Vaginal microflora in postmenopausal women on hormone replacement therapy

To study the spectrum of vaginal microflora in postmenopausal women on hormone replacement therapy (HRT) and to compare the efficacy of Papanicolaou (Pap) smears with other methods for their detection. Eighty postmenopausal women were recruited for the study. These included 40 women who had attained spontaneous and were on HRT (User 1); 20 hysterectomised women on only estrogen therapy (User 2) and 20 controls (Non users). Their clinical data was recorded and specimens were collected for vaginal cultures (for aerobic bacteria and fungi), vaginal pH, Gram stain and Pap stain on cervical-vaginal smears and toluidine blue on wet smears. Vaginal pH was significantly lower in Users as compared to Non users. Lactobacilli and Gardnerella were more frequently isolated from Users while Bacteroides and E. coli were more common in Non users. Cultures were significantly more sensitive than Gram stained direct vaginal smears in detection of aerobic bacteria; however, Candida could be detected on Gram stain alone in all the cases. Frequency of detection of organisms significantly improved by application of Gram stain to the cervico-vaginal smears. However, clinically relevant organisms like Candida, Gardnerella and Mobiluncus could be identified on Pap smears alone in >50% cases. Lactobacilli could be readily identified in Pap smears in 98% cases. Wet mounts could detect cocci more easily as compared to Pap smears. Altered vaginal microbial profile in post menopausal women receiving HRT may cause bacterial and fungal vaginitis. Although culture studies remain the gold standard to detect these microorganisms, Pap and Gram stains and wet smears provide useful supplements and may be used as alternative procedures especially in resource limited settings lacking adequate culture facilities.     

Substrate utilization during exercise in postmenopausal women on hormone replacement therapy

It has been suggested that due to the slight direct or indirect effect of estrogen on lipolytic activity, the age-related decrease in production associated with the menopause may heighten the risk of cardiovascular and metabolic disease in women. While hormone replacement therapy (HRT) alone may have little or no effect on body mass in postmenopausal women, data suggest it can alter the shift toward abdominal adiposity. Furthermore, estrogen may have a synergistic effect on exercise-induced reduction in fat mass. Accordingly, the purpose of this investigation was to examine the potential influence of HRT on substrate utilization during 30 min of treadmill exercise at approximately 80% maximal oxygen uptake (V˙O_2max) in postmenopausal women. Eight women were receiving HRT and nine women were not (NHRT). No significant differences between the HRT and NHRT groups were noted for age, body mass, body fat, V˙O_2max or the percentage of V˙O_2max maintained during exercise. Expired gas samples were analyzed every 30 s to determine respiratory exchange ratio (R) and %V˙O_2max. The R, total energy expended and percentage contributions from fats and carbohydrate were averaged over three periods during the exercise (min 1–10, 11–20, and 21–30). There was no effect of HRT on R, total energy expended or substrate contribution. Thus, treatment of postmenopausal women using HRT (primarily conjugated equine estrogens in doses of 0.625–1.25 mg·day^–1) did not appear to affect the percentages of fat and carbohydrate utilized during 30 min of treadmill exercise at 80% of V˙O_2max. However, the exercise responses in this group of menopausal women were consistent with a duration-dependent increased reliance on fat as an energy source during exercise of moderate to vigorous intensity as has been demonstrated in younger populations. Electronic Publication     

Effect of long-term hormone therapy on telomere length in postmenopausal women

Telomeres undergo attrition with each cell division, and telomere length is associated with age-related diseases and mortality in the elderly. Estrogen can influence the attrition of telomeres by diverse mechanisms. This is a retrospective case control study that investigated the influence of long-term hormone therapy (HT) on telomere length in postmenopausal women. We recruited 130 postmenopausal women from 55 to 69 years of age for this study, and divided them into two groups. The first group included 65 women who had been on estrogen and progesterone therapy for more than five years (HT group). The other group was composed of 65 women matched in age to the HT group who had never had HT (non- HT group). The relative ratios of telomere length of study subjects to a reference DNA from a healthy young female were measured using quantitative PCR. Plasma levels of lipid profiles, total antioxidant status (TAS), C-reactive proteins (CRP), fasting glucose levels, and estradiol levels were measured. Age at menopause, vitamin use, and exercise, alcohol, and cigarette smoking histories were also assessed in a questionnaire. Mean duration (+/- SD) of HT was 8.4 +/- 2.3 years. Prevalence of vitamin use and regular exercise were higher in the HT group than in the non-HT group (p < 0.01). Relative telomere length ratios in the HT group were significantly greater than those in the non-HT group (p < 0.01). HT was significantly correlated with the relative telomere length ratio in multivariate analysis when potential confounding variables were controlled for (p < 0.05). In conclusion, telomere lengths were longer in postmenopausal women who had a history of long-term HT than in postmenopausal women without HT. Long-term HT in postmenopausal women may alleviate telomere attrition.     

Anticardiolipin antibodies during hormone replacement therapy in healthy postmenopausal women

Objective: The aim of the study was to investigate IgG and IgM anticardiolipin (aCL) antibodies in the course of hormone replacement therapy (HRT).

Subjects and methods: Thirty clinically healthy postmenopausal women with no history of previous thrombotic events or autoimmune disease were divided in two groups: control group (n=12, mean age 52.9±4.5 years, and 6.2±3.6 years duration of amenorrhea) and a second group (n=18, mean age 53.6±3.5 years, and 5.7±4.5 years of amenorrhea) who were allocated to HRT, containing 2 mg 17-beta estradiol plus 1 mg norethisterone acetate daily for 6 months. ACL antibodies of IgG and IgM isotype were assessed using ELISA and the Kupperman menopausal index (KI) was calculated at baseline and after 3 and 6 months of treatment. Results: HRT had a beneficial effect on climacteric symptoms, evaluated by KI (baseline versus 3rd month and 3rd month versus 6th month, P<0.001). The KI did not change in the control group. The values of IgG at the three studied periods did not change significantly and were 14.1±4.2, 13.1±4.9 and 13.4±3.7 in the HRT group and 12.7±3.1, 13.7±1.8 and 13.1±3.8 GPL, respectively, in the control group. IgM aCL antibodies increased during HRT and were as follows: 7.7±4.8 at baseline, 12.9±5.6 at 3rd month and 9.3±3.2 MPL at 6th month. In the control group, IgM were 8.0±2.8; 7.9±2.3 and 7.1±2.3 MPL, respectively. The differences between the two groups were significant at the third and the 6th month (P<0.01 and P<0.05). Conclusion: These data suggest that HRT is associated with elevation of IgM ACA in healthy postmenopausal women. As IgG aACA are considered more pathogenic, it seems unlikely that the early prothrombogenic effects of HRT can be assigned to ACA.     

The effects of hormone therapy on pulmonary function tests in postmenopausal women

OBJECTIVE: To investigate the effects of hormone therapy (HT) administered to postmenopausal women on pulmonary function tests (PFT). METHODS: Eighty-two postmenopausal women who were having natural or surgically initiated menopause and had no risk factor that could affect the respiratory system were included into this prospective, randomized study. Twenty-five women who refused to use HT were assessed as the control group (Group I). Nineteen women who accepted using HT and who were having surgically initiated menopause were given continuous estrogen (Group II), 23 were given continuous estrogen and progesterone in combination (Group III) and 15 were given cyclic estrogen and progesterone combination (Group IV). Forced expiratory volume (FEV1), forced vital capacity (FVC), FEV1/FVC, forced expiratory flow rate over 25-75% of the forced vital capacity volume and peak expiratory flow rate were assessed at the beginning of the treatment and in the third month in order to evaluate the effects of HT regimens on the women's PFT. RESULTS: A statistically significant increase was observed only in the FEV1 and FVC parameters of Group III after three months of therapy (P<0.05). The comparison between pre- and posttherapy FEV1 and FVC values showed an increase in the Group IV, but the difference was not statistically significant, while there was no difference between basal and third month FEV1 and FVC values of the group receiving estrogen only. CONCLUSIONS: It was seen that particularly continuous combined HT regimen positively affected the FEV1 and FVC parameters of the postmenopausal women.     

Effect of hormone therapy on BP in normotensive and hypertensive postmenopausal women

High blood pressure (BP) ranks as the greatest risk factor for cardiovascular disease. The increased cardiovascular risk determined in recent interventional studies has led the health authorities in some countries to re-ignite the discussion about whether hypertension should be listed as a contraindication for hormone replacement therapy (HRT). We reviewed papers published since 1960 and listed in MEDLINE, EMBASE and Biosis, on studies that monitored the course of BP during HRT. We found that both primarily normotensive and hypertensive postmenopausal women actually run only a very low risk of BP increase during HRT, indeed, BP was often lowered. In one of our own studies 1397 hypertensive women with BP diastolic >95 mmHg received transdermal HRT regimens; BP was lowered by an average of 7 mmHg systolic and 9 mmHg diastolic. The results of the more recent 24-h ambulatory BP studies are particularly conclusive. At least 19 such studies have been performed, 13 placebo-controlled and 10 cross-over; 5 found no effect on BP and 14 studies demonstrated BP reductions. BP was lowered by treatment with transdermal estradiol in 11 of 13 studies and by oral estrogen in 4 of 11 studies. The effects were not consistent with regard to systolic or diastolic BP nor to action on day- and night-time BP. It cannot be ruled out that some women with a particular predisposition exhibit an abnormal reaction to the vasoactive effects of HRT, and there is a paucity of long-term data on risk populations, specifically on the progestogenic effects in patients with pre-existing arteriosclerotic lesions. In conclusion, the risk of developing hypertension during HRT is very low, but hormone therapy should always be appropriately indicated and during therapy BP should be checked regularly.     

Impact of hormone replacement therapy on endogenous estradiol metabolism in postmenopausal women

OBJECTIVES: Changes in estradiol metabolism may play a role in the pathophysiology of different diseases, of special interest being an increase in D-ring over A-ring metabolites for the risk of breast cancer. In the present work we investigated the effect of exogenous estradiol therapy on endogenous estradiol metabolism in postmenopausal women. METHODS: Three different studies were carried out in 126 women: in study A the women were treated for 4 weeks either with oral or with transdermal 17beta-estradiol, in study B for 4 weeks with oral or transdermal 17beta-estradiol sequentially combined with oral or transdermal norethisterone acetate, and in study C for 12 weeks either with oral 17beta-estradiol or with an oral continuous combination of 17beta-estradiol with the new progestin dienogest. As main representatives of the A- and D-ring metabolism, 2-hydroxyestrone (2-OHE1) and 16 alpha-hydroxyestrone (16-OHE1), respectively, were measured in 8 h night urine using enzyme immunoassay technique. RESULTS: Oral estradiol treatment resulted in a significant higher excretion of estradiol metabolites compared to transdermal treatment. Neither oral nor transdermal estradiol induced a significant change in the ratio of 16-OHE1 to 2-OHE1. The addition of oral or transdermal norethisterone acetate to estradiol did not alter on average the endogenous estradiol metabolism, although in individual patients a significant increase in 16-OHE1 metabolism was observed only with oral norethisterone. The continuous oral addition of dienogest did not lead to any significant change in estradiol metabolism. CONCLUSIONS: These results indicate that oral estradiol replacement therapy enhances the quantity of circulating estradiol metabolites. This may have a more negative impact on estrogenic target cells as compared to transdermal application. Progestin addition to estradiol replacement therapy seems to have no major impact on endogenous estradiol metabolism. Further studies, however, are necessary to evaluate the progestin effect in possible pre-disposed patients.     

Estrogens,hormone therapy,and hippocampal volume in postmenopausal women

The brain atrophies in late life. However, there are many factors that either magnify or mitigate the rate of atrophy. Loss of estrogens during menopause and administration of hormone therapy have both been hypothesized as sources of individual variation in the prevalence of cortical and subcortical atrophy and loss of cognitive function in late adulthood. In this review we critically summarize and assess the extant rodent and human neuroimaging studies that examine the link between estrogens and hippocampal morphology and function and focus predominantly on human studies of the hippocampus in postmenopausal women. Several cross-sectional studies report that the size of the hippocampus is larger in women receiving hormone therapy while several other cross-sectional studies report either negligible effects or smaller volumes in women receiving hormone therapy. We suggest that these differences might be caused by the variation between studies in the age of the samples studied, the duration of therapy, and the age at which hormone therapy is initiated. Unfortunately, all of the human studies reviewed here are cross-sectional in nature. With the lack of well-controlled randomized trials with neuroimaging measures on postmenopausal women both before and after some exposure interval, the effect of hormone therapy on hippocampal atrophy will remain equivocal and poorly understood.     

Haemostatic risk factors in healthy postmenopausal women taking hormone replacement therapy

OBJECTIVE: To compare changes in haemostatic parameters in healthy postmenopausal women taking either tibolone or 17beta-oestradiol/norethisterone acetate. METHODS: Factor VIIc, antithrombin, fibrinogen, thrombin-antithrombin complex (TAT), FDP (D-Dimer), tissue plasminogen activator (tPA) and plasminogen activator inhibitor I (PAI-1) were measured in 80 healthy postmenopausal women after 3, 6 and 12 months therapy with either 17beta-oestradiol/norethisterone acetate or tibolone. RESULTS: Both treatments significantly reduced fibrinogen, factor VIIc, antithrombin, tPA and PAI-1 antigen. Significantly lower levels of factor VIIc activity were observed on treatment with tibolone compared with 17beta-oestradiol/norethisterone acetate. TAT was unchanged with both treatments as was tPA activity. FDP (D-dimer) was increased on treatment with both preparations. CONCLUSIONS: The enhanced fibrin turnover and reduced antithrombin activity may play a role in the increased risk of venous thromboembolism in some susceptible women taking hormone replacement therapy (HRT) and could explain the lack of benefit of HRT in the secondary prevention of cardiovascular disease. The decreased levels of fibrinogen and factor VIIc found during treatment with 17beta-oestradiol/norethisterone acetate or tibolone may offer some degree of cardioprotection in healthy woman without pre-existing disease.     

Ultra low-dose hormone replacement therapy and bone protection in postmenopausal women

OBJECTIVES: The aim of the present study was to evaluate the effects of low doses of hormone replacement therapy (HRT) in normal young postmenopausal women. METHODS: In an open trial healthy, non-obese postmenopausal women received for 2 years a low-dose continuous combined HRT (LD-HRT) containing 1mg estradiol+0.5 mg norethisterone acetate each pill for 28 days, or 0.5 mg of 17beta-estradiol and 0.25 mg of norethisterone acetate (Ultra low dose, Ultra-LD-HRT) along with 1000 mg of calcium per day. Control group consisted of women receiving only 1000 mg of calcium per day, for 2 years. Menopausal symptoms were evaluated by the Green climacteric scale for the first 12 weeks of the study while bleeding profiles, bone mineral density (BMD) and bone turnover were assessed for 24 months. RESULTS: LD-HRT and Ultra-LD-HRT were effective in reducing menopausal clinical symptoms. In the control group, BMD significantly (P<0.05) decreased at the spine (-2.8+/-0.2%), and femoral neck (-2.8+/-0.7%). In LD-HRT treated group BMD showed a significant (P<0.05) increase at the spine (5.2+/-0.7%), and femoral neck (2.8+/-0.4%) after 24 months. In the Ultra-LD-HRT treated women spine and femoral neck BMD showed a significant (P<0.05) increase (2.0+/-0.3 and 1.8+/-0.3%, respectively) after 24 months. In these women treated with LD-HRT and Ultra-LD-HRT the BMD values were significantly (P<0.05) different from those measured in calcium-treated women. CONCLUSIONS: LD-HRT and Ultra-LD-HRT can alleviate subjective symptoms providing an effective protection against the postmenopausal decrease of BMD.     

Assessment of DNA damage in postmenopausal women under hormone replacement therapy

OBJECTIVE: To evaluate the possible DNA damage in peripheral blood leukocytes of postmenopausal women under different hormone replacement therapies (HRT), comet assay, a standard method for assessing genotoxicity has been used. METHOD: 46 women were categorized in three groups-Group A: 15 surgical menopausal women who underwent surgery for benign conditions, receiving conjugated equine estrogen, 0.625 mg/day (CEE) for 2.3 +/- 1.5 years, Group B: 16 spontaneous menopausal women receiving conjugated equine estrogen, 0.625 mg/day plus medroxyprogesteron acetate, 5mg/day (CEE + MPA) for 2.4 +/- 1.0 years and Group C: 15 spontaneous menopausal women receiving tibolone, 2.5mg/day for 2.4 +/- 1.3 years. Control group consisted of 15 spontaneous menopausal women who never had HRT. RESULTS: Significant differences in terms of DNA damage were observed between Group A and B with controls as mean total comet scores 23.93 +/- 5.84, 19.44 +/- 6.19 and 10.07 +/- 2.40, but no significance (P > 0.05) were detected between Group C and controls as mean total comet scores 12.07 +/- 3.65 and 10.07 +/- 2.40, respectively. CONCLUSION: Reduced DNA damage were observed with tibolone compared to CEE or CEE + MPA therapy. Studies of this approach are needed.     

Ascorbic acid status in postmenopausal women with hormone replacement therapy.

OBJECTIVES: Hormone oral contraceptives affected ascorbic acid status adversely in young women. In vitro, estrogens and progesterone inhibited ascorbic acid accumulation in intestinal cells. This is a pilot study to examine the relation between hormone replacement therapy (HRT) and plasma ascorbic acid levels among a group of healthy non-smoking postmenopausal women. METHODS: Healthy non-smoking postmenopausal women aged 48-72 years, 34 with HRT and 21 without HRT, were recruited in summer, 1997. Their fasting plasma ascorbic acid levels were measured and information on ascorbic acid intakes (diet and supplements) was collected through questionnaires. RESULTS: Women taking HRT in this study did not have significantly lower plasma ascorbic acid levels compared with non-HRT users. When subjects were further divided into groups based on ascorbic acid supplementation, HRT users without supplement had a lower mean plasma ascorbic acid level (54+/-16 microM, n=10) compared with non-HRT users (66+/-14 microM, n=12) (P=0.08 for the effect of therapy). HRT users and non-users taking ascorbic acid supplement had similar plasma levels (66+/-10 microM, n=24; 66+/-12 microM, n=9, respectively). CONCLUSION: HRT does not affect ascorbic acid status of healthy well-nourished non-smoking postmenopausal women that are using ascorbic acid supplement. Future larger case-control or supplement intervention study is needed.     

Endometrial bleeding in postmenopausal women: with and without hormone therapy

The aim of this study was to present a review of the potential mechanisms involved in the occurrence of endometrial bleeding in postmenopausal women using hormone therapy. Selected literature on the incidence of bleeding in postmenopausal women using estrogen progestogen therapy was reviewed. The incidence of spotting and bleeding in women using continuous-combined hormone therapy was presented. Relevant articles related to the role of angiogenic factors and vasculogenesis in the endometrium, endometrial leukocytes, and endometrial metalloproteinases were used for the review. The cause or etiology of endometrial bleeding with hormone therapy is unknown. Several options are known to alter angiogenesis or be involved in tissue remodeling during normal menstruation. Vascular endothelial growth factor and thrombospondin-1 are proangiogenic and antiangiogenic factors that could cause dysfunction in vasculogenesis that could result in blood vessel fragility and bleeding. The role of pericytes in maintaining vessel morphology and integrity is discussed. Endometrial leukocytes and metalloproteinases are involved in normal menstruation, but their role in postmenopausal bleeding is not clear suggesting involvement of mechanisms in the bleeding. There is limited information on clinical investigation into the etiology of postmenopausal bleeding associated with hormone therapy. The major cause of hormone therapy-related bleeding is unknown. Alterations in angiogenic factors that could result in vascular dysfunction and vessel breakdown provide a working hypothesis as to the potential cause of vessel breakdown.     

Influence of hormone replacement therapy on proteomic pattern in serum of postmenopausal women

OBJECTIVES: Proteomics approaches to cardiovascular biology and disease hold the promise of identifying specific proteins and peptides or modification thereof to assist in the identification of novel biomarkers. METHOD: By using surface-enhanced laser desorption and ionization time of flight mass spectroscopy (SELDI-TOF-MS) serum peptide and protein patterns were detected enabling to discriminate between postmenopausal women with and without hormone replacement therapy (HRT). RESULTS: Serum of 13 HRT and 27 control subjects was analyzed and 42 peptides and proteins could be tentatively identified based on their molecular weight and binding characteristics on the chip surface. By using decision tree-based Biomarker Patternstrade mark Software classification and regression analysis a discriminatory function was developed allowing to distinguish between HRT women and controls correctly and, thus, yielding a sensitivity of 100% and a specificity of 100%. The results show that peptide and protein patterns have the potential to deliver novel biomarkers as well as pinpointing targets for improved treatment. The biomarkers obtained represent a promising tool to discriminate between HRT users and non-users. CONCLUSION: According to a tentative identification of the markers by their molecular weight and binding characteristics, most of them appear to be part of the inflammation induced acute-phase response.     

Effect of estrogen replacement therapy on parathyroid hormone secretion in elderly postmenopausal women

OBJECTIVE: Women undergo two phases of involutional bone loss that have opposing effects on parathyroid hormone (PTH) secretion. During the early phase, the loss of the direct restraining effect of estrogen on bone resorption causes an outflow of skeletal calcium into the extracellular fluid. This causes a compensatory decrease in PTH secretion. In the late phase, loss of extraskeletal effects of estrogen (on intestinal and renal calcium handling) leads to increases in whole body losses of calcium and a compensatory increase in PTH secretion. Moreover, long-term estrogen replacement therapy (ERT) suppresses both basal and stimulated PTH secretion in these women. Whereas the effects of estrogen on PTH secretion have been assumed to be due to its extraskeletal actions, estrogen may also have direct effects on the parathyroid glands. The goal of the present study was to test for these possible direct effects of estrogen on PTH secretion. DESIGN: Basal and ethylenediaminetetraacetic acid (EDTA)-stimulated PTH secretion was assessed in 10 elderly postmenopausal women (mean age, 76.4 years) before and after acute (3 days) estrogen replacement with transdermal estradiol, 0.1 mg/day. In addition, similar studies were performed in 10 age-matched women (mean age, 74.5 years) who had been on long-term ERT. These women were studied before and after 3 days of estrogen withdrawal. RESULTS: Estrogen treatment or withdrawal had no significant effect on either basal or stimulated PTH secretion. CONCLUSIONS: These data provide evidence that, in elderly postmenopausal women, estrogen does not have significant direct effects on PTH secretion and point to the importance of the actions of estrogen on intestinal and renal calcium handling as the major mechanisms for its effects on modulating calcium homeostasis and, indirectly, PTH secretion.