b84983b5fcdef7033812b0a55baa02fa

1
2 A Heartfelt Message, Estrogen Replacement Therapy: Use It or Lose It
4 Robert C. Speth1,2*, Ph.D., Mikayla D’Ambra3, Hong Ji4 and Kathryn Sandberg, Ph.D.4*
5
1
6 College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL 33328
2
7 Department of Pharmacology and Physiology, College of Medicine, Georgetown Univ.,
8 Washington, DC 20057
3
9 Pinecrest High School, Fort Lauderdale, FL 33334
4
10 Center for the Study of Sex Differences in Health, Aging and Disease, Georgetown University,
11 Washington, DC 20057
12
13 * To whom reprint requests should be sent.
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Copyright © 2018 American Physiological Society. All rights reserved.
15
16 Abstract
17 The issue of cardiovascular and cognitive health in women is complex. During the premenopausal phase
18 of life women have healthy blood pressure (BP) levels that are lower than age-matched men and they
19 have less cardiovascular disease. However, in the post-menopausal stage of life women’s BP increases
20 and they are increasingly susceptible to cardiovascular disease, cognitive impairments and dementia,
21 exceeding the incidence in men. The major difference between pre- and post-menopausal women is the
22 loss of estrogen. Thus, it seemed logical that post-menopausal estrogen replacement therapy, with or
23 without a progestin, generally referred to as menopausal hormone treatment (MHT), would prevent these
24 adverse sequelae. However, despite initially promising results, a major randomized clinical trial refuted
25 the benefits of MHT leading to it falling from favor. However, reappraisal of this study in the framework
26 of a “Critical Window”, or “Timing Hypothesis” has changed our perspective on the benefit to risk ratio
27 of MHT and this review discusses the historical, current and future approaches to MHT.
28 Keywords:
29 estrogen, progesterone, estrogen replacement therapy, estrogen progestin therapy, menopausal hormone
30 therapy, cardiovascular disease, cognitive function, dementia, Alzheimer’s Disease, cancer, route of
31 administration
32 Take-home points:
33 1. Twentieth-century studies suggesting beneficial effects of menopausal hormone therapy (MHT)
34 on the cardiovascular system and cognition were likely correct despite the “Healthy Women
35 Bias” confound.
36 2. Timing is critical for initiation of MHT. The sooner it is initiated post-menopause, the greater the
37 benefits. But if initiation of MHT is delayed for more than 10 years post-menopause it may cause
38 more harm than benefit.
39 3. Estradiol generally confers greater benefits than conjugated equine estrogens.
40 4. Transdermal administration of estrogen affords greater benefits than oral administration.

41 5. Administration of estradiol immediately post-menopause for a limited duration (< 6 years) may
42 reduce the risk of breast and overall cancer incidence.
43 6. Unopposed estradiol (without added progestin) confers greater cardiovascular and cognitive
44 benefits, but should only be used in women who have had a hysterectomy.
45 7. Individual differences in risk factors for cancer and cardiovascular disease should be evaluated
46 as part of the criteria for determining whether MHT is appropriate.
47

48 Introduction
49 It is well established that the risk of cardiovascular disease (CVD) in pre-menopausal women with intact
50 ovaries is less than that of age-matched men (125). However, post-menopausal women have the same or
51 greater risk of CVD as age-matched men (10). A major difference between pre- and post-menopausal
52 women of similar age is the loss of ovarian hormones due to ovarian failure. Indeed, the levels of
53 circulating estradiol in post-menopausal women is less than that in age-matched men (63, 83, 122). The
54 earlier that ovarian failure occurs, either naturally or by surgical removal of the ovaries, the greater the
55 risk of CVD (167). This association led to idea that estrogen replacement therapy (ERT), or estrogen plus
56 a progestin therapy (EPT) could sustain the CVD protection that functioning ovaries likely provide. The
57 term hormone replacement therapy (HRT) and menopausal hormone replacement therapy (MHT) have
58 also been used to describe both ERT and EPT. To reduce ambiguity, this review will use ERT and EPT
59 to describe estrogen only and estrogen plus progestin replacement therapy strategies and MHT where the
60 specific nature of the hormone replacement therapy was not reported or was mixed. Throughout the
61 review, we also attempt to specify the particular estrogens and progestins studied since there are
62 numerous types of these classes of compounds. For example, 17-beta-estradiol (E2) is the major naturally
63 occurring estrogen in women whereas many studies of ERT use conjugated equine estrogens (CEE)
64 purified from horse serum, which contain 10 or more biologically active estrogens (23). At least two
65 studies (148, 174) report that E2 is superior to CEE in conferring cardiovascular and cognitive benefits.
66 The early observation that ERT and EPT substantially protected women from developing
67 osteoporosis (6, 107), led to the wide embrace and use of ERT/EPT. The large scale observational Nurses
68 Health Study, which followed the health of 121,700 nurses for an extended period, suggested that both
69 ERT (154) and EPT (55) also provided cardiovascular protective effects. In contrast, a concurrent study
70 of 1234 women (172) reported adverse cardiovascular effects of ERT. Conclusions from these studies
71 were questioned because these treatments were not documented in randomized clinical trials (RCTs) (70).
72 Furthermore, they were criticized for having too many younger women and not enough older women
73 (70). In addition, concerns for the “Healthy Woman Bias” (5) whereby women who chose MHT tended to

74 be healthier than women who chose not the use MHT, also could not be eliminated. To address this
75 question, two RCT studies were initiated. The Heart and Estrogen/Progestin Replacement Study (HERS)
76 (53, 70) investigated the effects of oral MHT on women with pre-existing coronary heart disease. The
77 Women’s Health Initiative (WHI) (92) studied the effect of EPT (oral administration of conjugated
78 equine estrogens (CEE) plus medroxyprogesterone acetate (MPA) in healthy mostly postmenopausal
79 women, and oral CEE in women with hysterectomies. Both of these studies failed to show cardiovascular
80 benefits of MHT.
81 Findings from these studies led to the recommendation that MHT not be used therapeutically for
82 prevention of CVD (9). Combined with concerns that estrogen can cause breast, ovarian and uterine
83 cancer, the use of MHT drastically declined (131). Further review of the WHI study, with stratification of
84 the subjects by age, has revealed an interaction of age and effect of MHT (90). These analyses have led to
85 a reconsideration of the potential benefits of MHT for protection against CVD in post-menopausal women
86 in accord with “The Timing Hypothesis” first put forward by Mikkola et al. (98) as “the window of
87 therapeutic opportunity” and soon thereafter by Dubey et al., (40) and Mendelsohn and Karas (94). These
88 observations were primarily derived from the dichotomous effects of ERT on atherosclerosis in monkeys
89 associated with time of ovariectomy and time of initiation of ERT (3, 171). Mikkola et al. (98), however,
90 also noted the disparity in ERT effects with age in the WHI study. Stated simply, “The Timing
91 Hypothesis” (also known as the “Window of Opportunity” (1) posits that initiation of ERT at, or shortly
92 after menopause, confers cardiovascular benefits, while delayed initiation of ERT, > 10 years post-
93 menopause, has adverse cardiovascular effects. While “The Timing Hypothesis” has had its detractors
94 (18), it is now generally accepted that initiation of ERT within 10 years of either naturally occurring or
95 surgically induced ovarian hormone deficiency confers cardiovascular benefits (66, 100), which
96 complement its known benefits on osteoporosis, without increasing overall cancer risk. An extension of
97 the WHI, the Women's Health Initiative Memory Study (WHIMS) as well as other studies including
98 Kronos Early Estrogen Prevention Study-Cognitive and Affective Study (KEEPS-Cog) (50) and
99 Women’s Health Initiative Memory Study – Young (WHIMS-Y) (42) specifically directed to assessing

100 the effects of MHT on cognitive function now suggest that cognitive impairments associated with MHT
101 in older (65-79 years old) do not occur if MHT is initiated at ages 50-54 (42) or within 6 to 36 months of
102 their last menses. While KEEPS-Cog and WHIMS-Y, both of which used CEE, did not show cognitive
103 benefits of MHT, other studies suggest that early post-menopausal initiation of MHT can have
104 neuroprotective effects on cognitive function and reduced risk of Alzheimer’s Disease and other
105 dementias (35, 99).
106
107 Current understanding of blood pressure (BP) and cardiovascular health
108 It is well recognized that treatment of hypertension is critical to preserving cardiovascular health.
109 Cardiovascular disease, which is to a large extent secondary to hypertension, remains the number one
110 killer in the United States and the rest of the world (108). The current guidelines for hypertension from
111 the Joint National Committee on Prevention, Detection, evaluation and Treatment of High Blood Pressure
112 (JNC 7), released in November 2017 (169) recommends treatment for systolic BP > 130 mm Hg. The
113 change in guidelines is based on the recent SPRINT trial in which cardiovascular outcomes for intensive
114 treatment (≤ 120/ 80 mm Hg) of individuals > 50 years old with a high risk of CVD was highly beneficial.
115 According to the old guidelines of beginning treatment in individuals with BPs ≥ 140/90 mm Hg, the
116 prevalence of hypertension is substantial at ~34% of the American population
117 (https://www.heart.org/idc/groups/ahamah-
118 public/@wcm/@sop/@smd/documents/downloadable/ucm_491265.pdf; accessed 1/8/18) and this
119 percentage will greatly increase with the new lower guidelines.
120
121 Ovarian hormones and cardiovascular health
122 Worldwide, women have lower BP than men: 122/77 versus 127/79 (systolic/diastolic, mm Hg),
123 respectively (2). Furthermore, CVD occurs earlier in men than women. The incidence of a first
124 cardiovascular event (per 1000 person years in the 45-54 age group) is: 10.1 in men and 4.2 in women
125 (103). Menopause and oophorectomy are both associated with an increased incidence of hypertension and

126 CVD (125, 136). Evidence from human and animal studies suggests gonadal hormones contribute to these
127 sex differences in the age of onset of hypertension and CVD, and play a protective role in the
128 cardiovascular health of women (12). Premenopausal women with functional ovaries that secrete estrogen
129 have a lower risk of CVD than age-matched postmenopausal women (153), and, early menopause (ages
130 40-45) is associated with an increased risk of CVD, see review (22). The functionality of the coronary
131 endothelium is also healthier in young premenopausal women compared to older postmenopausal women
132 (93).
133 Based upon these observations, it seemed logical that MHT would provide the cardiovascular benefits
134 of intact functioning ovaries. In a meta-analysis of MHT studies, Grady et al., (54) found that the relative
135 risk of coronary heart disease was 0.65 (0.59-0.71, 95% CI) in women who used ERT compared to
136 women who never used estrogen. However, the WHI study (92, 130, 150) in more than 16,000
137 postmenopausal women reported an increased risk of coronary heart disease in the EPT group over
138 placebo controls (HR 1.29, 95% CI 1.02-1.63) (92, 130) with no significant reduction in coronary heart
139 disease with ERT (HR 0.91, 95% CI 0.75-1.12) (9). This finding plus the increased risk of stroke and
140 pulmonary embolism in the ERT and EPT groups and the increase in invasive breast cancer in the EPT
141 group, led to early termination of the WHI despite substantial reductions in colorectal cancer and hip
142 fractures. Subsequent to this study, the use of MHT to provide cardiovascular benefit dramatically
143 decreased (131).
144 In succeeding years, researchers have continued to monitor WHI subjects and have begun to
145 challenge the conclusions of the WHI study, primarily based upon the wide age range of the subjects,
146 which masked age-related differential effects of MHT. Long-term observations and stratification of the
147 different age groups, now document that the time interval between menopause and initiation of MHT
148 differentiates beneficial from adverse effects (24, 90, 98). This has led to the development of “The
149 Timing Hypothesis” (64, 65) “critical period” (168) or “critical window theory” (87, 98, 170) which
150 suggests that initiation of MHT soon after menopause has benefits that outweigh the risks, while delays,
151 >10 years post menopause, in initiating MHT may have adverse cardiovascular and cognitive effects (40,

152 87, 101, 110, 132, 144, 170). The development of “The Timing Hypothesis” may be a classic case of déjà
153 vu. In their 1991 paper describing a 10-year follow-up of the Nurses Health Study, Stampfer et al. (154)
154 discuss a book chapter written in 1987 by one of the authors of the 1985 Framingham study (172) stating
155 that for coronary heart disease there was “…a nonsignificant protective effect among younger women, but
156 a nonsignificant adverse effect among older women”, (from reference 20 of Stampfer et al., (154)) from
157 estrogen treatment. In the déjà vu all over again category, one of the original studies that reported
158 beneficial effects of estrogen therapy for osteoporosis (6) reported that estrogen therapy begun 3 years
159 post oophorectomy increased bone mineral density, but when estrogen therapy was initiated 6 years post
160 oophorectomy there was no effect on the rate of loss of bone mineral density. LaCroix et al., (80) reported
161 an interaction between CEE therapy and age, with younger women showing a more favorable risk profile
162 for myocardial infarction, total mortality and global index of chronic diseases than older women.
163 We have used female Dahl salt-sensitive rats as a model for hypertension associated with salpingo-
164 bilateral oophorectomy in women (152). In this model, rats were ovariectomized at either 4.5 or 7 months
165 and E2 treatment was initiated at 7 months. E2 treatment reduced body weight and plasma angiotensin II
166 in both groups compared to untreated rats; however, E2 only blocked the ovariectomy-induced increase in
167 BP in rats in which E2 treatment was initiated immediately after ovariectomy. The expression of AT1
168 receptors was significantly increased in the brains of rats ovariectomized at 4.5 months and treated with
169 E2 at 7 months, while initiation of E2 treatment immediately after ovariectomy prevented this increase in
170 brain AT1 receptor binding (152). These animal studies are consistent with ‘The Timing Hypothesis’,
171 suggesting that a delay in initiating ERT following menopause reduces its efficacy and could have
172 adverse effects on cognitive function. Interestingly, a study of women with elected oophorectomies
173 without ERT revealed an increase in salt-sensitivity in a subpopulation of these women which could
174 foreshadow development of hypertension later in life due to increased renin-angiotensin system activity
175 (142). Tables 1 and 2 describe the more contemporary view of the benefits and risks of MHT, when
176 initiation of therapy occurs perimenopausally, < 10 years after menopause(~ by age 59), or at later ages.t
177 Menopausal hormone therapy and cancer

178 The incidence of reproductive tissue cancer in women generates a consider amount of fear. Thus, any
179 report of an increase in reproductive cancers in women leads to a reflexive avoidance of the causal
180 factors, no matter how small the increase in risk. Table 2 lists cancer risks of MHT with a primary
181 emphasis on the risks associated with perimenopausal or early post-menopause initiation of MHT (< 10
182 years post-menopause) initiation of MHT, or at later ages. Of note LaCroix et al (80) also reported an
183 interaction between age and colorectal cancer with younger women showing lower risk than older women
184 consistent with “The Timing Hypothesis”.
185
186 Relative risk versus absolute risk
187 An important consideration when balancing risk to benefit ratios is not only the increase in relative risk of
188 disease, but also the incidence of the disease. Santen and Petroni (139) refer to this as “Relative Versus
189 Attributable Risk” and point out how misleading relative risk determinations can be. They determined
190 that the attributable risk of a women getting breast cancer arising from taking ERT for 10 years starting at
191 age 50 was 2.8 per 100 women, but that 11.9 women per 100 would be spared an adverse cardiovascular
192 event, resulting in a net reduction of 9.1 incidences of disease (Figure 1). Since not everyone who
193 develops breast cancer or CVD will die from it, the numbers of people who die from breast cancer
194 decreases to 0.67 per 100 women, while the number of people saved from CVD-associated deaths is 4.4
195 per 100 women (139). Furthermore, if the reduction in the relative risk of women dying from hip
196 fractures with EPT is added in, the benefit to risk ratio becomes even greater. Moreover, a reappraisal of
197 the effects of ERT in women with hysterectomies in the WHI suggests that there may be no increase, and
198 a possible decrease in the incidence of breast cancer with ERT (9, 155). This factor was also noted in a
199 statement of the Endocrine Society supporting the use of “menopausal hormone therapy” in women aged
200 50-59 or within 10 years of menopause (138).
201 It should be kept in mind however, that individual risks for breast cancer cardiovascular disease
202 can also vary and can alter the risk to benefit ratio, e.g., a person at high risk for breast cancer and

203 minimal risk for cardiovascular disease, might be adversely affected by EPT. However, a person with
204 minimal risk factors for breast cancer and at high risk for cardiovascular disease might gain substantially
205 from EPT. More recent studies LaCroix et al., (80), and Gurney et al., (56) suggest that the relative risk
206 of breast cancer when initiated within the critical window post menopause and continued for an average
207 of 5.9 years reduces the incidence of breast cancer.
208 Although not directly applicable to MHT cancer risks, a recent study of birth control pill
209 (estrogen plus progestin) usage in 1.8 million premenopausal women concluded that the risk for breast
210 cancer was higher for women using hormonal contraception compared to non-users (102). However,
211 another study of the use of oral contraceptives indicated reduced risks for colorectal, endometrial,
212 ovarian, lymphatic, and hematopoietic cancers in women taking birth control pills, concluding that the
213 decrease in select cancers balances out and may override the increase in breast and cervical cancer
214 incidence (72, 101). An analysis of the net effect of oral contraceptive usage in England concluded that
215 their usage prevented 1600 cases of cancer in 2010 (116).
216
217 Variations in MHT
218 Analysis of the risk to benefit ratio of post-menopausal MHT is complicated by many variables:
219 unopposed estrogen versus estrogen plus a progestin (either with continuous or cycled progestin);
220 idiosyncratic characteristics of the estrogenic and progestogenic agents, cf. (31, 40, 88, 148, 168, 174);
221 Estrogen receptor (ER) subtype selectivity; route of administration of the MHT; MHT dosages; duration
222 of MHT. Kuhl (79) provides a comprehensive review of the variables associated with different estrogenic
223 and progestogenic preparations: their routes of administration, relative potencies, pharmacokinetic
224 characteristics, and tissue selectivity that covers these issues in much greater detail than is possible in this
225 brief review. In general, oral bioavailability of estrogens is poor due to limited absorption and
226 metabolism in the gastrointestinal tract and liver, however, transdermal absorption of estradiol varies
227 widely between individuals. A recent meta-analysis reported that oral, but not transdermal administration

228 of estradiol is associated with an increased risk of thromboembolism (135). In addition, oral (58, 75), but
229 not transdermal (58) estradiol increases angiotensinogen production by the liver. While the resulting
230 increase in plasma angiotensin II does not appear to increase BP, it is noteworthy that a study comparing
231 oral and transdermal administration of estradiol found a small reduction in BP in normotensive
232 oophorectomized women with transdermal, but not oral administration (7). Manhem et al. (89) also saw a
233 small reduction in BP in hypertensive post-menopausal women with transdermally administered estradiol.
234 Additionally, after 12 months of receiving transdermal estrogen, Beljic et al. (20) observed that post-
235 menopausal women with normal BP saw their systolic BPs significantly decrease, as did Seely et al.
236 (143), who’s study of 15 normotensive women showed a significant decrease in diastolic and mean BP
237 (~5 mm Hg) with the administration of transdermal estradiol. Thus, while MHT generally does not reduce
238 the post-menopausal rise in BP (123, 125) and may increase BP compared to placebo treated women
239 (158) regardless of time past menopause, this may be a result of preponderance of studies in which the
240 estrogen was administered orally. In view of the studies in which transdermally administered estradiol
241 caused small to moderate reductions in BP (7, 58, 89, 143), one of which concurrently showed no change
242 in BP with oral administration of estradiol (7), as well as two studies with orally administered estradiol
243 plus one study of combined oral estradiol and progestin that have shown reductions in BP compared to
244 placebo controls (58, 75, 163), the ability of transdermally administered estradiol to lower BP should be
245 investigated on a larger scale.
246 Additional variables that should also be considered are smoking/tobacco usage which is generally
247 controlled for in studies of ERT and EPT, but which is associated with substantially increased CVD and
248 incidence of cancer (13, 86, 126, 157); lifestyle (124, 126), hysterectomy; age at menopause or surgically
249 induced menopause (see below); ethnicity (112, 157); individual differences (79); lipid profile; body
250 weight/BMI (34) metabolic syndrome which is associated with increased cardiovascular risk factors:
251 increased BP, dyslipidemia, type II diabetes mellitus (4), and lean versus obese women(137); duration of
252 MHT therapy; duration of follow-up following MHT; weighting of adverse versus beneficial outcomes,
253 e.g. increased risk of specific cancers versus reduced risk of other cancers and osteoporosis; and what is

254 now most apparent; the time between menopause and beginning MHT. Of note, women who never
255 smoked were more likely to have a later age at menopause than current tobacco smokers (39, 82).
256 Moreover, as reviewed by Appelman et al., (10) women smokers have a greater increase in their CVD
257 risk than men.
258 Thus, while it is still not possible to make a definitive generic determination in favor of MHT for
259 cardiovascular benefits, newer data is increasingly in favor of MHT when initiated perimenopausally or
260 within the critical window post-menopausally (36). In particular, in women who have premature ovarian
261 insufficiency before age 40 either naturally or surgically have an increased risk of early mortality, CVD
262 and neurological disease (147), and MHT is strongly recommended unless there are contraindications
263 (14). This population has higher BP than age-matched women who are premenopausal, see review (136).
264 Additionally, MHT is well-established for relief of perimenopausal vasomotor symptoms; hot flashes and
265 night sweats, sleep disturbances, as well as urogenital atrophy (14, 32, 43, 140). In addition, the use of
266 ERT in women who have had a hysterectomy appears to have more benefit than EPT in women with an
267 intact uterus (36, 54, 90, 101, 141).
268 One issue related to post-menopausal MHT that has not been studied is cyclic administration of
269 an estrogen. In premenopausal women, estrogen as well as progesterone levels vary widely over the
270 menstrual cycle (173) whereas post-menopausal estrogen therapy and many EPT regimens maintain a
271 constant level of estrogen and progestin. Some MHT regimens cycle the progestin, most often 12 days
272 on/18 days off, which is associated with a greater increase in high density lipoprotein cholesterol (HDL-
273 C) than MHT with continuous progestin (161). There is anecdotal evidence of cyclic postmenopausal use
274 of ERT by some women, but we only found one study, a short-term randomized controlled trial, of 54
275 post-menopausal women (ages 50-65) which used cyclic estrogen (4) according to its use as a birth
276 control pill reporting an adverse effect of EPT on HbA1c levels in “normoglycemic” (HbA1c < 8%)
277 women with Type II diabetes mellitus. This study contrasts with an observational study of 15435 women
278 with Type II diabetes mellitus reporting that MHT use was associated with lower HbA1c levels (45)
279 which was challenged as being subject to the “Healthy Women Bias” (5).

280
281 Influence of estrogen receptor subtypes
282 The issue of ER subtype selectivity and expression may play a role in the cardiovascular and cognitive
283 protection afforded by ERT. There are three known ER subtypes: ERα ERß (33) and G protein coupled-
284 ER (GPER), also known as GPR30 and GPER1 (44, 97). The classical ERs, ERα and ERß are
285 cytoplasmic receptors that become transcription factors when bound by estrogen, thereby regulating the
286 expression of a number of genes, although ERα (29) and ERß can also localize to the plasma membrane
287 and signal through protein kinase pathways see review (114). Acute activation of ERα, also has
288 nongenomic effects such as activating endothelial nitric oxide (NO) synthase (40). Consistent with either
289 GPR30 or membrane localized ERα, estradiol was shown to induce a short latency NO release from
290 cultured endothelial cells (156). NO induces vasodilation, dilating blood vessels by relaxing the smooth
291 muscles lining the vessels. ERα has a significant role in maintaining “cardiometabolic health” (33), and its
292 mRNA has been shown to decrease with aging in mouse aorta (111), although its protein expression
293 remains relatively constant in human uterus (110).
294 Animal studies of ERß also indicate largely beneficial actions on the cardiovascular system,
295 although ERß is also associated with adverse effects. A study of uterine ERß expression showed that it
296 increased with time past menopause, corresponding with an increased inflammatory response to estrogen
297 (110). ERT increased NO production and decreased NADPH-oxidase activity in young, but not old mice,
298 concomitant with an increase in the ERß/ERα ratio in thoracic aorta of the old versus young mice (111).
299 However, a recent review of human and animal studies suggests that ERß exerts a host of protective
300 actions in the cardiovascular system, primarily targeting vascular endothelial cells (105).
301 GPER activation has a direct vasodilatory effect (11, 44, 57) and both activates (57) and inhibits
302 (44) cAMP formation. It also activates MAP kinases via transactivation of the epidermal growth factor
303 receptor (46), and other signaling pathways (44) in response to estrogen. It is present in osteoblasts (59)
304 and may be a major contributor to the osteogenic effects of estrogen (78). Of note, GPER is also a
305 receptor for aldosterone, for which it displays a higher affinity than for estrogen (44).

306
307 Adverse effects of estrogen loss, hypertension and CVD on cognition and progression to dementia
308 As noted above high BP, at least during mid-life, is a risk factor for cognitive impairment and dementia
309 (see review (77). And, while MHT at best lowers BP slightly, its beneficial effects on vascular
310 endothelium may have the same cardiovascular protective effects on the cerebral microvasculature as a
311 reduction in BP. Alzheimer’s Disease (AD) patients with hypertension show a faster rate of cognitive
312 decline than normotensive patients (21). Furthermore, patients with untreated hypertension show a more
313 rapid progression from mild cognitive impairment to AD than patients whose hypertension is treated with
314 a variety of antihypertensive agents (84). With additional therapy for diabetes and hyperlipidemia, the
315 progression to AD was slowed even more [63]. Similarly, patients showing good cardiovascular health in
316 terms of BP and blood glucose have more favorable cognitive function later in life (51). Recent studies in
317 humans suggest there is a link between endothelial dysfunction and AD pathology (37). Geriatric patients
318 with masked hypertension had significantly lower scores on Mini-Mental State Exam test and Categorical
319 Fluency Test than normotensive patients (41). A large meta-analysis of antihypertensive drug therapies
320 shows convincingly that reduction of elevated BP is associated with a substantial reduction in the risk of
321 dementia (133). In a geriatric African-American cohort cognitive decline was decreased by 38% with
322 antihypertensive therapy, independent of the drug class (106). Interestingly, an increased risk of cognitive
323 decline in women with elevated systolic BP and pulse has been reported (177). And finally, a meta-
324 analysis of 18 studies concluded that there was a strong trend towards decreased cognitive impairment
325 with antihypertensive therapy, with calcium channel blockers and renin-angiotensin inhibitors showing
326 the greatest benefits (133).
327 With respect to estrogen’s effects on cognitive function and dementia, especially AD, it has long
328 been known that estrogen has neuroprotective effects (95, 180), see also reviews (38, 47, 48, 96, 120,
329 129). These positive neurotropic effects have been reported to be mediated largely by the ER ß estrogen
330 receptor subtype, see review (164). However, in the hippocampus, the brain region most closely
331 associated with memory and learning, estradiol is reported to act on both ERα and ERß as well as GPER to

332 promote synaptic plasticity and neuroprotection (151, 166, 179), so all of these receptor subtypes likely
333 mediate the improvement of memory in rodent models of cognitive function. An early uncontrolled study
334 of the effects of ERT in women of unspecified ages in a retirement community showed a reduction in risk
335 of developing AD, with the reduction increasing with dose and duration of treatment (113). While the
336 randomized controlled WHIMS initially suggested an adverse effect of MHT (with CEE as the estrogenic
337 agent) on cognitive function and AD (42, 145), a recent 18 year follow-up study of the WHI (90) revealed
338 that the CEE only group had a significantly lower AD mortality (HR: 0.74; CI 0.59-0.94). The Cache
339 County, Utah study of more than 1800 women showed that MHT reduced the risk of AD, with the longest
340 usage (> 10 yrs) having the lowest risk (HR: 0.41, 95% CI 0.17-0.86) (178). Another recent long-term
341 study (71) showed long- (> 10 yrs) but not short-term (<10 yrs) MHT was associated with a reduced risk
342 of developing AD (HR: 0.53, 95% CI: 0.31-0.91). Interestingly, a recent study (19) to determine whether
343 ‘The Timing Hypothesis’ applied to estradiol’s beneficial effects on cognition in the non-human primate
344 model in which ‘The Timing Hypothesis’ for estradiol’s cardiovascular benefits occurred, indicated that a
345 much longer duration between menopause and ERT could elapse, during which estradiol could benefit
346 cognitive function. This observation is echoed in a large scale, 489,105 women, study of MHT which
347 showed a reduction in vascular dementia independent of time of initiation of MHT (99). Of note, these
348 investigators (99) suggested that the improved cardiovascular risk profile of E2 compared to CEE (141,
349 148) might explain the large (37-39%) reductions in the risk of death from vascular dementia in their
350 cohort. Additionally, Mikkola et al., (99) also reported a risk reduction for AD with longer duration, > 5
351 years, ERT/EPT. Studies reviewed by Faubion et al., (43) also support beneficial effects on cognitive
352 function and reduction of risk of dementia with MHT in accord with ‘The Timing Hypothesis’.
353 The selective estrogen receptor modulator (SERM) raloxifene, which is a weak partial agonist of
354 ERα with negligible agonist effect on ERß (17), and a preferential estrogenic agent on bone, was shown to
355 significantly reduce the risk of mild cognitive impairment ( RR: 0.67, 95% CI: 0.46-0.98) and marginally
356 reduce the risk of AD in a large cohort (7,487 women) with an average age of 66.3 years old (176). In
357 another study conducted on women aged 70-80 years old, raloxifene improved verbal memory compared

358 to a placebo group (73), which suggests that the cognitive benefits of SERM usage may not be subject to
359 ‘The Timing Hypothesis’ effect.
360 Additionally, as with CVD, the post-menopausal population that has undergone pre-menopausal
361 oophorectomy or early menopause, appears to be at higher risk for cognitive impairment and dementia
362 (14, 35, 104, 147) than those who undergo natural menopause. The Mayo Clinic Cohort Study of
363 Oophorectomy and Aging showed that the risk of cognitive impairment or dementia nearly doubled in
364 women who underwent bilateral oophorectomy prior to the age of natural menopause regardless of the
365 indication for oophorectomy (e.g., benign ovarian condition or for cancer prophylaxis) (127). This first
366 large-scale study of cognition with long-term follow up also showed that the risk of cognitive impairment
367 and dementia increased the younger the age at oophorectomy. These findings from women living in the
368 United States were confirmed in a Danish historical cohort study, published in 2010, that queried national
369 disease registries (119). The Danish study showed that the risk of dementia with onset before the age of
370 50, increased in women who underwent bilateral oophorectomy prior to the age of natural menopause,
371 again, with the risk increasing the younger the age at surgery. Furthermore, two longitudinal studies
372 analyzed by Bove et al. (25) showed that women who underwent surgical menopause at younger ages saw
373 more rapid rates of cognitive decline and found that the effect of each year of earlier surgical menopause
374 matched the effect of 6 months of aging in relation to the rate of cognitive decline. However, when
375 administered within the 5-year “window of opportunity”, MHT significantly, slowed cognitive decline
376 and risk of AD, in contrast to a worsening of cognitive decline and risk of AD with delayed initiation of
377 MHT after age 65, see review (128).
378
379 Current gaps in knowledge
380 The conflicting results from studies of MHT are likely due to differences in experimental design
381 including the composition of the therapeutic agents (e.g., type of estrogen and progesten), the mode of
382 treatment (e.g., oral vs. transdermal or vaginal), protocol (e.g., continuous or cycling progestin), treatment
383 duration and time of initiation post-menopausally, type of menopause, outcomes, and follow-up periods.

384 In addition, variations in expression and functionality of the different estrogen receptor subtypes
385 complicates the evaluation of the effects of post-menopausal MHT. These countless permutations
386 currently limit our ability to compare study outcomes on cardiovascular and cognitive health as well as
387 cancer risk and other effects. Individual differences in genetics and environment are also factors that
388 differentially affect a woman's response to MHT. Thus, even when the ideal MHT regimen for one's
389 health is identified, personalized medicine will remain critical to determining whether or not MHT is
390 indicated.
391 Limitations of the study
392 Entering the search term menopausal hormone therapy in Pubmed yielded 35924 articles. In selecting
393 180 articles for this review, we have cited approximately 0.5% of the literature on this topic. As a result,
394 there is a considerable potential for unintentional bias and omission of important studies despite our best
395 efforts to focus on the most salient articles relevant to our goal of evaluating the relative benefits and risks
396 of menopausal hormone therapy. In addition, the possibility of publication bias in favor of studies
397 showing significant effects cannot be ignored, although this bias would favor both positive and negative
398 effect observations similarly.
399
400 Summary and conclusions
401 It is increasingly apparent that postmenopausal MHT has cardiovascular and cognitive benefits, provided
402 it is initiated within the critical window of opportunity, i.e., less than 10 years post-menopause, and has
403 even better outcomes if 1) it is initiated perimenopausally, 2, it is administered transdermally, and 3) the
404 estrogenic agent is E2. Moreover, hysterectomized women appear to achieve better overall health
405 outcomes from ERT than women with intact uteri treated with EPT. The adverse effects of delayed MHT,
406 which distorted the results of the WHI study, have now been stratified from the early MHT treatment
407 further affirming the benefits of early MHT. Moreover, the breast cancer risk of MHT is far less than
408 originally reported in the WHI study, with a reduced risk in women with hysterectomies treated in the

409 early post-menopausal period only with estrogens less than 6 years (56, 80). Added to the reductions in
410 colorectal and other cancers associated with MHT, there is a net reduction in all cancers as well as all-
411 cause mortality with MHT. However, despite these positive observations, recommendations for MHT are
412 still limited to prevention of osteoporosis and perimenopausal vasomotor symptoms or protection from
413 adverse cognitive effects of early or premenopausal surgical menopause (121).
414 A lingering issue yet to be resolved is; how long should MHT be continued? And whether it
415 should be ERT or EPT. In view of the study suggesting that MHT > 10 years duration provides better
416 protection against AD than < 10 years duration (178) and the beneficial effects of continued MHT on
417 mood, the possibility of life-long MHT cannot be dismissed. There is evidence that more women are
418 continuing to take MHT for more than a decade, so observational studies will help determine the optimal
419 duration for MHT, although the “Healthy Women Bias” may continue to be a confound in interpreting
420 such studies. With close monitoring and continuing assessment of genetic and environmental risk factors
421 for cancers, dementia and CVD, there can be a refinement of the criteria for determining the optimal use
422 of MHT.
423
424 Acknowledgments: This work was supported by NIH grant R01-HL-119380 (RCS, HJ, KS), the Peptide
425 Radioiodination Shared Resource, Georgetown University (RCS), and the Cardiovascular Neuroscience
426 Fund, Nova Southeastern University (RCS).
427
428
429
430
431
432 Bibliography
433 1. Window of opportunity: menopause, estrogens and the brain. Proceedings of a multidisciplinary
434 Window of Opportunity workshop. January 15-17, 2010. Stanford, California, USA. Brain Res 1379: 1-
435 252, 2011.

436 2. (NCD-RisC). NRFC. Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of
437 1479 population-based measurement studies with 19.1 million participants. Lancet 389: 37-55, 2017.
438 3. Adams MR, Kaplan JR, Manuck SB, Koritnik DR, Parks JS, Wolfe MS, and Clarkson TB. Inhibition
439 of coronary artery atherosclerosis by 17-beta estradiol in ovariectomized monkeys. Lack of an effect of
440 added progesterone. Arteriosclerosis (Dallas, Tex) 10: 1051-1057, 1990.
441 4. Aguilar-Salinas CA, Arita Melzer O, Sauque Reyna L, Lopez A, Velasco Perez ML, Guillen LE,
442 Gomez Perez FJ, and Rull Rodrigo JA. Effects of estrogen/medrogestone therapy on the apoprotein B-
443 containing lipoproteins in postmenopausal women with type 2 diabetes mellitus under satisfactory and
444 non-satisfactory glycemic control. The Israel Medical Association journal : IMAJ 3: 137-143, 2001.
445 5. Aguilar-Salinas CA, Garcia-Garcia E, Gomez Perez FJ, and Rull JA. The healthy women bias and
446 hormone replacement therapy in women with type 2 diabetes. Diabetes Care 25: 246-247, 2002.
447 6. Aitken JM, Hart DM, and Lindsay R. Oestrogen replacement therapy for prevention of
448 osteoporosis after oophorectomy. British medical journal 3: 515-518, 1973.
449 7. Akkad AA, Halligan AW, Abrams K, and al-Azzawi F. Differing responses in blood pressure over
450 24 hours in normotensive women receiving oral or transdermal estrogen replacement therapy.
451 Obstetrics and gynecology 89: 97-103, 1997.
452 8. Anderson GL, Chlebowski RT, Aragaki AK, Kuller LH, Manson JE, Gass M, Bluhm E, Connelly S,
453 Hubbell FA, Lane D, Martin L, Ockene J, Rohan T, Schenken R, and Wactawski-Wende J. Conjugated
454 equine oestrogen and breast cancer incidence and mortality in postmenopausal women with
455 hysterectomy: extended follow-up of the Women's Health Initiative randomised placebo-controlled trial.
456 Lancet Oncol 13: 476-486, 2012.
457 9. Anderson GL, Limacher M, Assaf AR, Bassford T, Beresford SA, Black H, Bonds D, Brunner R,
458 Brzyski R, Caan B, Chlebowski R, Curb D, Gass M, Hays J, Heiss G, Hendrix S, Howard BV, Hsia J,
459 Hubbell A, Jackson R, Johnson KC, Judd H, Kotchen JM, Kuller L, LaCroix AZ, Lane D, Langer RD, Lasser
460 N, Lewis CE, Manson J, Margolis K, Ockene J, O'Sullivan MJ, Phillips L, Prentice RL, Ritenbaugh C,
461 Robbins J, Rossouw JE, Sarto G, Stefanick ML, Van Horn L, Wactawski-Wende J, Wallace R, and
462 Wassertheil-Smoller S. Effects of conjugated equine estrogen in postmenopausal women with
463 hysterectomy: the Women's Health Initiative randomized controlled trial. Jama 291: 1701-1712, 2004.
464 10. Appelman Y, van Rijn BB, Ten Haaf ME, Boersma E, and Peters SA. Sex differences in
465 cardiovascular risk factors and disease prevention. Atherosclerosis 241: 211-218, 2015.
466 11. Arefin S, Simoncini T, Wieland R, Hammarqvist F, Spina S, Goglia L, and Kublickiene K.
467 Vasodilatory effects of the selective GPER agonist G-1 is maximal in arteries of postmenopausal women.
468 Maturitas 78: 123-130, 2014.
469 12. Arnold AP, Cassis LA, Eghbali M, Reue K, and Sandberg K. Sex Hormones and Sex Chromosomes
470 Cause Sex Differences in the Development of Cardiovascular Diseases. Arterioscler Thromb Vasc Biol 37:
471 746-756, 2017.
472 13. Asay GRB, Homa DM, Abramsohn EM, Xu X, O'Connor EL, and Wang G. Reducing Smoking in
473 the US Federal Workforce: 5-Year Health and Economic Impacts From Improved Cardiovascular Disease
474 Outcomes. Public Health Rep 132: 646-653, 2017.
475 14. Baber RJ, Panay N, and Fenton A. 2016 IMS Recommendations on women's midlife health and
476 menopause hormone therapy. Climacteric : the journal of the International Menopause Society 19: 109-
477 150, 2016.
478 15. Bahl A, Pollanen E, Ismail K, Sipila S, Mikkola TM, Berglund E, Lindqvist CM, Syvanen AC,
479 Rantanen T, Kaprio J, Kovanen V, and Ollikainen M. Hormone Replacement Therapy Associated White
480 Blood Cell DNA Methylation and Gene Expression are Associated With Within-Pair Differences of Body
481 Adiposity and Bone Mass. Twin research and human genetics : the official journal of the International
482 Society for Twin Studies 18: 647-661, 2015.

483 16. Barefoot JC, and Schroll M. Symptoms of depression, acute myocardial infarction, and total
484 mortality in a community sample. Circulation 93: 1976-1980, 1996.
485 17. Barkhem T, Carlsson B, Nilsson Y, Enmark E, Gustafsson J, and Nilsson S. Differential response
486 of estrogen receptor alpha and estrogen receptor beta to partial estrogen agonists/antagonists. Mol
487 Pharmacol 54: 105-112, 1998.
488 18. Barrett-Connor E. Hormones and heart disease in women: the timing hypothesis. American
489 journal of epidemiology 166: 506-510, 2007.
490 19. Baxter MG, Santistevan AC, Bliss-Moreau E, and Morrison JH. Timing of cyclic estradiol
491 treatment differentially affects cognition in aged female rhesus monkeys. Behav Neurosci 2018.
492 20. Beljic T, Babic D, Marinkovic J, and Prelevic GM. The effect of hormone replacement therapy on
493 diastolic left ventricular function in hypertensive and normotensive postmenopausal women. Maturitas
494 29: 229-238, 1998.
495 21. Bellew KM, Pigeon JG, Stang PE, Fleischman W, Gardner RM, and Baker WW. Hypertension and
496 the rate of cognitive decline in patients with dementia of the Alzheimer type. Alzheimer disease and
497 associated disorders 18: 208-213, 2004.
498 22. Bertone-Johnson ER, and Manson JE. Early menopause and subsequent cardiovascular disease.
499 Menopause (New York, NY) 22: 1-3, 2015.
500 23. Bhavnani BR. Pharmacokinetics and pharmacodynamics of conjugated equine estrogens:
501 chemistry and metabolism. Proceedings of the Society for Experimental Biology and Medicine Society for
502 Experimental Biology and Medicine (New York, NY) 217: 6-16, 1998.
503 24. Bhupathiraju SN, Grodstein F, Rosner BA, Stampfer MJ, Hu FB, Willett WC, and Manson JE.
504 Hormone Therapy Use and Risk of Chronic Disease in the Nurses' Health Study: A Comparative Analysis
505 With the Women's Health Initiative. American journal of epidemiology 186: 696-708, 2017.
506 25. Bove R, Secor E, Chibnik LB, Barnes LL, Schneider JA, Bennett DA, and De Jager PL. Age at
507 surgical menopause influences cognitive decline and Alzheimer pathology in older women. Neurology
508 82: 222-229, 2014.
509 26. Bush TL, Barrett-Connor E, Cowan LD, Criqui MH, Wallace RB, Suchindran CM, Tyroler HA, and
510 Rifkind BM. Cardiovascular mortality and noncontraceptive use of estrogen in women: results from the
511 Lipid Research Clinics Program Follow-up Study. Circulation 75: 1102-1109, 1987.
512 27. Carrasquilla GD, Frumento P, Berglund A, Borgfeldt C, Bottai M, Chiavenna C, Eliasson M,
513 Engstrom G, Hallmans G, Jansson JH, Magnusson PK, Nilsson PM, Pedersen NL, Wolk A, and Leander K.
514 Postmenopausal hormone therapy and risk of stroke: A pooled analysis of data from population-based
515 cohort studies. PLoS Med 14: e1002445, 2017.
516 28. Casanova G, Bossardi Ramos R, Ziegelmann P, and Spritzer PM. Effects of low-dose versus
517 placebo or conventional-dose postmenopausal hormone therapy on variables related to cardiovascular
518 risk: a systematic review and meta-analyses of randomized clinical trials. J Clin Endocrinol Metab 100:
519 1028-1037, 2015.
520 29. Chaudhri RA, Schwartz N, Elbaradie K, Schwartz Z, and Boyan BD. Role of ERalpha36 in
521 membrane-associated signaling by estrogen. Steroids 81c: 74-80, 2014.
522 30. Chen Z, Bassford T, Green SB, Cauley JA, Jackson RD, LaCroix AZ, Leboff M, Stefanick ML, and
523 Margolis KL. Postmenopausal hormone therapy and body composition--a substudy of the estrogen plus
524 progestin trial of the Women's Health Initiative. The American journal of clinical nutrition 82: 651-656,
525 2005.
526 31. Cieraad D, Conradt C, Jesinger D, and Bakowski M. Clinical study comparing the effects of
527 sequential hormone replacement therapy with oestradiol/dydrogesterone and conjugated equine
528 oestrogen/norgestrel on lipids and symptoms. Archives of gynecology and obstetrics 274: 74-80, 2006.
529 32. Cintron D, Lahr BD, Bailey KR, Santoro N, Lloyd R, Manson JE, Neal-Perry G, Pal L, Taylor HS,
530 Wharton W, Naftolin F, Harman SM, and Miller VM. Effects of oral versus transdermal menopausal

531 hormone treatments on self-reported sleep domains and their association with vasomotor symptoms in
532 recently menopausal women enrolled in the Kronos Early Estrogen Prevention Study (KEEPS).
534 33. Clegg D, Hevener AL, Moreau KL, Morselli E, Criollo A, Van Pelt RE, and Vieira-Potter VJ. Sex
535 Hormones and Cardiometabolic Health: Role of Estrogen and Estrogen Receptors. Endocrinology 158:
536 1095-1105, 2017.
537 34. Collaborative-Group-on-Hormonal-Factors-in-Breast-Cancer. Breast cancer and hormone
538 replacement therapy: collaborative reanalysis of data from 51 epidemiological studies of 52,705 women
539 with breast cancer and 108,411 women without breast cancer. Collaborative Group on Hormonal
540 Factors in Breast Cancer. Lancet 350: 1047-1059, 1997.
541 35. Davey DA. Prevention of Alzheimer's disease, cerebrovascular disease and dementia in women:
542 the case for menopause hormone therapy. Neurodegenerative disease management 7: 85-94, 2017.
543 36. de Villiers TJ, Hall JE, Pinkerton JV, Perez SC, Rees M, Yang C, and Pierroz DD. Revised global
544 consensus statement on menopausal hormone therapy. Maturitas 91: 153-155, 2016.
545 37. Dede DS, Yavuz B, Yavuz BB, Cankurtaran M, Halil M, Ulger Z, Cankurtaran ES, Aytemir K,
546 Kabakci G, and Ariogul S. Assessment of endothelial function in Alzheimer's disease: is Alzheimer's
547 disease a vascular disease? J Am Geriatr Soc 55: 1613-1617, 2007.
548 38. Depypere H, Vierin A, Weyers S, and Sieben A. Alzheimer's disease, apolipoprotein E and
549 hormone replacement therapy. Maturitas 94: 98-105, 2016.
550 39. Dratva J, Gomez Real F, Schindler C, Ackermann-Liebrich U, Gerbase MW, Probst-Hensch NM,
551 Svanes C, Omenaas ER, Neukirch F, Wjst M, Morabia A, Jarvis D, Leynaert B, and Zemp E. Is age at
552 menopause increasing across Europe? Results on age at menopause and determinants from two
553 population-based studies. Menopause (New York, NY) 16: 385-394, 2009.
554 40. Dubey RK, Imthurn B, Barton M, and Jackson EK. Vascular consequences of menopause and
555 hormone therapy: importance of timing of treatment and type of estrogen. Cardiovascular research 66:
556 295-306, 2005.
557 41. Esme M, Yavuz BB, Yavuz B, Asil S, Tuna Dogrul R, Sumer F, Kilic MK, Kızılarslanoğlu MC, Varan
558 HD, Sagir A, Balci C, Halil M, and Cankurtaran M. Masked Hypertension is Associated With Cognitive
559 Decline in Geriatric Age–Geriatric MASked Hypertension and Cognition (G-MASH-cog) Study. The
560 Journals of Gerontology: Series A glx150-glx150, 2017.
561 42. Espeland MA, Rapp SR, Manson JE, Goveas JS, Shumaker SA, Hayden KM, Weitlauf JC,
562 Gaussoin SA, Baker LD, Padula CB, Hou L, and Resnick SM. Long-term Effects on Cognitive Trajectories
563 of Postmenopausal Hormone Therapy in Two Age Groups. J Gerontol A Biol Sci Med Sci 72: 838-845,
564 2017.
565 43. Faubion SS, Kuhle CL, Shuster LT, and Rocca WA. Long-term health consequences of premature
566 or early menopause and considerations for management. Climacteric : the journal of the International
567 Menopause Society 18: 483-491, 2015.
568 44. Feldman RD, and Limbird LE. GPER (GPR30): A Nongenomic Receptor (GPCR) for Steroid
569 Hormones with Implications for Cardiovascular Disease and Cancer. Annu Rev Pharmacol Toxicol 57:
570 567-584, 2017.
571 45. Ferrara A, Karter AJ, Ackerson LM, Liu JY, and Selby JV. Hormone replacement therapy is
572 associated with better glycemic control in women with type 2 diabetes: The Northern California Kaiser
573 Permanente Diabetes Registry. Diabetes Care 24: 1144-1150, 2001.
574 46. Filardo EJ, Quinn JA, Frackelton AR, Jr., and Bland KI. Estrogen action via the G protein-coupled
575 receptor, GPR30: stimulation of adenylyl cyclase and cAMP-mediated attenuation of the epidermal
576 growth factor receptor-to-MAPK signaling axis. Molecular endocrinology (Baltimore, Md) 16: 70-84,
577 2002.

578 47. Frick KM, Tuscher JJ, Koss WA, Kim J, and Taxier LR. Estrogenic regulation of memory
579 consolidation: A look beyond the hippocampus, ovaries, and females. Physiol Behav 2017.
580 48. Galea LAM, Frick KM, Hampson E, Sohrabji F, and Choleris E. Why estrogens matter for
581 behavior and brain health. Neurosci Biobehav Rev 76: 363-379, 2017.
582 49. Gan Y, Gong Y, Tong X, Sun H, Cong Y, Dong X, Wang Y, Xu X, Yin X, Deng J, Li L, Cao S, and Lu Z.
583 Depression and the risk of coronary heart disease: a meta-analysis of prospective cohort studies. BMC
584 psychiatry 14: 371, 2014.
585 50. Gleason CE, Dowling NM, Wharton W, Manson JE, Miller VM, Atwood CS, Brinton EA, Cedars
586 MI, Lobo RA, Merriam GR, Neal-Perry G, Santoro NF, Taylor HS, Black DM, Budoff MJ, Hodis HN,
587 Naftolin F, Harman SM, and Asthana S. Effects of Hormone Therapy on Cognition and Mood in Recently
588 Postmenopausal Women: Findings from the Randomized, Controlled KEEPS-Cognitive and Affective
589 Study. PLoS Med 12: e1001833; discussion e1001833, 2015.
590 51. Gonzalez HM, Tarraf W, Harrison K, Windham BG, Tingle J, Alonso A, Griswold M, Heiss G,
591 Knopman D, and Mosley TH. Midlife cardiovascular health and 20-year cognitive decline:
592 Atherosclerosis Risk in Communities Study results. Alzheimers Dement 2017.
593 52. Gordon JL, Rubinow DR, Eisenlohr-Moul TA, Xia K, Schmidt PJ, and Girdler SS. Efficacy of
594 transdermal estradiol and micronized progesterone in the prevention of depressive symptoms in the
595 menopause transition: A randomized clinical trial. JAMA psychiatry 2018.
596 53. Grady D, Herrington D, Bittner V, Blumenthal R, Davidson M, Hlatky M, Hsia J, Hulley S, Herd
597 A, Khan S, Newby LK, Waters D, Vittinghoff E, and Wenger N. Cardiovascular disease outcomes during
598 6.8 years of hormone therapy: Heart and Estrogen/progestin Replacement Study follow-up (HERS II).
599 Jama 288: 49-57, 2002.
600 54. Grady D, Rubin SM, Petitti DB, Fox CS, Black D, Ettinger B, Ernster VL, and Cummings SR.
601 Hormone therapy to prevent disease and prolong life in postmenopausal women. Annals of internal
602 medicine 117: 1016-1037, 1992.
603 55. Grodstein F, Stampfer MJ, Manson JE, Colditz GA, Willett WC, Rosner B, Speizer FE, and
604 Hennekens CH. Postmenopausal estrogen and progestin use and the risk of cardiovascular disease. The
605 New England journal of medicine 335: 453-461, 1996.
606 56. Gurney EP, Nachtigall MJ, Nachtigall LE, and Naftolin F. The Women's Health Initiative trial and
607 related studies: 10 years later: a clinician's view. J Steroid Biochem Mol Biol 142: 4-11, 2014.
608 57. Han G, Li F, Yu X, and White RE. GPER: a novel target for non-genomic estrogen action in the
609 cardiovascular system. Pharmacological research : the official journal of the Italian Pharmacological
610 Society 71: 53-60, 2013.
611 58. Hassager C, Riis BJ, Strom V, Guyene TT, and Christiansen C. The long-term effect of oral and
612 percutaneous estradiol on plasma renin substrate and blood pressure. Circulation 76: 753-758, 1987.
613 59. Heino TJ, Chagin AS, and Savendahl L. The novel estrogen receptor G-protein-coupled receptor
614 30 is expressed in human bone. J Endocrinol 197: R1-6, 2008.
615 60. Henderson VW, Benke KS, Green RC, Cupples LA, and Farrer LA. Postmenopausal hormone
616 therapy and Alzheimer's disease risk: interaction with age. J Neurol Neurosurg Psychiatry 76: 103-105,
617 2005.
618 61. Henderson VW, St John JA, Hodis HN, McCleary CA, Stanczyk FZ, Shoupe D, Kono N, Dustin L,
619 Allayee H, and Mack WJ. Cognitive effects of estradiol after menopause: A randomized trial of the
620 timing hypothesis. Neurology 87: 699-708, 2016.
621 62. Hildebrand JS, Gapstur SM, Feigelson HS, Teras LR, Thun MJ, and Patel AV. Postmenopausal
622 hormone use and incident ovarian cancer: Associations differ by regimen. Int J Cancer 127: 2928-2935,
623 2010.

624 63. Hildreth KL, Ozemek C, Kohrt WM, Blatchford PJ, and Moreau KL. Vascular dysfunction across
625 the stages of the menopausal transition is associated with menopausal symptoms and quality of life.
626 Menopause (New York, NY) 2018.
627 64. Hodis HN, and Mack WJ. Hormone replacement therapy and the association with coronary
628 heart disease and overall mortality: clinical application of the timing hypothesis. J Steroid Biochem Mol
629 Biol 142: 68-75, 2014.
630 65. Hodis HN, and Mack WJ. The timing hypothesis and hormone replacement therapy: a paradigm
631 shift in the primary prevention of coronary heart disease in women. Part 2: comparative risks. J Am
632 Geriatr Soc 61: 1011-1018, 2013.
633 66. Hodis HN, and Mack WJ. A "window of opportunity:" the reduction of coronary heart disease
634 and total mortality with menopausal therapies is age- and time-dependent. Brain Res 1379: 244-252,
635 2011.
636 67. Hodis HN, Mack WJ, Henderson VW, Shoupe D, Budoff MJ, Hwang-Levine J, Li Y, Feng M,
637 Dustin L, Kono N, Stanczyk FZ, Selzer RH, and Azen SP. Vascular Effects of Early versus Late
638 Postmenopausal Treatment with Estradiol. The New England journal of medicine 374: 1221-1231, 2016.
639 68. Hogervorst E. Estrogen and the brain: does estrogen treatment improve cognitive function?
640 Menopause Int 19: 6-19, 2013.
641 69. Hou N, Hong S, Wang W, Olopade OI, Dignam JJ, and Huo D. Hormone replacement therapy
642 and breast cancer: heterogeneous risks by race, weight, and breast density. Journal of the National
643 Cancer Institute 105: 1365-1372, 2013.
644 70. Hulley S, Grady D, Bush T, Furberg C, Herrington D, Riggs B, and Vittinghoff E. Randomized trial
645 of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal
646 women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. Jama 280: 605-613,
647 1998.
648 71. Imtiaz B, Tuppurainen M, Rikkonen T, Kivipelto M, Soininen H, Kröger H, and Tolppanen A-M.
649 Postmenopausal hormone therapy and Alzheimer disease: A prospective cohort study. Neurology 88:
650 1062-1068, 2017.
651 72. Iversen L, Sivasubramaniam S, Lee AJ, Fielding S, and Hannaford PC. Lifetime cancer risk and
652 combined oral contraceptives: the Royal College of General Practitioners' Oral Contraception Study. Am
653 J Obstet Gynecol 216: 580.e581-580.e589, 2017.
654 73. Jacobsen DE, Samson MM, Emmelot-Vonk MH, and Verhaar HJ. Raloxifene improves verbal
655 memory in late postmenopausal women: a randomized, double-blind, placebo-controlled trial.
657 74. Jensen LB, Vestergaard P, Hermann AP, Gram J, Eiken P, Abrahamsen B, Brot C, Kolthoff N,
658 Sorensen OH, Beck-Nielsen H, Nielsen SP, Charles P, and Mosekilde L. Hormone replacement therapy
659 dissociates fat mass and bone mass, and tends to reduce weight gain in early postmenopausal women: a
660 randomized controlled 5-year clinical trial of the Danish Osteoporosis Prevention Study. Journal of bone
661 and mineral research : the official journal of the American Society for Bone and Mineral Research 18:
662 333-342, 2003.
663 75. Jespersen CM, Arnung K, Hagen C, Hilden T, Nielsen F, Nielsen MD, and Giese J. Effects of
664 natural oestrogen therapy on blood pressure and renin-angiotensin system in normotensive and
665 hypertensive menopausal women. J Hypertens 1: 361-364, 1983.
666 76. Kawas C, Resnick S, Morrison A, Brookmeyer R, Corrada M, Zonderman A, Bacal C, Lingle DD,
667 and Metter E. A prospective study of estrogen replacement therapy and the risk of developing
668 Alzheimer's disease: the Baltimore Longitudinal Study of Aging. Neurology 48: 1517-1521, 1997.
669 77. Kennelly SP, Lawlor BA, and Kenny RA. Blood pressure and the risk for dementia: a double
670 edged sword. Ageing research reviews 8: 61-70, 2009.

671 78. Khan K, Pal S, Yadav M, Maurya R, Trivedi AK, Sanyal S, and Chattopadhyay N. Prunetin signals
672 via G-protein-coupled receptor, GPR30(GPER1): Stimulation of adenylyl cyclase and cAMP-mediated
673 activation of MAPK signaling induces Runx2 expression in osteoblasts to promote bone regeneration.
674 The Journal of nutritional biochemistry 26: 1491-1501, 2015.
675 79. Kuhl H. Pharmacology of estrogens and progestogens: influence of different routes of
676 administration. Climacteric : the journal of the International Menopause Society 8 Suppl 1: 3-63, 2005.
677 80. LaCroix AZ, Chlebowski RT, Manson JE, Aragaki AK, Johnson KC, Martin L, Margolis KL,
678 Stefanick ML, Brzyski R, Curb JD, Howard BV, Lewis CE, and Wactawski-Wende J. Health outcomes
679 after stopping conjugated equine estrogens among postmenopausal women with prior hysterectomy: a
680 randomized controlled trial. Jama 305: 1305-1314, 2011.
681 81. Lee JJ, Pedley A, Therkelsen KE, Hoffmann U, Massaro JM, Levy D, and Long MT. Upper Body
682 Subcutaneous Fat Is Associated with Cardiometabolic Risk Factors. Am J Med 130: 958-966.e951, 2017.
683 82. Lee JS, Hayashi K, Mishra G, Yasui T, Kubota T, and Mizunuma H. Independent association
684 between age at natural menopause and hypercholesterolemia, hypertension, and diabetes mellitus:
685 Japan nurses' health study. Journal of atherosclerosis and thrombosis 20: 161-169, 2013.
686 83. Leifke E, Gorenoi V, Wichers C, Von Zur Muhlen A, Von Buren E, and Brabant G. Age-related
687 changes of serum sex hormones, insulin-like growth factor-1 and sex-hormone binding globulin levels in
688 men: cross-sectional data from a healthy male cohort. Clinical endocrinology 53: 689-695, 2000.
689 84. Li J, Wang YJ, Zhang M, Xu ZQ, Gao CY, Fang CQ, Yan JC, and Zhou HD. Vascular risk factors
690 promote conversion from mild cognitive impairment to Alzheimer disease. Neurology 76: 1485-1491,
691 2011.
692 85. Lloyd-Jones DM, Leip EP, Larson MG, D'Agostino RB, Beiser A, Wilson PW, Wolf PA, and Levy
693 D. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age.
694 Circulation 113: 791-798, 2006.
695 86. Luo J, Margolis KL, Wactawski-Wende J, Horn K, Messina C, Stefanick ML, Tindle HA, Tong E,
696 and Rohan TE. Association of active and passive smoking with risk of breast cancer among
697 postmenopausal women: a prospective cohort study. Bmj 342: d1016, 2011.
698 87. Maki PM. Critical window hypothesis of hormone therapy and cognition: a scientific update on
699 clinical studies. Menopause (New York, NY) 20: 695-709, 2013.
700 88. Makkonen M, Saarikoski S, and Penttila I. Effects of oestradiol valerate plus two different
701 progestogens on serum lipids during post-menopausal replacement therapy. Maturitas 14: 43-48, 1991.
702 89. Manhem K, Ahlm H, Milsom I, and Svensson A. Transdermal oestrogen reduces daytime blood
703 pressure in hypertensive women [see comment]. J Hum Hypertens 12: 323-327, 1998.
704 90. Manson JE, Aragaki AK, Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Chlebowski RT,
705 Howard BV, Thomson CA, Margolis KL, Lewis CE, Stefanick ML, Jackson RD, Johnson KC, Martin LW,
706 Shumaker SA, Espeland MA, and Wactawski-Wende J. Menopausal Hormone Therapy and Long-term
707 All-Cause and Cause-Specific Mortality: The Women's Health Initiative Randomized Trials. Jama 318:
708 927-938, 2017.
709 91. Manson JE, Chlebowski RT, Stefanick ML, Aragaki AK, Rossouw JE, Prentice RL, Anderson G,
710 Howard BV, Thomson CA, LaCroix AZ, Wactawski-Wende J, Jackson RD, Limacher M, Margolis KL,
711 Wassertheil-Smoller S, Beresford SA, Cauley JA, Eaton CB, Gass M, Hsia J, Johnson KC, Kooperberg C,
712 Kuller LH, Lewis CE, Liu S, Martin LW, Ockene JK, O'Sullivan MJ, Powell LH, Simon MS, Van Horn L,
713 Vitolins MZ, and Wallace RB. Menopausal hormone therapy and health outcomes during the
714 intervention and extended poststopping phases of the Women's Health Initiative randomized trials.
715 Jama 310: 1353-1368, 2013.
716 92. Manson JE, Hsia J, Johnson KC, Rossouw JE, Assaf AR, Lasser NL, Trevisan M, Black HR,
717 Heckbert SR, Detrano R, Strickland OL, Wong ND, Crouse JR, Stein E, and Cushman M. Estrogen plus

718 progestin and the risk of coronary heart disease. The New England journal of medicine 349: 523-534,
719 2003.
720 93. Mathews L, Iantorno M, Schar M, Bonanno G, Gerstenblith G, Weiss RG, and Hays AG.
721 Coronary endothelial function is better in healthy premenopausal women than in healthy older
722 postmenopausal women and men. PloS one 12: e0186448, 2017.
723 94. Mendelsohn ME, and Karas RH. Molecular and cellular basis of cardiovascular gender
724 differences. S 308: 1583-1587, 2005.
725 95. Merchenthaler I, Dellovade TL, and Shughrue PJ. Neuroprotection by estrogen in animal
726 models of global and focal ischemia. Ann N Y Acad Sci 1007: 89-100, 2003.
727 96. Merlo S, Spampinato SF, and Sortino MA. Estrogen and Alzheimer's disease: Still an attractive
728 topic despite disappointment from early clinical results. Eur J Pharmacol 817: 51-58, 2017.
729 97. Meyer MR, and Barton M. Estrogens and Coronary Artery Disease: New Clinical Perspectives.
730 Advances in pharmacology (San Diego, Calif) 77: 307-360, 2016.
731 98. Mikkola TS, Clarkson TB, and Notelovitz M. Postmenopausal hormone therapy before and after
732 the women's health initiative study: what consequences? Annals of Medicine 36: 402-413, 2004.
733 99. Mikkola TS, Savolainen-Peltonen H, Tuomikoski P, Hoti F, Vattulainen P, Gissler M, and
734 Ylikorkala O. Lower Death Risk for Vascular Dementia Than for Alzheimer's Disease With
735 Postmenopausal Hormone Therapy Users. J Clin Endocrinol Metab 102: 870-877, 2017.
736 100. Miller VM, and Harman SM. An update on hormone therapy in postmenopausal women: mini-
737 review for the basic scientist. American journal of physiology Heart and circulatory physiology 313:
738 H1013-h1021, 2017.
739 101. Miller VM, and Manson JE. Women's Health Initiative Hormone Therapy Trials: New insights on
740 Cardiovascular Disease from Additional Years of Follow up. Current cardiovascular risk reports 7: 196-
741 202, 2013.
742 102. Mørch LS, Skovlund CW, Hannaford PC, Iversen L, Fielding S, and Lidegaard Ø. Contemporary
743 Hormonal Contraception and the Risk of Breast Cancer. New England Journal of Medicine 377: 2228-
744 2239, 2017.
745 103. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, de Ferranti S, Despres
746 JP, Fullerton HJ, Howard VJ, Huffman MD, Judd SE, Kissela BM, Lackland DT, Lichtman JH, Lisabeth LD,
747 Liu S, Mackey RH, Matchar DB, McGuire DK, Mohler ER, 3rd, Moy CS, Muntner P, Mussolino ME, Nasir
748 K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Sorlie PD, Stein J,
749 Towfighi A, Turan TN, Virani SS, Willey JZ, Woo D, Yeh RW, and Turner MB. Heart disease and stroke
750 statistics--2015 update: a report from the American Heart Association. Circulation 131: e29-322, 2015.
751 104. Muka T, Oliver-Williams C, Kunutsor S, Laven JS, Fauser BC, Chowdhury R, Kavousi M, and
752 Franco OH. Association of Age at Onset of Menopause and Time Since Onset of Menopause With
753 Cardiovascular Outcomes, Intermediate Vascular Traits, and All-Cause Mortality: A Systematic Review
754 and Meta-analysis. JAMA cardiology 1: 767-776, 2016.
755 105. Muka T, Vargas KG, Jaspers L, Wen KX, Dhana K, Vitezova A, Nano J, Brahimaj A, Colpani V,
756 Bano A, Kraja B, Zaciragic A, Bramer WM, van Dijk GM, Kavousi M, and Franco OH. Estrogen receptor
757 beta actions in the female cardiovascular system: A systematic review of animal and human studies.
758 Maturitas 86: 28-43, 2016.
759 106. Murray MD, Lane KA, Gao S, Evans RM, Unverzagt FW, Hall KS, and Hendrie H. Preservation of
760 cognitive function with antihypertensive medications: a longitudinal analysis of a community-based
761 sample of African Americans. Arch Intern Med 162: 2090-2096, 2002.
762 107. Nachtigall LE, Nachtigall RH, Nachtigall RD, and Beckman EM. Estrogen replacement therapy I:
763 a 10-year prospective study in the relationship to osteoporosis. Obstetrics and gynecology 53: 277-281,
764 1979.
765 108. Naghavi M, et al. Global, regional, and national age-sex specific mortality for

766 264 causes of death, 1980–2016: a systematic analysis for
767 the Global Burden of Disease Study 2016. Lancet 390: 1151-1210, 2017.
768 109. Norman RJ, Flight IH, and Rees MC. Oestrogen and progestogen hormone replacement therapy
769 for peri-menopausal and post-menopausal women: weight and body fat distribution. Cochrane
770 Database Syst Rev Cd001018, 2000.
771 110. Novella S, Heras M, Hermenegildo C, and Dantas AP. Effects of estrogen on vascular
772 inflammation: a matter of timing. Arterioscler Thromb Vasc Biol 32: 2035-2042, 2012.
773 111. Novensa L, Novella S, Medina P, Segarra G, Castillo N, Heras M, Hermenegildo C, and Dantas
774 AP. Aging negatively affects estrogens-mediated effects on nitric oxide bioavailability by shifting
775 ERalpha/ERbeta balance in female mice. PloS one 6: e25335, 2011.
776 112. Nwankwo T, Yoon SS, Burt V, and Gu Q. Hypertension among adults in the United States:
777 National Health and Nutrition Examination Survey, 2011-2012. NCHS data brief 1-8, 2013.
778 113. Paganini-Hill A, and Henderson VW. Estrogen replacement therapy and risk of Alzheimer
779 disease. Arch Intern Med 156: 2213-2217, 1996.
780 114. Palmisano BT, Zhu L, and Stafford JM. Role of Estrogens in the Regulation of Liver Lipid
781 Metabolism. Adv Exp Med Biol 1043: 227-256, 2017.
782 115. Paoletti AM, Cagnacci A, Di Carlo C, Orru MM, Neri M, D'Alterio MN, and Melis GB. Clinical
783 effect of hormonal replacement therapy with estradiol associated with noretisterone or drospirenone. A
784 prospective randomized placebo controlled study. Gynecological endocrinology : the official journal of
785 the International Society of Gynecological Endocrinology 31: 384-387, 2015.
786 116. Parkin DM. 10. Cancers attributable to exposure to hormones in the UK in 2010. British journal
787 of cancer 105 Suppl 2: S42-48, 2011.
788 117. Pearce CL, Chung K, Pike MC, and Wu AH. Increased ovarian cancer risk associated with
789 menopausal estrogen therapy is reduced by adding a progestin. Cancer 115: 531-539, 2009.
790 118. Pfeffer RI, Whipple GH, Kurosaki TT, and Chapman JM. Coronary risk and estrogen use in
791 postmenopausal women. American journal of epidemiology 107: 479-497, 1978.
792 119. Phung TK, Waltoft BL, Laursen TM, Settnes A, Kessing LV, Mortensen PB, and Waldemar G.
793 Hysterectomy, oophorectomy and risk of dementia: a nationwide historical cohort study. Dement
794 Geriatr Cogn Disord 30: 43-50, 2010.
795 120. Pike CJ, Carroll JC, Rosario ER, and Barron AM. Protective actions of sex steroid hormones in
796 Alzheimer's disease. Front Neuroendocrinol 30: 239-258, 2009.
797 121. Pinkerton JV SAF, Blake J, Cosman F, Hodis HN, Hoffstetter S, Kaunitz AM, Kingsberg SA, Maki
798 PM, Manson JE, Marchbanks P, McClung MR, Nachtigall LE, Nelson LM, Pace DT, Reid RL, Sarrel PM,
799 Shifren JL, Stuenkel CA, Utian WH. The 2017 hormone therapy position statement of The North
800 American Menopause Society. Menopause (New York, NY) 24: 728-753, 2017.
801 122. Price JF, Lee AJ, and Fowkes FG. Steroid sex hormones and peripheral arterial disease in the
802 Edinburgh Artery Study. Steroids 62: 789-794, 1997.
803 123. Pripp U, Hall G, Csemiczky G, Eksborg S, Landgren BM, and Schenck-Gustafsson K. A
804 randomized trial on effects of hormone therapy on ambulatory blood pressure and lipoprotein levels in
805 women with coronary artery disease. J Hypertens 17: 1379-1386, 1999.
806 124. Rao DC, Sung YJ, Winkler TW, Schwander K, Borecki I, Cupples LA, Gauderman WJ, Rice K,
807 Munroe PB, and Psaty BM. Multiancestry Study of Gene-Lifestyle Interactions for Cardiovascular Traits
808 in 610 475 Individuals From 124 Cohorts: Design and Rationale. Circulation Cardiovascular genetics 10:
809 2017.
810 125. Reckelhoff JF. Gender differences in the regulation of blood pressure. Hypertension 37: 1199-
811 1208, 2001.

812 126. Regev-Avraham Z, Baron-Epel O, Hammond SK, and Keinan-Boker L. Passive smoking, NAT2
813 polymorphism, and breast cancer risk in Israeli Arab women: a case-control study. Breast cancer (Tokyo,
814 Japan) 25: 176-184, 2018.
815 127. Rocca WA, Gazzuola-Rocca L, Smith CY, Grossardt BR, Faubion SS, Shuster LT, Kirkland JL,
816 Stewart EA, and Miller VM. Accelerated Accumulation of Multimorbidity After Bilateral Oophorectomy:
817 A Population-Based Cohort Study. Mayo Clinic proceedings 91: 1577-1589, 2016.
818 128. Rocca WA, Grossardt BR, and Shuster LT. Oophorectomy, estrogen, and dementia: a 2014
819 update. Mol Cell Endocrinol 389: 7-12, 2014.
820 129. Rocca WA, Grossardt BR, and Shuster LT. Oophorectomy, menopause, estrogen treatment, and
821 cognitive aging: clinical evidence for a window of opportunity. Brain Res 1379: 188-198, 2011.
822 130. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, Jackson RD,
823 Beresford SA, Howard BV, Johnson KC, Kotchen JM, and Ockene J. Risks and benefits of estrogen plus
824 progestin in healthy postmenopausal women: principal results From the Women's Health Initiative
825 randomized controlled trial. Jama 288: 321-333, 2002.
826 131. Rossouw JE, Manson JE, Kaunitz AM, and Anderson GL. Lessons learned from the Women's
827 Health Initiative trials of menopausal hormone therapy. Obstetrics and gynecology 121: 172-176, 2013.
828 132. Rossouw JE, Prentice RL, Manson JE, Wu L, Barad D, Barnabei VM, Ko M, LaCroix AZ, Margolis
829 KL, and Stefanick ML. Postmenopausal hormone therapy and risk of cardiovascular disease by age and
830 years since menopause. Jama 297: 1465-1477, 2007.
831 133. Rouch L, Cestac P, Hanon O, Cool C, Helmer C, Bouhanick B, Chamontin B, Dartigues JF, Vellas
832 B, and Andrieu S. Antihypertensive drugs, prevention of cognitive decline and dementia: a systematic
833 review of observational studies, randomized controlled trials and meta-analyses, with discussion of
834 potential mechanisms. CNS drugs 29: 113-130, 2015.
835 134. Roura E, Travier N, Waterboer T, de Sanjose S, Bosch FX, Pawlita M, Pala V, Weiderpass E,
836 Margall N, Dillner J, Gram IT, Tjonneland A, Munk C, Palli D, Khaw KT, Overvad K, Clavel-Chapelon F,
837 Mesrine S, Fournier A, Fortner RT, Ose J, Steffen A, Trichopoulou A, Lagiou P, Orfanos P, Masala G,
838 Tumino R, Sacerdote C, Polidoro S, Mattiello A, Lund E, Peeters PH, Bueno-de-Mesquita HB, Quiros JR,
839 Sanchez MJ, Navarro C, Barricarte A, Larranaga N, Ekstrom J, Lindquist D, Idahl A, Travis RC, Merritt
840 MA, Gunter MJ, Rinaldi S, Tommasino M, Franceschi S, Riboli E, and Castellsague X. The Influence of
841 Hormonal Factors on the Risk of Developing Cervical Cancer and Pre-Cancer: Results from the EPIC
842 Cohort. PloS one 11: e0147029, 2016.
843 135. Rovinski D, Ramos RB, Fighera TM, Casanova GK, and Spritzer PM. Risk of venous
844 thromboembolism events in postmenopausal women using oral versus non-oral hormone therapy: A
845 systematic review and meta-analysis. Thrombosis research 168: 83-95, 2018.
846 136. Sandberg K, and Ji H. Sex differences in primary hypertension. Biology of sex differences 3: 7,
847 2012.
848 137. Santen RJ. Menopausal hormone therapy and breast cancer. J Steroid Biochem Mol Biol 142: 52-
849 61, 2014.
850 138. Santen RJ, Allred DC, Ardoin SP, Archer DF, Boyd N, Braunstein GD, Burger HG, Colditz GA,
851 Davis SR, Gambacciani M, Gower BA, Henderson VW, Jarjour WN, Karas RH, Kleerekoper M, Lobo RA,
852 Manson JE, Marsden J, Martin KA, Martin L, Pinkerton JV, Rubinow DR, Teede H, Thiboutot DM, and
853 Utian WH. Postmenopausal hormone therapy: an Endocrine Society scientific statement. J Clin
854 Endocrinol Metab 95: s1-s66, 2010.
855 139. Santen RJ, and Petroni GR. Relative versus attributable risk of breast cancer from estrogen
856 replacement therapy. J Clin Endocrinol Metab 84: 1875-1881, 1999.
857 140. Santoro N, Allshouse A, Neal-Perry G, Pal L, Lobo RA, Naftolin F, Black DM, Brinton EA, Budoff
858 MJ, Cedars MI, Dowling NM, Dunn M, Gleason CE, Hodis HN, Isaac B, Magnani M, Manson JE, Miller
859 VM, Taylor HS, Wharton W, Wolff E, Zepeda V, and Harman SM. Longitudinal changes in menopausal

860 symptoms comparing women randomized to low-dose oral conjugated estrogens or transdermal
861 estradiol plus micronized progesterone versus placebo: the Kronos Early Estrogen Prevention Study.
863 141. Schierbeck LL, Rejnmark L, Tofteng CL, Stilgren L, Eiken P, Mosekilde L, Kober L, and Jensen JE.
864 Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women:
865 randomised trial. Bmj 345: e6409, 2012.
866 142. Schulman IH, Aranda P, Raij L, Veronesi M, Aranda FJ, and Martin R. Surgical menopause
867 increases salt sensitivity of blood pressure. Hypertension 47: 1168-1174, 2006.
868 143. Seely EW, Walsh BW, Gerhard MD, and Williams GH. Estradiol with or without progesterone
869 and ambulatory blood pressure in postmenopausal women. Hypertension 33: 1190-1194, 1999.
870 144. Shao H, Breitner JC, Whitmer RA, Wang J, Hayden K, Wengreen H, Corcoran C, Tschanz J,
871 Norton M, Munger R, Welsh-Bohmer K, and Zandi PP. Hormone therapy and Alzheimer disease
872 dementia: new findings from the Cache County Study. Neurology 79: 1846-1852, 2012.
873 145. Shumaker SA, Legault C, Kuller L, Rapp SR, Thal L, Lane DS, Fillit H, Stefanick ML, Hendrix SL,
874 Lewis CE, Masaki K, and Coker LH. Conjugated equine estrogens and incidence of probable dementia
875 and mild cognitive impairment in postmenopausal women: Women's Health Initiative Memory Study.
876 Jama 291: 2947-2958, 2004.
877 146. Shumaker SA, Legault C, Rapp SR, Thal L, Wallace RB, Ockene JK, Hendrix SL, Jones BN, 3rd,
878 Assaf AR, Jackson RD, Kotchen JM, Wassertheil-Smoller S, and Wactawski-Wende J. Estrogen plus
879 progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women: the
880 Women's Health Initiative Memory Study: a randomized controlled trial. Jama 289: 2651-2662, 2003.
881 147. Shuster LT, Rhodes DJ, Gostout BS, Grossardt BR, and Rocca WA. Premature menopause or
882 early menopause: long-term health consequences. Maturitas 65: 161-166, 2010.
883 148. Smith NL, Blondon M, Wiggins KL, Harrington LB, van Hylckama Vlieg A, Floyd JS, Hwang M, Bis
884 JC, McKnight B, Rice KM, Lumley T, Rosendaal FR, Heckbert SR, and Psaty BM. Lower risk of
885 cardiovascular events in postmenopausal women taking oral estradiol compared with oral conjugated
886 equine estrogens. JAMA Intern Med 174: 25-31, 2014.
887 149. Soares CN, Almeida OP, Joffe H, and Cohen LS. Efficacy of estradiol for the treatment of
888 depressive disorders in perimenopausal women: a double-blind, randomized, placebo-controlled trial.
889 Archives of general psychiatry 58: 529-534, 2001.
890 150. Spark MJ. Progest-erone, ogen, in? Which is it? Bmj 339: b5142, 2009.
891 151. Spencer-Segal JL, Tsuda MC, Mattei L, Waters EM, Romeo RD, Milner TA, McEwen BS, and
892 Ogawa S. Estradiol acts via estrogen receptors alpha and beta on pathways important for synaptic
893 plasticity in the mouse hippocampal formation. Neuroscience 202: 131-146, 2012.
894 152. Speth RC, Pang HW, Linares A, Bergoine S, Ji H, West CA, Wu X, Pai AV, Souza A, Zhu M,
895 Sandberg K. Age and Time Dependence of Post-Ovariectomy Estradiol Treatment on Cardiovascular
896 Regulation. In: Cardiovascular Aging: New Frontiers and Old Friends, edited by Beyer A DA, Katakam P,
897 LeBlanc AJ, Lesniewski L, Muller-Delp J, Seals D. Westminster, CO: American Physiology Society, 2017, p.
898 68.
899 153. Staessen JA, Ginocchio G, Thijs L, and Fagard R. Conventional and ambulatory blood pressure
900 and menopause in a prospective population study. J Hum Hypertens 11: 507-514, 1997.
901 154. Stampfer MJ, Colditz GA, Willett WC, Manson JE, Rosner B, Speizer FE, and Hennekens CH.
902 Postmenopausal estrogen therapy and cardiovascular disease. Ten-year follow-up from the nurses'
903 health study. The New England journal of medicine 325: 756-762, 1991.
904 155. Stefanick ML, Anderson GL, Margolis KL, Hendrix SL, Rodabough RJ, Paskett ED, Lane DS,
905 Hubbell FA, Assaf AR, Sarto GE, Schenken RS, Yasmeen S, Lessin L, and Chlebowski RT. Effects of
906 conjugated equine estrogens on breast cancer and mammography screening in postmenopausal women
907 with hysterectomy. Jama 295: 1647-1657, 2006.

908 156. Stefano GB, Prevot V, Beauvillain JC, Cadet P, Fimiani C, Welters I, Fricchione GL, Breton C,
909 Lassalle P, Salzet M, and Bilfinger TV. Cell-surface estrogen receptors mediate calcium-dependent nitric
910 oxide release in human endothelia. Circulation 101: 1594-1597, 2000.
911 157. Sung YJ, Winkler TW, de Las Fuentes L, Bentley AR, Brown MR, Kraja AT, Schwander K, Ntalla I,
912 Guo X, Franceschini N, Lu Y, Cheng CY, Sim X, Vojinovic D, Marten J, Musani SK, Li C, Feitosa MF,
913 Kilpelainen TO, Richard MA, Noordam R, Aslibekyan S, Aschard H, Bartz TM, Dorajoo R, Liu Y, Manning
914 AK, Rankinen T, Smith AV, Tajuddin SM, Tayo BO, Warren HR, Zhao W, Zhou Y, Matoba N, Sofer T,
915 Alver M, Amini M, Boissel M, Chai JF, Chen X, Divers J, Gandin I, Gao C, Giulianini F, Goel A, Harris SE,
916 Hartwig FP, Horimoto A, Hsu FC, Jackson AU, Kahonen M, Kasturiratne A, Kuhnel B, Leander K, Lee WJ,
917 Lin KH, an Luan J, McKenzie CA, Meian H, Nelson CP, Rauramaa R, Schupf N, Scott RA, Sheu WHH,
918 Stancakova A, Takeuchi F, van der Most PJ, Varga TV, Wang H, Wang Y, Ware EB, Weiss S, Wen W,
919 Yanek LR, Zhang W, Zhao JH, Afaq S, Alfred T, Amin N, Arking D, Aung T, Barr RG, Bielak LF, Boerwinkle
920 E, Bottinger EP, Braund PS, Brody JA, Broeckel U, Cabrera CP, Cade B, Caizheng Y, Campbell A, Canouil
921 M, Chakravarti A, Chauhan G, Christensen K, Cocca M, Collins FS, Connell JM, de Mutsert R, de Silva
922 HJ, Debette S, Dorr M, Duan Q, Eaton CB, Ehret G, Evangelou E, Faul JD, Fisher VA, Forouhi NG, Franco
923 OH, Friedlander Y, Gao H, Gigante B, Graff M, Gu CC, Gu D, Gupta P, Hagenaars SP, Harris TB, He J,
924 Heikkinen S, Heng CK, Hirata M, Hofman A, Howard BV, Hunt S, Irvin MR, Jia Y, Joehanes R, Justice AE,
925 Katsuya T, Kaufman J, Kerrison ND, Khor CC, Koh WP, Koistinen HA, Komulainen P, Kooperberg C,
926 Krieger JE, Kubo M, Kuusisto J, Langefeld CD, Langenberg C, Launer LJ, Lehne B, Lewis CE, Li Y, Lim SH,
927 Lin S, Liu CT, Liu J, Liu J, Liu K, Liu Y, Loh M, Lohman KK, Long J, Louie T, Magi R, Mahajan A, Meitinger
928 T, Metspalu A, Milani L, Momozawa Y, Morris AP, Mosley TH, Jr., Munson P, Murray AD, Nalls MA,
929 Nasri U, Norris JM, North K, Ogunniyi A, Padmanabhan S, Palmas WR, Palmer ND, Pankow JS,
930 Pedersen NL, Peters A, Peyser PA, Polasek O, Raitakari OT, Renstrom F, Rice TK, Ridker PM, Robino A,
931 Robinson JG, Rose LM, Rudan I, Sabanayagam C, Salako BL, Sandow K, Schmidt CO, Schreiner PJ, Scott
932 WR, Seshadri S, Sever P, Sitlani CM, Smith JA, Snieder H, Starr JM, Strauch K, Tang H, Taylor KD, Teo
933 YY, Tham YC, Uitterlinden AG, Waldenberger M, Wang L, Wang YX, Wei WB, Williams C, Wilson G,
934 Wojczynski MK, Yao J, Yuan JM, Zonderman AB, Becker DM, Boehnke M, Bowden DW, Chambers JC,
935 Chen YI, de Faire U, Deary IJ, Esko T, Farrall M, Forrester T, Franks PW, Freedman BI, Froguel P,
936 Gasparini P, Gieger C, Horta BL, Hung YJ, Jonas JB, Kato N, Kooner JS, Laakso M, Lehtimaki T, Liang KW,
937 Magnusson PKE, Newman AB, Oldehinkel AJ, Pereira AC, Redline S, Rettig R, Samani NJ, Scott J, Shu
938 XO, van der Harst P, Wagenknecht LE, Wareham NJ, Watkins H, Weir DR, Wickremasinghe AR, Wu T,
939 Zheng W, Kamatani Y, Laurie CC, Bouchard C, Cooper RS, Evans MK, Gudnason V, Kardia SLR,
940 Kritchevsky SB, Levy D, O'Connell JR, Psaty BM, van Dam RM, Sims M, Arnett DK, Mook-Kanamori DO,
941 Kelly TN, Fox ER, Hayward C, Fornage M, Rotimi CN, Province MA, van Duijn CM, Tai ES, Wong TY, Loos
942 RJF, Reiner AP, Rotter JI, Zhu X, Bierut LJ, Gauderman WJ, Caulfield MJ, Elliott P, Rice K, Munroe PB,
943 Morrison AC, Cupples LA, Rao DC, and Chasman DI. A Large-Scale Multi-ancestry Genome-wide Study
944 Accounting for Smoking Behavior Identifies Multiple Significant Loci for Blood Pressure. Am J Hum Genet
945 102: 375-400, 2018.
946 158. Swica Y, Warren MP, Manson JE, Aragaki AK, Bassuk SS, Shimbo D, Kaunitz A, Rossouw J,
947 Stefanick ML, and Womack CR. Effects of oral conjugated equine estrogens with or without
948 medroxyprogesterone acetate on incident hypertension in the Women's Health Initiative hormone
949 therapy trials. Menopause (New York, NY) 25: 753-761, 2018.
950 159. Tannen RL, Weiner MG, Xie D, and Barnhart K. Perspectives on hormone replacement therapy:
951 the Women's Health Initiative and new observational studies sampling the overall population. Fertil
952 Steril 90: 258-264, 2008.
953 160. Taskin O, Muderrisoglu H, Akar M, Simsek M, Mendilcioglu I, and Kursun S. Comparison of the
954 effects of tibolone and estrogen replacement therapy on echocardiographic basic cardiac functions in
955 post-menopausal women: a randomized placebo controlled study. Maturitas 48: 354-359, 2004.

956 161. The-Writing-Group-for-the-PEPI-Trial. Effects of estrogen or estrogen/progestin regimens on
957 heart disease risk factors in postmenopausal women. The Postmenopausal Estrogen/Progestin
958 Interventions (PEPI) Trial. The Writing Group for the PEPI Trial. Jama 273: 199-208, 1995.
959 162. Vaccarino V, McClure C, Johnson BD, Sheps DS, Bittner V, Rutledge T, Shaw LJ, Sopko G, Olson
960 MB, Krantz DS, Parashar S, Marroquin OC, and Merz CN. Depression, the metabolic syndrome and
961 cardiovascular risk. Psychosomatic medicine 70: 40-48, 2008.
962 163. van Ittersum FJ, van Baal WM, Kenemans P, Mijatovic V, Donker AJ, van der Mooren MJ, and
963 Stehouwer CD. Ambulatory--not office--blood pressures decline during hormone replacement therapy in
964 healthy postmenopausal women. Am J Hypertens 11: 1147-1152, 1998.
965 164. Vargas KG, Milic J, Zaciragic A, Wen KX, Jaspers L, Nano J, Dhana K, Bramer WM, Kraja B, van
966 Beeck E, Ikram MA, Muka T, and Franco OH. The functions of estrogen receptor beta in the female
967 brain: A systematic review. Maturitas 93: 41-57, 2016.
968 165. Wang K, Li F, Chen L, Lai YM, Zhang X, and Li HY. Change in risk of breast cancer after receiving
969 hormone replacement therapy by considering effect-modifiers: a systematic review and dose-response
970 meta-analysis of prospective studies. Oncotarget 8: 81109-81124, 2017.
971 166. Waters EM, Thompson LI, Patel P, Gonzales AD, Ye HZ, Filardo EJ, Clegg DJ, Gorecka J, Akama
972 KT, McEwen BS, and Milner TA. G-protein-coupled estrogen receptor 1 is anatomically positioned to
973 modulate synaptic plasticity in the mouse hippocampus. The Journal of neuroscience : the official journal
974 of the Society for Neuroscience 35: 2384-2397, 2015.
975 167. Wellons M, Ouyang P, Schreiner PJ, Herrington DM, and Vaidya D. Early menopause predicts
976 future coronary heart disease and stroke: the Multi-Ethnic Study of Atherosclerosis. Menopause (New
977 York, NY) 19: 1081-1087, 2012.
978 168. Wharton W, Gleason CE, Miller VM, and Asthana S. Rationale and design of the Kronos Early
979 Estrogen Prevention Study (KEEPS) and the KEEPS Cognitive and Affective sub study (KEEPS Cog). Brain
980 Res 1514: 12-17, 2013.
981 169. Whelton PK, Carey RM, Aronow WS, Casey DE, Jr., Collins KJ, Dennison Himmelfarb C,
982 DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC,
983 Jr., Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA, Sr., Williamson JD, and Wright JT, Jr.
984 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention,
985 Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American
986 College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of
987 the American College of Cardiology 2017.
988 170. Whitmer RA, Quesenberry CP, Zhou J, and Yaffe K. Timing of hormone therapy and dementia:
989 the critical window theory revisited. Annals of neurology 69: 163-169, 2011.
990 171. Williams JK, Anthony MS, Honore EK, Herrington DM, Morgan TM, Register TC, and Clarkson
991 TB. Regression of atherosclerosis in female monkeys. Arterioscler Thromb Vasc Biol 15: 827-836, 1995.
992 172. Wilson PW, Garrison RJ, and Castelli WP. Postmenopausal estrogen use, cigarette smoking, and
993 cardiovascular morbidity in women over 50. The Framingham Study. The New England journal of
994 medicine 313: 1038-1043, 1985.
995 173. Windham GC, Elkin E, Fenster L, Waller K, Anderson M, Mitchell PR, Lasley B, and Swan SH.
996 Ovarian hormones in premenopausal women: variation by demographic, reproductive and menstrual
997 cycle characteristics. Epidemiology (Cambridge, Mass) 13: 675-684, 2002.
998 174. Wroolie TE, Kenna HA, Williams KE, Powers BN, Holcomb M, Khaylis A, and Rasgon NL.
999 Differences in verbal memory performance in postmenopausal women receiving hormone therapy:
1000 17beta-estradiol versus conjugated equine estrogens. Am J Geriatr Psychiatry 19: 792-802, 2011.
1001 175. Wroolie TE, Kenna HA, Williams KE, and Rasgon NL. Cognitive Effects of Hormone Therapy
1002 Continuation or Discontinuation in a Sample of Women at Risk for Alzheimer Disease. Am J Geriatr
1003 Psychiatry 23: 1117-1126, 2015.

1004 176. Yaffe K, Krueger K, Cummings SR, Blackwell T, Henderson VW, Sarkar S, Ensrud K, and Grady D.
1005 Effect of raloxifene on prevention of dementia and cognitive impairment in older women: the Multiple
1006 Outcomes of Raloxifene Evaluation (MORE) randomized trial. The American journal of psychiatry 162:
1007 683-690, 2005.
1008 177. Yasar S, Ko JY, Nothelle S, Mielke MM, and Carlson MC. Evaluation of the effect of systolic
1009 blood pressure and pulse pressure on cognitive function: the Women's Health and Aging Study II. PloS
1010 one 6: e27976, 2011.
1011 178. Zandi PP, Carlson MC, Plassman BL, Welsh-Bohmer KA, Mayer LS, Steffens DC, and Breitner JC.
1012 Hormone replacement therapy and incidence of Alzheimer disease in older women: the Cache County
1013 Study. Jama 288: 2123-2129, 2002.
1014 179. Zhao L, and Brinton RD. Estrogen receptor alpha and beta differentially regulate intracellular
1015 Ca(2+) dynamics leading to ERK phosphorylation and estrogen neuroprotection in hippocampal neurons.
1016 Brain Res 1172: 48-59, 2007.
1017 180. Zhao L, Wu TW, and Brinton RD. Estrogen receptor subtypes alpha and beta contribute to
1018 neuroprotection and increased Bcl-2 expression in primary hippocampal neurons. Brain Res 1010: 22-34,
1019 2004.
1020
1021

1022
1023
1024

Table 1. Cardiovascular and other risks associated with post-menopausal hormone replacement therapy (ERT/EPT)
Effect EPT Type of

Effect ERT Type of
Condition Citation (estrogen + progestin) estrogen, Citation
estrogen
progestin
significant (30-55) CEE (55) significant (30-55) CEE, MPA (55)
significant (50-59),
CEE,E2 (24, 141) significant (45-58) E2, NETA (141)
Coronary artery (45-52
disease* moderate trend (50-
CEE (159) significant (55-79) CEE,norgestrel (159)
55)
No change (57-98) CEE (118) No change (55-80) CEE, MPA (70)
↑Systolic & diastolic
Tibolone or
Cardiac function function (<3yr post- (160)
CEE, MPA
menopause)
 nocturnal Systolic,
 nocturnal Systolic,
diastolic & Mean BP, t-E2,
t-E2, (143) diastolic & Mean BP (143)
↓ day Mean BP V-Progesterone
(56±1.5)
(56±1.5)
 Systolic & diastolic
↑Systolic BP (57-98) t-E2 (20) E2, digesterone (163)
Hypertension/ BP (Mean age 52.3)
reduction of BP  Systolic & diastolic
No change (40-70) CEE (26, 28) E2, NETA (115)
BP (47-55)
Lower diastolic BP E2/t-E2, CPA/
(58)
(45-53) progesterone
No change or trend
U, U (125)
(45-66)
Protection from
E2 or
ischemic stroke (<5 (27) Decreased risk (50-79) CEE, norgestrel (159)
CEE
Stroke/ yr post-menopause)
cerebrovascular Moderate (45-58), ns E2 (24) ↑Large trend (50-79) CEE, MPA (24)
accident No change (50-79) CEE (159) No change (45-58) E2, NETA (141)
No change (30-55) (45-
CEE (55,141) No Change (30-55) CEE, MPA (55)
58)
Pulmonary or ↑ trend (50-79 CEE (24) ↑Large (50-79) CEE, MPA (24)

thromboembolism ↑Large (55-80) CEE, MPA (70)
Improved profile (40- CEE, (26, 28, Improved profile (45- CEE, MPA/
(161)
70) CEE/E2, 161) 64)† progesterone
Hyperlipidemia/
lipid profile/ Progression (<6 yr Progression (<6 yr E2, V-progester-
E2 (67) (67)
atherosclerosis post-menopause) post-menopause) one
progression Improved profile (55-
CEE, MPA (70)
80)
Progression (<6 yr CEE/
(140)
post-menopause) progesterone
Vasomotor
Large (42-79) CEE, E2 (91, 140) Large (50-79) CEE, MPA (91)
symptoms
Type II diabetes Small trend CEE (24) Small trend CEE, MPA (24)
No change (43-70) E2, CEE (28) Small (45-58) ** E2, norhisterone (74)
Obesity No change (?) U (109) trend (50-79) CEE, MPA (30)
No change (?) U, U (109)
Hip fracture Moderate (50-79) CEE (24) Moderate (50-79) CEE, MPA (24, 130)
E2/CEE/U, MPA/ (15, 91,
Osteoporosis*** Moderate (54-72) E2 (15) Moderate (50-79)
progesterone 130)
Moderate improvement t-E2/CEE
Depression# (50, 149) Incidence (45-60)### t-E2, various (52)
(50-56), (40-55)## t-E2
E2/CEE,
Protective effect (<60) E2 (68) Protective effect (<60) (68)
MPA/various
Protective effect (PM-
Reduction (66.4±6.9) Raloxifene (176) MPA (43)
BSO)
Improved Protective effect
Raloxifene (73) U, U (25,144)
Cognitive performance (66.2±7) (menopause ≤5 years)
impairment Improved No change
E2/CEE (174,175) U, U (25,144)
performance (49-68) (menopause >5 years)
Impaired performance Impaired performance
CEE (145) CEE, MPA (145)
trend (65-79) trend (65-79)
No Change (<6 yr post-
No change (52.6±2.6) U (50) U, U (61)
menopause)

E2/t-E2,
No change (52.6±2.6) (50)
progesterone
Protective effect (40 E2/t-E2/V- Protective effect (40
(99) E2, MPA/NETA (99)
and older) E2 and older)
Protective effect (40-
U (170) Protective effect†† (?) U, U (178)
55)
Protective effect (28- Protective effect
U (76) Various, various (170)
Alzheimer’s 94) (“mid-life”)
disease, other Protective effect (?) U (113) ↑Large (“late-life”) Various, various (170)
dementias Risk (50-63) U (60) ↑Incidence (65-79) CEE, MPA (145,146)
Risk trend
Raloxifene (176) ↑Moderate (50-79) CEE, MPA (91)
(66.4±6.9),
↑Incidence (75-84) CEE (145,146)
↑Incidence (65-79) CEE (170)
↑Trend (50-79), CEE (91)
Trend (50-79) CEE (24, 90) Trend (50-79) CEE, MPA (24, 90)
Cardiovascular
Large trend (40-69,
deaths E2, CEE (26, 141) ↑Trend (50-79) CEE, MPA (130)
45-58)
CEE, E2, (24, 90, Moderate trend (50- CEE, MPA, (24, 90,
Moderate (?)
All cause CEE 141, 159) 79) CEE, norgestrel 159)
mortality Moderate trend (45- (24, 90,
CEE, E2 No change (55-80) CEE, MPA (70)
79) 141)
Beneficial effects are indicated in italics in bold font. (?) indicates unspecified age range, generally from meta-analysis data; *
includes myocardial infarction and heart failure, ** these studies report a redistribution of fat mass to the abdomen (increased waist
circumference and waist to hip ratio) as well as a shift from lean to fat mass and greater loss of bone mineral density in women who do
not receive MHT. Such changes are associated with an increased risk of CVD (30, 81). *** includes studies showing increased bone
#
density as a surrogate for reduced osteoporosis. depression has been shown to be a risk factor for CVD in particular ischemic heart
##
disease (16, 49, 162) four-year follow-up only; improvement in depression was seen only with oral conjugated estrogens, not

###
transdermally administered estrogen. may include some individuals with EPT. improvement was limited to women in early
menopause transition. † cyclic progestin was better than continuous progestin. CEE, conjugated equine estrogens; E2, 17-ß-estradiol; t-
E2 transdermal 17-ß-estradiol; V, vaginal; MPA, medroxyprogesterone acetate; NETA, norethisterone acetate; CPA, cyproterone
acetate; U, unspecified; PM-BSO, Pre-menopausal bilateral salpingo-oophorectomy onset MHT.

Table 2. Cancer risk associated with hormone replacement therapy (ERT/EPT)
Effect ERT ERT Citation Effect EPT EPT Citation

Condition
(age) (age) composition
Moderate
Moderate trend
E2 (141) trendǂ (45- E2, NETA (141)
(45-58)
58)
↑Moderate
Small trend E2 or CEE, (24, 69,
CEE (24, 91) trend (50-
(50-79) MPA 70, 130)
79)
Breast
 Significant ↑Moderate
cancer CEE (8) U (159)
(60-69) (?)
 Significant LaCroix ↑Large (50-
CEE various (34)
(50-79) (80) 55)
No change (50-
U (159) ↑Large (?) U (165)
55)
↑Small (?) U (162)
Ovarian ↑Moderate (50- (62, ↑Small (50- U, MPA, (62,
U
cancer 74), (?) 117) 74), (?) NETA 117)
Endomet ↑Small (?) Vari (54, Moderate CEE, MPA, (70,
rial ous 116) trend 116)
cancer
Cervical ↑Insignificant (35- U (134) No change U (134)
cancer 70) (35-70)
Moderate trend CEE (24, Moderate CEE, MPA (24)
Colorec-
(50-79) 130) trend
tal
cancer Moderate CEE, MPA (130)
(50-79)
All Itrend (50-59) CEE (24) No change CEE, MPA (24)
cancers (50-59)
Moderate trend CEE (24) Moderate CEE, MPA (24, 70,
All 90)
(50-59) trend (50-
cancer
79)
deaths
trend (50-79) CEE (90)86
Notes: Beneficial effects are indicated in italics in bold font; (?) indicates unspecified age range,
generally from meta-analysis data; "ns", indicates did not reach statistical significance; ǂdecrease
was greatest in younger women (< 50 years old); (69) reported wide variations in breast cancer
risk based upon ethnicity, breast density and obesity; (24) limited to 50-59 age group, also
includes reanalysis of the 50-59 age cohort of the Women's Health Initiative study with generally
similar results; (62) 5 years post hormone replacement therapy, no increase in ovarian cancer
risk was present; ERT, estrogen replacement therapy; EPT, estrogen-progestin replacement
therapy; CEE conjugated equine estrogens; E2, 17-ß-estradiol.

. .
Breast 5
Change in disease incidence

Breast Cancer
per 100 women with ERT

Cancer . .
Deaths
0
-5 Deaths
. . -10
Cardio-
vascular Cardiovascular
Disease -15 disease
. .
Before ERT After ERT

1
2 Figure Legend:
3 Figure 1. Relative and Attributable Risks for Breast Cancer and Cardiovascular Death with ERT. The
4 incidence of breast cancer is based upon statistics from the National Cancer Institute web site
5 https://www.cancer.gov/types/breast/risk-fact-sheet (accessed August 6, 2018). The incidence of
6 cardiovascular disease deaths is derived from Lloyd-Jones et al (83). The estimate of the relative risk for
7 breast cancer and coronary heart disease with ERT is from Santen and Petroni (136) but can vary
8 considerably based upon the type of ERT agents, routes of administration, duration of therapy, follow-up
9 period, and individual risk factors.
10
11
12


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1

2 A Heartfelt Message, Estrogen Replacement Therapy: Use It or Lose It

13 * To whom reprint requests should be sent.

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33 1. Twentieth-century studies suggesting beneficial effects of menopausal hormone therapy (MHT)

38 more harm than benefit.

39 3. Estradiol generally confers greater benefits than conjugated equine estrogens.

40 4. Transdermal administration of estrogen affords greater benefits than oral administration.

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42 reduce the risk of breast and overall cancer incidence.

46 as part of the criteria for determining whether MHT is appropriate.

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105 dementias (35, 99).

107 Current understanding of blood pressure (BP) and cardiovascular health

116 prevalence of hypertension is substantial at ~34% of the American population

118 public/@wcm/@sop/@smd/documents/downloadable/ucm_491265.pdf; accessed 1/8/18) and this

121 Ovarian hormones and cardiovascular health

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143 decreased (131).

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177 Menopausal hormone therapy and cancer

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184 consistent with “The Timing Hypothesis”.

186 Relative risk versus absolute risk

200 50-59 or within 10 years of menopause (138).

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207 of 5.9 years reduces the incidence of breast cancer.

215 their usage prevented 1600 cases of cancer in 2010 (116).

217 Variations in MHT

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245 investigated on a larger scale.

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257 risk than men.

267 intact uterus (36, 54, 90, 101, 141).

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281 Influence of estrogen receptor subtypes

293 remains relatively constant in human uterus (110).

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326 the greatest benefits (133).

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359 ‘The Timing Hypothesis’ effect.

377 MHT after age 65, see review (128).

379 Current gaps in knowledge

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391 Limitations of the study

398 effect observations similarly.

400 Summary and conclusions

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413 adverse cognitive effects of early or premenopausal surgical menopause (121).

426 Fund, Nova Southeastern University (RCS).

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