0.05, n = 6) in response to follicle-stimulating hormone (FSH) and luteinizing hormone (LH). In addition, cells in the multilayer microcapsules also secreted activin and inhibin in vitro. In contrast, when granulosa and theca cells were cultured in 2D culture, progesterone (P(4)) secretion increased while E(2) secretion decreased over a 30-day period. In summary, we have designed a multilayer engineered ovarian tissue that secretes sex steroids and peptide hormones and responds to gonadotropins, thus demonstrating the ability to recapitulate native ovarian structure ex vivo.

Oxytocin decreases corticosterone and nociception and increases motor activity in OVX rats

OBJECTIVES

In the present study the effects of oxytocin administered subcutaneously (s.c.) or intravaginally (i.vag.) on spontaneous motor activity, nociceptive thresholds and plasma corticosterone levels were examined in female ovariectomized (OVX) rats.

METHODS

Oxytocin (1 mg/kg s.c. or 100 microg i.vag.) was administered once a day for 10 days to OVX rats. Controls received saline s.c. or cellulose gel i.vag. Spontaneous motor activity was observed in an open-field arena, nociceptive thresholds were investigated by the tail-flick test, and corticosterone and oxytocin plasma levels were measured by radioimmunassay, 3, 4 and 5 days respectively, after the end of the treatment period.

RESULTS

Both oxytocin administered s.c. and i.vag. increased forward locomotion (p<0.05) and nociceptive thresholds (p<0.05) significantly. In addition, oxytocin s.c. increased the amount of locomotor activity (p<0.05). Plasma corticosterone levels were decreased (p<0.05) and oxytocin levels were unchanged when measured 5 days after the last administration of oxytocin s.c. or i.vag.

CONCLUSION

The present data indicate that oxytocin induces a spectrum of long-lasting effects in OVX rats, including an increase in spontaneous motor activity, elevation of nociceptive thresholds and decrease of corticosterone levels. Similar effects may be induced by estrogens. In addition, these data indicate that i.vag. administration of oxytocin may be used to induce oxytocin-mediated effects.

Sleep in peri-menopausal and post-menopausal women

Despite the fact that a large number of women report sleep disturbances associated with peri-menopausal and post-menopausal periods, there is a surprising lack of literature related to this issue. In fact, there has not been enough work in this area to even definitively establish whether there is a sleep disorder that is specifically related to these life-stage changes. Herein we review the available literature which suggests that insomnia may be directly linked to the changes that occur during the peri/post-menopausal periods. This insomnia appears to be due to night sweats caused by the hormonal changes which occur and which lead to an increase in arousals. Persistence of insomnia symptoms after adequate hormone replacement therapy may indicate that behavioral conditioning of the insomnia initially triggered by the night sweats may have occurred. Alternatively, such an insomnia in a peri/post-menopausal woman could be due to unresolved grief related to going through menopause or could reflect an independent sleep disorder, such as periodic movements of sleep, sleep apnea, depression, anxiety, etc. Whereas menopausal changes do not directly lead to an increase in sleep apnea they seemingly contribute to an increased risk for this disorder. In view of these considerations, we provide guidelines for the proper diagnosis and treatment of peri/post-menopausal women with sleep complaints.

Continuous-combined treatment of the menopause with combinations of oestradiol valerate and dienogest - a dose-ranging study

OBJECTIVES

To determine the progestational efficacy of continuous treatment with various doses of dienogest, combined with oestradiol valerate, on the basis of endometrial histology, effect on climacteric symptoms and bleeding profile in postmenopausal women.

METHODS

Patients were randomised to one of five fixed-combination treatments, oestradiol valerate 2.0 mg plus dienogest 0.5, 1.0, 2.0, 3.0 or 4.0 mg. Efficacy was assessed by endometrial biopsy, menstrual charts and change in climacteric symptoms.

RESULTS

The endometrium was classified as atrophic in 20.0, 31.3, 25.0, 55.6 and 57.1% of patients in the 0.5, 1.0, 2.0, 3.0 and 4.0 mg dienogest groups, respectively. The frequency of uterine bleeding was dose-dependent. The most favourable bleeding profile was seen in the 3.0 mg dienogest group, whereas the lower doses of dienogest had advantages with respect to the efficacy of the combined preparation.

CONCLUSIONS

Dienogest 2.0 and 3.0 mg are the optimal doses for combination with 2.0 mg oestradiol valerate for continuous-combined hormone replacement therapy.

Cardiovascular risk factors during sequentially combined 17 beta oestradiol and dydrogesterone (Femoston); results from a one-year study in postmenopausal women

OBJECTIVES

To assess the effects of Femoston (2 mg micronised 17 beta oestradiol daily, sequentially combined in one tablet with 10 mg dydrogesterone for 14 days per 28 day cycle) on the serum lipid profile of postmenopausal women.

METHODS

188 healthy postmenopausal women with intact uteri (aged 40 to 65 years) were enrolled in an open, multicentre, one-year study. Serum lipids and lipoproteins were measured at baseline and after 3, 6 and 12 months.

RESULTS

A total of 155 women completed the one-year study. Mean serum levels of total cholesterol and low-density lipoprotein (LDL)-cholesterol were significantly reduced (P < 0.01) at all assessments compared with baseline; the reductions observed at the final assessment were 5 and 20%, respectively. A significant increase of 20% (P < 0.01) was seen in high-density lipoprotein (HDL)-cholesterol levels by month 12. Mean levels of triglycerides were also increased (p < 0.01). Blood pressure and heart rate remained unchanged throughout the study.

CONCLUSIONS

The results show that the overall effects of Femoston on the serum lipid profile are comparable to those found with oestrogen therapy alone and should reduce the risk of cardiovascular disease in postmenopausal women.

Postmenopausal hormone replacement therapy--clinical implications

The menopause is defined as cessation of menstruation, ending the fertile period. The hormonal changes are a decrease in progesterone level, followed by a marked decrease in estrogen production. Symptoms associated with these hormonal changes may advocate for hormonal replacement therapy. This review is based on the English-language literature on the effect of estrogen therapy and estrogen plus progestin therapy on postmenopausal women. The advantages of hormone replacement therapy are regulation of dysfunctional uterine bleeding, relief of hot flushes, and prevention of atrophic changes in the urogenital tract. Women at risk of osteoporosis will benefit from hormone replacement therapy. The treatment should start as soon after menopause as possible and it is possible that it should be maintained for life. The treatment may be supplemented with extra calcium intake, vitamin D, and maybe calcitonin. Physical activity should be promoted, and cigarette smoking reduced if possible. Women at risk of cardiovascular disease will also benefit from hormone replacement therapy. There is overwhelming evidence that hormone therapy will protect against both coronary heart disease and stroke, and there is no increased risk of venous thrombosis or hypertension. A disadvantage of hormone replacement therapy is an increased risk of forming gall-bladder stones and undergoing cholecystectomy. Unopposed estrogen therapy gives a higher incidence of endometrial cancer in women with an intact uterus, but the contribution of progestins for about 10 days every month excludes this risk. Breast cancer in relation to estrogen-progestogen therapy has been given much concern, and the problem is still not fully solved. If there is a risk, it is small, and only after prolonged use of estrogen (15-20 years). The decision whether or not to use hormone replacement therapy should, of course, be taken by the individual woman in question, but her decision should be based on the available scientific information. It is the opinion of the authors that the advantages of hormone replacement therapy far exceed the disadvantages. We suggest that every woman showing any signs of hormone deprivation should be treated with hormone replacement therapy. This includes women with subjective or objective vaso-motor symptoms, genito-urinary symptoms, women at risk of osteoporosis (fast bone losers), and women at risk of cardiovascular diseases.

Estrogen replacement therapy and the risk of venous thrombosis

PURPOSE

Estrogen replacement therapy is believed by many physicians to cause thrombophlebitis and to be contraindicated in women at risk for this disease. However, clinical data supporting this assumption are scant, and further investigation is required.

PATIENTS AND METHODS

We tested the estrogen-thrombophlebitis association in a case-control study. Charts of all consecutive women aged 45 years or older with a primary or secondary discharge diagnosis of thrombophlebitis, venous thrombosis, or pulmonary embolism were reviewed; 121 cases and 236 controls matched for age, year of admission, admitting service, and socioeconomic status were obtained. Hormone use and nonuse were validated in a subset of randomly selected women.

RESULTS

Cases and controls, whose average age was 65 years, did not differ significantly on matching variables or on current use of exogenous estrogen (5.1% of cases versus 6.3% of controls). Other analyses that variously excluded women with a past history of thrombosis, women less than 50 years of age, women with thrombosis occurring after admission, and women whose estrogen use was indeterminate also did not support an increased risk of thrombotic disease. Adjustment for the presence of independent thrombotic risk factors did not alter the odds ratio for estrogen use.

CONCLUSION

This case-control study of older women, unselected for other thrombotic risk factors, does not support the commonly held assumption that replacement estrogen increases the risk of venous thrombosis.

Estrogen replacement therapy is not conducive of venous thromboembolism

Continued resistance to the use of hormone replacement therapy in menopausal women persists, in part because of concern over a possible relationship between estrogen use and venous thromboembolism. Numerous studies, both retro- and prospective, have failed to yield any evidence of increased relative risk for thrombosis: specific investigations have consistently failed to link estrogen use to clinically significant adverse changes in coagulation factors. We feel that any linkage of menopausal estrogen use and risk of venous thromboembolism is based on anecdotal comments and medical superstition.

Hot flashes: epidemiology and physiology

A review of the literature illustrates the many questions about hot flashes that remain unanswered. My survey addresses some of these questions. The prospective and retrospective descriptions of hot flashes provide a more detailed profile of the hot flash than has previously been available. Further, data from this survey demonstrate that while the patterns of hot flashes may be varied, there are commonalities in hot flash physiology and subjective manifestation. The data indicate that hot flashes may start much earlier and continue far longer than is commonly recognized by physicians or acknowledged in textbooks of gynecology. Studies of hot flash duration must control for age or age at hot flash onset, since the older the subjects, the more potential years of hot flashes and the greater the probability of encompassing the entire period of hot flashes. Hot flashes are not static; patterns may change with time. For some women, hot flashes become less frequent and less intense; for others, hot flashes may continue at hourly intervals well into old age. How common these experiences are for women of all ages still needs to be discovered. As expounded by Kaufert, McKinlay, Goodman, and many others, a greater effort must be made to standardize definitions and question formats as well as to improve methodology in epidemiologic investigations to facilitate comparability between studies and insure that proffered conclusions indeed reflect the questions being asked. Physiological studies are critical counterparts to the epidemiology; yet such studies have been too few. My work, by examining the physiology and psychophysiology of hot flashes, has raised additional questions about central and peripheral inputs that may affect the subjective experience of hot flashes. A more complete understanding of the thermoregulatory, cardiovascular, and psychophysiology of women with hot flashes are compared to women without will facilitate the prediction of who is most likely to be affected and the identification of additional approaches to the management of hot flashes.

[The climacteric--physiology or pathology?]

Nearly 30 years of a woman's life is spent after cessation of the reproductive function and about 30% of the female population in Europe is postmenopausal. The medical infirmities resulting from estrogen deprivation among postmenopausal women take a high toll. The greatest number of hip fractures because of osteoporosis occur in this group, resulting in a high death (20%-30%) and morbidity rate. Estrogen deprivation leads to a change of the lipid metabolism with acceleration of arteriosclerosis. While the "estrogen forever" era closed with a striking rise in the incidence of adenocarcinoma of the endometrium, combined estrogen-gestagen treatment drastically decreases the incidence of endometrial and breast carcinoma. Therefore, physicians must be aware of the benefits of estrogen-gestagen treatment and act appropriately.