Vascular and inflammatory effects of estrogen and anti-androgen therapy in the testis and epididymis of male to female transgender adults

The volume of ubiquitous chemicals with estrogenic properties is on the rise and some reports relate the increase in hormonal diseases to these compounds. A morphological and immunohistochemical analysis has been performed on 42 bilateral orchiectomy specimens from adult individuals who underwent gender reassignment surgery after receiving crossed-sex hormone therapy to give insight into vascular, inflammatory and epididymal changes following long-term treatment with estrogens and antiandrogens and raise awareness of the consequences of hormone therapy. The present study confirms previously reported findings in testicular parenchyma and epididymis, such as identification of three histological patterns according to lesion severity and cell dedifferentiation, and reports for the first time vascular and inflammatory lesions (atherosclerosis and vasculitis), both on testicle and epididymis. Cross-sex hormone therapy should be provided in specialized units in order to systematize treatments and ensure adequate follow-up.

Endocrine mechanisms in the pathogenesis of primary varicosis

Introduction: Varicose veins affect up to 40 % of men and up to 51 % of women. The patho-physiology of primary varicosis (chronic venous insufficiency, CVI) is poorly understood. Here, the available data on possible endocrine mechanisms in healthy and varicose veins are reviewed.

Methods: An extensive literature search was conducted in PubMed using the following key words: Chronic venous insufficiency, CVI, chronic venous disease, CVD, varicosis, saphenous vein, pathogenesis, hormone.

Results: Several theories ranging from incompetence of the valves to functional, biological or morphologic changes in different layers of the vein wall have been proposed. However, an increasing body of evidence suggests that endocrine mechanisms might be involved in the pathogenesis of primary varicosis. In this respect a growing number of hormones (e.g. estrogen, progesterone, relaxin-2, and oxytocin) and their receptors have been linked to primary varicosis in experimental, pharmacological and histological studies.

Conclusion: In summary, endocrine-based mechanisms seem to play a role in the pathogenesis of primary varicosis. This opens up the perspective for pharmacological treatments targeting the various described endocrine regulatory networks.

Duplex ultrasonography findings are not related to menstrual cycle phases in women with early symptoms of lower extremity chronic venous disease

PURPOSE

To investigate if duplex ultrasonography findings change according to the menstrual cycle phases in women with early symptoms of lower extremity chronic venous disease.

METHODS

Thirty women (60 extremities) aged 18-50 years with regular menstrual cycles who presented with complaints of telangiectasia and/or trunk varices with accompanying leg pain were evaluated prospectively by duplex ultrasonography at three different times of a single menstrual cycle. Previous DVT or menstrual irregularities were exclusion criteria. All exams were performed by the same radiologist, under the same conditions. Reflux was provoked in the deep veins, great saphenous vein (GSV), and small saphenous vein (SSV) using the Valsalva maneuver. Reflux times in each vein and average diameters of the GSV and SSV were recorded.

RESULTS

Reflux times showed no significant differences in any of the vein segments and the diameters of GSV and SSV were similar in the different menstrual phases (p > 0.05). Reflux was not predominant at any specific phase, and its presence was independent of menstrual phase.

CONCLUSIONS

Reflux was not specific to a particular phase of menstrual cycle in women with early symptoms of chronic venous disease.

Impact of elevated serum estradiol/free testosterone ratio on male varicose veins in a prospective study

OBJECTIVE

Although some studies indicate an association between increased levels of estradiol and varicose veins in women, the role of sex hormones on varicose veins have a question mark in men.

METHODS

We investigated estradiol-2/free testosterone (E2/fT) ratio relationship on varicosity in 100 male patients dividing them into two groups. Group A (n = 46) had varicose veins with endocrinological problems, especially infertility, whereas group B (n = 54) also had varicose veins but no endocrinological problems. Venous blood samples were drawn from both groups in the morning to detect the levels of serum estradiol (E2), androstenedione, dehydroepiandrostenedione sulphate and free testosterone (fT). Patient history, physical examination, colour duplex ultrasound of both limbs and classification of CEAP were performed in both groups. Serum E2/fT ratio was calculated in correspondence with CEAP classification. CEAP classification is the varicosity classification, and it is concerned about the clinical class (C), etiology (E), anatomical distribution (A) and underlying pathophysiology (P).

RESULTS

E2/fT ratio was significantly higher in group A (4.18 ± 0.54) compared with group B (2.98 ± 0.36). Moreover, there is a high correlation between serum E2/fT ratio and CEAP clinical classification in group A (4) compared with group B (2).

CONCLUSION

Serum E2/fT ratio is associated with varicose veins in male patients.

A systematic review of circulating markers in primary chronic venous insufficiency

OBJECTIVES

The etiology of primary chronic venous insufficiency is poorly understood. This systematic review aimed to summarize published evidence assessing the association of circulating markers with primary chronic venous insufficiency.

METHODS

A search was undertaken through the PubMed database using the terms "venous insufficiency" and "biological marker" or "plasma" or "serum". Search limits included English language, human subjects and studies with publication dates from 1994. Studies which classified patients using the Clinical-Etiology-Anatomy-Pathophysiology system of venous disease were analyzed.

RESULTS

Seventeen studies were included, which have examined > 60 different biomarkers. A total of 13 markers were assessed in >1 study with the number of primary chronic venous insufficiency cases ranging from 41 to 244 and the number of controls ranging from 30 to 144 in these studies. Circulating estradiol, homocysteine and vascular endothelial growth factor were the most consistently associated with primary chronic venous insufficiency.

CONCLUSIONS

Whilst a number of studies have examined biomarkers associated with primary chronic venous insufficiency, further studies are required using improved and standardized approaches on larger populations. Biomarker research may increase pathogenic knowledge and result in opportunities to decrease chronic venous insufficiency burden.

Low estradiol-to-testosterone ratio is associated with oligo-anovulatory cycles and atherogenic lipidic pattern in women with polycystic ovary syndrome

OBJECTIVE

The estradiol-to-testosterone (E2/T) ratio has been investigated in different diseases but few in vivo data are available with regard to its role in women with ovary syndrome (PCOS). The aim of this study was to evaluate the role of the E2/T ratio in the ovulatory function and metabolic pattern in such women.

METHODS

We retrospectively evaluated hyperandrogenemia, clinical hyperandrogenism, ovarian morphology, hypothalamo-hypophyseal axis and metabolic syndrome parameters in a cohort of 202 consecutive women affected by PCOS. An oral glucose tolerance test measured areas under the curve for insulin (AUC(2hIRI)), for glucose (AUC(2hglucose)), and the HOMA-IR and Matsuda index of insulin resistance were evaluated. Serum progesterone (Pg) was determined from day 20 to day 24 of the menstrual cycle and chronic oligo-anovulation was established if two consecutive cycles were anovulatory.

RESULTS

Women with PCOS with normal ovulation [66/202 (32.7%)] showed a significantly higher E2/T ratio than women with PCOS with chronic oligo/anovulation [136/202 (67.3%)] (p < 0.05). Using a series of multiple linear regression models, we also investigated which variables correlated with the E2/T ratio. The analysis showed a strongly positive correlation of the E2/T ratio with Pg (β =  0.473, p < 0.001) and a negative correlation with total cholesterol (β =  -0.433, p < 0.001).

CONCLUSIONS

Our data suggest that in women with PCOS a low E2/T ratio is not only associated with chronic oligo-anovulation, but is also a determinant factor of the atherogenic lipid profile.

Elevated sex steroid hormones in great saphenous veins in men

INTRODUCTION

High serum levels of estradiol are associated with clinical evidence of varicose veins in women; however, the relationship between serum sex steroid hormones and varicose veins in men is unclear. To address this issue, serum levels of testosterone, estradiol, and androstenedione were determined in the great saphenous (GSV) and cubital veins of men with varicose veins. Messenger RNA (mRNA) expression of sex steroid hormones, metabolizing enzymes, and their receptors was investigated in tissue samples of leg veins.

METHODS

This prospective study included 40 men, comprising 20 with varicose veins and reflux of the GSV (VM) and 20 with healthy veins (HM). All limbs were assessed by duplex ultrasound scanning of selected superficial and deep leg veins. Blood samples were taken from the cubital vein and from the GSV. Quantitative reverse-transcription polymerase chain reaction (qRT-PCR) analysis for sex steroid hormones, their metabolizing enzymes, and receptors in saphenous veins was performed in tissue samples of varicose (n = 6) and healthy veins (n = 6).

RESULTS

The VM group had significantly higher (P < .001) mean levels for serum testosterone (44.9 nmol/L; range, 8.8-225.1) and estradiol (242.2 pmol/L; range, 79-941) in varicose saphenous veins compared with cubital veins (testosterone, 15.5 nmol/L; range, 8.4-23.3; estradiol, 93.2 pmol/L; range, 31-147). Moreover, significantly (P < .001) higher mean serum estradiol levels (133.2 pmol/L; range, 63-239) were detected in the saphenous veins of the HM group compared with cubital veins (88.15 pmol/L; range, 37-153). Both groups had similar blood counts and serum androstenedione levels in the upper and lower extremity. Interestingly, qRT-PCR revealed that the mRNA expression of 5alpha-reductase type 1, 5alpha-reductase type 2, 17, 20 lyase, 17beta-hydroxysteroid dehydrogenase (17beta-HSD), aromatase and 3beta-HSD type 2, androgen and estrogen receptor 1 was down-regulated (P < .05) in all samples of varicose veins vs veins obtained from healthy men.

CONCLUSION

Elevated serum estradiol and testosterone levels were detected in men with varicose veins and reflux in the GSV compared with the patient's own arm veins. Enzymes and hormonal receptors involved in steroid metabolism were down-regulated in patients with GSV reflux and varicose veins, suggestive of a negative feedback regulation. These data support the notion of a possible causal relationship between sex steroids and varicose veins in men.