Increase in MMP-2 activity in overweight and obese women is associated with menopausal status.

BACKGROUND: Metalloproteinases (MMPs) are synthesized in the subendothelium and are involved in the atherosclerosis and cardiovascular disease process because of their major significance in vascular remodeling and plaque rupture. MMPs are also synthesized in adipose tissue during angiogenesis; however, the role of these enzymes in obesity and insulin-resistant states is still controversial. OBJECTIVE: To evaluate MMP-2 activity in the circulation of overweight and obese women and in normal-weight controls, and to associate the levels of these factors with metabolic, adipose tissue and inflammation biomarkers. METHODS: Plasma MMP-2 activity, adiponectin and C-reactive protein concentration, lipoprotein profile and HOMA were determined in 39 healthy women (13 normal weight and 26 overweight/obese). RESULTS: Overweight/obese women were older (p < 0.001) than normal-weight women; 20/26 of overweight/obese women were postmenopausal compared with 4/13 of normal-weight women. Overweight/obese women had significantly higher plasma activity of MMP-2 than controls (mean relative area: 0.81 (range 0.4-1.92) vs. 1.33 (range 0.4-3.1); p < 0.005); this difference was lost after adjusting for menopausal status. MMP-2 activity positively correlated with waist circumference (p < 0.002), HOMA (p < 0.003), and high-sensitivity C-reactive protein (p < 0.05), apolipoprotein B (p = 0.006) and triglyceride/high density lipoprotein (HDL) cholesterol index (p < 0.001), and negatively with HDL cholesterol (p < 0.001), HDL2 cholesterol (p < 0.008), HDL3 cholesterol (p < 0.05) and adiponectin (p < 0.05). The association with HOMA and adiponectin persisted even after adjusting for menopausal status. CONCLUSION: Our finding of increased plasma activity of MMP-2 in overweight/obese women, associated with menopausal status, is important given that it fits in with an early stage of cardiovascular disease; the association of MMP-2 activity with obesity markers may be a link between adipose tissue and risk for cardiovascular disease.

Age of menopause and impact of climacteric symptoms by geographical region.

OBJECTIVE: To describe differences in the age of onset of menopause and in the prevalence of climacteric symptoms in different geographical areas. DESIGN: Systematic review of published data on onset of menopause and symptoms in Europe, North America, Latin America and Asia. METHODS: We identified publications by searching electronic databases, including MEDLINE (1966-October 2009) and EMBASE (1975-October 2009). Primary search criteria were age of menopause and climacteric symptoms. A sensitive analysis that excluded papers without full data was performed. RESULTS: The median age at menopause in Europe ranges from 50.1 to 52.8 years, in North America from 50.5 to 51.4 years, in Latin America from 43.8 to 53 years, and in Asia from 42.1 to 49.5 years. The frequency of vasomotor symptoms varies widely depending on the geographical region, selection of criteria, and method of symptom identification. The prevalence of such symptoms ranges from 74% of women in Europe, 36-50% in North America, 45-69% in Latin America and 22-63% in Asia, as reported in different, large, epidemiological studies. CONCLUSION: There are wide geographical differences in the prevalence of menopausal symptomatology and some differences in the age of onset of menopause. Both in Asia and Latin America, women of poorer socioeconomic status have significantly earlier onset of menopause. Within a geographical region, there are ethnic differences in menopause symptoms. Given differences in study methodologies, firm conclusions are not possible. However, regional differences in age at menopause and in climacteric symptoms are important to acknowledge and lay the foundation for an informed approach to the management of menopause and an understanding of its impact on women's health in the different regions of the world.

Androgens in relationship to cardiovascular risk factors in the menopausal transition.

OBJECTIVE: To establish the relationship between androgens and cardiovascular disease (CVD) risk factors in the menopausal transition. METHODS: A total of 124 women were divided into four groups: 29 premenopausal (PreM), 35 women in the menopausal transition still menstruating (MTM), 29 women in the menopausal transition with 3-6 months amenorrhea (MTA), and 31 postmenopausal women (PostM). Levels of triglycerides, low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol, glucose and insulin were assayed in all samples and waist circumference was measured. In a subgroup of 83 women (19 PreM, 21 MTM, 28 MTA and 15 PostM), levels of total testosterone, androstenedione, dehydroepiandrosterone sulfate (DHEAS) and estradiol were determined. The free androgen index, Homeostasis Model Assessment (HOMA) index, Quantitative Insulin Sensitivity Check Index (QUICKI) and McAuley index, estradiol/total testosterone and triglyceride/HDL cholesterol ratios were calculated. RESULTS: Androstenedione was higher in MTA vs. PostM women (p < 0.05); DHEAS was higher in PreM women vs. the other three groups (p < 0.05). Sex hormone binding globulin (SHBG) in MTM women was higher than in MTA women (p < 0.05); the free androgen index was lower in MTM women than in MTA and PostM women. SHBG and the free androgen index showed negative and positive correlations, respectively with waist circumference, insulin resistance and lipids. In a multiple regression analysis, considering waist circumference, neither free androgen index nor SHBG showed significant differences between groups. The waist circumference correlated only with SHBG (p = 0.022) and correlations between SHBG and insulin resistance markers continued to be significant, but relationships between SHBG and lipoproteins and all correlations found with free androgen index were lost. CONCLUSIONS: An increment in the androgenic milieu that correlates with abdominal fat, insulin resistance and atherogenic lipoproteins becomes evident after the menopausal transition and suggests that evaluation of cardiovascular disease risk in these women should include androgens, considering that abdominal obesity is one of the main determinants of the relationship between androgenic parameters and cardiovascular risk factors.

Higher values of hepatic lipase activity in postmenopause: relationship with atherogenic intermediate density and low density lipoproteins.

OBJECTIVE: To investigate the enzymatic activity of hepatic lipase (HL) in postmenopausal women (PMW) and reproductive age women (RAW); and to evaluate the relationship between this enzyme and the atherogenic intermediate density lipoproteins (IDL) and low density lipoproteins (LDL), and antiatherogenic high density lipoproteins (HDL) and its subfractions (HDL2 and HDL3). DESIGN: We studied 55 PMW receiving no hormonal treatment in a cross-sectional study in comparison with a control group of 55 RAW, matched by body mass index. Follicle-stimulating hormone was > 40 mUI/ml in PMW and 3-12 mUI/ml in RAW. PMW presented at least 1 year of natural menopause and no more than 10 years of amenorrhea with E2 serum concentration < 15 pg/ml. RESULTS: HL activity was significantly higher in PMW versus RAW (14.0 +/- 1.4 vs. 10.9 +/- 0.4 micromol of fatty acids/ml of postheparin plasma, respectively, mean +/- SEM, p < 0.001). In PMW, IDL cholesterol showed a positive correlation with LDL cholesterol (r = 0.28, p < 0.05), and HDL2 cholesterol was inversely correlated with HL activity (r = 0.31, p < 0.05). HL was positively correlated with plasma concentration of LDL cholesterol in both groups (r = 0.27, p < 0.05). The higher values of HL activity and IDL cholesterol were independent of age. CONCLUSIONS: Higher HL activity is associated with a more atherogenic profile in PMW.

A comparative study of two hormone replacement therapy regimens on safety and efficacy variables.

OBJECTIVE: To assess the effect of tibolone on endometrial safety, plasma estradiol concentrations, lipid metabolism and climacteric symptoms in comparison to sequential conjugated equine estrogens and medroxyprogesterone acetate in postmenopausal women. METHODS: In a randomised, open-label, 6-cycle, group-comparative study, the effects on the aforementioned parameters were studied with tibolone 2.5 mg/day (N = 13) continuously, and with conjugated equine estrogens 0.625 mg/day continuously, combined with medroxyprogesterone acetate 5 mg/day (N = 11) (CEE/MPA) sequentially, during 12 days of each 28-day cycle. Within-group statistical analysis was performed with Student's t-test for paired samples, whereas between-group statistics were performed using the Student's t-test for independent groups. RESULTS: Cytological evaluation revealed no endometrial stimulation in either group. In the tibolone group, there were no effects on estradiol levels, whereas in the CEE/MPA group, an increase in total and non-SHBG-bound estradiol plasma levels was reported. In the tibolone group, there were significant decreases in plasma total cholesterol, triglycerides, HDL-cholesterol and VLDL-cholesterol, whereas no significant changes in LDL-cholesterol and IDL-cholesterol were reported. In the CEE/MPA group there were significant decreases in plasma total cholesterol, HDL-cholesterol and LDL-cholesterol, whereas there were no significant changes in triglycerides, IDL-cholesterol and VLDL-cholesterol. Climacteric symptoms, particularly vasomotor episodes, decreased similarly in both groups. CONCLUSIONS: Both tibolone and CEE/MPA were safe with respect to effects on the endometrium and both treatments induced changes in the plasma profiles of certain lipid and lipoprotein parameters. However, the overall clinical implications of these changes are unknown. Finally, both regimens were equally effective in the treatment of climacteric symptoms.

[Very low density lipoproteins and subclasses of intermediate density lipoproteins in postmenopausal women]. / Lipoprotéinas de muy baja densidad y subespecies de liproprotéinas de densidad intermedia en mujeres postmenopáusicas.

Post menopausal women present an increase of cardiovascular risk associated with the atherogenic plasma lipoproteins IDL and LDL. Our purpose was to study the composition of VLDL, IDL and the subfractions IDL-1 and IDL-2, and the Lipoprotein Lipase and Hepatic Lipase activities in a group of twelve healthy post menopausal women as compared with eleven fertile controls. The mean values of total cholesterol and LDL cholesterol were significantly increased in the post menopausal group compared to the controls (p < 0.005 and p < 0.001 respectively). The contribution of the HDL-cholesterol plasma concentration to total cholesterol was lower in the postmenopausal women (p < 0.02) although no one had HDL-cholesterol lower than 35 mg/dl and the mean value was 50 mg/dl. Postmenopausal women had increased concentrations of VLDL, total IDL and IDL-2 compared to controls (p < 0.05, p < 0.005 and p < 0.001 respectively). Plasma concentrations of total IDL was increased in postmenopausal women (33.6 +/- 3.4 vs 22.6 +/- 0.8 mg/dl, p < 0.005). The increase in total IDL was due to IDL-2 (19.9 +/- 1.7 vs 11.5 +/- 0.8 mg/dl, p < 0.001, in postmenopausal women vs controls). The IDL-2 subfraction was 60 +/- 2.6% of total IDL in postmenopausal women and 51 +/- 2.0% in controls (p < 0.02). In postmenopausal women and in controls the ratio triglyceride/protein (which indicates particles size) was significantly higher in IDL-1 than in IDL-2 (p < 0.005 and p < 0.01 respectively), but this ratio did not show differences when VLDL, total IDL and IDL-2 were compared between postmenopausal and control women. Then, the increased plasma concentration of these lipoproteins would show an increased number of particles in the postmenopausal women vs controls. There were no differences in the Lipoprotein Lipase and Hepatic Lipase activities between both groups. Lipoprotein Lipase vs total IDL-triglycerides and IDL-2-triglycerides showed a significant inverse correlation in controls (p < 0.05) but not in postmenopausal women. We conclude that the qualitative and quantitative study of the lipoproteins shows a more atherogenic profile in the postmenopausal group, with an increase in the concentration and number of particles of VLDL, total IDL and IDL-2.

[Intermediate-density lipoproteins and liver lipase in postmenopausal women]. / Lipoproteínas de densidad intermedia y lipasa hepática en mujeres post-menopáusicas.

In order to evaluate atherogenic lipoproteins in post-menopause, we studied 73 healthy women, 49 to 65 years old (Post-menopausal Group), with 1 to 10 years of amenorrhea and body mass index below 27 Kg/m2, and 20 young women (Control Group). We have determined plasma cholesterol concentration in the lipoproteins of intermediate density in addition to the classical lipoprotein parameters: total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides and fractionation of lipoproteins by electrophoresis. In 63 women from the Post-menopausal Group and 16 from the Control Group we studied the activity of hepatic lipase. Among these patients we selected at random 25 post-menopausal women and 13 controls to add measurements of triglycerides in the lipoproteins of intermediate density. Table 1 shows that the average plasma concentration of total cholesterol in the Post-menopausal Group was higher than that of the Controls (p < 0.001). The same was found for LDL-cholesterol (p < 0.001) and for triglycerides (p < 0.001) whereas the average concentration of HDL-cholesterol did not show significant differences. The Post-menopausal Group had high values of plasma lipoproteins of intermediate density, even with normal phenotypes (Table 2). Cholesterol but also triglycerides (Fig. 1) were responsible for this increase. A triglyceride rich lipoprotein subspecies of intermediate density was predominant in 73% of Post-menopausal women vs 23% of the Controls (p < 0.01, Table 3). No differences in hepatic lipase activity were seen between the two groups (Table 4), and non statistic correlation between the enzyme activity and IDL-triglycerides or HDL-cholesterol.(ABSTRACT TRUNCATED AT 250 WORDS)

[Bone mineral density in climacteric. Identification of patients with risk of developing osteoporosis]. / Densidad mineral ósea en el climaterio. Identificación de pacientes con riesgo de desarrollar osteoporosis.

The bone mineral density (BMD) of the lumbar spine was determined by dual photon absorptiometry in 98 normal females: 26 premenopausal between 40 and 48 years of age and 72 unselected women 1 to 20 years after the onset of menopause, all of them attending the Menopause Clinic of the Hospital. The results were as follows: Premenopause 1.20 +/- 0.09; Postmenopause: 1.8 years: 1.16 +/- 0.10; 5.3 years: 1.10 +/- 0.12; 9.0 years: 1.06 +/- 0.12; 15.1 years: 1.01 +/- 0.11 g/cm2. The total bone loss during the period of observation was 16%. The cross-sectional data appears to fit an exponential curve with approximate diminution of 2.0%/year at the onset and 1%/year 10 years after the menopause. The individual values obtained in 45 females between 1 and 10 years postmenopause are plotted in Figure 2. Two patients with BMD below 0.9 g/cm2 were specially studied. One of them had asymptomatic primary hyperparathyroidism and the other overt osteoporosis with a crush fracture of a dorsal vertebra. Following the average bone loss of the group and assuming that the BMD should not fall at age 65 below the theoretical threshold for spine fractures (0.98 g/cm2) a risk curve was designed: 58% of the women were above and 42% below. This percentage is similar to the number of females who suffer osteoporotic fractures at age 70. Considering the Quetelet index (weight in kg/height in m2) the females were divided in 3 groups: above 30, between 30 and 23 and below 23.(ABSTRACT TRUNCATED AT 250 WORDS)

Metabolic syndrome throughout the menopausal transition: influence of age and menopausal status.

OBJECTIVE: To assess the relationship between the main components of both the metabolic syndrome and insulin resistance and menopausal status in the menopausal transition. METHODS: A total of 124 healthy women were divided into four groups according to their menstrual status: the first group consisted of 35 women in menopausal transition with menstrual bleeding (MTM) and with cycles between 35 and 80 days; the second group was composed of 29 women in menopausal transition with 3-6 months of amenorrhea (MTA). The third group consisted of 31 postmenopausal women (PostM) and the fourth group of 29 premenopausal women (PreM) with regular cycles. The metabolic syndrome was evaluated following the ATP III criteria. Evaluation of insulin resistance was made through the HOMA, QUICKI and McAuley indices and the triglycerides/high density lipoprotein (HDL) cholesterol ratio. RESULTS: The triglycerides/HDL cholesterol ratio increased in MTM, MTA and PostM women in comparison with PreM women. A slight decrease in the QUIKI index (p = 0.06) and a decrease in the McAuley index (p < 0.001) were observed in MTM, MTA and PostM women in comparison to PreM women. The relative frequencies of metabolic syndrome in the four groups were: PreM, 0%; MTM, 20%; MTA, 21%; and PostM, 22% (p = 0.0001). The most frequent markers of the metabolic syndrome were increased waist circumference, low HDL cholesterol levels and hypertension. Linear regression between menopausal status and metabolic syndrome was lost when age was added to the model. CONCLUSIONS: The frequency of metabolic syndrome increased from the time of the menopausal transition to the postmenopause. Abdominal obesity was the most frequent feature observed. Nevertheless, aging erased the effect of the menopause on the metabolic syndrome. In order to prevent cardiovascular disease, the metabolic syndrome must be evaluated from the time of the menopausal transition.

Once and twice a week transdermal estradiol delivery systems: clinical efficacy and plasma estrogen levels.

We compared the clinical efficacy and circulating estrogen levels from two transdermal delivery systems, 'drug-in-adhesive' type, in 20 healthy postmenopausal women. Both patches, developed by Beta Pharmaceutical Laboratories in Argentina, deliver estradiol at a rate of 50 micrograms/day; the replacement frequency of system A (TrialSat) was twice a week and for system B (TrialSat LA) once a week. The women were treated for 180 days, in a continuous regimen, with additional oral medroxyprogesterone acetate 5 mg/day for 14 days of each cycle. Blood samples were taken at the end of the wearing period: the 3rd day for Group A and the 7th day for Group B, to determine levels of estradiol, estrone, non-sex hormone binding globulin (SHBG)-bound estradiol and SHBG. Both treatments had similar clinical efficacy and were well tolerated. Plasma estradiol levels were higher in Group A throughout the study, probably owing to the different sampling times. SHBG and non-SHBG-bound estradiol were unchanged in both groups. As there was a similar performance of both delivery systems, the 7-day patch may be preferable, and produce greater compliance.

Effect of melatonin on the luteinizing hormone release induced by clomiphene and luteinizing hormone-releasing hormone.

The effect of melatonin on the LH-release response after the administration of synthetic LH-RH and clomiphene citrate was investigated in adult male rats. The sc administration of melatonin (1 mg/day) for 6 days produced a significant decrease in serum LH levels and in seminal vesicles and ventral prostate weights. On the other hand, the daily injection of 0.01 mg/100 g of body weight of clomiphene citrate during 6 days significantly stimulated LH levels and the weights of the accessory sex glands. Simultaneous treatment with melatonin and clomiphene produced an inhibitory effect similar to that obtained with melatonin alone. Neither pretreatment with melatonin alone. Neither pretreatment with melatonin (1 mg/day, sc for 6 days) nor its simultaneous iv administration (500 mug) with 75 ng of LH-RH modified the LH-release in response to the hypothalamic hormone. The fact that melatonin was able to suppress the effect of clomiphene, which is probably exerted at the hypothalamic level, but not the actiion of LH-RH on the pituitary, appears to indicate that the hypothalamus may be the site involved in the inhibitory effect of the pineal principle on the reproductive function.

Estriol affects prolactin and LH secretion in rats.

The effects of estriol on serum prolactin (PRL) and LH levels, on the pituitary response to TRH and LHRH and on the synthesis and release of PRL from the anterior pituitary gland were investigated in female rats. The increase of serum PRL levels after estradiol administration was found to be associated with an increase of glutamic acid decarboxylase (GAD) and GABA-transaminase (GABA-T) in the hypothalamus. Thus, a study was carried out on the effects of estradiol and estriol on PRL secretion and on GAD, GABA-T and gamma-amino butyric acid (GABA) in the hypothalamus and the anterior pituitary. Under basal and TRH-stimulated conditions, estriol increased serum PRL levels, decreased basal serum LH levels, and increased the response to LHRH, in terms of LH release. Estradiol and estriol increased the synthesis and release of 3H-PRL from hemipituitary glands in incubations of pretreated animals. Both estrogens induced hyperprolactinemia, concomitantly with an increase of hypothalamic GAD and GABA-T activity. Estriol increased hypothalamic GABA concentration, but did not modify GABA concentration in the pituitary glands. Our results show that estriol, at relatively high doses, seems to be active in increasing PRL synthesis and release and in decreasing serum LH levels; it can also modify pituitary response to TRH and LHRH stimulation.

Lipid and lipoprotein profile in menopausal transition. Effects of hormones, age and fat distribution.

The behavior of lipoproteins during the menopausal transition and their relationship with sex hormones and body fat distribution is still unclear. Our aim was to evaluate atherogenic IDL, LDL, Lp(a) and antiatherogenic HDL lipoproteins in four groups of women: premenopausal (n = 20), menopausal transition women with menstrual bleeding (n = 31), menopausal transition women with 3 to 6 months amenorrhea (n = 36), and postmenopausal women (n = 30). We also measured their FSH, LH and estradiol levels along with BMI and waist circumference. Menopausal transition and postmenopausal women showed higher values of waist circumference (p < 0.0032), LDL-cholesterol (p < 0.002), IDL-cholesterol (p < 0.002) and apoprotein B (p < 0.0001) than premenopausal women. Total-cholesterol (p < 0.0001), triglycerides (p < 0.004), IDL-cholesterol and Lp(a) were higher in menopausal transition women with amenorrhea and in postmenopausal women in comparison with premenopausal women. After adjustment according to age and waist circumference, multiple regression analysis showed the increase in total-cholesterol and LDL-cholesterol to be linearly associated to menopausal status and estradiol concentration, whereas Lp(a) was only related to menopausal status. Age was found to be an independent variable in relation to apoprotein B concentration changes. The effect of menopausal status on TG levels did not remain in the model when age, waist and BMI were included (beta = 0.05, p = 0.356). HDL-cholesterol levels were the same in all the groups. Menopause, age and the increase in abdominal fat distribution were three independent and significant factors impairing lipoprotein profiles from the beginning of the menopausal transition.

Thyroid profile modifications during oral hormone replacement therapy in postmenopausal women.

There are few data available about changes in thyroid hormone profiles after hormone replacement therapy (HRT). We analyzed the effect of two different oral estrogens/progestins (E/P) associations on thyroid hormones and thyroxine-binding globulin (TBG) levels in 14 postmenopausal normal women distributed at random into two groups. Both groups received daily for a year 2 mg of estradiol valeriante per os. In Group A (n = 7), estrogen was associated with norethisterone acetate. In Group B, estrogen was associated with promegestone in a similar schedule to Group A. Blood samples were withdrawn to measure estradiol (E2), thyroxine (T4), triiodothyronine (T3), free T4 (fT4), thyroid-stimulating hormone (TSH) and TBG before and after 3, 6 and 12 months of treatment. Estradiol level increased significantly in both groups, being higher in Group A than in B. Under therapy, T4 and TBG levels were increased in both groups, but within the normal range. T4 mean level increased by 34% in Group A and 20% in Group B. TBG increment was slightly significant for Group A (p < 0.02); with only a trend in Group B (p = 0.08). T3, fT4 and TSH levels did not change significantly and remained within the normal range. Oral therapy with associated E/P produces moderate increases in T4 and TBG levels. Our results suggest that in postmenopausal women on oral HRT, fT4 and TSH levels are the most useful tools to evaluate the thyroid axis status.

Assessment of the metabolic tolerance in postmenopausal women over a 1-year period of two hormone replacement therapies containing estradiol in combination with either norgestrel or trimegestone.

This double-blind, randomized, multi-center study compared the metabolic tolerance of a combined formulation containing estradiol (E2) and trimegestone (TMG) with a standard hormone replacement therapy (HRT) containing estradiol valerate (EV) and norgestrel (NG). Blood lipids, glucose and fibrinogen concentrations were measured in the study which was conducted over 13 cycles, each of 28 days, and included 634 subjects in two randomized groups. A total of 481 subjects completed the study. The circulating concentrations of high density lipoprotein (HDL), HDL2, HDL3 cholesterol and apolipoprotein A1 were increased in the E2 + TMG group and reduced in the EV + NG group. Total cholesterol, low density lipoprotein (LDL) cholesterol, apolipoprotein B and lipoprotein(a) concentrations were decreased in both treatment groups; however, the reduction in LDL cholesterol was greater in the E2 + TMG group. Similar lipid findings were found in a subgroup that excluded subjects who had less than 3 months washout from a previous HRT, who provided a blood sample outside the day 17-28 window, or who were taking beta-blockers or thiazide diuretics. Blood glucose concentrations were reduced slightly in both treatment groups. A significant reduction in fibrinogen was also seen in both groups over the course of the study. The changes in lipid profile, especially HDL cholesterol, were more beneficial in the E2 + TMG group in comparison with the EV + NG group. This reflects the lack of androgenic action of trimegestone in comparison with norgestrel, which exhibits an androgenic effect and prevents the estrogen-induced increase in HDL cholesterol. The results of the study suggest that the use of trimegestone in combination with E2 may be preferable to norgestrel because of the more favorable lipid profile.

A 1-year comparison of the efficacy and clinical tolerance in postmenopausal women of two hormone replacement therapies containing estradiol in combination with either norgestrel or trimegestone.

This double-blind, randomized, multi-center study compared the efficacy and clinical tolerance of a combined formulation containing 2 mg estradiol (E2) and 0.5 mg trimegestone (TMG) with a standard hormone replacement therapy containing estradiol valerate (E2V) and norgestrel (NG) in the treatment of climacteric symptoms. The study was conducted over 13 cycles, each of 28 days, and involved 634 subjects, of whom 481 completed the study. The primary efficacy variable was the percentage of subjects who showed at least a 50% reduction from baseline in the mean daily number of hot flushes in cycle 3. This was observed in 98.5% of the subjects in the E2 + TMG group and 93.3% of the subjects in the E2V + NG group (95% confidence interval of the difference, -8.6, -1.9). Significant differences in favor of the E2 + TMG combination were observed in the reduction in the mean daily number and severity of hot flushes, and in the percentage of subjects who had hot flushes at baseline but no hot flushes during treatment. There were no significant differences between the treatments in the Kupperman index and in urogenital signs or symptoms. Treatment with the E2 + TMG combination was well tolerated and the incidences of adverse events were similar in the two treatment groups. Breast pain was the main adverse event, possibly related to treatment that resulted in discontinuation. The mean number of bleeding days per cycle was significantly lower with the E2 + TMG combination than with the E2V + NG combination. The incidences of endometrial hyperplasia were low and comparable in both treatment groups. It was concluded that the E2 + TMG combination was either equivalent or superior to the E2V + NG combination in the treatment of hot flushes and other climacteric symptoms, and that its bleeding profile was favorable.