Long term effects of tibolone on the genital tract in postmenopausal women

Management of genitourinary syndrome of menopause in breast cancer survivors: An update

There is increasing attention about managing the adverse effects of adjuvant therapy (Chemotherapy and anti-estrogen treatment) for breast cancer survivors (BCSs). Vulvovaginal atrophy (VVA), caused by decreased levels of circulating estrogen to urogenital receptors, is commonly experienced by this patients. Women receiving antiestrogen therapy, specifically aromatase inhibitors, often suffer from vaginal dryness, itching, irritation, dyspareunia, and dysuria, collectively known as genitourinary syndrome of menopause (GSM), that it can in turn lead to pain, discomfort, impairment of sexual function and negatively impact on multiple domains of quality of life (QoL). The worsening of QoL in these patients due to GSM symptoms can lead to discontinuation of hormone adjuvant therapies and therefore must be addressed properly. The diagnosis of VVA is confirmed through patient-reported symptoms and gynecological examination of external structures, introitus, and vaginal mucosa. Systemic estrogen treatment is contraindicated in BCSs. In these patients, GSM may be prevented, reduced and managed in most cases but this requires early recognition and appropriate treatment, but it is normally undertreated by oncologists because of fear of cancer recurrence, specifically when considering treatment with vaginal estrogen therapy (VET) because of unknown levels of systemic absorption of estradiol. Lifestyle modifications and nonhormonal treatments (vaginal moisturizers, lubricants, and gels) are the first-line treatment for GSM both in healthy women as BCSs, but when these are not effective for symptom relief, other options can be considered, such as VET, ospemifene, local androgens, intravaginal dehydroepiandrosterone (prasterone), or laser therapy (erbium or CO2 Laser). The present data suggest that these therapies are effective for VVA in BCSs; however, safety remains controversial and a there is a major concern with all of these treatments. We review current evidence for various nonpharmacologic and pharmacologic therapeutic modalities for GSM in BCSs and highlight the substantial gaps in the evidence for safe and effective therapies and the need for future research. We include recommendations for an approach to the management of GSM in women at high risk for breast cancer, women with estrogen-receptor positive breast cancers, women with triple-negative breast cancers, and women with metastatic disease.

Tibolone as Hormonal Therapy and Neuroprotective Agent

Tibolone (TIB), a selective tissue estrogenic activity regulator (STEAR) in clinical use by postmenopausal women, activates hormonal receptors in a tissue-specific manner. Estrogenic activity is present mostly in the brain, vagina, and bone, while the inactive forms predominate in the endometrium and breast. Conflicting literature on TIB's actions has been observed. While it has benefits for vasomotor symptoms, bone demineralization, and sexual health, a higher relative risk of hormone-sensitive cancer has been reported. In the brain, TIB can improve mood and cognition, neuroinflammation, and reactive gliosis. This review aims to discuss the systemic effects of TIB on peri- and post-menopausal women and its role in the brain. We suggest that TIB is a hormonal therapy with promising neuroprotective properties.

Fertility Sparing Treatment in Patients With Early Stage Endometrial Cancer, Using a Combination of Surgery and GnRH Agonist: A Monocentric Retrospective Study and Review of the Literature

Objectives: To evaluate the efficacy and safety of gonadotropin-releasing hormone (GnRH) agonist after endometrial resection in women suffering early stage endometrial carcinoma (EC) and/or endometrial intra-epithelial neoplasia (EIN). Design: A retrospective review of clinical files between January 1999 and December 2016. Setting: University hospital. Patients: Eighteen women younger than 41 years with grade 1 endometrial carcinoma (G1EC) and/or Endometrial intra-epithelial neoplasia (EIN).

INTERVENTIONS

All patients received GnRH agonist for 3 months after an endometrial resection combined with a laparoscopy to exclude concomitant ovarian tumor and/or other extra-uterine disease. The patient underwent a follow-up of 3 months interval with endometrial sampling by hysteroscopy. Main Outcome Measure(s): The recurrence rate and the pregnancy rate after fertility sparing treatment. Results: We identified 9 patients with EIN (50%), 7 patients with G1EC (38.9%), 1 with combined histology (5.5%), and 1 with G2EC (5.5%). After a median follow-up of 40.7 months, 12 patients conserved their uterus (66.7%), and 8 (53.3%) patients were pregnant with a total of 14 pregnancies among those who tried to become pregnant. We observed a complete response rate in 12 patients (66.7%) but 3 of these patients relapsed (25%). We also found a stable disease in 6 patients (33.3%). Conclusions: Compared with other fertility sparing treatments, GnRH agonist after surgery is an effective fertility-sparing strategy for women with EIN and/or G1EC. We recommend hysterectomy once a family has been completed even if the literature does not clearly lead to radical surgery.

Effects of Tibolone on the Central Nervous System: Clinical and Experimental Approaches

Hormone replacement therapy (HRT) increases the risk of endometrial and breast cancer. A strategy to reduce this incidence is the use of tibolone (TIB). The aim of this paper was to address the effects of TIB on the central nervous system (CNS). For the present review, MEDLINE (via PubMed), LILACS (via BIREME), Ovid Global Health, SCOPUS, Scielo, and PsycINFO (ProQuest Research Library) electronic databases were searched for the results of controlled clinical trials on peri- and postmenopausal women published from 1990 to September 2016. Also, this paper reviews experimental studies performed to analyze neuroprotective effects, cognitive deficits, neuroplasticity, oxidative stress, and stroke using TIB. Although there are few studies on the effect of this hormone in the CNS, it has been reported that TIB decreases lipid peroxidation levels and improves memory and learning. TIB has important neuroprotective effects that could prevent the risk of neurodegenerative diseases in postmenopausal women as well as the benefits of HRT in counteracting hot flashes, improving mood, and libido. Some reports have found that TIB delays cognitive impairment in various models of neuronal damage. It also modifies brain plasticity since it acts as an endocrine modulator regulating neurotransmitters, Tau phosphorylation, and decreasing neuronal death. Finally, its antioxidant effects have also been reported in different animal models.

Atrophic vaginitis in breast cancer survivors: a difficult survivorship issue

Management of breast cancer includes systematic therapies including chemotherapy and endocrine therapy can lead to a variety of symptoms that can impair the quality of life of many breast cancer survivors. Atrophic vaginitis, caused by decreased levels of circulating estrogen to urinary and vaginal receptors, is commonly experienced by this group. Chemotherapy induced ovarian failure and endocrine therapies including aromatase inhibitors and selective estrogen receptor modulators can trigger the onset of atrophic vaginitis or exacerbate existing symptoms. Symptoms of atrophic vaginitis include vaginal dryness, dyspareunia, and irritation of genital skin, pruritus, burning, vaginal discharge, and soreness. The diagnosis of atrophic vaginitis is confirmed through patient-reported symptoms and gynecological examination of external structures, introitus, and vaginal mucosa. Lifestyle modifications can be helpful but are usually insufficient to significantly improve symptoms. Non-hormonal vaginal therapies may provide additional relief by increasing vaginal moisture and fluid. Systemic estrogen therapy is contraindicated in breast cancer survivors. Continued investigations of various treatments for atrophic vaginitis are necessary. Local estrogen-based therapies, DHEA, testosterone, and pH-balanced gels continue to be evaluated in ongoing studies. Definitive results are needed pertaining to the safety of topical estrogens in breast cancer survivors.

Pharmacologic therapy for female sexual dysfunction

Female sexual dysfunction (FSD) is a common health issue that can have significant negative effects on overall well-being and quality of life. The primary purpose of this article is to review commonly noted pharmacologic therapies for FSD. The pathophysiology, clinical evaluation, and selected nonpharmacologic therapies are also briefly addressed as well as recommendations for practice.

An update on the pharmacological management of female sexual dysfunction

INTRODUCTION

Female sexual dysfunction (FSD) is a global health issue, with as many as 12% of women over 18 years old reporting sexual difficulties associated with distress. It is a multifaceted problem with psychological and biological causes. Affected women tend to have an impaired quality of life, a decreased level of well-being and relationship issues. Hence there is a need for management options for affected women.

AREAS COVERED

This paper focuses on current pharmacological options for the treatment of FSD, particularly estrogens and androgens, which have been extensively studied. Some investigational drugs are also described, including the centrally acting agents such as flibanserin and bupropion, and intravaginal DHEA and testosterone, which may be useful as an alternative for women with specific conditions, such as breast cancer survivors.

EXPERT OPINION

Although approval for the use of testosterone for treatment of FSD is limited to some European countries and restricted to surgically menopausal women, there is extensive off-label use for this purpose. No other product has yet achieved regulatory approval for treatment of FSD. Completion of studies of nonhormonal FSD therapies and safety studies of testosterone may result in regulatory approval of such products for the treatment of FSD in the near future.

Endometrial adenocarcinoma in a 27-year-old woman

BACKGROUND

Endometrial adenocarcinoma usually occurs after menopause, but in 2%-14% of cases, it occurs in young patients (less than 40 years of age) who are eager to preserve their fertility. Its treatment includes hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy, and, in some cases, radiation therapy.

AIM

To describe a case of endometrial adenocarcinoma occurring in a young woman and to undertake a literature review of risk factors and therapeutic options proposed for young women wishing to preserve their fertility.

CASE

We report a case of endometrial cancer in a 27-year-old woman treated for resistant menorrhagia and cared for in our department as well as in the Salah Azaiez Institute.

CONCLUSION

Endometrial adenocarcinoma rarely occurs in young women. In such cases, other therapeutic options can be proposed: progesterone therapy and LH-RH (Luteinzing-Hormone-Releasing-Hormone) agonists therapy in order to preserve fertility in younger patients.

Amelioration of sexual adverse effects in the early breast cancer patient

BACKGROUND

As the number of breast cancer survivors increases, the long term consequences of breast cancer treatment are gaining attention. Sexual dysfunction is a common complaint amongst breast cancer survivors, and there are few evidence based recommendations and even fewer well designed clinical trials to establish what treatments are safe or effective in this patient population.

DESIGN

We conducted a PubMed search for articles published between 1995-2009 containing the terms breast cancer, sexual dysfunction, libido, vaginal dryness, testosterone, and vaginal estrogen. We initially reviewed articles focusing exclusively on sexual issues in breast cancer patients. Given the paucity of clinical trials addressing sexual issues in breast cancer patients, we also included studies evaluating both hormone and non-hormone based interventions for sexual dysfunction in post-menopausal women in general.

CONCLUSIONS

Among breast cancer survivors, vaginal dryness and loss of libido represent some of the most challenging long term side effects of breast cancer treatment. In the general post-menopausal population, topical preparations of estrogens and testosterone both appear to improve sexual function; however there are conflicting reports about the efficacy and safety of these interventions in women with a history of breast cancer, and further research is warranted.

Women's health, breast health: a review of the gynecologic effects of breast cancer

Breast cancer is very common and seen in both premenopausal and postmenopausal women. Research into prevention, better screening, and more effective treatments is occurring continually, and changes are translated into clinical practice relatively quickly. It is important for women's health care providers to have an understanding of breast cancer treatments and the gynecologic side effects. For premenopausal women interested in fertility, options should be discussed prior to chemotherapy. Issues pertaining to pregnancy after breast cancer should be discussed in a multidisciplinary fashion, involving the obstetrician/gynecologist, breast surgeon, and oncologist. Ovarian suppression is often used as part of breast cancer treatment in premenopausal women with hormone positive disease, and menopausal symptoms may be severe. Hormonal therapies including tamoxifen and the aromatase inhibitors are used in the treatment of hormone positive breast cancers. Each of these drugs has a variety of gynecologic implications. Understanding the options for treatment for menopausal complaints in breast cancer patients is important for women's health providers. Although most breast cancers are sporadic, a small percentage will be due to mutations in the BRCA genes. It is important for women's health providers to take an appropriate family history and refer to genetic counselors for possible testing when hereditary cancer is suspected. This review focuses on the various women's health issues pertaining to breast cancer and treatment.

The long-term effects of tibolone on aortic stiffness and endothelial function

OBJECTIVE

To investigate the effect of 10 years of treatment with tibolone on aortic stiffness and endothelial function.

DESIGN

Cross-sectional study of women currently participating in an open-label, non-randomized study of the long-term efficacy of tibolone. A total of 113 recently postmenopausal women were recruited in 1988. Fifty-eight agreed to take tibolone 2.5 mg daily and 55 were followed during the study as matched controls (who chose not to take any form of hormone replacement therapy (HRT) for the duration of the study). The groups were matched for age, weight and time since last menstrual period.

SETTING

A Central London Teaching Hospital.

SUBJECTS

After 10 years, 60 women remained in the study, 32 in the tibolone group and 28 in the control group. All of these women were invited to participate in this pilot study and attend the Menopause Research Unit. Fourteen women from each group agreed to attend. The main outcome measures were aortic stiffness, measured by pulse wave velocity, and endothelial function, as assessed by flow-mediated dilatation of the brachial artery.

RESULTS

Pulse wave velocity was significantly lower in the tibolone group (10.4 +/- 1.2) than in the control group (11.6 +/- 1.2), p = 0.042. The flow-mediated dilatations were similar in both groups.

CONCLUSION

In this study, long-term use of tibolone over 10 years has a beneficial effect on aortic stiffness. The differences seen in brachial artery vasoreactivity failed to reach statistical significance. Whether this is a true indication of the effects of long-term tibolone on brachial artery vasoreactivity will only be determined by performing a larger, placebo-controlled, randomized study.

Sexuality and the menopause

Sexuality is innate within all women to a greater or lesser extent, and is affected by a number of extrinsic factors that occur in the menopausal transition. Assessing hormone status is difficult as evidence exists that sex hormones may differ between ethnic groups, and that bio-assays may be insensitive at lower testosterone levels. Data are available on the prevalence of female sexual dysfunction, but results from cross-sectional studies differ from those of longitudinal studies. The original traditional models of human sexual response have been challenged, and new models have been defined which show more complex interaction between intrinsic and extrinsic factors. Definitions of sexual dysfunction have been redefined. There are a limited number of randomized, placebo-controlled trials of drugs to improve sexual function. These include sildenafil citrate, tibolone and hormone replacement therapy. Randomized controlled trials on testosterone replacement in naturally and/or surgically menopausal patients with female sexual dysfunction have been criticized for a high placebo response rate and short duration. This chapter seeks to put sexuality into perspective and to define both function and dysfunction.

Dyspareunia in postmenopausal women: a critical review

BACKGROUND

Dyspareunia, or pain during sexual intercourse, is among the problems most frequently reported by postmenopausal women. Past literature has almost unanimously attributed dyspareunic pain occurring during or after the menopausal transition to declining estrogen levels and vaginal atrophy.

OBJECTIVES

To critically review the literature on the prevalence, risk factors, etiology, clinical presentation and treatment of postmenopausal dyspareunia. The present review also examines the traditional and widely held conceptualization of postmenopausal dyspareunia as a direct symptom of hormonal decline.

METHODS

Searches of medical and psychological databases were performed for relevant articles and empirical studies. The methodological quality and outcomes of the studies were systematically reviewed.

RESULTS

Available empirical evidence suggests that dyspareunia is common in postmenopausal women, and that it is not highly correlated with menopausal status, estrogen levels or vaginal atrophy. Decreasing levels of endogenous estrogen contribute to the development of dyspareunia in postmenopausal women suffering from vaginal atrophy. Hormonal supplementation is beneficial in alleviating their pain. However, a substantial proportion of treated women do not report relief.

CONCLUSIONS

Postmenopausal dyspareunia occurring concurrently with vaginal atrophy is strongly associated with a lack of estrogen in the genital tract. However, a significant percentage of postmenopausal women experience dyspareunic pain that is not caused by hypoestrogenism. It is likely that other types of dyspareunia that occur premenopausally are also occurring in postmenopausal women. Research is needed to adequately address this issue. A change in perspective toward a multiaxial pain-focused approach is proposed for future research concerning dyspareunia in postmenopausal women.

Effects of tibolone and raloxifene on health-related quality of life and sexual function

OBJECTIVES

Study to compare the effects of tibolone and raloxifene on health-related quality of life, sexuality and vaginal atrophy.

METHODS

A double-blind, randomized study was conducted in 308 osteopenic, but otherwise healthy, postmenopausal women (mean age 66 years) who received tibolone 1.25mg/day or raloxifene 60 mg/day for 2 years. Health-related quality of life was assessed by the women's health questionnaire (WHQ), sexual function by the McCoy female sexuality questionnaire (MFSQ) and vaginal atrophy by assessing the karyopycnotic index (KI) and vaginal maturation (VM).

RESULTS

At week 104, the tibolone group showed a trend towards an improved health-related quality of life (HRQoL) mean score in eight out of nine WHQ domains. HRQoL scores approximated values for premenopausal women, being pre-defined as "clinically relevant". The raloxifene group showed a trend to a diminished HRQoL mean score from baseline to week 104. No difference could be assessed between the tibolone and raloxifene group in mean total score and separate domains' scores of the MFSQ, except for the vaginal lubrication domain (p=0.037). The increase in KI and VM was statistically significantly greater with tibolone than with raloxifene (for both KI and VM p<0.0001). Tibolone and raloxifene were equally well tolerated.

CONCLUSIONS

In older postmenopausal women, tibolone treatment showed a trend towards an improvement in quality of life and sexuality when compared to raloxifene.

Efficacy of tibolone as "add-back therapy" in conjunction with a gonadotropin-releasing hormone analogue in the treatment of uterine fibroids

OBJECTIVE

To assess the efficacy of tibolone add-back therapy with Goserelin treatment of uterine fibroids.

DESIGN

Randomized placebo-controlled study.

SETTING

Gynecology department of an inner-city teaching hospital.

PATIENT(S)

Seventy-five women of reproductive age with uterine fibroids.

INTERVENTION(S)

All women were given monthly SC implants of 3.6 mg goserelin and were randomized to take 3 months of placebo followed by 3 months of tibolone 2.5 mg daily (delayed administration), tibolone 2.5 mg daily for 6 months, or placebo for 6 months.

MAIN OUTCOME MEASURE(S)

Changes in bone mineral density (BMD) at the hip and spine, fibroid and uterine size, and patient symptomatology.

RESULT(S)

In the tibolone group, 2% loss of BMD at the spine was observed compared with 5.5% loss in the placebo group. For total hip, tibolone led to a 0.7% gain in BMD compared with a loss of 1.7% in the placebo group. Tibolone did not affect GnRH analogue-induced fibroid shrinkage. Vasomotor symptom scores in women taking tibolone were 2.2 and were significantly lower than those taking placebo or in the delayed administration groups (mean scores 2.9 and 2.7, respectively).

CONCLUSION(S)

Tibolone appears to be a safe and effective add-back therapy which can be given from the commencement of GnRH analogue treatment for fibroids.

Selective tissue distribution of tibolone metabolites in mature ovariectomized female cynomolgus monkeys after multiple doses of tibolone

Tibolone is a selective tissue estrogenic activity regulator (STEAR). In postmenopausal women, it acts as an estrogen on brain, vagina, and bone, but not on endometrium and breast. Despite ample supporting in vitro data for tissue-selective actions, confirmative tissue levels of tibolone metabolites are not available. Therefore, we analyzed tibolone and metabolites in plasma and tissues from six ovariectomized cynomolgus monkeys that received tibolone (0.5 mg/kg/day by gavage) for 36 days and were necropsied at 1, 1.25, 2.25, 4, 6, and 24 h after the final dose. The plasma and tissue levels of active, nonsulfated (tibolone, 3alpha-hydroxytibolone, 3beta-hydroxytibolone, and Delta(4)-tibolone), monosulfated (3alpha-sulfate,17beta-hydroxytibolone and 3beta-sulfate,17beta-hydroxytibolone), and disulfated (3alpha,17beta-disulfated-tibolone and 3beta,17betaS-disulfated-tibolone) metabolites were measured by validated gas chromatography with mass spectrometry and liquid chromatography with tandem mass spectrometry. Detection limits were 0.1 to 0.5 ng/ml (plasma) and 0.5 to 2 ng/g (tissues). In brain tissues, estrogenic 3alpha-hydroxytibolone was predominant with 3 to 8 times higher levels than in plasma; levels of sulfated metabolites were low. In vaginal tissues, major nonsulfated metabolites were 3alpha-hydroxytibolone and the androgenic/progestagenic Delta(4)-tibolone; disulfated metabolites were predominant. Remarkably high levels of monosulfated metabolites were found in the proximal vagina. In endometrium, myometrium, and mammary glands, levels of 3-hydroxymetabolites were low and those of sulfated metabolites were high (about 98% disulfated). Delta(4)-Tibolone/3-hydroxytibolone ratios were 2 to 3 in endometrium, about equal in breast and proximal vagina, and 0.1 in plasma and brain. It is concluded that tibolone metabolites show a unique tissue-specific distribution pattern explaining the tissue effects in monkeys and the clinical effects in postmenopausal women.

Endometrial effects of tibolone

BACKGROUND AND OBJECTIVES

The Tibolone Histology of the Endometrium and Breast Endpoints Study is a multicenter, randomized, double-blind study designed to address the conflicting reports in the literature about the endometrial safety of tibolone (1.25 or 2.5 mg/d). Tibolone was compared with continuous combined conjugated equine estrogen (CEE) plus medroxyprogesterone acetate (MPA) (0.625 + 2.5 mg/d).

METHODS

Subjects were randomized in a 1:1:2 ratio to tibolone 1.25 mg/d, 2.5 mg/d, and CEE/MPA, respectively. The one-sided 95% confidence interval (CI) has been evaluated for the incidence of abnormal endometrial histology (hyperplasia or carcinoma) and hyperplasia and carcinoma separately for each of the two treatment groups and the treatment groups combined after 1 and 2 yr of treatment with tibolone, compared with CEE/MPA.

RESULTS

A total of 3240 women were randomized, with 3224 receiving at least one dose of study medication. The incidence and upper one-sided 95% CI for the incidence of abnormal endometrium (hyperplasia or carcinoma), and hyperplasia and carcinoma separately, were calculated at end point, yr 1, and yr 2. The incidence (upper one-sided 95% CI) of abnormal endometrium at end point was 0.0 (0.5), 0.0 (0.4), and 0.2 (0.5) in the tibolone 1.25 mg, 2.5 mg, and CEE/MPA groups, respectively. During the entire treatment period, amenorrhea was reported more frequently with tibolone 1.25 mg (78.7%) and 2.5 mg (71.4%) than CEE/MPA (44.9%).

CONCLUSION

The Tibolone Histology of the Endometrium and Breast Endpoints Study results confirm previous findings that tibolone does not induce endometrial hyperplasia or carcinoma in postmenopausal women, and it is associated with a better vaginal bleeding profile than CEE/MPA.

Tibolone for the treatment of moderate to severe vasomotor symptoms and genital atrophy in postmenopausal women

OBJECTIVE

To demonstrate the safety and efficacy of tibolone (1.25 and 2.5 mg) in the treatment of moderate to severe vasomotor symptoms and symptoms associated with vaginal atrophy.

DESIGN

A placebo-controlled, double-blind, randomized, multicenter study was conducted on 396 healthy postmenopausal women experiencing a minimum of 7 moderate to severe hot flashes per day (60 per week). Participants were randomized to receive tibolone 1.25 or 2.5 mg or placebo once daily for 12 weeks. Assessments were done at weeks 4, 8, and 12. The severity and frequency of hot flashes were recorded in patient diaries on a daily basis.

RESULTS

Tibolone 2.5 mg significantly (P < 0.001) reduced the average number of hot flashes compared with placebo at week 4 (-7.82 vs -5.27), week 8 (-9.71 vs -5.86), and week 12 (-10.14 vs -5.85). The difference between tibolone 1.25 mg and placebo was significant (P < 0.001) at week 8 (-7.96) and week 12 (-8.32). Findings for the average daily severity of hot flashes were similar, with significantly greater reductions at week 4 (P < 0.05) and weeks 8 and 12 (P < 0.001) for tibolone 2.5 mg versus placebo and at weeks 8 and 12 for tibolone 1.25 mg versus placebo (P < 0.001). A menopausal atrophic symptom questionnaire revealed that tibolone 2.5 mg significantly (P < 0.05) reduced nocturia compared with placebo at weeks 4, 8, and 12 and urinary urgency at week 4. Compared with placebo, both doses of tibolone also significantly (P < 0.001) increased the vaginal maturation value from baseline. The overall incidence of adverse events was similar in all treatment groups.

CONCLUSIONS

Tibolone is effective and well tolerated for the treatment of moderate to severe vasomotor symptoms and the effects of vaginal atrophy associated with menopause.

[The benefits and risks of hormonal replacement therapy--an update]

Hormonal replacement therapy (HRT) with estrogens and gestagens has been used for more than 40 years in the treatment of menopausal complaints and can be considered an effective treatment for vaso-vegetative symptoms and urogenital atrophy. During the past few years many women and doctors have revised their opinions of HRT. The reasons for this change of view are mainly three large international studies: the Heart and Estrogen/Progestin Study, the Women's Health Initiative Study and the One Million Women Study. In this review we summarize the data from the most important studies and point out the actual status of the controversial discussion on the benefits and risks of HRT.

Endometrial cancer patients and tibolone: A matched case–control study

OBJECTIVE

To evaluate whether tibolone had adverse effects on the prognosis of endometrial cancer patients.

METHODS

In this retrospective matched case-control study, out of 396 patients with endometrial cancer from January 1997 to December 2002, 68 patients who underwent complete surgical staging were identified as tibolone users (cases). For each case, one control as tibolone non-user was matched for stage and grade of disease, in this order of priority (ratio users: non-users, 1:1).

RESULTS

There were no significant differences in age (p = 0.11), stage (p = 1.00), grade (p = 0.96) and treatment modality (p = 0.55) between two arms. The mean duration of follow-up for tibolone users and tibolone non-users is 48.0 months and 54.4 months, respectively (p = 0.12). In tibolone users, a total of four patients recurred and two out of four patients died of disease. In tibolone non-users, there were three recurrences and all of three patients died of disease. There were no significant differences in disease free survival (p = 0.52) and overall survival (p = 0.61) between two arms. And there was no significant difference in disease free survival according to the duration of tibolone use (p = 0.14).

CONCLUSION

There was no evidence that tibolone had adverse effects on the disease free survival and overall survival of endometrial cancer patients. So, tibolone could be used in these patients.

Histological and immunohistochemical evaluation of postmenopausal endometrium after 3 weeks of treatment with tibolone, estrogen only, or estrogen plus progestagen

OBJECTIVE

To evaluate histological and immunohistochemical parameters of short-term (21 days) tibolone, estrogen-only, and estrogen+progestagen treatment in the human postmenopausal endometrium.

DESIGN

An observational, open, nonrandomized, controlled study.

SETTING

Three collaborating centers: Amphia Hospital in Breda, Albert Schweitzer Hospital in Dordrecht, Erasmus Medical Center in Rotterdam, the Netherlands.

PATIENT(S)

Thirty healthy, postmenopausal women.

INTERVENTION(S)

Control group (n = 9), no hormonal treatment; tibolone group (n = 8), patients were treated with 2.5 mg of tibolone (administered orally) every day, starting 21 days before surgery; estrogen group (n = 7), patients were treated with 2 mg of E(2) (Zumenon, administered orally; Zambon, Amerfoort; The Netherlands) every day, starting 21 days before surgery; estrogen+progestagen group (n = 6), patients were treated with 2 mg of E(2) (Zumenon, administered orally) and 5 mg of medroxyprogesterone acetate (administered orally) every day, starting 21 days before surgery.

MAIN OUTCOME MEASURE(S)

Uterine tissues were collected, and two pathologists independently assessed histology. Immunohistochemical parameters measured were estrogen receptor alpha, progesterone receptor A/B, Hoxa10, Ki67, and Bcl-2.

RESULT(S)

On the basis of a number of histological and immunohistochemical parameters measured after 21 days of treatment, it was observed that tibolone displays clearly less stimulation (proliferation) of the human postmenopausal endometrium than estrogen at the beginning of a treatment, but the stimulation is higher than with estrogen+progestagen.

CONCLUSION(S)

Short-term (21 days) tibolone treatment results in a small stimulation of proliferation of the endometrium, and because long-term treatment with tibolone has been demonstrated to lead to an atrophic endometrium, it may be concluded that the stimulatory effect, as observed in this study, is transient in nature. It is hypothesized that tibolone first displays a more estrogenic mode of action, which over time, is counterbalanced by the induction of its progestagenic properties.

Effects of tibolone on nuclear receptors in human endometrial cells

OBJECTIVE

Tibolone regulates estrogenic activity in a tissue-selective manner. The purpose of this study was to evaluate the effects of tibolone on the mRNA content of nuclear receptors, estrogen receptor-alpha and beta (ERalpha and ERbeta), progesterone receptor (PR), and androgen receptor (AR) in human endometrial stromal and glandular cells.

STUDY DESIGN

Human endometrial stromal and glandular cells were isolated from endometrial tissue fragments and separately incubated with tibolone and its metabolites. Nuclear receptor mRNA was determined using real-time polymerase chain reaction (PCR).

RESULTS

In endometrial stromal cells, tibolone, Delta4-tibolone, and 3betaOH-tibolone, but not 3alphaOH-tibolone, significantly reduced ERalpha mRNA by approximately 60% and ERalpha protein by approximately 80%. No reduction of ERalpha was observed in endometrial glandular cells. Tibolone induced PR mRNAs to various extents and reached up to 6-fold in glandular cells, but only a moderate increase (approximately 1.5-fold) in stromal cells. Tibolone increased ERbeta and had little effect on AR mRNA in endometrial cells.

CONCLUSION

The results showed the majority of the nuclear receptors were not significantly altered. However, tibolone significantly reduced ERalpha in stromal cells and increased PR in glandular cells. These biological effects may play essential roles in averting stimulation of the endometrium in tibolone users.

Le profil clinique des femmes qui utilisent la tibolone est-il le même que celui des femmes utilisant un traitement hormonal classique ? Données d'une enquête nationale en France

OBJECTIVES

To compare the pre-existing risk profiles for breast or endometrial cancer of menopaused women receiving tibolone or another hormone replacement therapy in France, with a view to examining the possibility of biases of selection of patients and of detection of these cancers in the Million Women Study.

PATIENTS AND METHODS

Nationwide survey conducted in France among a representative sample of 153 gynaecologists. The particulars of the last two consulting menopaused women treated with tibolone (N = 306) and of the last two treated with a classical estrogen-progestogen therapy (N = 306) were collated then analysed.

RESULTS

Compared to those treated with a classical estrogen-progestogen therapy, more women receiving tibolone were aged 60 years or over (40 vs 31%; P < 0.01). More of them had risk factors for breast cancer (history of mastodynia or mastopathy, elevated mammographic breast density) (6 vs 50%; P < 0.01). More of them had a history of uterine investigation or exploration or of irregular bleeding (61 vs 53% of women with a history of irregular bleeding; P < 0.05). Overall, 84% of women treated with tibolone had at least one risk factor for breast or endometrial cancer vs 75% of those receiving a classical estrogen-progestogen therapy (P < 0.01).

DISCUSSION AND CONCLUSION

Owing to its specific properties, tibolone is generally prescribed to women with a higher risk profile for breast or endometrial cancer than those receiving a classical estrogen-progestogen therapy, which may entail patient selection and cancer detection biases in non-randomised, open-label, observational studies.

Tibolone: Clinical recommendations and practical guidelines

An international multidisciplinary panel of experts in the management of the menopause met at the 4th Amsterdam Menopause Symposium in October 2004 to determine the specific place of tibolone, a synthetic steroid with a unique clinical profile, within the wide range of currently available postmenopausal therapy options. The consensus was that tibolone is a valuable treatment option for women with climacteric complaints. As well as relieving vasomotor symptoms, tibolone has positive effects on sexual well-being and mood, and improves vaginal atrophy and urogenital symptoms. Prevention of bone loss with tibolone is comparable to that seen with estrogen therapy (ET) and estrogen/progestogen therapy (EPT). As tibolone rarely causes endometrial proliferation, no additional progestogen is required. It also has good tolerability, being associated with a low incidence of vaginal bleeding and of breast pain. Tibolone does not increase mammographic density. Absolute numbers of women at increased risk for breast cancer are estimated to be low or absent with both tibolone and ET, and the risk with tibolone should be significantly lower than that with EPT. Tibolone might therefore be preferable to EPT in certain women who have not been hysterectomised. Based on the evidence available, the panel proposed a number of subgroups of postmenopausal women with vasomotor symptoms in whom tibolone might have added value; these included women with sexual dysfunction, mood disorders, fibroids and urogenital complaints, as well as those with breast tenderness or high mammographic breast density with EPT use.

Long-term effects of tibolone on the endometrium as assessed by bleeding episodes, transvaginal scan and endometrial biopsy

INTRODUCTION

Period-free hormone replacement therapy (HRT) obliterates the need for withdrawal bleeds. There is a need to ensure that, if these preparations are to be used in the long term, they still achieve amenorrhea.

AIMS

To assess the bleeding rates and the endometrial status over 10 years in women who were taking tibolone compared to an age-matched control group.

METHODS

A total of 110 recently postmenopausal women were recruited into a prospective, non-randomized, open-label study. Bleeding episodes were assessed by 6-monthly symptomatology questionnaires. Annual transvaginal scans were performed to assess endometrial thickness in all women who gave consent from 1997 onwards. In the tibolone group, endometrial biopsies were performed every year; in the control group, they were performed only if the reported vaginal bleeding and/or endometrial thickness on ultrasound were >5 mm.

RESULTS

Over the entire 10-year period, 39.7% of women in the tibolone group and 12.7% of control subjects experienced vaginal blood loss. However, the rate of amenorrhea in the tibolone group after 1 year of treatment was 86.4%; in the control group, it was 94.1%. At the 10-year visit, the rates of amenorrhea were 60.3% in the tibolone groups and 87.3% in the control group. This is statistically significant, p = 0.001. The mean (+/- standard deviation) endometrial thickness after 10 years was 2.2 mm (+/- 1.2 mm) in the tibolone group vs. 1.8 mm (+/- 0.4 mm) in the control group. These differences were not statistically significant (p = 0.33). Sufficient material from endometrial biopsies could only be obtained in three subjects in the tibolone group. One case of simple hyperplasia was detected.

CONCLUSION

Tibolone therapy leads to high rates of amenorrhea after 10 years, with minimal evidence of adverse effects on endometrial pathology.

Long-term effects of tibolone on mammographic density

OBJECTIVE

To investigate the long-term effect of tibolone on mammographic density.

DESIGN

Open-label, nonrandomized study.

SETTING

Academic research environment.

PATIENT(S)

Postmenopausal women.

INTERVENTION(S)

Tibolone was administered orally, mammograms were performed annually.

MAIN OUTCOME MEASURE(S)

Mammographic density according to the Wolfe classification, performed by two independent radiologists, both of whom were blinded to treatment group.

RESULT(S)

No statistically significant differences were found between the two groups in baseline demographic data. There were no statistically significant differences in mammographic density between the control and active groups at baseline or at 10 years.

CONCLUSION(S)

This pilot study shows that tibolone does not adversely alter the mammographic density of the breasts over 10 years of treatment.

Endometrial assessment in women using tibolone or placebo: 1-year randomized trial and 2-year observational study

OBJECTIVE

To assess the effects of tibolone on the endometrium of postmenopausal women.

DESIGN

A 1-year randomized, double-blind, placebo-controlled clinical trial and a 2-year open clinical trial. The placebo-controlled trial included 40 participants: 20 in the placebo group and 20 in the tibolone group; in the open trial, 17 participants receiving tibolone were assessed over 24 months. Transvaginal ultrasonography was carried out to assess endometrial thickness, and endometrial appearance was assessed on hysteroscopy. In addition, endometrial samples were submitted to histological examination. The occurrence of uterine bleeding and other adverse effects was also assessed.

RESULTS

Results suggest that tibolone does not exert a stimulatory effect on the endometrium: unaltered endometrial thickness, atrophic appearance of most endometria on hysteroscopy, and endometrial histology classified as atrophic, hypotrophic with incipient secretion, or hypotrophic with weak proliferation (one case). Tibolone was effective in the treatment of climacteric symptoms, and only 8.7% of the participants presented uterine bleeding during treatment.

CONCLUSIONS

Tibolone seems to be an effective option for the treatment of climacteric symptoms in postmenopausal women, especially in women who do not want to experience uterine bleeding again.

Effect of tibolone and its metabolites on vascular endothelial growth factor isoforms 121 and 165 and thrombospondin-1 mRNA in Ishikawa cells

OBJECTIVE

To compare the mRNA expression of vascular endothelial growth factor (VEGF) 121 and 165 isoforms and thrombospondin-1 (TSP-1) after incubation with tibolone and tibolone metabolites 3alpha-hydroxytibolone, 3beta-hydroxytibolone, Delta4-tibolone, and 17beta-estradiol (E2) in cultured Ishikawa cells.

DESIGN

Ishikawa cells (immortalized from a well-differentiated human adenocarcinoma cell line) were cultured in vitro to confluence. Tibolone, 3alpha-hydroxytibolone, 3beta-hydroxytibolone, Delta4-tibolone and E2 at concentrations of 1.0, 0.1 and 0.01 micromol/L were added to confluent cells and further cultured for an additional 24 h. Control cells were treated with medium in absence of hormone. Total RNA was extracted from control and treated Ishikawa cells. After reverse transcription, VEGF, TSP-1 and the housekeeping gene, beta-actin cDNAs, were amplified in a polymerase chain reaction spiked with 33p-dCTP. Relative abundance of VEGF 121 and 165 isoforms and TSP-1 mRNA was measured by scintillation spectroscopy.

RESULTS

E2, tibolone, 3alpha-hydroxytibolone, and 3beta-hydroxytibolone increased both VEGF 121 and 165 mRNA compared with the control. However, Delta4-tibolone had no effect on either VEGF 121 or 165 mRNA compared with the control. Delta4-Tibolone increased TSP-1 mRNA expression compared with control levels. E2, tibolone, 3alpha-hydroxytibolone, and 3beta-hydroxytibolone did not increase TSP-1 mRNA expression at any concentration.

CONCLUSIONS

Tibolone and the 3alpha- and 3beta-tibolone metabolites with E2 increased VEGF 121 and 165 isoforms. Conversely, Delta4-tibolone, which is reported to have progestational-like activity, did not stimulate VEGF 121 and VEGF 165 but increased TSP-1 mRNA synthesis in cultured Ishikawa cells. We hypothesize, based on these data, that the clinical finding of no endometrial growth in women using tibolone may be partly related to alterations in these angiogenic factors.

Les alternatives au traitement hormonal substitutif de la ménopause : le point épidémiologique

OBJECTIVE

Recent results put into question the risks/benefits ratio of hormone replacement therapy and emphasize the importance of precise knowledge of the effects of other treatments that exist for postmenopausal symptoms or diseases. Our aim is to analyze their effect.

METHODS

A review of randomized trials or epidemiological studies was undertaken.

RESULTS

Bisphophonates, calcitonin, parathormone, strontium ranelate, calcium and vitamin D have specific effects on bone. The efficacy of bisphophonates for prevention and treatment of osteoporosis has been proven and parathormone and strontium ranelate seem promising. These treatments are useful for women at high risk of osteoporosis who do not suffer from menopausal symptoms. Tibolone, SERMs and phytoestrogens exert effects on various tissues. SERMs are very promising, but they do not improve climacteric symptoms and their long term effects are still unknown. Tibolone has beneficial effects on climacteric symptoms and on bone loss, but recent results concerning its effects on the risk of breast cancer call into question its interest. The beneficial effects of phytoestrogens on bone and on vasomotor symptoms need to be confirmed.

CONCLUSION

At this time, none of the existing treatments for postmenopausal symptoms or diseases is ideal. The existence of several options for treatments of symptoms or diseases of the postmenopause is helpful as it affords several choices for physicians and for women who sometimes need to be treated for many years. However several questions remain unanswered concerning the long term effects of these treatments.

Conservative treatment may be beneficial for young women with atypical endometrial hyperplasia or endometrial adenocarcinoma

OBJECTIVE

To evaluate whether an alternative treatment to radical hysterectomy exists for young women with endometrial adenocarcinoma.

DESIGN

A review of the literature (70 articles) plus personal results.

SETTING

University hospital.

PATIENT(S)

Women with atypical endometrial hyperplasia or adenocarcinoma.

MAIN OUTCOME MEASURE(S)

The recurrence rate and the pregnancy rate after conservative therapy.

CONCLUSION(S)

Conservative treatment of well-differentiated stage I endometrial adenocarcinoma can be considered in young patients, with close surveillance to diagnose any possible recurrence.

Tibolone and risk of endometrial polyps: a prospective, comparative study with hormone therapy

OBJECTIVE

To assess the incidence of endometrial polyps during postmenopausal replacement therapy with tibolone, using an appropriate control group.

DESIGN

A total of 485 postmenopausal women were included in this open, prospective, comparative study for a duration of 36 months. Of this group, 249 women received 2.5 mg/day of tibolone and 244 women served as controls, receiving continuous-combined estrogen-progestogen therapy (HT). Transvaginal ultrasound, hysteroscopy, and directed biopsies were performed before treatment was initiated and at the end of the study.

RESULTS

Two hundred twenty-one of the women receiving tibolone and 203 receiving continuous-combined HT completed the study. Endometrial polyps were detected in 74 women (33.4%) from the tibolone group and in 22 women (10.8%) from the HT group (P < 0.01). The vaginal bleeding rate did not differ between the groups. The frequency of atrophic polyps was significantly higher in the tibolone group (P < 0.01). No difference was found in the size of the polyps.

CONCLUSIONS

Tibolone increases by threefold the risk for endometrial polyps.

Female sexuality

Female sexuality is an extraordinarily complex process. The physician needs to be aware of the patient's sexuality and whether or not there are sexual concerns. Physiologic changes over the lifespan can interact with sexual performance as can a variety of disease processes. Partner and relationship issues must also be taken into account. Physicians need to include a sexual history as part of their general history and should not be judgmental of their patients' sexual practices. Sexual disorders in women are defined and delineated by those issues causing personal distress. Again, one person's distress may be quite normal to another. The important aspects of care consist of listening, educating, and providing support to the patient. There is increasing interest but a continued need for data in the use of testosterone in women with decreased libido. The use of sildenafil for female sexual dysfunction remains controversial as a benefit. Overall, there is a need for the development of well-organized, randomized, controlled studies on appropriate assessment and intervention for sexual dysfunction in women.

Menopause: new therapies

The risk-benefit ratio of traditional postmenopausal hormone therapy is considered by many to be unacceptable. Low-dose oestrogen-progestin therapy (oral or non-oral and continuous or pulsatile) may have a better risk-benefit ratio, but this remains unproven. Steroids with selective tissue activation, such as tibolone, alleviate symptoms and protect against bone loss, but long-term safety data are lacking. Selective oestrogen receptor modulators (SERMs), such as raloxifene, prevent bone loss when used alone, and may soon be combined with oestradiol to treat symptoms and prevent osteoporotic fracture. Effects of SERMs on the cardiovascular system are currently being evaluated.

Progestogenic effects of tibolone on human endometrial cancer cells

Tibolone, a synthetic steroid acting in a tissue-specific manner and used in hormone replacement therapy, is converted into three active metabolites: a Delta(4) isomer (exerting progestogenic and androgenic effects) and two hydroxy metabolites, 3 alpha-hydroxytibolone (3 alpha-OH-tibolone) and 3beta-OH-tibolone (exerting estrogenic effects). In the present study an endometrial carcinoma cell line (Ishikawa PRAB-36) was used to investigate the progestogenic properties of tibolone and its metabolites. This cell line contains progesterone receptors A and B, but lacks estrogen and androgen receptors. When tibolone was added to the cells, complete conversion into the progestogenic/androgenic Delta(4) isomer was observed within 6 d. Furthermore, when cells were cultured with tibolone or when the Delta(4) isomer or the established progestagen medroxyprogesterone acetate was added to the medium, marked inhibition of growth was observed. Interestingly, 3 beta-OH-tibolone also induces some inhibition of growth. These growth inhibitions were not observed in progesterone receptor-negative parental Ishikawa cells, and progestagen-induced growth inhibition of PRAB-36 cells could readily be reversed using the antiprogestagen Org-31489. Upon measuring the expression of two progesterone-regulated genes (fibronectin and IGF-binding protein-3), tibolone, the Delta(4) isomer and medroxyprogesterone acetate showed similar gene expression regulation. These results indicate that tibolone, the Delta(4) metabolite, and to some extent 3 beta-OH-tibolone exert progestogenic effects. Tibolone and most likely 3 beta-OH-tibolone are converted into the Delta(4) metabolite.

Hormone replacement therapy: current controversies

Postmenopausal hormonal therapy is used to manage the climacteric symptoms that impair the quality of life of a substantial number of women. The difficulty is achieving the desired effects with minimal side-effects and no adverse health risks. Fundamental to this is understanding the physiology of oestrogen in women and the metabolism of the therapeutic compounds. Although the effects of oral oestrogen therapy have been studied extensively, there is insufficient evidence to assess adequately the independent effects of progestin use, other oestrogen compounds, differing doses and duration of treatment. We have reviewed some basic concepts of oestrogen physiology and how these relate to exogenous oestrogen administration, the risks of greatest concern, and the role of androgens and newer treatment alternatives.

Pros and cons of existing treatment modalities in osteoporosis: a comparison between tibolone, SERMs and estrogen (+/-progestogen) treatments

Tibolone, selective estrogen receptor modulators (SERMs) like tamoxifen and raloxifene, and estrogen (+/-progestogen) treatments prevent bone loss in postmenopausal women. They exert their effects on bone via the estrogen receptor (ER) and the increase in bone mass is due to resorption inhibition. The effect of SERMs on bone mineral density is less than that with the other treatments, but the SERM raloxifene still has a positive effect on vertebral fractures. In contrast to tibolone and estrogens (+/-progestogen), SERMs do not treat climacteric complaints, whilst estrogen plus progestogen treatments cause a high incidence of bleeding. Estrogen plus progestogen combinations have compromising effects on the breast. Tibolone and SERMs do not stimulate the breast or endometrium. Unlike SERMs, tibolone does not possess antagonistic biological effects via the ER in these tissues. Estrogenic stimulation in these tissues is prevented by local metabolism and inhibition of steroid metabolizing enzymes by tibolone and its metabolites. SERMs and estrogen (+/-progestogen) treatments increase the risk of venous thromboembolism (VTE), whilst estrogen (+/-progestogen) combinations have unwanted effects on cardiovascular events. So far, no detrimental effects of tibolone have been observed with respect to VTE or cardiovascular events. The clinical profile of tibolone therefore has advantages over those of other treatment modalities. It is also clear that tibolone is a unique compound with a specific mode of action and that it belongs to a separate class of compounds that can best be described as selective, tissue estrogenic activity regulators (STEARs).

Effects of tibolone and continuous combined hormone replacement therapy on bleeding rates, quality of life and tolerability in postmenopausal women

OBJECTIVE

To compare the effects of tibolone and conjugated equine oestrogens continuously combined with medroxyprogesterone acetate on bleeding rates, quality of life (QoL) and tolerability.

DESIGN

A double-blind, randomised comparative trial.

SETTING

Thirty-seven centres in six European countries.

POPULATION

Five hundred and one postmenopausal women, under 65 years of age with an intact uterus.

INTERVENTIONS

For 12 months, women received daily treatment with tibolone 2.5 mg (n = 250), or conjugated equine oestrogens 0.625 mg continuously combined with medroxyprogesterone acetate 5 mg (CEE-MPA, n = 251).

MAIN OUTCOME MEASURES

The primary outcome was vaginal bleeding rate during cycles 4-6. The secondary outcomes were vaginal bleeding rate during cycles 1-3, 7-9 and 10-13, cumulative bleeding rate, QoL, wellbeing, climacteric symptoms, urogenital complaints and tolerability.

RESULTS

Treatment with tibolone led to a significantly lower bleeding rate during cycles 4-6 compared with CEE-MPA (15.0% vs 26.9%; P = 0.004); there was a similar difference during cycles 1-3. Both treatments improved QoL, wellbeing, climacteric symptoms and urogenital complaints. By intent-to-treat analysis, tibolone significantly improved sexual drive, interest and/or performance, compared with CEE-MPA at 12 months (P = 0.017). Although both treatments were well tolerated, there was a significantly lower incidence of breast tenderness with tibolone than CEE-MPA (2.4% vs 17.1%; P < 0.001).

CONCLUSION

The vaginal bleeding rate during cycles 4-6 was significantly lower in women using tibolone. Both treatments improved QoL, wellbeing, climacteric symptoms and urogenital symptoms. Breast tenderness was significantly less frequent with tibolone.

The effects of tibolone on mood and libido

OBJECTIVE

To review published data pertaining to the effects of tibolone on sexual parameters, mood, and cognitive function in postmenopausal women.

DESIGN

A review of all relevant published, peer-reviewed studies.

RESULTS

Tibolone is a compound that can be selectively metabolized by individual tissues to its estrogenic, progestogenic, or androgenic metabolites and hence exhibits tissue-specific hormonal effects. Tibolone also lowers sex hormone binding globulin, thus increasing free estradiol and testosterone levels. Tibolone alleviates climacteric vasomotor symptoms and displays a dominant progestogenic effect on the endometrium. Tibolone normalizes the vaginal karyopyknotic and maturation indexes and alleviates symptomatic atrophic vaginitis. Women treated with tibolone report significant reductions in vaginal dryness and dyspareunia, effects that may be secondary to both estrogenic and androgenic actions. Randomized studies indicate tibolone has positive effects on mood compared with placebo and alleviates several adverse mood parameters to a similar extent as conventional hormone replacement therapy. Improved mood is associated with increased plasma beta-endorphin. With respect to cognition, tibolone seems to improve semantic memory but does not significantly improve recognition memory. Tibolone is associated with improvements in sexual function that seem to be greater than those achieved with standard hormone replacement therapy.

CONCLUSION

Published studies indicate beneficial effects of tibolone on both libido and mood, which otherwise significantly compromise physical, psychological, and social well-being. Hence, tibolone provides another option for menopausal women experiencing loss of libido as part of their symptomatology or who have persistent low libido despite adequate estrogen/progestin replacement therapy.

"Extracts from "Clinical evidence": Menopausal symptoms

DEFINITION

Menopause begins one year after the last menstrual period. Symptoms often begin in the perimenopausal years. INCIDENCE/PREVALENCE: In the United Kingdom the mean age for the menopause is 50 years 9 months. The median onset of the perimenopause is between 45.5 and 47.5 years. One Scottish survey (of 6096 women aged 45 to 54 years) found that 84% had experienced at least one of the classic menopausal symptoms, with 45% finding one or more symptoms a problem. AETIOLOGY/RISK FACTORS: Urogenital symptoms of menopause are caused by decreased oestrogen concentrations, but the cause of vasomotor symptoms and psychological effects is complex and remains unclear.

PROGNOSIS

Menopause is a physiological event. Its timing may be genetically determined. Although endocrine changes are permanent, menopausal symptoms such as hot flushes, which are experienced by about 70% of women, usually resolve with time. However, some symptoms, such as genital atrophy, may remain the same or worsen.

AIMS

To reduce or prevent menopausal symptoms, and to improve quality of life with minimum adverse effects.

OUTCOMES

Frequency and severity of vasomotor, urogenital, and psychological symptoms; quality of life.

METHODS

Clinical Evidence search and appraisal December 1999. We included only randomised controlled trials (RCTs) and systematic reviews that met Clinical Evidence quality criteria.