Conjugated equine oestrogens and blood clotting: a follow-up report

A simplified method to quantitate atherosclerosis in the rabbit aorta

A simple method to quantitatively evaluate atherosclerosis in the rabbit aorta by measuring macroscopic lesion areas (%) was attempted in the present study. Ten female New Zealand white rabbits were fed on a cholesterol-rich diet (5/1000 g of food) during 4 months. Five of them were oophorectomized at the beginning and all were sacrificed at the end. Total levels of cholesterol increased from 50.7+/-14.7 mg/dl to 782.8+/-296.0. No significant differences were observed between oophorectomized and intact rabbits. At 4 months, the cholesterol-rich diet caused in both, intact and oophorectomized rabbits, atherosclerotic lesions affecting 17 and 46% of the aortic surface, respectively. This method may be more practical, easy and useful for quantitative evaluation of aortic atherosclerosis in a large number of rabbits, than histological observations of serial sections of rabbit's aortas.

Hemostatic Factors and Ischemic Heart Disease Risk Among Postmenopausal Women

The following is a review of (largely) epidemiologic evidence on whether changes in plasma hemostatic concentrations occur with menopause and with postmenopausal hormone therapy which may have an impact on risk of ischemic heart disease. To date, only plasma fibrinogen has been positively associated with long-term risk of disease among women; however, data are sparse. Taken together, the evidence supports an impact of endogenous sex hormone levels on thrombotic potential and points to a modest increase in a number of plasma hemostatic factor levels at menopause. Results of studies of estrogen therapy are somewhat conflicting. Observational findings suggest that, except for possibly the Factor VII level, estrogen therapy may prevent the menopause-related rise in plasma hemostatic factors. In contrast, controlled experiments have found increased markers of thrombin generation with use of common formulations of estrogen therapy. The hemostatic effects found with oral preparations do not appear to occur with transdermal forms of estrogen although data are limited. Overall, the evidence shows menopause to have an impact on plasma levels of hemostatic factors which appears to be modified by use of oral estrogen. Whether these alterations in plasma levels have an impact on risk of ischemic heart disease among postmenopausal women remains to be demonstrated.

In vitro platelet function in controlled ovarian hyperstimulation cycles

OBJECTIVE

To determine the effects of elevated endogenous E2 levels on in vitro platelet function in patients undergoing controlled ovarian hyperstimulation (COH).

DESIGN

Women with normal ovulatory cycles and patients undergoing COH on cycle day 3 and near ovulation (preovulatory follicles were at least 16 mm in diameter) were studied. Serum E2, Thrombostat 4000, (V. d. Goltz, Seeon, Germany), von Willebrand factor antigen (vWF-Ag), and platelet aggregation and adenosine triphosphate (ATP) release to adenosine diphosphate (ADP), collagen (COL), and arachidonic acid (AA) were measured.

SETTING

University-based outpatient infertility clinic.

PATIENT(S)

Twenty-two consenting infertile women undergoing COH cycles and 14 women with documented ovulatory cycles.

MAIN OUTCOME MEASURE(S)

Whole blood platelet aggregation with ADP, COL, AA, and Thrombostat 4000.

RESULTS(S)

Estradiol levels rose significantly at peak times (P = 0.011). No changes were noted in in vitro platelet function measured by the Thrombostat 4000 and by whole blood platelet aggregation with ADP and AA and in ATP release with ADP, COL, or AA. Aggregation with collagen was increased because of likely elevations in vWF-Ag levels.

CONCLUSION(S)

No significant changes in in vitro platelet function were noted in 19 women undergoing COH with E2 levels two to three times that observed in oral contraceptive or hormone replacement therapy users, suggesting no increased risk for arterial thromboembolism.

The effect of hormone replacement therapy of the age-related rise of factor VIIc, and its activity state

Although hormone replacement therapy (HRT) appears to protect women from ischaemic heart disease (IHD), its use is associated with increased factor clotting activity (VIIc), an independent risk factor for IHD. The nature of this factor VII rise was therefore examined in a cross-sectional study of 279 women aged between 40 and 65 years. Ninety-four were pre-menopausal, 44 were post-menopausal and taking HRT, whilst 141 were post-menopausal non-users. For those women on oestrogen-only HRT, the mean factor VIIc was 144%, compared to 130% for post-menopausal non-users, and 116% for those on combined HRT. These differences were significant (p = 0.01). Oestrogen-only users also had significantly higher mean levels of factor VIIa (3.3 ng/ml) compared to non-users (2.2 ng/ml) and those on oestrogen-progestogen HRT (2.2 ng/ml-p = 0.015). In contrast for factor VII antigen the mean values of the three groups were similar. Analysis of the age-regression slopes showed a significant age-related rise in factor VIIc of 1.2% per annum (p < 0.01) for post-menopausal non-users. There was a similar increase in factor VII antigen (2.1%) but no rise in factor VIIa. For all HRT users there was no change with age for any of the factor VII measures. Thus the age-related rise in factor VIIc appears to be due to an increase in factor VII zymogen alone, and taking HRT seems to abolish such a rise. In contrast, the increased factor VIIc seen with oestrogen-only HRT appears to be secondary to factor VII activation.

Prospective study of exogenous hormones and risk of pulmonary embolism in women

BACKGROUND

Current use of oral contraceptives (OCs) is a well-recognised risk factor for venous thrombosis and consequent pulmonary embolism (PE). Little is known about residual effects of past OC use. Furthermore, few epidemiological studies have assessed the relation between postmenopausal use of hormones and thrombotic disease.

METHODS

In this prospective study information was obtained through questionnaires sent every 2 years (1976-92) to 1125,93 women aged 30-55 in 1976. We excluded women with previously diagnosed cardiovascular disease or cancer in 1976 and at the beginning of each subsequent 2-year follow-up period.

FINDINGS

From self-reports and medical records, we documented 123 cases of primary PE (no identified antecedent cancer, trauma, surgery, or immobilisation). Current users of postmenopausal hormones had an increased risk of primary PE (relative risk adjusted for multiple risk factors 2.1 [95% CI 1.2-3.8]). However, past use showed no relation to PE (1.3 [0.7-2.4]). In current users of OCs the risk of primary PE was about twice that in non-users (2.2 [0.8-5.9]), but this finding was based on only five cases who were current OC users. Users of OCs in the past had no increase in risk of PE (0.8 [0.5-1.2]). These relations were consistent irrespective of cigarette-smoking status.

INTERPRETATION

Primary PE was uncommon in this cohort. The risk was increased by current though not past use of postmenopausal hormones or OCs.

The menopause and hormone replacement therapy: lipids, lipoproteins, coagulation and fibrinolytic factors

OBJECTIVES

To review the recent literature concerning the effects of the menopause and hormone replacement therapy (HRT) on the plasma lipoprotein and hemostatic system, as well as on the interaction between these two coronary heart disease (CHD) risk factor systems. METHODS. Collection of information from relevant scientific journals, and by the use of Medline and Current Contents.

RESULTS

The mainly beneficial effects of unopposed oral estrogen replacement on the plasma lipoprotein pattern are preserved to different degrees after addition of progestin to the regimen. Nortestostorone-derived progestins tend to lower HDL cholesterol levels more than progesterone derivatives. The slight triglyceride-elevating effect on conjugated equine estrogens was in a large study not significantly counteracted by progesterone derivatives but can, according to other studies, be reversed by nortestosterone-derived progestins. A limited number of studies on transdermal administration of estradiol has suggested that the effects on plasma lipoproteins are smaller than during oral administration. There is no convincing evidence that currently used HRT regimens would significantly increase the risk of thrombosis. Nevertheless, the finding in some studies that plasma triglyceride elevations could in theory be associated with impaired fibrinolysis and enhanced coagulation merit further attention as some HRT regimens tend to increase plasma triglyceride levels. From a theoretical point of view, transdermal estrogen delivery would be preferable in women at risk for thrombosis, as they have less pronounced effects on liver functions, including production of hemostatic factors and very-low-density lipoprotein triglycerides.

CONCLUSIONS

While the numerous existing HRT regimens provide many alternative and useful possibilities, further studies are needed concerning (a) novel progestins with minimal HDL cholesterol lowering effects, (b) transdermal and other non-oral routes for HRT, (c) possible antioxidative properties of estrogen and (d) metabolic links between the lipoprotein and hemostatic risk factor systems.

Impact of weight loss on plasminogen activator inhibitor (PAI-1), factor VII, and other hemostatic factors in moderately overweight adults

Based on previous cross-sectional findings, we hypothesized that weight loss could improve several hemostatic factors associated with cardiovascular disease. In a randomized controlled trial, moderately overweight men and women were assigned to one of four weight loss treatment groups or to a control group. Measurements of plasminogen activator inhibitor-1 (PAI-1) antigen, tissue-type plasminogen activator (t-PA) antigen, D-dimer antigen, factor VII activity, fibrinogen, and protein C antigens were made at baseline and after 6 months in 90 men and 88 women. Net treatment weight loss was 9.4 kg in men and 7.4 kg in women. There was no net change (p > 0.05) in D-dimer, fibrinogen, or protein C with weight loss. Significant (p < 0.05) decreases were observed in the combined treatment groups compared with the control group for mean PAI-1 (31% decline), t-PA antigen (24% decline), and factor VII (11% decline). Decreases in these hemostatic variables were correlated with the amount of weight lost and the degree that plasma triglycerides declined; these correlations were stronger in men than women. These findings suggest that weight loss can improve abnormalities in hemostatic factors associated with obesity.

Hemostatic factors according to menopausal status and use of hormone replacement therapy

The rise in cardiovascular disease (CVD) risk after menopause may be reduced by hormone replacement therapy (HRT) although the mechanism is unclear. Because little is known about the potential role of hemostatic factors, fibrinogen level and other coagulation parameters were measured in a study on the change in CVD risk factors through the climacteric (the Healthy Women Study). Of 239 subjects measured to date, 32 taking aspirin or other medications thought to alter coagulation were excluded from analyses. Results (adjusted for age and obesity) showed that women taking HRT had lower plasma concentrations of fibrinogen and higher levels of plasminogen and factor VIIc than did postmenopausal subjects not taking HRT. Pre- as compared with postmenopausal women had lower plasma levels of fibrinogen, factor VIIc, and antithrombin III. Adjusting for cigarette smoking did not change the findings. Thus, among women aged 49 to 55, selected hemostatic measures varied (within normal ranges) by menopausal status and were altered by HRT. These findings generally support a hypothesis of hemostatic change contributing to the increase of CVD after menopause. The fact that subjects taking HRT showed no increase in fibrinogen relative to premenopausal women is consistent with an observed decreased risk of CVD among women taking HRT, while the implication of an elevation in factor VIIc among these women is uncertain.

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.

Transdermal estradiol substitution therapy for the induction of puberty in female hypogonadism

Fifteen patients aged 14.5-27.3 years (mean +/- SE 18.8 +/- 0.9) with pubertal development failure underwent replacement therapy with estradiol (E2) using a transdermal therapeutic system (TTS). Fourteen of them were affected by hypogonadotropic hypogonadism (11 with thalassemia major, 3 with multiple pituitary hormone deficiency), the 15th patient had an asymmetric gonadal dysgenesis (karyotype 45, X 0/46, XY). Two sizes (5 and 10 cm2) of E2 TTS, delivering respectively 25 and 50 micrograms of E2 a day for 3 1/2 days, were used in this study. All patients were initially given the lower dose of 25 micrograms, twice weekly for 3 weeks each month; 6 months after starting therapy, 5-10 mg oral medroxyprogesterone acetate (MPA) daily was added during the third week. Later, the following sequence was used: 25 micrograms E2 TTS (twice weekly), on days 1 through 14, and 50 micrograms E2 TTS (twice weekly), on days 15 through 25 of each month. On days 15 through 25, 5 mg daily of MPA were administered orally. The period of treatment ranged from 0.5 to 3 years. Breast development was obtained in all cases. The vaginal maturation index rose. Ultrasonography showed an increase of uterine size and uterine shape became of pubertal type. Withdrawal bleeding occurred in all patients. Plasma E2 levels rose to normal levels, estrone (E1) levels increased slightly. No change in plasma SHBG levels was observed. Urinary E2, E1 and estriol rose to maximum levels the 3rd day after the application of each system. Neither systemic side effects nor adverse metabolic effects were observed except for an increased sensitivity to the platelet aggregating agents.(ABSTRACT TRUNCATED AT 250 WORDS)

Haemostatic changes during continuous oestradiol-progestogen treatment of postmenopausal women

To identify changes in haemostatic balance during continuous oestradiol-progestogen treatment, 60 postmenopausal women with climacteric complaints, mean age 55.4 years (range 44-68) were randomly allocated to receive one of four hormone replacement regimens for one year. All four formulations were administered daily and continuously, each contained 2 mg of 17 beta-oestradiol in combination with either norethisterone acetate, 1 mg (group A) or 0.5 mg (group B) or megestrol acetate, 5 mg (group C) or 2.5 mg (group D). No significant changes occurred during treatment within or between the groups in platelet count, fibrinogen and 2-antiplasmin. Activated partial thromboplastin time was shortened (P less than 0.05) in group D and a decline in factor VII activity and antigen (P less than 0.001) and in ATIII activity (P less than 0.05) was noted in group A. Protein C tended to decline in all treatment groups but statistically significant changes were noted only in groups A and C. Two women developed crural thrombosis during the observation period.

Oestrogen replacement therapy and cardiovascular disease in post-menopausal women. A review

The possible role played by oestrogens in modifying the occurrence of ischaemic heart disease (IHD) in particular and cardiovascular disease (CVD) in general in post-menopausal women has long been controversial. Analysis of the literature reveals a difference between the findings of epidemiological studies published before 1980 and those published more recently. In the former, it was reported that the risk in women using oestrogen replacement therapy (ERT) either remained unchanged or increased in relation to that in non-users. In the latter, the trend changed and ERT was shown to have a definite protective effect. These contradictory results might be explained by a change in prescribing habits, involving the use of lower oestrogen doses and the selection of women with no CVD risk factors as recipients of long-term ERT. The protective effects of ERT have been attributed to metabolic changes induced by oestrogens, namely the increase in high density lipoprotein (HDL) cholesterol observed after oral therapy. Recently, long-term studies using non-oral oestrogens delivered either by implant, or the percutaneous or transdermal routes have indicated the same favourable changes in lipid profiles as seen with oral ERT, provided follow-up is maintained for at least 6 mth. Factors other than lipids that are involved in CVD should also be evaluated in order to clarify the mechanism via which ERT affords cardiovascular protection in post-menopausal women.

Estrogen replacement therapy: indications, contraindications, and agent selection

Three groups of indications exist for postmenopausal estrogen use: relief of symptoms related to estrogen deficiency, osteoporosis prophylaxis and treatment, and cardioprotection. Estrogen replacement therapy enhances a woman's sense of well-being and reduces the morbidity, mortality, and health care costs associated with osteoporosis and atherosclerotic heart disease. There are a few absolute contraindications to estrogen replacement therapy. Many estrogen preparations are currently available in the United States. Establishing equivalencies among the different preparations is complicated by the many physiologic and pharmacologic effects of estrogens and the variety of treatment end points used. Most estrogens have the same biologic effect provided equivalent blood levels are achieved. Estrogen replacement therapy has proved beneficial to selected postmenopausal women.

Estimated long-term effect of calcitonin treatment in acute osteoporotic spine fractures

A 12-month prospective controlled study was conducted in 28 patients with acute osteoporotic spine fractures to evaluate and compare the effect of calcitonin treatment and cyclical hormone replacement therapy on forearm bone mineral content (BMC) and bone turnover. We established two treatment groups and a control group of women with postmenopausal osteoporosis (n = 28). Group A (n = 10) received 100 U of calcitonin by subcutaneous self-application on alternate days and oral calcium (Ca) for 6-8 weeks. Group B (n = 10) received cyclical estrogen/gestagen replacement therapy over 12 months and oral calcium. The control group (n = 8) received analgetic treatment and 500 mg Ca daily. BMC was measured by single photon absorptiometry (SPA) with I 125 before and 6 and 12 months after the onset of the therapies. Ca, phosphorus (P), alkaline phosphatase, and 2-hour urinary OH-proline excretion were measured to classify bone turnover. One year after the onset of the two therapies, forearm BMC measured by SPA showed a significant increase in the group under hormone replacement therapy (P less than 0.025) as well as in the calcitonin group (P less than 0.05), although the latter underwent treatment only over a short period (6-8 weeks). In the same period, BMC decreased significantly in the control group (P less than 0.025). These results demonstrate that short-term calcitonin treatment over 6-8 weeks is as effective as long-term hormone replacement therapy, both therapies increasing forearm BMC measured by SPA.

Ethanol metabolism and hepatotoxicity. Does sex make a difference?

The role of gender as a variable that might affect the metabolism of ethanol and thus the hepatotoxicity of ethanol is evaluated. First, the pharmacodynamics of ethanol are reviewed with particular attention to hormone effects on ethanol absorption and metabolism. Specific differences between males and females relative to ethanol pharmacokinetic parameters are discussed, including gender differences in the volume of distribution and putative hormonal effects on achieved blood alcohol levels. In addition, attention is directed toward the metabolic capacity of alcohol dehydrogenase and the microsomal ethanol-oxidizing system with respect to effects of both sex differences and hormonal manipulations on the activity of these ethanol-metabolizing enzymes. Finally, the studies on the concept of sex-related differences in susceptibility to alcohol hepatotoxicity are examined.

Climacteric symptoms after oral and percutaneous hormone replacement therapy

One hundred and ten (110) healthy early post-menopausal women with mild subjective vasomotor symptoms (mean Kupperman index score 11) participated in a long-term, double-blind, placebo-controlled therapeutic trial. The effects of 2 hormone regimens were evaluated. Group I received percutaneous oestrogen therapy for 2 yr, opposed by oral micronized progesterone (200 mg) during the second year, while Group II received oral 17 beta-oestradiol valerate together with cyproterone acetate (CPA). The serum oestrogen concentrations differed markedly in the 2 treatment groups. In Group I the serum/oestrone/oestradiol ratio was 1 (comparable to the pre-menopausal value), but in group II the ratio was greater than 5. Despite the difference in the serum oestradiol and oestrone concentrations, the mean symptom scores were rapidly and similarly reduced in both treatment groups (P less than 0.001). They remained low throughout the study and were not significantly different from pre-menopausal values.

Serum levels of unbound 17beta-oestradiol during oral and percutaneous postmenopausal replacement therapy

The metabolic effects of oestrogen therapy are influenced by the route of administration. Compared with oral treatment, percutaneous administration may have theoretical advantages with respect to liver metabolism, but there are also potential disadvantages related to the specific kinetics of this route. The increase of SHBG binding capacity is much less pronounced, which might result in excess amounts of unbound, biologically-active steroid during therapy. The serum concentrations of unbound 17 beta-oestradiol were calculated in two groups of postmenopausal women during replacement therapy with equivalent amounts of oral and percutaneous oestrogen. A highly significant and quite similar increase of the free fraction as well as in total 17 beta-oestradiol was found in both groups of women, in spite of the fact that SHBG binding capacity was unchanged during percutaneous therapy. Albumin binding and the total serum concentration of 17 beta-oestradiol were found to be more important for the regulation of unbound steroid concentration than variations in SHBG binding capacity. In conclusion, there was no evidence that percutaneous administration per se would carry an increased risk of over-treatment.

Effect of oestrogen replacement therapy on blood coagulation factors in postmenopausal women

Natural oestrogens "Premarin", (Ayerst, conjugated equine oestrogens) "Harmogen", (Abbott, piperazine oestrone sulphate) and "Progynova" (Schering, oestradiol valerate) alone and in combination with proestational agents such as "Primolut N", (Schering, norethisterone) "Neogest", (Schering, norgestrel), "Norgeston", (Schering, levonorgestrel), "Duphaston" (Duphar, dydrogesterone) did not have adverse effects on clotting factors. One patient developed deep vein thrombosis following treatment using "Progynova" (oestradiol valerate) alone and a second patient suffered from mild myocardial infarction following the use of "Premarin" (conjugated equine oestrogens) alone.

Percutaneous oestrogen therapy opposed by lynestrenol or natural progesterone--effects on circulating oestrogens, FSH, sex hormone binding globulin and pregnancy zone protein

Three groups of post-menopausal women were treated with percutaneous 17 beta-oestradiol 3 mg daily opposed by lynestrenol 5 mg or natural micronized progesterone 200 mg and 300 mg, respectively. During 6 mth of cyclic replacement oestrogen serum levels were increased corresponding to follicular phase values. The pre-treatment ratio E1/E2 was unchanged which is in contrast to oral therapy. Progesterone had a much weaker effect on FSH levels than lynestrenol. Women treated with progestogen had regular withdrawal bleedings, while the micronized progesterone was insufficient in this respect. No increase of the oestrogen-sensitive liver proteins, sex hormone binding globulin (SHBG) and pregnancy zone protein (PZP), was recorded in spite of a marked increase in circulating oestrogens.

A comparison of liver protein induction in postmenopausal women during oral and percutaneous oestrogen replacement therapy

Two groups of postmenopausal women with climacteric symptoms were investigated during unopposed cyclic replacement therapy with tablets of micronized 17 beta-oestradiol (2 mg daily) and percutaneous 17 beta-oestradiol (3 mg daily). The resultant serum levels of 17 beta-oestradiol, total oestrone and three liver proteins: sex-hormone-binding globulin (SHBG), pregnancy-zone protein (PZP) and caeruloplasmin were followed. In both groups similar levels of serum 17 beta-oestradiol (ca 500 pM) were recorded, while the increase of total oestrone was much more pronounced after oral treatment. During oral therapy the serum levels of all three proteins showed a marked increase after the first cycle and the levels then remained stable. In contrast, protein levels were unchanged during percutaneous treatment, in spite of the highly increased concentrations of circulating oestrogens. This observation is important as several side-effects of oestrogen therapy may be related to liver function.

Effects of percutaneous estradiol and conjugated estrogens on the level of plasma proteins and triglycerides in postmenopausal women

Percutaneous administration of estradiol (E2) is a new substitutive treatment for postmenopausal women. In order to compare hepatic action of percutaneous E2 with that of conjugated estrogens, 18 postmenopausal women were allocated at random to receive one of these two types of natural estrogens for 21 days. Eight patients (group I) received conjugated estrogens orally, 1.25 mg daily. Ten patients (group II) were told to apply percutaneous E2 ointment, 5 gm (i.e., 3 mg of E2), each evening on the abdominal skin. E2, estrone (E1), follicle-stimulating hormone (FSH), and luteinizing hormone (LH), and several markers of estrogen action were evaluated before and after treatment. Both types of treatment were biologically effective, as indicated by the decrease in plasma gonadotropins and the increase in estrogen levels. However, conjugated estrogens produced a greater increase in E1 than in E2; hence, the E2/E1 ratio was 0.57 in group I, whereas it was approximately 1 in group II. Plasma renin substrate increased significantly (by 180%) in group I but not in group II. In the same way, conjugated estrogens produced a modest (12%) but significant decrease in antithrombin III, whereas there was no variation with percutaneous E2. Sex steroid-binding protein was the most sensitive parameter for the hepatic action of estrogen, and increased by 18.66% with percutaneous E2 and by 150% with conjugated estrogens. Plasma triglycerides tended to increase in group I and to decrease in group II, but not significantly. Therefore, percutaneous administration of of E2, in contrast to conjugated estrogens, can produce plasma levels of estrogens closer to those observed in the follicular phase and less alterations in protein synthesis. This lesser toxicity may be explained partially by the route of administration, since with percutaneous administration of E2, the steroid bypasses the liver.

Menopausal status associated with increased inhibition of blood coagulation

Postmenopausal women receiving estrogen replacement therapy (ERT) are not as prone to inappropriate venous and arterial thrombosis as are younger women taking oral contraceptives. To establish whether menopausal status per se has any effect on the coagulation-fibrinolytic system normal premenopausal women (mean age 29 years) were compared with younger (mean age 23) and older (mean age 51) surgically menopausal women and a group of naturally postmenopausal women (mean age 53). The results show that in postmenopausal women, irrespective of age or type, the shift is away from clot formatiuon and toward clot inhibition and fibrinolysis as determined by static in vitro analysis. This was characterized by statistically significant increases in antithrombin III antigen, alpha 1-antitrypsin antigen, and plasminogen activity. These changes may help to explain in part why ERT does not appear to cause increased thrombosis in older women.

Haemostatic changes in tall girls treated with high doses of ethinyloestradiol

Haemostasis was studied in 8 tall girls during treatment with high doses of synthetic oestrogens for a period of 1 to 28 months. The girls received 0.5 mg ethinyloestradiol daily from day 1 to day 25 and 15 mg norethisteron daily from day 21 to day 25. All were without clinical signs of thromboembolism. Factors of the prothrobmin complex were significantly elevated in the tall girls compared to healthy controls of the same age. Fibrinogen was also significantly elevated. Factor VIII-related antigen was significantly higher in the tall girls and the ratio between factor VIII activity and factor VIII-related antigen was significantly decreased in the tall girls, as compared to the controls. Thrombin time was significantly shortened. Tests of primary haemostasis showed an increased tendency for thrombocytes to adhere to glass and to aggregate spontaneously and after stimulation with ADP or collagen. Whether these in vitro signs of hypercoagulability indicate an enhanced risk of throbmoembolic complications in tall girls treated with high doses of oestrogens remains to be established. However, these girls should be watched carefully for clinical signs of throbmoembolic complications during treatment.

A double-blind cross-over study of piperazine oestrone sulphate and placebo with coagulation studies

A double-blind trial of piperazine oestrone sulphate was performed over a period of 14 months on 55 menopausal women complaining of depressiona and hot flushes. Depression was not affected but the hot flushes were significantly lessened by the oestrogen treatment. After three months of piperazine oestrone sulphate there were no significant accelerations of prothrombin time or increases in factors VII or X but, after six months, there was an acceleration in the prothrombin time. After 14 months those who received piperazine oestrone sulphate for the first six months showed a significant increase in alpha 1-antitrypsin and factor VIIR:AG. Oestrone piperazine sulphate appears to produce less marked changes in coagulation than oestrogen-containing oral contraceptives or conjugated equine oestrogens.

A study of the effectiveness of propranolol in menopausal hot flushes

A prospective, double-blind, randomized comparison of propranolol, 40 mg three times daily, and matching placebo showed propranolol to be no more effective than placebo in controlling hot flushes in a group of 25 perimenopausal women. Other menopausal symptoms, such as insomnia and palpitations, were equally unaffected. However, a very close correlation was found between the daily atmospheric temperature and the number of flushes occurring in the group.

The comparative effects of a synthetic and a 'natural' oestrogen on the haemostatic mechanism in patients with primary amenorrhoea

A synthetic and a natural oestrogen were administered alternately for three months to nine women with primary amenorrhoea using a randomized cross-over schedule. Measurements of haemostatic function were performed before and at the end of each treatment period. No significant change in haemostatic function was observed after treatment with the 'natural' oestrogen, oestriol succinate. In contrast, treatment with a synthetic oestrogen, ethinyloestradiol, caused shortening of the prothrombin time and an increase in plasma concentration of factor VII and plasminogen. These data support other observations in suggesting that natural oestrogens may have fewer potentially adverse effects on haemostatic function than synthetic oestrogen.

The effects of long-term therapy with oestriol succinate on the haemostatic mechanism in postmenopausal women

In a previous report we showed that oestriol succinate administered to postmenopausal women caused fewer changes in haemostatic function over a four-month period than ethinyloestradiol. Potential longer-term effects were studied in postmenopausal women treated for osteoporosis with oestriol succinate for up to 12 months. Over this period there was no significant change in concentration of plasma coagulation factors, an increase in plasminogen concentration and euglobulin lysis activity, and an inconsistent increase in platelet sensitivity to aggregation induced by ADP and collagen. The relative lack of effect of oestriol succinate on coagulation function is encouraging with regard to the future incidence of thromboembolic complications of therapy.