1. Critical Issue of Disentangling Menopause from Aging S. Mitchell Harman, MD, PhD Director and President Kronos Longevity Research Institute Phoenix, Arizona S. Mitchell Harman, MD, PhD Director and President Kronos Longevity Research Institute Phoenix, Arizona Nanette F. Santoro, MD Professor and Director Department of Ob/Gyn and Women’s Health Albert Einstein College of Medicine Bronx, New York

2. Defining the Stages of Reproductive Aging Premenopause Regular cycling without interruption Early transition 7days between cycles 7days between cycles Late transition >60–90 days amenorrhea but 60–90 days amenorrhea but <12 months amenorrhea Postmenopause 12 months amenorrhea

3. Hormonal Significance of Transition Stages Estrogen Status Signs and Symptoms Premenopause Estrogen replete, elevated in some circumstancesEstrogen replete, elevated in some circumstances No prolonged hypoestrogenemiaNo prolonged hypoestrogenemia Bone density preservedBone density preserved Mild increase in symptomsMild increase in symptoms Early transition

4. Hormonal Significance of Transition Stages Estrogen Status Signs and Symptoms Premenopause Estrogen replete, elevated in some circumstancesEstrogen replete, elevated in some circumstances No prolonged hypoestrogenemiaNo prolonged hypoestrogenemia Bone density preservedBone density preserved Mild increase in symptomsMild increase in symptoms Early transition Late transition Estrogen declining Estrogen-dependent processes impacted Biggest increase in hot flashesBiggest increase in hot flashes Biggest increase in vaginal symptomsBiggest increase in vaginal symptoms Bone demineralization beginsBone demineralization begins Sleep problems worsenSleep problems worsen

5. Annual Rate of Change in Bone Mineral Density over the Menopause Transition -0.03 -0.02 -0.01 0 0.01 BMD Change (g/dm 2 /y) Lumbar spine Total hip Postmenopause Late transition Early transition Premenopause Region BMD = bone mineral density. Reprinted from Finkelstein JS, et al. J Clin Endocrinol Metab. 2008;93:861, with permission from The Endocrine Society.

6. Vasomotor Symptoms Increase Across the Transition Transition Stage OR 95% CI Premenopause–– Early transition 1.861.47–2.34 Late transition 6.644.80–9.20 Postmenopause4.963.51–7.01 Gold EB, et al. Am J Public Health. 2006;96:1226. OR = odds ratio; CI = confidence interval.

7. Follow the Estrogen The previously presented types of processes follow along and correlate with estradiol and follicle-stimulating hormone patterns The previously presented types of processes follow along and correlate with estradiol and follicle-stimulating hormone patterns  Vasomotor symptoms  Sleep disturbances  Bone density

8. FSH, Estradiol, and Inhibin Changes in Relation to Final Menstrual Period Reprinted from Burger HG, et al. J Clin Endocrinol Metab. 1999;84:4025, with permission from The Endocrine Society. FSH = follicle-stimulating hormone.

9. Age-Related Processes Decreased distensibility of blood vessels Decreased distensibility of blood vessels –Increased blood pressure Increased insulin resistance Increased insulin resistance Increased atherogenesis Increased atherogenesis Increased body mass index Increased body mass index

10. Complex Interactions Menopause interacts with atherogenesis Menopause interacts with atherogenesis  Estrogen retards accumulation of complex plaque BUT  Once complex plaque is present, estrogen may –Destabilize plaque, increasing cardiovascular risk –Increase thrombotic tendency (oral route) Mendelsohn ME, et al. Science. 2005;308:1587.

11. Age-Related Diseases Potentially Linked to Estrogen Treatment Vascular diseases Vascular diseases –Coronary heart disease –Stroke –Thrombophlebitis/pulmonary embolus Malignancies Malignancies –Breast cancer –Endometrial cancer –Ovarian cancer –Lung cancer –Colon cancer Osteoporosis Osteoporosis Alzheimer’s disease–dementias Alzheimer’s disease–dementias Macular degeneration Macular degeneration

12. Observational Studies of ERT/HRT and CHD 00.51.02.05.0 Stampfer MJ, et al (1985) Wilson PW, et al (1985) Bush TL, et al (1987) Petitti DB, et al (1987) Boysen G, et al (1988) Criqui MH, et al (1988) Henderson BE, et al (1988) van der Giezen AM, et al (1990) Wolf PH, et al (1991) Falkeborn MI, et al (1992) Psaty BM, et al (1994) Folsom AR, et al (1995) Relative Risk Grodstein F, et al (1996 a ) ERT = estrogen-replacement therapy; HRT = hormone-replacement therapy; CHD = coronary heart disease. Adapted from Burkman RT, et al. Am J Obstet Gynecol. 2001;185:S13, with permission from Elsevier. a Grodstein F, et al. N Engl J Med. 1996;335:453.

13. Breast Cancer Cardiovascular Events Strokes Thromboembolic Disease Colon Cancer All Fractures Deaths 050100150200 Estrogen + progestin Placebo Outcomes Incidences of Clinical Events in the Women’s Health Initiative Estrogen + Progestin Trial Number per 10,000 Women per Year JAMA. 2002;288:321. Graphic courtesy of S. Mitchell Harman, MD.

14. Estrogen plus Progestin and the Risk of CHD in Various Subgroups of WHI Women 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 2.2 2.4 2.6 Risk Ratio For CVD 051015202530 Years Postmenopause at Randomization <10 10–19 ≥20 ? HR = 0.62 r =.994 P =.071 Assume mean postmenopausal durations of 5, 15, and 25 years for the <10, 10-20, and ≥20 year groups, respectively (actual means not provided). Extrapolate the best fit regression line to a value of 0 postmenopausal years. Draw best fit regression line. Hazard Ratio for CHD No. of cases of CHD (annualized percentage) SubgroupP value for Interaction Age (y) E + PPlacebo0.36 50-–5937 (0.22)27 (0.17) 60–6975 (0.35)68 (0.34) 70–7976 (0.78)52 (0.55) Years since menopause0.33 <1031 (0.19)34 (0.22) 10–1963 (0.38)51 (0.32) ≥2074 (0.75)44 (0.46) 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 1.27 1.05 1.44 0.89 1.22 1.71 CHD = coronary heart disease; WHI = Women’s Health Initiative; E+P = estrogen + progestin; CVD = cardiovascular disease. Top graphic from Manson JE, et al. N Engl J Med. 2003;349:530. Copyright © 2003. Massachusetts Medical Society. All rights reserved. Bottom graphic courtesy of S. Mitchell Harman, MD.

15. Event Hazard Ratios by Age Subgroups in WHI Estrogen-Only Arm 0.00.51.01.52.02.53.0 Hazard Ratio (95% CI) 50–59 60–69 70–79 50–59 Stroke 60–69 70–79 50–59 Thromboembolism 60–69 70–79 50–59 Breast Cancer 60–69 70–79 HR = 0.56 Coronary Heart Disease HR = 1.08 HR = 1.22 HR = 0.72 WHI = Women’s Health Initiative; HR = hazard ratio; CI = confidence interval. Adapted from Anderson GL, et al. JAMA. 2004;291:1701, with permission from the American Medical Association. In 50–59 y Group

16. Vascular biologist’s definition of primary prevention Clinician’s definition of primary prevention Adventitia Media lamina Fatty streak/plaque Internal elastic Clarkson TB. Int J Fertil. 2002;47:61. Courtesy of TB Clarkson, MD. Necrotic core Plaque Fibrous cap MMP-9 Fibrous Plaque cap Gradual, progressive (years) Event Thrombus Sudden, rapid, (hours) Primary Prevention of Atherosclerosis Estrogen effects ?

17. Differential Effects of Oral vs Transdermal Estrogen Therapy on Thromboembolic Disease Study Oral Estrogen OR (95% CI) Transdermal Estrogen OR (95% CI) Scarabin TY, et al (2003) 1 3.5(1.8–6.8) 0.9 0.9(0.5–1.6) Canonico M, et al (2007) 2 4.2(1.5–11.6)0.9(0.4–2.1) 1. Scarabin TY, et al. Lancet. 2003;362:428. 2. Canonico M, et al. Circulation. 2007;115:840.

18. CEE Use Women- Years Cases Multivariate Risk Ratio Adjusted (95% CI) Never313,6611601.0-- 0.3 mg/d 19,96440.43(0.16–1.16) 0.625 mg/d 116,150731.44(1.07–1.93) 1.25+ mg/d 39,026292.00(1.32–3.05) Effects of Estrogen by Dose on Ischemic Stroke Risk in the Nurses Health Study CEE = conjugated equine estrogen. Adapted from Grodstein F, et al. Ann Internal Med. 2000;133:933, with permission from the American College of Physicians.

19. Causes of Death Among US Women Heart Disease (45%) Other (25%) COPD (4%) Pneumonia (4%) Ovarian Cancer (<2%) Breast Cancer (4%) Lung Cancer (5%) Other Cancer (11%) Graphic courtesy of S. Mitchell Harman, MD. COPD = chronic obstructive pulmonary disease.

20. Grodstein F, et al. N Engl J Med. 1997;336:1769. Copyright © 1997. Massachusetts Medical Society. All rights reserved. Never Cause of Death All causes Relative risk (95% CI) 1.00.63(0.56–0.70)1.03(0.94–1.12) Coronary heart disease 1.00.47(0.32–0.69)0.99(0.75–1.30) Stroke 1.00.68(0.39–1.16)1.07(0.68–1.69) All cancer 1.00.71(0.62–0.81)1.04(0.92–1.17) Breast cancer 1.00.76(0.56–1.02)0.83(0.63–1.09) a Values are adjusted for age, age at menopause, type of menopause, body mass index, diabetes, high blood pressure, high cholesterol, smoking, oral contraceptive use, family history of myocardial infarction or breast cancer, parity. Current Past Hormone Use – Adjusted a Relative Risk of Death in the Nurses Health Study

21. Conclusions Physiologic changes associated with aging process may be inappropriately attributed to menopause Physiologic changes associated with aging process may be inappropriately attributed to menopause It is not always possible to isolate menopause or estrogen per se as the sole variable It is not always possible to isolate menopause or estrogen per se as the sole variable Many relationships are time dependent, complex, and require further elucidation Many relationships are time dependent, complex, and require further elucidation

22. Hormone therapy in menopausal women has complex and variable (beneficial and adverse) effects on risks for several major age-related diseases Hormone therapy in menopausal women has complex and variable (beneficial and adverse) effects on risks for several major age-related diseases Outcomes depend in part upon Outcomes depend in part upon –Agent(s) –Dose –Route of administration –Timing of initiation –Duration of treatment –Patient characteristics (age, habits, genetic) Net effects (risk/benefit ratio) and all-cause mortality appear beneficial for recently menopausal women Net effects (risk/benefit ratio) and all-cause mortality appear beneficial for recently menopausal women Conclusions