Fiorenza Bruschi

The Sacrospinous Vaginal Vault Suspension: Critical Analysis of Outcomes

Abstract: One hundred and three women with a preoperative diagnosis of a pelvic support defect underwent right sacrospinous fixation of the vaginal apex. The procedure was performed either therapeutically (in 63 subjects with vaginal vault eversion) or prophylactically (40 patients with severe uterovaginal prolapse), and was associated with other reconstructive procedures to repair the coexisting cystocele, enterocele or rectocele. Preoperative and postoperative assessments of each vaginal site were compared and the results in the cure of stress urinary incontinence, if present, were evaluated with regard to the type of surgery performed. The overall rate of satisfactory results in the repair of the superior vaginal defect was 94%, and good anatomic results were achieved in the repair of either enterocele or rectocele. Conversely, the repair of the anterior vaginal wall was not as good as in the posterior and superior vaginal sites. Stress urinary incontinence was successfully managed in 72% of the women using different anti-incontinence procedures.

Lipoprotein(a) and other lipids after oophorectomy and estrogen replacement therapy

Objective To assess the effect of surgical menopause and subsequent estrogen replacement therapy (ERT) on lipoprotein(a) [Lp(a)] and common lipids. Methods In 24 healthy premenopausal women, lipids (total cholesterol, low-density lipoprotein [LDL] and highdensity lipoprotein [HDL] cholesterol, and triglycerides) and gonadotropins (FSH, LH) were measured the day before hysterectomy with bilateral oophorectomy and then after 1, 2, and 3 months. Blood was also drawn after 2, 4, 6, and 15 days to exclude the effect of surgery on Lp(a). In 19 women who volunteered for ERT, the lipid profile was assayed again after 3, 6, and 12 months of treatment. Results Lipoprotein(a) levels rose significantly over the 3 months after surgery, from a mean ± standard deviation (SD) 5.7 ± 6.1 mg/dL to 10.4 ± 9.2 mg/dL. Total cholesterol and LDL cholesterol levels increased significantly over the first 2 months; HDL cholesterol decreased significantly during the 3 months of follow-up (by 10, 17, and 20%) (P < .001). Plasma triglycerides did not change after surgery. Three months following ERT, Lp(a) and total cholesterol were significantly decreased (28 and 11%, respectively), as was LDL cholesterol (33%) after 6 months. High-density lipopromein cholesterol increased by 24% after 6 months of treatment, and triglycerides rose significantly in the year of therapy (37%). Conclusion These findings suggest that surgical menopause induces atherogenic changes in the lipid profile in 3 months and that ERT soon reverses them.

Effects of oral and transdermal hormone replacement therapy on lipoprotein(A) and lipids: A randomized controlled trial

Objective:Our purpose was to compare the effect of oral and transdermal hormone replacement therapy on lipoprotein(a) and other plasma lipids in healthy postmenopausal women. Design:A total of 120 postmenopausal women were enrolled in a prospective randomized controlled study, and allocated either to transdermal 17β-estradiol (50 μg/day) or to oral conjugated estrogen (0.625 mg/day). Forty-one age-matched women were used as the reference group. Plasma lipids and lipoproteins were determined every 3 months and differences were sought by statistical analysis. Results:Plasma lipoprotein(a) dropped after 3 months of treatment either with transdermal estradiol (p < 0.01) or oral estrogen (p < 0.01). Lipoprotein(a) was reduced by 12% and 22%, respectively. No further decreases were seen later on. Plasma total and low-density lipoprotein (LDL) cholesterol concentrations were decreased significantly with both treatments after 3 months of therapy. No difference was seen in the lowering effect on lipoprotein(a), LDL and total cholesterol concentrations between regimens. Plasma high-density lipoprotein (HDL) cholesterol and triglyceride concentrations increased throughout the study only in patients treated with oral estrogen. Conclusions:These data demonstrate that hormone replacement therapy reduces the concentration of lipoprotein(a) when given both orally and transdermally. The lowering effect is achieved quickly because the maximal effect is observed after 3 months of therapy.

Hormonal agents used in lowering lipoprotein(a)

Lipoprotein(a) (Lp(a)) plasma concentrations in Caucasian populations are classified as a quantitative genetic trait. Although the prevailing view has been that Lp(a) levels are affected by age and gender, recent data are beginning to indicate otherwise. Lp(a) levels change throughout life especially in females after menopause. Lp(a) levels decrease in women treated with anabolic steroids such as stanozolol and danazol. The Lp(a) plasma concentration is also profoundly affected by sex hormone variations during pregnancy. In men with prostatic cancer Lp(a) levels are reduced about 50% by estrogen therapy, and increased 20% by orchidectomy. We have evaluated the changes in Lp(a) and lipid levels in postmenopausal women following estrogen/progestogen replacement therapy. The mean level of Lp(a) in treated women was about 50% lower after 6 and 12 months of replacement therapy. A significant correlation between basal Lp(a) levels and the changes at either 6 or 12 months was observed, suggesting that therapy was particularly efficacious in those women with high basal Lp(a) levels. One year after therapy cessation, Lp(a) concentrations tended to return to pre-therapy values. In addition estrogen-progestogen treatment significantly lowered total-cholesterol (12%) and LDL-cholesterol (28%), and increased HDL-cholesterol (18%). From these studies it appears that sex hormones are actively involved in the modulation of plasma Lp(a) levels and that both female and male sex hormones possess a lowering effect. The results confirm a direct effect of sex hormones on Lp(a) metabolism and suggest that estrogen-progestogen treatment of postmenopausal women can improve the lipid profile not only by lowering total- and LDL-cholesterol and raising HDL cholesterol, but also by lowering plasma Lp(a).

Changes in Sex Hormone-Binding Globulin Plasma Concentrations Induced by Body Weight and Estrogen Status in Perimenopausal Years

A cross-sectional study was conducted on 562 healthy perimenopausal women, with a mean age of 52.6 years, to follow perimenopausal changes in sex hormone-binding globulin (SHBG) plasma levels during the perimenopausal years. According to menstrual history and follicle-stimulating hormone (FSH) levels, 398 women were considered postmenopausal, and 164 were premenopausal. Women with a body mass index (BMI) of <25 were considered to be of average weight, and those with a BMI > 25 were thought to be overweight. To study the effect of oral hormone replacement therapy, 153 women in the postmenopausal group were given 0.625 mg/day of oral conjugated estrogen plus medroxyprogesterone acetate, 10 mg/day, for 12 days every 3 months. SHBG levels were assayed at baseline and after 12 months of therapy. SHBG was positively associated with 17 β-estradiol plasma levels (r = 0.09, p < 0.05), and there was a strong negative correlation with BMI (r = −0.27, p < 0.001). After menopause, SHBG plasma levels dropped significantly (p < 0.05), but only in lean women. Similarly, hormone replacement therapy increased SHBG plasma levels in lean postmenopausal women (p < 0.001) but not among overweight treated women. These findings indicate that circulating estrogens are the main factor in SHBG metabolism in lean women, while obesity apparently abolishes the hormonal influence of ovarian estrogen and of hormone replacement therapy.

Sustained prolactin release associated with precocious ovarian failure

Five women after precocious menopause and 1 patient with primary ovarian failure showed a simultaneous elevation of plasma gonadotropin and prolactin. The hypersecretion of plasma prolactin was still present 6 months after ovarian failure. After 12-18 months of observation while FSH and LH concentration remained elevated, prolactin concentrations normalized in 5 women and decreased in 1.

Effects of Hormone Replacement Therapy on Lipids and Lipoproteins in Dyslipidemic Postmenopausal Women: A Comparison Between Transdermal and Oral Estrogen

The physiologic effects of combination hormone replacement therapy are less well established than the effects of estrogen alone. Recently the Postmenopausal Estrogen/ Progestin Interventions (PEPI) Trial [1] offered the most definitive conclusion that estrogen alone or in combination with a progestin decreased low density lipoprotein (LDL) cholesterol and increased high density lipoprotein (HDL) cholesterol. The higher levels of triglycerides, although potentially detrimental, seem to be related to an increased production of large very low density lipoproteins (VLDL), which are less atherogenic than small VLDL. Reports of the metabolic effect of transdermal estrogen are conflicting. Overall, it seems that transdermal estradiol is less effective than oral estrogen on LDL and HDL cholesterol, whereas a fall in triglycerides has been reported [2]. Recently, the National Cholesterol Education Program Adult Treatment Panel II Guidelines suggested hormone replacement therapy an alternative to standard treatments for dyslipidemic postmenopausal women [3].

Effect of oral and transdermal H.R.T. on vertebral bone mineral density after menopause

LUMBAR SPINAL BONE MINERAL DENSITY CHANGE AND VERTEBRAL FRACTURE RATE J. Michael Sprafka*, Rolf J. Sebaldt. Jonathan D. Adachi, Marilyn Gordon, Marjofie Steele. *Procter & Gamble Pharmaceuticals, Cincinnati, OH and St. Josephs Hospital, McMaster University, Hamilton, ON, Canada Background: Postmenopaasa/ osteoperosis is associated with increased risk of vertebral fracture CalF). Lumbar spinal (I.,S) bone mineral density (BMD) is a predictor of VF. Estrogen replacement therapy and intermittent cyclical therapy with etidronste are used in the prevention and treatment of postmenopausal osteoporosis. Patients and setting: Postmenopansal women were assessed at a tertiary referral centre in consultation for either prevention or treatment of osteoporosis. Objective: To determine whether changes in LS BMD and rates of VF are comparable between women treated with estrogen and those taking etidroaate. Results: 1451 women who were at least 8 years post-menopause were assessed during the 4.5-year study period (1990-1994). Of these women, 1081 were seen at least once in follow-up, at which time medication use was determined. Of these women, 605 used either estrogen (169) or etidronate (436) but not both and used no other osteoporosis medication.

Lipoprotein(a) Changes in Perimenopausal Years

Several publications, over the last decade, reported the influence of sex hormones on lipoprotein(a) plasma levels. We studied Lp(a) changes in perimenopausal years and the effect of two different schedules of hormone replacement therapy (HRT) on Lp(a) plasma levels. According to menstrual history and FSH plasma levels, 424 women were divided in two groups: 112 were in premenopause and 312 were postmenopausal women with a mean time since last period of 5 years. No difference in Body Mass Index (BMI) was seen between groups, but postmenopausal women were older than premenopausal ones. Lp(a) plasma levels were significantly higher after menopause (p<.01); no significant difference was seen with aging but, at any age considered, premenopausal women have lower Lp(a) plasma levels than the postmenopausal counterpart.