The midlife transition and the risk of cardiovascular disease and cancer Part I: magnitude and mechanisms

Heart disease and cancer are the leading causes of death in the United States. In women, the clinical appearance of both entities-coronary heart disease and cancer (breast, endometrium, and ovary)-escalate during the decades of the midlife transition encompassing the menopause. In addition to the impact of aging, during the interval between the age of 40 and 65 years, the pathophysiologic components of metabolic syndrome also emerge and accelerate. These include visceral adiposity (measured as waist circumference), hypertension, diabetes, and dyslipidemia. Osteoporosis, osteoarthritis, sarcopenia, depression, and even cognitive decline and dementia appear, and most, if not all, are considered functionally related. Two clinical reports confirm the interaction linking the emergence of disease: endometrial cancer and metabolic syndrome. One describes the discovery of unsuspected endometrial cancer in a large series of elective hysterectomies performed in aged and metabolically susceptible populations. The other is from the Women's Health Initiative Observational Study, which found a positive interaction between endometrial cancer and metabolic syndrome regardless of the presence or absence of visceral adiposity. Both provide additional statistical support for the long-suspected causal interaction among the parallel but variable occurrence of these common entities-visceral obesity, heart disease, diabetes, cancer, and the prevalence of metabolic syndrome. Therefore, 2 critical clinical questions require analysis and answers: 1: Why do chronic diseases of adulthood-metabolic, cardiovascular, endocrine-and, in women, cancers of the breast and endometrium (tissues and tumors replete with estrogen receptors) emerge and their incidence trajectories accelerate during the postmenopausal period when little or no endogenous estradiol is available, and yet the therapeutic application of estrogen stimulates their appearance? 2: To what extent should identification of these etiologic driving forces require modification of the gynecologist's responsibilities in the care of our patients in the postreproductive decades of the female life cycle? Part l of this 2-part set of "expert reviews" defines the dimensions, gravity, and interactive synergy of each clinical challenge gynecologists face while caring for their midlife (primarily postmenopausal) patients. It describes the clinically identifiable, potentially treatable, pathogenic mechanisms driving these threats to quality of life and longevity. Part 2 (accepted, American Journal of Obstetrics & Gynecology) identifies 7 objectives of successful clinical care, offers "triage" prioritization targets, and provides feasible opportunities for insertion of primary preventive care initiatives. To implement these goals, a reprogrammed, repurposed office visit is described.

The midlife transition and the risk of cardiovascular disease and cancer Part II: strategies to maximize quality of life and limit dysfunction and disease

Chronic dysfunction, disabilities, and complex diseases such as cardiovascular disease, diabetes mellitus type 2, osteoporosis and certain cancers, among other burdens, emerge and accelerate in midlife women. Previously in part l, we described the clinical and laboratory research findings that more readily explain and clarify the underlying pathogenetic mechanisms driving these clinical burdens, including new findings on how in particular visceral obesity and the emergence and acceleration of various components of metabolic syndrome-glucotoxicity and lipotoxicity-and a chronic systemic inflammatory state abetted by the loss of ovarian production of estradiol and the inevitable inroads of aging generate this spectrum of clinical problems. These research insights translate into opportunities for effective care strategies leading to prevention, amelioration, possible correction, and enhanced quality of life. To achieve these goals, updated detailed diagnostic, management, and therapeutic guidelines implemented by a reprogrammed and repurposed "menopause" office visit are described. A triage mechanism-when to refer to other specialists for further care-is emphasized. The previously polarized views of menopausal hormone therapy have narrowed significantly, leading to the construction of a more confident, unified, and wider clinical application. Accordingly, a menopausal hormone therapy program providing maximum benefit and minimum risk, accompanied by an algorithm for enhanced shared decision making, is included.

SAT-151 Regulation of Low-Density Lipoprotein Receptor Expression in Triple Negative Breast Cancer

Preclinical models and clinical studies suggest that hypercholesterolemia promotes breast cancer progression ^1,2. The expression of the low-density lipoprotein receptor (LDLR) has been positively associated with poorer recurrence-free survival in human breast cancer studies ³. Mechanistically, LDLR has been demonstrated to play a role in the increased tumor growth associated with hypercholesterolemia, as knock-down of LDLR led to decreased tumor growth in setting of elevated circulating LDL cholesterol. The aim of this study was to identify factors which up-regulate expression of LDLR in triple negative breast cancer (TNBC). In glioblastoma, hyper-activation of the epidermal growth factor receptor (EGFR) signaling pathway has been associated with greater LDLR expression and susceptibility to targeting of cholesterol metabolism⁴. As EGFR is frequently expressed in TNBC⁵, we examined if increased LDLR expression is associated with activation of the EGFR signaling pathway in TNBC. The expression of LDLR in the TNBC cell lines, MDA-MB-231 (231) and MDA-MB-468 (468) was examined pre- and post-EGF stimulation of the EGFR and in the presence of chemical inhibitors. Cells were grown in DMEM/10% FBS/1% Pen/strep (P/S), and experiments were performed under reduced serum conditions at 1.25%FBS/DMEM/1%P/S. In the absence of stimulation, LDLR protein expression was 3-fold higher in 231 vs 468 cell lines. This was despite mRNA expression being comparable at baseline, suggesting that the difference in protein expression was post-transcriptionally mediated. Treatment with 10 ng/mL EGF for 2 hours led to an increased activation of the EGFR, phosphorylation of Akt and extracellular signal regulated kinase (ERK) in both cell lines but induced an increase in LDLR protein and mRNA expression only in 468 cells. Treatment of 468 cells with EGF after exposure to actinomycin, a transcription inhibitor, revealed that EGF treatment resulted in reduced degradation of LDLR mRNA (p = 0.002) over 3 hours, suggesting that the EGF-induced increase in LDLR expression was by protection of LDLR mRNA from degradation. Chemical inhibition of the ERK pathway with 20 μM UO126 reduced both the EGF-induced increase in LDLR expression in 468 cells (p = 0.015) as well as the high baseline expression of LDLR by half in 231 cells (p = 0.001). Overall our results suggest that the EGFR/ERK signaling pathway regulates LDLR expression in TNBC, supporting the increased anabolic needs of this aggressive, swiftly expanding form of breast cancer.

References:¹Alikhani, N. et al., Oncogene32, 961-967 (2013), ²Pelton, K. et al., Am. J. Pathol.184, 2099-2110 (2014), ³Gallagher, E. J. et al., Oncogene36, 6462-6471 (2017), ⁴Guo, D. et al., Cancer Discov.1, 442-456 (2011), ⁵Reis‐Filho, J. S. & Tutt, A. N. J. Histopathology52, 108-118 (2008).

SUN-131 The Roles of Two Insulin Receptor Isoforms in Triple Negative Breast Cancer Growth

Systemic hyperinsulinemia is believed to be an important factor in the progression of a number of cancers, including breast cancer by activating the insulin receptor (IR) signaling cascade in the tumor cells. The IR is expressed in two isoforms, IR-A and IR-B. IR-B is the full-length isoform, while IR-A is lacking 12 amino acids in the α-subunit due to exon 11 alternative splicing. IR-A is predominantly expressed in cancer tissues, while IR-B is mostly expressed in metabolic tissues. The IR and closely related insulin-like growth factor 1 receptor (IGF-1R) are expressed in different ratios in cancer cells. Compared with estrogen receptor positive breast cancers, triple negative breast cancers (TNBC) frequently have higher ratios of IR to IGF-1R. Hyperinsulinemia is associated with increased prevalence of TNBC in pre-menopausal women. Although new targeted therapies are emerging, among breast cancer subtypes TNBC continues to carry the worst prognosis and therefore developing a greater understanding of the links between IR signaling and TNBC progression is critical. The aim of this study is to understand the role of IR-A and IR-B on proliferation, metastasis and metabolism in breast cancer cells. We stably overexpressed human IR-A (IR-A OE) and IR-B (IR-B OE) in TNBC MDA-MB-231 (231) and murine c-myc/vegf overexpressing Mvt1 cells with lentiviral transduction using pLVX-IRES-puro HIV-1-based expression vectors with cDNA encoding the human IR-A,IR-B and control cDNA sequences. Native murine IR was silenced using lentiviral transduction of shRNA in the Mvt1 cells. Overexpression of IR was confirmed at a protein level by western blot, and RNA isoform expression was confirmed using real time PCR. Cell proliferation assays were performed in DMEM/10% FBS and revealed that MDA-MB-231 cells with IR-A OE cells had 15% higher proliferation rates than 231 IR-B OE cells. We then examined the IR signaling pathways by western blot in DMEM/10% FBS. No differences in phosphorylated or total ERK1/2 were observed between control, 231 IR-A OE and 231 IR-B OE cells. 231 IR-A OE cells were found to have 15-fold greater Akt phosphorylation (Ser473) than 231 control cells (p=0.0008) and 4 fold higher pAkt(Ser473) compared with 231 IR-B OE cells (p=0.0016). Further, we found that 231 IR-A OE cells had approximately 2 fold greater expression of c-myc protein compared with both 231 control (p=0.047) and 231 IR-B OE cells (p=0.026). No differences in c-myc expression were observed between 231 IRB OE and 231 control cells. In our previous studies we found that insulin stimulates c-myc expression and silencing the IR reduces c-myc expression in cancer cells. Our current studies show that IR-A, rather than IR-B is the insulin receptor isoform that regulates c-myc expression in human TNBC. Reference: (1) Belfiore et al., Endocr Relat Cancer. 2011; 18(4):R125-R147. (2) Ferguson et al., Breast Cancer Res. 2012; 14(1): R8.

SAT-137 The Effect of Hypertriglyceridemia on Triple Negative Breast Cancer Progression

Obesity is associated with increased cancer risk and cancer-associated mortality^1,2. Hypertriglyceridemia (HTG), a component of the metabolic syndrome which frequently co-exists with obesity, has been associated with increased breast cancer risk and mortality in triple negative breast cancer (TNBC)^3,4. To determine if HTG is causally related to enhanced TNBC progression in the absence of other obesity-associated characteristics, TNBC growth and metastasis in a mouse model of HTG was examined. Mice overexpressing human apolipoprotein C3 (AC3) were backcrossed onto FVB/N background and crossed with recombination-activating gene 1 (Rag1) knockout mice to generate immunodeficient HTG mice. AC3 mice relative to wild-type (WT) littermates showed a 20-fold higher circulating triglycerides (p < 0.0001) and elevated very low density lipoprotein (VLDL) cholesterol (p = 0.001). No differences in body weight, body composition, blood glucose or plasma insulin levels were observed between the two groups, allowing for investigation on the influence of HTG on TNBC without confounders such as hyperinsulinemia or hyperglycemia. AC3 mice orthotopically implanted with the mouse mammary tumor cell line, Mvt1, showed both increased tumor growth (AC3 vs WT: 1157.0 ± 84.2 vs 707.2 ± 58.6 mm³, p = 0.0009) and lung metastasis (AC3 vs WT: 57.3 ± 3.0 vs 32.9 ± 5.3 mm³, p = 0.001) relative to WT mice. Immunodeficient Rag1/AC3 mice likewise, showed increased tumor growth compared to WT controls when implanted with human TNBC MDA-MB-231 cells (AC3 vs WT: 363.2 ± 113.9 vs 92.95 ± 16.2 mm³, p = 0.038). To investigate how HTG affects tumor lipid metabolism, serum and tumors from both groups were analyzed by liquid chromatography/mass spectrometry. Total alkyl-acyl, di-acyl-phosphatidylcholines and sphingomyelin concentrations were higher in the serum of AC3 mice relative to WT. In contrast, no overall difference in tumor phospholipid or acylcarnitine content was noted between AC3 and WT mice, suggesting no difference in fatty acid oxidation in the setting of HTG. Mvt1 tumors from AC3 and WT mice were analyzed by RNA sequencing. Decreased expression of genes associated with cholesterol synthesis (Fdft1, Pvmk, Acss2) were found in tumors from AC3 mice. Tumors from AC3 mice also showed decreased protein expression of LDLR, which is associated with LDL cholesterol uptake. Overall, these findings suggest that HTG, independently of other obesity-associated characteristics such as hyperinsulinemia and hyperglycemia, leads to changes in intracellular lipid metabolism and promotes TNBC progression.

References: ¹Chan, D. S. M. et al. Ann. Oncol. Off. J. Eur. Soc. Med. Oncol.25, 1901-1914 (2014). ²Pierobon, M. & Frankenfeld, C. L. Breast Cancer Res. Treat.137, 307-314 (2013). ³Lofterød, T. et al. BMC Cancer18, 654 (2018).⁴Goodwin, P. J. et al. Nutr. Cancer27, 284-292 (1997).

Endometrial cancer in elderly women: A histologic and steroid receptor study

BACKGROUND

Information on steroid receptor content in endometrial tissue of aging women is limited and somewhat controversial. The high incidence of endometrial cancer (EC) and the implication of hormone replacement therapy (HRT) in this group prompted the investigation of steroid receptors and endometrial cancer histology in the elderly.

OBJECTIVE

Review of histologic characteristics correlated with estrogen and progesterone receptors (ER and PR) status in EC in women over 75 years of age in order to determine the prevalence of a more aggressive endometrial neoplasm arising in late postmenopausal atrophic endometrium of elderly patients.

METHODS

Histologic slides and deeper sections stained immunohistologically for ER/PR from 54 cases of EC in women aged 75-95 years were reviewed. The histologic characteristics and degree of differentiation were correlated with the steroid receptor status, evaluated on a scale of 0-3. Benign endometrial tissue from women of the same group was used as controls.

RESULTS

The 57.4% endometrioid adenocarcinomas were mostly moderately and poorly differentiated. The nonendometrioid carcinomas were anaplastic, papillary, clear cell, squamous cell, mixed müllerian and nongestational choriocarcinoma. The staining intensity for ER/PR decreased with the degree of dedifferentiation being weak or absent in nonendometrioid tumors.

CONCLUSION

Elderly patients have less differentiated EC displaying histologically nonendometrioid patterns ('alienation') with no differential loss of receptors in cancer. ER/PR are partly preserved in endometrioid tumors and controls. We conclude that differential loss of receptor capacity is not a factor in pathogenesis of this age-related cancer.

Menopause-related oral alveolar bone resorption: a review of relatively unexplored consequences of estrogen deficiency

OBJECTIVE

The alveolar processes of the maxilla and mandible provide the bony framework for tooth support. Osteoporotic changes of these bones may directly affect tooth stability and retention. This report reviews studies that have evaluated the relationship between systemic osteoporosis and oral alveolar bone mass as well as the effect of estrogen use on oral alveolar bone and tooth retention.

DESIGN

Ten years (1989-1998) literature review.

RESULTS

Studies reviewed demonstrate a positive correlation between systemic bone mass and systemic osteoporosis to oral bone resorption. Estrogen replacement therapy affects oral bone in a manner similar to the way it affects other sites.

CONCLUSIONS

It is evident that postmenopausal estrogen users may retain more teeth after menopause. Sustained oral health and better tooth retention are potentially additional benefits for hormone replacement therapy users after menopause.

Functional anatomy and physiology of the female breast

As mammals, we define our biologic class by the function of the breast in nourishing our young. As obstetricians, we seek to enhance or diminish function; as gynecologists, the appearance of inappropriate lactation (galactorrhea) may signify serious disease. In this article, development, differentiation, and functional anatomy of the breast is discussed. The hormonal interactions responsible for these events and the physiologic function of this vital reproductive organ during the life cycle of the woman is emphasized.

Incidence of autoimmune antibodies in failed embryo transfer cycles

PROBLEM

The presence of antiphospholipid antibodies lupus anticoagulant (LAC), anticardiolipin antibody (ACA) as well as antinuclear antibody (ANA) has been associated with early spontaneous pregnancy loss and adverse pregnancy outcome. The purpose of this study was to investigate the possible role of autoimmune antibodies (LAC, ACA, and ANA) as a cause of implantation failure following embryo transfer (ET) after in vitro fertilization (IVF).

METHOD

Three groups were studied: Group I, 56 patients who failed to conceive following ET; group II, 14 patients who have conceived following IVF-ET and delivered or are carrying an uncomplicated ongoing pregnancy; and group III, 69 patients who were new candidates for IVF-ET.

RESULTS

Eighteen out of 56 (32.1%) of patients who failed to conceive following previous IVF-ET cycle (group I) tested positive for one or more of the autoimmune antibodies. None of the 14 patients of group II tested positive for autoimmune antibodies (P < .02). Seven out of the 69 patients (10%) of group III were found positive to one or more of the autoimmune factor. This rate is significantly lower than the rate of positive autoimmune antibodies detected in group I (P < .003). Fifteen patients of the 18 who tested positive for autoimmune antibodies and who had previously failed to conceive following ET underwent a subsequent IVF-ET cycle while being treated with prednisone and aspirin. Seven out of the 15 (46.6%) conceived and were able to sustain a clinical ongoing pregnancy.

CONCLUSIONS

Patients receiving ET are carrying viable embryos within the intrauterine environment. Therefore, in this unique group of patients, failure to demonstrate a positive pregnancy test represents an implantation failure or a very early postimplantation loss. The results of this study suggest that periimplantation events may be affected by autoimmune antibodies. Very early miscarriage or implantation failure may be related to the same pathophysiological mechanism that causes recurrent miscarriages and is diagnosed incorrectly as infertility.

Gynecologic manifestations of Sjögren's syndrome

OBJECTIVE

Sjögren's syndrome is a chronic, inflammatory autoimmune disease in which the salivary and lacrimal glands are progressively destroyed by lymphocytes and plasma cells. Because women are affected 10 times more often than men, we studied gynecologic manifestations of Sjögren's syndrome.

STUDY DESIGN

One thousand questionnaires were sent to women with Sjögren's syndrome in New York, New Jersey, Connecticut, and Pennsylvania. Five hundred thirty-nine women responded.

RESULTS

Women with Sjögren's syndrome reported significant vaginal dryness. There was no relationship of Sjögren's syndrome to either the incidence of infertility or miscarriage, although the 4% incidence of congenital anomalies in offspring was relatively high. Of the congenital anomalies, nine of 19 (47%) were cardiac. A long menstrual cycle (> 35 days) was associated with infertility and neuropathy.

CONCLUSIONS

The vaginal dryness in women with Sjögren's syndrome is not surprising, because the nasal and esophageal mucosae are also dry in this disorder. The relationship of infertility to a long menstrual cycle may simply indicate the presence of ovulatory dysfunction or inadequate luteal phase unrelated to Sjögren's syndrome. The relationship of neuropathy to a long menstrual cycle may be related to repeated, prolonged estrogen or progesterone exposure during the long cycles or to involvement of hypothalamic-pituitary-ovarian function.

Menopause medicine: current treatment options and trends

Demographic trends and increasing demand, as well as the intricacy of the emerging field of menopause medicine, dictates the need for a multidisciplinary approach for the care of the peri- and postmenopausal patient. A menopausal program benefits the individual patient by obviating the acute symptoms and by preventing long-term consequences. As morbidity and mortality rates associated with the long-term implications are reduced, substantial public health aspects are also beneficially affected. Cost effectiveness of a menopause program and routine HRT should be calculated as the net present value (NPV) for the health care financing program, and should prove to be greater than the NPV of future costs anticipated without an investment in primary preventive menopause program. We believe that the educated use of a menopause counseling program will yield an increasing benefit for the individual patient and the community. Should menopause be regarded as an endocrinopathy, thus justifying routine HRT, or are we engaged in the "medicalization" of a physiologic process? Bearing in mind the data reviewed above, it seems to us that ample reason exists to make every woman aware of the opportunity to receive long-term HRT. The decision to use it depends heavily on the patient's own informed assessment of her particular benefit-risk equation. Combined-continuous estrogen-gestagen replacement seems to provide the desired multisystem beneficial effects, and at the same time be the most convenient and associated with the least short-term side effects. Although emerging trends regarding the long-term risks associated with the use of such regimes are reassuring, more information needs to be elaborated before final conclusions can be offered.

Diagnosis and management of perimenopausal and postmenopausal bleeding

The menopausal years are characterized by a deficiency of progesterone and relative hyperestrogenism. This hormonal imbalance creates an environment favorable for the development of endometrial hyperplasia. The pathologic progression of hyperplasia to endometrial carcinoma can be arrested with progestogen therapy. A simple diagnostic approach for peri- and postmenopausal bleeding disorders is presented, along with a rational treatment regimen. Some of the risks and benefits of hormonal replacement therapy are discussed.

The microenvironment of the ovarian follicle

Observations on the steroid and peptide concentrations and interactions in the microenvironment of the human ovarian follicle have led to an understanding of three important issues in reproductive biology: (1) how the oocyte-granulosa-cell complex matures, (2) how a single follicle is selected and prepared for ovulation and (3) how the events are synchronized so that an ovum ready for fertilization is extruded at ovulation. These findings have clinical significance.

The neuroendocrinology of amenorrhea

Hypothalamic amenorrhea has a pathophysiologic basis. Loss of gonadotropin-releasing-hormone (GnRH) pulse amplitude and frequency is the proximal event in the evolution of hypogonadotropic hypogonadal amenorrhea. Except for rare conditions in which the parenchymal source of GnRH is destroyed, the major cause of dysfunction in GnRH is thought to be related to abnormalities of the neurotransmitters that control GnRH synthesis, storage and timely discharge. The dopamine/norepinephrine and endorphin systems are the principal targets of current research. This new knowledge should have a major impact on physicians' thinking about hypothalamic amenorrhea. A spectrum of clinically recognizable disorders appears in conjunction with alterations in GnRH secretions. Temperature control, appetite, fluid volume and behavioral distortions are now understandable as expressions of expanding hypothalamic dysfunction.

A practical approach for the evaluation of women with abnormal polytomography or elevated prolactin levels

Based upon the experience gained in the evaluation of 60 patients with abnormal polytomography and/or elevated prolactin levels, the following observations can be made: Patients with amenorrhea, amenorrhea and galactorrhea, galactorrhea alone, or anovulatory cycles and infertility may or may not have pituitary tumors. Clinical symptoms do not always correlate with the prolactin level, and patients with normal prolactins may have pituitary tumors. The incidence of empty sella is significant (15.8% in this series). Visual field examination is not a useful screening procedure, but evaluation of thyroid function is important to detect the occasional patient with hypothyroidism (3.5% in this series). The insulin tolerance test is not helpful in detecting the presence of pituitary tumors or in guiding management decisions, and the CT scan contributes little and should be omitted from the evaluation process. A straightforward, economical, and efficient approach to this clinical problem is presented.

Plasma estradiol window and urinary estriol glucuronide determinations for monitoring menotropin induction of ovulation

The plasma estradiol response is maximal 8--10 hours following mentropin injection. To obtain closer control, a menotropin protocol using 5 PM--8 PM injections and 8 AM blood sampling with a plasma estradiol window of 1000--2000 pg/ml was evaluated with simultaneous calibration of a urinary estriol glucuronide radioimmunoassay. One hundred twenty-eight paired urine and plasma samples were assayed in 48 cycles. In 26 cycles with paired samples on the day of human chorionic gonadotropin (hCG) injection, there were no cases of severe hyperstimulation, 2 cases of moderate hyperstimulation, and 11 pregnancies (42% of cycles given hCG). A window of between 40 and 100 micrograms/day of urinary estriol glucuronide corresponded to the 1000--2000 pg/ml plasma estradiol window by regression analysis. The pregnancy and hyperstimulation rates were compared with those observed in protocols previously published. Radioimmunoassay of urinary estriol glucuronide is faster and simpler than radioimmunoassay of plasma estradiol.

Ovulation and pregnancy rates with clomiphene citrate

A review of recent experience with clomiphene citrate at the Yale-New Haven Medical Center yields the following conclusions: 1) Clomiphene citrate administered at high doses (150 mg and 200 mg) is effective in inducing ovulation in women who would otherwise have failed to conceive if treatment were restricted to only lower dosage regimens. 2) Therapy with clomiphene citrate should be initiated with the 50-mg dose. The 100-mg dose should be reserved for those who fail with the lower dose. 3) Children resulting from clomiphene-induced ovulations appear to be developing normally both mentally and physically. Congenital malformations found in children from clomiphene-induced pregnancies are those seen commonly in general obstetric practice resulting in no significant problems for the children. 4) After 3 ovulations with clomiphene citrate approximately 50% of the patients can be expected to conceive. A 50% conception rate after 3 ovulations with clomiphene citrate does not represent a discrepancy between ovulation rates and pregnancy results, for it agrees statistically with the results obtained for the general population.