Conjugated Equine Estrogens Group Research Articles

Effect of Nigella sativa L. extract on improving memory function through reducing GSK3β activation and Aβ42/40 ratio

Context: Alzheimer’s disease (AD) is one of the biggest causes of public health problems today, especially in older, where women have a greater risk of developing AD than men. However, the current AD therapy has not been satisfactory. Nigella sativa(NS) has bioactive compounds of flavonoid compounds and estrogenic effects that could be alternative medicine. Aims: To evaluate an extract of N. sativa on improving memory function through reducing GSK3β activation and Aβ42/40 ratio in a model of AD in rats. Methods: This research was an experimental study with the post-test-only group design using 24 Wistar rats divided into eight groups. Conjugated equine estrogen (CEE) 0.018-0.0036 mg/day and NS 100, 200, and 400 mg/kg BW were administered orally two weeks before intraperitoneal AlCl3 induction, then continued for up to 8 weeks. In the last five days of the study, the Morris water maze memory test was performed to analyze the expression of amyloid β (Ab), neurofibrillary tangles (NFT), glycogen synthase kinase 3β (GSK3β), and Aβ42/40 ratio. Results: There were significant differences in the memory test (p = 0.000), the expression Aβ40 (p = 0.000), Aβ42 (p = 0.000), NFT (p = 0.000) and GSK3β levels (p = 0.000). The lowest expression of Aβ40 in the NS100 group, Aβ42 in the NS400, NFT in the CEE group, and GSK3β levels in the NS100 group. Administration of NS increased the plasma ratio of Ab42/40 with the highest mean in the CEE group (p = 0.001). Conclusions: The administration of NS extract affected improving memory function by decreasing the expression of Aβ, NFT, GSK3β in ovariectomized Wistar rats supplemented with AlCl3.

Conjugated equine estrogen used in postmenopausal women associated with a higher risk of stroke than estradiol

This study aimed to evaluate the risk of ischemic stroke (IS) in hormone therapy (HT) with oral conjugated equine estrogen (CEE) and estradiol (E2) in postmenopausal women in Taiwan. A retrospective cohort study was conducted using the Taiwan National Health Insurance Research Database, a population-based healthcare claims dataset. Eligible women, aged 40–65 years, who received HT with E2 and CEE orally were enrolled. The primary outcome was IS. Propensity score matching with menopausal age and comorbidities was used. Cox proportional hazard regression models were used to calculate the incidence and hazard ratios (HRs) for IS. The mean menopausal ages of the E2 and CEE groups were 50.31 ± 4.99 and 50.45 ± 5.31 years, respectively. After adjusting for age and comorbidities, the incidence of IS was 1.17-fold higher in the women treated with CEE than in those treated with E2 (4.24 vs. 3.61/1000 person-years), with an adjusted HR (aHR) of 1.23 (95% confidence interval [CI] 1.05–1.44). Moreover, HT with CEE initiated within 5 years of menopause had a higher HR than E2 (aHR = 1.20; 95% CI 1.02–1.42). In conclusion, HT with oral CEE might be associated with a higher risk of IS than E2 in postmenopausal Taiwanese women. The use of HT with CEE should be cautioned with the risk of IS.

Effects of hormone therapy on brain structure: A randomized controlled trial.

Objective:To investigate the effects of hormone therapy on brain structure in a randomized, double-blinded, placebo-controlled trial in recently postmenopausal women.Methods:Participants (aged 42–56 years, within 5–36 months past menopause) in the Kronos Early Estrogen Prevention Study were randomized to (1) 0.45 mg/d oral conjugated equine estrogens (CEE), (2) 50 μg/d transdermal 17β-estradiol, or (3) placebo pills and patch for 48 months. Oral progesterone (200 mg/d) was given to active treatment groups for 12 days each month. MRI and cognitive testing were performed in a subset of participants at baseline, and at 18, 36, and 48 months of randomization (n = 95). Changes in whole brain, ventricular, and white matter hyperintensity volumes, and in global cognitive function, were measured.Results:Higher rates of ventricular expansion were observed in both the CEE and the 17β-estradiol groups compared to placebo; however, the difference was significant only in the CEE group (p = 0.01). Rates of ventricular expansion correlated with rates of decrease in brain volume (r = −0.58; p ≤ 0.001) and with rates of increase in white matter hyperintensity volume (r = 0.27; p = 0.01) after adjusting for age. The changes were not different between the CEE and 17β-estradiol groups for any of the MRI measures. The change in global cognitive function was not different across the groups.Conclusions:Ventricular volumes increased to a greater extent in recently menopausal women who received CEE compared to placebo but without changes in cognitive performance. Because the sample size was small and the follow-up limited to 4 years, the findings should be interpreted with caution and need confirmation.Classification of evidence:This study provides Class I evidence that brain ventricular volume increased to a greater extent in recently menopausal women who received oral CEE compared to placebo.

Comparison of the symptomatic response in Indian menopausal women with different estrogen preparations for the treatment of menopausal symptoms: a randomized controlled trial.

To compare symptomatic response in Indian women using different estrogen preparations for treatment of menopausal symptoms. A randomized, single blind, four arm, parallel assignment study was conducted in VMMC and SJH, New Delhi, India. 200 Indian menopausal women were recruited and assigned into four treatment groups viz., estradiol valerate (E2V), conjugated equine estrogen (CEE), isoflavones and Placebo group. The statistical significance of categorical variables was determined by Chi-square, Fisher's exact test. In case of quantitative variable parametric test Student's t test was used. In case of quantitative variables where data are not normally distributed, Kruskal-wallis test and Wilcoxon Mann-Whitney test were used. Symptomatic response in vasomotor/vaginal symptoms was assessed in all groups. Both E2V and CEE groups were effective in reducing severity and frequency of hot flashes. 91.9% decrease was observed in mean hot flash score in the E2V group after 24weeks of treatment, 89.2% in the CEE group, 60.42% decrease in the isoflavones group. While placebo led to 47.9% decrease in mean hot flash score. After 24weeks of therapy there was significant increase in vaginal health index in the E2V and CEE and the isoflavones group. No serious side effect was reported in any of the groups. Low doses of both CEE and E2V were equally effective for management of vasomotor/vaginal symptoms when administered over 24weeks. However, it seems more reasonable to replenish with less costly and bio-identical hormone, i.e. micronized estradiol valerate which is equally effective. The trial was registered under Clinical trial registry of India prospectively (number: CTRI/2012/04/002566).

Treatment with 17β-estradiol in postmenopausal women is associated with lower PiB-PET retention

Treatments to reduce the amyloid plaque burden in the aging, cognitively normal population may prevent or delay the development of dementia. Pittsburgh compound B (PiB) binds to amyloid plaque and provides a surrogate for amyloid β pathology using PET. PiB-PET retention is a frequent finding in the aging, cognitively normal population. We investigated whether the treatment of postmenopausal women with menopausal hormone therapy (MHT) would have an association with amyloid burden measured by PiB-PET. Participants were recruited from the Kronos Early Estrogen Prevention Study (KEEPS), which was a randomized, placebo controlled trial to evaluate cardiovascular effects of MHT in recently menopausal women. PiB imaging was performed on a subgroup of subjects about 7 years after initiating 4 years of MHT where women within 6-36 months of their last menses had been randomized to either oral conjugated equine estrogen (CEE), Premarin, 0.45mg/day (N=17); or transdermal 17β-estradiol (TE), Climara, 50μg/day (N=21) (each with progesterone 200mg/day for 12 days/month) or placebo pills and patch (N=30). Participants had full clinical and neuropsychometric assessments. PiB images from each group were compared after treatment using a global SUVr measurement as a continuous measure. Positive PiB-PET scans were seen in 3(18%), 1(5%) and 1(3%) with median(range) SUVr's of 1.27 (1.19, 1.76), 1.25 (1.12, 1.75), 1.28 (1.20, 1.44) in the CEE, TE, and placebo groups respectively. A trend for reduced PiB retention was seen in the TE group vs. placebo (p=0.08). Among women who were APOE 4+ (N=18), we observed differences in PiB retention between CEE vs. TE (p=0.049) and TE vs. placebo (p=0.055) groups. No significant differences were observed in APOE 4- participants (n=40). (Figure). Boxplots of PiB ratios by treatment status. For ε4 positive only (right box), the p-values between 3 groups are as follows; CEE vs. Estradiol = 0.049, CEE vs. Placebo = 0.25 and Estradiol vs. Placebo = 0.055. The box on left has all subjects with e4 positives in red. The middle box has e4 negative subjects only. P-values are from Kruskal-Wallis and Wilcoxon rank sum tests. PiB cutoff for positivity at 1.4 is shown by a red-hashed line. These preliminary findings in a small number of women suggest an active role of TE for reducing amyloid brain deposition in postmenopausal women when treated for 4 years, shortly after menopause. These data may provide the rationale for a clinical trial to further investigate these findings in a larger population. These findings would support the observation that 17β-estradiol reduces the release of Aβ peptides in preclinical models. This interaction seems to be most pronounced in APOE 4+ women.

Abstract 267: Histomorphometric Evaluation of Estrogen Effects on Coronary Artery Atherosclerosis: Inhibition of Plaque Formation, Reduction in Plaque Size and Promotion of Positive Remodeling Independent of Plaque Complications

Introduction: Whether and to what extent postmenopausal estrogen therapy has beneficial effects on progression of coronary artery atherosclerosis is controversial. In previous studies with monkey models we have shown that the stage of plaque progression modulates estrogen benefits and have led to the “timing hypothesis”. In this study, we used a histomorphometric approach to understand better the effects of estrogen therapy on critical components of atherosclerosis pathogenesis. Our hypothesis was that estrogen therapy would inhibit the initial development of atherosclerotic plaques, result in smaller but not less complicated plaques and among subjects that developed plaques, it would promote positive arterial remodeling. Methods: Forty-eight surgically postmenopausal monkeys (Macaca fascicularis) were fed a moderately atherogenic diet and randomly assigned to receive no treatment (CTL) or a women’s equivalent dose of conjugated equine estrogen (CEE) (0.45 mg/day). The experimental period lasted for 20 months (equivalent to 5 years in humans). At the end of the experiment, prevalence of atherosclerotic plaques was determined. From those monkeys with affected arteries, plaque extent, severity and prevalence of stenosis were determined. Results: Prevalence: The CEE treated group had significantly fewer monkeys with coronary artery atherosclerosis compared to the CTL group (CTL: 57 % vs. CEE: 33 % p=0.005). Extent: Among affected monkeys, the mean plaque size was significantly smaller in the CEE treated group compared to the CTL group (CTL: 0.30 ± 0.048 mm2 vs. CEE: 0.153 ± 0.028 mm2 p=0.015). Remodeling: The proportion of stenotic plaques was lower in the CEE group compared to the CTL group (CTL: 11.14 % vs. CEE: 1.34 % p= 0.008). Severity: CEE treatment did not have a beneficial effect on coronary artery severity (% of complicated [AHA grade≥ III] plaques- CTL: 52.34 % vs. 49.61 %, p=0.397). Conclusions: These histomorphometric findings support previous evidence that beginning of estrogen therapy in the perimenopausal transition prevents plaque initiation. Among affected cases, estrogen treated monkeys had smaller plaques but were equally complicated. Notably, estrogen also promoted positive arterial remodeling among affected arteries.

Endometrial profile of bazedoxifene acetate alone and in combination with conjugated equine estrogens in a primate model

Concerns of breast cancer risk in postmenopausal women taking combined estrogen + progestin therapy have generated interest in the use of selective estrogen receptor modulators (SERMs) as potential progestin alternatives. Endometrial proliferation and cancer risk are major concerns, however, for estrogens and certain types of SERMs when given alone. The primary aim of this study was to evaluate the endometrial profile of bazedoxifene acetate (BZA), a third-generation SERM, alone and in combination with conjugated equine estrogens (CEE) in a postmenopausal primate model. Ninety-eight ovariectomized cynomolgus monkeys (Macaca fascicularis) were randomized to receive no hormone treatment (controls), BZA 20 mg, CEE 0.45 mg, or the combination of BZA 20 mg + CEE 0.45 mg once daily for 20 months in a parallel-arm study design. The primary outcome measure was endometrial epithelial proliferation. BZA + CEE and BZA treatment resulted in significantly less endometrial epithelial area and Ki67 expression compared with CEE (P < 0.001 for all). The prevalence of endometrial hyperplasia and other estrogen-induced morphologic changes in the BZA + CEE and BZA groups was not significantly different from controls. The addition of BZA to CEE completely inhibited the expression of estrogen receptor-α-regulated genes (TFF1 and PGR), whereas BZA alone had no effect. BZA + CEE and BZA treatment also resulted in lower estrogen receptor-α protein expression in the endometrium compared with the control and CEE groups (P < 0.05 for all). BZA given at a clinically relevant dose inhibits estrogen effects on the endometrium and lacks uterotropic effects when given alone.

Effects of hormonally active agents on steroid hormone receptor expression and cell proliferation in the myometrium of ovariectomized macaques.

Hormone replacement therapy and selective estrogen receptor modulators have been controversial treatment options for postmenopausal women because of their potential health benefits and/or risks. In this study, we determine the effects of the hormonally active compounds, conjugated equine estrogens (CEE), medroxyprogesterone acetate (MPA), CEE + MPA, and tamoxifen (TAM) on the myometrium of ovariectomized macaques. Immunoexpression of estrogen receptor-α (ERα), progesterone receptor (PR), and Ki-67 in the myometrium is assessed. We found no significant difference in ERα myometrial expression in the CEE, MPA, and CEE + MPA treatment groups, but there was a significant decrease in expression in animals administered TAM versus controls. Conjugated equine estrogen-, TAM-, and CEE + MPA-treated animals had significantly increased expression of PR in myometrial cells and there was no difference in PR expression in cells from MPA-treated animals versus control animals. Myometrial cell proliferation did not significantly differ between the controls and any of the treatment groups, although normalized Ki-67 values were somewhat higher in the CEE and TAM groups. These data suggest that ERα and PR expression in the myometrium is influenced by treatment with hormonally active agents.

Menopausal symptom experience before and after stopping estrogen therapy in the Women's Health Initiative randomized, placebo-controlled trial

The aim of this study was to assess vasomotor and other menopausal symptoms before starting estrogens or placebo, 1 year later, again at trial closure, and after stopping estrogens or placebo. The role of baseline symptoms and age was examined, as was the frequency and determinants of hormone use and symptom management strategies after discontinuing conjugated equine estrogens (CEE) or placebo. Intent-to-treat analyses of 10,739 postmenopausal women before and 1 year after randomization to CEE or placebo at 40 clinical centers and a cohort analysis of participants (n = 3,496) who continued taking assigned study pills up to trial closure and completed symptom surveys shortly before (mean, 7.4 +/- 1.1 y from baseline) and after (mean, 306 +/- 55 d after trial closure) stopping pills were performed. Generalized linear regression modeled vasomotor symptoms, vaginal dryness, breast tenderness, pain/stiffness, and mood swings as a function of treatment assignment and baseline symptoms, before and after stopping study pills. Approximately one third of participants reported at least one moderate to severe symptom at baseline. Fewer symptoms were reported with increasing age, except joint pain/stiffness, which was similar among age groups. At 1 year, hot flashes, night sweats, and vaginal dryness were reduced by CEE, whereas breast tenderness was increased. Breast tenderness was also significantly higher in the CEE group at trial closure. After stopping, vasomotor symptoms were reported by significantly more women who had reported symptoms at baseline, compared with those who had not, and by significantly more participants assigned to CEE (9.8%) versus placebo (3.2%); however, among women with no moderate or severe symptoms at baseline, more than five times as many reported hot flashes after stopping CEE (7.2%) versus placebo (1.5%). CEE significantly reduced vasomotor symptoms and vaginal dryness in women with baseline symptoms but increased breast tenderness. The likelihood of experiencing symptoms was significantly higher after stopping CEE than placebo regardless of baseline symptom status. These potential effects should be considered before initiating CEE to relieve menopausal symptoms.

Effects of Kuntai Capsule and hormone replacement therapy on cognitive function and mental symptoms of early postmenopausal women: a randomized controlled trial

Conjugated equine estrogen (CEE) treatment, a hormone replacement therapy, is restricted for use in perimenopausal and postmenopausal women because of security issues. Consequently, traditional Chinese herbal medicine has become an alternative choice for the patients with contraindications to hormone replacement therapy. To evaluate the efficacy and safety of Kuntai Capsule and CEE in treating cognitive function disorder and mental symptoms of early postmenopausal women. A total of 57 cases of early postmenopausal women from Outpatient Department of West China Women and Children's Hospital were included. The subjects were randomly divided into two groups: Kuntai group with 28 cases and CEE group with 29 cases. The patients in Kuntai group received 6 g Kuntai capsules three times a day. The patients in CEE group received CEE 0.3 mg and 0.6 mg alternately once a day (average dose of 0.45 mg/d). The patients with intact uterus in CEE group were treated with 2 mg medroxyprogesterone acetate daily. In one-year treatment course, the recognition function and mental symptoms of each patient were investigated by questionnaires of Mini-Mental State Examination (MMSE), Kupperman, and quality of life (QOL) every three months. Both intention-to-treat (ITT) and per-protocol set (PPS) analyses were done. The MMSE, Kupperman index and QOL scores at each time point were improved as compared with those before treatment (P<0.05), however there were no statistical differences between the two groups (P>0.05). The MMSE scores showed a tendency to escalate while mental symptoms investigated by Kupperman index and QOL scale showed a downtrend. No severe adverse effects occurred in the study phase and no statistical difference in incidence of side effects between the two groups was found except for vaginal bleeding. The incidence rates of vaginal bleeding in CEE and Kuntai groups were 39.3% and 11.1% respectively (P=0.029). Both Kuntai Capsule and CEE may contribute to maintain the cognitive function and ameliorate mental symptoms of early postmenopausal women.

Effects of different postmenopausal hormone therapy regimens on cerebral blood flow and cognitive functions

The purpose of this study was to compare the effects of different postmenopausal hormone therapy regimens, namely conjugated equine estrogens (CEE), CEE plus medroxyprogesterone acetate (MPA), tibolone, and raloxifene on cerebral blood flow and cognitive functions. A total of 64 healthy postmenopausal women admitted to the Department of Obstetrics and Gynecology, Cumhuriyet University, Turkey were included in this study. Patients were divided into five groups with respect to the treatment protocols: CEE 0.625 mg/day (n=13); CEE 0.625 mg/day + MPA 2.5 mg/day (n=14); tibolone 2.5 mg/day (n=11); raloxifene 60 mg/day (n=9); and control (n=17). The CEE group included only women with surgical menopause. Those who were on hormonal therapy, who had previously used hormonal therapy, who had neurological disorders, or who did not accept the longterm follow-up were excluded from the study. Demographic and clinic characteristics were recorded. Before starting the therapy regimens, cerebral blood flow was evaluated by internal carotid artery and middle cerebral artery peak systolic velocity, and pulsatility index measurements via Doppler ultrasonography. Cognitive functions were evaluated by the Standardized Mini-Mental Test. The mean follow-up period was 10.9+/-2.4 months, ranging between 8 and 16 months. After the follow-up period, the cerebral blood flow, and cognitive function of each woman was re-evaluated. Demographic and clinical characteristics of the women were not significantly different between the study groups (P>0.05). There were no significant differences between the pretreatment and posttreatment values for cerebral blood flow indices and cognitive function scores in any of the study groups (P>0.05). Different postmenopausal hormone therapy regimens have not revealed any significant effects on either cerebral blood flow or cognitive function.

Premarin improves memory, prevents scopolamine-induced amnesia and increases number of basal forebrain choline acetyltransferase positive cells in middle-aged surgically menopausal rats

Conjugated equine estrogen (CEE) is the most commonly prescribed estrogen therapy, and is the estrogen used in the Women's Health Initiative study. While in-vitro studies suggest that CEE is neuroprotective, no study has evaluated CEE's effects on a cognitive battery and brain immunohistochemistry in an animal model. The current experiment tested whether CEE impacted: I) spatial learning, reference memory, working memory and long-term retention, as well as ability to handle mnemonic delay and interference challenges; and, II) the cholinergic system, via pharmacological challenge during memory testing and ChAT-immunoreactive cell counts in the basal forebrain. Middle-aged ovariectomized (Ovx) rats received chronic cyclic injections of either Oil (vehicle), CEE-Low (10 μg), CEE-Medium (20 μg) or CEE-High (30 μg) treatment. Relative to the Oil group, all three CEE groups showed less overnight forgetting on the spatial reference memory task, and the CEE-High group had enhanced platform localization during the probe trial. All CEE groups exhibited enhanced learning on the spatial working memory task, and CEE dose-dependently protected against scopolamine-induced amnesia with every rat receiving the highest CEE dose maintaining zero errors after scopolamine challenge. CEE also increased number of ChAT-immunoreactive neurons in the vertical diagonal band of the basal forebrain. Neither the ability to remember after a delay nor interference, nor long-term retention, was influenced by the CEE regimen used in this study. These findings are similar to those reported previously for 17 β-estradiol, and suggest that CEE can provide cognitive benefits on spatial learning, reference and working memory, possibly through cholinergic mechanisms.

Effects of tibolone and conventional HRT on the expression of estrogen and progesterone receptors in the breast

ObjectiveThere is evidence that long-term hormone replacement therapy (HRT) is associated with an increased breast cancer risk. The aim of this study was to assess the effects of tibolone on estrogen and progesterone receptors in comparison to the effects of conventional HRT in the breast of surgically postmenopausal macaques. MethodSixty macaques were bilaterally ovariectomized 3 months before hormonal treatment was initiated. The animals were randomized into four treatment groups, including tibolone (TIB), conjugated equine estrogens (CEE), conjugated equine estrogens+medroxyprogesterone acetate (CEE+MPA) and control animals (C). After 2 years treatment, breast tissues were collected, fixed and paraffin embedded. Immunohistochemistry assays with monoclonal antibodies for estrogen receptors (ERα and ERβ) and progesterone receptors (PRA and PRB) were performed. ResultsThe expression of ERα was markedly decreased in the CEE+MPA group as compared to C and TIB groups. The TIB group was not different from the C and CEE groups. No significant differences were found for ERβ immunostaining. The expression of PRA was strongly increased in the TIB group as compared to the C and CEE+MPA groups. Immunostaining of PRB was increased in the CEE and TIB treated animals as compared to both C and CEE+MPA groups. ConclusionsTibolone increased the expression of both PRA and PRB, without affecting ERα and ERβ expression in the macaque breast. These findings indicate that the effects of tibolone in breast tissue could be mediated via differential regulation of PRA and PRB isoforms and therefore distinct from those observed with conventional HRT.

Re: Conjugated Equine Estrogen and Risk of Benign Proliferative Breast Disease: A Randomized Controlled Trial

Background Estrogens stimulate proliferation of breast epithelium and may therefore increase the risk of benign proliferative breast disease, a condition that is associated with increased risk of breast cancer. We tested the effect of conjugated equine estrogen (CEE) on risk of benign proliferative breast disease in the Women ’ s Health Initiative (WHI) randomized controlled trial. Methods In the WHI CEE trial, 10 739 postmenopausal women were randomly assigned to 0.625 mg/d of CEE or to placebo. Baseline and annual breast examinations and mammograms were required. We identified women in the trial who reported breast biopsies that were free of cancer, obtained the associated histological sections, and subjected them to standardized central review. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). All statistical tests were two-sided. Results A total of 232 incident cases of benign proliferative breast disease were ascertained during follow-up (average duration, 6.9 years), with 155 in the CEE group and 77 in the placebo group. Use of CEE was associated with a more than two-fold increase in the risk of benign proliferative breast disease (HR = 2.11, 95% CI = 1.58 to 2.81). For benign proliferative breast disease without atypia, the HR was 2.34 (95% CI = 1.71 to 3.20), whereas for atypical hyperplasia, it was 1.12 (95% CI = 0.53 to 2.40). Risk varied little by levels of baseline characteristics. Conclusion Use of 0.625 mg/d of CEE was associated with a statistically significant increased risk of benign proliferative breast disease.

Health Risks and Benefits 3 Years After Stopping Randomized Treatment With Estrogen and Progestin

The Women's Health Initiative trial of estrogen plus progestin was a double blind, placebo-controlled, randomized study that evaluated a combination of 0.625 mg of conjugated equine estrogens (CEE) and 2.5 mg of medroxyprogesterone acetate (MPA) daily in 16,608 women 50-79 years of age. The trial was stopped after 5.6 years of follow-up because of the lack of overall health benefit and an increased risk of invasive breast cancer. The postintervention phase began in mid 2002 and averaged 2.4 years of follow-up. Participants were monitored semiannually. The increased risk of cardiovascular disease events observed in women assigned to CEE or MPA treatment was not apparent in the postintervention phase. The annualized risk level was 1.97% in the CEE or MPA group and 1.91% in placebo recipients. The risk of malignant disease was greater in the CEE or MPA group than in the placebo group (1.56% versus 1.26%); the hazard ratio (HR) was 1.24, with a 95% confidence interval (CI) of 1.04-1.48. The HR for breast cancer was 1.27 (95% CI, 0.91-1.78). During follow-up after the intervention there was a moderate trend toward a lower HR. All-cause mortality was somewhat higher in the CEE or MPA group than in placebo recipients. A global index of risks and benefits was unchanged from the time of randomization. This index included, in addition to the two primary end-points of coronary heart disease and breast cancer, stroke, pulmonary embolism, endometrial cancer, colorectal cancer, hip fracture, and death from other causes. A major implication of this postintervention study is that women who receive combined estrogen and progestin therapy must be closely observed after treatment ends because of a sustained increase in the risk of malignant disease including breast cancer.

Increases in Serum Estrone Sulfate Level Are Associated with Increased Mammographic Density during Menopausal Hormone Therapy

Menopausal hormone therapy increases mammographic density. We determined whether increases in serum estrone sulfate (E(1)S) levels during menopausal hormone therapy predict increased mammographic density. We measured percent mammographic density and serum E(1)S levels in 428 participants of the Postmenopausal Estrogen/Progestin Interventions study who were randomly assigned to daily conjugated equine estrogen (CEE) 0.625 mg alone, CEE + daily medroxyprogesterone acetate (MPA) 2.5 mg, CEE + cyclical MPA (10 mg days 1-12 per 28-day cycle), or CEE + cyclical micronized progesterone (10 mg days 1-12). Serum E(1)S levels were determined by RIA. Information about covariates was determined by annual questionnaire. Using linear regression, we determined the association between change in E(1)S level from baseline to 12 months and change in percent mammographic density (by semiquantitative interactive threshold method). After controlling for baseline mammographic density, age, body mass index, alcohol intake, parity, smoking, ethnicity, physical activity, and age at first pregnancy, mammographic density increased by 1.3% for every 1 ng/mL increase in E(1)S level (P < 0.0001). The association between change in E(1)S level and change in mammographic density differed by treatment group (greater effect in CEE + cyclical MPA group versus CEE group; P = 0.05). After controlling for treatment group, change in the ratio of E(1)S to E(1) was also positively associated with change in mammographic density. Increases in serum E(1)S levels during menopausal hormone therapy are associated with increases in mammographic density. The relative contribution of E(1)S and E(1) to stimulation of breast tissue awaits further elucidation.

Conjugated Equine Estrogen and Risk of Benign Proliferative Breast Disease: A Randomized Controlled Trial

Estrogens stimulate proliferation of breast epithelium and may therefore increase the risk of benign proliferative breast disease, a condition that is associated with increased risk of breast cancer. We tested the effect of conjugated equine estrogen (CEE) on risk of benign proliferative breast disease in the Women's Health Initiative (WHI) randomized controlled trial. In the WHI CEE trial, 10,739 postmenopausal women were randomly assigned to 0.625 mg/d of CEE or to placebo. Baseline and annual breast examinations and mammograms were required. We identified women in the trial who reported breast biopsies that were free of cancer, obtained the associated histological sections, and subjected them to standardized central review. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). All statistical tests were two-sided. A total of 232 incident cases of benign proliferative breast disease were ascertained during follow-up (average duration, 6.9 years), with 155 in the CEE group and 77 in the placebo group. Use of CEE was associated with a more than two-fold increase in the risk of benign proliferative breast disease (HR = 2.11, 95% CI = 1.58 to 2.81). For benign proliferative breast disease without atypia, the HR was 2.34 (95% CI = 1.71 to 3.20), whereas for atypical hyperplasia, it was 1.12 (95% CI = 0.53 to 2.40). Risk varied little by levels of baseline characteristics. Use of 0.625 mg/d of CEE was associated with a statistically significant increased risk of benign proliferative breast disease.

Health Risks and Benefits 3 Years After Stopping Randomized Treatment With Estrogen and Progestin

The Women's Health Initiative (WHI) trial of estrogen plus progestin vs placebo was stopped early, after a mean 5.6 years of follow-up, because the overall health risks of hormone therapy exceeded its benefits. To report health outcomes at 3 years (mean 2.4 years of follow-up) after the intervention was stopped. The intervention phase was a double-blind, placebo-controlled, randomized trial of conjugated equine estrogens (CEE) 0.625 mg daily plus medroxyprogesterone acetate (MPA) 2.5 mg daily, in 16,608 women aged 50 through 79 years, recruited by 40 centers from 1993 to 1998. The postintervention phase commenced July 8, 2002, and included 15 730 women. Semi-annual monitoring and outcomes ascertainment continued per trial protocol. The primary end points were coronary heart disease and invasive breast cancer. A global index summarizing the balance of risks and benefits included the 2 primary end points plus stroke, pulmonary embolism, endometrial cancer, colorectal cancer, hip fracture, and death due to other causes. The risk of cardiovascular events after the intervention was comparable by initial randomized assignments, 1.97% (annualized rate) in the CEE plus MPA (343 events) and 1.91% in the placebo group (323 events). A greater risk of malignancies occurred in the CEE plus MPA than in the placebo group (1.56% [n = 281] vs 1.26% [n = 218]; hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.04-1.48). More breast cancers were diagnosed in women who had been randomly assigned to receive CEE plus MPA vs placebo (0.42% [n = 79] vs 0.33% [n = 60]; HR, 1.27; 95% CI, 0.91-1.78) with a modest trend toward a lower HR during the follow-up after the intervention. All-cause mortality was somewhat higher in the CEE plus MPA than in the placebo group (1.20% [n = 233] vs 1.06% [n = 196]; HR, 1.15; 95% CI, 0.95-1.39). The global index of risks and benefits was unchanged from randomization through March 31, 2005 (HR, 1.12; 95% CI, 1.03-1.21), indicating that the risks of CEE plus MPA exceed the benefits for chronic disease prevention. The increased cardiovascular risks in the women assigned to CEE plus MPA during the intervention period were not observed after the intervention. A greater risk of fatal and nonfatal malignancies occurred after the intervention in the CEE plus MPA group and the global risk index was 12% higher in women randomly assigned to receive CEE plus MPA compared with placebo. clinicaltrials.gov Identifier: NCT00000611.

Conjugated equine estrogen, raloxifene and arterial stiffness in postmenopausal women

Methods We analyzed the influence of conjugated equine estrogen (CEE) and raloxifene on arterial stiffness. Sixty-seven healthy, normotensive women 1–10 years into menopause were assigned to receive oral placebo, conjugated equine estrogen 0.625 mg, or raloxifene 60 mg. Arterial stiffness was evaluated by measuring the carotid–femoral and femoral–dorsalis pedis pulse wave velocity (CF PWV, FP PWV). Systolic pressure augmentation index (AI) at the carotid artery was obtained with applanation tonometry.Results Arterial stiffness was not affected by any treatment regimen: placebo (CF PWV before vs. after: 644 vs. 626 cm/s, p = 0.09; FP PWV before vs. after: 1006 vs. 1012 cm/s,p = 0.77; AI before vs. after = 30 vs. 29%, p = 0.55), CEE (CF PWV before vs. after: 642 vs. 600 cm/s, p = 0.11; FP PWV before vs. after: 952 vs. 971 cm/s, p = 0.66; AI before vs. after: 25 vs. 32%, p = 0.82), and raloxifene (CF PWV before vs. after: 636 vs. 601 cm/s, p = 0.12; FP PWV before vs. after: 964 vs. 941 cm/s, p = 0.62; AI before vs. after: 25 vs. 25%, p = 0.65). A correlation occurred between basal stiffness and the degree of reduction in indexes measured, indicating that the higher the basal stiffness, the greater the degree of reduction, particularly in the CEE group: CF PWV (r = − 0.602, p = 0.001); FP PWV (r = − 0.455, p = 0.022); AI (r = − 0.410, p = 0.042).Conclusions Conjugated equine estrogen and raloxifene do not seem to affect arterial stiffness of healthy normotensive women less than 10 years since menopause. Reduction in arterial stiffness seems related to its basal level.

Serum Lipoprotein(a) Dynamics before/after Menopause and Long-term Effects of Hormone Replacement Therapy on Lipoprotein(a) Levels in Middle-aged and Older Japanese Women

To assess lipoprotein(a) Lp(a) dynamics before and after menopause and to examine long-term changes during hormone replacement therapy (HRT) in middle-aged and older Japanese women. (1) Serum total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and Lp(a) concentrations of 526 patients were compared. The patients were divided into 3 groups on the basis of menopausal status (premenopause, perimenopause, postmenopause). (2) Serum markers of lipid metabolism were measured at baseline and at 6-month intervals in 161 postmenopausal women who continuously received HRT with conjugated equine estrogen (CEE) and medroxyprogesterone acetate (MPA) for 4 years. (3) Changes in serum concentrations of markers were compared among 120 women with hypercholesterolemia who were randomly assigned to receive HRT (CEE plus MPA, or transdermal estradiol plus MPA) or pravastatin. (1) Lp(a) concentrations were significantly higher in the postmenopausal women than in the premenopausal or perimenopausal women. (2) The mean Lp(a) concentration after 6 months of HRT decreased by about 19%, and similar levels were maintained for 4 years (3). The mean Lp(a) concentration after 6 months of HRT decreased by 19.9% in the CEE plus MPA group, but did not change significantly in the transdermal estradiol plus MPA group or the pravastatin group. Our results suggest that HRT with CEE plus MPA is useful for the management of elevated serum Lp(a) concentrations in middle-aged and older women. However, follow-up studies are needed to determine whether this finding is related to the future prevention of coronary heart disease events.