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LeBoff MS, Greenspan SL, Insogna KL, Lewiecki EM, Saag KG, Singer AJ, Siris ES. The clinician's guide to prevention and treatment of osteoporosis. Osteoporos Int 2022; 33:2049-2102. [PMID: 35478046 PMCID: PMC9546973 DOI: 10.1007/s00198-021-05900-y] [Citation(s) in RCA: 234] [Impact Index Per Article: 117.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 02/19/2021] [Indexed: 12/16/2022]
Abstract
Osteoporosis is the most common metabolic bone disease in the USA and the world. It is a subclinical condition until complicated by fracture(s). These fractures place an enormous medical and personal burden on individuals who suffer from them and take a significant economic toll. Any new fracture in an adult aged 50 years or older signifies imminent elevated risk for subsequent fractures, particularly in the year following the initial fracture. What a patient perceives as an unfortunate accident may be seen as a sentinel event indicative of bone fragility and increased future fracture risk even when the result of considerable trauma. Clinical or subclinical vertebral fractures, the most common type of osteoporotic fractures, are associated with a 5-fold increased risk for additional vertebral fractures and a 2- to 3-fold increased risk for fractures at other sites. Untreated osteoporosis can lead to a vicious cycle of recurrent fracture(s), often resulting in disability and premature death. In appropriate patients, treatment with effective antifracture medication prevents fractures and improves outcomes. Primary care providers and medical specialists are critical gatekeepers who can identify fractures and initiate proven osteoporosis interventions. Osteoporosis detection, diagnosis, and treatment should be routine practice in all adult healthcare settings. The Bone Health and Osteoporosis Foundation (BHOF) - formerly the National Osteoporosis Foundation - first published the Clinician's Guide in 1999 to provide accurate information on osteoporosis prevention and treatment. Since that time, significant improvements have been made in diagnostic technologies and treatments for osteoporosis. Despite these advances, a disturbing gap persists in patient care. At-risk patients are often not screened to establish fracture probability and not educated about fracture prevention. Most concerning, the majority of highest risk women and men who have a fracture(s) are not diagnosed and do not receive effective, FDA-approved therapies. Even those prescribed appropriate therapy are unlikely to take the medication as prescribed. The Clinician's Guide offers concise recommendations regarding prevention, risk assessment, diagnosis, and treatment of osteoporosis in postmenopausal women and men aged 50 years and older. It includes indications for bone densitometry as well as fracture risk thresholds for pharmacologic intervention. Current medications build bone and/or decrease bone breakdown and dramatically reduce incident fractures. All antifracture therapeutics treat but do not cure the disease. Skeletal deterioration resumes sooner or later when a medication is discontinued-sooner for nonbisphosphonates and later for bisphosphonates. Even if normal BMD is achieved, osteoporosis and elevated risk for fracture are still present. The diagnosis of osteoporosis persists even if subsequent DXA T-scores are above - 2.5. Ongoing monitoring and strategic interventions will be necessary if fractures are to be avoided. In addition to pharmacotherapy, adequate intake of calcium and vitamin D, avoidance of smoking and excessive alcohol intake, weight-bearing and resistance-training exercise, and fall prevention are included in the fracture prevention armamentarium. Where possible, recommendations in this guide are based on evidence from RCTs; however, relevant published data and guidance from expert clinical experience provides the basis for recommendations in those areas where RCT evidence is currently deficient or not applicable to the many osteoporosis patients not considered for RCT participation due to age and morbidity.
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Affiliation(s)
- M. S. LeBoff
- grid.38142.3c000000041936754XBrigham and Women’s Hospital, Harvard Medical School, 221 Longwood Ave, Boston, MA 02115 USA
| | - S. L. Greenspan
- grid.412689.00000 0001 0650 7433University of Pittsburgh Medical Center, 1110 Kaufmann Building, 3471 Fifth Ave, Pittsburgh, PA 15213 USA
| | - K. L. Insogna
- grid.47100.320000000419368710Yale School of Medicine, 333 Cedar St, New Haven, CT 06520 USA
| | - E. M. Lewiecki
- grid.266832.b0000 0001 2188 8502University of New Mexico Health Sciences Center, 300 Oak St NE, Albuquerque, NM 87106 USA
| | - K. G. Saag
- grid.265892.20000000106344187University of Alabama at Birmingham, 1720 2nd Avenue South, FOT 820, Birmingham, AL 35294 USA
| | - A. J. Singer
- grid.411663.70000 0000 8937 0972MedStar Georgetown University Hospital and Georgetown University Medical Center, 3800 Reservoir Road NW, 3rd Floor, Washington, DC 20007 USA
| | - E. S. Siris
- grid.21729.3f0000000419368729Columbia University Irving Medical Center, 180 Fort Washington Ave, Suite 9-903, New York, NY 10032 USA
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Abstract
PURPOSE Current concepts regarding estrogen and its mechanistic effects on breast cancer in women are evolving. This article reviews studies that address estrogen-mediated breast cancer development, the prevalence of occult tumors at autopsy, and the natural history of breast cancer as predicted by a newly developed tumor kinetic model. METHODS This article reviews previously published studies from the authors and articles pertinent to the data presented. RESULTS We discuss the concepts of adaptive hypersensitivity that develops in response to long-term deprivation of estrogen and results in both increased cell proliferation and apoptosis. The effects of menopausal hormonal therapy on breast cancer in postmenopausal women are interpreted based on the tumor kinetic model. Studies of the administration of a tissue selective estrogen complex in vitro, in vivo, and in patients are described. We review the various clinical studies of breast cancer prevention with selective estrogen receptor modulators and aromatase inhibitors. Finally, the effects of the underlying risk of breast cancer on the effects of menopausal hormone therapy are outlined. DISCUSSION The overall intent of this review is to present data supporting recent concepts, discuss pertinent literature, and critically examine areas of controversy.
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Flores VA, Pal L, Manson JE. Hormone Therapy in Menopause: Concepts, Controversies, and Approach to Treatment. Endocr Rev 2021; 42:720-752. [PMID: 33858012 DOI: 10.1210/endrev/bnab011] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Indexed: 12/22/2022]
Abstract
Hormone therapy (HT) is an effective treatment for menopausal symptoms, including vasomotor symptoms and genitourinary syndrome of menopause. Randomized trials also demonstrate positive effects on bone health, and age-stratified analyses indicate more favorable effects on coronary heart disease and all-cause mortality in younger women (close proximity to menopause) than in women more than a decade past menopause. In the absence of contraindications or other major comorbidities, recently menopausal women with moderate or severe symptoms are appropriate candidates for HT. The Women's Health Initiative (WHI) hormone therapy trials-estrogen and progestin trial and the estrogen-alone trial-clarified the benefits and risks of HT, including how the results differed by age. A key lesson from the WHI trials, which was unfortunately lost in the posttrial cacophony, was that the risk:benefit ratio and safety profile of HT differed markedly by clinical characteristics of the participants, especially age, time since menopause, and comorbidity status. In the present review of the WHI and other recent HT trials, we aim to provide readers with an improved understanding of the importance of the timing of HT initiation, type and route of administration, and of patient-specific considerations that should be weighed when prescribing HT.
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Affiliation(s)
- Valerie A Flores
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lubna Pal
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - JoAnn E Manson
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Thilakasiri P, Huynh J, Poh AR, Tan CW, Nero TL, Tran K, Parslow AC, Afshar-Sterle S, Baloyan D, Hannan NJ, Buchert M, Scott AM, Griffin MD, Hollande F, Parker MW, Putoczki TL, Ernst M, Chand AL. Repurposing the selective estrogen receptor modulator bazedoxifene to suppress gastrointestinal cancer growth. EMBO Mol Med 2020; 11:emmm.201809539. [PMID: 30885958 PMCID: PMC6460354 DOI: 10.15252/emmm.201809539] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Excessive signaling through gp130, the shared receptor for the interleukin (IL)6 family of cytokines, is a common hallmark in solid malignancies and promotes their progression. Here, we established the in vivo utility of bazedoxifene, a steroid analog clinically approved for the treatment of osteoporosis, to suppress gp130‐dependent tumor growth of the gastrointestinal epithelium. Bazedoxifene administration reduced gastric tumor burden in gp130Y757F mice, where tumors arise exclusively through excessive gp130/STAT3 signaling in response to the IL6 family cytokine IL11. Likewise, in mouse models of sporadic colon and intestinal cancers, which arise from oncogenic mutations in the tumor suppressor gene Apc and the associated β‐catenin/canonical WNT pathway, bazedoxifene treatment reduces tumor burden. Consistent with the proposed orthogonal tumor‐promoting activity of IL11‐dependent gp130/STAT3 signaling, tumors of bazedoxifene‐treated Apc‐mutant mice retain excessive nuclear accumulation of β‐catenin and aberrant WNT pathway activation. Likewise, bazedoxifene treatment of human colon cancer cells harboring mutant APC did not reduce aberrant canonical WNT signaling, but suppressed IL11‐dependent STAT3 signaling. Our findings provide compelling proof of concept to support the repurposing of bazedoxifene for the treatment of gastrointestinal cancers in which IL11 plays a tumor‐promoting role.
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Affiliation(s)
- Pathum Thilakasiri
- Olivia Newton-John Cancer Research Institute, School of Cancer Medicine, La Trobe University, Heidelberg, Vic., Australia
| | - Jennifer Huynh
- Olivia Newton-John Cancer Research Institute, School of Cancer Medicine, La Trobe University, Heidelberg, Vic., Australia
| | - Ashleigh R Poh
- Olivia Newton-John Cancer Research Institute, School of Cancer Medicine, La Trobe University, Heidelberg, Vic., Australia
| | - Chin Wee Tan
- The Walter and Eliza Hall Institute, Melbourne, Vic., Australia
| | - Tracy L Nero
- ACRF Rational Drug Discovery Centre, St Vincent's Institute, Melbourne, Vic., Australia.,Department of Biochemistry and Molecular Biology, Bio21 Institute, University of Melbourne, Melbourne, Vic., Australia
| | - Kelly Tran
- Olivia Newton-John Cancer Research Institute, School of Cancer Medicine, La Trobe University, Heidelberg, Vic., Australia
| | - Adam C Parslow
- Olivia Newton-John Cancer Research Institute, School of Cancer Medicine, La Trobe University, Heidelberg, Vic., Australia.,Department of Molecular Imaging and Therapy, Austin Health, Melbourne, Vic., Australia
| | - Shoukat Afshar-Sterle
- Olivia Newton-John Cancer Research Institute, School of Cancer Medicine, La Trobe University, Heidelberg, Vic., Australia
| | - David Baloyan
- Olivia Newton-John Cancer Research Institute, School of Cancer Medicine, La Trobe University, Heidelberg, Vic., Australia
| | - Natalie J Hannan
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Vic., Australia
| | - Michael Buchert
- Olivia Newton-John Cancer Research Institute, School of Cancer Medicine, La Trobe University, Heidelberg, Vic., Australia
| | - Andrew Mark Scott
- Olivia Newton-John Cancer Research Institute, School of Cancer Medicine, La Trobe University, Heidelberg, Vic., Australia.,Department of Molecular Imaging and Therapy, Austin Health, Melbourne, Vic., Australia.,Department of Medicine, University of Melbourne, Melbourne, Vic., Australia
| | - Michael Dw Griffin
- Department of Biochemistry and Molecular Biology, Bio21 Institute, University of Melbourne, Melbourne, Vic., Australia
| | - Frederic Hollande
- Department of Clinical Pathology, University of Melbourne Centre for Cancer Research, Victorian Comprehensive Cancer Centre, University of Melbourne, Melbourne, Vic., Australia
| | - Michael W Parker
- ACRF Rational Drug Discovery Centre, St Vincent's Institute, Melbourne, Vic., Australia.,Department of Biochemistry and Molecular Biology, Bio21 Institute, University of Melbourne, Melbourne, Vic., Australia
| | | | - Matthias Ernst
- Olivia Newton-John Cancer Research Institute, School of Cancer Medicine, La Trobe University, Heidelberg, Vic., Australia
| | - Ashwini L Chand
- Olivia Newton-John Cancer Research Institute, School of Cancer Medicine, La Trobe University, Heidelberg, Vic., Australia
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Lovre D, Peacock E, Katalenich B, Moreau C, Xu B, Tate C, Utzschneider KM, Gautier JF, Fonseca V, Mauvais-Jarvis F. Conjugated Estrogens and Bazedoxifene Improve β Cell Function in Obese Menopausal Women. J Endocr Soc 2019; 3:1583-1594. [PMID: 31384719 PMCID: PMC6676076 DOI: 10.1210/js.2019-00074] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/31/2019] [Indexed: 12/21/2022] Open
Abstract
CONTEXT Studies suggest that menopausal hormone therapy (MHT) prevents type 2 diabetes (T2D). The combination of conjugated estrogens (CE) with the selective estrogen receptor modulator bazedoxifene (BZA) is an MHT that improves obesity and T2D in preclinical models of menopausal metabolic syndrome. The effect of CE/BZA on adiposity and glucose homeostasis in obese postmenopausal women is unknown. OBJECTIVE To investigate the effect of CE/BZA on body composition, glucose homeostasis, and markers of inflammation in obese postmenopausal women. RESEARCH DESIGN INTERVENTION AND PARTICIPANTS Randomized, double-blind, placebo-controlled pilot trial of 12 obese menopausal women assigned to 12-week treatment with CE 0.45 mg/BZA 20 mg (n = 7) or placebo (n = 5). At baseline and after 12 weeks, we assessed body composition (dual-energy X-ray absorptiometry), glucose homeostasis (IV glucose tolerance test), and inflammation biomarkers. RESULTS Women treated with CE/BZA exhibited increased β cell function using homeostatic model assessment-B [median (interquartile range) CE/BZA vs placebo: 18.5 (-0.9 to 320.6) μU/mM vs -25.5 (-39.9 to -0.1) μU/mM; P = 0.045], and decreased basal glucose concentrations (Gb) [-5.2 (-9.2 to -1.7) mg/dL vs 2.7 (0.9 to 4.9) mg/dL; P = 0.029]. Insulin sensitivity was higher in the placebo arm [1.35 (1.12 to 1.82) (μU/mL) min-1 vs -0.24 (-1.50 to 0.19) (μU/mL) min-1; P = 0.029]. No changes between treatment groups were observed for the acute insulin response to glucose (AIRg), the disposition index (DI), body composition, and inflammatory biomarkers. CONCLUSIONS A 12-week treatment of obese postmenopausal women with CEs/BZA improves fasting β cell function and glucose concentrations without change in AIRg, HOMA-IR, DI, body composition, or markers of inflammation.
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Affiliation(s)
- Dragana Lovre
- Section of Endocrinology and Metabolism, Tulane University Health Sciences Center, New Orleans, Louisiana
- Section of Endocrinology, Southeast Louisiana Veterans Healthcare System, New Orleans, Louisiana
| | - Erin Peacock
- Department of Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana
| | - Bonnie Katalenich
- Clinical Translational Unit, School of Medicine, Tulane University, New Orleans, Louisiana
| | - Cynthia Moreau
- Clinical Translational Unit, School of Medicine, Tulane University, New Orleans, Louisiana
| | - Beibei Xu
- Section of Endocrinology and Metabolism, Tulane University Health Sciences Center, New Orleans, Louisiana
| | - Chandra Tate
- Section of Endocrinology and Metabolism, Tulane University Health Sciences Center, New Orleans, Louisiana
| | - Kristina M Utzschneider
- Division of Metabolism, Endocrinology and Nutrition, VA Puget Sound Health Care System and University of Washington, Seattle, Washington
| | - Jean-François Gautier
- Department of Diabetes and Endocrinology, Assistance Publique-Hôpitaux de Paris, Lariboisière Hospital, University Paris-Diderot Paris-7, Paris, France
- INSERM UMRS 1138, Cordeliers Research Center, Paris, France
| | - Vivian Fonseca
- Section of Endocrinology and Metabolism, Tulane University Health Sciences Center, New Orleans, Louisiana
- Section of Endocrinology, Southeast Louisiana Veterans Healthcare System, New Orleans, Louisiana
| | - Franck Mauvais-Jarvis
- Section of Endocrinology and Metabolism, Tulane University Health Sciences Center, New Orleans, Louisiana
- Section of Endocrinology, Southeast Louisiana Veterans Healthcare System, New Orleans, Louisiana
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Arao Y, Korach KS. Transactivation Function-1-Mediated Partial Agonist Activity of Selective Estrogen Receptor Modulator Requires Homo-Dimerization of the Estrogen Receptor α Ligand Binding Domain. Int J Mol Sci 2019; 20:ijms20153718. [PMID: 31366023 PMCID: PMC6695978 DOI: 10.3390/ijms20153718] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 07/24/2019] [Accepted: 07/26/2019] [Indexed: 11/16/2022] Open
Abstract
The isolation of estrogen receptor alpha (ERα) cDNA was successful around 30 years ago. The characteristics of ERα protein have been examined from various aspects, primarily through in vitro cell culture studies, but more recently using in vivo experimental models. There remains, however, some uncharacterized ERα functionalities. In particular, the mechanism of partial agonist activity of selective estrogen receptor modulators (SERMs) that involves control of the N-terminal transcription function of ERα, termed AF-1, is still an unsolved ERα functionality. We review the possible mechanism of SERM-dependent regulation of ERα AF-1-mediated transcriptional activity, which includes the role of helix 12 of ERα ligand binding domain (LBD) for SERM-dependent AF-1 regulation. In addition, we describe a specific portion of the LBD that associates with blocking AF-1 activity with an additional role of the F-domain in mediating SERM activity.
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Affiliation(s)
- Yukitomo Arao
- Receptor Biology Section, Reproductive and Developmental Biology Laboratory, National Institute of Environmental Health Sciences/NIH, Durham, NC 27709, USA.
| | - Kenneth S Korach
- Receptor Biology Section, Reproductive and Developmental Biology Laboratory, National Institute of Environmental Health Sciences/NIH, Durham, NC 27709, USA.
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Flores VA, Leone C, Taylor HS, Stachenfeld NS. Effects of bazedoxifene/conjugated estrogens on reproductive endocrinology and reproductive tract ultrasonographic appearance in premenopausal women: a preliminary study. Gynecol Endocrinol 2019; 35:390-394. [PMID: 30668182 DOI: 10.1080/09513590.2018.1559288] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Bazedoxifene (BZA) paired with conjugated estrogens (CE) is the first tissue selective estrogen receptor complex (TSEC) approved by the United States Food and Drug Administration for the treatment of menopausal symptoms. Clinical trials in menopausal women and in premenopausal murine models of endometriosis have demonstrated safety and efficacy, however, the impact of BZA/CE on premenopausal women is not known. Here we report a case series study in premenopausal women assessing effects of BZA/CE on reproductive hormones, and uterine/ovarian ultrasonographic appearance. After one monitoring cycle, five subjects underwent daily administration of BZA/CE (20 mg/0.45 mg) for 12 weeks, and were followed for 4 weeks after treatment. Uterine/ovarian morphology was assessed with ultrasound, and endocrinologic function with ovulation prediction kits and serum assessment of reproductive hormones throughout the menstrual cycle. All subjects demonstrated an LH surge on the medication; interestingly there was a significant decrease in luteinizing hormone level during treatment compared to posttreatment values. BZA/CE was well-tolerated in premenopausal women and did not induce clinically relevant reproductive hormone changes, endometrial alterations, or abnormal ovarian folliculogenesis.
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Affiliation(s)
- Valerie A Flores
- a Department of Obstetrics, Gynecology, and Reproductive Sciences , Yale School of Medicine , New Haven , CT , USA
| | - Cheryl Leone
- b The John B. Pierce Laboratory , Yale School of Medicine , New Haven , CT , USA
| | - Hugh S Taylor
- a Department of Obstetrics, Gynecology, and Reproductive Sciences , Yale School of Medicine , New Haven , CT , USA
| | - Nina S Stachenfeld
- a Department of Obstetrics, Gynecology, and Reproductive Sciences , Yale School of Medicine , New Haven , CT , USA
- b The John B. Pierce Laboratory , Yale School of Medicine , New Haven , CT , USA
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Abstract
The 2017 Hormone Therapy Position Statement of The North American Menopause Society (NAMS) updates the 2012 Hormone Therapy Position Statement of The North American Menopause Society and identifies future research needs. An Advisory Panel of clinicians and researchers expert in the field of women's health and menopause was recruited by NAMS to review the 2012 Position Statement, evaluate new literature, assess the evidence, and reach consensus on recommendations, using the level of evidence to identify the strength of recommendations and the quality of the evidence. The Panel's recommendations were reviewed and approved by the NAMS Board of Trustees.Hormone therapy (HT) remains the most effective treatment for vasomotor symptoms (VMS) and the genitourinary syndrome of menopause (GSM) and has been shown to prevent bone loss and fracture. The risks of HT differ depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. Treatment should be individualized to identify the most appropriate HT type, dose, formulation, route of administration, and duration of use, using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of the benefits and risks of continuing or discontinuing HT.For women aged younger than 60 years or who are within 10 years of menopause onset and have no contraindications, the benefit-risk ratio is most favorable for treatment of bothersome VMS and for those at elevated risk for bone loss or fracture. For women who initiate HT more than 10 or 20 years from menopause onset or are aged 60 years or older, the benefit-risk ratio appears less favorable because of the greater absolute risks of coronary heart disease, stroke, venous thromboembolism, and dementia. Longer durations of therapy should be for documented indications such as persistent VMS or bone loss, with shared decision making and periodic reevaluation. For bothersome GSM symptoms not relieved with over-the-counter therapies and without indications for use of systemic HT, low-dose vaginal estrogen therapy or other therapies are recommended.This NAMS position statement has been endorsed by Academy of Women's Health, American Association of Clinical Endocrinologists, American Association of Nurse Practitioners, American Medical Women's Association, American Society for Reproductive Medicine, Asociación Mexicana para el Estudio del Climaterio, Association of Reproductive Health Professionals, Australasian Menopause Society, Chinese Menopause Society, Colegio Mexicano de Especialistas en Ginecologia y Obstetricia, Czech Menopause and Andropause Society, Dominican Menopause Society, European Menopause and Andropause Society, German Menopause Society, Groupe d'études de la ménopause et du vieillissement Hormonal, HealthyWomen, Indian Menopause Society, International Menopause Society, International Osteoporosis Foundation, International Society for the Study of Women's Sexual Health, Israeli Menopause Society, Japan Society of Menopause and Women's Health, Korean Society of Menopause, Menopause Research Society of Singapore, National Association of Nurse Practitioners in Women's Health, SOBRAC and FEBRASGO, SIGMA Canadian Menopause Society, Società Italiana della Menopausa, Society of Obstetricians and Gynaecologists of Canada, South African Menopause Society, Taiwanese Menopause Society, and the Thai Menopause Society. The American College of Obstetricians and Gynecologists supports the value of this clinical document as an educational tool, June 2017. The British Menopause Society supports this Position Statement.
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Khan A, Fortier M. Ostéoporose pendant la ménopause. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:S465-S483. [DOI: 10.1016/j.jogc.2016.09.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kim J, Mauvais-Jarvis F. The combination of conjugated equine estrogens with bazedoxifene prevents streptozotocin-induced diabetes in female mice. ACTA ACUST UNITED AC 2016. [DOI: 10.19185/matters.201605000017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
OBJECTIVE Insomnia both as a symptom and as part of chronic insomnia disorder is quite common in menopause. Comorbid conditions, such as restless legs syndrome and obstructive sleep apnea, occur with high prevalence among perimenopausal women with insomnia. Insomnia in this population group is associated with adverse health outcomes, and there are no clear standards on how to treat it. METHODS Based on extensive literature search, 76 articles were identified. Two authors independently graded evidence according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence. RESULTS Evaluation and treatment of other comorbid sleep disorders are recommended, as is cognitive-behavioral therapy for insomnia. Hormone therapy, eszopiclone, escitalopram, gabapentin, isoflavones, valerian, exercise, and hypnosis are suggested. Zolpidem, quiteiapine XL, citalopram, mirtazapine followed by long-acting melatonin, ramelteon, Pycnogenol, Phyto-Female Complex, yoga, and massage may be considered. Kampo formulas are not recommended. Acupuncture may not be suggested, and cognitive-behavioral therapy that is not tailored for insomnia probably should not be considered. CONCLUSIONS Although a variety of interventions are shown to be helpful in improving sleep in menopause, there is a need for well-designed head-to-head trials with uniform outcome measures.
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Lin CC, Chou CH, Fan YM, Yin JH, Chung CH, Chien WC, Sung YF, Tsai CK, Lin GY, Lin YK, Lee JT. Increased Risk of Dementia Among Sleep-Related Movement Disorders: A Population-Based Longitudinal Study in Taiwan. Medicine (Baltimore) 2015; 94:e2331. [PMID: 26705224 PMCID: PMC4697990 DOI: 10.1097/md.0000000000002331] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 11/20/2015] [Accepted: 11/26/2015] [Indexed: 01/30/2023] Open
Abstract
Sleep-related movement disorders (SRMD) are sleep disorders. As poor sleep quality is associated with cognitive impairment, we hypothesized that SRMD patients were exposed to a great risk for developing dementia.The present study was aimed to retrospectively examine the association of SRMD and dementia risk.A retrospective longitudinal study was conducted using the data obtained from the Longitudinal Health Insurance Database (LHID) in Taiwan. The study cohort enrolled 604 patients with SRMD who were initially diagnosed and 2416 patients who were randomly selected and age/gender matched with the study group. SRMD, dementia, and other confounding factors were defined according to International Classification of Diseases Clinical Modification Codes. Cox proportional-hazards regressions were employed to examine adjusted hazard ratios (HR) after adjusting with confounding factors.Our data revealed that patients with SRMD had a 3.952 times (95% CI = 1.124-4.767) higher risk to develop all-cause dementia compared with individuals without SRMD. The results showed that SRMD patients aged 45 to 64 exhibited highest risk of developing all-cause dementia (HR: 5.320, 95% CI = 1.770-5.991), followed by patients age ≥65 (HR: 4.123, 95% CI = 2.066-6.972) and <45 (HR: 3.170, 95% CI = 1.050-4.128), respectively. Females with SRMD were at greater risk to develop all-cause dementia (HR: 4.372, 95% CI = 1.175-5.624). The impact of SRMD on dementia risk was progressively increased by various follow-up time intervals (<1 year, 1-2 years, and ≥2 years).The results suggest that SRMD is linked to an increased risk for dementia with gender-dependent and time-dependent characteristics.
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Affiliation(s)
- Chun-Chieh Lin
- From the Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei (C-CL, C-HC, J-HY, Y-FS, C-KT, G-YL, Y-KL, J-TL), Department of Nuclear Medicine of Cardinal Tien Hospital, Xindian Dist (Y-MF), School of Medicine, Fu-Jen Catholic University, New Taipei City (Y-MF), Division of Neurology, Department of Medicine, Cheng Hsin General Hospital (J-HY), Taiwanese Injury Prevention and Safety Promotion Association (C-HC); and School of Public Health, National Defense Medical Center, Taipei, Taiwan, R.O.C (W-CC)
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Kim JH, Lee JH, Kim YJ. Retraction: Protective effects of bazedoxifene paired with conjugated estrogens on pancreatic β-cell dysfunction. Biol Pharm Bull 2015. [PMID: 26548420 DOI: 10.1248/bpb.b15-00585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This article has been retracted by the Editorial Committee of The Pharmaceutical Society of Japan because it contains scientific misconduct. Although the data published in this article were generated in part by the first author, the authors violated authorship and sponsorship protocol.
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Affiliation(s)
- Jun Ho Kim
- Department of Medicine, Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine
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Selektive Östrogenrezeptormodulatoren (SERM). GYNAKOLOGISCHE ENDOKRINOLOGIE 2015. [DOI: 10.1007/s10304-015-0003-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, Lindsay R. Clinician's Guide to Prevention and Treatment of Osteoporosis. Osteoporos Int 2014; 25:2359-81. [PMID: 25182228 PMCID: PMC4176573 DOI: 10.1007/s00198-014-2794-2] [Citation(s) in RCA: 1951] [Impact Index Per Article: 195.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 06/24/2014] [Indexed: 02/07/2023]
Abstract
The Clinician's Guide to Prevention and Treatment of Osteoporosis was developed by an expert committee of the National Osteoporosis Foundation (NOF) in collaboration with a multispecialty council of medical experts in the field of bone health convened by NOF. Readers are urged to consult current prescribing information on any drug, device, or procedure discussed in this publication.
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Affiliation(s)
- F Cosman
- Helen Hayes Hospital, West Haverstraw, NY, USA,
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Pinkerton JV, Thomas S. Use of SERMs for treatment in postmenopausal women. J Steroid Biochem Mol Biol 2014; 142:142-54. [PMID: 24373794 DOI: 10.1016/j.jsbmb.2013.12.011] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 12/05/2013] [Accepted: 12/10/2013] [Indexed: 02/01/2023]
Abstract
Selective estrogen receptor modulators (SERMs) are synthetic non-steroidal agents which have varying estrogen agonist and antagonist activities in different tissues, most likely due to the receptor conformation changes associated with that SERM's binding and the subsequent effect on transcription. Clinical trials aim to differentiate amongst SERMs on selected target tissues for use in postmenopausal women including effects on breast, bone, cardiovascular venous thrombosis risk, endometrium, vagina, vasomotor symptoms, and brain. This paper describes differences in clinical effects on selected target tissues of SERMs that are approved, discontinued or in development. FDA approved SERMs include tamoxifen and toremifene used for prevention and treatment of breast cancer, raloxifene approved for prevention and treatment of osteoporosis and prevention of invasive breast cancer, and ospemifene approved for treatment of dyspareunia from menopausal vaginal atrophy. The FDA approved first tissue selective estrogen complex (TSEC) a pairing of conjugated equine estrogens with the SERM, bazedoxifene. This pairing reduces the risk of endometrial hyperplasia that can occur with the estrogenic component of the TSEC without the need for a progestogen in women with a uterus. It also allows for the estrogenic benefits on relief of hot flashes and prevention of bone loss without stimulating the breast or the endometrium. In clinical practice, the tissue-selective actions of SERMs, alone or paired with estrogens, allow for individualization in meeting the treatment needs of postmenopausal women by providing targeted tissue effects. This article is part of a Special Issue entitled 'Menopause'.
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Affiliation(s)
- Joann V Pinkerton
- Department of Obstetrics & Gynecology, Division of Midlife Health, University of Virginia Health System, Charlottesville, VA, United States.
| | - Semara Thomas
- Department of Obstetrics & Gynecology, Division of Midlife Health, University of Virginia Health System, Charlottesville, VA, United States
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Acaz-Fonseca E, Sanchez-Gonzalez R, Azcoitia I, Arevalo MA, Garcia-Segura LM. Role of astrocytes in the neuroprotective actions of 17β-estradiol and selective estrogen receptor modulators. Mol Cell Endocrinol 2014; 389:48-57. [PMID: 24444786 DOI: 10.1016/j.mce.2014.01.009] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 01/08/2014] [Accepted: 01/08/2014] [Indexed: 01/04/2023]
Abstract
Neuroprotective actions of 17β-estradiol (estradiol) are in part mediated by direct actions on neurons. Astrocytes, which play an essential role in the maintenance of the homeostasis of neural tissue, express estrogen receptors and are also involved in the neuroprotective actions of estradiol in the brain. Estradiol controls gliosis and regulates neuroinflammation, edema and glutamate transport acting on astrocytes. In addition, the hormone regulates the release of neurotrophic factors and other neuroprotective molecules by astrocytes. In addition, reactive astrocytes are a local source of neuroprotective estradiol for the injured brain. Since estradiol therapy is not free from peripheral risks, alternatives for the hormone have been explored. Some selective estrogen receptor modulators (SERMs), which are already in use in clinical practice for the treatment of breast cancer, osteoporosis or menopausal symptoms, exert similar actions to estradiol on astrocytes. Therefore, SERMs represent therapeutic alternatives to estradiol for the activation of astroglia-mediated neuroprotective mechanisms.
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Affiliation(s)
| | | | - Iñigo Azcoitia
- Departamento de Biología Celular, Facultad de Biología, Universidad Complutense de Madrid, E-28040 Madrid, Spain
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21
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Naqvi H, Sakr S, Presti T, Krikun G, Komm B, Taylor HS. Treatment with bazedoxifene and conjugated estrogens results in regression of endometriosis in a murine model. Biol Reprod 2014; 90:121. [PMID: 24740602 DOI: 10.1095/biolreprod.113.114165] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Bazedoxifene (BZA), a selective estrogen receptor modulator (SERM), inhibits the action of estrogens on endometrial proliferation. Here, we evaluate the effect of a tissue-selective estrogen complex (TSEC) containing BZA and conjugated estrogens (CE) on ectopic endometrial lesions in a mouse model of endometriosis. Experimental endometriosis was created in 60 female CD-1 mice. The mice were randomly divided into 10 groups that received varying doses of either BZA (1, 2, 3, or 5 mg/kg/day), BZA (1, 2, 3, or 5 mg/kg/day) in combination with CE (3 mg/kg/day), CE treatment alone (3 mg/kg/day), or vehicle control for 8 wk. Treatment with BZA alone or the TSEC containing BZA/CE led to a decrease in endometriotic lesion size compared to controls. The mean surface area of the untreated lesions was 19.6 mm(2). Treatment with BZA or BZA/CE resulted in reduced lesion size (to 8.8 and 7.8 mm(2), respectively). No significant difference was found in lesion size between the BZA and BZA/CE treatment groups or between different doses of either treatment. Ovarian cyst formation was not evident in the treated groups. Treatment with the TSEC containing higher BZA dosages (3 and 5 mg/kg/day) led to significantly lower levels of estrogen receptor (Esr1) mRNA expression compared to the control treatment. No differences were observed in expression of progesterone receptor (Pgr). Immunohistochemical analysis also demonstrated a decrease in ESR protein. The combination of CE and BZA may prove to be a novel treatment option for endometriosis.
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Affiliation(s)
- Hanyia Naqvi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Sharif Sakr
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Thomas Presti
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Graciela Krikun
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | | | - Hugh S Taylor
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut Department of Molecular, Cellular, and Developmental Biology, Yale University, New Haven, Connecticut
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Kim JH, Meyers MS, Khuder SS, Abdallah SL, Muturi HT, Russo L, Tate CR, Hevener AL, Najjar SM, Leloup C, Mauvais-Jarvis F. Tissue-selective estrogen complexes with bazedoxifene prevent metabolic dysfunction in female mice. Mol Metab 2014; 3:177-90. [PMID: 24634829 DOI: 10.1016/j.molmet.2013.12.009] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 12/20/2013] [Accepted: 12/21/2013] [Indexed: 12/11/2022] Open
Abstract
Pairing the selective estrogen receptor modulator bazedoxifene (BZA) with estrogen as a tissue-selective estrogen complex (TSEC) is a novel menopausal therapy. We investigated estrogen, BZA and TSEC effects in preventing diabetisity in ovariectomized mice during high-fat feeding. Estrogen, BZA or TSEC prevented fat accumulation in adipose tissue, liver and skeletal muscle, and improved insulin resistance and glucose intolerance without stimulating uterine growth. Estrogen, BZA and TSEC improved energy homeostasis by increasing lipid oxidation and energy expenditure, and promoted insulin action by enhancing insulin-stimulated glucose disposal and suppressing hepatic glucose production. While estrogen improved metabolic homeostasis, at least partially, by increasing hepatic production of FGF21, BZA increased hepatic expression of Sirtuin1, PPARα and AMPK activity. The metabolic benefits of BZA were lost in estrogen receptor-α deficient mice. Thus, BZA alone or in TSEC produces metabolic signals of fasting and caloric restriction and improves energy and glucose homeostasis in female mice.
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Key Words
- AMPKα, AMP-activated protein kinase α
- AUC, area-under the curve
- Akt, protein kinase B
- BAT, brown adipose tissue
- BZA, bazedoxifene
- Bazedoxifene
- CE, conjugated equine estrogens
- E2, 17β-estradiol
- ER, estrogen receptor
- FAS, fatty acid synthase
- FGF21, fibroblast growth factor 21
- GIR, glucose infusion rate
- H&E, hematoxylin and eosin
- HFD, high-fat diet
- HGP, hepatic glucose production
- ITT, insulin tolerance test
- Insulin resistance
- LPL, lipoprotein lipase
- Lcn2, lipocalin 2
- Menopause
- Metabolic syndrome
- NAFLD, non-alcoholic fatty liver disease
- OGTT, oral glucose tolerance test
- OVX, ovariectomy
- PTT, pyruvate tolerance test
- RBP4, retinol binding protein 4
- RER, respiratory exchange ratio
- Rd, rate of whole-body glucose disappearance
- SERM, selective estrogen receptor modulator
- TBARS, thiobarbituric acid reactive substances
- TG, triacylglycerol
- TSEC, tissue-selective estrogen complex
- Tissue-selective estrogen complexes
- Type 2 diabetes
- UCPs, uncoupling proteins
- VO2, oxygen consumption
- WAT, white adipose tissue.
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Affiliation(s)
- Jun Ho Kim
- Department of Medicine, Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Matthew S Meyers
- Department of Medicine, Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Saja S Khuder
- Center for Diabetes and Endocrine Research, Department of Physiology and Pharmacology, University of Toledo College of Medicine and Life Sciences, Toledo, OH 43614, USA
| | - Simon L Abdallah
- Center for Diabetes and Endocrine Research, Department of Physiology and Pharmacology, University of Toledo College of Medicine and Life Sciences, Toledo, OH 43614, USA
| | - Harrison T Muturi
- Center for Diabetes and Endocrine Research, Department of Physiology and Pharmacology, University of Toledo College of Medicine and Life Sciences, Toledo, OH 43614, USA
| | - Lucia Russo
- Center for Diabetes and Endocrine Research, Department of Physiology and Pharmacology, University of Toledo College of Medicine and Life Sciences, Toledo, OH 43614, USA
| | - Chandra R Tate
- Department of Medicine, Division of Endocrinology and Metabolism, Tulane University Health Sciences Center, School of Medicine, New Orleans, LA 70112, USA
| | - Andrea L Hevener
- Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Sonia M Najjar
- Center for Diabetes and Endocrine Research, Department of Physiology and Pharmacology, University of Toledo College of Medicine and Life Sciences, Toledo, OH 43614, USA
| | - Corinne Leloup
- Department of Medicine, Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Franck Mauvais-Jarvis
- Department of Medicine, Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA ; Department of Medicine, Division of Endocrinology and Metabolism, Tulane University Health Sciences Center, School of Medicine, New Orleans, LA 70112, USA
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Abstract
For many years it has been perceived wisdom that hormone replacement therapy for women with a uterus should include a progestin to prevent the proliferative effects of estrogen on the endometrium and endometrial cancer. But, with the reports from the Women's Health Initiative (WHI) and Million Women Study indicating that such regimens are associated with an increased risk of breast cancer, whereas unopposed estrogen may not increase this risk, or even reduce it, it is pertinent to reassess the merits of adding a progestin. In addition, the suggestion from the WHI that the effects of estrogen and progestins are a 'class effect' are clearly inaccurate, as there is particular evidence from the French E3N cohort studies of differential effects of progestins, with progesterone and dydrogesterone additions showing no increase in risk of breast cancer. The data are presented but an answer to the posed question remains unclear and as usual dependent on the circumstances and views of each individual woman and her medical adviser.
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Affiliation(s)
- D W Sturdee
- Solihull Hospital, Heart of England NHS Foundation Trust, Solihull, UK
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Santen RJ, Yue W, Heitjan DF. Occult breast tumor reservoir: biological properties and clinical significance. Discov Oncol 2013; 4:195-207. [PMID: 23632998 DOI: 10.1007/s12672-013-0145-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 04/11/2013] [Indexed: 12/31/2022] Open
Abstract
Small, occult, undiagnosed breast cancers are found at autopsy in up to 15.6 % of women dying from unrelated causes with an average of 7 % from eight separate studies. The mammographic detection threshold of breast tumors ranges from 0.88 to 1.66 cm in diameter based on the patient's age. Tumor growth rates, expressed as "effective doubling times," vary from 10 to >700 days. We previously reported two models, based on iterative analysis of these parameters, to describe the biologic behavior of undiagnosed, occult breast tumors. Our models facilitate interpretation of the Women's Health Initiative (WHI) and antiestrogen breast cancer prevention studies. A nude mouse xenograft model was used to validate our assumption that breast tumors grow in a log-linear fashion. We then used our previously reported occult tumor growth (OTG) and computer-simulated tumor growth models to analyze various clinical trial data. Parameters used in the OTG model included a 200-day effective doubling time, 7 % prevalence of occult tumors, and 1.16 cm detection threshold. These models had been validated by comparing predicted with observed incidence of breast cancer in eight different populations of women. Our model suggests that menopausal hormone therapy with estrogens plus a progestogen (E + P) in the WHI trial primarily promoted the growth of pre-existing, occult lesions and minimally initiated de novo tumors. We provide a potential explanation for the lack of an increase in breast cancer incidence in the subgroup of women in the WHI who had not received E + P prior to randomization. This result may have reflected a leftward skew in the distribution of occult tumor doublings and insufficient time for stimulated tumors to reach the detection threshold. Our model predicted that estrogen alone reduced the incidence of breast cancer as a result of apoptosis. Understanding of the biology of occult tumors suggests that breast cancer "prevention" with antiestrogens or aromatase inhibitors represents early treatment rather than a reduction in de novo tumor formation. Our models suggest that occult, undiagnosed tumors are prevalent, grow slowly, and are the biologic targets of a hormone therapy in menopausal women and of antiestrogen therapy for prevention.
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Affiliation(s)
- Richard J Santen
- Department of Internal Medicine, Division of Endocrinology, University of Virginia, Charlottesville, VA 22908-1416, USA.
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Benefits and recently identified limitations of bazedoxifene acetate for postmenopausal symptoms. Menopause 2013; 20:252-3. [DOI: 10.1097/gme.0b013e318286cc45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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McDaniel RE, Maximov PY, Jordan VC. Estrogen-mediated mechanisms to control the growth and apoptosis of breast cancer cells: a translational research success story. VITAMINS AND HORMONES 2013; 93:1-49. [PMID: 23810002 DOI: 10.1016/b978-0-12-416673-8.00007-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The treatment and prevention of solid tumors have proved to be a major challenge for medical science. The paradigms for success in the treatment of childhood leukemia, Hodgkin's disease, Burkett's lymphoma, and testicular carcinoma with cytotoxic chemotherapy did not translate to success in solid tumors--the majority of cancers that kill. In contrast, significant success has accrued for patients with breast cancer with antihormone treatments (tamoxifen or aromatase inhibitors) that are proved to enhance survivorship, and remarkably, there are now two approved prevention strategies using either tamoxifen or raloxifene. This was considered impossible 40 years ago. We describe the major clinical advances with nonsteroidal antiestrogens that evolved into selective estrogen receptor modulators (SERMs) which successfully exploited the ER target selectively inside a woman's body. The standard paradigm that estrogen stimulates breast cancer growth has been successfully exploited for over 4 decades with therapeutic strategies that block (tamoxifen, raloxifene) or reduce (aromatase inhibitors) circulating estrogens in patients to stop breast tumor growth. But this did not explain why high-dose estrogen treatment that was the standard of care to treat postmenopausal breast cancer for 3 decades before tamoxifen caused tumor regression. This paradox was resolved with the discovery that breast cancer resistance to long-term estrogen deprivation causes tumor regression with physiologic estrogen through apoptosis. The new biology of estrogen action has been utilized to explain the findings in the Women's Health Initiative that conjugated equine estrogen alone given to postmenopausal women, average age 68, will produce a reduction of breast cancer incidence and mortality compared to no treatment. Estrogen is killing nascent breast cancer cells in the ducts of healthy postmenopausal women. The modulation of the ER using multifunctional medicines called SERMs has provided not only significant improvements in women's health and survivorship not anticipated 40 years ago but also has been the catalyst to enhance our knowledge of estrogen's apoptotic action that can be further exploited in the future.
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Affiliation(s)
- Russell E McDaniel
- Department of Oncology, Georgetown University, Lombardi Comprehensive Cancer Center, Washington, District of Columbia, USA
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