Combined Hormone Replacement Therapy Research Articles

Cholesterol biosynthesis inhibitor RO 48-8071 reduces progesterone receptor expression and inhibits progestin-dependent stem cell-like cell growth in hormone-dependent human breast cancer cells.

Clinical trials and studies have shown that postmenopausal women undergoing combination hormone replacement therapy containing estrogen and progestin have an increased risk of breast cancer compared with women taking estrogen or placebo alone. Using animal models, we have previously shown that synthetic progestins, including medroxyprogesterone acetate (MPA), which is widely used clinically, accelerate breast cancer tumor growth and promote metastasis. Furthermore, we have found that MPA elevates CD44 protein expression and aldehyde dehydrogenase (ALDH) activity, two markers of cancer stem cells (CSCs), and increases mammosphere formation, another hallmark of stem cells, in hormone-dependent T47-D human breast cancer cells. Herein, we show that RO 48-8071 (RO), an inhibitor of cholesterol synthesis, reduced MPA-induced CD44 protein expression in two hormone-dependent human breast cancer cell lines, T47-D and BT-474. Because we have previously shown that MPA induction of CD44 is progesterone receptor (PR) dependent, we examined RO’s effects on PR protein and mRNA expressions in T47-D cells. PR mRNA levels remained unchanged after RO treatment; however, RO significantly reduced the protein expression of both PR receptor isoforms, PR-A and PR-B. Using the proteasome inhibitor MG-132, we demonstrated that RO decreases PR protein expression in T47-D cells via the proteasomal degradation pathway. Importantly, treatment of T47-D cells with RO abolished MPA-induced mammosphere formation. Based on our observations, we contend that RO may represent a novel means of preventing MPA-induced CSC expansion. RO could be used clinically to both treat and prevent hormone-dependent breast cancers, which represent the majority of human breast cancers. RO may also have clinical utility in reducing resistance to antihormone therapy.

Effect of Combined Hormonal Replacement Therapy on the Aldosterone/Renin Ratio in Postmenopausal Women.

Plasma aldosterone/renin ratio (ARR) is the most popular screening test for primary aldosteronism (PA). Because both estrogen and progesterone (including in oral contraceptive agents) affect aldosterone and renin levels, we studied the effects of combined hormonal replacement therapy (HRT) on ARR; renin was measured as both direct renin concentration (DRC) and plasma renin activity (PRA). Fifteen normotensive, healthy postmenopausal women underwent measurement (seated, midmorning) of plasma aldosterone, DRC, PRA, electrolytes, and creatinine and urinary aldosterone, cortisol, electrolytes, and creatinine at baseline and after 2 weeks and 6 weeks of treatment with combined HRT (conjugated estrogens 0.625 mg and medroxyprogesterone 2.5 mg daily). Combined HRT was associated with statistically significant increases in aldosterone [median (range): baseline, 150 (85 to 600); 2 weeks, 230 (129 to 790); 6 weeks, 434 (200 to 1200) pmol/L; P < 0.001 (Friedman test)] and PRA [2.3 (1.2 to 4.3), 3.8 (1.4 to 7.0), 5.1 (1.4 to 10.8) ng/mL/h, respectively; P < 0.001] but decreases in DRC [21 (10 to 31), 21 (10 to 39), and 14 (8.0 to 30) mU/L, respectively; P < 0.01], leading to increases in ARR calculated by DRC [7.8 (3.6 to 34.8), 11.4 (5.4 to 48.5), and 30.4 (10.5 to 90.2), respectively; P < 0.001]. The ARR calculated by DRC exceeded the cutoff value (70) in three patients after 6 weeks. There were no significant changes in ARR calculated by PRA [79 (26 to 184), 91 (23 to 166), and 88 (50 to 230), respectively; P = 0.282], plasma electrolytes and creatinine, or any urinary measurements. The combined oral HRT used in this study is capable of significantly increasing ARR with a risk of false-positive results during screening for PA but only if DRC (and not PRA) is used to calculate the ratio.

Clinical observation of growth hormone intrauterine perfusion combined with replacement cycle in the treatment of thin endometrium

Objective To investigate the effects of the frozen embryo transplantation for patients with poor outcome of endometrial growth by using growth hormone (GH) intrauterine perfusion combined with replacement cycle in the treatment of thin endometrium. Methods This was a prospective study and study participants were consecutively recruited between Jun 2014 and September 2015. A total of 88 frozen thawed embryo transfer cycles was divided into two groups from the Reproductive Center of Hunan Provincial Maternal and Child Health Hospital. Group A were 63 hormone replacement therapy (HRT) cycles and Group B were 25 GH intrauterine perfusion combined HRT cycles. Results The endometrial thickness of 22 thin endometrium patients from Group B were increased above 7 mm on progesterone day. The endometrial thickness on transplant day of Group A was (9.28±1.64)mm, which was significantly higher than Group B (7.9±0.86)mm (P 0.05), but the implantation rate of group A was significantly lower than that of group B (20% vs 52.17%) (P 0.05). Conclusions GH uterine cavity perfusion was a useful method for treatment of thin endometrium, and was helpful for improvement of endometrial thickness and receptivity, improved embryo implantation environment by assistance for HRT under the high estrogen levels. Key words: Growth hormone; Infusions, parenteral; Hormone replacement therapy; Endometrium; Embryo transfer

Risk and Prognostic Factors in Cerebral Venous Thrombosis

Objective and design: Cerebral venous thrombosis (CVT) differs from deep venous thrombosis (DVT) in prognosis, risk factors and treatment. We analyzed data gathered in our prospective CVT single-center registry in search of risk and prognostic factors. Data from 73 patients were available.Results: JAK2 mutation (11%) and Leiden mutation of factor V (11%) were the most common among genetic risk factors. The most common acquired risk factor was the use of combined hormonal contraception (COC) or hormonal replacement therapy (HRT) in 64% of female patients. No specific cause was found in 22% of cases. Complete recanalization was present in 44% of cases, more often in female than in male (p=0.0287) and in younger patients (p=0.045). We found final mRS score one and higher in 29% of patients. These patients did not use COC/HRT (p=0.021) or did not achieve complete recanalization (p=0.0058). Patients with higher mRS score tend to be older (p=0.081).Conclusions: COC/HRT use and complete recanalization can be considered when adjusting the length of anticoagulation therapy. JAK2 mutation should be screened in all patients with CVT.

Management of Premenstrual Syndrome: Green-top Guideline No. 48.

Management of Premenstrual Syndrome: Green-top Guideline No. 48.

Abstract 1807: Progestin enrichment of the cancer stem cell-like pool provides novel therapeutic targets for hormone-dependent human breast cancer

Abstract Clinical trials in post-menopausal women show that combined hormone replacement therapy (HRT), containing both estrogen (E) and a progestin (P) such as medroxyprogesterone acetate (MPA), is associated with an increased risk of breast cancer compared with E alone (JNCI, 2000, 92:328). We previously showed that both natural and synthetic P accelerate tumor development in vivo, a process that is blocked by anti-progestins (Can Res 2007; 67:9929). Furthermore, P also increases lymph node metastasis (Menopause 2010; 17:1040), leading us to hypothesize that P-induced tumor growth and metastasis may be mediated by an enrichment of the pool of cancer stem cell (CSC)-like cells. This increases the proliferative and metastatic potential of already existing tumors. CSCs are a small and highly tumorigenic cell population present in most tumors, which have self-renewal properties. In tumors of the breast, the CSC subpopulation has a phenotypic signature that is CD24 −/low, CD44 high and aldehyde dehydrogenase-positive (ALDH+) (Cell Stem Cell, 2007; 1:555). Using flow cytometry to measure CD44 density under a variety of experimental conditions we sought to determine whether P influences expression of CSC markers in P-responsive human breast tumors that grow in vivo. Following exposure of T47-D cells for 24 h with physiological levels (10 nM) of natural and synthetic P, CD44 protein expression was increased considerably. Compared with controls, induction of CD44 increased 10-fold in response to MPA (Control 5.9%, MPA 60.7%). Alternative steroid hormones failed to induce CD44 in tumor cells. This phenotypic shift was blocked by the anti-progestin RU-486, indicating that the process is mediated via progesterone receptors (PR). Cells treated with P formed mammospheres more easily than their non-treated counterparts, and a subset of the cell population with induced CD44 high also demonstrated high ALDH enzyme activity. RT-PCR analysis showed that MPA specifically induced CD44v3 and CD44v6 transcripts. Importantly, a variety of synthetic P similarly induced CD44 protein expression. Based on our observations we contend that exposure of breast cancer cells to synthetic P, such as MPA, may lead to an enrichment of the CSC-like pool, supporting the development of P-accelerated tumors in vivo. These findings also suggest that a novel means by which to combat P-dependent tumor growth might be through blockade of CD44 functions in the pool of stem cell-like cells. This could be achieved by immunotherapeutic means, using tissue selective antiprogestins, or through a combination approach involving both immunotherapy against CD44 and small molecule targeting of PR. Supported in part by COR award from the College of Veterinary Medicine, and by generous gifts from donors of Ellis Fischel Cancer Center, University of Missouri. Citation Format: Sandy Goyette, Benford Mafuvadze, Matthew T. Cook, Yayun Liang, Salman M. Hyder. Progestin enrichment of the cancer stem cell-like pool provides novel therapeutic targets for hormone-dependent human breast cancer. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1807.

Drospirenone plus estradiol and the risk of serious cardiovascular events in postmenopausal women

Objectives: To compare incidence rates of serious cardiovascular events, particularly arterial thromboembolic events (ATE), in users of hormone replacement therapy (HRT), particularly oral continuous combined preparations.Methods: Prospective, controlled cohort study with four arms: women using (1) drospirenone (DRSP)/estradiol, (2) other oral continuous combined HRT (HRTcc), (3) all other oral HRTs, and (4) non-oral HRT. The study population consisted of women aged 40+ years in seven European countries who were new users of HRT at the time of inclusion. All patient-reported outcomes of interest were validated by the treating physicians. A multifaceted, four-level follow-up procedure ensured low loss to follow-up rates. The final analysis is based on Cox regression models comparing the cohorts.Results: In total, 30 597 women were recruited by 1052 study centers. Follow-up reflects 101 715 woman-years of observation. Loss to follow-up was about 2.8%. Risk estimates for general serious adverse events were similar for all cohorts. Incidence rates for serious cardiovascular events were 98.4 (DRSP/estradiol) and 169.7 (HRTcc) per 10 000 woman-years. The corresponding incidence rates for ATE were 10.9 and 29.7 events per 10 000 woman-years with an adjusted hazard ratio of 0.5 (95% confidence interval 0.3–0.8). The initiation rate for antihypertensive treatment after start of HRT was substantially lower for women using DRSP/estradiol compared to the other cohorts.Conclusions: DRSP/estradiol is associated with general health risks similar to other oral and non-oral HRT but is probably associated with lower ATE risk.Clinical trial registration: NCT00214903, US National Library of Medicine.

Sex hormones and the risk of keratinocyte cancers among women in the United States: A population-based case-control study.

Men are at a higher risk of developing both squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) than women, but there is emerging evidence that women may be experiencing greater increases in the incidence rates of these malignancies than men. One possible explanation is the expanding use of sex steroids among women, although only a few studies have examined this hypothesis. As part of a population-based, case-control study of women in New Hampshire, USA, we sought to evaluate the risk of SCC, BCC, and early-onset BCC in relation to exogenous and endogenous sex hormones. We found that oral contraceptive (OC) use was associated with an increased risk of SCC (OR = 1.4, 95% CI = 1.1-1.8) and BCC (OR = 1.4, 95% CI = 1.0-1.8), particularly high estrogen dose (>50 mg) OC use. Hormone replacement therapy (HRT) use also related to SCC, with an elevated OR largely for progestin use (OR = 1.4, 95% CI = 1.1-1.8). Additionally, both OC use and combination HRT use were associated with more aggressive BCC subtypes. In contrast, menstrual and reproductive history did not appear to influence keratinocyte cancer risk in our data. Our findings provide evidence that use of sex steroids may enhance risk of keratinocyte cancer.

Ductal Carcinoma In-Situ in Turner Syndrome Patient undergoing Hormone Replacement Therapy: A Case Report

Turner’s syndrome is a rare congenital disease which affects about 1 in every 2500-3000 live-born females. This happens due to chromosomal abnormalities in a phenotypic female, causing increased gonadotropin concentrations and low concentrations of estrogens from infancy. As a result, hormone replacement therapy is started in most adolescent Turner syndrome patients to initiate and sustain sexual maturation. Accordingly, most Turner’s syndrome patients undergo several decades of estrogen replacement therapy, from puberty to post-menopausal age. The highly publicized findings of the Women’s Health Initiative have called into question the appropriateness of hormone replacement therapy in adolescents with Turner’s syndrome. Those concerns were mostly theoretical extrapolations, as few prospective studies of cancer occurrence in women with Turner syndrome have been reported. Consequently, several recent publications have challenged those extrapolations, based on the assertion that the levels of hormone replacement in Turner syndrome patients are well below the physiologic levels observed in normal menstruating women, as well as the fact that these women are significantly younger than those studied by the Women’s Health Initiative. In discord to those reports, we present a case of ductal carcinoma in-situ in a 40-year-old Turner patient, who had undergone over two decades of combined hormone replacement therapy. The patient underwent an elective excisional biopsy for a palpable mass, with histopathology revealing a complex fibroadenoma with a nidus of ductal carcinoma in-situ. The lesion was noted to be estrogen receptor positive and progesterone receptor negative, with heavy staining for HER-2/Neu receptor. The patient was treated with tamoxifen. While a rare case, it is imperative for the astute clinician to keep in mind the consequences of long-term hormone replacement therapy in Turner’s syndrome patients in order to avoid missed diagnosis of breast cancer for optimum management of these patients.

Migraine during perimenopause.

Migraine affects the female sex to a greater extent than the male, with a female:male ratio of 3:1. Hormonal fluctuations during the reproductive life may influence migraine occurrence and intensity, both in a positive or negative way. Many women experience migraine approaching menopause, but the trend of migraine symptoms may vary according to the different stages of the perimenopause. If a woman is already a migraineur subject, the attacks often worsen during both the early and late phases of menopausal transition, whereas an onset of migraine is quite rare[1]. According to some authors, women with premenstrual syndrome (PMS) before menopause have an increased prevalence of migraine in late menopausal transition, and a subsequent reduction of the attacks in postmenopause[2]. The presence of PMS can be considered one of the predictors of migraine trend during the menopausal transition, since women with PMS are more sensitive to hormonal fluctuations and more prone to develop moderate to severe menopausal symptoms[3]. Hormone replacement therapy (HRT) can be used during the late premenopausal phase and the first years of postmenopause in order to counteract climacteric symptoms[4]. The effect of HRT on migraine has been investigated, either in its role of provoking or preventing the attacks. HRT should be administered continuously, without intervals, to avoid sudden estrogen deprivation and the consequent possible onset of migraine[5]. Treatment with estradiol-based gels and transdermal patches is preferable to oral formulation as it maintains constant serum hormone levels. In contrast to guidelines on the use of estroprogestinic contraceptives, migraine with aura is not an absolute contraindication to HRT when the way of administration is topical with a low dose of natural estrogens. If the aura recurs or worsens, HRT should be in any case discontinued[6]. When the effect of tibolone versus continuous combined HRT regimen in migraine is compared, a significant reduction in the hours with pain-limiting daily activities and of the amount of analgesics intake can be observed, even if there is no reduction of the days with migraine[7]. Natural menopause is associated with a lower incidence of migraine as compared with surgical menopause[8]; data on migraine prevalence in relation to the type of surgical procedure are till now unclear and contradictory[9].

Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement.

Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement This consensus statement provides important guidelines for deceased donation to the transplant community. The document defines the standard of care for intensive care units regarding: (1) Definitions of death; (2) Timing and request for authorization; (3) Use of donors with malignancies and infections; (4) Testing for human immunodeficiency virus, hepatitis B and C; (5) Hemodynamic management; (6) Fluid resuscitation; (7) Vasoactive drugs; (8) Hemodynamic monitoring; (9) Endocrine dysfunction and hormone replacement; (10) Pediatric donor issues; (11) Specific organ management: heart, kidney, liver, lung and pancreas. The authors confirm the important impact that donation after circulatory determination of death (DCD) can make to increase the availability of organs. They highlight that liver and lungs can be used from selected DCD donors for transplantation. Clinicians must be prepared for potential DCD scenarios in which death does not occur within the established time after withdrawal of life-sustaining therapy: appropriate protocols should be in place to return the patient to a critical care setting for continuing care and to provide appropriate family support. The authors comment that intensive care unit caregivers and OPO representatives should provide all patients with equal opportunities for organ donation. One important recommendation is the early referral of potential donors to procurement agencies to increase the period available to evaluate a patient’s medical suitability for donation and to relay information to families in a manner that minimizes time pressure. The group recommends that OPO or designated coordinators with expertise should request authorization for organ donation in all institutions, using a collaborative approach with the rest of the healthcare team. There are several recommendations regarding malignancies and infections, but in general, risks of donor transmission must be weighed against risks for a potential recipient of not receiving the organ. Determinations about an individual donor’s medical suitability for organ donation should be made in conjunction with the local OPO and involved transplant centers. The authors recommend that patients with bacterial meningitis are suitable organ donors as long as they have received therapy directed against an identified or presumed pathogen while organ recipients get treated with a similar antibiotic regimen for 5 to 10 days. Organs should not be procured from patients with undiagnosed febrile illnesses, encephalitis, meningitis, or flaccid paralysis of unknown etiology. The use of nucleic acid amplification testing to detect the presence of human immunodeficiency virus RNA reduces the likelihood of unrecognized viremia by approximately half in all high-risk behavior categories; therefore, the use of nucleic-acid amplification testing was recommended for high-risk behavior groups. A frequent challenge for kidney and lung procurement is conflicting fluid requirements for the donor. Traditionally, aggressive fluid resuscitation and management were thought to result in improved procurement of kidneys, whereas a conservative fluid replacement strategy is thought to benefit the quality of lungs. The authors recommend a central venous catheter and/or pulmonary artery catheter to manage fluids: a combination of hormone replacement therapy and CVP-targeted fluid resuscitation should be the gold standard. Specific variables include a mean arterial pressure of 60 to 70 mm Hg, urinary output of 1 to 3 mL/kg per hour, a decrease in dose of vasoactive agents (dopamine ≤ 10 μg/kg per minute), and a left ventricular ejection fraction of at least 45%. Isotonic crystalloids and lactated Ringer are recommended as first line fluid management. Dopamine and arginine vasopressin replacement should be considered when hypotension persists despite adequate volume resuscitation. High-dose corticosteroid administration reduces the potential deleterious effects of the inflammatory cascade set in place subsequent to brain death. Ideally, steroids should be administered after blood has been collected for tissue typing as the expression of human leukocyte antigen may be suppressed. Thyroid replacement therapy—either alone or as part of a combination hormone therapy with intravenous arginine vasopressin, corticosteroids, and insulin—should be considered for hemodynamically unstable donors or for potential cardiac donors with abnormal (<45%) left ventricular ejection fraction. Specific aspects of death declaration for pediatric donors, including management goals are detailed in this report and differ from adult donors. Furthermore, organ-specific considerations are discussed in great detail—an extremely helpful tool in donor management and procurement.

Abstract 866: The proportion of breast and gynecological cancers in Australian women that can be attributed to the use of oral contraceptives and hormone replacement therapy

Abstract Introduction: In 2008 The International Agency for Research on Cancer concluded that combined oral contraceptives (OCs) are a cause of cancer of the breast and cervix but decrease the risk of ovarian and endometrial cancer. They also concluded that estrogen-only hormone replacement therapy (HRT) increases the risk of both endometrial and ovarian cancer, while use of estrogen plus progestogen (combined) HRT increases the risks of breast cancer. The level of risk associated with each cancer type varies by duration and recency of use of hormones. Our aim was to calculate the proportion of breast and gynecological cancers arising in Australian women (population attributable fractions - PAF) that could be attributed to these commonly used hormonal medications. Methods: We calculated PAFs using the standard formula, which requires an estimate of the relative risk for each exposure-cancer association and the prevalence of the causal factor in the population. Relative risks were obtained from published pooled or meta-analyses of the associations and prevalence estimates were derived from Australian National Health Survey estimates or other large national studies. For factors inversely associated with cancer we calculated the “prevented fraction” and estimated the number of cancers that were prevented due to exposure to the factor. Results: The estimated PAFs suggested that fewer than 5% of breast and gynecological cancers in Australia in 2010 could be attributed to oral contraceptive use and estimates were similar for HRT use. However, the calculated preventive fractions for oral contraceptives suggested that the numbers of endometrial and ovarian cancers may have been 46% and 24% higher respectively if no Australian women had used OCs. Given combined HRT increases breast cancer risk and breast cancer is much more common than endometrial or ovarian cancer we also assessed the likely effect if all women taking combined HRT instead took estrogen-only HRT. Under this scenario, we estimate the absolute numbers of ovarian and endometrial cancers would increase slightly but the number of breast cancers attributable to HRT use would decrease substantially. Conclusions: Our analyses suggest that the use of combined OCs confers more benefit than harm with respect to cancer incidence, with a small increase in breast/cervical cancer diagnoses weighed against a much larger decrease in numbers of endometrial and ovarian cancers. In contrast, our results indicate that there would be fewer cancers overall if women did not use HRT. When HRT is required, most guidelines recommend that women with a uterus take combined HRT to prevent endometrial cancer. However, our findings suggest that, in terms of total cancer burden, it might be safer for women to avoid progestogens and use estrogen-only HRT for symptom relief. Future studies should examine this possibility. Citation Format: Susan J. Jordan, Louise Wilson, David Whiteman, Penelope Webb, PAF Project Group. The proportion of breast and gynecological cancers in Australian women that can be attributed to the use of oral contraceptives and hormone replacement therapy. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 866. doi:10.1158/1538-7445.AM2015-866

Abstract 2725: Progesterone promotes estrogen induced mammary tumorigenesis through the activation of nodal and notch signaling

Abstract Nodal and Notch are considered to be important embryonic morphogens, regulating cell - cell communication, determining left - right asymmetry and in formation of the mesoderm. Cellular processes in embryogenesis can be compared to processes occurring during tumorigenesis. Nodal has been shown to re emerge in aggressive triple negative breast carcinomas, and Notch is known to promote breast cancer. The role of Nodal and Notch in breast carcinomas is being studied; however hormonal regulation of theses two cancer-promoting genes is unknown. Ovarian hormones Estrogen (E) and Progesterone (P) play a vital role in the normal development and function of breast tissue, while extensive exposure to these hormones increases the risk of breast cancer. Studies conducted by the Women's Health Initiative (WHI) have demonstrated that combined Hormone Replacement Therapy (HRT) increases breast cancer risk. The objective of this study is to determine whether P promotes E induced mammary tumorigenesis through the activation of Nodal and Notch signaling. To study the molecular mechanism, MCF-7 cells were cultured and treated with hormones: E, P, E+P and E+Mifepristone (MP - a progesterone antagonist). MTS assay for cellular proliferation, PCR array for gene expression, and western blot for protein expression, were performed. MTS assay showed increased cell proliferation of MFC-7 hormone treatment E+P when compared to control. PCR array analysis showed significant alteration of genes associated with Nodal signaling, specifically Lefty in E+MP treatment, protein expression analysis showed activation of Notch and up - regulation of its downstream targets HES1 and HEY1 with E and P individual and combination treatments while it was down regulated in E+MP treatment. Based on our findings, we suggest that P mediates E induced mammary tumorigenesis through the activation of Nodal and Notch signaling, proposing a possible crosstalk between both pathways in the development and progression of breast cancer. Citation Format: Diego A. Pedroza, Arunkumar Arumugam, Sushmita Nandy, Ramadevi Subramani, Thiyagarajan Boopalan, Rajkumar Lakshmanaswamy. Progesterone promotes estrogen induced mammary tumorigenesis through the activation of nodal and notch signaling. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2725. doi:10.1158/1538-7445.AM2015-2725

Bias in Observational Studies of the Association between Menopausal Hormone Therapy and Breast Cancer.

BackgroundDuring the period 1985-2000 the breast cancer incidence rates increased 50% in the age group invited to mammography screening in Norway and Sweden. Simultaneously, use of hormone replacement treatment therapy (HT) increased 5 times. Several influential observational studies showed that HT was associated with 50% to 100% increased risk of breast cancer and most for those using combined (estrogen plus progestin) hormone replacement therapy (CHT). In contrast, the randomized WHI trial reported that CHT increased the risk by 10% for those not having previously used hormones and 24% when including previous users in the analyses. In another randomized trial, estrogen use only was not associated with any increased risk at all. After the WHI trial was published in 2003, use of HT dropped 70% within 5 years in Norway and Sweden while breast cancer rates were essentially unchanged. After 2008, HT use has dropped further and breast cancer incidence rates have started increasing again. The study objective is to calculate and to explain potential bias in the observational study design.Methods and FindingsHere we use data from the randomized WHI trial and analyze these data as done in the observational studies to calculate the magnitude of the potential biases in the observational study design. Time varying effect of hormones and categorization of the follow-up time may increase the hazard ratio for long-term users from 1.10 to 1.48. Selective retrospective reporting of hormone use may further increase the hazard ratio to 1.68.ConclusionsWe suggest that the mechanism causing higher hazard ratio of breast cancer (compared to the observational studies) is the time-varying effect of CHT on the breast cancer risk and selective retrospective reporting of hormone use. Other risk factors for the increase in breast cancer risk in the age group 50-69 years should be considered, for example, overdiagnosis.

Ultra-low-dose estradiol and norethisterone acetate: bleeding patterns and other outcomes over 52 weeks of therapy

Background Continuous combined hormone replacement therapy (HRT) with 0.5 mg 17β-estradiol (E2) + 0.1 mg norethisterone acetate (NETA) received marketing approval based on 24-week results. The current study collected data up to 52 weeks, including consideration of bleeding, a major reason for stopping HRT.Methods This 52-week (13 lunar-month), non-interventional, prospective study involved 169 women from Norway and Sweden receiving daily oral 0.5 mg E2 + 0.1 mg NETA to treat menopausal symptoms. Incidences and cumulative rates of amenorrhea (no bleeding or spotting) and no bleeding (women could have spotting) were evaluated, together with hot flushes and quality of life.Results Overall, > 78% and > 90% of subjects were amenorrheic or had no bleeding, respectively, in each of the first 3 lunar months, while > 88% and > 96% were amenorrheic or had no bleeding, respectively, in each of lunar months 10, 11 and 12. Cumulative rates of amenorrhea and no bleeding were 67% and 83%, respectively, in lunar months 1–3, and 84% and 94%, respectively, in lunar months 10–12. The number of hot flushes declined during treatment (means at weeks 1, 12 and 52, respectively: 15.5, 5.0 and 4.1 [mild]; 19.0, 3.0 and 2.3 [moderate]; 10.8, 1.1 and 0.9 [severe]). Improvement in all four domains of the Menopause-Specific Quality of Life-Intervention questionnaire (vasomotor, psychosocial, physical and sexual) was evident by week 26.Conclusion For women receiving 0.5 mg E2 + 0.1 mg NETA, lack of bleeding-related side-effects, together with beneficial effects on hot flush symptoms and quality of life, may promote treatment continuance.

Pharmaceutical intervention in menopausal patients with hormone replacement therapy in a community pharmacy from Antofagasta

Context: Hormone replacement therapy (HRT) is the most widely used treatment for controlling the effects of menopause. This type of therapy causes some drug-related problems (DRP), which requires monitoring to control the negative effects and ensure patient adherence to therapy. Aims: Perform a pharmacotherapeutic monitoring and educate to menopausal patients in HRT of a community pharmacy from the city of Antofagasta. Methods: A 98-menopausal patients underwent a pharmaceutical intervention to identify the PRM and its resolution. It was applied to them a survey before and after educational activities about this disease and HRT to determine the knowledge on the subject. Results: During the pharmacotherapeutic monitoring was determined that 55% of patients using combined HRT. 62 DRPs were detected, of which 43 were resolved (69%); the most were Patient-Pharmacist (73%). The better resolution DRP were DRP 4(b) “frequency of inadequate administration” and DRP 2(a) “no medical indication”. At baseline, 90% had an inadequate level of knowledge about the disease and THR, 8% intermediate, and only 2% adequate. After the implementation of the education strategy, the level of knowledge increased, achieving at the end of the study only intermediate (10%) and adequate (90%) levels. Conclusions: The results confirm the importance of pharmaceutical intervention for the identification and resolution of DRP and the requirement to establish educational strategies to increase the knowledge about menopause and HRT in menopausal patients.

Red clover isoflavones enriched with formononetin lower serum LDL cholesterol-a randomized, double-blind, placebo-controlled study.

Although postmenopausal combined hormone replacement therapy reduces the risk of hip fracture, long-term use may be associated with an increased risk of breast cancer, and in women more than 10 years after menopause it is associated with an increased risk of cardiovascular disease. Isoflavones, because of preferential binding to estrogen receptor beta, may retain the beneficial effects on bone but lessen the adverse effects on the breast. The objective of this study was to study the effects of an isoflavone obtained from red clover (Rimostil) on bone mineral density, and on low-density lipoprotein (LDL) cholesterol. In a double-blind, randomized, placebo-controlled trial, 50 mg of Rimostil was given to women who were menopausal for at least 1 year. Bone mineral density of the spine, femoral neck and forearm and serum LDL cholesterol were measured at baseline and at 6-month intervals. The duration of follow-up was 2 years. There was no beneficial effect of Rimostil on bone density at any site. There was a 12% fall in serum LDL cholesterol in the Rimostil-treated arm, which was significantly greater than the 2% drop seen in the control arm (P=0.005).

Synthetic gestagens exert differential effects on arterial thrombosis and aortic gene expression in ovariectomized apolipoprotein E-deficient mice.

Combined hormone replacement therapy with oestrogens plus the synthetic progestin medroxyprogesterone acetate (MPA) is associated with an increased risk of thrombosis. However, the mechanisms of this pro-thrombotic effect are largely unknown. The purpose of this study was to: (i) compare the pro-thrombotic effect of MPA with another synthetic progestin, norethisterone acetate (NET-A), (ii) determine if MPA's pro-thrombotic effect can be antagonized by the progesterone and glucocorticoid receptor antagonist mifepristone and (iii) elucidate underlying mechanisms by comparing aortic gene expression after chronic MPA with that after NET-A treatment. Female apolipoprotein E-deficient mice were ovariectomized and treated with placebo, MPA, a combination of MPA + mifepristone or NET-A for 90 days on a Western-type diet. Arterial thrombosis was measured in vivo in a photothrombosis model. Aortic gene expression was analysed using microarrays; GeneOntology and KEGG pathway analyses were conducted. MPA's pro-thrombotic effects were prevented by mifepristone, while NET-A did not affect arterial thrombosis. Aortic gene expression analysis showed, for the first time, that gestagens induce similar effects on a set of genes potentially promoting thrombosis. However, in NET-A-treated mice other genes with potentially anti-thrombotic effects were also affected, which might counterbalance the effects of the pro-thrombotic genes. The pro-thrombotic effects of synthetic progestins appear to be compound-specific, rather than representing a class effect of gestagens. Furthermore, the different thrombotic responses elicited by MPA and NET-A might be attributed to a more balanced, 'homeostatic' gene expression induced in NET-A- as compared with MPA-treated mice.

Effects of transdermal and oral hormone replacement therapies on monocyte chemoattractant protein-1 levels: a randomized clinical trial

ObjectivesTo assess the effects of oral and transdermal hormone replacement therapies (HRT) on levels of important cardiovascular disease (CVD) markers, MCP-1 and homocyteine, in the early postmenopausal period. Study designSeventy-six healthy, early postmenopausal women were enrolled in the study. Patients were randomly assigned to receive oral or transdermal HRT for 6 months. The first group received continuous combined oral HRT containing 1mg 17β-estradiol and 0.5mg norethisterone acetate (n=39), and the second group received sequential transdermal HRT releasing 50μg/day estradiol alone given twice a week on days 1–14 and 50μg/day estradiol plus 0.25mg/day norethisterone acetate given twice a week on days 15–28 (n=37). Circulating levels of MCP-1 and homocysteine, along with other CVD markers, were assessed before and after treatment in all patients. ResultsThere were no significant differences between the baseline characteristics of the two groups. Baseline serum MCP-1 levels were similar between the oral and transdermal HRT groups (150.1±12.8 vs. 145.2±11.6pg/ml; P=.219). The mean MCP-1 levels did not change after 6 months of HRT in both oral (150.1±12.8 vs. 153.6±12.5pg/ml; P=.192) and transdermal HRT groups (145.2±11.6 vs. 146.1±15.1pg/ml; P=.419). Moreover, there was no significant difference between the groups in MCP-1 serum levels after 6 months of HRT. Similarly, no difference was found in serum homocyteine levels following 6 months of HRT. ConclusionsBoth oral continuous and sequential transdermal HRTs do not have significant effects on serum MCP-1 and homocyteine levels in women during the early postmenopausal period.

Abstract A126: Oral contraceptives and late first childbirth increase the risk of androgen receptor-negative breast cancer: The Malmö Diet and Cancer cohort

Abstract Aim: The importance of the androgen receptor (AR) as a prognostic factor and a possible treatment target is currently debated. However, the impact of lifestyle factors on AR status in breast cancer has not yet been addressed. The aim of this study was to evaluate the influence of hormonal lifestyle factors on AR-defined breast cancer risk. Materials and methods: The population-based prospective Malmö Diet and Cancer Study including 16,459 women were followed using record-linkage with national cancer registries. Baseline data of all women in the cohort included socioeconomic factors, reproductive factors including use of exogenous hormones and anthropometry. During an average follow-up of 12.8 years, 747 cases of invasive breast cancer were diagnosed. AR was assessed immunohistochemically by monoclonal antibody Ab-1 (Clone AR441, Thermo Scientific, USA). A tumor was considered AR positive (AR+) when &amp;gt;10% positive nuclei. A valid AR score was obtained from 516 tumors. The expression of ER, PR, Ki67 along with information on HER2 status, tumor size, histological type, tumor grade and axillary lymph node involvement was obtained. Reproductive factors were compared with tumor characteristics based on AR status. Distribution of clinicopathological data and odds ratios in relation to AR status were analyzed. Hazard ratios (HR) were calculated using Cox's proportional hazards analysis. Survival analyses in relation to AR status were carried out using Kaplan-Meier Log Rank test. Results: A total of 467 tumors (90.5%) were AR+ and 49 tumors (9.5%) were AR negative (AR-). AR positivity correlated significantly to lower tumor grade, lower proliferation and ER and PR co-expression. There was a significant trend of increasing risk of AR- breast cancer by increasing age at first childbirth (HR&amp;lt;20 yrs=0.37, HR21-25 yrs =0.76, HRnulliparous=1.00, HR26-≥30 yrs=1.35, HR&amp;gt;30 yrs =2.01, Ptrend=0.002 among parous women). The risk for AR+ breast cancer was not affected by age at first birth. Ever oral contraceptive (OC) users had an increased risk of AR- breast cancer (HR=2.10, 95% CI 1.16-3.81, P=0.015) compared to never users. OC use was neither associated with risk for breast cancer in general nor with AR+ breast cancer. The use of combined estrogen and progestin hormonal replacement therapy (cHRT) was significantly associated with increased risk for breast cancer (HRall=2.13, P=&amp;lt;0.0001) irrespective of AR status (HRAR-=2.35, P=0.014, HRAR+=2.03, P=&amp;lt;0.0001) compared to non-users of HRT and irrespective of prior OC use. None of the anthropometric measures differed according to AR status. Conclusion: In conclusion, reproductive factors and exogenous hormones influenced the risk for AR-defined breast cancer. Specifically, the older the age at first childbirth, the higher the risk for AR- breast cancer. Similarly, ever OC users had a higher risk of AR- breast cancer compared to never users. This study contributes to a deepened understanding of AR in relation to breast cancer risk factors and may yield improved risk stratification tools for breast cancer prevention and treatment. Citation Format: Karin Elebro, Salma Butt, Mozhgan Dorkhan, Helena Jernström, Signe Borgquist. Oral contraceptives and late first childbirth increase the risk of androgen receptor-negative breast cancer: The Malmö Diet and Cancer cohort. [abstract]. In: Proceedings of the AACR Special Conference on Advances in Breast Cancer Research: Genetics, Biology, and Clinical Applications; Oct 3-6, 2013; San Diego, CA. Philadelphia (PA): AACR; Mol Cancer Res 2013;11(10 Suppl):Abstract nr A126.