Application of multivariate statistical analysis and network pharmacology to explore the mechanism of Danggui Liuhuang Tang in treating perimenopausal syndrome

ETHNOPHARMACOLOGICAL RELEVANCE

Danggui Liuhuang Tang (DGLHT), first recorded in "Lan-Shi-Mi-Cang" (written in 1276 AD), is a famous classical formula. In 2018, it was listed in the Catalogue of Ancient Classic and Famous Prescriptions (First Batch) formulated by the National Administration of Traditional Chinese Medicine and the National Medical Products Administration. Perimenopausal syndrome (PMS) refers to a series of syndromes with autonomic nervous system dysfunction and neuropsychological symptoms. The treatment of PMS demands non-hormonal drugs. Natural products are considered to be effective substitutes for the treatment of PMS. It is reported that DGLHT has not only good therapeutic effects but also higher safety and fewer side effects in the treatment of PMS. However, the mechanism of DGLHT in treating PMS is not clear.

AIM OF THE STUDY

To explore the chemical basis and the mechanism of DGLHT in treating PMS.

MATERIALS AND METHODS

Multivariate statistical analysis was used to analyze the difference of components in supernatant before and after compatibility of DGLHT based on LC-MS data. The qualitative analysis was performed on the precipitate formed in the decocting process using LC-MS while the quantitative analysis on the potential markers using LC-UV. Then, the potential markers were analyzed by network pharmacology. The regulatory effect of DGLHT on FSH, P and E₂ were carried out in PMS rats.

RESULTS

Five potential markers, epiberberine, coptisine, palmatine, berberine and baicalin, were screened from the analysis of compounds in the supernatant. Four complexes, composed of potential marker monomers, were identified in the sediment, including two that have not been reported. The key targets of potential markers include TNF, NOS3, EGFR, ESR1, PTGS2, AR, CDC42 and RPS6KB1. The top signaling pathways include the cGMP-PKG signaling pathway, PI3K-Akt signaling pathway and estrogen signaling pathway. DGLHT could call back the hormone levels of P and E₂ in PMS rats.

CONCLUSION

DGLHT active ingredients, epiberberine, coptisine, palmatine, berberine and baicalin contribute a lot to the therapeutic effect. And DGLHT takes effect by regulating hormones secreted by the ovary.

The Cortisol and ACTH Response to Dex/CRH Testing in Women With and Without Perimenopausal Depression

CONTEXT

Abnormalities in the hypothalamic-pituitary-adrenal (HPA) axis are frequent accompaniments of depression, and studies have documented the role of stress and stressful life events in the ontogeny of perimenopausal depressions (PMD). Because HPA axis function in women is further modulated both by aging and ovarian steroids, it is possible that a dysregulated HPA axis contributes to the increased risk of PMD.

OBJECTIVE

We examined HPA axis function in perimenopausal women with and without depression using the combined dexamethasone-corticotropin-releasing hormone (Dex/CRH) test.

METHODS

Dex/CRH tests were performed on 20 women with PMD and 20 women who were also perimenopausal but without current or past depression (control women). Main outcome measures were plasma levels of cortisol and adrenocorticotropin (ACTH) and 24-hour urinary free cortisol (UFC). Five women took chronic stable medications, otherwise all women were medically healthy, and both groups were comparable with respect to reproductive stage and age. Standardized symptom rating scales were administered to each woman prior to Dex/CRH testing.

RESULTS

No group differences were present in either baseline or stimulated ACTH and cortisol secretion. Baseline plasma measures of estradiol, progesterone, and 24-hour UFC levels similarly did not differ in PMD and control women.

CONCLUSION

Despite reports of increased stress responsiveness in PMD, we observed no abnormalities of HPA axis activity associated with PMD compared with women without depression. These findings suggest that PMD is not uniformly associated with HPA dysregulation and could reflect underlying pathophysiologic processes that are distinct from women with nonreproductive-related depressions.

Evaluation of Clinical Meaningfulness of Red Clover (Trifolium pratense L.) Extract to Relieve Hot Flushes and Menopausal Symptoms in Peri- and Post-Menopausal Women: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The meta-analysis presented in this article covered the efficacy of red clover isoflavones in relieving hot flushes and menopausal symptoms in perimenopausal and postmenopausal women. Studies were identified by MEDLINE (PubMed), Embase, and the Cochrane Library searches. The quality of the studies was evaluated according to Cochrane criteria. A meta-analysis of eight trials (ten comparisons) demonstrated a statistically significant reduction in the daily incidence of hot flushes in women receiving red clover compared to those receiving placebo: weighted mean difference (WMD—weighted mean difference) −1.73 hot flushes per day, 95% CI (confidence interval) −3.28 to −0.18; p = 0.0292. Due to 87.34% homogeneity, the performed analysis showed substantive difference in comparisons of postmenopausal women with ≥5 hot flushes per day, when the follow-up period was 12 weeks, with an isoflavone dose of ≥80 mg/day, and when the formulations contained a higher proportion of biochanin A. The meta-analysis of included studies assessing the effect of red clover isoflavone extract on menopausal symptoms showed a statistically moderate relationship with the reduction in the daily frequency of hot flushes. However, further well-designed studies are required to confirm the present findings and to finally determine the effects of red clover on the relief of flushing episodes.

Management of perimenopause disorders: hormonal treatment

Perimenopause represents a transition period of a woman's life during which physiological, affective, psychological, and social changes mark progression from a woman's fertile life to menopause, with wide sexual hormones fluctuations until the onset of hypergonadotropic hypogonadic amenorrhea. Contraception during menopause should not only avoid unwanted pregnancies, but also improve quality of life and prevent wide range of condition affecting this population. Hormonal contraceptives confer many noncontraceptive benefits for women approaching menopause: treatment of abnormal uterine bleeding, relief from vasomotor symptoms, endometrial protection in women using estrogen therapy, musculoskeletal protection, and mood disorders protection. The main point remains selecting the most adequate contraceptive option for each woman, considering her risk factor, comorbidities, and keeping in mind the possibility of continuing contraception until reaching menopause and even further, creating a bridge between perimenopause and menopause hormonal therapy. Correct perimenopause management should rely on individualized medical therapy and multidisciplinary approach considering lifestyle and food habits as part of general good health of a woman.

GnRH-a-Induced Perimenopausal Rat Modeling and Black Cohosh Preparations' Effect on Rat's Reproductive Endocrine

BACKGROUND

Endometriosis (EMS) is an estrogen-dependent disease, which easily recurs after operation. Gonadotropin-releasing hormone agonist (GnRH-a), an estrogen-inhibiting drug, can effectively inhibit the secretion of gonadotropin by pituitary gland, so as to significantly decrease the ovarian hormone level and facilitate the atrophy of ectopic endometrium, playing a positive role in preventing postoperative recurrence. The application of GnRH-a can lead to the secondary low estrogen symptoms, namely the perimenopausal symptoms, and is a main reason for patients to give up further treatment. The add-back therapy based on sex hormones can well address the perimenopausal symptoms, but long-term use of hormones may cause the recurrence of EMS, as well as liver function damage, venous embolism, breast cancer and other risks, which has long been a heated topic in the industry. Therefore, it is necessary to find effective and safe anti-additive drugs soon. Studies at home and abroad show that, as a plant extract, isopropanolic extract of cimicifuga racemosa (ICR) can well relieve the perimenopausal symptoms caused by natural menopause. Some studies have preliminarily confirmed that black cohosh preparations can antagonize perimenopausal symptoms of EMS patients treated with GnRH-a after operation.

OBJECTIVE

To establish a rat model of perimenopausal symptoms induced by GnRH-a injection, for the purposes of laying a foundation for further research and preliminarily exploring the effect of black cohosh preparations on reproductive endocrine of the rat model.

METHOD

The rat model of perimenopausal symptoms was established by GnRH-a injection, and normal saline (NS injection) was used as the control. The rats were randomly divided into four groups according to different modeling methods and drug intervention schemes. GnRH-a injection + normal saline intervention group (GnRH-a + NS), normal saline injection control + normal saline intervention group (NS + NS), GnRH-a injection + estradiol intervention group (GnRH-a + E2), and GnRH-a injection + black cohosh preparations intervention group (GnRH-a + ICR). After modelling was assessed to be successful with the vaginal smear method, the corresponding drugs were given for intervention for 28d. In the process of rat modeling and drug intervention, the skin temperature and anus temperature of the rat tails were measured every other day, the body weights of the rats were measured every other day, and the dosage was adjusted according to the body weight. After the intervention was over, the serum sex hormone level, the uterine weight, the uterine index, and the endometrial histomorphology changes, as well as the ovarian weight, the ovarian index, and the morphological changes of ovarian tissues of each group were measured.

RESULTS

(1) The vaginal cell smears of the control group (NS + NS) showed estrous cycle changes, while other model rats had no estrous cycle of vaginal cells. (2) The body weight gains of the GnRH-a + NS, GnRH-a + E2 and GnRH-a + ICR groups were significantly higher than that of the NS + NS control group. The intervention with E2 and ICR could delay the weight gain trend of rats induced by GnRH-A. (3) After GnRH-a injection, the temperature of the tail and anus of rats showed an overall upward trend, and the intervention with E2 and ICR could effectively improve such temperature change. (4) The E2, FSH, and LH levels in the GnRH-a + NS, GnRH-a + E2, and GnRH-a + ICR groups were significantly lower than those in the NS + NS group (P < 0.01). The E2 level was significantly higher and the LH level was significantly lower in the GnRH-a + E2 group than those in the GnRH-a + NS and GnRH-a + ICR groups (P < 0.05). Compared with those of the GnRH-a + NS and GnRH-a + ICR groups, the FSH level of the GnRH-a + E2 group showed a slight downward trend, but the difference was not statistically significant (P > 0.05). There was no significant difference in the levels of sex hormones between the GnRH-a + NS group and GnRH-a + ICR group (P > 0.05). (5) Compared with those of the NS + NS group, the uterine weight and uterine index of the GnRH-a + NS, GnRH-a + E2 and GnRH-a + ICR groups significantly decreased (P < 0.01). In a comparison between the groups, the uterine weight and uterine index in the GnRH-a + NS and GnRH-a + ICR groups were significantly lower than those in the GnRH-a + E2 group (P < 0.01). There was a statistical difference in the uterine weight and uterine index between the GnRH-a + NS group and GnRH-a + ICR group (P > 0.05). (6) Compared with those of the NS + NS group, the ovarian weight and ovarian index of the GnRH-a + NS, GnRH-a + E2 and GnRH-a + ICR groups significantly decreased (P < 0.01). There was no statistical difference in the ovarian weight and ovarian index among the GnRH-a + E2, GnRH-a + NS and GnRH-a + ICR groups (P > 0.05). (7) Compared with those in the NS + NS group, the number of primordial follicles increased significantly, while the number of growing follicles and mature follicles decreased significantly in the GnRH-a + NS, GnRH-a + E2, and GnRH-a + ICR groups (P < 0.01), but there was a statistical difference in the total number of follicles among the four groups (P > 0.05).

CONCLUSIONS

The GnRH-a injection could achieve the desired effect. The animal model successfully achieved a significant decrease in the E2, FSH, and LH levels in rats, and could cause the rats to have rising body surface temperature similar to hot flashes in the perimenopausal period. The intervention with E2 and ICR could effectively relieve such "perimenopausal symptoms", and ICR had no obvious effect on the serum sex hormone level in rats.

The effect of soy isoflavone combined with calcium on bone mineral density in perimenopausal Chinese women: a 6-month randomised double-blind placebo-controlled study

This study was a prospective, randomised, double-blind, placebo-controlled clinical trial and aimed to compare the effect of placebo, soy isoflavone, calcium and soy isoflavone combined with calcium on bone mineral density (BMD). One hundred and sixty perimenopausal women with osteoporosis or osteopenia were enrolled and randomised into four groups: control, soy isoflavone, calcium and soy isoflavone combined with calcium groups. After intervention, compared with control, isoflavone and calcium groups, mean changes from their corresponding baseline values of BMD, calcium/phosphorus, vitamin D and glutathione peroxidase (GSH-pX) activity were significantly increased, however, those of phosphorus, osteocalcin, luteinizing hormone (LH) and follicle stimulating hormone (FSH) were significantly decreased in isoflavone combined with calcium group. The results showed that soy isoflavone, calcium and isoflavone combined with calcium therapy were effective and safe on attenuating BMD loss in perimenopausal women and isoflavone combined with calcium therapy was better than soy isoflavone and calcium alone.

Pharmacokinetic Interactions of a Hop Dietary Supplement with Drug Metabolism in Perimenopausal and Postmenopausal Women

Botanical dietary supplements produced from hops (Humulus lupulus) containing the chemopreventive compound xanthohumol and phytoestrogen 8-prenylnaringenin are used by women to manage menopausal symptoms. Because of the long half-lives of prenylated hop phenols and reports that they inhibit certain cytochrome P450 enzymes, a botanically authenticated and chemically standardized hop extract was tested for Phase I pharmacokinetic drug interactions. Sixteen peri- and postmenopausal women consumed the hop extract twice daily for 2 weeks, and the pharmacokinetics of tolbutamide, caffeine, dextromethorphan, and alprazolam were evaluated before and after supplementation as probe substrates for the enzymes CYP2C9, CYP1A2, CYP2D6, and CYP3A4/5, respectively. The observed area under the time-concentration curves were unaffected, except for alprazolam which decreased 7.6% (564.6 ± 46.1 h·μg/L pre-hop and 521.9 ± 36.1 h·μg/L post-hop; p-value 0.047), suggesting minor induction of CYP3A4/5. No enzyme inhibition was detected. According to FDA guidelines, this hop dietary supplement caused no clinically relevant pharmacokinetic interactions with respect to CYP2C9, CYP1A2, CYP2D6, or CYP3A4/5. The serum obtained after consumption of the hop extract was analyzed using ultra-high performance liquid chromatography-tandem mass spectrometry to confirm compliance. Abundant Phase II conjugates of the hop prenylated phenols were observed including monoglucuronides and monosulfates as well as previously unreported diglucuronides and sulfate-glucuronic acid diconjugates.

The Effect of Perimenopausal Transdermal Estradiol and Micronized Progesterone on Markers of Risk for Arterial Disease

BACKGROUND

The arterial effects of hormone therapy remain controversial. This study tested the effects of transdermal estradiol plus intermittent micronized progesterone (TE + IMP) in healthy perimenopausal and early postmenopausal women on several mechanisms involved in the pathophysiology of arterial disease.

METHODS

Healthy perimenopausal and early postmenopausal women, ages 45 to 60 years, were enrolled in this randomized, double-blind, placebo-controlled trial. Women were randomized to receive TE (0.1 mg/day) + IMP (200 mg/day for 12 days) or identical placebo patches and pills for 12 months. Outcomes included: change in stress reactivity composite z-score (combining inflammatory, cortisol, and hemodynamic responses to a standardized psychological laboratory stressor); flow-mediated dilation (FMD) of the brachial artery (an index of vascular endothelial function); baroreflex sensitivity; and metabolic risk (presence of the metabolic syndrome or insulin resistance), all assessed at baseline and at months 6 and 12.

RESULTS

Of 172 women enrolled, those assigned to TE + IMP tended to have higher resting baroreflex sensitivity than those assigned to placebo across the 6- and 12-month visits. Although treatment groups did not differ in terms of the other prespecified outcomes, a significant treatment-by-age interaction was found for FMD and stress reactivity such that an age-related decrease in FMD and increase in stress reactivity were seen among women assigned to placebo but not those assigned to TE + IMP. Women on TE + IMP also had lower resting diastolic blood pressure, lower levels of low-density lipoprotein cholesterol, and higher baroreflex sensitivity during stress testing.

CONCLUSIONS

TE + IMP tended to improve cardiac autonomic control and prevented age-related changes in stress reactivity and endothelial function among healthy perimenopausal and early postmenopausal women.

Antidepressant-like effects of Xiaochaihutang in perimenopausal mice

ETHNOPHARMACOLOGICAL RELEVANCE

Xiaochaihutang (XCHT) is a traditional Chinese medicine prescription for thousand years in China. Our previous researches show that XCHT has antidepressant-like effects in several depression models, but effect and mechanism of XCHT in perimenopausal depression are still vague.

AIM OF THE STUDY

To reveal the antidepressant-like effect and mechanism of XCHT in perimenopausal mice.

MATERIALS AND METHODS

Perimenopausal depression model is executed by ovariectomy combined with chronic unpredictable mild stress (OVX-CUMS). Tail suspension test (TST), forced swim test (FST), elevated plus-maze (EPM), novelty suppressed feeding (NSF) and locomotor activity are used to assess antidepressant-like effects of XCHT. The Level of estradiol (E₂), follicle-stimulating hormone (FSH), gonadotrophin releasing hormone (GnRH), corticosterone (CORT), adrenocorticotrophic hormone (ACTH) and corticotropin releasing hormone (CRH) are evaluated by ELISA. Antidepressant mechanisms of XCHT in OVX-CUMS mice are analyzed by 5-hydroxytryptamine (5-HT), tryptophan hydroxylase 2 (TPH2) and estrogen receptor α and β (ERα/β).

RESULTS

The results show that OVX-CUMS significantly increases the immobility time in TST and FST, increases latency to feed, decreases food consumption in NSF and both the time spend and number of entries in open arms in EPM. While, oral administration of XCHT can significantly normalize above depression-like behaviors in OVX-CUMS mice. Moreover, XCHT also remarkably normalized levels of 5-HT, 5-HIAA, E₂, GnRH, CORT, ACTH and CRH in OVX-CUMS mice. Finally, the expression of ERβ and TPH2 are decreased by OVX-CUMS in prefrontal cortex and hypothalamus, and XCHT can restore these decrease.

CONCLUSION

Current findings suggest XCHT can alleviate perimenopausal depression-like behaviors, restore 5-HT and hormones in OVX-CUMS mice, which may be related to normalizing the functions of HPA/HPO axis and enhancing expression of ERβ and TPH2 in prefrontal cortex and hypothalamus.

Efficacy of self-made Gengnian decoction on phosphatidylinositol 3-kinases/protein kinase B/mammalian target of rapamycin signaling pathway in perimenopausal rats

OBJECTIVE

To investigate the efficacy of self-made Gengnian decoction on expressions of phosphatidylinositol 3-kinase (PI3K), protein kinase B (Akt) and mammalian target of rapamycin (mTOR) in ovarian tissues of perimenopausal rats. They were identified with symptom pattern of kidney-Yang deficiency in terms of Traditional Chinese Medicine.

METHODS

Female Sprague-Dawley rats aged 10-12 months were selected. Estrous cycle was observed by vaginal smears of keratinocytes to screen the perimenopausal model rats. The chosen rats were randomly divided into five groups, including perimenopausal model of kidney-Yang deficiency group (24 rats), self-made Gengnian decoction of high-dose group (24 rats), self-made Gengnian decoction of middle-dose group (24 rats), self-made Gengnian decoction of low dose group (24 rats) and tibolone control group (24 rats). In addition, rats aged 4-6 months were selected as young control group. The perimenopausal model rats of kidney-Yang deficiency were prepared by alternative intramuscular injection of hydrocortisone 5 mg·kg－1·d－1 The successfully prepared models in self-made Gengnian decoction of high-dose, middle-dose and low-dose groups and tibolone control group were given self-made Gengnian decoction 26.4, 13.2 and 6.6 mg·kg－1·d－1, and tibolone tablets solvent 0.22 mg·kg－1·d－1, respectively, through intragastric administration. Models group and young control group were given the same dose of normal saline, 1 time a day for 15 consecutive days. 24 h after the last administration, blood and ovarian tissues were collected after anesthesia with 20% ethyl carbamate. The follicles of different levels in ovarian tissue were observed and counted by histopathological hematoxylin-eosin staining. Enzyme linked immunosorbent assay was applied to test insulin-like growth factor-1 (IGF-1) level in the serum of experimental rats. The expression levels of PI3K, phosphorylated-Akt (p-Akt) and phosphorylated-mTOR (p-mTOR) mRNA in ovarian tissue were detected by quantitative real-time polymerase chain reaction.

RESULTS

The total follicle counts of perimenopausal model rats with kidney-Yang deficiency were significantly reduced, and the number of follicles (mainly increased in preantral follicles and antral follicles) in perimenopausal model rats with kidney-Yang deficiency was significantly increased after intervention of high and middle doses of Gengnian decoction and tibolone (P < 0.05). Compared with normal rats in young control group, the levels of IGF-1 in serum of perimenopausal rats with kidney-Yang deficiency were significantly decreased (P < 0.01), and those intervened by high dose of Gengnian decoction and tibolone were significantly up-regulated. The relative expression levels of PI3K, p-Akt, p-mTOR mRNA in ovarian tissues of perimenopausal rats with kidney-Yang deficiency were significantly lower than those of young rats (P < 0.01), and those intervened by high dose of Gengnian decoction and tibolone were significantly up-regulated (P < 0.05).

CONCLUSION

Self-made Gengnian decoction can increase the levels of IGF-1, PI3K, Akt and mTOR mRNA expression in serum.

Safety and feasibility of estrogen receptor-β targeted phytoSERM formulation for menopausal symptoms: phase 1b/2a randomized clinical trial

OBJECTIVE

PhytoSERM is a formulation of genistein, daidzein, and S-equol that has an 83-fold selective affinity for estrogen receptor-β (ERβ); and may enhance neuron function and estrogenic mechanisms in the brain without having peripheral estrogenic activity.

METHODS

We conducted an overarching, two-stage, dose-ranging, double-blinded, randomized, placebo-controlled trial of 12 weeks duration comparing 50 and 100 mg/d of phytoSERM with placebo for noncognitively impaired, perimenopausal women aged 45 to 60, with intact uteri and ovaries, with at least one cognitive complaint, and one vasomotor-related symptom. Primary objectives were to assess safety and tolerability of a 50 and 100 mg daily dose; and, secondly, to evaluate potential indicators of efficacy on cognition and vasomotor symptoms over 4 and 12 weeks, and using an embedded, 4-week, 2-period, placebo-controlled crossover trial for a subset of participants.

RESULTS

Seventy-one women were randomized to treatment; 70 were evaluated at 4 weeks; 12 were entered into the crossover study; 5 did not complete 12 weeks. Reasons for discontinuation were withdrawal of consent (n = 1) and lost to follow-up (n = 4). Adverse events occurred in 16.7% (n = 4) placebo, 39.1% (n = 9) 50 mg/d, and 29.2% (n = 7) 100 mg/d treated participants; 85% were mild and none was severe. Vaginal bleeding occurred in 0, placebo; 1, 50 mg; and 3, 100 mg/d participants.

CONCLUSIONS

The phytoSERM formulation was well tolerated at 50 and 100 mg daily doses. Based on safety outcomes, vaginal bleeding at the 100 mg dose, and vasomotor symptoms and cognitive outcomes at 12 weeks, a daily dose of 50 mg was considered preferable for a phase 2 efficacy trial.

Biological effects of melatonin on osteoblast/osteoclast cocultures, bone, and quality of life: Implications of a role for MT2 melatonin receptors, MEK1/2, and MEK5 in melatonin-mediated osteoblastogenesis

The Melatonin Osteoporosis Prevention Study (MOPS) demonstrated that nightly melatonin resulted in a time-dependent decrease in equilibrium ratios of serum osteoclasts and osteoblasts in perimenopausal women. This study examines mechanisms related to the ratios of osteoblasts and osteoclasts using coculture models (transwell or layered) of human mesenchymal stem cell (MSC) and human peripheral blood monocytes (PBMCs). Human MSC/PBMC cocultures exposed to melatonin in osteogenic (OS+) medium for 21 days induced osteoblast differentiation and mineralization; however, only in layered cocultures did melatonin inhibit osteoclastogenesis. Melatonin effects were mediated through MT2 melatonin receptors, MEK1/2, and MEK5. In layered but not transwell cocultures, melatonin increased OPG:RANKL ratios by inhibiting RANKL, suggesting that contact with osteoclasts during osteoblastogenesis inhibits RANKL secretion. Melatonin modulated expression of ERK1/2, ERK5, β1 integrin, GLUT4, and IRβ that was dependent upon the type of coculture; however, in both cultures, melatonin increased RUNX2 and decreased PPARγ expression, indicating a role for metabolic processes that control osteogenic vs adipogenic cell fates of MSCs. Furthermore, melatonin also has osteoblast-inducing effects on human adipose-derived MSCs. In vivo, one-year nightly melatonin (15 mg/L) given to neu female mice in their drinking water increased pErk1/2, pErk5, Runx2, and Opg and Rankl levels in bone consistent with melatonin's already reported bone-enhancing effects. Finally, analysis of daily logs from the MOPS demonstrated a significant improvement in mood and perhaps sleep quality in women receiving melatonin vs placebo. The osteoblast-inducing, bone-enhancing effects of melatonin and improvement in quality of life suggest that melatonin is a safe and effective bone loss therapy.

Neurovegetative disorders of perimenopausal women treated with docosahexaenoic acid (DHA, 625 mg)

The study evaluated the effect of DHA 625 mg in women who experience menopausal symptoms, on sexuality and quality of life (QoL), and on the auditory brainstem response (ABR). Forty-two perimenopausal women were enrolled. The Kupperman Index (KI) was used to evaluate menopause symptoms. The Short Form-36 (SF-36), Female Sexual Function Index (FSFI), and the Female Sexual Distress Scale (FSDS) were used to assess QoL, sexual function, and sexual distress, respectively. Auditory evoked potentials to measure the ABR. The study had one follow-up at 6 months. The women reported an improvement in the KI total score (p < .001). Moreover, women reported QoL improvements in all the psychological categories (p < .001), but not in physical categories (p = NS). FSFI and FSDS total scores increased (p < .01) and the FSDS score decreased (p < .01), mainly due to arousal (p < .03) and lubrication (p < .05) sexual aspects. The ABR wave latencies were lower than the baseline values (p < .05). DHA could be effective in modulating some perimenopausal symptoms in women and, consequently could contribute to improve their QoL and sexual life. Finally, DHA seems to have a direct activity on the neuronal conduction time into the audiological system.

Total glucosides of Curculigo rhizome to perimenopausal period mice model

To investigate the effects of total glucosides of Curculigo rhizome (TGC) to perimenopausal period (PMS) mice model. After removed the bilateral ovaries induced the PMS mice model, high, medium and low doses of TGC group were partly given TGC solution 400,200,100mg•kg-1, administered once a day, continuously 21 days. Compared with the model group (MG) mices, each dose of TGC group could significantly improve the activities of mice, increase thymus, uterus, spleen index(TI, UI, SI), the levels of testosterone(T), estradiol (E₂), reduce the level of luteinizing hormone (LH), the high dose of TGC group(HD-C) group has the best effects. It prompted that TGC has the effect in treatment of PMS mice model, the HD-C group of TGC has the best effects.

Estradiol therapy and breast cancer risk in perimenopausal and postmenopausal women: a systematic review and meta-analysis

OBJECTIVE

To investigate the association between estradiol therapy and incidence of breast cancer, taking into consideration of different types of combined progestogen, the duration of exposure and the type of regimen.

METHOD

A systematic review and meta-analysis.

RESULT

A total of 14 studies were included in our study. In estradiol-only therapy analysis, meta-analysis resulted a pooled OR =0.90, 95% CI (0.40, 2.02) from the RCTs and pooled OR = 1.11, 95% CI (0.98, 1.27) from observational studies. However, in the analysis of estradiol-progestogen therapy, the risk of breast cancer varies according to the type of progestogen and the duration with more than five years (OR = 2.43, 95% CI (1.79, 3.29)) presented a higher risk than using less than five years (OR = 1.49, 95% CI (1.03, 2.15)).

CONCLUSIONS

Estradiol-only therapy carries no risk for breast cancer, while the breast cancer risk varies according to the type of progestogen. Estradiol therapy combined with medroxyprogesterone, norethisterone and levonorgestrel related to an increased risk of breast cancer, estradiol therapy combined with dydrogesterone and progesterone carries no risk. The breast cancer risk rise progressively by prolonged use, furthermore, comparing to sequential therapy, continuous therapy carries a higher risk.

Effects of nutraceuticals on quality of life and sexual function of perimenopausal women

PURPOSE

The aim of the study was to evaluate the effects of nutraceuticals containing Equol, Resveratrol, Quecitine and Passiflora (Zemiar^®, Avantgarde, Pomezia, Rome, Italy) on quality of life (QoL) and sexual function in perimenopausal women.

METHODS

Sixty perimenopausal women having vasomotor symptoms and being in the -1, +1a of the STRAW system (amenorrhea for longer than 60 days and FSH < 20 UI/L) were enrolled. The modified Kupperman Index (KI) was used to evaluate menopause symptoms. The Short Form-36 (SF-36), Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (FSDS) were used to assess QoL, sexual function and sexual distress, respectively. The study had two follow-ups at 3 and 6 months.

RESULTS

The women reported an improvement in the KI total score from the baseline (35 ± 4) to the 1st (21 ± 3, p < 0.05) and the 2nd (18 ± 2, p < 0.01) follow-ups. At the 1st follow-up, the women reported QoL improvements in some functions (p < 0.05); at the 2nd follow-up, they reported improvements in all categories (p < 0.001). At baseline, the total FSFI score was 23.1 ± 1.2 and the FSDS score was 18.1 ± 1.4, both indicating sexual dysfunction with sexual distress. FSFI and FSDS total scores did not change at the 1st follow-up (p = NS). On the contrary, at the 2nd follow-up, the FSFI score had risen to (27.6 ± 1.5) (p < 0.001) and the FSDS score had dropped to (11.3 ± 1.2) (p < 0.001).

CONCLUSIONS

Nutraceuticals can be effective in modulating the perimenopausal symptoms in women. The progressive reduction of the vasomotor symptoms reported by women over the nutraceutical usage could contribute to improve their QoL and sexual life.

Why perimenopausal women should consider to use a levonorgestrel intrauterine system

OBJECTIVE

The use of a levonorgestrel intrauterine system (LNG-IUS) is useful in preventing pregnancy and for the treatment of menstrual disturbances. A smooth or symptom-free transition to and through menopause is possible when LNG-IUS is combined with estrogen therapy. Unfortunately the majority of physicians are generally unaware of this usefulness combined hormonal therapy in the pre-, peri- and postmenopausal women.

DESIGN AND METHOD

Based on long-term clinical experience with LNG-IUS in the form of Femilis®, 104 women where followed from the premenopause through the menopausal transition into the postmenopause. These perimenopausal women received supplemental 17 β-estradiol by gel or patch, or orally as estradiol valerate. Patients received one or two separate Femilis insertions at 5 year intervals. Main outcome measures included acceptability and continued use of the combined regimen for the treatment of climacteric symptoms and for prevention of cardiovascular disease, osteoporosis and other adverse effects caused by estrogen deprivation.

RESULTS

The average age at insertion was 48 years (range 28-58) and the total duration of use was 137 months (range 80-161). The Femilis LNG-IUS was well tolerated as the number of removals for LNG-IUS-related reasons was low. The LNG-IUS was well retained in the uterine cavity as no expulsions were observed. Seven women were lost to follow-up. Eighty-six women (82%) opted for replacement of an LNG-IUS at expiry after 5 years and continued with the estrogen therapy.

CONCLUSION

Intrauterine progestogen delivery for endometrial suppression in combination with estrogen therapy in the symptomatic perimenopausal women is highly practical as it combines the benefits of prevention of endometrial proliferation and treatment of menorrhagia and hyperplasia, if present. In addition, the contraceptive effect of locally administered LNG is highly desirable as many perimenopausal women run considerable risk of unintended pregnancy. For these reasons, the author views this regimen as one of the most effective, safest and best accepted route resulting in high patient compliance. It is important to convey this message to general practitioners as well as women.

[Effectiveness of Electroacupuncture of Zigong (EX-CA 1), etc. in Treatment of Perimenopausal Syndrome Women]

OBJECTIVE

To evaluate the curative effect of electroacupuncture(EA) of Zigong (EX-CA 1) and Tianshu (ST 25) and acupuncture of Sanyinjiao (SP 6) and Guanyuan (CV 4) for perimenopausal syndrome(PMS).

METHODS

Fifty-eight PMS patients were equally and randomized into acupuncture group and medication group. EA (10 Hz/50 Hz, 30 min in duration) was applied at Zigong (EX-CA 1) and Tianshu (ST 25) in combination with manual acupuncture stimulation of Sanyinjiao (SP 6) and Guanyuan (CV 4) by twirling the acupuncture needles with small amplitude and till deqi. The treatment was conducted once every other day, three times a week, 8 weeks altogether. The patients of the medication group were asked to take estradiol valerate (1 mg/time, qd) for 3 weeks, then, to have one week's rest and continuously took estradiol valerate(1 mg/d) and medroxyprogesterone 17-acetate (8 mg/d) for 10 days. The therapeutic effects were assessed by Menopause Rating Scale Questionnaire[MRS, composing of 3 areas:somatic (4 items), psychological(4 items) and urogenital (3 items) domain]. Serum estradiol (E₂), follicle stimulating hormone(FSH) and luteotrophic hormone (LH) contents were assayed using ELISA.

RESULTS

After the treatment, the scores of the MRS and the contents of serum FSH and LH were significantly decreased in both the acupuncture and medication groups (P<0.01), and serum E₂ contents significantly increased in the two groups (P<0.01). No significant differences were found between the two groups in the total effective rates (P>0.05). Eight weeks' follow-up showed that the MRS score of the acupuncture group was significantly lower than that of the medication group (P<0.05). Of the two 29 PMS patients in the medication and acupuncture groups, 3 (10.3%) and 2 (6.9%) cases were under control, 22 (75.9%) and 21 (72.4%) experienced a marked improvement in their symptoms, 3 (10.3%) and 4(13.8%) were effective, 1 (3.4%) and 2(6.9%) invalid, with the effective rates being 96.6% and 93.1%, respectively. Eight weeks' follow-up showed that the long-term effect of the acupuncture therapy was obviously superior to that of the medication (P<0.05) according to MRS score.

CONCLUSIONS

Acupuncture therapy is effective in relieving clinical symptoms of PMS women by regulating endocrine hormones, being similar to medication.

Evaluation of safety of modified-Danggui Buxue Tang in rodents:immunological, toxicity and hormonal aspects

ETHNOPHARMACOLOGICAL RELEVANCE

Radix Astragali (RA), Radix Angelicae Sinensis (RAS) and Folium Epimedii (FE) are three of the extensively applied herbs among traditional Chinese medicines for gynecological disorders and osteoporosis. A derivative herbal formula-RRF, consisting of the three medicines with a weight ratio of 5:1:5, is derived from a famous Chinese herbal formula-Danggui Buxue Tang (DBT). RRF has shown noteworthy perimenopause ameliorating effect in both ovariectomized rats and natural aging female rats, which might represent a promising candidate for the treatment of perimenopausal disorders. The aim of this study was to evaluate its immunological potential, chronic toxicity and reproductive effects by 26-week repeated daily administration in female rats, in order to optimize its safe use.

MATERIALS AND METHODS

The effect of RRF on immunological function was studied by macrophage phagocytosis, immune organ index, serum immunoglobulin level as well as delayed type hypersensitivity (DTH) in mice. For toxicity assessment, acute toxicity study was performed according to fixed dose procedure with a single oral administration of RRF to mice. In the oral chronic toxicity, 120 female rats were administrated RRF orally in 0, 1100, 4400, or 8800mg/kg/day doses for 26 weeks. Clinical signs, mortality, body weights, feed consumption, haemato-biochemical parameters, organ weights, histopathology and reproductive hormone profiles were examined at the end of the 13- and 26-week dosing period, as well as after the 4-week recovery period.

RESULTS

Oral administration of RRF at three doses (282, 564 and 1128mg/kg) significantly increased the indices of phagocytosis K, as compared with prednisone acetate (PR) group (p<0.05 or 0.01). Exposure of RRF dose-dependently boosted circulating serum IgM level (all p<0.01) in response to CRBC in PR-induced mice. Furthermore, RRF treatment elicited a significant increment (all p<0.01) in DNFB-induced DTH response and the immune organ indices in a dose-dependent manner in mice, in parellel to DNFB-induced group. In the single dose acute toxicity and repeated dose 90-day chronic toxicity investigations, no toxic signs/mortality were observed. RRF treatment did not cause any toxicologically significant changes in clinical signs, food consumption, body weight, relative organ weight, hematological parameters, clinical chemistry, gross pathology and histopathology between treatment and control groups. No treatment related gross/histopathological lesions were observed and no target organ was identified. Long-term repeated administration of RRF exerted a significant promotion on serum level of steroid hormone estradiol, progesterone and testosterone release, along with decrease of circulating pituitary follicle stimulating hormone, luteinizing hormone, and prolactin levels in female rats. The No Observed Adverse Effect Level (NOAEL) of RRF was determined to be over 8800mg/kg/day for elderly female rats, a dose that was equivalent to 50 times of human dose.

CONCLUSION

The present investigation demonstrated that RRF possessed appreciable immunopotentiating activity and had a relatively wide margin of safety. Long-term treatment of RRF exhibited estrogenic properties, and retarded certain age-associated degenerations. RRF might have the potential for further development as a safe and effective alternative/complementary to conventional medication in relieving perimenopausal symptoms.

[Discussion on strategy of treatment of perimenopausal syndrome with Chinese and Western Medicine]

Perimenopausal syndrome refers to a series of physical and mental symptoms ,caused by the fluctuation of the sex hormones in the menopause, which is one of the common diseases in gynecology. With the acceleration of the aging population ir the world, it has caused the world's attention. Modern medicine has developed rapidly in the field of basic theory and clinical research, but there are still some problems in the treatment. Clinical treatment is mainly in hormone replacement therapy, but there are some potential risks, adverse reactions and many contraindications, thereby reducing patients' compliance and tolerance. Traditional Chinese medicine under the guidance of the concept of wholism cure perimenopausal syndrome based on syndrome differentiation, which has unique advantages, such as a variety of ways, less side effect, curative effect, which was patients more and more welcome. It is very important for the study to explore the perimenopausal syndrome.

[Pro-health prevention in perimenopausal women with regard to estrogen treatment]

According to the latest demographic forecast in Poland is observed the progressive aging of the population with growing population of perimenopausal women. This is a special time in woman's life, in which there are many metabolic changes, neurovegetative symptoms and mental changes. All of them are connected with decreased concentration of sex hormones. Very important in this period are health behaviors, including healthy lifestyle, regular exercises and proper diet. Highly effective in removing menopausal symptoms is hormone replacement therapy. It also prevents the effects of metabolic disorders. This therapy is primary prevention of cardiovascular diseases and osteoporosis, depression, Alzheimer's and Parkinson's disease and urogenital atrophy. It also has to delay the process of aging. Clinical studies of HERS, WHI and MWS caused extreme caution in the use of hormone replacement therapy and distrust for this therapy between doctors and their patients. It is therefore important to establish priorities for action and individualized therapy, depending on the indications and contraindications for its use.

[Experimental study on efficiency of Spanishneedles Herb eye drops in treating perimenopausal xerophthalmia in rabbits]

OBJECTIVE

To investigate the efficiency of Spanishneedles Herb eye drops in treating perimenopausal xerophthalmia in rabbits.

METHOD

Totally 36 rabbits (36 right eyes) were ovariectomized, and 2 months later divided into three groups: the experimental group (group A, n = 12) given Spanishneedles Herb eye drops, the control group (group B, n = 12) given PBS and the model group (group C, n = 12) given no drug. The Schirmer I test (SIT), fluorescent (FL), total tear protein, diastase activity, lactoferrin and lysozyme contents and confocal scanning microscopy were performed at before the treatment and at 1 w, 2 w, 1 mo, 2 mo after the treatment.

RESULT

Before the treatment, There was no significant difference in SIT, FL, total tear protein, lysozyme, lactoferrin and amylase activity between two groups. Two months later after the treatment, both the group B and the group A showed differences degrees of changes in SIT, FL, total tear protein, lysozyme, lactoferrin and amylase activity compared with that before the treatment, with statistical differences (P < 0.05); At each time point, both groups revealed statistical differences in SIT, FL, total tear protein, lysozyme, lactoferrin and amylase activity (1 < 0.05). Two months later alter the treatment, densities of basal epithelial cells and inflammatory cells in the group A were (4 122 ±416) cells/mm2 and (339 ± 131) cells/mm2, while that in the group B were (3 343 ± 424) cells/mm2 and (49 ± 17) cells/mm2, with statistical differences between them (P < 0.05).

CONCLUSION

Spanishneedles Herb eye drops could effectively treat perimenopausal xerophthalmia in rabbit caused by sex hormones decline.

Dehydroepiandrosterone for women in the peri- or postmenopausal phase

BACKGROUND

During menopause a decreasing ovarian follicular response generally causes a fluctuation and eventual decrease in estrogen levels. This can lead to the development of various perimenopausal and postmenopausal symptoms (for example hot flushes, night sweats, vaginal dryness). Dehydroepiandrosterone (DHEA) is one of the main precursors of androgens, which in turn are converted to testosterone and estrogens. It is possible that the administration of DHEA may increase estrogen and testosterone levels in peri- and postmenopausal women to alleviate their symptoms and improve general wellbeing and sexual function (for example libido, dyspareunia, satisfaction). Treatment with DHEA is controversial as there is uncertainty about its effectiveness and safety. This review should clearly outline the evidence for DHEA in the treatment of menopausal symptoms and evaluate its effectiveness and safety by combining the results of randomised controlled trials.

OBJECTIVES

To assess the effectiveness and safety of administering DHEA to women with menopausal symptoms in the peri- or postmenopausal phase.

SEARCH METHODS

The databases that we searched (3 June 2014) with no language restrictions applied were the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS. We also searched conference abstracts and citation lists in the ISI Web of Knowledge. Ongoing trials were searched in the trials registers. Reference lists of retrieved articles were checked.

SELECTION CRITERIA

We included randomised controlled trials comparing any dose and form of DHEA by any route of administration versus any other active intervention, placebo or no treatment for a minimal treatment duration of seven days in peri- and postmenopausal women.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data after assessing eligibility for inclusion and quality of studies. Authors were contacted for additional information.

MAIN RESULTS

Twenty-eight trials with 1273 menopausal women were included in this review. Data could be extracted from 16 trials to conduct the meta-analysis. The overall quality of the studies was moderate to low with the majority of studies that were included in the meta-analysis having reasonable methodology. Compared to placebo, DHEA did not improve quality of life (standardised mean difference (SMD) 0.16, 95% confidence interval (CI) -0.03 to 0.34, P = 0.10, 8 studies, 287 women (132 from parallel and 155 from crossover trials), I² = 0%, moderate quality evidence; one trial of the nine that reported on this outcome was removed in a sensitivity analysis as it was judged to be at high risk of bias). DHEA was found to be associated with androgenic side effects (mainly acne) (odds ratio (OR) 3.77, 95% CI 1.36 to 10.4, P = 0.01, 5 studies, 376 women, I² = 10%, moderate quality evidence) when compared to placebo. No associations were found with other adverse effects. It was unclear whether DHEA affected menopausal symptoms as the results from the trials were inconsistent and could not easily be pooled to provide an overall effect due to different types of measurement (for example continuous, dichotomous, change and end scores). DHEA was found to improve sexual function (SMD 0.31, 95% CI 0.07 to 0.55, P = 0.01, 5 studies, 261 women (239 women from parallel trials and 22 women from crossover trials), I² = 0%; one trial judged to be at high risk of bias was removed during sensitivity analysis) compared to placebo.There was no difference in the acne associated with DHEA when comparing studies that used oral DHEA (OR 2.16, 95% CI 0.47 to 9.96, P = 0.90, 3 studies, 136 women, I² = 5%, very low quality evidence) to one study that used skin application of DHEA (OR 2.74, 95% CI 0.10 to 74.87, P = 0.90, 1 study, 22 women, very low quality evidence). The effects did not differ for sexual function when studies using oral DHEA (SMD 0.11, 95% CI -0.13 to 0.35, P = 0.36, 5 studies, 340 women, I² = 0) were compared to a study using intravaginal DHEA (SMD 0.42, 95% CI 0.03 to 0.81, 1 study, 218 women). Test for subgroup differences: Chi² = 1.77, df = 1 (P = 0.18), I² = 43.4%. Insufficient data were available to assess quality of life and menopausal symptoms for this comparison.There were insufficient data available to compare the effects of DHEA to hormone therapy (HT) for quality of life, menopausal symptoms, and adverse effects. No large differences in treatment effects were found for sexual function when comparing DHEA to HT (mean difference (MD) 1.26, 95% CI -0.21 to 2.73, P = 0.09, 2 studies, 41 women, I² = 0%).

AUTHORS' CONCLUSIONS

There is no evidence that DHEA improves quality of life but there is some evidence that it is associated with androgenic side effects. There is uncertainty whether DHEA decreases menopausal symptoms, but DHEA may slightly improve sexual function compared with placebo.

Hormone replacement therapy in the treatment of perimenopausal depression

The menopause transition is associated with a two to fourfold increased risk in major depressive disorder (MDD) and clinical elevations in depressive symptoms. While the pathophysiological mechanisms underlying this increased risk remain uncertain, ovarian hormone fluctuation is believed to play a role. To the extent that this is the case, hormone replacement therapy (HRT), through its hormone-stabilizing effects, represents a viable antidepressant treatment. The current review summarizes the most recent literature evaluating the efficacy of HRT in treating MDD in peri- and postmenopausal women. In addition, to provide a clinical context in which to interpret this research, the endocrinology and clinical phenomenology related to depression with onset in the menopause transition (D-MT) are discussed. The available evidence suggests that HRT, specifically involving estrogen delivered through a skin patch, is a promising intervention in the treatment of D-MT. However, HRT of any form is an ineffective antidepressant in women who are well into the postmenopausal period.

Chaihu-Shugan-San administration ameliorates perimenopausal anxiety and depression in rats

Chaihu-Shugan-San (CSS) is a traditional Chinese herbal formula that is widely used for treating perimenopausal symptoms in China; however, its mechanisms remain unknown. The present study was designed to investigate potential CSS mechanisms in rats with unpredicted chronic mild stress (UCMS) and normally aging rats (52 weeks of age). We performed the sucrose consumption test along with the forced swimming test to confirm depression-like behavior and the open field test (OFT) to confirm anxiety-like behavior in the animals. In addition, we used an enzyme-linked immunosorbent assay to measure serum and hippocampal estradiol (E₂) levels and a quantitative real-time polymerase chain reaction to assess hippocampal mRNA levels of estrogen receptors (ERs) α and β as well as G protein-coupled receptor 30 (GPR30). We found that CSS administration resulted in a significant increase in the ratio of hippocampal ERα and ERβ mRNA (ERα/ERβ ratio) in UCMS rats (p<0.001). However, no significant changes were observed in E₂ levels, ERα mRNA expression, and GPR30 mRNA expression. In contrast, changes in ERα/ERβ mRNA ratio were sensitively associated with changes in mood states in the animal models. These findings suggest that enhancement of ERα/ERβ ratio may play a role in the pharmacological mechanisms of CSS. Furthermore, this ratio can be employed as a potential index for evaluating mood states in animal models and can be considered as a therapeutic target for perimenopausal anxiety and depression in the future.

Effect of low-dose French maritime pine bark extract on climacteric syndrome in 170 perimenopausal women: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To evaluate the efficacy of a relatively low daily dosage of Pycnogenol French maritime pine bark extract for improvement of climacteric symptoms.

STUDY DESIGN

In a double-blind, placebo-controlled study 170 perimenopausal women were enrolled and treated with 30 mg Pycnogenol or placebo twice daily over a period of 3 months. Climacteric symptoms were evaluated by the Women's Health Questionnaire (WHQ) and by the Kupperman index, accompanied by an investigation of sex hormones and routine blood chemistry.

RESULTS

Seven women dropped out of each group due to noncompliance or personal reasons, but not as a result of treatment. A significant placebo effect was apparent in this study, suggesting an improvement of a majority of the WHQ categories. Compared to baseline, Pycnogenol significantly (p < 0.05) improved all symptoms with the exception of formication sensation and abnormal perceptions. Pycnogenol was found to be especially effective for improving vasomotor and insomnia/sleep problem symptoms, which were significantly better after 4 and 12 weeks than with placebo (p < 0.05). Total Kupperman's index for perimenopausal symptom severity score decreased significantly by 56% as compared to placebo (-39%) after 12 weeks of treatment (p < 0.05). Symptom score was also significantly better already after 4 weeks of treatment with Pycnogenol as compared to placebo.

CONCLUSION

This study, applying a relatively low daily dose, allows identification of those climacteric symptoms which respond particularly well to supplementation with Pycnogenol.

Black cohosh (Cimicifuga spp.) for menopausal symptoms

BACKGROUND

Menopause can be a distressing and disruptive time for many women, with many experiencing hot flushes, night sweats, vaginal atrophy and dryness. Postmenopausal women are also at increased risk of osteoporosis. Interventions that decrease the severity and frequency of these menopausal symptoms are likely to improve a woman's well-being and quality of life. Hormone therapy has been shown to be effective in controlling the symptoms of menopause; however, many potentially serious adverse effects have been associated with this treatment. Evidence from experimental studies suggests that black cohosh may be a biologically plausible alternative treatment for menopause; even so, findings from studies investigating the clinical effectiveness of black cohosh have, to date, been inconsistent.

OBJECTIVES

To evaluate the clinical effectiveness and safety of black cohosh (Cimicifuga racemosa or Actaea racemosa) for treating menopausal symptoms in perimenopausal and postmenopausal women.

SEARCH METHODS

Relevant studies were identified through AARP Ageline, AMED, AMI, BioMed Central gateway, CAM on PubMed, CINAHL, CENTRAL, EMBASE, Health Source Nursing/Academic edition, International Pharmaceutical Abstracts, MEDLINE, Natural medicines comprehensive database, PsycINFO, TRIP database, clinical trial registers and the reference lists of included trials; up to March 2012. Content experts and manufacturers of black cohosh extracts were also contacted.

SELECTION CRITERIA

All randomised controlled trials comparing orally administered monopreparations of black cohosh to placebo or active medication in perimenopausal and postmenopausal women.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data and completed the 'Risk of bias' assessment. Study authors were contacted for missing information.

MAIN RESULTS

Sixteen randomised controlled trials, recruiting a total of 2027 perimenopausal or postmenopausal women, were identified. All studies used oral monopreparations of black cohosh at a median daily dose of 40 mg, for a mean duration of 23 weeks. Comparator interventions included placebo, hormone therapy, red clover and fluoxetine. Reported outcomes included vasomotor symptoms, vulvovaginal symptoms, menopausal symptom scores and adverse effects. There was no significant difference between black cohosh and placebo in the frequency of hot flushes (mean difference (MD) 0.07 flushes per day; 95% confidence interval (CI) -0.43 to 0.56 flushes per day; P=0.79; 393 women; three trials; moderate heterogeneity: I(2) = 47%) or in menopausal symptom scores (standardised mean difference (SMD) -0.10; 95% CI -0.32 to 0.11; P = 0.34; 357 women; four trials; low heterogeneity: I(2) = 21%). Compared to black cohosh, hormone therapy significantly reduced daily hot flush frequency (three trials; data not pooled) and menopausal symptom scores (SMD 0.32; 95% CI 0.13 to 0.51; P=0.0009; 468 women; five trials; substantial heterogeneity: I(2) = 69%). These findings should be interpreted with caution given the heterogeneity between studies. Comparisons of the effectiveness of black cohosh and other interventions were either inconclusive (because of considerable heterogeneity or an insufficient number of studies) or not statistically significant. Similarly, evidence on the safety of black cohosh was inconclusive, owing to poor reporting. There were insufficient data to pool results for health-related quality of life, sexuality, bone health, vulvovaginal atrophic symptoms and night sweats. No trials reported cost-effectiveness data. The quality of included trials was generally unclear, owing to inadequate reporting.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to support the use of black cohosh for menopausal symptoms. However, there is adequate justification for conducting further studies in this area. The uncertain quality of identified trials highlights the need for improved reporting of study methods, particularly with regards to allocation concealment and the handling of incomplete outcome data. The effect of black cohosh on other important outcomes, such as health-related quality of life, sexuality, bone health, night sweats and cost-effectiveness also warrants further investigation.

Melatonin osteoporosis prevention study (MOPS): a randomized, double-blind, placebo-controlled study examining the effects of melatonin on bone health and quality of life in perimenopausal women

The purpose of this double-blind study was to assess the effects of nightly melatonin supplementation on bone health and quality of life in perimenopausal women. A total of 18 women (ages 45-54) were randomized to receive melatonin (3mg, p.o., n=13) or placebo (n=5) nightly for 6months. Bone density was measured by calcaneal ultrasound. Bone turnover marker (osteocalcin, OC for bone formation and NTX for bone resorption) levels were measured bimonthly in serum. Participants completed Menopause-Specific Quality of Life-Intervention (MENQOL) and Pittsburgh Sleep Quality Index (PSQI) questionnaires before and after treatment. Subjects also kept daily diaries recording menstrual cycling, well-being, and sleep patterns. The results from this study showed no significant change (6-month-baseline) in bone density, NTX, or OC between groups; however, the ratio of NTX:OC trended downward over time toward a ratio of 1:1 in the melatonin group. Melatonin had no effect on vasomotor, psychosocial, or sexual MENQOL domain scores; however, it did improve physical domain scores compared to placebo (mean change melatonin: -0.6 versus placebo: 0.1, P<0.05). Menstrual cycling was reduced in women taking melatonin (mean cycles melatonin: 4.3 versus placebo: 6.5, P<0.05), and days between cycles were longer (mean days melatonin: 51.2 versus placebo: 24.1, P<0.05). No differences in duration of menses occurred between groups. The overall PSQI score and average number of hours slept were similar between groups. These findings show that melatonin supplementation was well tolerated, improved physical symptoms associated with perimenopause, and may restore imbalances in bone remodeling to prevent bone loss. Further investigation is warranted.

Adjuvant hormonal therapy in perimenopausal patients

This section considers the treatment options for perimenopausal women with breast cancer. The perimenopause period begins in the so-called stage 2 of menopausal transition (early menopausal transition, where the length of the cycles changes by 7 days or more) and ends after 12 months of amenorrhea. It is characterized by an early increase in follicle-stimulating hormone and is associated with the presence of anovulatory cycles, irregular periods, and loss of menstrual cycles. The recommended treatment is tamoxifen (TAM) with or without ovarian ablation for 2 or 3 years followed by a re-evaluation. TAM should be maintained if the patient is premenopausal and aromatase inhibitors (AI) are recommended once the menopausal status is confirmed. Ovarian suppression is an acceptable adjuvant therapy in those patients with hormone-sensitive tumors. AI should only be used in postmenopausal women or in combination with chemical castration in premenopausal women. This supplement paper includes the key points of roundtable presentations and discussions of hormonal therapy in breast cancer.

Supplementation with Pycnogenol® improves signs and symptoms of menopausal transition

AIM

The aim of this study was to evaluate the efficacy of Pycnogenol® standardized pine bark extract for alleviation of signs and symptoms associated with menopausal transition.

METHODS

Pycnogenol® was used by 38 women as daily supplement in a dosage of 100 mg over an eight week period and menopausal symptoms were evaluated by means of a scoring system, based on a total number of 33 common signs and symptoms. A parallel control group of 32 comparable women was also followed up for the same period. Pycnogenol® was well tolerated, no side effects were reported and the compliance was very good with 98.6% of tablets used as prescribed. A range of 33 menopausal symptoms were evaluated using a scoring system with values ranging from zero (absent) to maximum 4 (very serious).

RESULTS

A subset of six most common symptoms comprising hot flushes, night sweats, mood swings, irregular periods, loss of libido and vaginal dryness showed a decrease from average 2.67/4 to 1.45/4 after 8 weeks supplementation with Pycnogenol®. The control group of women showed no change from initial average 2.72/4 to 2.73/4 after eight weeks. The improvement of symptoms was statistical significant compared to the control group. Further symptoms related to fatigue, sleeping disorders, concentration and memory problems, dizziness, depression and irritability all improved significantly with Pycnogenol® compared to baseline values but did not reach statistical significance compared to the control group of women. The sensation of pain related to headaches, breast pain, the feeling of "electric shocks", tingling extremities, burning tongue and itchy skin all improved significantly after intake of Pycnogenol® for eight weeks compared to baseline. Specifically the sensation of "electric shocks" and digestive problems improved significantly with Pycnogenol® as compared to women in the control group. The presence of elevated oxidative stress in women was investigated measuring capillary blood plasma free radicals. Oxidative stress was significantly lowered after four weeks (P<0.05) and eight weeks (P<0.022) in the Pycnogenol® group while no significant changes were observed in the control group at any time.

CONCLUSION

Pycnogenol® significantly contributed to reduce signs and symptoms associated with menopausal transitions in women investigated in this study. Furthermore, Pycnogenol® improved the quality of life of most women and these benefits may be at least in part attributed to decreased oxidative stress levels.

Case series of perimenopausal women with insomnia treated with mirtazapine followed by prolonged-release melatonin add-on and monotherapy

OBJECTIVES

The sedating antidepressant mirtazapine is used off label for insomnia in perimenopausal women. Despite its apparent efficacy, mirtazapine causes significant increases in appetite and weight gain. Prolonged-release melatonin (PRM) is approved for primary insomnia in patients aged 55 years and older. A clinical experience with PRM add-on to mirtazapine in facilitating mirtazapine withdrawal while maintaining improved sleep quality and abrogating weight gain in perimenopausal women with insomnia is described.

METHODS

Eleven perimenopausal women (ages 45-52; FSH = 53 ± 8; normal BMI, 22.9 ± 0.6) with insomnia, who do not suffer from depression as assessed by the Hamilton scale, were treated with 15 mg mirtazapine (Remeron®) for 2-4 weeks. PRM, 2 mg (Circadin®), was then added on, and mirtazapine was tapered off for another 1-3 months. Prospective data on body weight and subjectively assessed sleep quality and well-being (assessed by the Pittsburgh Sleep Quality Index, PSQI, and Well-Being Index, WHO-5, respectively) were collected before, during, and at the end of the treatment.

RESULTS

Sleep quality ratings improved significantly (by 103% on average) during combined mirtazapine and PRM intake and 180% during subsequent intake of PRM alone or together with very low doses of mirtazapine (P < 0.05 for all). Well-being significantly improved by 83% during the treatment. Seven of 11 women demonstrated weight gain following mirtazapine intake, five of whom have started to reduce weight following mirtazapine withdrawal and PRM intake. No adverse events were reported.

CONCLUSION

Application of mirtazapine followed by PRM add-on and monotherapy improves sleep in perimenopausal women while evading mirtazapine-induced weight gain. These results warrant further investigation of a larger population in controlled clinical trials.

Midkine, a heparin-binding protein, is increased in the diabetic mouse kidney postmenopause

Estrogen is thought to protect against the development of chronic kidney disease, and menopause increases the development and severity of diabetic kidney disease. In this study, we used streptozotocin (STZ) to induce diabetes in the 4-vinylcyclohexene diepoxide (VCD)-treated mouse model of menopause. DNA microarrays were used to identify gene expression changes in the diabetic kidney postmenopause. An ANOVA model, CARMA, was used to isolate the menopause effect between two groups of diabetic mice, diabetic menopausal (STZ/VCD) and diabetic cycling (STZ). In this diabetic study, 8,864 genes of the possible 15,600 genes on the array were included in the ANOVA; 99 genes were identified as demonstrating a >1.5-fold up- or downregulation between the STZ/VCD and STZ groups. We randomly selected genes for confirmation by real-time PCR; midkine (Mdk), immediate early response gene 3 (IEX-1), mitogen-inducible gene 6 (Mig6), and ubiquitin-specific protease 2 (USP2) were significantly increased in the kidneys of STZ/VCD compared with STZ mice. Western blot analysis confirmed that Mdk and IEX-1 protein abundance was significantly increased in the kidney cortex of STZ/VCD compared with STZ mice. In a separate study, DNA microarrays and CARMA analysis were used to identify the effect of menopause on the nondiabetic kidney; VCD-treated mice were compared with cycling mice. Of the possible 15,600 genes on the array, 9,142 genes were included in the ANOVA; 20 genes were identified as demonstrating a >1.5-fold up- or downregulation; histidine decarboxylase and vanin 1 were among the genes identified as differentially expressed in the postmenopausal nondiabetic kidney. These data expand our understanding of how hormone status correlates with the development of diabetic kidney disease and identify several target genes for further studies.

[Effects of yikunning on the expressions of bcl-2 and bax in rat ovaries during perimenopausal period]

OBJECTIVE

To investigate the effects of Yikunning (YKN, Chinese Traditional Medicine) on the expressions of bcl-2 and bax in rat ovaries during perimenopausal period.

METHODS

Thirty female Wistar rats during perimenopausal period were selected by unforced aging. Then the rats were divided into 3 groups randomly: YKN group, Livial control group and Aged control group. Ten young female Wistar rats were selected as young control group. Intragastric administrations were conducted for 4 weeks once daily continuously. The expressions of Bcl-2 Bax mRNAs and proteins in rat ovaries were detected by RT-PCR and Western blot.

RESULTS

The levels of Bcl-2, Bax mRNAs and proteins in rat ovaries in YKN group were higher than those in Aged control group, which showed differences among them (P < 0.01). The Bcl-2/Bax mRNA rate and protein rate in rat ovaries in YKN group were higher than those in Aged control group, which showed differences among them (P < 0.05 or P < 0.01).

CONCLUSION

YKN could increase the expressions of Bcl-2, Bax mRNAs and proteins and up-regulate the Bcl-2/Bax mRNA rate, protein rate in rat ovaries during perimenopausal period, which might be one of the molecular mechanisms of YKN postponed the ovarian failure and cured perimenopausal syndrome.

[Effect of zuoguiyin on the expression of ovarian follicle-stimulating hormone receptor in rats during peri-menopausal period]

OBJECTIVE

To investigate the effect and mechanism of Zuoguiyin (ZGY, a Chinese medical remedy for regulating qi and nourishing yin) on expression of ovarian follicle-stimulating hormone receptor (FSHR) in rats during peri-menopausal period (PMP).

METHODS

PMP rats were administered with low (13.78 g/kg), middle (20.67 g/kg) and high (31.00 g/kg) dose ZGY respectively by gastrogavage for eight weeks. FSHR mRNA and protein expressions were detected by RT-PCR and immunohistochemistry respectively. Besides, granulosa cells, collected from pregnant mare serum treated nonage rats, were incubated, and the level of FSHR mRNA expression in the cultured cells were detected after various disposals.

RESULTS

(1) Ovarian levels of FSHR mRNA and protein expressions in PMP rats were significantly lower than those in young rats (P<0.01), but were up-regulated significantly by ZGY treatment (P<0.01). (2) As compared with the control, FSHR mRNA expression increased in cultured granulosa cells after treated by ZGY extract; the increasing effect of ZGY was enhanced by combined treatment with Forskolin and attenuated by Genistein (a tyrosine protein kinase inhibitor).

CONCLUSION

ZGY could improve the ovarian functions during PMP by up-regulating the expression of FSHR and raise the ovarian responsibility to FSH, which may be possibly realized by activating cAMP-protein kinase and tyrosine protein kinase signal pathway.

[Effect of Zuoguiyin on expression of ovarian VEGF and SPARC in rats during peri-menopausal period]

OBJECTIVE

To investigate the effect of one kind of regulating-qi and Nourishing-yin Chinese herbs Zuoguiyin on the expression of rats ovarian vascular endothelial growth factor (VEGF) and secreted protein acidic rich in cysteine (SPARC) during the period of peri-menopause.

METHOD

The animal models of perimenopause rats were established by natural aging. Perimenopause rats were treated by intragastric administration (ig) with low (13.78 g x kg(-1)), middle (20.67 g x kg(-1)) and high (31 g x kg(-1)) dose of Zuoguiyin for 8 weeks. Expression of VEGF and SPARC mRNA were detected by RT-PCR. Immunohistochemistry was used to evaluate expression levels of VEGF protein.

RESULT

Compared with that in the control group, ovarian expression levels of VEGF mRNA and its protein in rats during peri-menopause increased significantly (P < 0.01). Middle and high dose of Zuoguiyin could both down-regulate the expression of VEGF in ovaries of praesenilis rats, and the difference has statistical significance (P < 0.01). Expression levels of SPARC mRNA in rat ovaries during peri-menopausal period decreased obviously compared to that in the control group (P < 0.01). Middle and high dose of Zuoguiyin could greatly promote ovarian SPARC mRNA expression of praesenilis rats (P < 0.01).

CONCLUSION

The abnormal changes of VEGF and SPARC may play an important role in the aging process of ovary. Zuoguiyin, one kind of regulating-qi and Nourishing-yin Chinese herbs, can improve ovarian vascular formation through down-regulating the expression of VEGF meanwhile up-regulating the expression of SPARC. And it may delay aging by this way.

Sex hormones and mood in the perimenopause

The focus of this chapter is the relationship between the onset of depression in women and the reproductive events of the menopause transition. Epidemiologic studies have documented that the majority of women do not become depressed during the menopause transition. However, recent longitudinal studies suggest that in some women, the reproductive events related to the menopause transition could play a role in the onset of depression. No abnormality of ovarian hormones has been identified that distinguishes women with depression from those who remain asymptomatic during the menopause transition. Nonetheless, several findings suggest a role of ovarian hormones in the onset of these depressions. First, episodes of depression cluster during the stage of the menopause transition that is accompanied by estradiol withdrawal. Second, randomized controlled trials have documented the short-term (3-6 weeks) antidepressant efficacy of estradiol in depressed perimenopausal women. Third, experimentally induced estradiol withdrawal triggers mood symptoms in some women. Thus, although depression is not a uniform accompaniment of the menopause transition, in some women, age-related changes in ovarian estrogen production may alter central nervous system function and predispose them to develop depression.

[Efficacy and safety of remifemin compared to tibolone for controlling of perimenopausal symptoms]

OBJECTIVE

To investigate the efficacy and safety of remifemin (isopropanolic extract of cimicifuga racemosa) treating perimenopausal symptoms in comparison of tibolone.

METHODS

One hundred and eighty postmenopausal women at range of 40 - 60 years old were enrolled in a multicenter, randomized and double blind study. They were divided into remifemin and tibolone group at ratio 1:1. The therapeutic strategy was remifemin 20 mg bid po for 12 weeks in remifemin group and tibolone 2.5 mg qd po for 12 weeks in tibolone group. To evaluate therapeutic effect, total score of Kupperman menopause index (KMI) was used as the major observed index and single item score of KMI were secondary observed index. Safety warning was determined by laboratory tests and adverse events at timepoint of before, at 4 and 12 weeks treatment.

RESULTS

(1) Total score of KMI: it were 24 +/- 5 in remifemin group and 25 +/- 6 in tibolone group before treatment. At timepoint of 4 weeks treatment, it were 11 +/- 6 in remifemin group and 11 +/- 7 in tibolone group. At timepoint of 12 weeks treatment, it were 7 +/- 6 in remifemin group and 6 +/- 5 in tibolone group. Total KMI score between two groups did not show statistical difference at various timepoint (P > 0.05). (2) Single item score of KMI: when compared before, at 4 and 12 weeks treatment, did show remarkable difference (P < 0.05) either in remifemin or in tibolone group. However, those single items of KMI score did not show statistical difference between 4 and 12 weeks timepoint in each treatment group (P > 0.05). (3) Adverse effect: the incidence of adverse effect in remifemin group was significantly lower than that of tibolone group. None case with vaginal bleeding was observed in remifemin group, however, 17 cases with vaginal bleeding occurred in tibolone group (19%, 17/90). The incidence of breast swelling were 16% (14/90) in remifemin group and 36% (32/90) in tibolone group; before treatment, the thickness of endometrium were (2.6 +/- 1.1) mm in remifemin group and (2.8 +/- 1.1) mm in tibolone group; at timepoint of 12 weeks treatment, the thickness of endometrium were (2.9 +/- 1.4) mm in remifemin group and (3.4 +/- 2.0) mm in tibolone group. In comparison of thickness of endometrium before and at 12 weeks treatment, no remarkable changes was observed in remifemin group, however, endometrium displayed significantly thicker in tibolone group.

CONCLUSIONS

Our study suggested that remifemin was one effective and safe agent to manage women with climacteric symptom. It has similar therapeutic effect and lower incidence of adverse effect when compared with tibolone.

Efficacy of the special extract ERr 731 from rhapontic rhubarb for menopausal complaints: a 6-month open observational study

BACKGROUND

The special extract ERr 731 from the roots of rhapontic rhubarb has been in widespread use in Germany since 1993, and the current regulations have required an evaluation of its risk:benefit ratio in daily use.

OBJECTIVE

To demonstrate the efficacy and tolerability ofERr 731 in menopausal women in everyday practice.

DESIGN

Three hundred sixty-three menopausal women with menopausal symptoms were enrolled at 70 German gynecological practices and received ERr 731 for 6 months. Women visited the practices for a baseline assessment and after 3 and 6 months.

MAIN OUTCOME MEASURES

Primary outcome criterion was the change of the Menopause Rating Scale (MRS) total score after 6 months. Other assessments included compliance, tolerability, health-related quality of life, and occurrence of adverse events.

RESULTS

After 6 months of treatment with ERr 731 in 252 women, there was a significant decrease of the MRS total score from 14.5 points at baseline to 6.5 points (P<.0001). The reduction of the MRS score was more pronounced in women with a score of > or =18 points at baseline. One tablet per day was sufficient to reduce the symptoms significantly in the majority of women. The health-related quality of life improved markedly. A good or very good treatment outcome was reported by the majority of the participating women. One adverse event was reported that was assessed as having no relation to ERr 731 intake.

CONCLUSION

ERr 731 is a well-tolerated and safe medication for the successful treatment of menopausal symptoms in peri- and postmenopausal women.

Escitalopram versus ethinyl estradiol and norethindrone acetate for symptomatic peri- and postmenopausal women: impact on depression, vasomotor symptoms, sleep, and quality of life

OBJECTIVE

To examine the efficacy and tolerability of escitalopram (ESCIT) compared to estrogen and progestogen therapy (EPT) for the treatment of symptomatic peri- and postmenopausal women.

DESIGN

Forty women (aged 40-60 years) with depressive disorders and menopause-related symptoms were randomly assigned to an 8-week open trial with ESCIT (flexible dose, 10-20 mg/day; fixed dose, 10 mg/day for the first 4 weeks) or estrogen plus progestogen therapy (ethinyl estradiol 5 microg/day plus norethindrone acetate 1 mg/day). Primary outcome measures included Montgomery-Asberg Depression Rating Scale and the Greene Climacteric Scale at week 8. Secondary outcome measures included the Clinical Global Impressions as well as sleep and quality of life assessments.

RESULTS

Thirty-two women (16 on EPT, 16 on ESCIT) were included in the analyses. Full remission of depression (score of <10 on the Montgomery-Asberg Depression Rating Scale) was observed in 75% (12/16) of subjects treated with ESCIT, compared to 25% (4/16) treated with EPT (P = 0.01, Fisher's exact tests). Remission of menopause-related symptoms (>50% decrease in Greene Climacteric Scale scores) was noted in 56% (9/16) of women treated with ESCIT compared to 31.2% (5/16) on EPT (P = 0.03, Pearson's chi2 tests). Improvement in sleep, hot flashes, and quality of life was observed with both treatments.

CONCLUSIONS

ESCIT is more efficacious than EPT for the treatment of depression and has a positive impact on other menopause-related symptoms. ESCIT may constitute a treatment option for symptomatic menopausal women who are unable or unwilling to use hormone therapy.

Can myomectomy be suggested for perimenopausal women before administering hormone replacement therapy?

OBJECTIVES

The aim of this study was to evaluate whether abdominal myomectomy could be a choice for patients with symptomatic fibroids above the age of 48 years, who wish to get hormonal replacement therapy and desire to retain their uterus.

METHODS

We performed 504 abdominal myomectomies between 1990 and 2004. The mean age was 33+/-4.09 years, 9 (1.8%; 9/504) patients were above 48 years and 6 (1.19%; 6/504) of them requested hormonal replacement therapy (HRT) after the enucleation of fibroids. Data of these nine cases were compared to a matched control group of patients who had hysterectomy in the same year in 3 months to those who underwent abdominal myomectomy with same indications for surgery, same location, size and number of fibroids. The main aim of our study was to compare perioperative morbidity, duration of hospital stay between myomectomy and hysterectomy groups and determine the recurrence of fibroids and/or symptoms in 1 year with HRT in the myomectomy group.

RESULTS

The perioperative morbidity did not differ between the compared groups. In the myomectomy group with 1-year HRT we did not observe the recurrence of fibroids and symptoms.

CONCLUSION

Our data suggest that abdominal myomectomy may be a satisfactory option for perimenopausal women with symptomatic fibroids who wish to retain their uterus and get HRT.

The Association Between Mammographic Breast Density and Bone Mineral Density in the Study of Women's Health Across the Nation

BACKGROUND

Bone mineral density and mammographic breast density are each associated with markers of lifetime estrogen exposure. The association between mammographic breast density and bone mineral density in early perimenopausal women is unknown.

METHODS

We analyzed data from a cohort (n = 501) of premenopausal (no change in menstrual regularity) and early perimenopausal (decreased menstrual regularity in past 3 months) participants of African-American, Caucasian, Chinese, and Japanese ethnicity in the Study of Women's Health Across the Nation. Using multivariable linear regression, we examined the cross-sectional association between percent mammographic density and bone mineral density (BMD).

RESULTS

Percent mammographic density was statistically significantly inversely associated with hip BMD and lumbar spine BMD after adjustment (body mass index, ethnicity, age, study site, parity, alcohol intake, cigarette smoking, physical activity, age at first childbirth) in early perimenopausal, but not premenopausal, women. In early perimenopausal women, every 0.1g/cm(2) greater hip BMD predicted a 2% lower percent mammographic density (95% confidence interval -37.0 to -0.6%, p = 0.04).

CONCLUSION

Mammographic breast density is inversely associated with BMD in the perimenopausal participants of this community-based cohort. The biological underpinnings of these findings may reflect differential responsiveness of breast and bone mineral density to the steroid milieu.

Low-dose hormone therapy in the perimenopause

OBJECTIVE

To evaluate the effects of low-dose hormone therapy (LD-HT) on bleeding pattern and vasomotor symptoms in perimenopausal women.

METHODS

In a prospective, open-label study at an University clinic, 120 perimenopausal women suffering from irregular menstrual cycles and hot flushes were randomized to micronized 17beta-estradiol 1 mg plus dydrogesterone 10 mg sequential added (LD-HT; group A: 60 subjects) or dydrogesterone 10 mg from day 15 to 28 (group B: 60 subjects). Number and severity of hot flushes and bleeding pattern were assessed throughout the study.

RESULTS

Women in group A experienced a significant reduction in number of hot flushes while no significant variation was observed in group B. The incidence of cyclic bleeding was 86% in group A and 76% in group B, the mean duration was significantly lower in group A than in group B.

CONCLUSIONS

LD-HT may control both irregular bleeding and hot flushes in perimenopausal women.

The levonorgestrel intrauterine system for use in peri- and postmenopausal women

The intrauterine system (IUS) delivering levonorgestrel (LNG; Mirena), initially developed as a long-acting method of contraception, has demonstrated its efficacy and safety in a large number of users all over the world. The local delivery of a small dose of a highly effective progestin in the uterine cavity maintains the endometrium in a nonproliferative state and reduces the number of bleeding days, thus preventing anemia, an important medical benefit, especially in developing countries. In addition, the intrauterine delivery of a progestin allows the treatment of other medical conditions and prevention of endometrial hyperplasia, in postmenopausal women receiving estrogen therapy. During the perimenopausal years, the IUS provides an effective contraception as occasional ovulations occur. In addition, by its direct effect on the endometrium, it prevents the occurrence of menorrhagia, a frequent condition in the premenopause. After cessation of the ovarian function, when estrogen therapy may be initiated, the IUS would ensure endometrial protection as a transition to the menopause and as long as hormone therapy is needed. Although the circulating levels of LNG are very low, minor side effects related to the androgenic properties of LNG have been reported. In addition, the insertion of the system needs a skilled health provider and may be difficult or painful when the uterus is small or atrophic. The development of smaller devices is warranted for these specific situations.

Estrogen, estrogen treatment and the post-reproductive woman's brain

From early embryonic life to death, estrogen is a primary regulator of brain neurogenesis and cell number, synaptogenesis and synaptolysis, multiple cognitive and autonomic functions, vascular function, immune responses and defense measures against brain lesions and dystrophy. Although recent attention has focused on the roles of estrogen during the climacteric, knowing estrogen's role in brain development and reproductive function is necessary to understand what happens when this powerful influence is removed during the climacteric. This review will therefore address the full picture, with stress on the later-life role of estrogen in the brain.

A tale of two studies: the importance of setting, subjects and context in two randomized, controlled trials of a web-based decision support for perimenopausal and postmenopausal health decisions

OBJECTIVE

Knowledge relevant to women's peri- and postmenopausal health decisions has been evolving rapidly. Web-based decision supports can be rapidly updated and have the potential to improve the quality of patients' decisions. We developed and tested a web-based decision support for peri- and postmenopausal health decisionmaking.

METHODS

We recruited 409 women aged 45-75 for one randomized, controlled trial and 54 women with an upcoming clinic appointment for a subsequent trial. Women were randomized to use the web-based decision support versus a printed brochure (first trial) and usual care (second trial). Outcomes were changes in decisional satisfaction, decisional conflict, and knowledge, both within each trial and compared across the trials.

RESULTS

Intervention subjects had greater increases in decisional satisfaction in the second trial and knowledge in both trials. A high dropout rate among women randomized to the website in the first trial effectively negated benefits in that trial, but not in the second.

CONCLUSIONS

The utility of this web-based decision support in two trials depended on a number of factors that appear related to the urgency of making a decision.

PRACTICE IMPLICATIONS

Decision aids should be targeted to patients actively trying to make a decision.

Urinary Incontinence and Estrogen

Is hormone replacement therapy an effective treatment?

The levonorgestrel-releasing intrauterine system as an alternative to hysterectomy in peri-menopausal women

INTRODUCTION

Hysterectomy is one of the most common surgical procedures performed in gynecological practice, and the most common indication for hysterectomy is menorrhagia or excessive menstrual bleeding. Approximately 10-15% of fertile women have menorrhagia, defined as a menstrual blood loss (MBL) of >80 mL. Since operative treatment in the form of a hysterectomy carries a not insignificant risk of morbidity and mortality, various forms of medical treatment have been advocated as initial treatment.

RESULTS

Antifibrinolytic agents, e.g., tranexamic acid (40-50% reduction), prostaglandin synthetase inhibitors (20-25% reduction), oral contraceptives (40-50%) and the intrauterine release of progestin with the levonorgestrel-releasing intrauterine system (LNG-IUS; 86-97% reduction), have all been shown to reduce MBL and to be effective in the treatment of idiopathic menorrhagia. In comparative and noncomparative trials, the greatest reduction in MBL has been achieved with the LNG-IUS. Thus, this system has been proposed as an alternative to hysterectomy in women with menorrhagia. In a randomized controlled trial, the LNG-IUS was compared with hysterectomy. Only 42% of the women randomized to the LNG-IUS system subsequently underwent a hysterectomy during the 5-year observation period, and the total costs (direct and indirect) were 40% lower with the LNG-IUS than with hysterectomy.

CONCLUSION

Despite the strong evidence that medical treatment and, in particular, the LNG-IUS are effective, many hysterectomies and endometrial ablations/resections are performed annually without first evaluating medical treatment.

Training or EPT in perimenopause on balance and flushes

With advancing age, the postural balance function deteriorates as a consequence of decreased functional capacity. Deteriorating balance is a risk factor for bone fractures due to increased risks of falls. It has been suggested that the loss of estrogen, which occurs in relation to the menopause, may be associated with loss of balance. Regular physical exercise without balance training has, in some studies, been shown to have positive effects on the postural balance. The aim of the present study was to examine balance function during the perimenopausal period, and evaluate the effect of estrogen plus progesterone therapy (EPT) or aerobic training on balance. Sixty perimenopausal women were recruited to the study. The subjects were then randomised to either physical training (n=20), EPT (n=20), or to a control group (n=20). The study period was 18 months. Postural stability was measured every third month using a custom-made force platform. The women using EPT achieved better results in 3 of 6 parameters, after 18 months.