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Edey KA, Rundle S, Hickey M. Hormone replacement therapy for women previously treated for endometrial cancer. Cochrane Database Syst Rev 2018; 5:CD008830. [PMID: 29763969 PMCID: PMC6494585 DOI: 10.1002/14651858.cd008830.pub3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Endometrial cancer is the sixth most common cancer in women worldwide and most commonly occurs after the menopause (75%) (globocan.iarc.fr). About 319,000 new cases were diagnosed worldwide in 2012. Endometrial cancer is commonly considered as a potentially 'curable cancer,' as approximately 75% of cases are diagnosed before disease has spread outside the uterus (FIGO (International Federation of Gynecology and Obstetrics) stage I). The overall five-year survival for all stages is about 86%, and, if the cancer is confined to the uterus, the five-year survival rate may increase to 97%. The majority of women diagnosed with endometrial cancer have early-stage disease, leading to a good prognosis after hysterectomy and removal of the ovaries (oophorectomy), with or without radiotherapy. However, women may have early physiological and psychological postmenopausal changes, either pre-existing or as a result of oophorectomy, depending on age and menopausal status at the time of diagnosis. Lack of oestrogen can cause hot flushes, night sweats, genital tract atrophy and longer-term adverse effects, such as osteoporosis and cardiovascular disease. These changes may be temporarily managed by using oestrogens, in the form of hormone replacement therapy (HRT). However, there is a theoretical risk of promoting residual tumour cell growth and increasing cancer recurrence. Therefore, this is a potential survival disadvantage in a woman who has a potentially curable cancer. In premenopausal women with endometrial cancer, treatment induces early menopause and this may adversely affect overall survival. Additionally, most women with early-stage disease will be cured of their cancer, making longer-term quality of life (QoL) issues more pertinent. Following bilateral oophorectomy, premenopausal women may develop significant and debilitating menopausal symptoms, so there is a need for information about the risk and benefits of taking HRT, enabling women to make an informed decision, weighing the advantages and disadvantages of using HRT for their individual circumstances. OBJECTIVES To assess the risks and benefits of HRT (oestrogen alone or oestrogen with progestogen) for women previously treated for endometrial cancer. SEARCH METHODS We searched the Cochrane Register of Controlled Trials (CENTRAL 2017, Issue 5), MEDLINE (1946 to April, week 4, 2017) and Embase (1980 to 2017, week 18). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of review articles. SELECTION CRITERIA We included randomised controlled trials (RCTs), in all languages, that examined the efficacy of symptom relief and the safety of using HRT in women treated for endometrial cancer, where safety in this situation was considered as not increasing the risk of recurrence of endometrial cancer above that of women not taking HRT. DATA COLLECTION AND ANALYSIS Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. We used standard methodological procedures expected by Cochrane. MAIN RESULTS We identified 2190 unique records, evaluated the full text of seven studies and included one study with 1236 participants. This study reported tumour recurrence in 2.3% of women in the oestrogen arm versus 1.9% of women receiving placebo (risk ratio (RR) 1.17, 95% confidence interval (CI) 0.54 to 2.50; very low-certainty evidence). The study reported one woman in the HRT arm (0.16%) and three women in the placebo arm (0.49%) who developed breast cancer (new malignancy) during follow-up (RR 0.80, 95% CI 0.32 to 2.01; 1236 participants, 1 study; very low-certainty evidence). The study did not report on symptom relief, overall survival or progression-free survival for HRT versus placebo. However, they did report the percentage of women alive with no evidence of disease (94.3% in the HRT group and 95.6% in the placebo group) and the percentage of women alive irrespective of disease progression (95.8% in the HRT group and 96.9% in the placebo group) at the end of the 36 months' follow-up. The study did not report time to recurrence and it was underpowered due to closing early. The authors closed it as a result of the publication of the Women's Health Initiative (WHI) study, which, at that time, suggested that risks of exogenous hormone therapy outweighed benefits and had an impact on study recruitment. No assessment of efficacy was reported. AUTHORS' CONCLUSIONS Currently, there is insufficient high-quality evidence to inform women considering HRT after treatment for endometrial cancer. The available evidence (both the single RCT and non-randomised evidence) does not suggest significant harm, if HRT is used after surgical treatment for early-stage endometrial cancer. There is no information available regarding use of HRT in higher-stage endometrial cancer (FIGO stage II and above). The use of HRT after endometrial cancer treatment should be individualised, taking account of the woman's symptoms and preferences, and the uncertainty of evidence for and against HRT use.
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Affiliation(s)
| | - Stuart Rundle
- Northern Gynaecological Oncology CentreGynaecological OncologyQueen Elizabeth HospitalSheriff HillGatesheadUKNE9 6SX
| | - Martha Hickey
- The Royal Women's HospitalThe University of MelbourneLevel 7, Research PrecinctMelbourneVictoriaAustraliaParkville 3052
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Edey KA, Rundle S, Hickey M. Hormone replacement therapy for women previously treated for endometrial cancer. Hippokratia 2016. [DOI: 10.1002/14651858.cd008830.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | - Stuart Rundle
- Northern Gynaecological Oncology Centre; Gynaecological Oncology; Queen Elizabeth Hospital Sheriff Hill Gateshead UK NE9 6SX
| | - Martha Hickey
- The Royal Women's Hospital; The University of Melbourne; Level 7, Research Precinct Melbourne Victoria Australia Parkville 3052
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Brinton LA, Felix AS. Menopausal hormone therapy and risk of endometrial cancer. J Steroid Biochem Mol Biol 2014; 142:83-9. [PMID: 23680641 PMCID: PMC3775978 DOI: 10.1016/j.jsbmb.2013.05.001] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 04/09/2013] [Accepted: 05/06/2013] [Indexed: 11/29/2022]
Abstract
Endometrial cancer is clearly a hormonally responsive tumor, with a critical role played by estrogens unopposed by progestins. Numerous epidemiologic studies have shown substantial risk increases associated with use of unopposed estrogens, especially among thin women. This risk, however, can be reduced if progestins are added to the therapy. The manner in which progestins are prescribed is a critical determinant of risk. Most studies show that women who have ever used progestins continuously (>25 days/months) are at somewhat reduced risk relative to non-users (meta-analysis relative risk, RR, based on observational studies=0.78, 95 confidence intervals, CI, 0.72-0.86). The reduced risk in greatest among heavy women. In contrast, women who have ever used progestins sequentially for <10 days each month are at increased risk, with meta-analysis results showing on overall RR of 1.76 (1.51-2.05); in contrast, progestins given for 10-24 days/month appear unrelated to risk (RR=1.07, 0.92-1.24). These risks were based on varying patterns of usage, with little information available regarding how endometrial cancer risk is affected by duration of use, type and/or dose of estrogen or progestin, or mode of administration. Effects may also vary by clinical characteristics (e.g., differences for Type I vs. II tumors). Further resolution of many of these relationships may be dependent on pooling data from multiple studies to derive sufficient power for subgroups of users. With changing clinical practices, it will be important for future studies to monitor a wide range of exposures and to account for divergent effects of different usage patterns. This article is part of a Special Issue entitled 'Menopause'.
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Affiliation(s)
- Louise A Brinton
- Hormonal and Reproductive Epidemiology Branch, National Cancer Institute, Rockville, MD 20852-7234, United States.
| | - Ashley S Felix
- Hormonal and Reproductive Epidemiology Branch, National Cancer Institute, Rockville, MD 20852-7234, United States
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Janzen DM, Cheng D, Schafenacker AM, Paik DY, Goldstein AS, Witte ON, Jaroszewicz A, Pellegrini M, Memarzadeh S. Estrogen and progesterone together expand murine endometrial epithelial progenitor cells. Stem Cells 2013; 31:808-22. [PMID: 23341289 PMCID: PMC3774116 DOI: 10.1002/stem.1337] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 12/17/2012] [Indexed: 01/27/2023]
Abstract
Synchronous with massive shifts in reproductive hormones, the uterus and its lining the endometrium expand to accommodate a growing fetus during pregnancy. In the absence of an embryo the endometrium, composed of epithelium and stroma, undergoes numerous hormonally regulated cycles of breakdown and regeneration. The hormonally mediated regenerative capacity of the endometrium suggests that signals that govern the growth of endometrial progenitors must be regulated by estrogen and progesterone. Here, we report an antigenic profile for isolation of mouse endometrial epithelial progenitors. These cells are EpCAM(+) CD44(+) ITGA6(hi) Thy1(-) PECAM1(-) PTPRC(-) Ter119(-), comprise a minor subpopulation of total endometrial epithelia and possess a gene expression profile that is unique and different from other cells of the endometrium. The epithelial progenitors of the endometrium could regenerate in vivo, undergo multilineage differentiation and proliferate. We show that the number of endometrial epithelial progenitors is regulated by reproductive hormones. Coadministration of estrogen and progesterone dramatically expanded the endometrial epithelial progenitor cell pool. This effect was not observed when estrogen or progesterone was administered alone. Despite the remarkable sensitivity to hormonal signals, endometrial epithelial progenitors do not express estrogen or progesterone receptors. Therefore, their hormonal regulation must be mediated through paracrine signals resulting from binding of steroid hormones to the progenitor cell niche. Discovery of signaling defects in endometrial epithelial progenitors or their niche can lead to development of better therapies in diseases of the endometrium.
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Affiliation(s)
- DM Janzen
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - D Cheng
- The Howard Hughes Medical Institute, University of California, Los Angeles, CA 90095, USA
| | - AM Schafenacker
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - DY Paik
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - AS Goldstein
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
- Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research, University of California, Los Angeles, CA 90095, USA
| | - ON Witte
- The Howard Hughes Medical Institute, University of California, Los Angeles, CA 90095, USA
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
- Department of Microbiology, Immunology and Molecular Genetics, University of California, Los Angeles, CA 90095, USA
- Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research, University of California, Los Angeles, CA 90095, USA
| | - A Jaroszewicz
- Department of Molecular, Cell and Developmental Biology
| | - M Pellegrini
- Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research, University of California, Los Angeles, CA 90095, USA
- Department of Molecular, Cell and Developmental Biology
| | - S Memarzadeh
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
- Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research, University of California, Los Angeles, CA 90095, USA
- The VA Greater Los Angeles Health Care System, Los Angeles, CA, 90073, USA
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Chisholm NC, Juraska JM. Factors influencing the cognitive and neural effects of hormone treatment during aging in a rodent model. Brain Res 2013; 1514:40-9. [PMID: 23419893 DOI: 10.1016/j.brainres.2013.02.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 02/06/2013] [Accepted: 02/11/2013] [Indexed: 12/18/2022]
Abstract
Whether hormone treatment alters brain structure or has beneficial effects on cognition during aging has recently become a topic of debate. Although previous research has indicated that hormone treatment benefits memory in menopausal women, several newer studies have shown no effect or detrimental effects. These inconsistencies emphasize the need to evaluate the role of hormones in protecting against age-related cognitive decline in an animal model. Importantly, many studies investigating the effects of estrogen and progesterone on cognition and related brain regions have used young adult animals, which respond differently than aged animals. However, when only the studies that have examined the effects of hormone treatment in an aging model are reviewed, there are still varied behavioral and neural outcomes. This article reviews some of the important factors that can influence the behavioral and neural outcomes of hormone treatment including the type of estrogen administered, whether or not estrogen is combined with progesterone and if so, the type of progesterone used, as well as the route, mode, and length of treatment. How these factors influence cognitive outcomes highlights the importance of study design and avoiding generalizations from a small number of studies. This article is part of a Special Issue entitled Hormone Therapy.
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Affiliation(s)
- Nioka C Chisholm
- Department of Psychology, University of Illinois at Urbana - Champaign, Champaign, IL 61820, USA.
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Effects of long-term treatment with estrogen and medroxyprogesterone acetate on synapse number in the medial prefrontal cortex of aged female rats. Menopause 2012; 19:804-11. [PMID: 22617337 DOI: 10.1097/gme.0b013e31824d1fc4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The present study investigated the effects of long-term hormone treatment, including the most commonly prescribed progestin, medroxyprogesterone acetate, during aging on synaptophysin-labeled boutons, a marker of synapses, in the medial prefrontal cortex (mPFC) of rats. METHODS Female Long Evans hooded rats were ovariectomized at middle age (12-13 mo) and were placed in one of four groups: no replacement (n = 5), 17β-estradiol alone (n = 6), estradiol and progesterone (n = 7), or estradiol and medroxyprogesterone acetate (n = 4). Estradiol was administered in the drinking water and progestogens were administered via subcutaneous pellets that were replaced every 90 days. After 7 months of hormone replacement, the animals were euthanized, and the brains were stained for synaptophysin, a membrane component of synaptic vesicles. The density of synaptophysin-labeled boutons was quantified in the mPFC using unbiased stereology and multiplied by the volume of the mPFC to obtain the total number. RESULTS Animals receiving estradiol and medroxyprogesterone acetate had significantly more synaptophysin-labeled boutons in the mPFC than did animals not receiving replacement (P < 0.03) and those receiving estradiol and progesterone (P < 0.02). In addition, there was a nonsignificant trend for animals receiving estradiol alone to have more synapses than those receiving estradiol and progesterone. CONCLUSIONS This study is the first to examine the effects of estradiol and medroxyprogesterone acetate during rat aging on cortical synaptic number. Estradiol with medroxyprogesterone acetate, but not progesterone, resulted in a greater number of synapses in the mPFC during aging than did no replacement.
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Phipps AI, Doherty JA, Voigt LF, Hill DA, Beresford SAA, Rossing MA, Chen C, Weiss NS. Long-term use of continuous-combined estrogen-progestin hormone therapy and risk of endometrial cancer. Cancer Causes Control 2011; 22:1639-46. [PMID: 21909949 DOI: 10.1007/s10552-011-9840-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 08/30/2011] [Indexed: 10/17/2022]
Abstract
The daily administered dose of progestin in continuous-combined estrogen-progestin therapy is provided to counteract the proliferative effect of estrogen on the postmenopausal endometrium. However, there remains some uncertainty as to whether use of such a combined regimen, over the long term, is associated with an altered risk of endometrial cancer. We pooled data from four population-based case-control studies of endometrial cancer in western Washington State. Cases, ages 45-74, were diagnosed between 1985 and 2005. Using logistic regression with the adjustment for confounding factors, women who had exclusively used continuous-combined estrogen-progestin therapy (90 endometrial cancer cases, 227 controls) were compared with women who had never used any type of hormone therapy (774 cases, 1,116 controls). Associations with duration and recency of use were evaluated overall and within strata defined by body mass index. Long-term use of continuous-combined estrogen-progestin therapy (≥10 years) was associated with a reduced risk of endometrial cancer (OR = 0.37, 95% CI: 0.21-0.66). This association was most pronounced in women with a body mass index ≥30 kg/m(2) (OR = 0.19, 95% CI: 0.05-0.68). Associations did not differ according to recency of use. These results suggest that long duration of use of continuous-combined estrogen-progestin therapy is associated with a reduced risk of endometrial cancer.
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Affiliation(s)
- Amanda I Phipps
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. N., Seattle, WA 98109, USA.
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Abstract
This article reviews publications dating back more than a century describing investigations of the endometrium, including those examining the relationship between endometrial hyperplasia and carcinoma, the influence of estrogens on the endometrium, and strategies for protecting the endometrium from unopposed estrogen stimulation. Endometrial hyperplasia and carcinoma studies date from before 1900. The influence of endogenous estrogens on the endometrium became evident with observations of endometrial hyperplasia and/or carcinoma in women with estrogen-secreting tumors or polycystic ovarian disease. Later, observational studies and randomized, controlled trials suggested a relationship between unopposed estrogens and endometrial cancer and hyperplasia. The first, and to date only, effective clinical strategy for protecting the endometrium from unopposed estrogen stimulation has been the use of progestins. A new approach for endometrial protection in menopausal therapy is the pairing of a selective estrogen receptor modulator (SERM) with estrogen(s), also known as a tissue selective estrogen complex (TSEC). Effective protection of the endometrium as well as treatment of menopausal symptoms and prevention of osteoporosis would be key elements for a clinically useful TSEC.
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Affiliation(s)
- J H Pickar
- Wyeth Research, Collegeville, PA 19101, USA
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Razavi P, Pike MC, Horn-Ross PL, Templeman C, Bernstein L, Ursin G. Long-term postmenopausal hormone therapy and endometrial cancer. Cancer Epidemiol Biomarkers Prev 2010; 19:475-83. [PMID: 20086105 DOI: 10.1158/1055-9965.epi-09-0712] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Estrogen-alone therapy (ET) or estrogen and progestin (EPT) as menopausal hormone therapy (HT) has been commonly used to alleviate menopausal symptoms. Treatments containing > or = 10 days per month of progestin are considered relatively safe with respect to endometrial cancer risk. However, the endometrial safety of long-term EPT regimens is uncertain. We conducted a case-control study of 311 invasive endometrial cancer cases and 570 controls nested within the California Teachers Study cohort. We used unconditional logistic regression to obtain odds ratios (OR) and 95% confidence intervals (95% CI) for the association between long-term HT use and endometrial cancer risk, and to assess the modifying effect of body mass index (BMI). Long-term (> or = 10 years) use of ET, sequential EPT with <10 days per month progestin, and continuous-combined EPT (> or = 25 days/month progestin) were all associated with an elevated risk of endometrial cancer (OR, 4.5; 95% CI, 2.5-8.1; OR, 4.4; 95% CI, 1.7-11.2; and OR, 2.1; 95% CI, 1.3-3.3, respectively; all P(trend) < 0.001). The risk associated with short-term use was elevated only for ET preparations. The association for continuous-combined EPT was confined to thinner women (BMI, <25 kg/m2; P(interaction) = 0.03). Among heavier women (BMI, > or = 25 kg/m2), use of continuous-combined EPT was associated with a statistically nonsignificant reduction in risk. These findings confirm that long-term use of ET, sequential EPT, or, among normal weight women, continuous-combined EPT is associated with increased risk of endometrial cancer.
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Affiliation(s)
- Pedram Razavi
- University of Southern California, Department of Preventive Medicine, Norris Comprehensive Cancer Center, Los Angeles, California, USA
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Bolaji II, Mortimer G, Grimes H, O'dwyer EM. Endometrial response in oestrogenised postmenopausal women after treatment with oral progesterone: results of a prospective analysis. J OBSTET GYNAECOL 2009. [DOI: 10.3109/01443619209025947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Barbosa IC, Coutinho EM, Oladapo L, Noronha CF, Mota RLS, Lopes ACV, Lopes RC. An open-label study of subdermal implants of estradiol-only versus subdermal implants of estradiol plus nomegestrol acetate: effects on symptom control, lipid profile and tolerability. Gynecol Endocrinol 2009; 25:269-75. [PMID: 19408176 DOI: 10.1080/09513590802632480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To compare the effects of continuous 17-beta estradiol-only silastic implants with those of continuous 17-beta estradiol plus continuous nomegestrol acetate silastic implants on symptom control, lipid profile and tolerability in postmenopausal women. METHODS This was an open-label, parallel-group study. Women with and without uterus and no contraindications to hormone therapy (HT) in this study, we consider as HT the replacement of Estrogens-only and Estrogens + Progestogens Therapy, were enrolled. Each subject was assigned to receive four 17-beta estradiol-only silastic implants (women without uterus), or four 17-beta estradiol plus one nomegestrol acetate silastic implant (women with intact uterus), for 1 year. RESULTS A total of 40 subjects were enrolled and received, the silastic implants of which 40 (100.0%) subjects completed the study (n = 20, estradiol only; n = 20, estradiol plus nomegestrol acetate). The incidence of postmenopausal symptoms decreased significantly. No significant decreases in total cholesterol (1.3%), low-density lipoprotein cholesterol (1.1%), triglycerides (1.2%) and fasting glucose ((1.3%) serum levels were observed in both groups, whereas high-density lipoprotein (HDL) cholesterol increased significantly (2.8%), during the study in both groups. The incidences of adverse events were similar in both treatment groups. CONCLUSIONS Women treated with 17-beta estradiol-only silastic implants or 17-beta estradiol plus nomegestrol acetate silastic implants showed significant improvement of postmenopausal symptoms, including urogenital and sexual health symptoms and a significant increase in HDL cholesterol and no significant differences in other lipid profiles and tolerability.
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Affiliation(s)
- Ione Cristina Barbosa
- Maternidade Climério de Oliveira, Teaching Hospital, Federal University of Bahia, Bahia, Brazil.
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Abstract
Postmenopausal women using continuous combined estrogen/progestin therapy (ccEPT) are likely to have irregular bleeding or spotting. The use of estrogen with 12-14 days of a progestin is called cyclic (scEPT). This method results in regular endometrial bleeding at a scheduled time. The mechanism(s) involved in this regimen that result in bleeding could be similar to a spontaneous menstrual bleeding episode in a menachal woman, but there are no data in this regard. This aspect of regular scheduled bleeding in postmenopausal women will not be addressed in this article due to the paucity of information. The effect of cyclic progestogen with continuous estrogen on the endometrium could result in similar local mechanisms for endometrial bleeding as seen wth ccEPT. The mechanism(s) involved in endometrial bleeding is unknown. Several reports have highlighted a number of potential pathophysiologic mechanisms. Most of the investigation into the mechanisms involved in endometrial bleeding has been in women using progestin only contraceptive methods not ccEPT. The use of ccEPT could be construed as similar but not identical to that of a continuous progestin only contraceptive since the progestin in ccEPT is delivered daily. The potential mechanism(s) involved in endometrial bleeding includes the following: changes in the ratio of vascular endothelial growth factor to Thrombospondin-1 (pro- versus anti-angiogenic factors); alterations in metalloproteinases and tissue inhibitor of metalloproteinases (TIMP); changes in tissue factor a known haemostasis mediator in the endometrium; and increased endometrial leukocytes with a particular emphasis on uterine natural killer (uNK) cells. Each of these potential causes has been the subject of both in vivo and in vitro investigations. There is no clear linkage between any of these hypotheses and the onset or cessation of uterine bleeding in ccEPT users. No good therapeutic option to control the bleeding or spotting exists at this time. Evaluation and monitoring of the patient regarding endometrial safety is of paramount importance.
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Affiliation(s)
- David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA.
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Ovarian, Endometrial, and Colorectal Cancers. Obstet Gynecol 2004; 104:77S-84S. [PMID: 15458937 DOI: 10.1097/01.aog.0000138797.20914.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pinto AB, Binder EF, Kohrt WM, Bronder DR, Williams DB. Effects of trimonthly progestin administration on the endometrium in elderly postmenopausal women who receive hormone replacement therapy: a pilot study. Am J Obstet Gynecol 2003; 189:11-5. [PMID: 12861131 DOI: 10.1067/mob.2003.335] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the effect of trimonthly progestin administration on the endometrium in elderly postmenopausal women who receive hormone replacement therapy. STUDY DESIGN This was a prospective, randomized, double-blind, placebo-controlled study at a university teaching program. Twenty-five postmenopausal women who were >or=75 years old with an intact uterus were assigned randomly to receive conjugated equine estrogens (0.625 mg/d plus medroxyprogesterone acetate 5 mg/d for 13 days every 3 months (n = 13) or placebo (n = 12) for 9 months). At the end of the 9 months, patients in the hormone replacement therapy arm continued therapy for an additional 9 months. Statistical analysis was performed with the Student t test, the chi(2) test, and the Fisher exact test. RESULTS Transvaginal sonography was performed at baseline and at 9 and 18 months. Endometrial biopsy was performed if the endometrial thickness was >4 mm or as clinically indicated at 18 months. Patients in the hormone replacement therapy group demonstrated a significant increase in endometrial thickness between baseline (3.9 + 0.8 mm) and 9 months (8.0 + 4.8 mm). There were no cases of endometrial hyperplasia at the 18-month endometrial biopsy. CONCLUSION Trimonthly progestin administration in elderly postmenopausal women who receive hormone replacement therapy may be a reasonable alternative to the monthly administration of progestin in hormone replacement therapy.
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Affiliation(s)
- Anil B Pinto
- Department of Obstetrics and Gynecology, Washington University School of Medicine, USA
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Manzella D, Fornaro F, Carbonella M, Picardi C, Paolisso G, Colacurci N. Effect of tibolone administration on heart rate variability and free fatty acid levels in postmenopausal women. Fertil Steril 2002; 78:1005-9. [PMID: 12413985 DOI: 10.1016/s0015-0282(02)04200-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the effects of tibolone on heart rate variability and plasma free fatty acid levels in postmenopausal women. DESIGN Randomized, placebo-controlled trial. SETTING University hospital. PATIENT(S) Thirty postmenopausal women. INTERVENTION(S) Tibolone, 2.5 mg/d, or placebo for 4 months. MAIN OUTCOME MEASURES Variability in heart rate and changes in the lipid profile. RESULT(S) Anthropometric data were unchanged throughout the study. Compared with placebo, long-term tibolone administration was associated with a decrease in plasma levels of low-density lipoprotein cholesterol, triglyceride, and free fatty acid and homeostasis model assessment index. Furthermore, tibolone administration was associated with an increase in RR interval, total power, and high frequency and decrease in low frequency and the low frequency/high frequency ratio. Finally, the delta decrease in plasma free fatty acid levels correlated with delta low frequency/high frequency ratio independently of age, delta body mass index, delta homeostasis model assessment index, and low-density lipoprotein cholesterol levels. CONCLUSION(S) Long-term tibolone administration improves the ratio of cardiac sympathetic tone to parasympathetic tone in postmenopausal women.
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Affiliation(s)
- Daniela Manzella
- Department of Geriatric Medicine and Metabolic Diseases, Second University of Naples, Naples, Italy
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Riis BJ, Lehmann HJ, Christiansen C. Norethisterone acetate in combination with estrogen: effects on the skeleton and other organs. A review. Am J Obstet Gynecol 2002; 187:1101-16. [PMID: 12389012 DOI: 10.1067/mob.2002.122852] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This article is focused on the use of norethisterone acetate as progestogen in hormone replacement therapy. Emphasis is made on the fact that the primary reason for adding a progestogen to hormone replacement therapy is to protect the endometrium against hyperplasia. In this paper we review data that demonstrate that hormone replacement therapy that includes norethisterone acetate has positive effects on the postmenopausal bone metabolism and that it increases bone mass more than expected and more than treatment with alendronate. All available evidence is reviewed to show that norethisterone acetate, if given in the correct dosage, does not influence serum lipids and lipoproteins in any negative way. It is furthermore shown that norethisterone acetate seems to be superior compared to other progestogens to provide optimum bleeding control and endometrial protection. Also, hormone replacement therapy combinations with norethisterone acetate efficiently alleviate hot flushes. Hormone replacement therapy and the risk of breast cancer and the role of progestogens are discussed.
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17
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Regan MM, Emond SK, Attardo MJ, Parker RA, Greenspan SL. Why do older women discontinue hormone replacement therapy? JOURNAL OF WOMEN'S HEALTH & GENDER-BASED MEDICINE 2001; 10:343-50. [PMID: 11445025 DOI: 10.1089/152460901750269661] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Postmenopausal women who choose hormone replacement therapy (HRT) often discontinue this therapy within 1 year. Few studies have considered why older women (aged > or =65 years) discontinue therapy. To investigate this question and its relationship to HRT-related side effects, we analyzed data collected during the 3-month open-label (active HRT and alendronate placebo) run-in phase of a clinical trial for osteoporosis prevention and treatment in older women. Among women discontinuing the trial, we ascertained a primary reason based on the patients' records and classified it as related or unrelated to HRT. The incidence of specific HRT-related side effects reported during the run-in phase was abstracted from the trial database and compared between patients continuing in the trial and those discontinuing for HRT-related reasons. Of the 485 women who began the 3-month run-in phase, 112 (23%) discontinued the trial. Specifically, 73 (15%) women discontinued for reasons considered HRT related. Breast swelling/tenderness (26 women) and bloating (9 women) were more often primary reasons for discontinuation than were bleeding or spotting (7 women). Comparing all reported side effects, bloating was more common in women discontinuing because of HRT than in women continuing in the trial (18% versus 3%, p < or = 0.001), whereas other complaints were similar or lower: breast swelling/tenderness (59% versus 67%, p > 0.05), bleeding (16% versus 17%, p > 0.05), spotting (23% versus 41%, p < or = 0.05). Bloating, of which women discontinuing complained significantly more often, and breast swelling/tenderness, the most frequently cited primary reason for discontinuation, may be more important factors than bleeding or spotting in an older woman's decision to discontinue HRT.
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Affiliation(s)
- M M Regan
- Charles A. Dana Research Institute, Harvard-Thorndike General Clinical Research Centre, Beth Israel Deaconess Medical Centre and Harvard Medical School, Boston, Massachusetts, USA
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18
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Rozenberg S. Clinical evidence supporting the rationale for constant oestrogen, intermittent progestogen hormone replacement therapy. Eur J Obstet Gynecol Reprod Biol 2001; 94:86-91. [PMID: 11134831 DOI: 10.1016/s0301-2115(00)00301-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hormone replacement therapy (HRT) effectively relieves vasomotor and other symptoms associated with menopause, yet is underutilised by the majority of menopausal women. Current HRT regimens combine continuous oestrogen with continuous or sequential progestogen in order to achieve the beneficial effects of oestrogen while avoiding the potential for increased risk of endometrial cancer. Uterine bleeding and other adverse progestogenic effects are major reasons for patient noncompliance and early discontinuation of combination HRT, which can ultimately limit the achievement of long-term oestrogenic benefits. A novel constant 17beta-oestradiol, intermittent norgestimate regimen has been developed based on theoretical hormone receptor dynamics in an attempt to minimise the hormonal doses needed, thereby potentially reducing the occurrence of adverse effects associated with higher oestrogen and progestogen doses. Clinical trial data with this novel low-dose HRT regimen demonstrate effective relief of vasomotor symptoms in postmenopausal women, acceptable bleeding rates, no endometrial hyperplasia, beneficial effects on lipids, and excellent tolerability. This regimen has the potential to increase long-term use resulting in important clinical benefits.
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Affiliation(s)
- S Rozenberg
- Department of Obstetrics and Gynaecology, St. Pierre Hospital, 322 Rue Haute B-1000, Brussels, Belgium
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19
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Hill DA, Weiss NS, Beresford SA, Voigt LF, Daling JR, Stanford JL, Self S. Continuous combined hormone replacement therapy and risk of endometrial cancer. Am J Obstet Gynecol 2000; 183:1456-61. [PMID: 11120510 DOI: 10.1067/mob.2000.108081] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Postmenopausal women who receive sequential hormone replacement therapy with estrogen combined with progestogen for 10 to 24 d/mo for a prolonged period may have an elevated endometrial cancer risk relative to those who have never received hormone replacement therapy. We investigated whether daily use of estrogen and progestogen (continuous combined hormone replacement therapy) could diminish any excess endometrial cancer risk. STUDY DESIGN A population-based study in Washington State obtained interview data from 969 women aged 45 to 74 years with endometrial cancer diagnosed during 1985 through 1991 or 1994 through 1995 and from 1325 age-matched control subjects selected primarily by random digit dialing. Women who had received only continuous combined hormone replacement therapy were compared with women who had only received another hormone replacement therapy regimen or who had never received hormone replacement therapy. RESULTS The risk of endometrial cancer among users of continuous combined hormone replacement therapy (n = 9 case patients, n = 33 control subjects) relative to women who had never received hormone replacement therapy was 0.6 (95% confidence interval, 0.3-1.3); the risk relative to women who received hormone replacement that included progestogen for 10 to 24 d/mo was 0.4 (95% confidence interval, 0.2-1.1). Most continuous combined hormone replacement therapy use was short-term (<72 months) or recent (in the previous 24 months). CONCLUSION Women who had received continuous combined hormone replacement therapy for several years did not appear to be at any increased risk for endometrial cancer relative to women who had never received hormone replacement therapy and may in fact be at decreased risk for endometrial cancer.
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Affiliation(s)
- D A Hill
- Department of Epidemiology, University of Washington, Seattle, WA, USA
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20
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Li C, Samsioe G, Wilaman K, Lidfelt J, Nerbrand C, Agardh CD, Schersten B. Effects of norethisterone acetate addition to estradiol in long term HRT. Maturitas 2000; 36:139-52. [PMID: 11006501 DOI: 10.1016/s0378-5122(00)00146-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the efficacy and tolerability of hormone replacement therapy (HRT) among postmenopausal women living in the Lund area of Southern Sweden and to analyze treatment effects in different types or routes of HRT administration, as well as to compare with unopposed estrogen therapy. METHOD in an ongoing, large population-based, prospective cohort study, this interim analysis included 3900 women. Of them, 693 postmenopausal women were eligible in the present analyses as they continued to use one of the four commercial HRT products for at least 2-3 years, i.e. continuous oral estradiol (E(2)) 2 mg+norethisterone acetate (NETA) 1 mg (CON-O), sequential oral estradiol 2 mg + norethisterone acetate 1 mg (CYC-O), sequential transdermal estradiol 50 microg + norethisterone acetate 250 microg (CYC-TRANS) and estradiol monotherapy. These women completed one generic questionnaire and one specific 'hormonal' questionnaire, as well as a personal interview pertaining to socio-demographics, detailed status of HRT use, and therapeutic efficacy and untoward side-effects by HRT. RESULTS comparing the three combined E(2)+NETA groups with E(2) monotherapy, the beneficial effects on sexual desire and emotional well-being were significantly less in the combined groups than in E(2) monotherapy group. There was no significant difference regarding the negative side-effects between the groups. No significant difference was found between CON-O and CYC-O groups either in positive effects or in negative side-effects. A higher prevalence of positive effects was found in CYC-TRANS group than that in CYC-O group, especially in amelioration of sleep and urinary symptoms. Higher odd ratios of negative effects by HRT, such as irregular bleeds, weight gain, food craving and skin disorders were also found in CYC-TRANS group. CONCLUSION in long-term HRT administration, the addition of a progestogen in HRT could compromise the beneficial effects of estradiol, particularly, the effects on women's emotional well being and psychosexual functioning. Administration of NETA continuously and sequentially had similar therapeutic efficacy and tolerability. More marked positive effects, such as improving of sleep and urinary symptoms, as well as nuisance side-effects, i.e. irregular bleeds, weight gain, food craving and skin disorders were encountered by the women using sequential transdermal regimen
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Affiliation(s)
- C Li
- Department of Obstetrics and Gynecology, Lund University Hospital, S-221 85, Lund, Sweden
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21
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Gisclon LG, Curtin CR, Larson KL, Natarajan J, Wong FA, Morrison DN, Bourg D. Lack of effect of a high-fat meal on the bioavailability of 17 beta-estradiol/norgestimate in healthy postmenopausal women. J Clin Pharmacol 2000; 40:762-9. [PMID: 10883418 DOI: 10.1177/00912700022009404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The effect of a high-fat meal on the absorption and pharmacokinetics of 17 beta-estradiol (E2), estrone (E1), estrone sulfate (E1S), and 17-deacetylnorgestimate (17d-NGM) were determined in this two-way complete crossover study of a single dose of E2/NGM (2 mg/180 micrograms) in 24 postmenopausal women. Equal numbers of subjects were randomly assigned to two treatment sequences indicated by the order of fed and fasting treatments. Serial blood samples were collected before and after dosing and assayed using validated methods. Food had no effect on the pharmacokinetics of E2, the pharmacologically active estrogen species. Food increased the rates of formation of E1 and E1S and slowed the formation of 17d-NGM. However, because E1 and E1S are pharmacologically less active metabolites of E2, and since the pharmacokinetic alterations in 17d-NGM were observed over a short time period, these results are probably of no clinical relevance. The extent of formation of all analytes, as measured by AUC, was not affected by food. In conclusion, administration of a tablet containing 17 beta-estradiol/norgestimate (2 mg/180 micrograms) was safe and well tolerated by healthy postmenopausal women and may be given without regard to the timing of meals in relation to dosing.
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Affiliation(s)
- L G Gisclon
- Robert Wood Johnson Pharmaceutical Research Institute, Spring House, PA 19477, USA
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22
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Heikkinen JE, Vaheri RT, Ahomäki SM, Kainulainen PM, Viitanen AT, Timonen UM. Optimizing continuous-combined hormone replacement therapy for postmenopausal women: a comparison of six different treatment regimens. Am J Obstet Gynecol 2000; 182:560-7. [PMID: 10739508 DOI: 10.1067/mob.2000.104767] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We sought to determine the optimum estradiol valerate-medroxyprogesterone acetate regimens for efficacy and safety. STUDY DESIGN We performed a 24-month, randomized, double-blind phase II study. Four hundred nineteen women who were postmenopausal for at least 3 years were placed in six parallel treatment groups and received 1 or 2 mg estradiol valerate with either 2.5 or 5 mg medroxyprogesterone acetate. In two groups the dose of estradiol valerate was increased from 1 to 2 mg estradiol valerate after 6 months. RESULTS A marked improvement of climacteric symptoms was observed, and most women had no bleeding even during the first 3 months of treatment. The best bleeding pattern was achieved with 1 mg estradiol valerate and 2.5 or 5 mg medroxyprogesterone acetate, and in most groups the bleeding pattern improved over time. No cases of hyperplasia were observed. CONCLUSION All regimens alleviated climacteric symptoms and provided excellent bleeding control, even during the early weeks of treatment. A choice of various dose combinations offers flexibility of dosing, thus enabling therapy to be tailored to the needs of individual women.
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Lobo RA, Zacur HZ, Caubel P, Lane R. A novel intermittent regimen of norgestimate to preserve the beneficial effects of 17beta-estradiol on lipid and lipoprotein profiles. Am J Obstet Gynecol 2000; 182:41-9. [PMID: 10649155 DOI: 10.1016/s0002-9378(00)70489-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study was undertaken to evaluate the effects of 3 dosage levels of intermittent norgestimate plus a constant dose of 17beta-estradiol on blood lipid and lipoprotein concentrations in 236 postmenopausal women. STUDY DESIGN In this multicenter, double-blind, parallel-group trial the subjects were randomly assigned to receive 1 mg estradiol daily or 1 mg estradiol daily plus intermittent (3 days off and 3 days on) doses of 30 microg, 90 microg, or 180 microg norgestimate for 360 days. RESULTS The regimens of 1 mg estradiol plus 30 microg norgestimate and 1 mg estradiol plus 90 microg norgestimate increased concentrations of high-density lipoprotein cholesterol, HDL(2) high-density lipoprotein cholesterol, HDL(3) high-density lipoprotein cholesterol (except the regimen of 1 mg estradiol plus 30 microg norgestimate at 7 months), and apolipoprotein apo A-I. They decreased total cholesterol concentration, low-density lipoprotein cholesterol concentration, low-density lipoprotein/high-density lipoprotein ratio, apolipoprotein apo B concentration, and Lp(a) lipoprotein concentration, and they attenuated estradiol-induced increases in triglyceride concentrations. In contrast, the regimen of 1 mg estradiol plus 180 microg norgestimate reduced concentrations of high-density lipoprotein cholesterol, high-density lipoprotein HDL(3) cholesterol, and apolipoprotein apo A-I at 7 months and increased the low-density lipoprotein/high-density lipoprotein ratio at 7 months. CONCLUSIONS An intermittent regimen of norgestimate at 30 or 90 microg daily administered for 3 days off followed by 3 days on preserved the beneficial lipid and lipoprotein changes induced by continuous therapy with 1 mg 17beta-estradiol daily; however, 180 microg norgestimate did not do so.
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Affiliation(s)
- R A Lobo
- Columbia Presbyterian Medical Center, New York, NY 10032, USA
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24
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Duncan AM, Underhill KE, Xu X, Lavalleur J, Phipps WR, Kurzer MS. Modest hormonal effects of soy isoflavones in postmenopausal women. J Clin Endocrinol Metab 1999; 84:3479-84. [PMID: 10522983 DOI: 10.1210/jcem.84.10.6067] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Soy isoflavones have been hypothesized to exert hormonal effects in postmenopausal women. To test this hypothesis, we studied the effects of three soy powders containing different levels of isoflavones in 18 postmenopausal women. Isoflavones were consumed relative to bodyweight [control: 0.11 +/- 0.01; low isoflavone (low-iso): 1.00 +/- 0.01; high isoflavone (high-iso): 2.00 +/- 0.02 mg/kg/day] for 93 days each in a randomized crossover design. Blood was collected on day 1 of the study (baseline) and days 36-38, 64-66, and 92-94 of each diet period, for analysis of estrogens, androgens, gonadotropins, sex hormone binding globulin (SHBG), prolactin, insulin, cortisol, and thyroid hormones. Vaginal cytology specimens were obtained at baseline and at the end of each diet period, and endometrial biopsies were performed at baseline and at the end of the high-iso diet period, to provide additional measures of estrogen action. Overall, compared with the control diet, the effects of the low-iso and high-iso diets were modest in degree. The high-iso diet resulted in a small but significant decrease in estrone-sulfate (E1-S), a trend toward lower estradiol (E2) and estrone (E1), and a small but significant increase in SHBG. For the other hormones, the few significant changes noted were also small and probably not of physiological importance. There were no significant effects of the low-iso or high-iso diets on vaginal cytology or endometrial biopsy results. These data suggest that effects of isoflavones on plasma hormones per se are not significant mechanisms by which soy consumption may exert estrogen-like effects in postmenopausal women. These data also show that neither isoflavones nor soy exert clinically important estrogenic effects on vaginal epithelium or endometrium.
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Affiliation(s)
- A M Duncan
- Department of Food Science and Nutrition, University of Minnesota, St. Paul 55108, USA
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25
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Bjarnason K, Cerin A, Lindgren R, Weber T. Adverse endometrial effects during long cycle hormone replacement therapy. Scandinavian Long Cycle Study Group. Maturitas 1999; 32:161-70. [PMID: 10515673 DOI: 10.1016/s0378-5122(99)00033-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Treatment with unopposed estrogen is known to increase the risk of endometrial hyperplasia, atypia, and carcinoma, and therefore the administration of a progestin during hormone replacement therapy (HRT) is recommended. The addition of a progestin may cause unwanted side effects. Progestin administration of various durations are therefore used in HRT. STUDY DESIGN Data were obtained about endometrial histopathology, bleeding interval and compliance in 240 early postmenopausal women receiving HRT with a progestin administered for 10 days during 12 week or 4 week cycles of estrogen administration. These regimens were studied for as long as 4 years. The daily estrogen given was 17beta-estradiol 2 mg per day which was reduced to 1 mg day during the last 6 days of each cycle. The progestin used was norethindrone acetate, given at a dose of 1 mg per day. RESULTS The incidence of endometrial hyperplastic changes, i.e. simple or complex hyperplasia, atypia or cancer, was significantly higher in the 12 weeks cycle than in the monthly cycle group (P = 0.003), with an overall annual incidence of 5.6% in the 12 weeks cycle group and 1% in the monthly cycle group. One case of atypical hyperplasia and one case of endometrial adenocarcinoma was observed in the long cycle group. Long cycle treatment produced more irregular bleeding pattern. Accordingly, the rate of drop-out due to bleeding was significantly higher in the long cycle group (P<0.01). CONCLUSION We conclude that the long cycle HRT modality investigated did not improve compliance and may increase the risk of endometrial hyperplasia and eventually cancer compared to conventional HRT with a monthly cycle. Caution using long cycle HRT regimens is advisable, and careful monitoring of the endometrium during treatment is recommended.
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Affiliation(s)
- K Bjarnason
- Novo Nordisk A/S, Clinical Development, Bagsvaerd, Denmark
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De Leo V, la Marca A, Morgante G, Lanzetta D. Comparison of two HRT regimens with bimonthly and monthly progestin administration in postmenopause. Maturitas 1999; 31:171-7. [PMID: 10227012 DOI: 10.1016/s0378-5122(98)00061-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Here we report the results of a study in which natural estrogens were given transdermally cyclically and continuously for 1 year, and a progestin of the latest generation, namely nomegestrol acetate, was given for 10 days every month and for 15 days every 2 months. METHODS The patients were a group of 34 post-menopausal women (51-56 years), 18 of whom (group A) were treated with continuous transdermal estradiol (50 micrograms/day) and cyclic oral nomegestrol at a dose of 5 mg/day for 15 days every 2 months for 1 year. The other 16 women (group B) were treated with cyclic transdermal estradiol for 3 weeks with oral nomegestrol for 10 days (12-21)/month. Endometrial thickness was evaluated by transvaginal ultrasonography before and after treatment. At the end of treatment, an endometrial biopsy was performed. Serum total cholesterol, HDL, LDL and triglycerides were assessed at baseline and every 4 months. The characteristics of the cycle were deduced from the diary cards recorded by the women. RESULTS No significant differences were found in the mean interval between the last dose of nomegestrol and the start of bleeding or in the duration of bleeding. The total number of days of bleeding per year was significantly lower in group A than group B (27 +/- 12 vs. 52 +/- 18; P < 0.01). Total serum cholesterol and LDL significantly decreased after 1 year of treatment in both groups, HDL-cholesterol and triglycerides were found increased at most of the time points studied. CONCLUSIONS The present protocol involving continuous transdermal administration of estrogen combined with oral progestin every 2 months gave good control of the menstrual cycle, did not increase the risk of endometrial pathology and met with good patient compliance.
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Affiliation(s)
- V De Leo
- Department of Obstetrics and Gynecology, University of Siena, Policlinico Le Scotte, Italy.
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27
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Timmer CJ, Geurts TB. Bioequivalence assessment of three different estradiol formulations in postmenopausal women in an open, randomized, single-dose, 3-way cross-over study. Eur J Drug Metab Pharmacokinet 1999; 24:47-53. [PMID: 10412891 DOI: 10.1007/bf03190010] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim of the study was to assess the bioavailability of estradiol (E2) following oral, single-dose administration of equimolar doses of three HRT preparations in a 3-way cross-over study in postmenopausal women. METHODS 18 healthy subjects were enrolled. Free E2 and estrone (E1) serum concentrations were determined using commercially available immunoassay kits. Bioequivalence testing was performed between the following oral formulations: (a) 1.5 mg E2 tablets versus 2 mg E2V tablets; and (b) 1.5 mg E2 plus 0.15 mg DSG tablets versus 1.5 mg E2 tablets. RESULTS For both E2 and E1 the E2 tablet was bioequivalent with both the E2V and the E2/DSG tablet with respect to the rate and extent of absorption (bioavailability). Although the mean tmax values of the three tablet formulations were similar, the variability was too large to prove formal bioequivalence. CONCLUSION E2 tablets and E2/DSG tablets were bioequivalent and also bioequivalence of E2 tablets with commercially available E2V was found, which ensures a sequential HRT preparation without large variations in estrogen serum concentrations.
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Affiliation(s)
- C J Timmer
- Department of Drug Metabolism and Kinetics, NV Organon, Oss, The Netherlands
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Bissonnette F, Lussier-Cacan S, Fugère P, Bérubé S. Metabolic effect of two hormonal preparations in postmenopausal women. Maturitas 1997; 27:275-84. [PMID: 9288700 DOI: 10.1016/s0378-5122(97)00042-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To compare the metabolic and endocrinological effects of estradiol valerate/cyproterone acetate (EV/CPA) to a regimen of conjugated estrogens/medroxyprogesterone acetate (CE/MPA) in postmenopausal women. METHODS Lipid profile, endocrinological parameters, coagulation factors, renin and angiotensinogen were followed in postmenopausal women randomized to EV/CPA or CE/MPA during 12 cycles. RESULTS Following 12 cycles of treatment, total plasma cholesterol decreased more with EV/CPA than with CE/MPA. Low-density cholesterol decreased with EV/CPA while it increased with CE/MPA. High-density cholesterol remained fairly unchanged, and triglycerides increased significantly in both groups. Estradiol and estrone levels increased significantly more with EV/CPA than with CE/MPA while the sex-hormone-binding globulin increased more with CE/MPA. Follicle stimulating and luteinizing hormone levels also decreased significantly. Total testosterone and dihydroepiandrosterone sulfate remained stable. Total levothyroxine serum levels increased significantly, but thyroid stimulating hormone and triiodothyronine levels remained stable. Coagulation parameters also remained stable. Angiotensinogen increased, while plasma renin activity and blood pressure remained unchanged. CONCLUSION It is concluded that both EV/CPA and CE/MPA produce favourable metabolic effects. A better lipid profile, compatible with decreased cardiovascular risk, is observed with the EV/CPA regimen. Higher circulating estrogen levels may explain in part this observation.
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Affiliation(s)
- F Bissonnette
- Department of Obstetrics and Gynecology, Université de Montréal, Hôpital Saint-Luc, Québec, Canada
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Gomes AM, Baracat EC, Simões MJ, Haidar MA, Focchi GR, Evêncio-Neto J, de Lima GR. Morphologic and morphometric aspects of the endometrium of postmenopausal women before and after cyclic oestrogen replacement treatment. Eur J Obstet Gynecol Reprod Biol 1997; 74:79-82. [PMID: 9243208 DOI: 10.1016/s0301-2115(97)00077-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of the study is to observe the morphology and morphometry of the endometrium of postmenopausal women treated with cyclic conjugated oestrogens. STUDY DESIGN Three groups of nine postmenopausal women received cyclic conjugated oestrogens for 21 days (with a seven-day pause) during six months. The endometrial specimens were obtained using a modified Novak suction curet, in the second or third day of the period of drug washout. The slides were stained with haematoxylin and eosin (H.E.) in order to measure epithelial height and determine the gland/stroma ratio. RESULTS Morphologic examination showed that single daily doses of 0.3 mg of conjugated oestrogens caused discrete endometrial proliferation after three and six months of treatment. However, a more intense effect was observed in women receiving doses of 0.625 and 1.25 mg/day of the hormone, in the same period. Morphometric study revealed significant increases both in epithelial thickness and in the gland-stroma ratio, specially in women receiving higher doses of the conjugated oestrogen (0.625 and 1.25 mg/day). CONCLUSIONS We concluded that there were marked proliferative alterations without atypias in the endometrium of women that received 0.625 and 1.25 mg of conjugated oestrogens during six months.
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Affiliation(s)
- A M Gomes
- Department of Gynecology and Obstetrics of Escola Paulista de Medicina, Universidade Federal de São Paulo, Brazil
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Hänggi W, Lippuner K, Riesen W, Jaeger P, Birkhäuser MH. Long-term influence of different postmenopausal hormone replacement regimens on serum lipids and lipoprotein(a): a randomised study. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1997; 104:708-17. [PMID: 9197875 DOI: 10.1111/j.1471-0528.1997.tb11982.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To assess the influence of three different postmenopausal hormone replacement therapies on levels of serum lipids and lipoprotein(a) [Lp(a)]. DESIGN Open, randomised, controlled study. PARTICIPANTS One hundred and forty healthy, early postmenopausal women. INTERVENTIONS The women were randomised to receive continuous 17 beta-oestradiol, either orally (2 mg daily; n = 35) or transdermally (50 micrograms daily; n = 35), plus 10 mg dydrogesterone daily for 14 days of each 28-day cycle; or 2.5 mg tibolone daily (n = 35). Thirty-five untreated women acted as controls. MAIN OUTCOME MEASURES Fasting blood samples were analysed at baseline, 6, 12 and 24 months for low-density lipoprotein (LDL)-cholesterol, high-density lipoprotein (HDL)-cholesterol, very low density lipoprotein (VLDL), total cholesterol, triglycerides, lipoprotein(a)[Lp(a)], apolipoproteins A-1, A-2 and B, fibrinogen, and antithrombin factor III. RESULTS At 24 months oral oestradiol increased mean HDL cholesterol (7%; 95% CI 1-14), compared with no change in the transdermal group and a decrease of 26.8% in the tibolone group (95% CI 22.9-30.5); oral oestradiol decreased mean LDL cholesterol (11.8%; 95% CI 6.3-19), compared with no change in the tibolone group. Changes in apolipoprotein A-1 and B showed a similar pattern to HDL and LDL cholesterol, respectively. Oral oestradiol increased serum triglycerides (30%; 95% CI 18-42) after 24 months, compared with no change in the tibolone and transdermal oestradiol groups. Tibolone decreased serum Lp(a) by 36.6% after 24 months (95% CI 8.3-56.2), oral oestradiol decreased levels by 29.4% (95% CI 2-51.1), compared with no change in the transdermal oestradiol group. CONCLUSIONS Oral and to a lesser extent transdermal oestradiol when sequentially combined with dydrogesterone, showed a beneficial influence on serum lipids regarding the cardiovascular disease risk, which was not seen with tibolone. The significance of Lp(a) levels on cardiovascular disease risk remains to be determined.
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Affiliation(s)
- W Hänggi
- Department of Gynaecology and Obstetrics, University of Bern, Switzerland
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Gelfand M, Fugère P, Bissonnette F. Cardiovascular risk factors during sequentially combined 17 beta oestradiol and dydrogesterone (Femoston); results from a one-year study in postmenopausal women. Maturitas 1997; 26:125-32. [PMID: 9089562 DOI: 10.1016/s0378-5122(96)01089-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To assess the effects of Femoston (2 mg micronised 17 beta oestradiol daily, sequentially combined in one tablet with 10 mg dydrogesterone for 14 days per 28 day cycle) on the serum lipid profile of postmenopausal women. METHODS 188 healthy postmenopausal women with intact uteri (aged 40 to 65 years) were enrolled in an open, multicentre, one-year study. Serum lipids and lipoproteins were measured at baseline and after 3, 6 and 12 months. RESULTS A total of 155 women completed the one-year study. Mean serum levels of total cholesterol and low-density lipoprotein (LDL)-cholesterol were significantly reduced (P < 0.01) at all assessments compared with baseline; the reductions observed at the final assessment were 5 and 20%, respectively. A significant increase of 20% (P < 0.01) was seen in high-density lipoprotein (HDL)-cholesterol levels by month 12. Mean levels of triglycerides were also increased (p < 0.01). Blood pressure and heart rate remained unchanged throughout the study. CONCLUSIONS The results show that the overall effects of Femoston on the serum lipid profile are comparable to those found with oestrogen therapy alone and should reduce the risk of cardiovascular disease in postmenopausal women.
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Affiliation(s)
- M Gelfand
- Jewish General Hospital, Montréal, Quebec, Canada
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Abstract
The use of hormone replacement therapy (HRT) in the immediate postmenopause for the relief of menopausal symptoms and for the prevention of osteoporosis and cardiovascular disease is well established. The continuation of treatment beyond the age of 60 years is likely to maximise these long term benefits and there is now increasing evidence to suggest that commencing treatment de novo in women of this age is likely to be beneficial. Many women remain symptomatic well into their sixties and the introduction of HRT at this stage will not only relieve these symptoms but will also conserve bone density and reduce future osteoporotic fracture risk. Furthermore, HRT appears to reduce the risk of cardiovascular disease, even in those women with pre-existing heart disease. The possible association between HRT and breast cancer remains controversial. Overall, there seems to be a slight increase in risk with long term HRT usage (longer than 10 years) but certain subgroups of women may be more at risk. This review discusses the merits and potential problems of prescribing HRT to the elderly and gives some guidance on the type, dose and route of administration of estrogen and progestogen to be used. Poor compliance with HRT is a major problem and the more widespread use of pretreatment counselling together with a wider range of products should have a positive impact in this area. The final decision about whether to continue or commence HRT in the elderly should be an informed one made by the woman and her clinician together.
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Affiliation(s)
- S Jacobs
- Department of Obstetrics and Gynaecology, Poole Hospital NHS Trust, Dorset, England
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Lindgren R, Risberg B, Hammar M, Berg G. Transdermal hormonal replacement therapy with transdermal progestin every second month. Maturitas 1995; 22:25-30. [PMID: 7666813 DOI: 10.1016/0378-5122(95)00913-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Unopposed estrogen therapy may induce endometrial hyperplasia. To protect the endometrium, estrogen replacement therapy should be combined with a progestin in menopausal women with an intact uterus. The aim of this open non-comparative study was to evaluate the effects on bleeding control and endometrium of 'spacing-out' the 14-day progestin therapy to every second month during transdermal combined hormonal replacement therapy. METHODS Sixty-eight healthy women, previously treated with sequential combined transdermal hormonal replacement therapy every month for 3 years, were treated for the following 2 years in cycles with 6 weeks of transdermal estradiol 50 micrograms/daily (Estraderm, Ciba-Geigy), followed by 2 weeks of combined norethisterone acetate 0.25 mg/day and 50 micrograms estradiol per day. RESULTS Annual endometrial biopsies diagnosed hyperplasia in one woman during the second year whereas most biopsies showed a secretory endometrium. Vaginal ultrasound showed no correlation to either bleeding-pattern or histopathological diagnosis. Most women had a regular bleeding-pattern. CONCLUSIONS Transdermal progestin every second month might be an alternative to regular monthly sequential hormonal replacement therapy.
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Affiliation(s)
- R Lindgren
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of Linköping, Sweden
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Siseles NO, Halperin H, Benencia HJ, Berg G, Pilnik S, Mesch V, Arrighi B, Wikinski RW. A comparative study of two hormone replacement therapy regimens on safety and efficacy variables. Maturitas 1995; 21:201-10. [PMID: 7616869 DOI: 10.1016/0378-5122(94)00889-f] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To assess the effect of tibolone on endometrial safety, plasma estradiol concentrations, lipid metabolism and climacteric symptoms in comparison to sequential conjugated equine estrogens and medroxyprogesterone acetate in postmenopausal women. METHODS In a randomised, open-label, 6-cycle, group-comparative study, the effects on the aforementioned parameters were studied with tibolone 2.5 mg/day (N = 13) continuously, and with conjugated equine estrogens 0.625 mg/day continuously, combined with medroxyprogesterone acetate 5 mg/day (N = 11) (CEE/MPA) sequentially, during 12 days of each 28-day cycle. Within-group statistical analysis was performed with Student's t-test for paired samples, whereas between-group statistics were performed using the Student's t-test for independent groups. RESULTS Cytological evaluation revealed no endometrial stimulation in either group. In the tibolone group, there were no effects on estradiol levels, whereas in the CEE/MPA group, an increase in total and non-SHBG-bound estradiol plasma levels was reported. In the tibolone group, there were significant decreases in plasma total cholesterol, triglycerides, HDL-cholesterol and VLDL-cholesterol, whereas no significant changes in LDL-cholesterol and IDL-cholesterol were reported. In the CEE/MPA group there were significant decreases in plasma total cholesterol, HDL-cholesterol and LDL-cholesterol, whereas there were no significant changes in triglycerides, IDL-cholesterol and VLDL-cholesterol. Climacteric symptoms, particularly vasomotor episodes, decreased similarly in both groups. CONCLUSIONS Both tibolone and CEE/MPA were safe with respect to effects on the endometrium and both treatments induced changes in the plasma profiles of certain lipid and lipoprotein parameters. However, the overall clinical implications of these changes are unknown. Finally, both regimens were equally effective in the treatment of climacteric symptoms.
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Affiliation(s)
- N O Siseles
- Climacteric Section, Hospital Italiano, Buenos Aires, Argentina
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Burch DJ, Spowart KJ, Jesinger DK, Randall S, Smith SK. A dose-ranging study of the use of cyclical dydrogesterone with continuous 17 beta oestradiol. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1995; 102:243-8. [PMID: 7794851 DOI: 10.1111/j.1471-0528.1995.tb09102.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To establish the lowest dose of cyclical dydrogesterone that protects against endometrial hyperplasia induced by continuous 2 mg 17 beta oestradiol, and to study the dose effect on vaginal bleeding and side effects. DESIGN Double-blind, prospectively randomised dose-ranging study. SETTING Menopause clinics in the UK and The Netherlands. SUBJECTS Three hundred and seventy-one postmenopausal women with intact uteri, aged 40 to 60. INTERVENTIONS Administration of six 28-day treatment cycles of continuous daily micronised 17 beta oestradiol with a randomly allocated dose of 5 to 20 mg of dydrogesterone added for the last 14 days of each. MAIN OUTCOME MEASURES Histological assessment of adequate progestational endometrial response, bleeding patterns and adverse effects. RESULTS The study was completed by 320 subjects (86%). Endometrial transformation occurred in over 94% of those taking 5 mg of dydrogesterone, and in over 97% of those on higher doses, without significant differences between the 10, 15 and 20 mg groups. Acceptable bleeding patterns were found at all doses, with the incidence of withdrawal bleeding rising with increasing dose. The day of onset of bleeding was predictable from cycle to cycle, and occurred later in the 20 mg group than in the others. The incidence of noncyclic bleeding was about 6% at all doses. Withdrawal occurred in 3.3% due to unacceptable bleeding and in 5.4% due to side effects. There was no relation with dose. CONCLUSIONS A dydrogesterone-17 beta oestradiol combination hormone replacement therapy confers endometrial protection with an acceptable bleeding pattern and few side effects At least 10 mg of dydrogesterone for 14 days is required for acceptable endometrial protection.
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Affiliation(s)
- D J Burch
- Department of Obstetrics and Gynaecology, Rosie Maternity Hospital, Cambridge
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Nand SL, Webster MA, Wren BG. Continuous combined piperazine oestrone sulphate and medroxyprogesterone acetate hormone replacement therapy--a study of bleeding pattern, endometrial response, serum lipid and bone density changes. Aust N Z J Obstet Gynaecol 1995; 35:92-6. [PMID: 7772012 DOI: 10.1111/j.1479-828x.1995.tb01841.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
This pilot study was conducted to establish the optimum oral dosage of medroxyprogesterone acetate (Provera) given daily in combination with a fixed dose of piperazine oestrone sulphate (Ogen), as hormone replacement therapy. A group of 32 nonhysterectomized, symptomatic menopausal women were randomly allocated to receive piperazine oestrone sulphate 1.25 mg daily and medroxyprogesterone acetate 2.5 mg, 5 mg or 10 mg daily for a 2-year period. This was an open study and the patients were reviewed at 3-monthly intervals for 2 years. Vaginal bleeding was reported by 58% of patients after the first 3 months of treatment. There was a gradual decline in the reported incidence of bleeding over the following 6 months particularly by women in the 5 mg and 10 mg Provera group. Only 10% of patients were still recording slight bleeding in the 10 mg group at 12 months. By 24 months all the women in the 5 mg and 10 mg Provera groups had ceased bleeding. There were 2 patients in the 2.5 mg Provera group with persistent proliferative endometrium at 24 months. All the remaining patients had atrophic endometrium. There was no significant difference in serum lipid changes between the 3 groups, but there was an overall reduction in total cholesterol, triglycerides and low density lipoprotein cholesterol in all women. There was no significant difference in bone mineral density changes between the groups over the 2-year period. Endometrial protection with increased incidence of amenorrhoea, without significant adverse effects, was seen with the use of 5 mg and 10 mg of provera.
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Affiliation(s)
- S L Nand
- Centre for the Management of Menopause, Royal Hospital for Women, New South Wales
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De Cecco L, Gerbaldo D, Cristoforoni P, Ferraiolo A, Remorgida V, Baracchini P, Fulcheri E. Morphological aspects of human endometrium during hormone replacement therapy. Ann N Y Acad Sci 1994; 734:263-70. [PMID: 7978927 DOI: 10.1111/j.1749-6632.1994.tb21756.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- L De Cecco
- Department of Obstetrics and Gynecology, University of Genoa, Italy
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Prelević GM, Beljić T, Balint-Perić L, Petrović J, Elliesen J. Effect of two different progestins (cyproterone acetate and norgestrel), administered in a cyclical estradiol valerate regimen, on markers of bone turnover. Gynecol Endocrinol 1994; 8:209-14. [PMID: 7847107 DOI: 10.3109/09513599409072457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
It has been suggested that some progestogens could have a stimulating effect on bone formation. This study was therefore undertaken in order to compare the influence of cyproterone acetate and norgestrel on bone metabolism when administered in a discontinuous, sequentially combined regimen with estradiol valerate. Twenty healthy early postmenopausal women were randomly assigned to treatment with either Cyclo-Progynova, containing 0.5 mg of norgestrel, or Climen, containing 1 mg of cyproterone acetate (CPA), over two 28-day cycles. Markers of bone resorption-fasting urinary hydroxyproline/creatinine and calcium/creatinine ratios - and of bone formation-serum alkaline phosphatase and osteocalcin-were determined initially, before the start of treatment and thereafter twice weekly (a total of 17 assessments for each women) during the 8-week treatment period. Serum osteocalcin concentrations were slightly but not significantly higher throughout the study period in women receiving Climen, compared to those taking Cyclo-Progynova. Cyclical fluctuation of serum osteocalcin levels were more pronounced in women with a high baseline level of osteocalcin. During the period of progestogen administration, osteocalcin concentrations were either similar to or even lower than those in the phase of administration of estradiol valerate alone. Serum calcium and alkaline phosphatase concentrations were relatively stable during the study period with both treatment regimens. Urinary excretion of calcium and hydroxyproline varied during the cycle but the variation was unrelated to either type or time of progestogen administration. Mean urinary hydroxyproline excretion during the 8-week study period was similar for both preparations, although the mean decrease in the urinary hydroxyproline/creatinine ratio was insignificantly higher for the CPA-containing preparation.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- G M Prelević
- Academic Department of Medicine, Royal Free Hospital, London, UK
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39
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40
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Woodruff JD, Pickar JH. Incidence of endometrial hyperplasia in postmenopausal women taking conjugated estrogens (Premarin) with medroxyprogesterone acetate or conjugated estrogens alone. The Menopause Study Group. Am J Obstet Gynecol 1994; 170:1213-23. [PMID: 8178840 DOI: 10.1016/s0002-9378(94)70129-6] [Citation(s) in RCA: 162] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE We evaluated four oral combinations of conjugated estrogens (Premarin) and medroxyprogesterone acetate in preventing endometrial hyperplasia, which can occur with conjugated estrogens alone. STUDY DESIGN This was a 1-year prospective, double-blind, randomized, multicenter study in 1724 postmenopausal women. All five groups took conjugated estrogens (0.625 mg) daily. The respective medroxyprogesterone acetate dosages were 2.5 and 5.0 mg daily (groups A and B) and 5.0 and 10.0 mg for 14 days per 28-day cycle (groups C and D). RESULTS Among the 1385 patients with valid biopsy data, endometrial hyperplasia developed in 20% in the conjugated estrogens-treated group and < or = 1% in each of the four conjugated estrogens/medroxyprogesterone acetate-treated groups. The incidence of endometrial hyperplasia did not differ significantly between any of the conjugated estrogens/medroxyprogesterone acetate regimens. However, none of the patients receiving the two higher medroxyprogesterone acetate dosages (groups B and D) had endometrial hyperplasia. CONCLUSION The endometrial hyperplasia incidence was significantly lower in women treated with conjugated estrogens and medroxyprogesterone acetate than in women treated with conjugated estrogens alone.
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Affiliation(s)
- J D Woodruff
- Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, Maryland
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41
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Incidence of endometrial hyperplasia in postmenopausal women taking conjugated estrogens (Premarin) with medroxyprogesterone acetate or conjugated estrogens alone. Am J Obstet Gynecol 1994. [DOI: 10.1016/s0002-9378(13)90437-3] [Citation(s) in RCA: 109] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Wiseman LR, McTavish D. Transdermal estradiol/norethisterone. A review of its pharmacological properties and clinical use in postmenopausal women. Drugs Aging 1994; 4:238-56. [PMID: 8199397 DOI: 10.2165/00002512-199404030-00006] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The combined transdermal estradiol/norethisterone therapeutic system is designed to deliver both estradiol and norethisterone into the systemic circulation at a constant rate for up to 4 days when affixed to the skin. Transdermal administration avoids hepatic first-pass metabolism, allowing therapeutic concentrations of the progestogen and estrogen to be maintained in postmenopausal women following low dose administration. Transdermal norethisterone does not appear to alter the potentially beneficial effects of transdermal estradiol on total cholesterol, low-density lipoprotein (LDL) or triglyceride levels, or metabolic parameters of bone resorption or vaginal cytology. Protection of the endometrium from the effects of unopposed estradiol is achieved by sequential treatment with transdermal estradiol/norethisterone for 2 weeks of each 28-day cycle, and the majority of patients experience a regular vaginal bleeding pattern with this treatment regimen. Menopausal symptoms are improved to a similar extent during the transdermal estradiol-only and combined estradiol/norethisterone treatment phases. The transdermal therapeutic system has been well accepted by patients in clinical trials. It is generally well tolerated, the most common adverse effect being local irritation at the site of application. Estrogen- and progestogen-related systemic adverse events are reported in a small proportion of patients. Thus, the combined estradiol/norethisterone transdermal delivery system offers a more convenient and consistent method of progestogen administration. Together with its therapeutic efficacy when administered at lower dosages than oral therapy, it is likely to further improve patient compliance during hormone replacement therapy.
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Affiliation(s)
- L R Wiseman
- Adis International Limited, Auckland, New Zealand
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von Dadelszen P, Gillmer MD, Gray MD, McEwan HP, Pyper RJ, Rollason TP, Wright A. Endometrial hyperplasia and adenocarcinoma during tibolone (Livial) therapy. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1994; 101:158-61. [PMID: 8305393 DOI: 10.1111/j.1471-0528.1994.tb13085.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- P von Dadelszen
- Department of Obstetrics and Gynaecology, John Radcliffe Hospital, Oxford, UK
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Abstract
OBJECTIVE To review the anatomy, physiology, clinical symptoms, long-term health effects, and treatment of the menopause and climacteric syndrome, with a special emphasis on features, such as incontinence, particularly relevant to geriatric medicine. DATA SOURCES English-language publications on menopause and the climacteric. STUDY SELECTION Articles and books containing recent information pertinent to the topics covered. Studies in human subjects were given priority, but primate studies that amplify physiologic concepts are included. DATA SYNTHESIS Due to increased longevity, the average US woman will spend one-third of her life as a postmenopausal individual. Anatomic and physiologic changes associated with the peri- and postmenopausal state include hot flushes, genitourinary atrophy, and bone loss. Possible correlates of the menopausal transition and postmenopause include affective changes and unfavorable alterations in lipoproteins and other cardiac risk factors. Clinical correlates of these changes can include incontinence, sexual dysfunction, increased risk of fracture, dysphoric mood, and increased risk of cardiovascular disease. Formal indications for estrogen therapy are hot flushes, genital atrophy, and osteoporosis prevention; other common clinical uses are reviewed. Non-contraceptive estrogens can be administered orally, transdermally, vaginally, or by injection. Each route and preparation has some unique features with respect to actions and side effects. Progestins, in adequate doses, protect against the unwanted side effect of endometrial hyperplasia; alternatives to progestin use are presented. Non-hormonal alternatives for some peri- and postmenopausal symptoms are described. CONCLUSIONS A discussion of the menopause and the benefits and risks of hormone therapy should be part of the routine health care of older women. Since the use of hormone therapy is elective, health care providers must elicit the goals, needs, and preferences of each patient, supply her with relevant information, and serve as a facilitator of her individual decision.
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Affiliation(s)
- G A Greendale
- Division of General Internal Medicine, UCLA School of Medicine
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45
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Session DR, Kelly AC, Jewelewicz R. Current concepts in estrogen replacement therapy in the menopause. Fertil Steril 1993; 59:277-84. [PMID: 8425617 DOI: 10.1016/s0015-0282(16)55667-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To provide a review of the risks and benefits of hormonal replacement therapy in the menopause, including new therapeutic regimens and modes of delivery. DESIGN A review of the literature to identify published studies was accomplished using a computerized bibliographical search (Medline). RESULTS Replacement therapy is effective in treating symptoms of estrogen deficiency and in lowering the risk of osteoporosis and cardiovascular disease. The daily administration of an estrogen and progestin eliminates the withdrawal bleed and increases patient compliance. This continuous form of therapy also consistently suppresses the endometrium, decreasing the risk of hyperplasia. More studies investigating the effect of continuous therapy on the lipid profile and cardiovascular disease are needed. CONCLUSIONS New therapeutic regimens and modes of delivery decrease risk and increase patient acceptance of hormonal replacement therapy.
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Affiliation(s)
- D R Session
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
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46
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Marsh MS, Whitehead MI. The practicalities of hormone replacement therapy. BAILLIERE'S CLINICAL ENDOCRINOLOGY AND METABOLISM 1993; 7:183-202. [PMID: 8435052 DOI: 10.1016/s0950-351x(05)80275-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
An appropriate regimen of HRT using oestrogen with or without progestogen can be found for the majority of patients. In many cases this will be the first or second therapy that is chosen and for most women will be one of the combination packs that are commercially available. In a significant number of patients, however, these formulations will either not control symptoms or bleeding or will cause unacceptable progestogenic side-effects. Separate prescribing of oestrogen and progestogen will then be required. We suspect that the reported low compliance of women taking HRT in the general population may be related to the deficiencies of the available combination packs and reluctance of physicians to separately prescribe the oestrogen and progestogen components of HRT. The latter is understandable as the literature contains so few guidelines concerning prescribing. It is hoped that progestogens that have less side-effects than the C-19 steroids (currently universally used in combination packs of HRT) will be incorporated into new formulations. The option of prescribing oestrogens to non-hysterectomized women in the form of continuous combined therapy is not available to many physicians because the necessary endometrial sampling every 12-18 months cannot be arranged; the current outpatient methods of sampling require experience of manipulation of instruments within the uterine cavity that is usually only acquired during gynaecological training. There are still many uncertainties about the appropriate combination of oestrogen and progestogen that should be incorporated into a continuous combined regimen to avoid the troublesome bleeding that occurs in a significant proportion of women when starting this therapy. Many previous studies were seriously flawed and further research, carefully designed and conducted, is urgently needed.
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Jensen LC, Obel EB, Lindhard A, Steendahl E, Fink B. Frequency of curettage in middle-aged women treated with sequential preparations versus untreated women. Maturitas 1992; 15:61-9. [PMID: 1326709 DOI: 10.1016/0378-5122(92)90063-a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Over a 2-month period a register was kept of all dilatation and curettage procedures performed in Frederiksborg County, Denmark, involving women aged 40-59 years. The total recorded was 284. In the same period, questionnaires were sent out to 1200 women in the county who fell within the same, randomly selected age group, to establish the number of women treated with sequential oestrogen/progestogen and those who had been hysterectomized. Based on the results and the total female population in the county, it was calculated that the frequency of the procedure in sequentially-treated women as compared with untreated women was 3.1 times higher in the 55-59 age group. In the 40-54 age group no difference in the incidence of curettage in the sequentially-treated women could be demonstrated.
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Byrjalsen I, Thormann L, Riis BJ, Christiansen C. Secretory endometrial protein PP14 in serum from post-menopausal women receiving continuous combined oestradiol-cyproterone acetate: correlation with serum hormone concentrations and bleeding patterns. Maturitas 1992; 15:39-46. [PMID: 1388220 DOI: 10.1016/0378-5122(92)90060-h] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The secretory endometrial protein PP14 was measured in serum from 49 healthy, early post-menopausal women receiving continuous combined oestradiol valerate/cyproterone acetate (2 mg E2V + 1 mg CPA daily) or placebo over a period of 2 years. In the hormone group, serum PP14 increased from 2.1 micrograms/l to a maximum of 8.1 micrograms/l after 1 month of treatment, then fell after 3 months to 3.8 micrograms/l and remained at that level for the rest of the 2-year period. After the first month, the occurrence of uterine bleeding was associated with significantly increased serum PP14 levels. Bleeding was not correlated with the serum concentration of 17 beta-oestradiol (E2) or CPA, or the CPA/E2 ratio. Serum PP14 was significantly dependent on the serum concentration of E2, but not on that of CPA. The present data confirm that serum PP14 levels reflect the secretory phase of the endometrium and that bleeding during continuous combined hormone replacement therapy is probably caused by a sub-optimal hormonal balance.
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Affiliation(s)
- I Byrjalsen
- Department of Clinical Chemistry, Glostrup Hospital, University of Copenhagen, Denmark
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Critchley HO, Farrell EA, Healy DL. Safety of post-menopausal hormone replacement. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 1992; 22:103-5. [PMID: 1530529 DOI: 10.1111/j.1445-5994.1992.tb02785.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Voigt LF, Weiss NS, Chu J, Daling JR, McKnight B, van Belle G. Progestagen supplementation of exogenous oestrogens and risk of endometrial cancer. Lancet 1991; 338:274-7. [PMID: 1677110 DOI: 10.1016/0140-6736(91)90417-n] [Citation(s) in RCA: 212] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The favourable effects of exogenous progestagen on the endometrium are well known, but have not been adequately quantified with respect to endometrial cancer. The benefits of progestagen need to be weighted against its possible untoward effects on the risk of breast cancer and cardiovascular disease. A population-based case-control study of endometrial cancer was undertaken to evaluate the benefits of progestagen use. 158 incident cases were identified between 1985 and 1987 among women aged 40-64 years who were residents of King County, Washington. Detailed interviews were conducted and the responses were compared with those of 182 controls selected by random telephone digit dialling. The risk of endometrial cancer among women who had used unopposed oestrogen for more than 3 years was over five times that of women who had used no hormones (relative risk [RR] 5.7, 95% confidence interval [Cl] 2.5-12.8), whereas those who had also used a progestagen for at least six months of that time had an RR of only 1.6 (95% Cl 0.6-3.9). The RR differed according to days per month that progestagen was used: 2.4 (0.6-9.3) for progestagen use of less than 10 days per month versus 1.1 (0.4-3.6) for use of 10 or more days per month. These results provide additional evidence that the use of progestagen for 10 or more days per cycle can reduce the excess risk of endometrial cancer associated with long-term postmenopausal oestrogen use.
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Affiliation(s)
- L F Voigt
- Fred Hutchinson Cancer Research Center, Seattle, WA 98195
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