Dolores Perovano Pardini

Fitoestrogênios: posicionamento do Departamento de Endocrinologia Feminina da Sociedade Brasileira de Endocrinologia e Metabologia (SBEM)

To evaluate the benefit of phytoestrogens (PhE) in hormone replacement therapy of menopause (HRTM), the Department of Female Endocrinology of the Brazilian Society of Endocrinology and Metabolism convened a group of specialists to perform a bibliographic review. Only articles that met strict scientific methodological criteria were included. PhE exhibit both estrogenic and antiestrogenic actions, mainly on estrogen (E) receptors b, with much less estrogenic potency than estradiol. PhE content of vegetal sources varies, depending on cultivation, harvesting, storage and industrialization. Conversion of precursors to active phytohormones in the human body exhibits great individual variability. Most studies with PhE was done in vitro or in laboratory animals and could not always be extrapolated to humans. Some studies on the climateric syndrome suggest little improvement of hot flushes but not of vaginal dryness or mood instability. Regarding lipid metabolism, soy-rich food but not isolated isoflavones promotes reduction of total cholesterol, LDL-chol and triglyceride levels, but does not raise HDL-chol as E do, and promotes elevation of lipoprotein (a), which are reduced by E. Although some short-term studies suggest improvement of bone mineral density with isoflavones, no reduction in fracture rate is demonstrated. We conclude that there are no convincing evidences to support the use of PhE or soy-rich food as alternatives to HRTM.

Alterações hormonais da mulher atleta

The purpose of this review is to focus the exercise as a modulator of human reproduction and to summarize and integrate current data concerning the hypothalamus-pituitary-gonadal axis in exercising women. The prevalence of menstrual dysfunctions, as the luteal phase deficiency, oligomenorrhea, amenorrhea and menarcheal delay are greater among athletes than in the general population. Many factors undergo changes during the course of an athletic training program and any or all of these may contribute to disturbances in menstrual cyclicity. A number of risk factors have been identified as predisposing women to the development of menstrual irregularities, such as low body weight, body fat and hypoestrogenic status. Hypoestrogenism may affect peak bone mass in the puberty and lead to irreversible premature bone loss. This paper reviews the physiologic effects of fitness training on various endocrine systems and provides clinical information about specific endocrine disturbances in athlete women.

Terapia hormonal da menopausa

Embora a reposicao estrogenica esteja disponivel ha mais de 6 decadas, as mulheres e mesmo os profissionais da saude estao confusos pelas opinioes divergentes em relacao aos riscos e beneficios da terapia hormonal na menopausa (THM), estrogenica (TE) ou estro-progestagenica (TEP). A principal indicacao para terapeutica hormonal na menopausa e o alivio dos sintomas menopausais, tais como sintomas vasomotores, alteracoes genito-urinarias e a prevencao de osteoporose nas pacientes de risco. Em outras areas de pesquisa, principalmente ao que se refere aos efeitos nos sistemas cardiovasculares e nervoso central, os resultados atuais na literatura sao conflitivos. O tratamento por mais de 5 anos nao adiciona risco significativo para câncer de mama, mas diminui significativamente o risco de fratura osteoporotica. Algumas mulheres podem ser susceptiveis a risco tromboembolico precoce, mas quando a TH for adequada apos avaliacao individualizada, os beneficios superam os riscos e o tratamento deve ser recomendado. Estudos futuros sao necessarios para identificar novas indicacoes para TH e diminuir ou abolir seus riscos. A pesquisa clinica continua na identificacao de fatores geneticos que possam influenciar a resposta individual a TH, diferentes formulacoes estrogenicas, diferentes vias de administracao e liberacao, alem das opcoes de dose. Nas mulheres que apresentam os sintomas da sindrome climaterica de forma severa durante a peri e pos-menopausa ja existem evidencias conclusivas oriundas de varios estudos randomizados controlados de que a TH e a unica terapia com resultados satisfatorios. Os medicos devem sempre fazer suas decisoes terapeuticas com base nos riscos e beneficios individuais de cada paciente, tendo a responsabilidade e o dever de promover as condicoes para a mulher atravessar a transicao menopausica com qualidade de vida.

Terapia de reposição hormonal na menopausa

Although estrogen has been clinically available for more than six decades, women have been confused by different opinions regarding the risks and benefits of menopausal hormone therapy (HT), estrogen therapy (ET), and estrogen-progestin therapy (EPT). The publication of randomized controlled trials (RCTs), notably, the Heart and Estrogen/progestin Replacement Study (HERS) and Women’s Health Initiative (WHI), has intensified the risk vs. benefit controversy. Millions of women are treated with HT for relief of menopausal symptoms, including vasomotor flushes and sweats, for which estrogen is uniquely and highly effective. Others may continue longer-term treatment in the hope that HT will help to prevent chronic disease. The preservation of bone mass with continuing estrogen therapy and reduction of subsequent risk of fracture is well established. Observational studies of the metabolic and vascular effects of estrogens have suggested a potential benefit in reducing the risk of vascular disease, but recently published randomized controlled trials demonstrated no evidence of benefit in women with established vascular disease or in apparently healthy women. The increased risks of breast cancer and thromboembolic disease have been confirmed in these trials, with evidence of increased risk of stroke. The absolute incidence of an adverse event is low, and the risk of stroke in an individual woman in a single year is very small, but with long-term use, the risks are cumulative over time. The risk-benefit balance needs to be individualized for each woman.

Síndrome dos ovários policísticos, síndrome metabólica, risco cardiovascular e o papel dos agentes sensibilizadores da insulina

The Polycystic Ovary Syndrome (PCOS) affects 6 to 10% of women of childbearing age. Insulin resistance and hyperinsulinemia are present in nearly all PCOS patients and play a central role in the development of both hyperandrogenism and metabolic syndrome (MS). MS occurs in approximately 43% of PCOS patients, raising the cardiovascular risk to up seven fold in these patients. Several serum, functional and structural markers of endothelial dysfunction and subclinical atherosclerosis were described in PCOS patients, even those young and non-obese. However, despite the fact that PCOS adversely affects the cardiovascular profile, long-term studies did not demonstrate a consistent raise in cardiovascular mortality, which seems to be more observed in the post-menopausal period. Recently, oral contraceptives are being substituted for insulin sensitizing agents (metformin and glitazones) in the PCOS treatment, due to their effects on insulin resistance and cardiovascular risk.

Polycystic ovary syndrome: clinical and laboratory evaluation

OBJECTIVE To evaluate clinically, and with laboratory, tests, women with polycystic ovary syndrome (PCO). PATIENTS One hundred and twelve women with PCO were studied. METHODS The following data was recorded: Current age; age at menarche; menstrual irregularity, occurrence of similar cases in the family; fertility, obstetric history; body mass index (BMI); and presence of hirsutism. Serum measurements of follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, free testosterone, and dehydroepiandrosterone sulfate were taken. RESULTS All patients presented either oligomenorrhea (31 percent), periods of secondary amenorrhea (9 percent), or both alterations (60 percent). The majority of the patients were infertile (75.6 percent). The LH/FSH ratio was higher than 2:1 in 55 percent of the patients and higher than 3:1 in 26.2 percent. The ultrasonographic aspect of the ovaries was considered to be normal in 31 percent. CONCLUSION The main clinical feature of the PCO is the irregularity of menses since menarche, and that the laboratory tests would be important to exclude other disorders such as hyperprolactinemia or hyperandrogenemia caused by late-onset congenital adrenal hyperplasia.

Terapia hormonal da menopausa: posicionamento do Departamento de Endocrinologia Feminina e Andrologia da SBEM em 2004.

Hormonal Therapy of Menopause: 2004 Position of the Department of Female Endocrinology and Andrology of the Brazilian Society of Endocrinology and Metabolism. After randomized clinical trials produced impact and questions at the medical community on menopause hormonal therapy (MHT), the Depar- tment of Female Endocrinology and Andrology of the Brazilian Society of Endocrinology convened a group of specialists to produce an informative, critical and position paper, offering guidelines for those who practice or are called to express their opinion on menopause therapy. MHT is indicat- ed for relief of vasomotor symptoms, maintenance of vaginal trophism, bone mass and collagen preservation, sexual and general well-being. Studies on primary cardiovascular prevention are not conclusive, and thus insufficient to indicate or not MHT for this purpose. Schemes and forms of association should de individualized. Whenever possible, one should use 17-beta estradiol, associated to natural progesterone or its derivatives in women with an intact uterus, at the lowest effective doses. Duration of therapy depends on its aims, and should be periodically re-evaluated through an individual indication/contra-indication balance. Orientation toward a healthier lifestyle, with smoking cessation, adequate calcium intake and a low fat diet, together with regular physical activity is funda- mental during menopause.

Serum levels of androstanediol glucuronide, total testosterone, and free testosterone in hirsute women

OBJECTIVE To determine the serum levels of androstanediol glucuronide (3 alpha-diol G), total T, and free T in hirsute and nonhirsute women. DESIGN Controlled clinical study. PATIENTS Hirsute women with oligomenorrhea, hirsute women with regular ovulatory cycles, and nonhirsute women with regular cycles were selected. MAIN OUTCOME MEASURE Serum levels of 3 alpha-diol G, total T, and free T were measured in 8 hirsute with oligomenorrhea and 11 hirsute women with regular ovulatory cycles and compared with 20 nonhirsute women with regular cycles (control group). Serum 3 alpha-diol G was also measured during the follicular, periovulatory, and luteal phases in hirsute women with regular cycles. RESULTS Serum levels of 3 alpha-diol G did not change during the menstrual cycle, in addition we observed that there was no difference between the levels of 3 alpha-diol G, total T, and free T in hirsute women with regular cycles when compared with normal women. These three serum androgens were elevated only in the hirsute women with oligomenorrhea. Besides, there was better correlation between total T and free T (r = 0.81) than total T and 3 alpha-diol G (r = 0.49) or free T and 3 alpha-diol G (r = 0.66). CONCLUSION The findings suggest that serum 3 alpha-diol G does not provide additional benefit as a marker of hirsutism than serum total or free T.

Terapêutica de reposição hormonal na osteoporose da pós menopausa

Postmenopausal hormone therapy is widely believed to prevent osteoporosis. This review report the mainly effects, mechanisms of actions and indications for the mainly steroids used in the postmenopausal osteoporosis.

Effect of hormone replacement therapy on the bone mass and urinary excretion of pyridinium cross-links

CONTEXT The menopause accelerates bone loss and is associated with an increased bone turnover. Bone formation may be evaluated by several biochemical markers. However, the establishment of an accurate marker for bone resorption has been more difficult to achieve. OBJECTIVE To study the effect of hormone replacement therapy (HRT) on bone mass and on the markers of bone resorption: urinary excretion of pyridinoline and deoxypyridinoline. DESIGN Cohort correlational study. SETTING Academic referral center. SAMPLE 53 post-menopausal women, aged 48-58 years. MAIN MEASUREMENTS Urinary pyr and d-pyr were measured in fasting urine samples by spectrofluorometry after high performance liquid chromatography and corrected for creatinine excretion measured before treatment and after 1, 2, 4 and 12 months. Bone mineral density (BMD) was measured by dual energy X-ray absorptiometry (DEXA) before treatment and after 12 months of HRT. RESULTS The BMD after HRT was about 4.7% (P < 0.0004); 2% (P < 0.002); and 3% (P < 0. 01) higher than the basal values in lumbar spine, neck and trochanter respectively. There were no significant correlations between pyridinium cross-links and age, weight, menopause duration and BMD. The decrease in pyr and d-pyr was progressive after HRT, reaching 28.9% (P < 0.0002), and 42% (P < 0.0002) respectively after 1 year. CONCLUSIONS Urinary pyridinoline and deoxypyridinoline excretion decreases early in hormone replacement therapy, reflecting a decrease in the bone resorption rate, and no correlation was observed with the bone mass evaluated by densitometry.