Timing Estrogen After MenoPaUSe

Large clinical trials have shown a reduced incidence of type 2 diabetes in postmenopausal
women randomized to estrogen-based hormone therapy compared to placebo. Moreover, studies
suggest development of diabetes is reduced in postmenopausal women who used hormone therapy
for a part of the postmenopausal period compared to women who never used hormone therapy.
Consistent with this, our preliminary data suggest that the timing of estrogen treatment
relative to the menopause may be an important determinant of whether there are favorable
effects on insulin action. Our observations suggest that estrogen improves insulin
sensitivity in early postmenopausal women, but may decrease insulin sensitivity in those
more than 10 years past menopause. More and more studies suggest estrogens have divergent
effects on cardiovascular risk when initiated close to the onset of menopause rather than
distant from the menopause; we hypothesize this is also true for diabetes risk. The goal of
this study is to determine whether the effects of estrogen on insulin metabolism are
different in women who are early postmenopausal compared to late postmenopausal. To meet our
goal, we propose to measure insulin sensitivity in women who are within 6 years of the onset
of menopause or more than 10 years beyond the menopause and who have not used hormone
therapy previously. All women will be studied on two separate occasions, one day with and
one day without short-term (1 week) treatment with transdermal estradiol. We expect that
estradiol will increase insulin sensitivity in early postmenopausal women and decrease
insulin sensitivity in late postmenopausal women. We also expect that estrogen receptors in
fat and muscle may change with increasing time after menopause. Thus, we will collect fat
and muscle biopsies to compare changes in estrogen receptors between early and late
postmenopausal women and in response to 1 week of estradiol treatment. We believe these
studies will provide evidence for a benefit of estradiol on insulin sensitivity when
administered early, but not late, after menopause; likely contributing to delayed onset of
type 2 diabetes in postmenopausal women.

Inclusion Criteria:

- aged 45-70 yr

- postmenopausal (no menses ≥12 mo or bilateral oophorectomy and FSH >30 IU/L)

- ≤6yrs or ≥10yrs of menopause (last menses or oophorectomy)

- BMI <30 kg/m2 and weight stable (±2kg in past 2mo)

- non-smokers

- sedentary to moderately active (<3 days/wk of structured exercise)

- naïve to estrogen-based hormone therapies (previous use ≤6 months)

- CBC, CMP and TSH values within normal ranges specified by lab

Exclusion Criteria:

- underwent a partial hysterectomy (i.e., one or both ovaries left intact)

- underwent menopause (natural, chemical, or surgical) prior to age 45yr

- are between >6yr and <10yr of menopause (last menses or oophorectomy)

- previously used (>6 mo) or are currently using any formulation of estrogen-based HT
(e.g., oral Premarin, transdermal 17beta-estradiol, selective estrogen receptor
modulators)

- have T2DM or are being treated with glucose-lowering/ insulin sensitizing medications

- have uncontrolled hypertension (SBP>140 and/or DBP>90 mmHg)

- have hypertriglyceridemia (>400 mg/dL)

- have contraindications to estrogen therapy (history of venous thromboembolism, heart
disease, myocardial infarction, hormone sensitive cancer)

- have contraindications to biopsies (severe anemia, blood clotting disorders)