An evaluation of clinical response to piperazine oestrone sulphate ('Harmogen') in menopause patients

Oral oestrogen and combined oestrogen/progestogen therapy versus placebo for hot flushes

BACKGROUND

Hot flushes and night sweats are common symptoms experienced by menopausal women. Hormone therapy (HT), containing oestrogens alone or oestrogens together with progestogens in a cyclic or continuous regimen, is often recommended for their alleviation.

OBJECTIVES

To examine the effect of oral HT compared to placebo on these vasomotor symptoms and the risk of early onset side-effects.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders Group and Subfertility Group trials register (searched May 2002). This register is based on regular searches of MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, the handsearching of 20 relevant journals and conference proceedings, and searches of several key grey literature sources. We also contacted all relevant pharmaceutical companies, The Journal of the International Menopause Society and Climacteric.

SELECTION CRITERIA

Double-blind, randomised, placebo-controlled trials of oral HT for at least three months duration.

DATA COLLECTION AND ANALYSIS

Study quality and outcome data were assessed independently. Random effects models were considered appropriate due to the variety of trial methodologies. The meta-analyses were explored for sensitivity to trial quality and therapy duration. Symptom frequency and severity were assessed separately, together with withdrawals and side-effects. Frequency data were analysed using the Weighted Mean Difference (WMD) between treatment and placebo outcomes. For severity data, odds ratios were estimated from the proportional odds model. From 115 references originally identified, 24 trials meeting the selection criteria were included in the review. Study participants totaled 3,329. Trial duration ranged from three months to three years.

MAIN RESULTS

There was a significant reduction in the weekly hot flush frequency for HT compared to placebo (WMD -17.92, 95% CI -22.86 to -12.99). This was equivalent to a 75% reduction in frequency (95% CI 64.3 to 82.3) for HT relative to placebo. Symptom severity was also significantly reduced compared to placebo (OR 0.13, 95% CI 0.07 to 0.23). Withdrawal for lack of efficacy occurred significantly more often on placebo therapy (OR 10.51, 95% CI 5.00 to 22.09). Withdrawal for adverse events, commonly breast tenderness, oedema, joint pain and psychological symptoms, was not significantly increased (OR 1.25, 95% CI 0.83 to 1.90), although the occurrence of any adverse events was significantly increased for HT (OR 1.41, 95% CI 1.00 to 1.99). In women who were randomised to placebo treatment, a 57.7% (95% CI 45.1 to 67.7) reduction in hot flushes was observed between baseline and end of study.

REVIEWERS' CONCLUSIONS

Oral HT is highly effective in alleviating hot flushes and night sweats. Therapies purported to reduce such symptoms must be assessed in blinded trials against a placebo or a validated therapy because of the large placebo effect seen in well conducted randomised controlled trials, and also because during menopause symptoms may fluctuate and after menopause symptoms often decline. Withdrawals due to side-effects were only marginally increased in the HT groups despite the inability to tailor HT in these fixed dose trials. Comparisons of hormonal doses, product types or regimens require analysis of trials with these specific "within study" comparisons.

Postmenopausal Hormone Therapy and Migraine Headache

BACKGROUND

Estrogen withdrawal has been described as a trigger for migraine headache, and some studies suggest that estrogen and progestin may exacerbate migraine. No population-based studies have examined the association between hormone therapy (HT) and migraine among postmenopausal women.

METHODS

To examine the association between HT and migraine headache in postmenopausal women, we used self-report of HT use, HT characteristics, and migraine headache within the past year among 17,107 postmenopausal female health professionals enrolled in the Women's Health Study.

RESULTS

Analyses were restricted to the 17,107 of 21,788 postmenopausal women who were postmenopausal at baseline and who were never (38.5%) or current (61.5%) users of HT. Of these, 1,909 (11.2%) experienced migraine headache within the last year. Women with migraine headache were significantly younger, had a younger age at menopause, were more likely to have had a surgical menopause, and were more likely to be current users of HT. After adjusting for age, race, smoking, alcohol use, ever use of oral contraception, age at menopause, and menopause type, the odds ratio (OR) for migraine headache was 1.42 (95% CI 1.24-1.62) for women who were current users of HT compared with never users. ORs were similar for users of estrogen alone (OR 1.39, 95% CI 1.14-1.69) and users of both estrogen and progestin (OR 1.41, 95% CI 1.22-1.63).

CONCLUSIONS

In this cross-sectional study, current HT use was associated with higher rates of migraine headache than nonuse. Clinical trials are needed to determine if HT increases the incidence of migraine in postmenopausal women.

Role of estrogen in the aetiology and treatment of mood disorders

Worldwide, the prevalence of depression in women is significantly greater than in men. Available data suggest that estrogen, or its absence, is strongly implicated in the regulation of mood and behaviour, as well as in the pathobiology of mood disorders. The multiple effects of estrogens and their complex interactions with the CNS and endocrine system have been well documented, although the specific, multifaceted role of estrogen in each dysphoric state has yet to be elucidated. Several facts suggest that estrogen plays a vital role in the precipitation and course of mood disorders in women. Gender differences in the prevalence of depression first appear after menarche, continue through reproductive age, and dissipate after perimenopause. Periods of hormonal fluctuations or estrogen instability (i.e. premenstrually, postpartum, perimenopausally) have been associated with increased vulnerability to depression among susceptible women. It is plausible that the phenotype of these depressions is distinguishable from those that are not associated with reproductive events or that occur in men. Based on current knowledge, estrogen treatment for affective disorders may be efficacious in two situations: (i) to stabilise and restore disrupted homeostasis - as occurs in premenstrual, postpartum or perimenopausal conditions; and (ii) to act as a psychomodulator during periods of decreased estrogen levels and increased vulnerability to dysphoric mood, as occurs in postmenopausal women. There is growing evidence suggesting that estrogen may be efficacious as a sole antidepressant for depressed perimenopausal women. It is still unclear whether estrogen is efficacious as an adjunct to selective serotonin reuptake inhibitors or as one of the paradigms to manage treatment-resistance depression in menopausal women, but such efficacy is plausible.

Sex hormones and chronic headache in women

Women experience changes in headache pattern in relation to changes in their reproductive cycles. Menarche, menses, pregnancy, menopause and the use of exogenous oestrogen-containing medications frequently alter baseline headache patterns. Changing patterns of headache in women may be linked to alterations in levels of sex hormones. Sex hormones directly influence headache by affecting the activity of a variety of neurochemicals important for headache, including serotonin (5HT). Treating headache alterations in women may include therapies that modify sex hormones or neurochemicals.

Hormone-related headache

The normal female life cycle is associated with hormonal milestones including menarche, pregnancy, OC use, menopause, and the use of HRT. Menarche marks the onset of menses and cyclic changes in hormone levels. Pregnancy is associated with rising noncyclic levels of sex hormones. Menopause is associated with declining noncyclic levels. Hormonal OC use during the reproductive years and HRT in menopause are therapeutic hormonal interventions that alter the levels and cycling of sex hormones. These events and interventions may cause a change in the prevalence or intensity of headache. Headaches associated with OC use or menopausal HRT may be related, in part, to periodic discontinuation of oral sex hormone preparations. The treatment of migraine associated with changes in sex hormone levels is difficult, and patients often are refractory to therapy. Based on what is known of the pathophysiology of migraine, a logical approach to the treatment of headaches that are associated with menses, menopause, and OCs using abortive and preventive medications and hormonal manipulations has been presented.

Oral oestrogen replacement therapy versus placebo for hot flushes

BACKGROUND

Hot flushes and night sweats are common symptoms experienced by menopausal women. Hormone replacement therapy (HRT), containing oestrogens alone or oestrogens together with progestogens in a cyclic or continuous regimen, is often recommended for their alleviation.

OBJECTIVES

To examine the effect of oral HRT compared to placebo on these vasomotor symptoms and the risk of early onset side-effects.

SEARCH STRATEGY

As developed by the Menstrual Disorders Group and Subfertility group of the Cochrane Collaboration.

SELECTION CRITERIA

Double-blind, randomised, placebo-controlled trials of oral HRT therapy for at least three months duration.

DATA COLLECTION AND ANALYSIS

Study quality and outcome data were assessed independently. Random effects models were considered appropriate due to the variety of trial methodologies. The meta-analyses were explored for sensitivity to trial quality and therapy duration. Symptom frequency and severity were assessed separately, together with withdrawals and side-effects. Frequency data were analysed using the Weighted Mean Difference (WMD) between treatment and placebo outcomes. For severity data, odds ratios were estimated from the proportional odds model. From 99 references originally identified, 21 trials meeting the selection criteria were included in the review. Study participants totalled 2,511. Trial duration ranged from three months to three years.

MAIN RESULTS

There was a significant reduction in the weekly hot flush frequency for HRT compared to placebo (WMD -17.46, 95% CI -24.72, -10.21). This was equivalent to a 77% reduction in frequency (95% CI 58.2, 87.5) for HRT relative to placebo. Symptom severity was also significantly reduced compared to placebo (OR 0.13, 95% CI 0.08, 0.22). Withdrawal for lack of efficacy occurred significantly more often on placebo therapy (OR 17.25, 95% CI 8.23, 36.15). Withdrawal for adverse events, commonly breast tenderness, oedema, joint pain and psychological symptoms, was not significantly increased for HRT therapy (OR 1.38, 95% CI 0.87, 2.21). In women who were randomised to placebo treatment, a 50.8% (95% CI 41.7, 58.5) reduction in hot flushes was observed between baseline and end of study.

REVIEWER'S CONCLUSIONS

Oral HRT is highly effective in alleviating hot flushes and night sweats. Therapies purported to reduce such symptoms must be assessed in blinded trials against a placebo or a validated therapy. Withdrawals due to side-effects were only marginally increased in the HRT groups despite the inability to tailor HRT in these fixed dose trials. Comparisons of hormonal doses, product types or regimens require analysis of trials with these specific "within study" comparisons.

Modulation of myofascial pain by the reproductive hormones: a preliminary report

STATEMENT OF PROBLEM

The predominance of myofascial pain in women in childbearing years suggests that the reproductive hormones may play a role in this pain disorder.

PURPOSE

The potential influence of these hormones on myofascial pain was evaluated.

METHODS

Pain patterns were compared across three consecutive menstrual cycles in oral contraceptives users (OC group) and nonusers (Non-OC group).

RESULTS

Preliminary results showed that within menstrual cycle variability of daily pain was higher than the nonusers group. In addition to their low variation, pain levels of oral contraceptives users remained positive across the hormonal cycle, whereas in nonusers, peaks of pain alternated frequently with pain-free periods. These data suggest that pain levels in oral contraceptives users may be more constant than those of nonusers.

CONCLUSIONS

This potential hormonal influence on myofascial pain levels among oral contraceptives users may represent one of the various adverse effects induced by oral contraceptives at the trigeminal area in sensitive subjects. Evidence supporting the link between estrogen, nitric oxide, and inflammatory processes is presented.

Migraine and ovarian steroid hormones

This chapter reviews clinical and epidemiological data that support a role for ovarian steroid hormones in the migraine syndrome. Changes in the clinical presentation of migraine are discussed on the basis of current knowledge of biochemistry and pharmacology of ovarian steroids. Finally, special treatment considerations of ovarian hormone-sensitive migraine are discussed.

A meta-analysis of the effect of hormone replacement therapy upon depressed mood

This meta-analysis had two objectives: (a) to aggregate data from studies that used hormone replacement therapy (HRT) and a quantitative measure of depressed mood in order to examine the effectiveness of HRT upon menopausal depressed mood; and (b) to review the methodologies of this literature base. The overall effect size for HRT was 0.68. This indicated that the average treatment patient had lower levels of depressed mood than 76% of the control patients. Analyses of specific hormone treatments suggested that (a) estrogen significantly reduced depressed mood (ES = 0.69); (b) progesterone alone, and in combination with estrogen, was associated with smaller reductions in depressed mood (ES = 0.39, ES = 0.45, respectively); and (c) androgen alone and in combination with estrogen was associated with greater reductions in depressed mood (ES = 1.37; ES = 0.90, respectively). In summary, HRT appeared to be effective in reducing depressed mood among menopausal women. The methodological review indicated that most studies used adequate sample sizes, controlled research designs, random assignment, double-blind treatment manipulations, and valid and reliable measures of depression. Limitations in the interpretation of these results are discussed and recommendations for improved methodology are provided.

Sex hormones and headache

A variety of evidence suggests a link between migraine and the female sex hormones. Women with migraine outnumber men by at least a 2:1 ratio and definite patterns of development and attacks are noted at menarche and throughout the period of menses, related to trimester of pregnancy, and again at menopause, although it may also regress. Hormonal replacement with estrogen can exacerbate migraine; oral contraceptives can change the character and frequency of migraine headache. This article will cover approaches to the therapy of hormone-related headaches associated with the menstrual cycle, menopause, and oral contraceptives.

Effect of oestrogen and testosterone implants on psychological disorders in the climacteric

In a double-blind trial oestradiol, oestradiol/testosterone, or placebo implants were assessed for their effects on psychological symptoms in women attending a menopause clinic. After two months, women receiving active treatment scored better than the placebo group on a self-rating scale of distress, on anxiety, and on depression (p less than 0.05). Postmenopausal but not perimenopausal women improved after placebo, and at 4 months the scores in the three groups no longer differed significantly.

Sleep disorders

Advancements in sleep research have led to the development of new standards of what is normal sleep and arousal and new diagnostic tests for the detection of sleep disorders. Millions of adults have frequent or chronic complaints about the quality and quantity of their sleep. Sleep complaints increase with increasing age and are more common in women than in men and in women over 45 than in younger women. Sedative-hypnotic drugs are taken more frequently by women than men, and the incidence of use increases with increasing age. Studies of sleep and sleep disturbances during the perimenopausal period suggest that difficulty falling asleep and frequent nocturnal awakenings result from hormonal changes, vasomotor symptoms, and possibly psychologic factors. Other causes for sleep complaints in menopausal and postmenopausal women are occult sleep disorders, especially periodic leg movements in sleep and sleep apnea syndrome. Sleeping pills are inappropriate for most patients with sleep complaints. If sleep difficulties persist after a trial of good sleep hygiene, further evaluation at a sleep disorders center is indicated.

Psychological effects of progestogens in the post-menopausal years

Progestogens are increasingly being advocated as a necessary and integral part of hormone replacement therapy. Yet few studies have measured the acceptability of these regimes. One factor profoundly affecting acceptability, and thus patient compliance, is the presence of adverse psychological effects of progestogens. There have been few double-blind trials which have evaluated such effects of progestogens and compared them with the effects of oestrogen administration alone. There is some evidence of less favourable effects when certain progestogens are added to oestrogen or used alone. Whilst the literature is limited there is an indication that adverse effects of progestogens may relate to dosage, type of progestogen and individual sensitivity of women to hormone provocation of symptoms. Further studies are needed to test these hypotheses.

A randomised, double-blind, cross-over study into the effect of sequential mestranol and norethisterone on climacteric symptoms and biochemical parameters

A randomised, double-blind, cross-over study into the effect of graded sequential mestranol and norethisterone on climacteric symptoms was performed. The study group consisted of 23 post-menopausal women who had previously undergone hysterectomy. Active therapy resulted in a significant reduction in hot flushes and night sweats. There was a slight improvement in insomnia, lack of energy and confidence but the other symptoms were not significantly altered. A small placebo effect was noted but this was only significant 1 mth after active treatment had been discontinued in the group of women receiving placebo second. Active treatment also resulted in a significant reduction in serum sodium, calcium, albumin, alkaline phosphatase and cholesterol, and increase in serum triglycerides, but no alteration in the other biochemical parameters, weight or blood pressure.

A review of studies of the psychological symptoms found at the menopause

The scientific literature was reviewed in order to determine whether psychological symptoms were directly associated with the menopause. Aetiology theories of symptoms include biological, psychological, sociological and multifactorial. There is evidence that psychological symptoms do occur in increased frequency in relationship to declining ovarian function. The severity of these symptoms may be affected by sociological variables. Administration of oestrogens alone or in combination with progestogens appear to alleviate some of the symptoms. More detailed research is needed into the relationship between psychological symptoms and the menopause.

Replacement therapy and piperazine oestrone sulphate ('Harmogen') and its effect on memory

A formal memory test was administered to 18 female patients with signs or symptoms of oestrogen deficiency taking part in a double-blind study of piperazine oestrone sulphate. A significant improvement in memory was seen in the treated group compared with the placebo group. The findings are discussed.