Showing papers by "Howard N. Hodis published in 2007"

Estrogen and progestogen use in peri- and postmenopausal women: March 2007 position statement of The North American Menopause Society

Abstract: Objective: To update the evidence-based position statement published by The North American Menopause Society (NAMS) in 2004 regarding recommendations for estrogen and progestogen use in peri- and postmenopausal women. Design: NAMS followed the general principles established for evidence-based guidelines to create this updated document. An Advisory Panel of clinicians and researchers expert in the field of women's health was enlisted to review the 2004 NAMS position statement, compile supporting statements, and reach consensus on recommendations. The Panel's recommendations were reviewed and approved by the NAMS Board of Trustees. The position statements published by NAMS do not represent "practice standards" that would be codified and held up as standards by regulating bodies and insurance agencies. Rather, they are prevailing opinion pieces in a best effort attempt to incorporate current evidence into practical clinical recommendations. Results: With the primary goal being to evaluate the risk-benefit ratio of peri- and postmenopausal estrogen therapy (ET) and estrogen-progestogen therapy (EPT) for both disease prevention and treatment of menopause-related symptoms, current evidence allowed for a clear distinction between areas of consensus and areas for which the Panel determined that there was inadequate evidence for any conclusion to be reached. The document lists all of these areas along with clear explanatory comments. A comprehensive list of key references is provided. The absence of evidence is also recognized in the list of needs for further research recommended by the Panel. Conclusions: Current evidence supports the use of ET or EPT for menopause-related symptoms and disease prevention in appropriate populations of peri- and postmenopausal women.

Progression of carotid artery intima-media thickening in HIV-infected and uninfected adults.

Abstract: Objectives To compare the rate of change in intima-media thickness (IMT) of the carotid artery among uninfected subjects and HIV-infected subjects receiving or not receiving protease inhibitor (PI) regimens over a 144 week period. Design This prospective, matched cohort study enrolled 133 subjects into 45 triads (groups of three subjects matched by age, sex, race/ethnicity, smoking status, blood pressure, and menopause) from university based outpatient HIV clinics. Each triad consisted of one subject from each of the following groups: 1, HIV-infected subjects with continuous use of PI therapy for > or = 2 years; 2, HIV-infected subjects without prior PI use; 3, HIV-uninfected subjects. Methods Standardized ultrasound images of carotid IMT were collected at weeks 0, 2, 24, 48, 72, 96, and 144. The main outcome was the yearly progression rate of carotid IMT (mm/year). Results The median yearly IMT progression rate in groups 1, 2, and 3 was 0.0096, 0.0058, and 0.0085 mm/year, respectively. There were no statistically significant differences in progression between groups 1 and 2, or between the combined HIV-positive groups and the HIV-negative control group. A multicovariate model examining predictors of progression in carotid IMT among all subjects contained low density lipoprotein cholesterol and homocysteine. Among HIV subjects, predictors included nadir CD4 cell count and ritonavir use. Conclusions HIV infection and PI use did not contribute substantially to the rate of carotid IMT progression in our matched study.

Postmenopausal hormone therapy in clinical perspective.

Abstract: Although many of the risks and benefits of postmenopausal hormone therapy are known, only recently has the magnitude of these effects and their perspective to other therapies become more fully understood. Careful review of randomized controlled trials indicates that the risks of postmenopausal hormone therapy including breast cancer, stroke and venous thromboembolism are similar to other commonly used agents. Overall, these risks are rare (less than 1 event per 1,000 women) and even rarer when initiated in women less than 60 years of age or within 10 years of menopause. In addition, the literature indicates similar benefit of postmenopausal hormone therapy, in women who initiate hormone therapy in close proximity to menopause, to other medications used for the primary prevention of coronory heart disease in women.

Effect of antihypertensive therapy on progression of carotid intima-media thickness in patients with type 2 diabetes mellitus.

Abstract: Antihypertensive therapy reduces the incidence of cardiovascular events in people with diabetes mellitus (DM). However, the effects of treatment on subclinical atherosclerosis are less well studied. Results of a post hoc cohort analysis of the association between antihypertensive treatment and carotid artery intima-media thickness (CIMT) in the Troglitazone Atherosclerosis Regression Trial (TART), a randomized trial designed to evaluate the impact of troglitazone treatment on CIMT progression in adults with insulin-requiring type 2 DM, are reported. CIMT, blood pressure (BP), and use of antihypertensive agents were measured throughout the 2-year treatment period. In multivariable mixed-effects models, the annual rate of change in CIMT in relation to BP and duration of antihypertensive agent use, adjusting for covariates, was evaluated. Higher systolic BP was associated with a higher CIMT progression rate (p = 0.03). This association was reduced by antihypertensive treatment in a duration-dependent manner (p for interaction = 0.035). Adjustment for age, treatment assignment, and change in fasting glucose during the trial did not attenuate these associations. In conclusion, regular use of antihypertensive agents reduces the harmful impact of increased BP on atherosclerosis progression in patients with DM. The antiatherogenic effect of antihypertensive agents, including BP normalization and possible direct vascular wall protection, can be detected by CIMT progression using B-mode ultrasound in patients with DM.

Estrogen therapy and coronary-artery calcification.

Abstract: To the Editor: In their article on the Women’s Health Initiative Coronary-Artery Calcium Study (WHI-CACS), Manson et al. (June 21 issue)1 provide insight into another mechanism by which estrogen therapy reduces coronary heart disease (CHD) in women who have undergone hysterectomy and who initiate such therapy close to menopause.2 The authors’ findings further support the hypothesis that early initiation of such therapy has a beneficial effect.3 For women under the age of 60 years, scientific evidence indicates that estrogen therapy is as efficacious in reducing CHD as are other primary prevention therapies, such as lipid-lowering drugs and aspirin, and is more effective in reducing total mortality.4 For women in this age group, estrogen therapy has a risk profile that is no greater than that of other medications used for primary prevention of CHD in women.4 Studies by the WHI, other randomized trials, and observational studies (including the WHI observational study) show significant trends toward a greater benefit with respect to total mortality and CHD with a longer duration of estrogen therapy.2,4 WHI-CACS was similar to the Estrogen in the Prevention of Atherosclerosis Trial5 in providing mechanistic evidence for a role of estrogen therapy in the prevention of CHD in postmenopausal women. WHI not only has confirmed the known benefits from observational studies but also has clearly shown the relative safety of estrogen therapy under randomized, controlled conditions in women under the age of 60 years (Table 1).2,4

Postmenopausal hormone therapy and cardiovascular disease: Making sense of the evidence

Abstract: Controversy surrounding the cardioprotective role of postmenopausal hormone therapy continues. This controversy is fueled in part by the body of evidence that indicates a duality of hormone therapy on potential risks and benefits. The totality of evidence indicates that the effects of postmenopausal hormone therapy are affected by age, state of the target tissue, duration of therapy, and timing of initiation, according to time since menopause. This review presents evidence supporting a cardioprotective role of hormone therapy in young postmenopausal women as well as a potentially negative effect in older postmenopausal women. These data are reviewed in relation to the evidence that hormone therapy prevents new onset diabetes mellitus, and that the risks of hormone therapy are rare and even rarer in young postmenopausal women. The cardioprotective role of postmenopausal hormone therapy will only be resolved by refined research guided by the results from previous studies.

Carotid artery intima-media thickness after raloxifene treatment.

Abstract: Background: Raloxifene, a selective estrogen receptor modulator (SERM), decreases total and low-density lipoprotein cholesterol (LDL-C) in postmenopausal women and inhibits increases in intima-media thickness (IMT) in animal models. We tested whether up to 8 years exposure to raloxifene had an effect on subclinical atherosclerosis in the 4-year Multiple Outcomes of Raloxifene Evaluation (MORE) trial and the follow-up study, the 4-year Continuing Outcomes Relevant to Evista (CORE) trial. Methods: A subsample of postmenopausal women with osteoporosis, who had completed the MORE and CORE trials and were on average 68 years of age and 19 years postmenopausal at randomization into MORE, participated in this substudy. Within 6 months of cessation of study drug in CORE, right common carotid artery IMT (CIMT) and carotid artery stiffness and arterial compliance were measured at one of two sites (San Diego and San Francisco) using high-resolution B-mode ultrasound. CIMT and arterial stiffness measures were compare...

Randomized Controlled Trials and the Effects of Postmenopausal Hormone Therapy on Cardiovascular Disease: Facts, Hypotheses, and Clinical Perspective

Abstract: Publisher Summary This chapter reviews the randomized controlled trials designed to study the effects of hormone therapy on cardiovascular disease with the totality of data currently available. The cumulated randomized controlled trial data indicate that after 4 to 6 years of use, hormone therapy reduces coronary heart disease risk relative to placebo in women with or without pre-existing coronary heart disease. In addition, early initiation of hormone therapy relative to menopause is also associated with a reduction in coronary heart disease. The randomized controlled trial results are supported by approximately 40 observational studies also indicating that initiation of hormone therapy at the menopausal transition or early in the postmenopausal period and continued for a prolonged period of time results in significant reductions in coronary heart disease and overall mortality. Comparison of the results from randomized controlled trials, observational studies, and case-control studies indicate that selection bias and confounding do not explain the consistent evidence that hormone therapy is associated with a duration- and time dependent lowering of coronary heart disease. The discordance in coronary heart disease outcome between randomized controlled trials and observational studies is a function of the differences in study design and the characteristics of the populations studied.