A Review of Hormone and Non-Hormonal Therapy Options for the Treatment of Menopause

Association between Extract Rheum rhaponticum 731 (ERr 731) prescription and subsequent breast cancer

AIMS

The special extract ERr 731 from the roots of rhapontic rhubarb has been prescribed for women with menopausal symptoms for more than 30 years. The aim of the present study is to evaluate the association between ERr 731 therapy and subsequent breast cancer in women in a real-world setting. ERr 731 users were compared to women without this therapy as well as women receiving hormone therapy.

METHODS

This retrospective cohort study included data of women treated by 260 office-based gynecologists in Germany who received a prescription for ERr 731 between 1993 and 2022 (IQVIA Disease Analyzer database). These women were matched to women without ERr 731 prescriptions as well as women with hormone replacement therapy (HRT) prescriptions (1:3) using nearest neighbor propensity scores. A univariate Cox regression analysis was conducted to evaluate the associations between ERr 731 prescription and breast cancer risk compared to women without ERr 731 prescription and women with HRT prescriptions.

RESULTS

A total of 5,686 women with versus 17,058 women without ERr 731 prescription were available for the first analysis, and 2,616 women with ERr 731 prescription (a proportion of the 5,686 women used in the first analysis) and 7,848 women with HRT prescriptions for the second (average age 52-53 years). ERr 731 was not associated with an increased risk of breast cancer diagnosis when the group of women with ERr 731 prescription was compared to women without (OR: 1.01, 95% CI: 0.81-1.26) or to that of women with HRT prescription ((OR: 0.96, 95% CI: 0.69-1.33). No associations were observed in age-stratified analyses or in women with and without menopausal or other perimenopausal disorders.

CONCLUSION

The present study provides strong evidence that ERr 731 is not associated with an increased risk of breast cancer diagnosis compared to both non-users and HRT users. Given its favorable safety profile, ERr 731 may represent a viable alternative to HRT, particularly for women concerned about breast cancer risk.

PD-E2: a nano-scaled delivery for estradiol to decrease uterus damage and increase bone mineral density

It is well known that a specific application of 17β-estradiol (E2) is in hormone replacement therapy (HRT), but it is capable of inducing uterine gland cysts. However, the concentration of E2 that causes uterine gland cysts and bone loss remains unknown. To better understand this, we used an ovariectomized (OVX) mouse as the animal model and administered poly-α,β-DL-aspartyl-Lys-coupled E2 (PD-E2) as the bone targeting agent. HPLC-FT-MS analysis showed that the amounts of E2 in the uterus and the femurs of the OVX mice treated with 2.3 μmol kg-1 per day of E2 were 0.62 ± 0.15 ng g-1 and 0.31 ± 0.09 ng g-1, respectively, while the amounts of E2 in the uterus and the femurs of the OVX mice treated with 10 nmol kg-1 per day of PD-E2 were 0 ± 0 ng g-1 and 1.11 ± 0.27 ng g-1, respectively. The data suggested that if the amount of E2 in the uterus was equal to 0.62 ± 0.15 ng g-1, the uterine gland will form cysts, and if the amount of E2 in the femurs was less than 0.31 ± 0.09 ng g-1, the bone loss will be significant. Furthermore, the nano-scaled PD-E2 agent reported in this study provides an innovative strategy for HRT.

Breast Cancer Risk and Management in the Endocrine Clinic: A Comprehensive Review

OBJECTIVE

This review seeks to provide endocrine clinicians with a comprehensive analysis of breast cancer risk, diagnostic modalities and management strategies in women with endocrine disorders, with particular emphasis on the influence of metabolic factors such as diabetes and obesity, and the role of Menopausal Hormone Therapy (MHT).

DESIGN

The review examines a spectrum of endocrine disorders commonly encountered in clinical practice, including Multiple Endocrine Neoplasia Types 1 (MEN1), 2 (MEN2) and 4 (MEN4), Von Hippel-Lindau syndrome (VHL), Pheochromocytoma and Paraganglioma (PPGL), Acromegaly, Hyperprolactinaemia, Polycystic Ovary Syndrome (PCOS), Congenital Adrenal Hyperplasia (CAH), Turner Syndrome, alongside metabolic conditions such as diabetes and obesity and the effects of MHT. The review critically appraises each disorder's association with breast cancer risk, screening implications and therapeutic management.

PATIENTS

This analysis focuses on women with the aforementioned endocrine and metabolic disorders, assessing their specific breast cancer risk profiles, informed by the latest clinical evidence and molecular insights.

MEASUREMENTS

The review comprehensively evaluates current evidence-based approaches to screening, diagnostic accuracy and treatment in this patient cohort. Emphasis is placed on the metabolic derangements, hormonal influences and genetic predispositions that modulate breast cancer risk, providing disorder-specific recommendations for individualised care.

RESULTS

The findings indicate a significantly elevated breast cancer risk in patients with MEN1, necessitating early initiation of MRI screening by age 40. In MEN2, emerging evidence suggests that combining RET inhibitors with endocrine therapy may yield clinical benefits, although further research is needed to validate this approach. The breast cancer risk associated with MEN4 and VHL syndromes, while documented, remains less well-characterised, requiring further investigation. Diabetes and obesity are confirmed as major modifiable risk factors, particularly in postmenopausal women, where hyperinsulinemia and metabolic dysfunction contribute to increased incidence and poorer outcomes, notably in triple-negative breast cancer (TNBC). The role of MHT, particularly combined oestrogen-progestogen therapy, is strongly associated with increased breast cancer risk, particularly for hormone receptor-positive malignancies, necessitating cautious use and personalised treatment planning. In contrast, oestrogen-only MHT appears to confer a reduced risk in women post-hysterectomy. For patients with PCOS, CAH and Turner Syndrome, while definitive evidence of elevated breast cancer risk is lacking, individualised screening strategies and careful hormone therapy management remain essential due to the complex interplay of hormonal and metabolic factors.

CONCLUSIONS

The review highlights the need for personalised breast cancer screening and management protocols in women with endocrine and metabolic disorders. For high-risk groups such as MEN1 patients, early initiation of MRI screening is warranted. In women with diabetes and obesity, targeted interventions addressing hyperinsulinemia and metabolic dysfunction are critical to mitigating their increased cancer risk. The association between MHT and breast cancer underscores the importance of individualised risk stratification in hormone therapy administration, particularly in women with predisposing genetic or endocrine conditions. Enhanced surveillance tailored to the unique risk profiles of endocrine disorder patients will facilitate early detection and improve clinical outcomes. However, further large-scale studies are necessary to refine these associations and develop robust, evidence-based guidelines.

Hypopituitarism and Cardiovascular Risk

Hypopituitarism, resulting from a partial or complete deficiency of anterior or posterior pituitary hormones, is associated with increased cardiovascular (CV) morbidity and mortality. This heterogeneous endocrinological disorder may arise from various etiologies, including genetic mutations, pituitary tumors, traumatic brain injury, and autoimmune diseases. Hypopituitarism often results in multiple endocrine deficits that contribute to metabolic dysregulation characterized by insulin resistance, dyslipidemia, and increased visceral adiposity, all known risk factors for CV disease (CVD). Additionally, the presence of chronic inflammation and endothelial dysfunction further increases the risk of CVD in these patients. While standard hormone replacement therapy (HRT) is crucial for restoring hormonal balance, it can sometimes have adverse metabolic effects that can exacerbate atherosclerosis and CVD. Emerging evidence suggests that optimizing HRT regimens and addressing specific hormone deficiencies, such as growth hormone and cortisol, may reduce these risks and improve CV outcomes. This review comprehensively analyzes the etiology, pathophysiological mechanisms underlying CV risk in anterior pituitary dysfunction, and treatment strategies to mitigate CV morbidity and mortality in patients with hypopituitarism.

Jazz dancing for improving cardiorespiratory fitness, body composition, muscle strength, and sleep quality in postmenopausal women: a randomized clinical trial with 6- and 12-month follow-ups

OBJECTIVE

The aim of the study was to analyze the effects of 16 weeks of Jazz Dance training compared to a control group in postmenopausal women, postintervention, and at the 6- and 12-month follow-ups, on cardiorespiratory fitness, body composition, muscle strength, and sleep quality.

METHODS

Two-arm randomized clinical trial with a total of 47 women (jazz dance intervention group [JDIG] [n = 23] and control group (CG) [n = 24]) with a mean age of 53.41 ± 2.8 y. Data collection was carried out at four times, baseline, postintervention, and 6- and 12-month follow-ups using the 6-minute walk test (cardiorespiratory fitness); bioimpedance (body composition); isokinetic dynamometry (muscle strength); and the Pittsburgh Sleep Quality Index (sleep quality).

RESULTS

In the intention-to-treat analysis, the results showed positive differences for the JDIG in cardiorespiratory fitness at all time points (P = 0.034) and in the group x time interaction (P = <0.001). Lower limb muscle strength showed differences from baseline to postintervention and from baseline to the 12-month follow-up for the concentric force ratio (P = 0.021; P = 0.009). However, for peak extension and flexion, the results were not positive for the JDIG. There was a short-term improvement in sleep duration for the JDIG (P = 0.001) and significant intergroup differences in subjective sleep quality, where the JDIG showed better results compared to the CG (P = 0.041).

CONCLUSIONS

Jazz Dance is effective for improving cardiorespiratory fitness (in the short, medium, and long term) and sleep quality (in the short and medium term); however, it does not seem to have presented sufficient intensity and duration for facilitating changes in body composition or increasing lower limb muscle strength in postmenopausal women.

Palmitoylethanolamide in Postmenopausal Metabolic Syndrome: Current Evidence and Clinical Perspectives

Menopause leads to a decline in estrogen levels, resulting in significant metabolic alterations that increase the risk of developing metabolic syndrome-a cluster of conditions including central obesity, insulin resistance, dyslipidemia, and hypertension. Traditional interventions such as hormone replacement therapy carry potential adverse effects, and lifestyle modifications alone may not suffice for all women. This review explores the potential role of palmitoylethanolamide (PEA), an endogenous fatty acid amide, in managing metabolic syndrome during the postmenopausal period. PEA primarily acts by activating peroxisome proliferator-activated receptor-alpha (PPAR-α), influencing lipid metabolism, energy homeostasis, and inflammation. Evidence indicates that PEA may promote the browning of white adipocytes, enhancing energy expenditure and reducing adiposity. It also improves lipid profiles by boosting fatty acid oxidation and decreasing lipid synthesis, potentially lowering low-density lipoprotein cholesterol and triglyceride levels while increasing high-density lipoprotein cholesterol. Additionally, the anti-inflammatory properties of PEA enhance insulin sensitivity by reducing pro-inflammatory cytokines that interfere with insulin signaling. PEA may aid in weight management by influencing appetite regulation and improving leptin sensitivity. Furthermore, its neuroprotective effects may address the mood disturbances and cognitive decline associated with menopause. Given these multifaceted biological activities and a favorable safety profile, PEA may represent a promising non-pharmacological supplement for managing metabolic syndrome in postmenopausal women. However, further large-scale clinical studies are necessary to establish its efficacy, optimal dosing, and long-term safety. If validated, PEA could become an integral part of strategies to improve metabolic and neuropsychological health outcomes in this population.

The development and evaluation of a fact sheet resource for women managing menopausal-related cognitive complaints

OBJECTIVES

Cognitive symptoms are frequently reported by women during the menopause transition years. The aim of this research was to codesign and evaluate a fact sheet resource to help women understand and manage cognitive symptoms that may occur during menopause.

METHODS

This study adopted a codesign approach involving women during the menopause transition years as well as professionals to develop and evaluate a fact sheet, with a focus on acceptability and safety. Four phases (discover, define, develop, deliver) were conducted to develop, refine, and evaluate the fact sheet using a mixed-methods approach of focus groups, interviews, and surveys.

RESULTS

The discover phase identified a need for online educational resources for women in premenopause, perimenopause, and postmenopause to learn about menopause-related topics. The define and develop phases, relying on focus group sessions with perimenopausal and postmenopausal women, revealed common themes related to the experience of cognitive symptoms and a desire for management tips to optimize cognitive functioning. Structured interviews with professionals highlighted a desire for more concrete examples of cognitive symptoms. The results of the deliver phase found strong acceptability for the fact sheet, alongside requests for additional information on menopausal hormone therapy from premenopausal, perimenopausal, and postmenopausal women.

CONCLUSIONS

The study reported a wide range of cognitive symptoms among women during the menopause transition years. This study showed broad agreement on the fact sheet's acceptability and safety in addressing menopausal cognitive symptoms. Feedback on menopausal hormone therapy and management tips underscores the demand for more research on effective interventions.

Comprehensive Management of Menopausal Symptoms

Menopause is an inevitable physiologic process that typically occurs in women between the ages of 45 and 56 years old. It involves the permanent cessation of ovarian function and is recognized to have occurred when there has been no menstrual cycle for 12 consecutive months without another cause. Vasomotor symptoms, such as hot flushes and night sweats, and genitourinary syndrome of menopause, which includes symptoms of vaginal dryness, dyspareunia, and urinary incontinence, are common symptoms of menopause. Symptoms range from mild to severe, and for those interested in treating their symptoms, there are hormonal and nonhormonal options available. Choosing appropriate therapies is based on each individual's health history and personal preferences. Because menopause can affect mental, physical, and emotional health, it is critical for nurses to recognize the changes that occur in menopause so that they can make appropriate inquiries to elicit symptom information. Nurses play an important role in counseling and supporting individuals through the menopause transition with evidence-based guidance.

Treatment satisfaction, unmet needs, and new treatment expectations for vasomotor symptoms due to menopause: women's and physicians' opinions

OBJECTIVE

To assess treatment satisfaction, unmet treatment needs, and new vasomotor symptom (VMS) treatment expectations among women with moderate to severe VMS and physicians treating women with VMS.

METHODS

This noninterventional, nonrandomized survey included qualitative interviews and quantitative surveys of women and physicians in the US. Participating women had moderate to severe VMS in the past year and received ≥1 hormone therapy (HT), non-HT, or over-the-counter (OTC) treatment for VMS in the past 3 months. Participating physicians were obstetrician-gynecologists (OB-GYNs) and primary care physicians (PCPs) who treated ≥15 women with VMS in the past 3 months. Two online survey questionnaires were developed using insights from literature, qualitative interviews, and clinical experts. Menopause Symptoms Treatment Satisfaction Questionnaire (MS-TSQ) measured treatment satisfaction. Results were summarized descriptively.

RESULTS

Questionnaires were completed by 401 women with VMS and 207 physicians treating VMS. Among women, mean total MS-TSQ score ranges were 62.8-67.3 for HT, 59.8-69.7 for non-HT, and 58.0-64.9 for OTC treatments. Among physicians, mean total MS-TSQ scores were considerably higher for HT than for non-HT and OTC treatments (HT: 73.4-75.6; non-HT: 55.6-62.1; OTC: 49.2-54.7). Women reported "lack of effectiveness" (41.2%), and physicians reported "long-term safety concerns" (56.5%) as main features that do not meet their current treatment expectations. The majority of women and physicians would consider trying a new non-HT treatment for VMS (75.8 and 75.9%, respectively).

CONCLUSIONS

Treatment satisfaction and new treatment expectations were similar but with some differences between women and physicians; the need for additional treatments for VMS was identified.

Advanced drug delivery technologies for postmenopausal effects

Postmenopause is the 12-month absence of menstrual periods, characterized by decreased estrogen and progesterone levels, leading to physical and psychological alterations such as hot flashes, mood swings, sleep disruptions, and skin changes. Present postmenopausal treatments include hormone replacement therapy, non-hormonal drugs, lifestyle modifications, vaginal estrogen therapy, bone health treatments, and alternative therapies. Advanced drug delivery systems (ADDSs) are essential in managing postmenopausal effects (PMEs), offering targeted and controlled delivery to alleviate symptoms and improve overall health. This review emphasizes such ADDSs for addressing PMEs. Emerging trends such as artificial ovaries are also reviewed. Additionally, the prospects of technologies such as additive manufacturing (3D and 4D printing) and artificial intelligence in further tailoring therapeutic strategies against PMEs are provided.

Effectiveness and safety of fezolinetant in alleviating vasomotor symptoms linked to Menopause.: A systematic review and Meta-Analysis

BACKGROUND & OBJECTIVE

Vasomotor symptoms (VMS) are the most common symptoms during menopause including hot flushes and night sweats. They are highly disruptive to the quality of life. Fezolinetant is an FDA-approved non-hormonal selective neurokinin3 receptor antagonist for the treatment of VMS. In this study, we aim to assess the efficacy and safety of fezolinetant for VMS associated with menopause.

METHODS

Databases were searched until September 2023 for relevant studies comparing fezolinetant against placebo. Data was extracted into an online form and analyzed using RevMan (Version 5.4.1). The GRADE approach was conducted to evaluate the quality of evidence regarding efficacy outcomes. We included randomized controlled trials (RCTs) comparing fezolinetant to placebo in postmenopausal women experiencing VMS. Exclusion criteria comprised studies involving participants with contraindications to fezolinetant or those evaluating its efficacy for indications other than VMS associated with menopause.

RESULTS

Six studies were included in this study involving 3301 patients. Compared to placebo, fezolinetant reduced the frequency of VMS episodes from baseline (SMD = -0.64, 95 % CI [-0.77, -0.5]) and (SMD = -0.63, 95 % CI [-0.72, -0.53] at weeks 4 and 12 respectively. Additionally, fezolinetant reduced VMS severity score (SMD = -0.59, 95 %CI [-0.77, -0.42]) and (SMD = -0.4, 95 % CI [-0.54, -0.27]) at weeks 4 at 12 respectively. These reductions were positively reflected on Menopause specific quality of life score (SMD = -0.46, 95 %CI [-57, -0.34]), (SMD = -0.37, 95 %CI [-0.48, -0.25]) at weeks 4 and 12 respectively. Regarding safety analysis, fezolinetant showed increased risk for drug-related TEAEs (RR = 1.47, 95 %CI [1.06,2.04]), serious TEAEs (RR = 1.67, 95 %CI [1.09,2.55]), fatigue (RR = 4.05, 95 %CI [1.27,12.88]), arthralgia (RR = 2.83, 95 %CI [1.02,7.8]) and ALT or AST > 3 times (RR = 2, 95 %CI [1.12,3.57]), with no other statistically significant difference regarding other safety terms.

CONCLUSION

Fezolinetant has demonstrated efficacy in reducing the frequency and severity of VMS in postmenopausal women, leading to an improvement in their quality of life. These findings suggest that Fezolinetant may serve as a viable alternative to hormonal therapy for managing VMS.

Gynecologic Care of Black Breast Cancer Survivors

Purpose of Review

Black patients suffer from breast cancer-related racial health disparities, which could have implications on their gynecologic care. This review explores considerations in the gynecologic care of Black breast cancer survivors.

Recent Findings

Black people have a higher risk of leiomyoma and endometrial cancer, which could confound bleeding patterns such as in the setting of tamoxifen use. As Black people are more likely to have early-onset breast cancer, this may have implications on long-term bone and heart health. Black patients may be more likely to have menopausal symptoms at baseline and as a result of breast cancer treatment. Furthermore, Black patients are less likely to utilize assisted reproductive technology and genetic testing services.

Summary

It is important for healthcare providers to be well-versed in the intersections of breast cancer and gynecologic care. Black breast cancer survivors may have unique considerations for which practitioners should be knowledgeable.

The Menopausal Transition: Is the Hair Follicle "Going through Menopause"?

This article explores the link between menopause and changes in the hair follicle (HF) lifecycle, focusing on hormonal and metabolic dynamics. During menopause, hormonal fluctuations and aging can impact the HF, leading to phenomena such as thinning, loss of volume, and changes in hair texture. These changes are primarily attributed to a decrease in estrogen levels. However, not all women experience significant hair changes during menopause, and the extent of transformations can vary considerably from person to person, influenced by genetic factors, stress, diet, and other elements. Furthermore, menopause mirrors the aging process, affecting metabolism and blood flow to the HFs, influencing the availability of vital nutrients. The article also discusses the key role of energy metabolism in the HF lifecycle and the effect of hormones, particularly estrogens, on metabolic efficiency. The concept of a possible "menopause" clinically independent of menopause is introduced, related to changes in HF metabolism, emphasizing the importance of individual factors such as estrogen receptor responses, genetics, and last but not least, the microbiota in determining these dynamics.