Next Article in Journal
Factors Contributing to Resistance to Ischemia-Reperfusion Injury in Olfactory Mitral Cells
Previous Article in Journal
Rapid Specific PCR Detection Based on THCAS and CBDAS for the Prediction of Cannabis sativa Chemotypes: Drug, Fiber, and Intermediate
 
 
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Review

Hormone Replacement Therapy and Cardiovascular Health in Postmenopausal Women

Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
*
Author to whom correspondence should be addressed.
Int. J. Mol. Sci. 2025, 26(11), 5078; https://doi.org/10.3390/ijms26115078
Submission received: 4 March 2025 / Revised: 16 April 2025 / Accepted: 10 May 2025 / Published: 24 May 2025
(This article belongs to the Special Issue Hormone Replacement Therapy)

Abstract

Sex-related differences are found not only in the reproductive system but also across various biological systems, such as the cardiovascular system. Compared with premenopausal women, cardiovascular disease (CVD) tends to occur more frequently in adult men and postmenopausal women (Post-MW). Also, during the reproductive years, sex hormones synthesized and released into the blood stream affect vascular function in a sex-dependent fashion. Estrogen (E2) interacts with estrogen receptors (ERs) in endothelial cells, vascular smooth muscle, and the extracellular matrix, causing both genomic and non-genomic effects, including vasodilation, decreased blood pressure, and cardiovascular protection. These observations have suggested beneficial effects of female sex hormones on cardiovascular function. In addition, the clear advantages of E2 supplementation in alleviating vasomotor symptoms during menopause have led to clinical investigations of the effects of menopausal hormone therapy (MHT) in CVD. However, the findings from these clinical trials have been variable and often contradictory. The lack of benefits of MHT in CVD has been related to the MHT preparation (type, dose, and route), vascular ERs (number, variants, distribution, and sensitivity), menopausal stage (MHT timing, initiation, and duration), hormonal environment (progesterone, testosterone (T), gonadotropins, and sex hormone binding globulin), and preexisting cardiovascular health and other disorders. The vascular effects of sex hormones have also prompted further examination of the use of anabolic drugs among athletes and the long-term effects of E2 and T supplements on cardiovascular health in cis- and transgender individuals seeking gender-affirming therapy. Further analysis of the effects of sex hormones and their receptors on vascular function should enhance our understanding of the sex differences and menopause-related changes in vascular signaling and provide better guidance for the management of CVD in a gender-specific fashion and in Post-MW.

Graphical Abstract

1. Introduction

Cardiovascular disease (CVD), for example, hypertension (HTN), coronary artery disease (CAD), and stroke, is among the most common and costly diseases, causing ~30% of mortality in the United States and worldwide [1,2]. CVD involves changes in different vascular tissues and cells, including endothelial cells (ECs), vascular smooth muscle cells (VSMCs), and extracellular matrix (ECM). Genetics, age, and sex differences are major predisposing factors in vascular dysfunction and CVD [3]. In this context, the terms “sex” and “gender” should be carefully interpreted. “Sex” is a genetically defined state among mammals, dependent on the X and Y chromosomes and supported by the gonadal hormones. Sex assignment as male, female, or intersex usually occurs at birth based on the appearance of the external genitalia and is verified by analysis of the chromosomes and gonads. Thus, sex differences involve genetic, biological, and hormonal factors [4,5]. On the other hand, “gender” is a psycho-social state among humans, involving the person’s internal sense of belonging to certain societal categories as a man, woman, or nonbinary individual. Therefore, gender-related variations may be influenced by psychosocial factors and are subject to change over time [6,7].
Variations in sex chromosome genes influence the course of CVD [3,8]. The sex hormones estrogen (E2), progesterone (P4), and testosterone (T) also act on specific vascular receptors to stimulate steroid hormone-responsive genes and signaling pathways that reinforce the sex differences in CVD. The decline in sex hormones’ levels with age could influence vascular function and the course of CVD. Although CVD occurs less frequently in premenopausal women (Pre-MW) compared to adult men, its progression accelerates after menopause in postmenopausal women (Post-MW), ultimately surpassing the incidence observed in men [9,10]. Mechanistic studies have also shown marked effects of E2, P4, and T on ECs, VSMCs, ECM, and various proteases. Additionally, menopausal hormone therapy (MHT) improves menopausal vasomotor symptoms in Post-MW [11]. These findings have led to clinical trials investigating the effects of MHT on CVD; however, the outcomes have remained inconclusive [12], making it important to investigate the causes of MHT failure and further examine the vascular effects of sex hormones.
This review focuses on the effects of sex hormones on vascular function and the benefits/risks of MHT on cardiovascular Health and in Post-MW. As a narrative review, our goal was to synthesize key perspectives rather than exhaustively include all the relevant literature. The review cites 478 articles, selected following three steps: (1) Database search: The PubMed database was searched for relevant articles published between 2000–2024 using the keywords “hormone replacement therapy”, “menopausal hormone therapy”, and “cardiovascular health”. This initial research yielded ~820 articles. (2) Screening: Careful screening excluded non-English articles, case reports, and small-sample-size research without justification. On the other hand, when a recent article cited original and seminal research reports from previous years, these reports were included. This narrowed the search to 600 articles for further review. (3) Final inclusion: 478 articles were cited based on relevance, originality, impact, expert input, and novelty. The cited articles represent the most influential and evidence-supported research work in this field.
We first describe the synthesis and metabolism of sex hormones and the changes in their levels with age and their association with CVD. We then describe the effects of E2 and estrogen receptor (ERs) on vascular function. We describe the benefits of MHT for menopausal symptoms and the benefits versus risks of MHT in CVD. We also discuss the factors contributing to MHT failure in clinical trials, including the MHT preparation (type, dose, and route), vascular ERs (number, variants, distribution, and sensitivity), menopausal stage (MHT timing, initiation, and duration), hormonal environment (P4, T, gonadotropins, and sex hormone binding globulin), and preexisting cardiovascular health and other disorders. We conclude with some suggestions to enhance the vascular benefits of MHT on cardiovascular health in Post-MW and highlight the impact of using E2 and T supplementation in gender affirming therapy and their differential effects in cis- and transgender individuals.

2. Synthesis and Menopause-Related Changes of Sex Hormones

Sex hormones are primarily produced through the steroidogenic conversion of cholesterol in the gonads, but they are also synthesized in other tissues, such as the adrenal glands, adipose tissue, skeletal muscle, breast, and liver (Figure 1). Estrogens have a cyclopentanoperhydrophenanthrene nucleus, the basic ring structure of all steroids. Natural estrogens including estrone (E1), estradiol (E2), and estriol (E3) have four rings, namely A, B, C, and D; a hydroxyl group (OH) at C3; and an OH or a ketone group at C17 [13]. In Pre-MW, E2 is predominantly produced by the ovaries and shows maximal estrogenic activity. E1 can be generated in the liver through the conversion of E2 and is also derived from androstenedione in peripheral tissues. E1 is weaker than E2 because it lacks the 17β-OH group but could influence estrogenic activity when converted to E2. E3 is a weak estrogen with low affinity and activity on ERs [14].
Approximately 2–3% of endogenously secreted estrogens remain in an unbound, biologically active form. Due to the estrogens’ small molecular size and high lipophilicity, they are capable of rapid and widespread distribution. E2 has an estimated half-life of around 3 h and undergoes dynamic interconversion with E1. Natural estrogens are primarily metabolized in the liver through several enzymatic pathways, including oxidation and hydroxylation by cytochrome P450 enzymes, glucuronidation mediated by UDP-glucuronosyltransferase, sulfation via sulfotransferase, and O-methylation catalyzed by catechol O-methyltransferase [15]. E2 metabolism varies with polymorphisms in the genes encoding steroidogenic enzymes, race, age, menstrual cycle stage, menopausal status, enzyme modulators, and cigarette smoke [16].
Menopause is an age-related physiological transition defined by the absence of menstruation for 12 consecutive months. It is marked by diminished ovarian function, reduced levels of E2 and P4 secretion, and a modest yet consistent production of T [17,18] (Figure 1), causing relative increase in the T/E2 ratio (Figure 2). Also, while ovarian production and circulating levels of E2 and E1 are decreased, increased aromatase and 17β-HSD2,4 activity in adipose tissue leads to increased peripheral conversion of androgens to E1 and relative increase in circulating E1/E2 ratio in Post-MW [19]. In Post-MW, the main source of dehydroepiandrosterone, a precursor of estrogens and androgens, is the adrenal glands, with the ovaries contributing ~20% [20,21]. Also, in Post-MW, ~75% of androgens are synthesized in peripheral tissues from dehydroepiandrosterone, and ~25% of circulating T is secreted by the ovaries [22]. The non-aromatizable and more potent T derivative dihydrotestosterone (DHT) is markedly decreased or almost undetectable in Post-MW [23]. Early loss of ovarian function, whether due to primary ovarian insufficiency or elective bilateral oophorectomy, performed to lower the risk of ovarian cancer, can have a significant impact on women’s health. Although endocrine activity in postmenopausal ovaries is minimal, bilateral oophorectomy after menopause has been linked to reduced concentrations of E2, dehydroepiandrosterone [24,25], and serum T [17,20]. Among women aged 50 to 89 years, total bioavailable T levels were found to be 40–50% lower in those who had undergone oophorectomy compared to those with intact ovaries [26]. These findings indicate that postmenopausal ovaries continue to serve as an important source of androgens in older women, and the long-term implications of reduced T levels following oophorectomy warrant further investigation.
Steroid hormones are subject to metabolic processes and interconversion of their precursors and metabolites, which can affect both the absolute and relative levels of these hormones. This, in turn, may influence sex differences in CVD and vascular function and modulate the vascular effects of sex hormones.

3. Menopausal Symptoms and Menopause-Related CVD

Menopausal changes in sex hormone levels are linked to a range of vascular, metabolic, physical, and emotional symptoms that negatively impact the quality of life in Post-MW. Approximately 50% of women experience vasomotor and psychological symptoms, such as hot flushes, night sweats, sleep disturbances, stress, and mood swings, which begin during the menopausal transition and may persist for around 4.5 years [29,30]. The relationship between vasomotor symptoms and CVD varies depending on their type, severity, and the woman’s age. Women with hot flushes or night sweats are often found to have additional CVD risk factors, such as reduced E2 levels, heightened sympathetic and catecholaminergic activity, and elevated calcitonin gene-related peptide levels [31,32,33,34]. Sleep disturbances and mood fluctuations also contribute to adverse cardiovascular outcomes, increasing the risk of arterial stiffness and vascular dysfunction [35]. In the SWAN study of midlife women, depression was found to be associated with the progression of coronary artery calcification, a risk comparable to that linked with high body mass index (BMI) and systolic blood pressure (BP) [36]. Severe vasomotor symptoms, whether occurring before or after menopause, are linked to an elevated risk of CVD [37,38]. Among women <60 years, the risk of a cardiovascular event is higher in women with vasomotor symptoms than without. However, there is no difference among women >60 years [39]. In addition, hot flushes and night sweats show distinct associations with cardiovascular markers in women during early postmenopause [40]. These findings indicate that variable hormonal profiles contribute to the manifestation of menopausal symptoms and related cardiovascular risk, pointing to a highly individualized menopausal trajectory that uniquely influences the development of menopause-related CVD and its responsiveness to MHT [41].
Evidence from studies on sex differences supports a link between reduced ovarian function and an increased risk of CVD. The divergence in CVD risk between sexes begins as early as childhood and progresses along distinct life-course trajectories, shaped by genetic dimorphism and hormonal influences [42]. Adult males are more prone to developing ischemic heart disease and CAD compared to females, which often results in heart failure with reduced ejection fraction (HFrEF) and elevated mortality rate at a younger age [43,44,45]. Conversely, older women more frequently present with inflammation, increased vascular stiffness, and concentric left ventricular hypertrophy, predisposing them to heart failure with preserved ejection fraction (HFpEF) [46], with different disease progression and response to medications [47]. The onset of menopause, typically occurring around age 52, aligns with a notable rise in CVD prevalence [48]. Post-MW show a higher incidence of CAD and atherosclerosis compared to Pre-MW [49,50]. Although CAD develops several years later in women versus men [48], the gender gap in the CAD mortality rate ratio in men versus women narrows from 4–5 in middle age (30–64 years) to 2 at 65–89 years [51]. Since 1984, women have had a higher CVD mortality rate than men, and by the year 2000, around 60,000 more women than men succumbed to CVD. Also, while age-adjusted mortality from CAD has declined by roughly 50% since peaking in the 1960s, this reduction has been significantly less pronounced in certain populations, particularly among women, non-Caucasians, and those of lower socioeconomic status [52,53,54]. Postmenopausal sex hormone profiles are also closely tied to the elevated CVD risk observed in older women. Specifically, a higher T/E2 ratio in Post-MW correlates with increased incidence of CVD, CAD, and heart failure, with elevated T levels linked to greater risk and higher E2 levels associated with reduced CAD risk [55]. Additionally, BP tends to be lower in Pre-MW compared to adult men, but among Post-MW aged 65 years and above, the prevalence of HTN surpasses that in men [56,57] (Figure 2). Among the elderly, the number of women with HTN is twice that of men [58]. A study in China also showed that lower socioeconomic status was associated with a greater incidence of HTN and that women were more susceptible [59]. Women with HTN are also more likely than men to have vascular and myocardial stiffness at old age and more often have isolated systolic HTN, reflecting increased aortic stiffness [60]. Importantly, at the same level of cuff systolic BP, invasive aortic systolic BP in women is 4.4 mmHg higher than in men. This suggests that cuff BP may not be as effective in women as in men for identifying CVD risk associated with systolic BP and pulse pressure, raising the possibilities of underdiagnosis and missed treatment opportunities to prevent CVD events [61]. This may also explain why women have a higher CVD risk than men at the same cuff BP [62,63]. Taken together, these observations indicate that HTN significantly contributes to the heightened cardiovascular event risk observed in women and that conventional cuff-based BP measurements may underestimate this CVD risk [61]. Furthermore, the timing of menopause onset affects cardiovascular health. Women who experience early or premature ovarian insufficiency face elevated risks of developing HTN, aortic stenosis, CAD, heart failure, atrial fibrillation, ischemic stroke, and venous thromboembolism (VTE) and are more likely to experience increased overall mortality [49,64,65]. For both natural and surgical menopause, there is a graded relationship between menopausal age and CVD incidence. Studies have found that for every 1 year decrease in menopausal age, the incidence of CAD increases by 2% [66,67]. Compared with women with an average age of natural menopause, women with premature and early natural menopause have a markedly increased risk of experiencing a first non-fatal CVD, CAD, or stroke before the age of 60 [50]. Also, of the nine biomarkers were found to be positively associated with early menopause, five with an increased risk of future heart failure (adrenomedullin, adipsin, β2M, N-terminal pro-B-type natriuretic peptide (NT-proBNP), and C-reactive protein (CRP)), and four with major CVD (adipsin, β2M, NT-proBNP, and CRP), suggesting that distinct biological pathways may make women with early menopause more susceptible to CVD [68]. Bilateral oophorectomy leads to a much more abrupt loss of ovarian steroids than natural menopause, causing higher rates of HTN, CAD, heart failure, and VTE [69]. The risk of CVD was greatest in women who underwent surgical menopause at a younger age, especially <40 years, compared with women who had natural menopause at 50–54 years [67]. Therefore, elective bilateral oophorectomy should be discouraged at the time of hysterectomy surgery for benign disease, as it may increase CVD risk [70].
Distinct sex-based trajectories in CVD progression point toward a potential role of reduced ovarian E2 in its underlying pathophysiology. Biomarkers proposed for identifying premature ovarian insufficiency include shortened telomere length and reduced telomerase activity in granulosa cells [71]. Evidence from studies on Post-MW and individuals with polycystic ovary syndrome (PCOS) further supports the link between lower ovarian E2 levels and CVD [47,72]. Also, aromatase is an enzyme known to convert androgens into estrogens, and when it is pharmacologically inhibited in E2-dependent cancers, such inhibition has been associated with elevated cardiovascular risk [73]. Studies of specimens in the UK biobank revealed that higher levels of free circulating E2 correlated with reduced risk of heart failure in men [74]. However, the cardioprotective effects of E2 appear to wane in women after menopause, with a marked increase in heart failure incidence observed beyond 55 years of age [75,76]. Notably, pulmonary arterial hypertension (PAH) occurs across both sexes and all ages. In contrast to the male dominance in general CVD prevalence, familial PAH occurs more frequently in women, who also exhibit superior right ventricular function, improved prognosis, and higher survival —collectively known as the “E2 paradox”— possibly due to alterations in ERs and associated vascular pathways [77,78]. Also, stroke prevalence in women exhibits a unique trend [79]. Between the ages of 25–45 years, women have a higher incidence than men, and this trend persists in postmenopause, although the gender gap diminishes with advancing age, with men eventually equaling or surpassing women at very old age [80,81] (Figure 2).

4. Sex Differences in Vascular Function

The regulation of vascular tone is modulated by the functional interplay between ECs and VSMCs as well as the equilibrium between intrinsic and extrinsic mechanisms and diverse vasoconstrictive and vasodilatory stimuli. Among extrinsic regulators, neurohumoral influences are predominant, such as sympathetic nerve input and neurotransmitters, circulating catecholamines (epinephrine and norepinephrine), angiotensin II (Ang II), vasopressin, and 5-hydroxytryptamine (serotonin), most of which enhance vascular tone. Conversely, certain circulating agents like atrial natriuretic peptide exert vasodilatory effects, thus reducing tone. Intrinsic regulation includes myogenic responses originating from VSMCs, which contribute to increased tone, as compared to endothelium-derived relaxing factors like nitric oxide (NO), prostacyclin (PGI2), and endothelium-derived hyperpolarizing factor (EDHF). Contracting factors from ECs include endothelin-1 (ET-1) and thromboxane A2 (TXA2). Additionally, locally acting hormones and chemicals such as histamine and bradykinin may either constrict or dilate vessels, while hypoxia and metabolic by-products typically reduce vascular tone. Extrinsic mechanisms primarily affect systemic vascular resistance and BP, whereas intrinsic pathways enable microvasculature to adapt to fluctuations in intraluminal pressure and help fine-tune regional tissue perfusion and blood flow [82]. The active component of myogenic tone depends on intracellular Ca2+ signaling and the function of mechanosensitive Ca2+ channels in VSMCs [83], whereas passive components rely on structural proteins and enzymes involved in vascular remodeling and are Ca2+-independent.
Evidence from both human and animal studies demonstrates sex-based differences in vascular tone across various vascular regions and in response to extrinsic vasoconstrictors. For instance, the vasoconstrictive response to norepinephrine is significantly attenuated in the forearms of women compared to men. Calcitonin gene-related peptide, a factor likely involved in migraine pathophysiology, induced smaller relaxation and was less potent in middle meningeal arteries isolated from women versus men <50 years but showed no sex difference among ≥50 years groups [84]. In coronary arteries of pigs, oxidized low-density lipoprotein (LDL) was shown to amplify 5-hydroxytryptamine-induced contractions more significantly in males compared to females [85]. Also, in vivo studies revealed that male rats exhibited a more pronounced pressor response to vasopressin infusion than their female counterparts [86]. In rat aortas, phenylephrine triggers a stronger contractile response in males compared to females. This response does not differ between castrated and intact males, but it is significantly heightened in ovariectomized (OVX) females relative to intact females, indicating that variations in vascular tone between sexes are likely influenced by E2 levels and the activity of vascular ERs [87]. Sex-related distinctions have also been observed in intrinsic mechanisms governing vascular tone. For instance, differences have been documented in the regulation of myogenic tone and the contractile response to ET-1 in coronary resistance vessels of rats [88]. Moreover, in small murine arteries, modulation of myogenic tone by NO differs by sex, with EDHF contributing to enhanced vasodilation only in female vessels [89].
Variations in vascular function associated with sex and menopause are linked to distinct alterations in different components of the blood vessels. Endothelium-dependent brachial artery flow-mediated dilation (FMD) is highest in Pre-MW (~9.9%) and decreases progressively in perimenopause (early 8.2%, late 6.5%) and Post-MW (early 5.5%, late 4.7%) [90]. Measurements of forearm blood flow showed reduced vasodilator response to brachial artery infusion of acetylcholine (ACh) in hypertensive men and Pre-MW and Post-MW versus normotensive subjects, with a negative correlation with advancing age among all subjects. Among normotensive women, endothelium-dependent vasodilation was normal in Pre-MW but impaired in Post-MW. Among hypertensive subjects, decreased EC function with age was less in Pre-MW than in men but similar in Post-MW and men, suggesting that the protective effects of E2 on EC function decline in early menopause and worsen with prolonged E2 deficiency in Post-MW [90,91]. In Chinese women, arterial stiffness has been shown to increase more rapidly from mid-life into the postmenopausal phase, indicating that menopause may drive alterations in structural proteins and ECM [92]. Also, studies in chemically induced menopausal mice have demonstrated that cerebral arterioles exhibit heightened myogenic tone, attributed to reduced hyperpolarization of VSMCs, which is linked to diminished activity of large-conductance Ca2+-activated K+ channels (BKCa) [93].

5. Estrogen Receptors (ERs) in the Vasculature

E2 interacts with different vascular ER subtypes, including ERα, ERβ, G-protein coupled ER (GPER), and several ER variants [94,95]. The ESR1 gene on chromosome 6q25.1 encodes ERα, while ESR2 on chromosome 14q23-24.1 encodes ERβ [13]. Human ERα and ERβ have an overall 44% homology and share the domain structure observed in the nuclear receptor superfamily, i.e., A/B, C, D, E, and F domains (Figure 3). The A/B domain harboring the activation function 1 (AF-1) is involved in protein–protein interactions and transcriptional activation of target genes. The central C domain representing the DNA-binding domain (DBD) contains four cysteines arranged in two zinc fingers and is involved in DNA binding and receptor dimerization. DBD is highly conserved in ERα and ERβ and shares 95% amino acid identity such that both ERs bind the same E2 response elements (EREs), recognize similar DNA sequences, and regulate similar target genes. The D domain, or hinge domain, is not well conserved between ERα and ERβ (30%), and it facilitates ER association with heat-shock protein 90 (HSP90) and its nuclear localization. The E domain or ligand-binding domain (LBD) has ~55% homology between ERα and ERβ and harbors a ligand-dependent AF-2 that facilitates ligand binding and receptor dimerization. The F domain contains co-factor recruitment regions [15].
The LBDs of ERα and ERβ have similar affinities for E2. The LBD has twelve helices (H1–H12) folded into a 3-layered, anti-parallel, α-helical sandwich comprising a central core layer of α-helices H5, H6, H9, and H10 sandwiched between two additional layers of α-helices H1–4 and H7, H8, and H11, with H12 at the bottom [15]. This helical arrangement creates a wedge-shaped molecular scaffold and a sizeable ligand-binding cavity at the narrower end of LBD, into which the hormone binds. The binding of E2 with ER typically involves non-covalent H-bonding and additional hydrophobic contacts and interactions.
ERα and ERβ have been identified in the female reproductive system, the heart, blood vessels, lungs, brain, and bones, causing various effects on the cardiovascular, immune, nervous, and musculoskeletal systems [96,97]. ERα knockout (KO), ERβ KO, and ERα/ERβ double-KO mice survived but showed reproductive malfunction [98]. E2 binds to ERs with high affinity and specificity. E2 diffuses through the plasma membrane and complexes with cytosolic/nuclear ERα and ERβ, which bind to chromatin and promote transcription of genes with EREs, thus inducing genomic effects and altering vascular cell growth [99,100] (Figure 4). E2 also interacts with plasmalemmal ERα and ERβ to form homodimers or ERα/ERβ heterodimers, activate protein kinases and signaling pathways, and induce rapid non-genomic vascular effects [100,101,102,103,104]. ERα and ERβ have been detected in ECs [105,106,107] and are also expressed in VSMCs of the human coronary artery, aorta, iliac artery, and saphenous vein, with greater number in females versus males [108]. ERα was found in the rat uterine artery, and ERβ was abundant in the rat aorta, tail, and uterine arteries [109]. ERα was found to mediate many of the E2 vascular protective effects [110]. Also, E2-mediated cardioprotection against ischemia/reperfusion injury is mimicked by ERα agonists and unaffected by ERβ antagonists [111]. In macrophages, E2 via ERα inhibited inflammatory gene expression and lipopolysaccharide (LPS)-induced DNA binding, transcriptional activation, and nuclear translocation of p65 nuclear factor-κB (NFκB) [112]. In ascending aortic arteriosclerosis specimens from Post-MW, the endothelium showed a decrease in ERα expression and autophagy but increased inflammation and pyroptosis. Also, Post-MW showed increased macrophage activation and plaque instability with increased MCP-1, matrix metalloproteinase-9 (MMP-9), TLR4, MYD88, and NF-κB p65 and decreased ERα and TIMP-1 expression in the vascular endothelium. OVX female LDLR−/− mice also showed decreased serum E2 levels and arterial ERα expression and collagen content, in association with arterial macrophage accumulation, increases in plaque and necrotic core areas, and upregulated TLR4 and MMP-9 expression. E2 or phytoestrogen upregulated ERα and increased plaque stability by inhibiting macrophage accumulation and TLR4 signaling. In RAW264.7 cells, LPS decreased ERα and TIMP-1 expression and increased TLR4 activation, and these effects were reversed by E2 or phytoestrogen, and the E2 reversal was abolished by the ERα antagonist methylpiperidinopyrazole (MPP). Thus, decreased ERα expression promotes macrophage infiltration and plaque instability postmenopause, and activation of ERα alleviates atherosclerotic plaque instability by inhibiting TLR4 signaling and macrophage-related inflammation [113]. Also, in the aortas of OVX female ApoE−/− mice and homocysteine-treated HUVECs, E2 accelerated autophagy and ameliorated inflammation and cell pyroptosis, and these effects were reversed by inhibition/silencing of ERα [114]. Other studies showed greater expression of ERβ than ERα in human coronary arteries, particularly in VSMCs [115]. In rats, ERβ mRNA levels increased in response to aortic balloon injury [116]. Also, E2 activation of ERβ modulated tumor necrosis factor-α (TNFα)-induced inflammatory response in rat aortic VSMCs [117]. The process of E2/ER-mediated gene transactivation involves the translocation of E2/ER complex to the nucleus, where it binds to DNA and the ERE on specific genes, resulting in enhanced gene transcription. A study comparing the effects of ERα and ERβ on gene transactivation involved co-transfecting ER-negative HeLa cells with ERE2-TATAtk-CAT or vitellogenin (VIT-tk-CAT) promoter/reporter constructs, along with increasing amounts (1 to 100 ng) of ERα or ERβ expression vectors. After 24 h of treatment with 10 nM E2, chloramphenicol acetyltransferase (CAT) transcription driven by each promoter was measured. In E2-stimulated ER-transfected HeLa cells, ERα acted as a stronger gene transactivator at low ER concentrations, but as the ER concentration increased, ERα activity self-suppressed, and ERβ emerged as the stronger transactivator [108].
In addition to the wild-type ERα, there are five ERα variants that feature specific deletions in the exons encoding regions of the hormone-binding domain. These variants lack exon 4 (ERαΔ4), exon 5 (ERαΔ5), exon 6 (ERαΔ6), exon 7 (ERαΔ7), and both exons 6 and 7 (ERαΔ6,7) [118]. The expression of ERα splicing variants differs across various tissues, influencing certain facets of ERα signaling, and in some cases, these variants may even counteract the effects of full-length ERα [119]. Transient expression studies in HeLa cells demonstrated that increasing levels of ERαΔ7 progressively inhibited E2-induced transcriptional activation by both wild-type ERα and ERβ on ERE-driven promoters [120]. Variants of ERβ have also been identified, and further research is needed to understand their biological roles [118]. Investigating the function of ER variants in normal physiology as well as the changes in their expression, activity, and interactions with each other and wild-type ERs could provide valuable insights into the mechanisms that govern the shifts in E2 effects across different stages of a woman’s life. Estrogens interact with various ERs, each with distinct potencies for transactivating ERE-containing gene promoters and mediating cellular responses [121]. In comparison with E2 (Kd 0.1 nM), E1 (Kd 0.3 nM) and E3 (Kd 1.4 nM) have a lower affinity for ERα and display different cardiovascular effects [122,123]. Human ECs show varying responses to E2 and E1, with the E2/E1 ratio playing a critical role in determining the overall estrogenic effects [124].
GPER, also known as GPR30, is a 7-transmembrane G protein-coupled ER that plays a role in mediating rapid non-genomic effects [125]. GPER has been detected in various cellular regions and tissues, including the plasma membrane and endoplasmic reticulum of the brain, peripheral tissues, as well as the human mammary artery and saphenous vein [126,127,128]. In studies on mice, female mice showed reduced BP, pulse wave velocity, and arterial stiffness, with a more pronounced carotid artery ACh-induced relaxation compared to males. However, these sex differences were absent in GPER-deficient mice, highlighting the differential impact of nongenomic E2/GPER signaling on the vascular phenotype of males and females [129]. Also, treatment with the GPER agonist G1 was found to enhance vascular function and lessen myocardial ischemia/reperfusion injury in aging female rats [130]. Furthermore, GPER1 is involved in mediating protective cardiovascular and renal effects that help regulate BP, positioning GPER1 as a promising target for HTN management [131].

6. Cardiovascular Effects of E2

E2 is the primary sex hormone in women, playing a key role in the development of the reproductive system, maintaining metabolic balance, regulating energy production and distribution, promoting mitochondrial biogenesis, and facilitating adenosine triphosphate (ATP) synthesis [132]. In addition, E2 via nuclear ERs and GPER activates multiple cardiovascular effects on different vascular cells and biological processes (Table 1). For instance, E2 decreases the susceptibility to vascular inflammation, atherosclerosis, and cardiovascular events [133]. E2 promotes anti-inflammatory effects by decreasing neutrophil infiltration of the vascular wall, oxidative stress, and the expression of monocyte chemoattractant protein-1 and TNFα [111,117,134]. The decline of E2 levels during menopause impairs mitochondrial function and increases inflammation, pathologic angiogenesis, and microvascular disease [135]. E2 offers several vascular advantages, including alterations in circulating lipoproteins, prevention of lipoprotein oxidation, regulation of homocysteine levels, modulation of blood coagulation and fibrinolytic factors, and suppression of collagen accumulation in blood vessels [87,136]. Additionally, E2 may influence BP by inhibiting sympathetic vasoconstriction, regulating the renin–angiotensin–aldosterone system (RAAS), modulating salt sensitivity, controlling body mass, and reducing oxidative stress, all of which contribute to vascular inflammation as well as cardiovascular and renal damage and HTN [137]. In an OVX female 1-kidney deoxycorticosterone acetate (DOCA)-salt treated rat model of HTN, E2 replacement prevented DOCA-salt induced HTN and the underlying increases in GABAergic excitation in hypothalamic magnocellular arginine-vasopressin (AVP) neurons and subsequent increases in AVP release and plasma levels, likely through modulation of the expression/activity of NKCC1 (Cl importer) and KCC2 (Cl extruder) [138]. Importantly, E2 directly modulates vascular tone, causing various degrees of vasodilation in conduit vessels, small arteries, and microvessels through differential activation of ERs in ECs, VSMCs, and ECM [139].

6.1. Effects of E2 on ECs

ECs detect fluid shear stress and circulating cytokines, thereby participating in the regulation of blood flow, vasodilation and vasoconstriction, vascular permeability, macromolecule extravasation, blood fluidity, as well as platelet and leukocyte activity [209]. Elevated shear stress and enhanced sympathetic activity, oxidative stress, and vascular inflammation contribute to EC dysfunction, HTN, atherosclerosis, and platelet aggregation. OVX female ApoE−/− mice fed a high-fat diet showed accelerated atherosclerosis and increases in ferroptosis markers, plasma lipid peroxidation and iron deposition in the atherosclerotic plaque. Treatment with E2 or ferroptosis inhibitor ferrostatin-1 alleviated atherosclerosis, lipid peroxidation, and iron deposition and upregulated the cystine/glutamate antiporter (xCT) and glutathione peroxidase 4 (GPX4) in ECs. In ECs with oxidized-LDL or Erastin-induced ferroptosis, E2 promoted anti-ferroptosis effects through antioxidative mechanisms, improved mitochondrial function, and upregulated GPX4 expression, and these effects were attenuated by inhibition of nuclear factor erythroid 2-related factor 2 (NRF2), suggesting a role of EC ferroptosis in postmenopausal atherosclerosis progression and E2 protection against EC ferroptosis via the NRF2/GPX4 pathway [210]. ECs secrete both vasodilators like NO, PGI2, and EDHF and vasoconstrictors such as ET-1 and TXA2, along with vascular endothelial growth factor (VEGF). The binding of E2 to cytosolic or nuclear ERs initiates genomic responses, resulting in the phosphorylation of mitogen-activated protein kinase (MAPK, ERK1/2) and stimulation of EC proliferation [211]. In human ECs, E2 enhanced angiogenesis, wound healing, tube formation, ERK1/2 phosphorylation and adenosine, and decreased extracellular ATP and adenosine deaminase activity, and these effects were reversed by blocking ER or the adenosine receptor, suggesting that E2 modulates angiogenesis via ER and adenosine-mediated pathways [135]. In healthy Post-MW, infusion of E2 improved FMD and enhanced ACh-induced vasodilation in the forearm [212]. Also, infusion of E2 in dogs as well as in isolated rat and rabbit hearts increased coronary blood flow [213]. Additionally, ACh caused greater relaxation in the aorta of female versus male spontaneously hypertensive rats (SHRs) [214]. E2 facilitates vasodilation by enhancing the release of relaxing factors such as NO, PGI2, and EDHF while reducing the release of vasoconstrictors like ET-1 and TXA2 [215].
NO is a major vasodilator produced from the transformation of L-arginine to L-citrulline by neuronal NO synthase (nNOS and NOS I), inducible NOS (iNOS and NOS II), and endothelial NOS (eNOS and NOS III) [216]. While eNOS is Ca2+-dependent and rapidly regulates vascular tone, iNOS is Ca2+-independent and regulates vascular function in the long term. NO production is greater in Pre-MW versus men [217]. In microvessels isolated from subcutaneous fat biopsies, FMD was found to be lower in Post-MW compared to Pre-MW but showed improvement when Post-MW vessels were exposed to E2 or the ERα agonist propyl pyrazole triol (PPT) [218]. Additionally, E2 enhanced both basal and stimulated NO release in human coronary artery ECs. In OVX female guinea pigs, E2 supplementation elevated EC-derived NO production and increased coronary artery responsiveness to vasodilators [219]. Moreover, E2 contributes to vasodilation in pulmonary arteries by promoting EC NO synthesis [220]. Furthermore, arteries from female rats exhibit higher EC NO release than those from males, primarily attributed to elevated E2 levels in females [214,221].
E2-induced release of NO from ECs is partially mediated through the activation of nuclear ERs, engagement of genomic signaling pathways, and the subsequent upregulation of eNOS [105,221]. E2 promotes angiogenesis, upregulates VEGF and eNOS in human coronary ECs, and prevents destabilization of eNOS mRNA by TNFα [222,223]. E2 also enhances eNOS activity and vasodilation by activating EC plasmalemmal ERs and non-genomic pathways [221,224] (Figure 4). In resting conditions, eNOS is tightly bound to caveolin within the caveolae of the EC plasma membrane. Upon E2/ER activation, there is an elevation in cytosolic free Ca2+ concentration ([Ca2+]c), initiated by Ca2+ release from the endoplasmic reticulum and maintained through Ca2+ influx via store-operated channels [225]. Additionally, E2 acting through GPER may suppress plasma membrane Ca2+-ATPase (PMCA) function in ECs, thereby extending the duration of the Ca2+ signal. In support of this mechanism, PMCA and GPER have been shown to physically interact and modulate each other’s activity. Overexpression of GPER1 or its selective activation by G1 has been demonstrated to reduce PMCA function, limiting Ca2+ extrusion and increasing [Ca2+]c [226]. The rise in [Ca2+]c subsequently binds calmodulin, and this Ca2+/calmodulin complex facilitates the dissociation and translocation of eNOS from plasma membrane caveolin. E2 also activates MAPK and the PI3K/Akt pathway, promoting the phosphorylation and relocalization of cytosolic eNOS to the plasma membrane, where it undergoes myristoylation/palmitoylation, leading to its full activation [227,228]. In support, membrane-impermeant E2 binds plasmalemmal ERs and stimulates NO release from human ECs [227]. Also, E2 treatment in OVX female mice induces rapid NO production and vasodilation [229]. NO produced in response to E2 stimulation diffuses into adjacent VSMCs, where it activates guanylate cyclase, resulting in the generation of cyclic guanosine monophosphate (cGMP). Functioning as a second messenger, cGMP subsequently activates protein kinase G (PKG), which lowers VSMC [Ca2+]c by enhancing the activity of both PMCA and the sarcoplasmic/endoplasmic reticulum Ca2+-ATPase (SERCA). In addition, PKG phosphorylates and suppresses myosin light-chain kinase (MLCK), thereby reducing the sensitivity of actin–myosin filaments to [Ca2+]c and promoting VSM relaxation [230].
The role of ERα and ERβ in mediating NO release has also been examined [106]. Transfer of ERα gene into bovine aortic ECs was shown to upregulate eNOS expression [231]. In COS-7 cells co-transfected with ERα and eNOS, rapid activation of eNOS by E2 was successfully reconstituted [232]. Basal NO levels were reduced in ERα KO mice, indicating a predominant function of ERα in this process [233]. ERα-selective agonists were found to improve EC dysfunction in blood vessels of OVX female SHRs [234]. In human ECs, a truncated ERα isoform lacking the N-terminal region (ERα46) interacts with c-Src, PI3K, Akt, and eNOS within EC caveolae, contributing to E2-mediated activation of eNOS [235]. Other studies in COS-7 cells have shown that overexpression of ERβ enhanced its association with plasma membrane caveolae and E2-induced eNOS activity independently of ERα [236]. Moreover, the vasodilatory response to E2, along with the activation of MAPK and PI3K signaling pathways, is not observed in mice lacking both ERα and ERβ (double knockout) [229], suggesting that both ERα and ERβ are involved in NO production. The GPER agonist G1 also increases endothelial NO production through phosphorylation/activation of eNOS. In human EA.hy926 ECs and HUVECs, G1 increased eNOS and Kruppel-like factor-2 (KLF2) expression, and these effects were suppressed by silencing GPER or KLF2 or inhibition of Gαq and Gβγ. G1 also induced Ca2+ signaling and increased CaMKKβ, CaMKIIα, and AMPK phosphorylation/activity, which in turn promoted phosphorylation of histone deacetylase 5 and transcriptional KLF2, and the expression of eNOS, supporting a role of GPER in regulating eNOS levels [237].
E2 also has antioxidant effects that enhance NO bioactivity. Superoxide anion (O2•−) levels are greater in the aorta of male versus female rats [238]. In OVX female rats, protracted E2 deficiency causes activation of RAAS, increased BP, oxidative stress, plasma lipoperoxides and free radicals, and reduced levels of antioxidants and NO bioavailability [239], while E2 replacement decreases free radicals and increases nitrites/nitrates levels [240]. E2/ER complex translocates to the mitochondria, where it regulates mitochondria-encoded genes [136]. E2 also inhibits NADPH oxidase expression and the generation of reactive oxygen species (ROS), O2•−, H2O2, and peroxynitrite (ONOO); reduces oxidative stress; and enhances NO bioactivity [241,242], and some of these effects may involve downregulation of Ang II type 1 receptor [243]. Also, in HUVECs, E2 reverses H2O2-induced oxidative stress, cell senescence, and apoptosis by suppressing thrombospondin-1 expression and consequent TGF-β/Smad signaling [244].
PGI2 is an endothelium-derived relaxing factor synthesized through arachidonic acid metabolism via cyclooxygenase enzymes COX-1 and COX-2. Upon binding to prostanoid receptors on VSMCs, PGI2 activates adenylate cyclase, leading to the production of cyclic adenosine monophosphate (cAMP). The rise in cAMP subsequently activates protein kinase A (PKA), which reduces VSMC [Ca2+]c and diminishes myofilament sensitivity to Ca2+ through mechanisms similar to those employed by cGMP/PKG, ultimately resulting in VSM relaxation. E2 enhances ACh-induced dilation in subcutaneous vessels of Post-MW partly through COX-2 activation [245]. Also, in arteries from OVX female monkeys with experimentally induced atherosclerosis, PGI2 levels were found to be diminished, whereas local E2 treatment of the vessels enhanced PGI2 synthesis [246]. E2 increases urinary excretion of PGI2 metabolites in ERβ but not ERα KO mice, supporting a role for ERα in PGI2 production [247]. In other studies, E2 upregulated COX-1 and promoted PGI2 synthesis in fetal ovine pulmonary artery and mouse cerebral artery ECs through ERβ [221,248,249]. In contrast, the relaxation effect of E2 in rabbit coronary arteries remained unchanged following COX inhibition by indomethacin, indicating that prostanoids play only a limited role in this response [250]. E2 may trigger a vasodilator crosstalk such that an increase in NO would decrease COX-mediated effects [251].
The greater vascular relaxation in female versus male vessels may also involve EDHF and K+ channels [252]. ACh-induced hyperpolarization and relaxation of mesenteric arteries are smaller in male and OVX female versus intact female rats, and the differences are eliminated by K+ channel blockers. E2 replacement in OVX female rats improves ACh-induced vascular hyperpolarization and relaxation [253,254]. The effects of E2 on ECs vary along the arterial tree, with NO more dominant in large conduit arteries, while resistance vessels produce more EDHF [255].
E2 cardiovascular effects may also involve non-genomic enhancement of endothelial hydrogen sulfide (H2S) release. In HUVECs, E2 induced phosphorylation of cystathionine γ-lyase, the key enzyme in H2S generation. E2 enhanced the interaction of membrane ERα with Gαi-2/3 to transactivate particulate guanylate cyclase-A, produce cGMP, and activate PKG-Iβ, leading to phosphorylation of cystathionine γ-lyase and rapid release of H2S. Silencing of cystathionine γ-lyase or particulate guanylate cyclase-A in mice attenuated E2-induced aortic dilation, supporting a role of H2S as an E2/ERα-activated pathway [256]. E2/ER-induced release of H2S may also activate ATP-sensitive K+ channels (KATP) in VSMCs, thus promoting vascular hyperpolarization and relaxation [257].
E2 through ER also increases hemeoxygenase(HO)-2 activity and carbon monoxide (CO) production in HUVECs and human uterine artery ECs. Interestingly, low E2 concentrations (10−10 M) induced CO-mediated activation of soluble guanylyl cyclase and a 56% increase in cellular cGMP levels. By contrast, higher E2 concentrations had no effects, likely due to NOS-mediated NO release and inhibition of CO release, supporting crosstalk between E2/ER-induced vasodilator factors [258]. In ECs, CO also activates BKCa channels, resulting in ECs hyperpolarization and subsequent vascular wall hyperpolarization, diminished reactivity to vasoconstrictors, and vascular relaxation [259,260,261].
The sex differences in vascular tone also involve endothelium-derived contracting factors such as ET-1 and TXA2. ET-1 stimulates ETAR and ETB2R in VSMCs to induce contraction and ETB1R in ECs to cause vascular relaxation. In Post-MW with CAD, intracoronary administration of E2 decreases ET-1 in coronary sinus plasma [262]. ET-1 release, vascular tone, and BP are reduced in female versus male SHR [252,263]. In DOCA-salt hypertensive rats, mesenteric arteries of males exhibit stronger contraction to ET-1 than those of females, likely due to variations in ETBR expression. The expression of ET-1 and ETB2R as well as the vasoconstriction induced by the ETBR agonist IRL-1620, is more pronounced in mesenteric arteries of OVX females compared to intact females, with E2 replacement in OVX females reversing this effect, suggesting that E2 reduces ET-1 and ETB2R expression [264]. Additionally, aortic strips from male rats subjected to trauma hemorrhage show enhanced ET-1-induced contraction, which is reduced by E2 or the ERβ agonist diarylpropionitrile (DPN) treatment [265]. E2 also inhibits both basal production and ET-1 release from ECs stimulated by serum, TNFα, transforming growth factor-β1, Ang II, and thrombin [266,267]. EC release of the COX-derived vasoconstrictor TXA2 is also higher in male compared to female SHR [252].

6.2. Effects of E2 on VSMCs

Proliferation and migration of VSMCs contribute to the progression of intimal hyperplasia and atherosclerosis. While E2 promotes EC growth, it suppresses VSMC proliferation by inhibiting MAPK and activating protein phosphatases [268], stimulating the release of endothelial NO and subsequent increase in cGMP in VSMCs or increasing cyclic adenosine monophosphate (cAMP) and adenosine [269]. Also, E2-induced H2S protects against atherosclerosis by upregulating Kelch-like ECH-associated protein 1 (Keap1) expression and inhibiting VSMC calcification and by downregulating MMP-2 and α5β1 integrin expression and inhibiting VSMC proliferation/migration and vascular inflammation [270]. In cultured rat aortic VSMCs, E2 binding to ERα reduced cell proliferation by 50% and increased the expression of zinc finger transcription factor KLF4 and shifted it to the nucleus, partly through activation of PI3K, Akt phosphorylation, and induction of NOS, and these effects required KLF4 and manganese superoxide dismutase (MnSOD) as shown by transfection experiments. In a carotid artery injury model, MnSOD+/− mice showed more extensive neointima formation and Ki67 immunostaining than wild-type (WT) mice. E2 deficiency led to enhanced neointima formation and increased Ki67-positive proliferating cells in OVX WT and MnSOD+/− mice. E2 replacement prevented neointima formation in WT but not MnSOD+/− mice. Cultured VSMCs derived from MnSOD+/− mice showed enhanced proliferation as compared to WT VSMCs, and E2 treatment failed to inhibit proliferation in MnSOD+/− VSMCs, supporting a role of E2 in inhibiting VSMC proliferation through MnSOD and KLF4, thus providing potential targets for treatment of vascular restenosis [271]. Sirtuin 1 (SIRT1) is a class III histone deacetylase involved in vascular metabolism, atherosclerosis, and aging. Aortas from OVX mice showed marked VSMC hyperplasia and upregulation of SIRT1, which was reversed by E2 supplementation. Also, treatment of A7r5 VSMCs with E2 downregulated SIRT1 expression, increased apoptosis, and reduced proliferation, viability, and migration through Akt and ERK pathways, and these effects were reversed by resveratrol-induced activation of SIRT1, suggesting that E2 inhibits VSMC proliferation through regulation of SIRT1 expression by Akt and ERK pathways [272]. In human and porcine coronary artery SMCs, G1-induced activation of GPER inhibited cell proliferation, promoted differentiation, and increased α-actin and smooth muscle protein 22α (SM22α) [273]. Also, 2-methoxy-E2 inhibited VSMC proliferation and pulmonary vascular inflammation [274], showing similar efficacy to sildenafil and bosentan in alleviating monocrotaline-induced PAH in both male and female rats. Additionally, when combined with sildenafil or bosentan, 2-methoxy-E2 provided greater protection, reversed established PAH, and improved survival rates [275]. The distinct effects of E2 on EC versus VSMC growth likely depend on the specific ER subtype or the ERE present in the promoters of target genes. For example, E2 primarily activates ERα to upregulate miR-203, which suppresses VSMC proliferation while also enhancing the expression of miR-143 and miR-145, which promote communication between ECs and VSMCs [276].
E2 through activation of plasmalemmal ERs also rapidly inhibits VSMC contraction in endothelium-denuded rabbit and porcine coronary arteries [161,277]. The relaxing effects of E2 depend on the vascular bed, estrous cycle, and prior exposure to E2. For example, the largest relaxation in response to E2 is observed in the tail and mesenteric arteries of female rats during the pro-estrous phase. Additionally, E2 induces less microvascular relaxation in OVX+E2 compared to OVX rats, indicating that chronic exposure to E2 may reduce the expression of ERs [278]. Notably, the rapid ex vivo E2-induced vascular relaxation requires micromolar concentrations several times higher than the in vivo picomolar serum levels. As estrogens are lipophilic, their tissue concentrations are higher than those in the serum. Furthermore, higher concentrations of E2 may be necessary to trigger relaxation in the aorta, which contains multiple VSMC layers and dense collagen, unlike smaller microvessels with thinner media and fewer VSMCs.
VSMC contraction involves an increase in [Ca2+]c and myosin light-chain phosphorylation. Additionally, protein kinase C (PKC) and rho-kinase (ROCK) inhibit myosin light-chain phosphatase, enhancing the sensitivity of the contractile myofilaments to [Ca2+]c. VSMCs from the rat aorta are longer and have lower basal [Ca2+]c in females compared to males and in OVX+E2 females compared to OVX females [279]. In VSMCs incubated in a Ca2+-free solution, phenylephrine or caffeine induced small contractions and [Ca2+]c levels that were similar in both male and female rats whether intact or gonadectomized, suggesting no difference in intracellular Ca2+ release. However, in VSMCs exposed to a Ca2+-containing solution, phenylephrine or high KCl caused greater increases in contraction and [Ca2+]c in intact males and OVX females compared to intact or OVX+E2 females, pointing to sex differences in Ca2+ influx [279]. Supporting this finding, the expression of L-type Ca2+ channels is elevated in coronary VSMCs of male swine compared to females and in cardiomyocytes from ER-deficient mice [280,281]. E2 also inhibits PGF- and KCl-induced sustained VSM contraction, Ca2+ influx, and [Ca2+]c, supporting its role in blocking Ca2+ channels [161,162]. Additionally, E2 activates BKCa channels in coronary VSMCs, leading to hyperpolarization and inhibition of voltage-gated Ca2+ channels [171]. Furthermore, E2 blocks Ca2+ channels in A7r5 and aortic VSMCs [282]. E2 could also reduce VSMC [Ca2+]c by stimulating the plasmalemmal Ca2+ pump PMCA [168]. In rats, E2 attenuates endoplasmic reticulum stress and myocardial ischemia/reperfusion injury by upregulating SERCA2a [195]. Also, in male rat cardiac myocytes, E2 and G1 decreased Ca2+ transient, L-type Ca2+ current and sarcomere shortening and increased NO production, and these effects were reversed by the GPER antagonist G36, NOS inhibitor L-NAME, or PI3K inhibitor wortmannin, suggesting GPER-mediated negative inotropic effect through the PI3K-NOS-NO pathway [283].
Sex differences in vascular contraction may also be influenced by PKC and ROCK. Phorbol esters activate PKC, leading to a stronger contraction in the aorta of male rats compared to females. Also, the activation and translocation of α- and δ-PKC from the cytosol to the plasma membrane induced by phorbol esters are more pronounced in the aorta of male and OVX female rats compared to intact or OVX+E2 female rats, suggesting that E2 modulates PKC activity [173]. Furthermore, E2 treatment reduces the mRNA expression of ROCK in human coronary VSMCs [175].

6.3. E2 and ECM

The adventitia contains fibroblasts and ECM proteins such as collagen and elastin that are regulated by various proteases such as matrix metalloproteinases (MMPs). Sexually dimorphic and E2-regulated miRNAs affect EC mesenchymal transition and vascular fibrosis. E2 maintains ECM flexibility by regulating collagen and elastin turnover, modulating collagen synthesis/degradation, and maintaining the balance necessary for vascular elasticity and preventing fibrosis [284]. In OVX female rats subjected to stress induced by isoproterenol subcutaneous injections, E2 replacement reduced weight gain and BP and ET-1 expression, upregulated eNOS expression, facilitated vasomotor function, and prevented excessive intima-media thickening and collagen deposition in the aortic wall [285]. Also, prolonged treatment of female rat aorta with E2 caused increases in MMP-2 and MMP-9 gelatinolytic activity, suggesting E2-induced regulation of vascular remodeling [184]. E2 also promotes VSMC migration and the formation of varicose veins of the lower extremities, likely due to upregulation of MMP-2 and MMP-9 expression through the classical ER-mediated genomic pathways [286]. In human airway smooth muscle cells, TNFα or PDGF increased ECM deposition and MMP activity, which were reversed by the ERβ agonist WAY-200070 but not the ERα agonist PPT. WAY-200070 also decreased the activation of NF-κB and AP-1, suggesting a role of ERβ in regulating ECM production and deposition through suppression of NF-κB activity [287].
E2/ERs also regulate cardiac fibroblasts and distinctly affect cardiac fibrosis in males versus females [288]. E2 inhibits differentiation, and collagen synthesis in TGF-β1 stimulated cardiac fibroblasts by regulating cell division cycle 42 (Cdc42) and the downstream p21 (RAC1)-activated kinase 1 (Pak1)/JNK/c-Jun signaling pathway [289]. In OVX female mice, surgical induction of aortic constriction caused severe myocardial hypertrophy, fibrosis, and increased expression of the autophagy marker LC3II, and these effects were attenuated by the GPER agonist G1. Also, in H9c2 cells, G1 attenuated Ang II-induced hypertrophy and reduced LC3II expression, autophagy level, and Akt/mammalian target of rapamycin (mTOR) pathway [290]. G1 also reduced cardiac hypertrophy, fibrosis, atrial natriuretic peptide, brain natriuretic peptide and β-myosin heavy chain, and the augmented oxidative stress and apoptosis induced by Ang II in mice, whereas GPER deficiency exacerbated the Ang II effects [291], suggesting potential benefits of G1 in alleviating cardiac hypertrophy and fibrosis in Post-MW.

7. E2-Based MHT and CVD

E2 is administered both as a contraceptive and as part of MHT to alleviate symptoms experienced during menopause, including vaginal dryness, vasomotor symptoms, hot flushes, night sweats, and disturbances in sleep [11]. MHT is also an effective treatment for genitourinary syndrome of menopause. Given that E2 facilitates vasodilation and alleviates menopausal symptoms, MHT was initially believed to reduce the incidence and severity of HTN and CVD in Post-MW. Early observational findings from the Nurses’ Health Study (NHS) indicated a decreased risk of cardiovascular events and CVD-related mortality in Post-MW who received oral E2 [292,293] (Table 2). Among women undergoing elective coronary angioplasty, those using MHT experienced fewer cardiovascular events (12% versus 35%) and exhibited higher survival rates (93% versus 75%) compared to nonusers [294]. Nonetheless, findings from randomized clinical trials (RCTs) such as the Women’s Health Initiative (WHI) and the Heart and Estrogen/progestin Replacement Study (HERS) did not confirm cardiovascular protection and even reported an elevated risk of cerebrovascular events associated with MHT [295,296]. Both HERS and its follow-up study HERS II, along with pooled analyses, revealed no significant reduction in either primary CAD or secondary cardiovascular outcomes in Post-MW randomized to MHT versus placebo. Although a temporary decline in CAD events was observed in the MHT group during the later years of HERS, this benefit did not extend through long-term follow-up, ultimately leading to the conclusion that MHT should not be prescribed to reduce cardiovascular risk in Post-MW with existing CAD [297]. Additional concerns emerged regarding a potential association between MHT and increased VTE risk [298,299]. Furthermore, MHT use was linked to approximately a 35% higher risk of cerebral ischemia and stroke, as reported in the NHS [300], WHI [301], and the Women’s Estrogen for Stroke Trial (WEST) [302]. These observations have generated extensive research interest in the postmenopausal changes in estrogen regimens and formulations, ERs, cardiovascular health, and other biological systems as potential causes of lack of MHT benefits in CVD. The failure of MHT to elicit vascular benefits in RCTs could be related to the MHT type, dose, metabolism, route of administration, time of initiation and duration, the participants’ age, age-related changes in ER and post-ER signaling pathways, the pre-existing CVD and other clinical disorders, or the hormone environment and interaction with gonadotropins, SHBG, P4, and T (Figure 5).

7.1. MHT Type and CVD

Oral estrogens like conjugated equine estrogen (CEE) and E2 exhibit reduced bioavailability due to hepatic first-pass metabolism, during which they are transformed into E1 prior to entering the systemic circulation. While most MHT clinical trials have utilized oral estrogen formulations, mechanistic investigations tend to evaluate the direct vascular actions of E2. Certain synthetic estrogens, including diethylstilbestrol (Kd 0.04 nM) [122], esterified E2, and ethinyl-E2, demonstrate stronger binding affinity for ERα and may offer superior cardiovascular protection. Among Post-MW, use of esterified E2 has been associated with a reduced incidence of ischemic stroke and myocardial infarction (MI), without an observed increase in the risk of VTE when compared to CEE [298]. Tibolone is a synthetic steroid hormone with estrogenic, progestogenic and androgenic properties used for treatment of menopausal vasomotor symptoms and osteoporosis, but its cardiovascular benefits versus risks need to be examined [319].
Selective estrogen receptor modulators (SERMs) such as raloxifene, tamoxifen, and idoxifene are non-steroidal molecules that bind ERs and elicit purely estrogenic, partial estrogenic, or anti-estrogenic effects. SERMs decrease total cholesterol, low-density lipoprotein cholesterol (LDL-C), fibrinogen, interleukin-6 (IL-6), and TNFα. In the Raloxifene Use for The Heart (RUTH) trial, raloxifene treatment for ~5.6 years reduced the risk of invasive breast cancer in Post-MW with CVD but did not affect the risk of coronary events and increased the risk of stroke and VTE [310]. The Multiple Outcomes of Raloxifene Evaluation (MORE) study found that a 4-year course of raloxifene treatment had no impact on the incidence of cardiovascular events or stroke, although it was associated with a heightened risk of VTE [320]. PPT, which is a selective ERα agonist with 400-fold greater potency for ERα compared to ERβ, was shown to enhance FMD in the mesenteric vasculature of female mice [321]. Diarylpropionitrile (DPN), a selective ERβ agonist with 30–70 times higher potency for ERβ over ERα, induces rapid vasodilation through an NO-dependent mechanism [139]. Also, selective activation of GPER by G1 causes greater cardiovascular protection in OVX females than intact female or male rats [322]. Estrogenic agents that exhibit greater selectivity for specific ERs may improve the cardiovascular benefits associated with MHT in CVD.
Phytoestrogens, including flavonoids, isoflavonoids, stilbenes, and lignans, interact with ERs to exert estrogenic effects. Large quantities of food containing phytoestrogens, such as soybeans, red clover, wheat, and peas, are consumed by populations with lower rates of menopausal symptoms, osteoporosis, cancer, and CVD, including Japan, China, and Southeast Asia. In a double-blind RCT including Post-MW, supplementation with 56 g soy protein powder daily reduced mean, systolic, and diastolic BP compared with placebo group [323]. Other studies using soy-derived products in Post-MW showed a slight or no benefits on BP [324,325,326]. Further evaluation of the estrogenic effects of phytoestrogens is needed through well-conducted RCTs.

7.2. MHT Dose and CVD

The negative outcomes of MHT observed in RCTs may be attributed to the high doses used. Estrogens, being lipophilic, may have circulating levels that do not accurately represent their concentration within the vascular wall. Furthermore, E2 plays a role in adipose tissue metabolism, and a deficiency of E2 in Post-MW is linked to an increase in visceral fat. Adipose tissue exhibits P450 aromatase activity, converting androstenedione to E1, which elevates E1 levels in Post-MW with obesity. Additionally, adipose tissue releases IL-6 and TNFα, which influence vascular ERs signaling. Therefore, while a standard E2 dose in Pre-MW may be physiologically appropriate, it could lead to supraphysiological levels and adverse effects in Post-MW. CEE is available at low dose of 0.3 to 0.45 mg, standard dose of 0.625 mg, and high dose of 1.25 mg [327]. The Women’s Health, Osteoporosis, Progestin, Estrogen (HOPE) trial demonstrated a more favorable benefit/risk ratio with lower-dose CEE for preventing bone loss and alleviating vaginal atrophy, vasomotor symptoms, and endometrial bleeding [328]. The high E2 dose could also promote vascular inflammation. E2 administration in female mice for 3 consecutive months caused aortic inflammation similar to Takayasu arteritis. Also, treatment of mouse aortic VSMCs with high E2 concentrations decreased expression of contractile phenotypic markers and increased expression of macrophage-like phenotypic markers. This phenotypic switch was blocked by tamoxifen and KLF4 inhibitors and enhanced by Von Hippel–Lindau/hypoxia-inducible factor-1α (HIF-1α) interaction inhibitors, suggesting that E2-regulated phenotypic conversion of VSMCs to macrophages through Von Hippel–Lindau/HIF-1α/KLF4 axis is involved in E2-induced vascular inflammation associated with MHT use [329]. E2 also affects ECM remodeling through modulation of MMPs. Low E2 doses may inhibit MMPs and decrease collagen deposition [182], whereas high E2 doses activate MMPs and may promote vascular lesion formation and plaque destabilization [183,184]. In VSMCs from human coronary and umbilical arteries, supraphysiological concentrations of E2 elevated MMP-2 levels, which could impact vascular structure and integrity [183]. The degradation of ECM and instability of atherosclerotic plaques induced by MMPs could account for the association between alterations in the levels of MMP-2, MMP-9, and MMP-10 in Post-MW undergoing MHT and the heightened risk of cardiovascular events [330].

7.3. MHT Route of Administration and CVD

MHT can be administered orally or as a percutaneous gel, transdermal patch, subcutaneous implant, and vaginal preparation. Oral and transdermal estrogens formulations have similar efficacy [331]. Low-dose vaginal MHT shows little absorption into the systemic circulation and could be an option for Post-MW for whom systemic MHT is contraindicated, particularly women with a history of E2-dependent cancers, CVD, stroke, or VTE [332]. A nationwide Finnish cohort study including 195,756 Post-MW during the period between 1994 and 2009 found that vaginal MHT could reduce the risk of death from CAD and stroke in all age groups, with the highest risk reduction in women aged 50–59 years [333].
The route of administration could influence the effects of MHT on the cardiovascular system. Oral MHT undergoes first-pass metabolism and could produce benefits in the lipid profile, such as reduction in LDL-C and lipoprotein(a) and increases in high-density lipoprotein cholesterol (HDL-C), but it could increase triglycerides levels and promote thrombosis [334]. Also, despite the favorable effects of oral E2 on LDL-C, lipoprotein(a), and HDL-C levels, these subclinical benefits have not translated into reduction in CVD events or mortality among MHT users [48]. Transdermal E2 is absorbed directly into the bloodstream, bypassing the plasma E2 spikes associated with oral forms, and is converted to E1 at a rate comparable to that observed during the menstrual cycle, resulting in fewer side effects compared to oral estrogens [335]. In contrast with oral MHT, which increases triglycerides by 5% to 15%, transdermal MHT decreases triglyceride levels by 5% to 30% [336,337]. Also, because transdermal MHT preparations avoid the hepatic effect, they have less impact on coagulation factors and hemostasis [338] and a lower risk of VTE and stroke compared with oral MHT [339]. While oral E2 increases C-reactive protein in the vessel wall and may cause VTE [340], transdermal E2 increases brachial artery FMD without affecting C-reactive protein [341] and shows lower incidence of VTE [342].
Hormone replacement therapy using silastic and bioabsorbable hormone implants has gained considerable interest as a practical and effective route for treating menopausal symptoms and reduced sexual desire disorders. A retrospective study of 1,204,012 subcutaneous hormone implants during the time period between 2012 and 2019 including 376,254 men and women patients, 85% of whom were women, with 46% of them postmenopausal women, found that subcutaneous hormone implants were safer than other routes of administration of bioidentical hormone replacement therapy for both men and women [343]. Also, Pre-MW and Post-MW who reported comparable hormone deficiency symptoms showed similar improvement in total score of validated Health Related Quality of Life and Menopause Rating Scale as well as psychological, somatic and urogenital subscale scores when using T implant therapy, with better effects in women with severe complaints and greater improvement with higher T doses [344]. Nevertheless, based on relevant and recent research, the cardiovascular risks and safety of subcutaneous hormone implants for Post-MW remain to be thoroughly examined [345].

7.4. MHT and Menopausal Changes in ERs

The absence of vascular benefits from MHT in RCTs may also result from age-related, prolonged E2 deficiency, leading to alterations in ER expression, distribution, integrity, and post-ER signaling (Table 3). Polymorphisms in ERα at positions c.454–397 T>C (PvuII) and c.454–351 A>G (XbaI) have been associated with CAD severity in Post-MW [346]. Post-MW with the recessive ERα IVS1-397 polymorphism C/C genotype show greater HDL-C and apolipoprotein A-1 levels, brachial artery FMD, and endothelium-dependent dilation when compared to the dominant phenotype [347]. Also, among Post-MW with CAD treated with E2 or E2+P4, women with the ERα IVSI-401 polymorphism C/C genotype show two times greater increase in HDL-C levels when compared to control [306]. Age-related alterations in ER subtypes have been observed across various tissues. For example, ER is present in the retina of Pre-MW but not in men or Post-MW [348]. Also, menopause is linked to a decline in ERα expression and activity in the brain and liver, which impacts cognition and metabolism [349]. In female mice, aging leads to a reduction in ERα mRNA expression in the heart, while GPER mRNA levels rise [350]. Splice variants of ERα and ERβ, each with distinct signaling pathways, may influence vascular responses to MHT [97,118]. Full-length ERα (ERα66) and its truncated forms, such as ERα46, ERα36, and ERα30, may play distinct roles in regulating vascular function [351]. ERα46, which is localized to and dynamically targeted to the plasma membrane, enhances eNOS phosphorylation more effectively than membrane-bound ERα66 [352]. ERα36, which forms dimers with wild-type ERα66, can inhibit its activity, while ERα30, although not yet fully defined, may suppress ERα66 expression in breast cancer cells [353,354,355]. Research comparing early versus late E2 supplementation on the common carotid artery of OVX senescence-accelerated mice showed that delayed initiation of E2 supplementation increased ERα36 expression (associated with aging) without affecting ERα66 or ERα46 levels and in tandem with the negative effects of E2 [356]. Epigenetic modifications and methylation of CpG islands in the ERβ gene promoter also influence ERβ expression, vascular aging, and atherosclerosis [357]. Additionally, changes in ERα expression, E2 sensitivity, and signaling pathways modulate MHT effects differently in early (≤5 years) versus late Post-MW (>5 years past the final menstrual cycle) [358]. While ERα activation is linked to NO production and vascular protection [233], ERβ expression correlates with atherosclerotic plaque area in males [359], and the age-related shift in the ERβ/ERα ratio may promote a pro-oxidative response to E2 [360]. Interestingly, human arterioles from discarded adipose tissue showed higher EC expression of ERβ and GPER in women under 40 compared to those over 40 and in men, with ERα primarily localized in the adventitia. This finding has suggested that E2/ERβ fosters a more oxidative environment in microvascular ECs. Episodic high E2-induced oxidative stress may trigger protective mechanisms, and fluctuations in E2 levels in women not using MHT could allow time for recovery, whereas continuous MHT exposure may prevent recovery, leading to increased oxidative stress and vascular damage [255]. In ECs from peripheral veins, ERα expression was lower during the early follicular phase (lower E2) compared to the late follicular phase (higher E2) in Pre-MW and was even lower in Post-MW. ERα levels were positively correlated with eNOS expression, ser1177 phosphorylation, and endothelium-dependent brachial artery FMD, which were reduced in Post-MW, suggesting that fluctuations in estrogen status during the menopausal cycle and age-related E2 deficiency modulate EC ERα levels and vasodilatory effects [361]. Consistent with this concept, prolonged E2 deficiency in OVX female Sprague–Dawley rats is linked to a decrease in endothelial ERα expression and disrupted ERα/eNOS signaling in the aorta [362]. Aging also alters the subcellular distribution of ERα between the nucleus and cytoplasm in cholinergic neurons of mice [363]. To further test whether vascular ERs expression is reduced with aging, vascular reactivity and ERs were measured in the aorta, kidney, and heart of male and female mice of different ages. ERα and GPER were the predominant receptors in all tissues, whereas ERβ was mainly detectable in the kidney. Female mice showed higher ERα and GPER mRNA expression in the aorta and the heart. Aging affects ER transcript in a tissue-dependent manner. E2- and G1-induced vasodilation and GPER levels were reduced in the aorta of aging female mice. In the heart, ERα transcript decreased with aging, while GPER expression increased, suggesting differential impact of aging on cardiovascular ER expression in a sex- and tissue-specific pattern [350]. A separate study found no significant difference in ER expression between the aortas of aging and adult OVX SHR [364]. A deeper investigation into age-related changes in the expression of both full-length and truncated ER forms, their signaling pathways, and interactions with each other as well as with wild-type ERs, especially following menopause, could provide insights into the reasons for the absence of vascular benefits from MHT in Post-MW.

7.5. MHT Timing and Duration

Due to age-related changes in the vasculature, the timing of initiation and duration of MHT relative to menopause onset may influence cardiovascular outcomes [377]. Women tend to live longer, with an average life expectancy of 82.2 years, compared to men at 76.6 years [378]. Aging is linked to decline in cardiovascular function; EC senescence and dysfunction; increased VSMC proliferation, vascular remodeling, inflammation; and the development of atherosclerosis, all of which contribute to altered vascular responses to E2. As individuals age, reduced NO release and elevated ET-1 levels promote VSMC proliferation and predispose to a procoagulant state. Aging is also associated with progressive decreases in the elastin/collagen ratio, changes in the blood vessel’s architecture and mechanical properties, and increased arterial stiffening [379,380].
Estrogen may be an appropriate option for treatment of menopausal symptoms when initiated in healthy women <60 years or within 10 years of menopause onset, but it may have plaque-destabilizing and other adverse effects in advanced atherosclerosis [381]. In a Korean nationwide study of women entering menopause at ≥40 years with no history of CVD, including MHT users and a non-MHT group, an increased risk of CVD and stroke was observed with the administration of tibolone, oral E2, or transdermal E2 compared with the non-MHT group regardless of the age of starting MHT. However, among tibolone users, a longer period from entering menopause to taking 1.25 or 2.5 mg tibolone was specifically linked to a higher risk of CVD compared with non-MHT users [319]. Also, the average age of menopause in the United States is 51 years [312]. Participants in the NHS study were aged 30–55 years, with approximately 80% starting MHT within two years of menopause [300]. In contrast, women in the HERS study were around 67 years old and had been postmenopausal for several years [377]. Also, the WHI study included older women (aged 50–79 years), with those aged 50–59 years having been menopausal for about 6 years and exhibiting subclinical atherosclerosis [293]. The “timing” hypothesis suggests that as women age, they experience subclinical vascular and myocardial changes that begin during the menopausal transition and progressively worsen over time. This “timing” or “critical window” hypothesis asserts that the timing and duration of MHT are key factors for achieving positive cardiovascular outcomes. Studies such as the Kronos Early Estrogen Prevention Study (KEEPS) and the Early versus Late Intervention Trial with Estradiol (ELITE) have evaluated how MHT timing impacts atherosclerosis progression in early menopausal women [312]. In KEEPS, women aged 42–58 years who were 6–36 months postmenopausal were given low-dose oral CEE or weekly transdermal E2, both with cyclic oral micronized P4, or a placebo for 12 days per month [312]. ELITE compared the effects of early versus late MHT initiation by randomizing women who were less than 6 years or more than 10 years postmenopausal to receive oral E2 for 2–5 years. The SMART trial, which evaluated CEE/bazedoxifene treatment for 12 months in Post-MW, found favorable changes in lipid profiles for up to 2 years, without negative effects on lipid metabolism, coagulation, hemostatic balance, cardiovascular events, or VTE incidence [382]. In healthy Post-MW, oral E2 initiated within 6 years after menopause was linked to less progression of subclinical atherosclerosis compared to placebo, whereas initiation ≥10 years after menopause did not show this benefit [315]. Also, women under 50 years who had undergone surgical menopause experienced a reduced risk of CAD when using MHT compared to non-users [67]. For women approaching menopause, MHT reduced the risk of both subclinical and clinical CAD, and the elevated risk of VTE with oral MHT formulations was lessened when using transdermal E2 [383]. Taken together, these findings underscore the importance of MHT timing, with low-dose oral E2 and transdermal E2 showing benefits when used during the 3–5 years before menopause and in the immediate postmenopausal period, and for a duration lasting for about 5 years [384,385].

7.6. MHT and Preexisting Conditions in Post-MW

Pre-existing cardiovascular conditions may also influence the outcomes of MHT. At baseline, participants in the HERS study had CVD [312]. In the WHI study, although the primary goal was to evaluate the benefits of MHT for primary CVD prevention in healthy women, 36% of participants had HTN, 4.4% had diabetes, 49% were smokers, 34% were obese, and 13% were undergoing treatment for hypercholesterolemia. These conditions point to an underlying atherosclerotic process that could potentially interfere with the positive effects of E2. Although some studies show no clinically meaningful effect of oral E2 on BP in women with preexisting HTN, WHI showed that CEE, either alone or in combination with medroxy-progesterone acetate (MPA), increased BP by 1 to 1.5 mmHg [386,387]. As studies have shown that a 1 mmHg reduction in systolic BP can reduce the relative risk of major CVD by 2% and reduce heart failure events by 3% [388], women with HTN should be cautious in taking MHT. The Cardiovascular Health Study found a positive association between MHT and FMD in healthy Post-MW women older than 65 years, though no effect was observed in women over 80 with CVD or cardiovascular risk factors [389]. In a study on OVX cynomolgus monkeys receiving an atherosclerotic diet, early administration of CEE resulted in a 70% reduction in coronary artery plaque size, while delayed administration after moderate atherosclerosis developed reduced plaque by only 50%, and no protective effect was observed in monkeys who had been on the atherosclerotic diet for two years before receiving CEE [390]. Also, in OVX female rats with carotid artery balloon injury, E2 treatment reduced intimal hyperplasia and VSMC proliferation when administered on the day of injury or 15 min before, continuing for three days post injury, but it had no effect when treatment was initiated seven days after injury [391]. These findings emphasize the importance of timing in MHT initiation for potentially preventing or delaying CVD progression. During the menopausal transition, women typically maintain healthy arterial function, which allows MHT to offer vascular benefits. However, as CVD progresses in Post-MW, changes such as EC senescence/dysfunction, EC-to-mesenchymal transition, and increased levels of mesenchymal cell markers, vascular permeability, VSMC migration, and proteolytic enzymes alter ECM proteins and induce vascular remodeling, leading to reduced responsiveness to E2 [392].
Sex differences and menopause-related changes in the renal, gastrointestinal, endocrine, nervous, and immune systems have also been observed, potentially influencing the development of CVD and its response to MHT [215]. For instance, diabetes increases the risk of having MI or stroke by 2-fold. The relative risk for CVD mortality in patients with diabetes is greater in women (2.42) than in men (1.86), and female diabetic patients have a worse prognosis after MI and are more likely to develop congestive heart failure [393]. Also, coronavirus disease 2019 (COVID-19) is characterized by an exaggerated immune response with hypercytokinemia, inflammatory infiltration of the lungs, and acute respiratory distress syndrome that could lead to death. The risk of severe COVID-19 outcomes is lower in women than in men worldwide, suggesting that the female biological sex confers protective mechanisms [188]. E2 and other ER modulators could influence the course of COVID-19 infection by inhibiting viral replication and its effects on the cardiovascular/pulmonary/immune system, decreasing the production of cytokines responsible for the cytokine storm, and inhibiting the interaction of IL-6 with its receptor. In this respect, E2 deficiency and MHT could have significant impact on COVID-19 prognosis in Post-MW [394].

8. Influence of Hormonal Environment

The vascular response to E2 could be affected by the hormonal environment, the upstream gonadotropins, the extragonadal locally produced hormones by various tissues, sex hormone-binding globulin (SHBG), and the interaction with P4 and T and their precursors.

8.1. MHT and Gonadotropins

Gonadotropins, including follicle-stimulating hormone (FSH) and luteinizing hormone (LH), are secreted by the pituitary gland and act on the ovaries in females to stimulate the release of E2 and P4 and on the testes in males to promote the production of T and DHT [47]. During the menopausal transition, a notable drop in circulating E2 levels is typically accompanied by a significant rise in FSH concentrations [395]. This inverse correlation between E2 and FSH indicates that E2 continues to influence pituitary FSH secretion even after menopause [396]. Findings from the KEEPS trial revealed that recently menopausal women undergoing MHT for 48 months demonstrated more pronounced associations between hormone levels in both the oral CEE and transdermal E2 groups compared to placebo. Observed variations in the relationships among E2, T, FSH, and LH across the CEE, E2, and placebo arms suggested that different MHT protocols may distinctively influence pituitary–ovarian hormone levels, feedback loops, and endocrine interactions in early Post-MW [397]. Additionally, FSH concentrations have been reported to be higher among women who had used MHT for four or more years compared to non-users [398]. Notably, a higher incidence of cardiovascular events has been linked to the use of gonadotropin-releasing hormone (GnRH) agonists compared to antagonists [399], highlighting the importance of further investigating the interplay between MHT, gonadotropin levels, and cardiovascular risk.

8.2. Ovarian Versus Locally Produced Sex Hormones

Previous studies have predominantly concentrated on ovarian estrogen biosynthesis, circulating E2 concentrations, and the administration of exogenous estrogens. However, investigations into estrogens synthesized locally via autocrine or paracrine mechanisms, the related enzymatic pathways, and their vascular impacts remain limited. After ovarian E2 production declines during menopause, estrogens and androgens begin to be synthesized within peripheral tissues, where they exert local effects and undergo intracellular inactivation. The distribution of enzymes responsible for steroid synthesis and deactivation is highly cell- and tissue-specific, enabling the localized generation of minimal quantities of estrogens/androgens to satisfy physiological and metabolic demands [400].
Advancing age, increased adiposity, and psychological stress have all been associated with elevated local E2 synthesis. This phenomenon is considered a compensatory response to systemic E2 deficiency during menopause and is achieved by upregulating enzymes and molecular factors that promote local E2 generation and release. In Post-MW, estrogen production from autocrine and paracrine origins is relatively enhanced [401]. Also, OVX rats continue to produce E2 for a considerable period and do not fully reach a menopausal state until 16–18 months of age. Notably, adipose tissue serves as the main site of aromatase activity, contributing to the increased peripheral conversion of androgens into E1 during the postmenopausal period [19]. Additional research has demonstrated that Post-MW show elevated aromatase mRNA levels and increased immunohistochemical signals in human aortic SMCs, with even higher levels observed in those suffering from atherosclerosis [402]. Within the hippocampus, aging in women is accompanied by enhanced expression of nuclear ERα, aromatase, and components of the Golgi apparatus, indicating the presence of locally synthesized estrogens in the brain. These estrogens may facilitate the upregulation of ERα, thereby promoting neuronal metabolism in postmenopause. Conversely, patients with Alzheimer’s disease exhibit downregulation of both canonical and alternatively spliced ERα mRNA as well as aromatase gene expression, implying a reduction in local brain estrogen production and impaired ERα signaling [403]. Consequently, the role of locally synthesized sex hormones across various tissues should be carefully evaluated when developing MHT protocols for Post-MW.

8.3. MHT and Sex Hormone-Binding Globulin (SHBG)

A large proportion of circulating estrogens is tightly yet reversibly bound to SHBG. This extensive binding to plasma SHBG influences the pharmacokinetics and distribution volume of estrogens, and such parameters may be altered in Post-MW who present with hepatic or renal dysfunction. In women, SHBG concentrations are regulated through a dynamic balance, with estrogens acting as stimulators and androgens, insulin, excess adiposity, and fat distribution patterns functioning as inhibitors. Although SHBG levels do not show significant differences between Pre-MW and Post-MW, Post-MW typically exhibit a pronounced decline in circulating E2 while maintaining relatively stable T levels. Additionally, SHBG shows inverse correlations with BMI, waist-to-hip ratio, insulin, and T concentrations in both Pre-MW and Post-MW, while a positive correlation with E2 is observed exclusively in Pre-MW. Regression analysis further reveals that, in Pre-MW, SHBG levels are positively associated with E2 and negatively associated with T and insulin, with no clear link to waist-to-hip ratio. In contrast, Post-MW exhibit a negative association between SHBG and waist-to-hip ratio, with no significant correlation with E2, and a weaker association with T and insulin. These findings suggest that the regulatory factors of SHBG undergo changes during the menopausal transition, and a critical threshold of E2 might play a pivotal role in determining circulating SHBG concentrations [404]. Data from a cohort of healthy Post-MW aged 41 to 92 years demonstrated that while E2 levels remained relatively stable across subgroups, SHBG levels rose progressively with age, ranging from 43 to 68 nmol/L [405]. Additionally, in women who retained their ovaries, aging was linked to a 27% reduction in androstenedione levels and a 30% increase in SHBG levels, an effect not seen in oophorectomized women [26]. Among healthy Post-MW receiving E2 therapy, elevated free E2 and SHBG levels along with decreased free T were associated with lower subclinical atherosclerosis and reduced carotid intima-media thickness, likely mediated in part by favorable changes in lipid profiles [406].

9. Vascular Effects of Progesterone (P4)

Progesterone (P4) serves as the primary progestogen synthesized by the female ovary and the adrenal cortex. Cytoplasmic/nuclear P4 receptors (PRs) exist in two main isoforms, PR-A and PR-B, which originate from different transcriptional start sites within the same gene [407]. PR-B is the full-length form, comprising 933 amino acids. PR-A comprises 769 amino acids and is essentially the same as PR-B but lacks the initial 164 amino acids from the N-terminus, which contain a unique AF-3. Both PR-A and PR-B are located in the cytoplasm and translocate to the nucleus upon activation, but they have different expression, distinct roles, and specific functions in different tissues. PR-B is generally a stronger activator of gene transcription than PR-A. In some cases, PR-A activation may counteract PR-B-mediated effects [408]. PR-A and PR-B isoforms have been detected in ECs and VSMCs across several species, including humans, primates, rabbits, rats, and mice [409,410]. In human VSMCs, both wild-type PRs and two splice variants, one lacking exon 4 (PRΔ4) and another lacking exon 6 (PRΔ6), have been identified. Notably, PRΔ6 acts as a dominant-negative inhibitor of the transcriptional activity of wild-type PRs in Pre-MW, but this effect is absent in Post-MW [118]. A subclass of membrane PRs (mPRα, mPRβ, mPRγ, mPRδ, and mPRε) remains bound to the plasma membrane upon activation [411]. Membrane mPRα, mPRβ, and mPRγ mediate rapid, cell-surface-initiated P4 actions in ECs and VSMCs.
P4 exerts unique effects on the vasculature and influences the actions of E2. Like E2, studies support P4 anti-inflammatory effects through the regulation of COX, prostaglandin synthesis, and T-cell activation [190]. Also, P4 decreases innate immune inflammatory response and promotes immune tolerance and antibody production, thus mitigating the immune imbalance associated with the COVID-19 cytokine storm [188]. P4 exerts antihypertensive actions partially by modulating eNOS activity. Also, P4 promotes coronary vasodilation and NO release in pigs [412], upregulates eNOS in ovine uterine artery ECs [413], and stimulates NO-mediated relaxation in ovine uterine artery and rat aorta [414]. P4 upregulated eNOS expression in HUVECs and augmented eNOS promoter activity through a PR-A and specificity protein-1-dependent manner, while the PR antagonist RU-486 reduced eNOS expression and impaired vasodilation in rats [143]. In ECs, mPRs mediate rapid P4 signaling, resulting in increased NO synthesis [415]. Low doses of P4 could also potentiate the effects of low doses of E2 on NO production. In HUVECs, P4+E2 (5 nM) increased phosphorylation of ERK and Akt, eNOS phosphorylation, and NO production, and these effects were not observed with 5 nM of either P4 or E2 alone and were blocked with PI3K inhibitor wortmannin, Akt inhibitor ML-9, and MAPK inhibitors AZD6244 and U0126. Treatments with specific ER and PR agonists suggested a role of mPRα (PAQR7), GPER-1, and ERα but not ERβ in P4+E2-induced NO production. These observations suggest that a low concentration of P4+E2 rapidly increases NO production in HUVECs through mPRα, ERα, and GPER and downstream activation of PI3K/Akt and MAPK pathway [149]. P4 is also capable of rapidly activating COX, enhancing the production of PGI2, and suppressing Ang II-stimulated ET-1 release in bovine aortic ECs. In OVX SHR, P4 treatment reversed the cardiac damage caused by ovarian hormone deficiency and promoted bradykinin-induced endothelium-dependent coronary vasodilation, which was blocked by the COX inhibitor indomethacin, suggesting a role of the prostanoid pathway [148]. Low concentrations of P4+E2 also exerted genomic actions and increased mPRα, COX-1, and prostacyclin-synthase mRNA expression in HUVECs [149]. In OVX female rats, P4 treatment reversed the reduced baseline coronary perfusion pressure and restored the decreased endothelium-dependent bradykinin-induced coronary vasodilation. The P4 effects were not affected by blockade of the NO pathway or both the NO and prostanoids pathways but were abolished by combined blockade of NO, prostanoids, and epoxyeicosatrienoic acids, suggesting P4 activation of additional epoxyeicosatrienoic acids mediated hyperpolarization and vasodilation pathways in the coronary vascular bed [152]. The P4/PR-mediated coronary vasodilation in rats may be sex-specific, involving mainly NO and prostanoids in males and NO and EDHF pathways in females [416].
P4 inhibits rat aortic smooth muscle cell (RASMC) proliferation and migration [178] and facilitates the inhibitory effects of E2 on VSMC proliferation through inhibition of MAPK [266]. In pulmonary arterial SMCs, P4 reversed the IL-6-induced proliferation partly by decreasing phosphorylation of pro-proliferative Erk1/2 and Akt kinases and upregulating anti-proliferative pSmad1-Id1/2 axis. P4/PR also interacts with signal transducer and activator of transcription 3 (STAT3) and reduces IL-6-induced STAT3 nuclear translocation, chromatin binding, and transcription of downstream CCND1 and BCL2, thereby reversing IL-6-induced proliferation of pulmonary arterial SMCs. This may help explain the better prognosis of PAH in females [179]. However, other studies in RASMCs have suggested that P4 promotes cell proliferation, migration, and apoptosis; these effects need further examination [177]. P4 has also been shown to induce endothelium-independent relaxation in coronary arteries of primates, pigs, rabbits, and rats while reducing [Ca2+]c in coronary VSMCs of both porcine and rabbit origin [161,162]. In VSMCs, activation of P4/mPRα leads to a rapid decline in [Ca2+]c by modulating SERCA2 and phospholamban along with other signaling pathways, such as Gi, MAPK, Akt/PI3K, and RhoA [167]. Additionally, P4 suppresses VSMC contraction triggered by phorbol esters and inhibits PKC activity, primarily through elevation of intracellular cAMP levels [174].
However, P4 produces less vasorelaxation than E2 and antagonizes the favorable effects of E2 on NO production and vascular relaxation in the canine and porcine coronary artery [417]. Also, P4 counteracts the antioxidant effect of E2 by enhancing NADPH oxidase activity and ROS production and down-regulating superoxide dismutase in OVX mice [154]. In mouse renal arterial ECs, P4 increased ROS levels and abolished the H2O2-induced antioxidant response, glutathione production, and glutathione peroxidase activity [418]. P4/PR interaction with EC mineralocorticoid receptor (MR) could also contribute to the enhanced obesity-associated leptin-induced EC dysfunction in females versus males. In support, genetic deletion of either endothelial MR or PR in female mice prevents leptin-induced endothelial dysfunction [419]. P4 also upregulates vascular AT1R, promotes vasoconstriction [420], and diminishes E2 anti-inflammatory benefits in ischemic brain injury [15].
P4 could modify the effects of E2 on women’s health and the cardiovascular system. In women who have an intact uterus, P4 is co-administered with E2 to mitigate the risk of endometrial cancer [421]. Oral micronized P4 has also been shown to alleviate menopausal symptoms and enhance sleep quality [422,423]. Furthermore, the use of vaginal micronized P4 does not affect the metabolic and cardiovascular outcomes associated with non-oral E2 in early Post-MW [424]. Other studies showed that micronized P4 in combined MHT had a neutral effect on VTE, MI, and ischemic stroke [425]. In the REPLENISH trial, treatment of vasomotor symptoms in Post-MW with TX-001HR (E2+P4) did not affect glucose levels, total cholesterol, triglycerides, coagulation factors, or VTE incidence [426]. Other studies showed no attenuation of CEE-induced vasodilation by micronized P4 or medroxy-progesterone acetate (MPA) [427]. Also, the NHS showed a similar risk reduction for CAD in women taking CEE alone or CEE+MPA [300]. In rabbits, CEE and E2 conferred anti-atherosclerotic actions that were not prevented by MPA or other progestins [293].
Drospirenone (DRSP), a 17α-spironolactone derivative, binds to PR with an affinity comparable to that of natural P4. DRSP is commonly combined with ethinyl-E2 for use as an oral contraceptive and in MHT. It exerts stronger anti-androgenic effects than P4 and has anti-mineralocorticoid properties that oppose the salt-retaining effects of E2. Angeliq (E2+DRSP) reduces vertigo/dizziness and carotid intima-media thickness [428] and improves vascular parameters, EC function, reactive hyperemia, and vascular protection in normotensive early Post-MW [429]. Also, E2+DRSP, in combination with an angiotensin-converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB), lowers BP in hypertensive Post-MW [430]. In Post-MW with metabolic syndrome, both E2+DRSP and E2+dydrogesterone lower fasting blood glucose levels, but only E2+DRSP is effective in improving glycemic excursions, insulin sensitivity, lipid profiles, and inflammatory markers [431].
Other studies suggest that some progestins may negatively impact the vascular effects of MHT and diminish the beneficial effects of E2 on lipid profiles, and they could counteract the protective effects of CEE on coronary atherosclerosis and reduce E2-induced NO release in Post-MW. In healthy Post-MW, resting vascular resistance and resistance after cold pressor stimulation remained unchanged after 21 days of E2 therapy alone but significantly increased when MPA was added [432]. When Post-MW were treated with E2 for two weeks, followed by E2+norethisterone acetate for another two weeks, cGMP excretion was elevated in both phases, but PGI2 metabolites were higher in the E2 phase, whereas TXA2 metabolites increased in the E2+norethisterone acetate phase [433]. Also, oral E2/MPA increases TXA2 metabolite, but transdermal E2/MPA does not [434]. Additionally, treatment of human female coronary ECs with MPA or norethisterone acetate enhanced E2-induced reduction in MMP-1 and in turn affected plaque stability. Furthermore, CEE alone or CEE+MPA increased MMP-9 levels in Post-MW with established CAD [421]. In the HERS trial and one arm of the WHI trial, the heightened stroke risk in women taking CEE+MPA compared to non-users of MHT was related to MPA. Additionally, in the Postmenopausal Estrogen/Progestin Interventions (PEPI) trial, MPA reduced the positive effects of CEE on LDL-C and HDL-C levels [293]. In cynomolgus monkeys, E2 or E2+P4 exhibited similar anti-atherosclerotic effects, which were not observed in monkeys treated with CEE+MPA [435]. Notably, in surgically postmenopausal monkeys on an atherogenic diet, lipid lowering improved ACh-induced vasodilation, and CEE had no impact on vascular reactivity, but MPA impaired the beneficial effects of CEE on coronary flow reserve [436]. Also, while E2 alone improved cardiovascular function in OVX diabetic rats by reducing inflammatory cytokines and improving metabolic parameters, P4 alone or E2+P4 did not show substantial benefits [437]. Additionally, MPA negated the beneficial effects of E2 in reducing balloon injury and intimal thickening in rat models [438]. These complex interactions between E2 and P4 on vascular function could determine the outcome of combined E2/P4 therapy in postmenopausal CVD. Specifically, the impact of MPA on the absence of vascular benefits from MHT in RCTs requires further investigation.

10. Vascular Effects of Testosterone (T)

Androgens play a crucial role in maintaining reproductive function, secondary sexual characteristics, libido, metabolic processes, muscle mass, bone structure, and brain function in both men and women. Most of the androgens are produced by the testes, adrenal glands, and ovaries. Typically, about 10% of circulating T is irreversibly converted into its more potent derivative DHT by the enzyme 5α-reductase, found in tissues like the liver, prostate, genital skin, and hair follicles. T is also aromatized to E1 or E2, primarily in adipose tissue, which contributes to its indirect cardiovascular effects. This is supported by the observation that aromatase inhibitors reduce EC vasodilator function, likely by blocking T conversion to E2.
During the reproductive years, women produce 25% of circulating T from the ovaries, another 25% from the adrenal glands, and the remaining 50% from the peripheral conversion of androstenedione. Although serum T levels in women are significantly lower than in men, these levels do not substantially decrease after menopause, as the ovaries continue to produce androgens [28]. Bilateral oophorectomy in Pre-MW causes a reduction of around 50% in circulating T concentrations [17]. Also, women who undergo surgical bilateral oophorectomy have T levels 40–50% lower than those experiencing natural menopause, suggesting that natural menopause is a relatively hyperandrogenic state [439]. Longitudinal studies in Post-MW over 10 years have shown an age-related increase in total serum T and androstenedione alongside a decrease in E2 and DHT [440]. During the postmenopausal period, total T levels gradually increase with age from 19.9 to 26.2 ng/dL, whereas free T levels remain relatively stable between 3.7 and 4.6 pg/mL [405]. However, circulating levels of E2 and T may not accurately reflect their tissue concentrations, as both aromatase and 5α-reductase are present in various tissues, including blood vessels [441]. In the postmenopausal stage, each cell and peripheral tissue alongside the adipose tissue synthesizes small amounts of androgens to meet local metabolic needs [400]. Consistent with this concept, BMI has been linked to androgen metabolism in Post-MW [442].
Androgens bind to androgen receptors (ARs) in various tissues, including the cardiovascular system. The sensitivity of tissues to androgens depends on the activity of androgen metabolic enzymes, AR levels, polymorphisms, and co-regulators [443]. The use of aromatase and 5α-reductase inhibitors, often in breast cancer treatments, can alter androgen levels and lead to cardiovascular effects. Androgens might influence cardiovascular risk in Post-MW, with the relationships between circulating free E2, free T, SHBG, and their ratios being more predictive of carotid intimal thickening and the progression of CVD than the individual hormone levels alone. In Post-MW, higher E2 levels were associated with a reduced risk of CAD, whereas higher T levels and a higher T/E2 ratio were linked to an increased risk of cardiovascular events, CAD, and heart failure [55]. In primate VSMCs, E2+T upregulates AR expression, while E2 alone has minimal effects, suggesting an interaction between E2 and T in regulating ARs [444]. ARs are also expressed in rat ECs and VSMCs although at lower levels in females compared to males [445].
Although elevated T levels are linked to lower all-cause and cancer mortality in men, they may negatively affect cardiovascular and renal health in both men and Post-MW [446]. The higher BP and incidence of CVD in adult men are partially attributed to androgen-induced harmful cardiovascular effects. Supporting this concept, T impairs bradykinin-induced endothelium-dependent relaxation and NO production in porcine coronary arteries while enhancing TXA2-induced coronary vasoconstriction in guinea pigs [146]. Additionally, the AR antagonist flutamide induces vasodilation in rat blood vessels [447]. The increased cardiovascular and renal disease risk observed in Post-MW has also been related to a higher T/E2 ratio due to decreased ovarian E2 production. Furthermore, BP is higher in male compared to female SHR, decreases in castrated males, and rises in OVX females treated with T, indicating a connection between the increased T/E2 ratio and HTN after menopause [439]. Also, male mice fed a high-fat diet show reduced ACh-induced relaxation and increased ROS generation in aortic rings, and these effects are reversed in castrated mice and restored in mice treated with T, suggesting that T promotes oxidative stress and EC dysfunction during a high-fat diet [155]. In cardiomyocytes, DHT shows stronger binding to ARs than T and induces hypertrophy through activation of mTOR complex 1/40S ribosomal protein S6 kinase 1 [200]; upregulation of Ca2+ regulatory proteins, IP3/Ca2+, and MAPK; and increased contraction mechanisms [192]. In female mice, DHT treatment led to a more than twofold increase in carotid arterial stiffness and a reduction in aortic expression of ERα and GPER. Also, in cultured VSMCs, treatment with DHT, dexamethasone, or MPA resulted in a suppression of ERα expression, while DHT specifically inhibited GPER mRNA, indicating that androgens may contribute to arterial stiffening by downregulating ER expression [448].
Other research points to cardiovascular benefits of T and suggests that it influences lipid metabolism, enhances hepatic lipoprotein lipase activity, and reduces serum triglycerides and atherogenic lipids [165,449,450]. Lower serum T levels have been observed in men with chronic CVD compared to healthy men, and low circulating T levels are linked to increased atherosclerosis, CAD, and cardiovascular events [450,451], implying that T could affect the progression of angina, myocardial ischemia, and heart failure. Epidemiologic studies have also shown low serum T levels in men with abdominal aortic aneurysm (AAA). Furthermore, androgen deprivation therapy may exacerbate cardiovascular complications in prostate cancer patients. Androgen synthesis inhibitors are also associated with higher incidences of HTN, atrial tachyarrhythmia, and heart failure [399]. T might support coronary vasodilation in young men, while the elevated risk for angina and MI in older men could be related to reduced T levels. Notably, in men with established CVD, intracoronary T administration has been shown to increase coronary blood flow and alleviate myocardial ischemia [452]. Studies have also indicated that women with lower T levels have a higher incidence of cardiovascular events compared to those with higher T levels [453]. In women aged 50–59 years, T shows a positive association with low LDL-C and high HDL-C levels, while women with CVD tend to have lower T levels [454]. In healthy Post-MW, there is a positive correlation between plasma T levels and brachial artery FMD, implying that T may offer protective effects on ECs [455]. Elevated free T levels are also linked to a reduced risk of heart failure in Post-MW [74].
Experimental research further supports the vascular benefits of T. T treatment was shown to protect against vascular aging, improve cell senescence, and reduce intima-media thickness and vascular remodeling in the carotid artery and abdominal aorta of aging mice through the Gas6/Axl pathway [456]. Also, in a male murine model of AAA induced by topical CaCl2 application and Ang II-infusion, AAA formation, aortic inflammation, macrophages infiltration, and IL-6 expression were exacerbated in castrated mice and flutamide-implanted intact mice and prevented in T-treated mice, suggesting that selective AR modulators might be useful in aortic pathologies [457]. Also, DHT stimulates EC proliferation and angiogenesis by upregulating VEGF mRNA expression [159]. Additionally, T has been shown to induce relaxation in the coronary arteries of canines, pigs, and rabbits as well as in the aorta of rabbits and rats [161,458,459]. Canine intracoronary administration of T induces vasodilation and NO release [460]. In human aortic ECs, physiological T concentrations (1–100 nM) induced rapid increases in NO production and eNOS phosphorylation/activation that were simulated by DHT and blocked by the AR antagonist nilutamide, transfection with AR siRNA, Akt inhibitor SH-5, or PI3K inhibitor wortmannin, supporting that T rapidly induces EC NO production via AR-dependent and PI3K/Akt-mediated phosphorylation/activation of eNOS [144]. In human aortic ECs, T rapidly assembles a membrane complex of AR, caveolin-1, and c-Src, thereby facilitating a c-Src/PI3K/Akt cascade and subsequent activation of eNOS [145]. The vascular relaxation effect induced by T is partially diminished in the presence of K+ channel blockers, indicating the involvement of voltage-dependent K+ channels [458]. In human coronary artery ECs, T, non-permeant T conjugate, or the non-aromatizable DHT caused hyperpolarization and rapidly enhanced small- and large-conductance Ca2+-activated K+ currents (SKCa and BKCa), which were blocked by the AR antagonist flutamide, pertussis toxin, protein kinase A inhibitor H-89, or SKCa and BKCa channel blockers apamin and iberiotoxin, supporting T-induced rapid activation of SKCa and BKCa currents via a membrane AR, Gi/o protein, and protein kinase A [151]. In the aorta of SHR, T facilitates the release of EDHF and activates both voltage-dependent and BKCa channels. Nonetheless, a considerable portion of T-mediated vasodilation in both WKY and SHR occurs independently of the endothelium and is attributed to activation of ATP-sensitive K+ channels in VSMCs [461]. DHT influences the proliferation of human umbilical VSMCs in a concentration-dependent fashion, enhancing [3H]thymidine incorporation at low doses and suppressing it at higher doses [180]. Also, T promotes apoptosis in VSMCs through mitochondrial ROS generation [181]. Both T and DHT cause relaxation of the porcine coronary artery and a reduction in VSMC [Ca2+]c [161,162,458]. In porcine coronary artery, T induces more prominent inhibition of PGF- than KCl-induced contraction [161], implying inhibition of other PGF-activated contraction pathways, such as PKC. In cultured VSMCs, T ameliorated Ang II-induced cell senescence and collagen overexpression, decreased MMP-2 expression/activity, and increased the expression of TIMP-2, underscoring the protective effects of T on VSMCs senescence, collagen synthesis, and vascular aging [462].
Conditions linked to hormone imbalances may offer valuable insights into how the hormonal environment affects cardiovascular function. Polycystic ovary syndrome (PCOS) is marked by polycystic ovaries, amenorrhea, hirsutism, anovulatory infertility, elevated androgen and estrogen levels, obesity, insulin resistance, and lipid metabolism abnormalities. In individuals with PCOS, both insulin and LH promote androgen synthesis in ovarian theca cells, leading to higher levels of T and androstenedione. Hyperandrogenemia associated with PCOS may also contribute to BP dysregulation and a heightened cardiovascular risk through direct effects of T on the vascular system, baroreflex-mediated BP control, and renal responses to baroreceptor unloading [463]. Additionally, as many women with PCOS are overweight, the increased androgen levels, along with their conversion by aromatase, may elevate E1 concentrations in adipose tissue. Some research in PCOS patients has suggested a link between reduced ovarian E2 and CVD [72]. While women with PCOS exhibit CVD risk factors such as elevated BP, BMI, fasting glucose, hypertriglyceridemia, and low HDL-C, a retrospective study conducted in the UK did not find a higher incidence of cardiovascular morbidity or mortality among PCOS women [464]. Notably, Post-MW women and those with PCOS share similar sex hormone profiles characterized by E1 as the predominant estrogen, a deficiency of P4, and a relative rise in androgens. Additional research in women with PCOS and animal models could offer valuable insights into how other sex hormones influence the vascular effects of E2.
In men and Post-MW, exogenous androgens are sometimes administered off-label to improve libido, sexual health, and physical performance [465]. Some studies suggest that misuse of androgenic-anabolic steroids may increase the risk of CVD in males. Nonetheless, managing hypogonadism in older men has yielded inconsistent outcomes with respect to cardiovascular health [466]. In the T Cardiovascular Trial in older men, T treatment did not lead to a higher incidence of cardiovascular or prostate-related adverse events compared to placebo, although it was linked to an increase in the volume of noncalcified coronary artery plaques [467]. Also, the TRAVERSE (TheRapy for Assessment of long-term Vascular events and Efficacy ResponSE) study in hypogonadal men 45 to 80 years old with pre-existing or a high risk of CVD showed that daily transdermal 1.62% T gel did not increase the risk for major adverse cardiac events or prostate cancer [468]. However, in male Wistar rats, T treatment was associated with increased collagen deposition in the myocardial tissue, likely through downregulation of dickkopf1 (DKK1) mRNA expression, which may explain some of the cardiac structural abnormalities observed in some androgens abusers [469]. As a result, the Food and Drug Administration introduced stricter regulations on T replacement therapy and called for additional research to evaluate its cardiovascular safety [466]. Studies on the relationship between T and CVD events in Post-MW have yielded conflicting results, demonstrating that both high and low T levels are associated with an increased risk of CVD. The only evidence-based indication for T therapy is for the treatment of hypoactive sexual desire disorder in Post-MW at doses that approximate physiological T levels in Pre-MW [470]. Because oral T causes more side effects and hepatotoxicity and requires administration more than once a day, transdermal preparations are preferred [471].
Transgender and nonbinary individuals often receive gender-affirming hormone therapy to align their outward appearance with their gender. However, the renal and metabolic processes, parameters, and biomarkers are different in transgender versus cisgender individuals [472]. Extended exposure to E2, such as through oral contraceptives or gender-affirming hormone therapy, may contribute to altered CVD risk in both cisgender and transgender females. Research utilizing human arterioles obtained from discarded adipose tissue during surgery has demonstrated that NO-dependent FMD is generally preserved in females across different age groups. However, microvascular exposure to E2 for 16–20 h led to EC dysfunction in arterioles from both younger (<40 years) and older (≥40 years) females, with even more pronounced EC and VSMC impairment observed in vessels from biological males. Notably, females aged ≥40 and biological males exhibited reduced expression of ERβ and GPER in ECs when compared to females under 40 years old. Furthermore, ERα, the receptor most closely associated with the beneficial effects of E2, was found exclusively in the adventitia. These findings have suggested a potential cardiovascular risk linked to prolonged hormone exposure via contraceptive use or gender-affirming treatments [255]. This aligns with reports that the incidences of VTE and stroke are higher in transwomen receiving gender-affirming E2-based therapy than in cisgender men, which could be related to prolonged use and potential prothrombotic effects of E2 [473,474,475]. Also, some studies have suggested that transwomen receiving transgender E2 therapy have a higher incidence of MI than cismen [474]. However, other studies showed less pronounced disparities in MI incidence rates between transwomen and cismen [476], suggesting that factors beyond hormone therapy, such as socio-economic status and stress, may be involved. The impact of T on cardiovascular function, renal health, and metabolic conditions may vary significantly between transgender men (female to male) and cisgender women. Some studies showed a higher incidence of MI in transmen receiving gender-affirming T-based therapy than ciswomen [473]. These findings underscore the importance of tailored cardiovascular risk management for each individual and reveal the gaps in current research regarding the effects of various hormone therapies and regimens in different genders [473,476]. With larger studies, expanded cohort size, and extended follow-up in the transgender and nonbinary community, the data will allow further analyses of critical health endpoints across various categories of CVD and their potential modulation by different hormone formulations, routes of administration, and doses [475,476].

11. Discussion and Perspectives

Sex-based differences are recognized not only within the reproductive system but also across the cardiovascular pathophysiology, contributing to variations in CVD incidence between males and females as well as between Post-MW and Pre-MW. These disparities are influenced by gene expression associated with the X and Y chromosomes, along with age-dependent changes in the levels and balance of circulating E2, P4, and T. A decline in E2 levels is a hallmark of menopause, leading to characteristic menopausal symptoms and correlating with increased CVD risk. MHT helps alleviate menopausal symptoms by restoring E2 concentrations. Both epidemiological evidence and experimental research point toward vascular protective effects mediated by E2. CVD prevalence tends to be higher in adult males and in Post-MW compared to Pre-MW. Earlier observational studies proposed a protective vascular role for MHT. Also, mechanistic investigations have uncovered sex-specific variations in cardiovascular responses and revealed beneficial actions of E2/ERs, including promotion of vasodilation and inhibition of VSMC proliferation through both genomic and nongenomic pathways. Despite these findings, RCTs have not endorsed MHT for the primary prevention of CVD and have instead highlighted potential adverse effects, such as heightened risks of VTE and stroke.
Optimizing MHT by carefully selecting its type, dosage, administration route, timing, and duration alongside evaluating age-related alterations in ER subtypes, their distribution, responsiveness, and downstream signaling may enhance its effectiveness in alleviating menopausal vasomotor symptoms and improving vascular outcomes in CVD (Table 4). With the development of newer MHT formulations and optimizing factors such as dosage, route of delivery, and timing in relation to the menopausal stage, the cardiovascular benefits of MHT can be amplified in Post-MW. Reassessment of data from older RCTs including WHI by participant age and time since menopause suggests that for healthy women within 10 years of menopausal transition who have bothersome menopausal symptoms, the benefits of MHT outweigh its risks, with fewer CVD events in younger versus older women [477]. Future research should explore the hormonal milieu and age-associated shifts in endogenous levels of E2, FSH, SHBG, P4, and T, along with their metabolites, interactions, and potential links to CVD risk, especially during the menopausal transition. Additionally, sex hormones influence lipid profiles and coagulation pathways and play regulatory roles in the gut microbiota, immune function, and nervous system, all of which may indirectly impact CVD and its response to MHT.
Current guidelines suggest increased risk for endometrial cancer among women with a uterus taking E2-only MHT. Also, MHT is not indicated for primary or secondary prevention of CVD, dementia, or deterioration of cognitive function because of the greater risks of CAD, stroke, and VTE [477,478]. Despite this, MHT has proven effective in relieving vasomotor symptoms associated with menopause. A more detailed investigation into the cardiovascular impact of sex hormones across various formulations and treatment regimens as well as the vascular signaling alterations during menopause could refine the MHT strategies and optimize their efficacy in lowering the risk and the management of CVD in Post-MW.
We should note some of the limitations of this review. Our inclusion criteria may have inadvertently excluded relevant studies, particularly those published in non-English language or in less accessible journals, and some pertinent information may have been missed. Also, while our intended focus was on MHT and CVD in Post-MW, a substantial amount of information was derived from studies in men or male animals. Future reviews could address these gaps by employing broader language inclusion and describing more large-scale comprehensive studies in women and detailed experiments in female animals as they become available.

12. Conclusions

Understanding the specific effects of sex hormones and how different hormonal therapies affect various biological processes in a gender-specific manner is essential for effective CVD management. Investigating the distinct roles of E2, P4, and T as well as their interactions and metabolites could provide deeper insights into personalized and effective treatment strategies. This comprehensive knowledge would support the development of targeted therapies that optimize benefits while minimizing risks, ultimately contributing to improved cardiovascular outcomes across diverse populations. Rigorous research into these dynamic interactions is crucial to refine hormone therapy practices and tailor interventions to the unique physiological needs of each individual.

Author Contributions

Conceptualization, W.X. and R.A.K.; methodology, W.X. and R.A.K.; software, W.X. and R.A.K.; validation, W.X. and R.A.K.; formal analysis, W.X. and R.A.K.; investigation, W.X. and R.A.K.; resources, R.A.K.; data curation, W.X. and R.A.K.; writing—original draft preparation, W.X. and R.A.K.; writing—review and editing, W.X. and R.A.K.; visualization, W.X. and R.A.K.; supervision, R.A.K.; project administration, R.A.K.; funding acquisition, R.A.K. All authors have read and agreed to the published version of the manuscript.

Funding

This work was supported by grants from the National Heart, Lung, and Blood Institute (R56HL147889, R01HL147889-A1) to R.A. Khalil. W. Xia was a postdoctoral fellow and a visiting physician/scientist with a research scholarship from Jiangxi Provincial People’s Hospital, Jiangxi Province, China.

Conflicts of Interest

The authors declare no conflict of interest.

Abbreviations

ACh, acetylcholine; Ang II, angiotensin II; BKCa, large-conductance Ca2+-activated K+ channel; BMI, body mass index; BP, blood pressure; [Ca2+]c, cytosolic free calcium concentration; CAD, coronary artery disease; CEE, conjugated equine estrogen; CVD, cardiovascular disease; DHT, dihydrotestosterone; DRSP, drospirenone; E2, estrogen (17β-estradiol); EC, endothelial cell; ECM, extracellular matrix; EDHF, endothelium-derived hyperpolarizing factor; ELITE, Early versus Late Intervention Trial with Estradiol, eNOS, endothelial nitric oxide synthase; ER, estrogen receptor; ERE, estrogen response element; ET-1, endothelin-1; FMD, flow-mediated dilation; GPER, G protein-coupled receptor; HDL-C, high-density lipoprotein cholesterol; HERS, Heart and Estrogen/progestin Replacement Study; HTN, hypertension; IL-6, interleukin-6; KEEPS, Kronos Early Estrogen Prevention Study; KLF, Kruppel-like factor; KO, knockout; LDL-C, low-density lipoprotein cholesterol; MAPK, mitogen-activated protein kinase; MHT, menopausal hormone therapy; MI, myocardial infarction; MLCK, myosin light-chain kinase; MMP, matrix metalloproteinase; MPA, medroxyprogesterone acetate; NO, nitric oxide; NHS, Nurses’ Health Study; ONOO, peroxynitrite; OVX, ovariectomized; P4, progesterone; PAH, pulmonary arterial hypertension; PKG, protein kinase G; PCOS, polycystic ovary syndrome; PGI2, prostacyclin; PKC, protein kinase C; PMCA, plasma membrane Ca2+-ATPase; Post-MW, postmenopausal women; Pre-MW, premenopausal women; RCT, randomized clinical trial; ROCK, rho-kinase; SERCA, sarcoplasmic/endoplasmic reticulum Ca2+ ATPase; SHBG, sex hormone binding globulin; SERMs, selective estrogen receptor modulators; SHR, spontaneously hypertensive rat; SIRT1, Sirtuin 1; T, testosterone; TNFα, tumor necrosis factor-α; TXA2, thromboxane A2; VSMC, vascular smooth muscle cell; VTE, venous thromboembolism; WHI, Women’s Health Initiative.

References

  1. Martin, S.S.; Aday, A.W.; Almarzooq, Z.I.; Anderson, C.A.M.; Arora, P.; Avery, C.L.; Baker-Smith, C.M.; Gibbs, B.B.; Beaton, A.Z.; Boehme, A.K.; et al. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation 2024, 149, e347–e913. [Google Scholar]
  2. Global Cardiovascular Risk Consortium; Magnussen, C.; Ojeda, F.M.; Leong, D.P.; Alegre-Diaz, J.; Amouyel, P.; Aviles-Santa, L.; De Bacquer, D.; Ballantyne, C.M.; Bernabé-Ortiz, A.; et al. Global Effect of Modifiable Risk Factors on Cardiovascular Disease and Mortality. N. Engl. J. Med. 2023, 389, 1273–1285. [Google Scholar]
  3. Vaura, F.; Palmu, J.; Aittokallio, J.; Kauko, A.; Niiranen, T. Genetic, Molecular, and Cellular Determinants of Sex-Specific Cardiovascular Traits. Circ. Res. 2022, 130, 611–631. [Google Scholar] [CrossRef]
  4. Vaidakis, N. Conceptual controversies regarding the terms Gender and Sex. Psychiatriki 2020, 31, 271–274. [Google Scholar] [CrossRef]
  5. Ratnu, V.S.; Emami, M.R.; Bredy, T.W. Genetic and epigenetic factors underlying sex differences in the regulation of gene expression in the brain. J. Neurosci. Res. 2017, 95, 301–310. [Google Scholar] [CrossRef]
  6. Liszewski, W.; Peebles, J.K.; Yeung, H.; Arron, S. Persons of Nonbinary Gender—Awareness, Visibility, and Health Disparities. N. Engl. J. Med. 2018, 379, 2391–2393. [Google Scholar] [CrossRef]
  7. Ortona, E.; Pierdominici, M.; Rider, V. Editorial: Sex Hormones and Gender Differences in Immune Responses. Front. Immunol. 2019, 10, 1076. [Google Scholar] [CrossRef]
  8. Ober, C.; Loisel, D.A.; Gilad, Y. Sex-specific genetic architecture of human disease. Nat. Rev. Genet. 2008, 9, 911–922. [Google Scholar] [CrossRef]
  9. Stanhewicz, A.E.; Wenner, M.M.; Stachenfeld, N.S. Sex differences in endothelial function important to vascular health and overall cardiovascular disease risk across the lifespan. Am. J. Physiol. Heart Circ. Physiol. 2018, 315, H1569–H1588. [Google Scholar] [CrossRef]
  10. Samargandy, S.; Matthews, K.A.; Brooks, M.M.; Barinas-Mitchell, E.; Magnani, J.W.; Thurston, R.C.; El Khoudary, S.R. Trajectories of Blood Pressure in Midlife Women: Does Menopause Matter? Circ. Res. 2022, 130, 312–322. [Google Scholar] [CrossRef]
  11. Stefanick, M.L. Estrogens and progestins: Background and history, trends in use, and guidelines and regimens approved by the US Food and Drug Administration. Am. J. Med. 2005, 118 (Suppl. 12B), 64–73. [Google Scholar] [CrossRef]
  12. Hyvärinen, M.; Karvanen, J.; Juppi, H.-K.; Karppinen, J.E.; Tammelin, T.H.; Kovanen, V.; Aukee, P.; Sipilä, S.; Rantalainen, T.; Laakkonen, E.K. Menopausal symptoms and cardiometabolic risk factors in middle-aged women: A cross-sectional and longitudinal study with 4-year follow-up. Maturitas 2023, 174, 39–47. [Google Scholar] [CrossRef]
  13. Zhu, B.T.; Han, G.Z.; Shim, J.Y.; Wen, Y.; Jiang, X.R. Quantitative structure-activity relationship of various endogenous estrogen metabolites for human estrogen receptor alpha and beta subtypes: Insights into the structural determinants favoring a differential subtype binding. Endocrinology 2006, 147, 4132–4150. [Google Scholar] [CrossRef]
  14. Kuhl, H. Pharmacology of estrogens and progestogens: Influence of different routes of administration. Climacteric 2005, 8 (Suppl. 1), 3–63. [Google Scholar] [CrossRef]
  15. Smiley, D.A.; Khalil, R.A. Estrogenic compounds, estrogen receptors and vascular cell signaling in the aging blood vessels. Curr. Med. Chem. 2009, 16, 1863–1887. [Google Scholar] [CrossRef]
  16. Gruber, C.J.; Tschugguel, W.; Schneeberger, C.; Huber, J.C. Production and actions of estrogens. N. Engl. J. Med. 2002, 346, 340–352. [Google Scholar] [CrossRef]
  17. Stanczyk, F.Z.; Chaikittisilpa, S.; Sriprasert, I.; Rafatnia, A.; Nadadur, M.; Mishell, D.R., Jr. Circulating androgen levels before and after oophorectomy in premenopausal and postmenopausal women. Climacteric 2019, 22, 169–174. [Google Scholar] [CrossRef]
  18. Kotsopoulos, J.; Shafrir, A.L.; Rice, M.; Hankinson, S.E.; Eliassen, A.H.; Tworoger, S.S.; Narod, S.A. The relationship between bilateral oophorectomy and plasma hormone levels in postmenopausal women. Horm. Cancer 2015, 6, 54–63. [Google Scholar] [CrossRef]
  19. Hemsell, D.L.; Grodin, J.M.; Brenner, P.F.; Siiteri, P.K.; MacDonald, P.C. Plasma precursors of estrogen. II. Correlation of the extent of conversion of plasma androstenedione to estrone with age. J. Clin. Endocrinol. Metab. 1974, 38, 476–479. [Google Scholar] [CrossRef]
  20. Labrie, F.; Martel, C.; Balser, J. Wide distribution of the serum dehydroepiandrosterone and sex steroid levels in postmenopausal women: Role of the ovary? Menopause 2011, 18, 30–43. [Google Scholar] [CrossRef]
  21. Miller, W.L.; Auchus, R.J. The molecular biology, biochemistry, and physiology of human steroidogenesis and its disorders. Endocr. Rev. 2011, 32, 81–151. [Google Scholar] [CrossRef]
  22. Simpson, E.R. Sources of estrogen and their importance. J. Steroid Biochem. Mol. Biol. 2003, 86, 225–230. [Google Scholar] [CrossRef]
  23. Rothman, M.S.; Carlson, N.E.; Xu, M.; Wang, C.; Swerdloff, R.; Lee, P.; Goh, V.H.; Ridgway, E.C.; Wierman, M.E. Reexamination of testosterone, dihydrotestosterone, estradiol and estrone levels across the menstrual cycle and in postmenopausal women measured by liquid chromatography-tandem mass spectrometry. Steroids 2011, 76, 177–182. [Google Scholar] [CrossRef]
  24. Nunes, E.; Gallardo, E.; Morgado-Nunes, S.; Fonseca-Moutinho, J. Steroid hormone levels in postmenopausal hysterectomised women with and without ovarian conservation: The continuous endocrine function of the ovaries. J. Obstet. Gynaecol. 2023, 43, 2141618. [Google Scholar] [CrossRef]
  25. Mai, P.L.; Miller, A.; Black, A.; Falk, R.T.; Boggess, J.F.; Tucker, K.; Stuckey, A.R.; Rodriguez, G.C.; Wong, C.; Amatruda, T.T.; et al. Effect of risk-reducing salpingo-oophorectomy on sex steroid hormone serum levels among postmenopausal women: An NRG Oncology/Gynecologic Oncology Group study. Am. J. Obstet. Gynecol. 2022, 227, 61.e1–61.e18. [Google Scholar] [CrossRef]
  26. Laughlin, G.A.; Barrett-Connor, E.; Kritz-Silverstein, D.; von Muhlen, D. Hysterectomy, oophorectomy, and endogenous sex hormone levels in older women: The Rancho Bernardo Study. J. Clin. Endocrinol. Metab. 2000, 85, 645–651. [Google Scholar]
  27. Rannevik, G.; Jeppsson, S.; Johnell, O.; Bjerre, B.; Laurell-Borulf, Y.; Svanberg, L. A longitudinal study of the perimenopausal transition: Altered profiles of steroid and pituitary hormones, SHBG and bone mineral density. Maturitas 1995, 21, 103–113. [Google Scholar] [CrossRef]
  28. Burger, H.G.; Dudley, E.C.; Cui, J.; Dennerstein, L.; Hopper, J.L. A prospective longitudinal study of serum testosterone, dehydroepiandrosterone sulfate, and sex hormone-binding globulin levels through the menopause transition. J. Clin. Endocrinol. Metab. 2000, 85, 2832–2838. [Google Scholar] [CrossRef]
  29. Thurston, R.C.; Chang, Y.; Kline, C.E.; Swanson, L.M.; El Khoudary, S.R.; Jackson, E.A.; Derby, C.A. Trajectories of Sleep Over Midlife and Incident Cardiovascular Disease Events in the Study of Women’s Health Across the Nation. Circulation 2024, 149, 545–555. [Google Scholar] [CrossRef]
  30. Avis, N.E.; Crawford, S.L.; Greendale, G.; Bromberger, J.T.; Everson-Rose, S.A.; Gold, E.B.; Hess, R.; Joffe, H.; Kravitz, H.M.; Tepper, P.G.; et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern. Med. 2015, 175, 531–539. [Google Scholar] [CrossRef]
  31. Gupta, P.; Harte, A.; Sturdee, D.W.; Sharma, A.; Barnett, A.H.; Kumar, S.; McTernan, P.G. Effects of menopausal status on circulating calcitonin gene-related peptide and adipokines: Implications for insulin resistance and cardiovascular risks. Climacteric 2008, 11, 364–372. [Google Scholar] [CrossRef]
  32. Herber-Gast, G.; Brown, W.J.; Mishra, G.D. Hot flushes and night sweats are associated with coronary heart disease risk in midlife: A longitudinal study. BJOG 2015, 122, 1560–1567. [Google Scholar] [CrossRef]
  33. Muka, T.; Oliver-Williams, C.; Colpani, V.; Kunutsor, S.; Chowdhury, S.; Chowdhury, R.; Kavousi, M.; Franco, O.H. Association of Vasomotor and Other Menopausal Symptoms with Risk of Cardiovascular Disease: A Systematic Review and Meta-Analysis. PLoS ONE 2016, 11, e0157417. [Google Scholar] [CrossRef]
  34. Randolph, J.F., Jr.; Sowers, M.; Bondarenko, I.; Gold, E.B.; Greendale, G.A.; Bromberger, J.T.; Brockwell, S.E.; Matthews, K.A. The relationship of longitudinal change in reproductive hormones and vasomotor symptoms during the menopausal transition. J. Clin. Endocrinol. Metab. 2005, 90, 6106–6112. [Google Scholar] [CrossRef]
  35. Zhou, Y.; Yang, R.; Li, C.; Tao, M. Sleep disorder, an independent risk associated with arterial stiffness in menopause. Sci. Rep. 2017, 7, 1904. [Google Scholar] [CrossRef]
  36. Janssen, I.; Powell, L.H.; Matthews, K.A.; Cursio, J.F.; Hollenberg, S.M.; Sutton-Tyrrell, K.; Bromberger, J.T.; Everson-Rose, S.A. Depressive symptoms are related to progression of coronary calcium in midlife women: The Study of Women’s Health Across the Nation (SWAN) Heart Study. Am. Heart J. 2011, 161, 1186–1191.e1. [Google Scholar] [CrossRef]
  37. Zhu, D.; Chung, H.-F.; Dobson, A.J.; Pandeya, N.; Anderson, D.J.; Kuh, D.; Hardy, R.; Brunner, E.J.; Avis, N.E.; Gold, E.B.; et al. Vasomotor menopausal symptoms and risk of cardiovascular disease: A pooled analysis of six prospective studies. Am. J. Obstet. Gynecol. 2020, 223, 898.e1–898.e16. [Google Scholar] [CrossRef]
  38. Thurston, R.C.; Vlachos, H.E.A.; Derby, C.A.; Jackson, E.A.; Brooks, M.M.; Matthews, K.A.; Harlow, S.; Joffe, H.; El Khoudary, S.R. Menopausal Vasomotor Symptoms and Risk of Incident Cardiovascular Disease Events in SWAN. J. Am. Heart Assoc. 2021, 10, e017416. [Google Scholar] [CrossRef]
  39. Armeni, A.; Anagnostis, P.; Armeni, E.; Mili, N.; Goulis, D.; Lambrinoudaki, I. Vasomotor symptoms and risk of cardiovascular disease in peri- and postmenopausal women: A systematic review and meta-analysis. Maturitas 2023, 171, 13–20. [Google Scholar] [CrossRef]
  40. Hitchcock, C.L.; Elliott, T.G.; Norman, E.G.; Stajic, V.; Teede, H.; Prior, J.C. Hot flushes and night sweats differ in associations with cardiovascular markers in healthy early postmenopausal women. Menopause 2012, 19, 1208–1214. [Google Scholar] [CrossRef]
  41. El Khoudary, S.R.; Santoro, N.; Chen, H.-Y.; Tepper, P.G.; Brooks, M.M.; Thurston, R.C.; Janssen, I.; Harlow, S.D.; Barinas-Mitchell, E.; Selzer, F.; et al. Trajectories of estradiol and follicle-stimulating hormone over the menopause transition and early markers of atherosclerosis after menopause. Eur. J. Prev. Cardiol. 2016, 23, 694–703. [Google Scholar] [CrossRef]
  42. Ji, H.; Kwan, A.C.; Chen, M.T.; Ouyang, D.; Ebinger, J.E.; Bell, S.P.; Niiranen, T.J.; Bello, N.A.; Cheng, S. Sex Differences in Myocardial and Vascular Aging. Circ. Res. 2022, 130, 566–577. [Google Scholar] [CrossRef]
  43. Regitz-Zagrosek, V.; Gebhard, C. Gender medicine: Effects of sex and gender on cardiovascular disease manifestation and outcomes. Nat. Rev. Cardiol. 2023, 20, 236–247. [Google Scholar] [CrossRef]
  44. George, J.; Rapsomaniki, E.; Pujades-Rodriguez, M.; Shah, A.D.; Denaxas, S.; Herrett, E.; Smeeth, L.; Timmis, A.; Hemingway, H. How Does Cardiovascular Disease First Present in Women and Men? Incidence of 12 Cardiovascular Diseases in a Contemporary Cohort of 1,937,360 People. Circulation 2015, 132, 1320–1328. [Google Scholar] [CrossRef]
  45. Gerdts, E.; Regitz-Zagrosek, V. Sex differences in cardiometabolic disorders. Nat. Med. 2019, 25, 1657–1666. [Google Scholar] [CrossRef]
  46. da Silva, J.S.; Montagnoli, T.L.; de Sa, M.P.L.; Zapata-Sudo, G. Heart Failure in Menopause: Treatment and New Approaches. Int. J. Mol. Sci. 2022, 23, 15140. [Google Scholar] [CrossRef]
  47. Willemars, M.M.A.; Nabben, M.; Verdonschot, J.A.J.; Hoes, M.F. Evaluation of the Interaction of Sex Hormones and Cardiovascular Function and Health. Curr. Heart Fail. Rep. 2022, 19, 200–212. [Google Scholar] [CrossRef]
  48. El Khoudary, S.R.; Aggarwal, B.; Beckie, T.M.; Hodis, H.N.; Johnson, A.E.; Langer, R.D.; Limacher, M.C.; Manson, J.E.; Stefanick, M.L.; Allison, M.A.; et al. Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention: A Scientific Statement From the American Heart Association. Circulation 2020, 142, e506–e532. [Google Scholar] [CrossRef]
  49. Muka, T.; Oliver-Williams, C.; Kunutsor, S.; Laven, J.S.; Fauser, B.C.; Chowdhury, R.; Kavousi, M.; Franco, O.H. Association of Age at Onset of Menopause and Time Since Onset of Menopause With Cardiovascular Outcomes, Intermediate Vascular Traits, and All-Cause Mortality: A Systematic Review and Meta-analysis. JAMA Cardiol 2016, 1, 767–776. [Google Scholar] [CrossRef]
  50. Zhu, D.; Chung, H.-F.; Dobson, A.J.; Pandeya, N.; Giles, G.G.; Bruinsma, F.; Brunner, E.J.; Kuh, D.; Hardy, R.; Avis, N.E.; et al. Age at natural menopause and risk of incident cardiovascular disease: A pooled analysis of individual patient data. Lancet Public Health 2019, 4, e553–e564. [Google Scholar] [CrossRef]
  51. Bots, S.H.; Peters, S.A.E.; Woodward, M. Sex differences in coronary heart disease and stroke mortality: A global assessment of the effect of ageing between 1980 and 2010. BMJ Glob. Health 2017, 2, e000298. [Google Scholar] [CrossRef]
  52. Bairey Merz, C.N.; Shaw, L.J.; Reis, S.E.; Bittner, V.; Kelsey, S.F.; Olson, M.; Johnson, B.D.; Pepine, C.J.; Mankad, S.; Sharaf, B.L.; et al. Insights from the NHLBI-Sponsored Women’s Ischemia Syndrome Evaluation (WISE) Study: Part II: Gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease. J. Am. Coll. Cardiol. 2006, 47, S21–S29. [Google Scholar]
  53. Epstein, A.M.; Weissman, J.S.; Schneider, E.C.; Gatsonis, C.; Leape, L.L.; Piana, R.N. Race and gender disparities in rates of cardiac revascularization: Do they reflect appropriate use of procedures or problems in quality of care? Med. Care 2003, 41, 1240–1255. [Google Scholar] [CrossRef]
  54. Rao, S.V.; Kaul, P.; Newby, L.K.; Lincoff, A.M.; Hochman, J.; Harrington, R.A.; Mark, D.B.; Peterson, E.D. Poverty, process of care, and outcome in acute coronary syndromes. J. Am. Coll. Cardiol. 2003, 41, 1948–1954. [Google Scholar] [CrossRef]
  55. Zhao, D.; Guallar, E.; Ouyang, P.; Subramanya, V.; Vaidya, D.; Ndumele, C.E.; Lima, J.A.; Allison, M.A.; Shah, S.J.; Bertoni, A.G.; et al. Endogenous Sex Hormones and Incident Cardiovascular Disease in Post-Menopausal Women. J. Am. Coll. Cardiol. 2018, 71, 2555–2566. [Google Scholar] [CrossRef]
  56. Dubey, R.K.; Oparil, S.; Imthurn, B.; Jackson, E.K. Sex hormones and hypertension. Cardiovasc. Res. 2002, 53, 688–708. [Google Scholar] [CrossRef]
  57. Benjamin, E.J.; Muntner, P.; Alonso, A.; Bittencourt, M.S.; Callaway, C.W.; Carson, A.P.; Chamberlain, A.M.; Chang, A.R.; Cheng, S.; Das, S.R.; et al. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation 2019, 139, e56–e528. [Google Scholar] [CrossRef]
  58. Nwankwo, T.; Yoon, S.S.; Burt, V.; Gu, Q. Hypertension among adults in the United States: National Health and Nutrition Examination Survey, 2011-2012. NCHS Data Brief 2013, 133, 1–8. [Google Scholar]
  59. Ma, H.; Liu, F.; Li, J.; Chen, J.; Cao, J.; Chen, S.; Liu, X.; Yang, X.; Huang, K.; Shen, C.; et al. Sex Differences in Associations Between Socioeconomic Status and Incident Hypertension Among Chinese Adults. Hypertension 2023, 80, 783–791. [Google Scholar] [CrossRef]
  60. Mancusi, C.; Gerdts, E.; De Simone, G.; Abdelhai, Y.M.; Lønnebakken, M.T.; Boman, K.; Wachtell, K.; Dahlöf, B.; Devereux, R.B. Impact of isolated systolic hypertension on normalization of left ventricular structure during antihypertensive treatment (the LIFE study). Blood Press. 2014, 23, 206–212. [Google Scholar] [CrossRef]
  61. Picone, D.S.; Stoneman, E.; Cremer, A.; Schultz, M.G.; Otahal, P.; Hughes, A.D.; Black, J.A.; Bos, W.J.; Chen, C.-H.; Cheng, H.-M.; et al. Sex Differences in Blood Pressure and Potential Implications for Cardiovascular Risk Management. Hypertension 2022, 80, 316–324. [Google Scholar] [CrossRef]
  62. Ji, H.; Niiranen, T.J.; Rader, F.; Henglin, M.; Kim, A.; Ebinger, J.E.; Claggett, B.; Merz, C.N.B.; Cheng, S. Sex Differences in Blood Pressure Associations With Cardiovascular Outcomes. Circulation 2021, 143, 761–763. [Google Scholar] [CrossRef]
  63. Wei, Y.C.; George, N.I.; Chang, C.W.; Hicks, K.A. Assessing Sex Differences in the Risk of Cardiovascular Disease and Mortality per Increment in Systolic Blood Pressure: A Systematic Review and Meta-Analysis of Follow-Up Studies in the United States. PLoS ONE 2017, 12, e0170218. [Google Scholar] [CrossRef]
  64. Roeters van Lennep, J.E.; Heida, K.Y.; Bots, M.L.; Hoek, A. Cardiovascular disease risk in women with premature ovarian insufficiency: A systematic review and meta-analysis. Eur. J. Prev. Cardiol. 2016, 23, 178–186. [Google Scholar] [CrossRef]
  65. Xu, Z.; Chung, H.F.; Dobson, A.J.; Wilson, L.F.; Hickey, M.; Mishra, G.D. Menopause, hysterectomy, menopausal hormone therapy and cause-specific mortality: Cohort study of UK Biobank participants. Hum. Reprod. 2022, 37, 2175–2185. [Google Scholar] [CrossRef]
  66. Dam, V.; van der Schouw, Y.T.; Onland-Moret, N.C.; Groenwold, R.H.H.; Peters, S.A.E.; Burgess, S.; Wood, A.M.; Chirlaque, M.-D.; Moons, K.G.M.; Oliver-Williams, C.; et al. Association of menopausal characteristics and risk of coronary heart disease: A pan-European case-cohort analysis. Int. J. Epidemiol. 2019, 48, 1275–1285. [Google Scholar] [CrossRef]
  67. Zhu, D.; Chung, H.-F.; Dobson, A.J.; Pandeya, N.; Brunner, E.J.; Kuh, D.; Greenwood, D.C.; Hardy, R.; Cade, J.E.; Giles, G.G.; et al. Type of menopause, age of menopause and variations in the risk of incident cardiovascular disease: Pooled analysis of individual data from 10 international studies. Hum. Reprod. 2020, 35, 1933–1943. [Google Scholar] [CrossRef]
  68. Ramirez, M.F.; Honigberg, M.; Wang, D.; Parekh, J.K.; Bielawski, K.; Courchesne, P.; Larson, M.D.; Levy, D.; Murabito, J.M.; Ho, J.E.; et al. Protein Biomarkers of Early Menopause and Incident Cardiovascular Disease. J. Am. Heart Assoc. 2023, 12, e028849. [Google Scholar] [CrossRef]
  69. Honigberg, M.C.; Zekavat, S.M.; Aragam, K.; Finneran, P.; Klarin, D.; Bhatt, D.L.; Januzzi, J.L., Jr.; Scott, N.S.; Natarajan, P. Association of Premature Natural and Surgical Menopause With Incident Cardiovascular Disease. JAMA 2019, 322, 2411–2421. [Google Scholar] [CrossRef]
  70. Matthews, C.A. Management Strategies for the Ovaries at the Time of Hysterectomy for Benign Disease. Obstet. Gynecol. Clin. North. Am. 2016, 43, 539–549. [Google Scholar] [CrossRef]
  71. Fattet, A.-J.; Toupance, S.; Thornton, S.N.; Monnin, N.; Guéant, J.-L.; Benetos, A.; Koscinski, I. Telomere length in granulosa cells and leukocytes: A potential marker of female fertility? A systematic review of the literature. J. Ovarian Res. 2020, 13, 96. [Google Scholar] [CrossRef]
  72. Ollila, M.-M.; Arffman, R.K.; Korhonen, E.; Morin-Papunen, L.; Franks, S.; Junttila, J.; Piltonen, T.T. Women with PCOS have an increased risk for cardiovascular disease regardless of diagnostic criteria-a prospective population-based cohort study. Eur. J. Endocrinol. 2023, 189, 96–105. [Google Scholar] [CrossRef]
  73. Eissa, M.A.; Gohar, E.Y. Aromatase enzyme: Paving the way for exploring aromatization for cardio-renal protection. Biomed. Pharmacother. 2023, 168, 115832. [Google Scholar] [CrossRef]
  74. Lim, J.; Hashemian, M.; Blechter, B.; Roger, V.L.; Wong, J.Y.Y. Pre-diagnostic free androgen and estradiol levels influence heart failure risk in both women and men: A prospective cohort study in the UK Biobank. Eur. J. Heart Fail. 2024, 26, 540–550. [Google Scholar] [CrossRef]
  75. Owan, T.E.; Hodge, D.O.; Herges, R.M.; Jacobsen, S.J.; Roger, V.L.; Redfield, M.M. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N. Engl. J. Med. 2006, 355, 251–259. [Google Scholar] [CrossRef]
  76. Postigo, A.; Martinez-Selles, M. Sex Influence on Heart Failure Prognosis. Front. Cardiovasc. Med. 2020, 7, 616273. [Google Scholar] [CrossRef]
  77. Frost, A.E.; Badesch, D.B.; Barst, R.J.; Benza, R.L.; Elliott, C.G.; Farber, H.W.; Krichman, A.; Liou, T.G.; Raskob, G.E.; Wason, P.; et al. The changing picture of patients with pulmonary arterial hypertension in the United States: How REVEAL differs from historic and non-US Contemporary Registries. Chest 2010, 139, 128–137. [Google Scholar] [CrossRef]
  78. Batton, K.A.; Austin, C.O.; Bruno, K.A.; Burger, C.D.; Shapiro, B.P.; Fairweather, D. Sex differences in pulmonary arterial hypertension: Role of infection and autoimmunity in the pathogenesis of disease. Biol. Sex. Differ. 2018, 9, 15. [Google Scholar] [CrossRef]
  79. Kumar, A.; McCullough, L. Cerebrovascular disease in women. Ther. Adv. Neurol. Disord. 2021, 14, 1756286420985237. [Google Scholar] [CrossRef]
  80. Leppert, M.H.; Burke, J.F.; Lisabeth, L.D.; Madsen, T.E.; Kleindorfer, D.O.; Sillau, S.; Schwamm, L.H.; Daugherty, S.L.; Bradley, C.J.; Ho, P.M.; et al. Systematic Review of Sex Differences in Ischemic Strokes Among Young Adults: Are Young Women Disproportionately at Risk? Stroke 2022, 53, 319–327. [Google Scholar] [CrossRef]
  81. Ekker, M.S.; Verhoeven, J.I.; Vaartjes, I.; van Nieuwenhuizen, K.M.; Klijn, C.J.M.; de Leeuw, F.E. Stroke incidence in young adults according to age, subtype, sex, and time trends. Neurology 2019, 92, e2444–e2454. [Google Scholar] [CrossRef]
  82. Davis, M.J.; Hill, M.A. Signaling mechanisms underlying the vascular myogenic response. Physiol. Rev. 1999, 79, 387–423. [Google Scholar] [CrossRef]
  83. Welsh, D.G.; Morielli, A.D.; Nelson, M.T.; Brayden, J.E. Transient receptor potential channels regulate myogenic tone of resistance arteries. Circ. Res. 2002, 90, 248–250. [Google Scholar] [CrossRef]
  84. de Vries, T.; Boucherie, D.M.; Chan, K.Y.; Rubio-Beltran, E.; Labastida-Ramirez, A.; Labruijere, S.; Gupta, S.; van den Bogaerdt, A.; Vincent, A.; Dammers, R.; et al. Sex differences in CGRP-induced vasodilation of human middle meningeal arteries but not human coronary arteries: Implications for migraine. Cephalalgia 2024, 44, 3331024241254088. [Google Scholar] [CrossRef]
  85. Cox, D.A.; Cohen, M.L. Selective enhancement of 5-hydroxytryptamine-induced contraction of porcine coronary artery by oxidized low-density lipoprotein. J. Pharmacol. Exp. Ther. 1996, 276, 1095–1103. [Google Scholar] [CrossRef]
  86. Stallone, J.N.; Crofton, J.T.; Share, L. Sexual dimorphism in vasopressin-induced contraction of rat aorta. Am. J. Physiol. 1991, 260, H453–H458. [Google Scholar] [CrossRef]
  87. Orshal, J.M.; Khalil, R.A. Gender, sex hormones, and vascular tone. Am. J. Physiol. Regul. Integr. Comp. Physiol. 2004, 286, R233–R249. [Google Scholar] [CrossRef]
  88. Kingma, J.G., Jr.; Laher, I. Effect of endothelin on sex-dependent regulation of tone in coronary resistance vessels. Biochem. Biophys. Res. Commun. 2021, 540, 56–60. [Google Scholar] [CrossRef]
  89. Chan, M.V.; Bubb, K.J.; Noyce, A.; Villar, I.C.; Duchene, J.; Hobbs, A.J.; Scotland, R.S.; Ahluwalia, A. Distinct endothelial pathways underlie sexual dimorphism in vascular auto-regulation. Br. J. Pharmacol. 2012, 167, 805–817. [Google Scholar] [CrossRef]
  90. Moreau, K.L.; Hildreth, K.L.; Meditz, A.L.; Deane, K.D.; Kohrt, W.M. Endothelial function is impaired across the stages of the menopause transition in healthy women. J. Clin. Endocrinol. Metab. 2012, 97, 4692–4700. [Google Scholar] [CrossRef]
  91. Taddei, S.; Virdis, A.; Ghiadoni, L.; Mattei, P.; Sudano, I.; Bernini, G.; Pinto, S.; Salvetti, A. Menopause is associated with endothelial dysfunction in women. Hypertension 1996, 28, 576–582. [Google Scholar] [CrossRef] [PubMed]
  92. Lu, Y.; Pechlaner, R.; Cai, J.; Yuan, H.; Huang, Z.; Yang, G.; Wang, J.; Chen, Z.; Kiechl, S.; Xu, Q. Trajectories of Age-Related Arterial Stiffness in Chinese Men and Women. J. Am. Coll. Cardiol. 2020, 75, 870–880. [Google Scholar] [CrossRef]
  93. Blackwell, J.A.; Silva, J.F.; Louis, E.M.; Savu, A.; Largent-Milnes, T.M.; Brooks, H.L.; Pires, P.W. Cerebral arteriolar and neurovascular dysfunction after chemically induced menopause in mice. Am. J. Physiol. Heart Circ. Physiol. 2022, 323, H845–H860. [Google Scholar] [CrossRef] [PubMed]
  94. Kos, M.; Denger, S.; Reid, G.; Gannon, F. Upstream open reading frames regulate the translation of the multiple mRNA variants of the estrogen receptor alpha. J. Biol. Chem. 2002, 277, 37131–37138. [Google Scholar] [CrossRef]
  95. Scobie, G.A.; Macpherson, S.; Millar, M.R.; Groome, N.P.; Romana, P.G.; Saunders, P.T. Human oestrogen receptors: Differential expression of ER alpha and beta and the identification of ER beta variants. Steroids 2002, 67, 985–992. [Google Scholar] [CrossRef] [PubMed]
  96. Harris, H.A. Estrogen receptor-beta: Recent lessons from in vivo studies. Mol. Endocrinol. 2007, 21, 1–13. [Google Scholar] [CrossRef]
  97. Heldring, N.; Pike, A.; Andersson, S.; Matthews, J.; Cheng, G.; Hartman, J.; Tujague, M.; Ström, A.; Treuter, E.; Warner, M.; et al. Estrogen receptors: How do they signal and what are their targets. Physiol. Rev. 2007, 87, 905–931. [Google Scholar] [CrossRef]
  98. Krege, J.H.; Hodgin, J.B.; Couse, J.F.; Enmark, E.; Warner, M.; Mahler, J.F.; Sar, M.; Korach, K.S.; Gustafsson, J.; Smithies, O. Generation and reproductive phenotypes of mice lacking estrogen receptor beta. Proc. Natl. Acad. Sci. USA 1998, 95, 15677–15682. [Google Scholar] [CrossRef]
  99. Murphy, E. Estrogen signaling and cardiovascular disease. Circ. Res. 2011, 109, 687–696. [Google Scholar] [CrossRef]
  100. Menazza, S.; Murphy, E. The Expanding Complexity of Estrogen Receptor Signaling in the Cardiovascular System. Circ. Res. 2016, 118, 994–1007. [Google Scholar] [CrossRef]
  101. Gerhard, M.; Ganz, P. How do we explain the clinical benefits of estrogen? From bedside to bench. Circulation 1995, 92, 5–8. [Google Scholar] [CrossRef] [PubMed]
  102. Dan, P.; Cheung, J.C.; Scriven, D.R.; Moore, E.D. Epitope-dependent localization of estrogen receptor-alpha, but not -beta, in en face arterial endothelium. Am. J. Physiol. Heart Circ. Physiol. 2003, 284, H1295–H1306. [Google Scholar] [CrossRef] [PubMed]
  103. Razandi, M.; Oh, P.; Pedram, A.; Schnitzer, J.; Levin, E.R. ERs associate with and regulate the production of caveolin: Implications for signaling and cellular actions. Mol. Endocrinol. 2002, 16, 100–115. [Google Scholar] [CrossRef]
  104. Marino, M.; Galluzzo, P.; Ascenzi, P. Estrogen signaling multiple pathways to impact gene transcription. Curr. Genomics 2006, 7, 497–508. [Google Scholar] [CrossRef] [PubMed]
  105. Rubanyi, G.M.; Freay, A.D.; Kauser, K.; Sukovich, D.; Burton, G.; Lubahn, D.B.; Couse, J.F.; Curtis, S.W.; Korach, K.S. Vascular estrogen receptors and endothelium-derived nitric oxide production in the mouse aorta. Gender difference and effect of estrogen receptor gene disruption. J. Clin. Investig. 1997, 99, 2429–2437. [Google Scholar] [CrossRef]
  106. Mendelsohn, M.E. Genomic and nongenomic effects of estrogen in the vasculature. Am. J. Cardiol. 2002, 90, 3F–6F. [Google Scholar] [CrossRef]
  107. Kim-Schulze, S.; McGowan, K.A.; Hubchak, S.C.; Cid, M.C.; Martin, M.B.; Kleinman, H.K.; Greene, G.L.; Schnaper, H.W. Expression of an estrogen receptor by human coronary artery and umbilical vein endothelial cells. Circulation 1996, 94, 1402–1407. [Google Scholar] [CrossRef]
  108. Hodges, Y.K.; Tung, L.; Yan, X.D.; Graham, J.D.; Horwitz, K.B.; Horwitz, L.D. Estrogen receptors alpha and beta: Prevalence of estrogen receptor beta mRNA in human vascular smooth muscle and transcriptional effects. Circulation 2000, 101, 1792–1798. [Google Scholar] [CrossRef]
  109. Andersson, C.; Lydrup, M.L.; Ferno, M.; Idvall, I.; Gustafsson, J.; Nilsson, B.O. Immunocytochemical demonstration of oestrogen receptor beta in blood vessels of the female rat. J. Endocrinol. 2001, 169, 241–247. [Google Scholar] [CrossRef]
  110. Pare, G.; Krust, A.; Karas, R.H.; Dupont, S.; Aronovitz, M.; Chambon, P.; Mendelsohn, M.E. Estrogen receptor-alpha mediates the protective effects of estrogen against vascular injury. Circ. Res. 2002, 90, 1087–1092. [Google Scholar] [CrossRef]
  111. Jeanes, H.L.; Tabor, C.; Black, D.; Ederveen, A.; Gray, G.A. Oestrogen-mediated cardioprotection following ischaemia and reperfusion is mimicked by an oestrogen receptor (ER)alpha agonist and unaffected by an ER beta antagonist. J. Endocrinol. 2008, 197, 493–501. [Google Scholar] [CrossRef] [PubMed]
  112. Ghisletti, S.; Meda, C.; Maggi, A.; Vegeto, E. 17beta-estradiol inhibits inflammatory gene expression by controlling NF-kappaB intracellular localization. Mol. Cell Biol. 2005, 25, 2957–2968. [Google Scholar] [CrossRef]
  113. Meng, Q.; Bi, Y.; Feng, H.; Ding, X.; Zhang, S.; Chen, Q.; Wang, L.; Zhang, Q.; Li, Y.; Tong, H.; et al. Activation of estrogen receptor alpha inhibits TLR4 signaling in macrophages and alleviates the instability of atherosclerotic plaques in the postmenopausal stage. Int. Immunopharmacol. 2023, 116, 109825. [Google Scholar] [CrossRef]
  114. Meng, Q.; Li, Y.; Ji, T.; Chao, Y.; Li, J.; Fu, Y.; Wang, S.; Chen, Q.; Chen, W.; Huang, F.; et al. Estrogen prevent atherosclerosis by attenuating endothelial cell pyroptosis via activation of estrogen receptor alpha-mediated autophagy. J. Adv. Res. 2020, 28, 149–164. [Google Scholar] [CrossRef]
  115. Christian, R.C.; Liu, P.Y.; Harrington, S.; Ruan, M.; Miller, V.M.; Fitzpatrick, L.A. Intimal estrogen receptor (ER)beta, but not ERalpha expression, is correlated with coronary calcification and atherosclerosis in pre- and postmenopausal women. J. Clin. Endocrinol. Metab. 2006, 91, 2713–2720. [Google Scholar] [CrossRef] [PubMed]
  116. Lindner, V.; Kim, S.K.; Karas, R.H.; Kuiper, G.G.; Gustafsson, J.A.; Mendelsohn, M.E. Increased expression of estrogen receptor-beta mRNA in male blood vessels after vascular injury. Circ. Res. 1998, 83, 224–229. [Google Scholar] [CrossRef]
  117. Xing, D.; Feng, W.; Miller, A.P.; Weathington, N.M.; Chen, Y.-F.; Novak, L.; Blalock, J.E.; Oparil, S. Estrogen modulates TNF-alpha-induced inflammatory responses in rat aortic smooth muscle cells through estrogen receptor-beta activation. Am. J. Physiol. Heart Circ. Physiol. 2007, 292, H2607–H2612. [Google Scholar] [CrossRef] [PubMed]
  118. Hodges, Y.K.; Richer, J.K.; Horwitz, K.B.; Horwitz, L.D. Variant estrogen and progesterone receptor messages in human vascular smooth muscle. Circulation 1999, 99, 2688–2693. [Google Scholar] [CrossRef]
  119. Saito, K.; Cui, H. Estrogen Receptor Alpha Splice Variants, Post-Translational Modifications, and Their Physiological Functions. Cells 2023, 12, 895. [Google Scholar] [CrossRef]
  120. Garcia Pedrero, J.M.; Zuazua, P.; Martinez-Campa, C.; Lazo, P.S.; Ramos, S. The naturally occurring variant of estrogen receptor (ER) ERDeltaE7 suppresses estrogen-dependent transcriptional activation by both wild-type ERalpha and ERbeta. Endocrinology 2003, 144, 2967–2976. [Google Scholar] [CrossRef]
  121. Perkins, M.S.; Louw-du Toit, R.; Africander, D. A comparative characterization of estrogens used in hormone therapy via estrogen receptor (ER)-alpha and -beta. J. Steroid Biochem. Mol. Biol. 2017, 174, 27–39. [Google Scholar] [CrossRef]
  122. Rich, R.L.; Hoth, L.R.; Geoghegan, K.F.; Brown, T.A.; LeMotte, P.K.; Simons, S.P.; Hensley, P.; Myszka, D.G. Kinetic analysis of estrogen receptor/ligand interactions. Proc. Natl. Acad. Sci. USA 2002, 99, 8562–8567. [Google Scholar] [CrossRef] [PubMed]
  123. Kuiper, G.G.; Carlsson, B.; Grandien, K.; Enmark, E.; Häggblad, J.; Nilsson, S.; Gustafsson, J.A. Comparison of the ligand binding specificity and transcript tissue distribution of estrogen receptors alpha and beta. Endocrinology 1997, 138, 863–870. [Google Scholar] [CrossRef] [PubMed]
  124. Ivory, A.; Greene, A.S. Distinct roles of estrone and estradiol in endothelial colony-forming cells. Physiol. Rep. 2023, 11, e15818. [Google Scholar] [CrossRef] [PubMed]
  125. Visniauskas, B.; Kilanowski-Doroh, I.; Ogola, B.O.; Mcnally, A.B.; Horton, A.C.; Sugi, A.I.; Lindsey, S.H. Estrogen-mediated mechanisms in hypertension and other cardiovascular diseases. J. Hum. Hypertens. 2023, 37, 609–618. [Google Scholar] [CrossRef]
  126. Revankar, C.M.; Cimino, D.F.; Sklar, L.A.; Arterburn, J.B.; Prossnitz, E.R. A transmembrane intracellular estrogen receptor mediates rapid cell signaling. Science 2005, 307, 1625–1630. [Google Scholar] [CrossRef]
  127. Filardo, E.; Quinn, J.; Pang, Y.; Graeber, C.; Shaw, S.; Dong, J.; Thomas, P. Activation of the novel estrogen receptor G protein-coupled receptor 30 (GPR30) at the plasma membrane. Endocrinology 2007, 148, 3236–3245. [Google Scholar] [CrossRef]
  128. Haas, E.; Meyer, M.R.; Schurr, U.; Bhattacharya, I.; Minotti, R.; Nguyen, H.H.; Heigl, A.; Lachat, M.; Genoni, M.; Barton, M. Differential effects of 17beta-estradiol on function and expression of estrogen receptor alpha, estrogen receptor beta, and GPR30 in arteries and veins of patients with atherosclerosis. Hypertension 2007, 49, 1358–1363. [Google Scholar] [CrossRef]
  129. Ogola, B.O.; Abshire, C.M.; Visniauskas, B.; Kiley, J.X.; Horton, A.C.; Clark-Patterson, G.L.; Kilanowski-Doroh, I.; Diaz, Z.; Bicego, A.N.; McNally, A.B.; et al. Sex differences in vascular aging and impact of GPER deletion. Am. J. Physiol. Heart Circ. Physiol. 2022, 323, H336–H349. [Google Scholar] [CrossRef]
  130. Ma, J.; Hu, J.; Wang, X.; Zhang, S.; Li, Z.; Liu, J. Improvement of Cardiovascular Function in Aging Females by the Prolonged Activation of G Protein-Coupled Estrogen Receptor. J. Cardiovasc. Transl. Res. 2023, 16, 371–381. [Google Scholar] [CrossRef]
  131. Gohar, E.Y. G protein-coupled estrogen receptor 1 as a novel regulator of blood pressure. Am. J. Physiol. Renal Physiol. 2020, 319, F612–F617. [Google Scholar] [CrossRef] [PubMed]
  132. Sbert-Roig, M.; Bauzá-Thorbrügge, M.; Galmés-Pascual, B.M.; Capllonch-Amer, G.; García-Palmer, F.J.; Lladó, I.; Proenza, A.M.; Gianotti, M. GPER mediates the effects of 17beta-estradiol in cardiac mitochondrial biogenesis and function. Mol. Cell. Endocrinol. 2016, 420, 116–124. [Google Scholar] [CrossRef] [PubMed]
  133. Mendelsohn, M.E.; Karas, R.H. Molecular and cellular basis of cardiovascular gender differences. Science 2005, 308, 1583–1587. [Google Scholar] [CrossRef] [PubMed]
  134. Miller, A.P.; Feng, W.; Xing, D.; Weathington, N.M.; Blalock, J.E.; Chen, Y.-F.; Oparil, S. Estrogen modulates inflammatory mediator expression and neutrophil chemotaxis in injured arteries. Circulation 2004, 110, 1664–1669. [Google Scholar] [CrossRef]
  135. Cassavaugh, J.; Qureshi, N.; Csizmadia, E.; Longhi, M.S.; Matyal, R.; Robson, S.C. Regulation of Hypoxic-Adenosinergic Signaling by Estrogen: Implications for Microvascular Injury. Pharmaceuticals 2023, 16, 422. [Google Scholar] [CrossRef]
  136. Miller, V.M.; Duckles, S.P. Vascular actions of estrogens: Functional implications. Pharmacol. Rev. 2008, 60, 210–241. [Google Scholar] [CrossRef]
  137. Sabbatini, A.R.; Kararigas, G. Estrogen-related mechanisms in sex differences of hypertension and target organ damage. Biol. Sex. Differ. 2020, 11, 31. [Google Scholar] [CrossRef]
  138. Jin, X.; Bin Kim, W.; Kim, M.-N.; Jung, W.W.; Kang, H.K.; Hong, E.-H.; Kim, Y.S.; Shim, W.J.; Han, H.C.; Colwell, C.S.; et al. Oestrogen inhibits salt-dependent hypertension by suppressing GABAergic excitation in magnocellular AVP neurons. Cardiovasc. Res. 2020, 117, 2263–2274. [Google Scholar] [CrossRef]
  139. Reslan, O.M.; Yin, Z.; do Nascimento, G.R.; Khalil, R.A. Subtype-specific estrogen receptor-mediated vasodilator activity in the cephalic, thoracic, and abdominal vasculature of female rat. J. Cardiovasc. Pharmacol. 2013, 62, 26–40. [Google Scholar] [CrossRef]
  140. Haynes, M.P.; Li, L.; Sinha, D.; Russell, K.S.; Hisamoto, K.; Baron, R.; Collinge, M.; Sessa, W.C.; Bender, J.R. Src kinase mediates phosphatidylinositol 3-kinase/Akt-dependent rapid endothelial nitric-oxide synthase activation by estrogen. J. Biol. Chem. 2003, 278, 2118–2123. [Google Scholar] [CrossRef]
  141. Brosnihan, K.B.; Li, P.; Figueroa, J.P.; Ganten, D.; Ferrario, C.M. Estrogen, nitric oxide, and hypertension differentially modulate agonist-induced contractile responses in female transgenic (mRen2)27 hypertensive rats. Am. J. Physiol. Heart Circ. Physiol. 2008, 294, H1995–H2001. [Google Scholar] [CrossRef] [PubMed]
  142. Simoncini, T.; Mannella, P.; Fornari, L.; Caruso, A.; Willis, M.Y.; Garibaldi, S.; Baldacci, C.; Genazzani, A.R. Differential signal transduction of progesterone and medroxyprogesterone acetate in human endothelial cells. Endocrinology 2004, 145, 5745–5756. [Google Scholar] [CrossRef] [PubMed]
  143. You, Y.; Tan, W.; Guo, Y.; Luo, M.; Shang, F.-F.; Xia, Y.; Luo, S. Progesterone promotes endothelial nitric oxide synthase expression through enhancing nuclear progesterone receptor-SP-1 formation. Am. J. Physiol. Heart Circ. Physiol. 2020, 319, H341–H348. [Google Scholar] [CrossRef]
  144. Yu, J.; Akishita, M.; Eto, M.; Ogawa, S.; Son, B.-K.; Kato, S.; Ouchi, Y.; Okabe, T. Androgen receptor-dependent activation of endothelial nitric oxide synthase in vascular endothelial cells: Role of phosphatidylinositol 3-kinase/akt pathway. Endocrinology 2010, 151, 1822–1828. [Google Scholar] [CrossRef] [PubMed]
  145. Yu, J.; Akishita, M.; Eto, M.; Koizumi, H.; Hashimoto, R.; Ogawa, S.; Tanaka, K.; Ouchi, Y.; Okabe, T. Src kinase-mediates androgen receptor-dependent non-genomic activation of signaling cascade leading to endothelial nitric oxide synthase. Biochem. Biophys. Res. Commun. 2012, 424, 538–543. [Google Scholar] [CrossRef]
  146. Rubio-Gayosso, I.; Garcia-Ramirez, O.; Gutierrez-Serdan, R.; Guevara-Balcazar, G.; Muñoz-García, O.; Morato-Cartajena, T.; Zamora-Garza, M.; Ceballos-Reyes, G. Testosterone inhibits bradykinin-induced intracellular calcium kinetics in rat aortic endothelial cells in culture. Steroids 2002, 67, 393–397. [Google Scholar] [CrossRef]
  147. Sobrino, A.; Oviedo, P.J.; Novella, S.; Laguna-Fernandez, A.; Bueno, C.; García-Pérez, M.A.; Tarín, J.J.; Cano, A.; Hermenegildo, C. Estradiol selectively stimulates endothelial prostacyclin production through estrogen receptor-alpha. J. Mol. Endocrinol. 2010, 44, 237–246. [Google Scholar] [CrossRef]
  148. da Costa, D.T.; Goncalves, L.T.; Giesen, J.A.S.; Dos Santos, R.L. Progesterone modulates endothelium-dependent coronary vascular reactivity in SHR. J. Mol. Endocrinol. 2021, 66, 171–180. [Google Scholar] [CrossRef]
  149. Pang, Y.; Thomas, P. Additive effects of low concentrations of estradiol-17beta and progesterone on nitric oxide production by human vascular endothelial cells through shared signaling pathways. J. Steroid Biochem. Mol. Biol. 2016, 165, 258–267. [Google Scholar] [CrossRef]
  150. Scotland, R.S.; Madhani, M.; Chauhan, S.; Moncada, S.; Andresen, J.; Nilsson, H.; Hobbs, A.J.; Ahluwalia, A. Investigation of vascular responses in endothelial nitric oxide synthase/cyclooxygenase-1 double-knockout mice: Key role for endothelium-derived hyperpolarizing factor in the regulation of blood pressure in vivo. Circulation 2005, 111, 796–803. [Google Scholar] [CrossRef]
  151. Ruamyod, K.; Watanapa, W.B.; Shayakul, C. Testosterone rapidly increases Ca2+-activated K(+) currents causing hyperpolarization in human coronary artery endothelial cells. J. Steroid Biochem. Mol. Biol. 2017, 168, 118–126. [Google Scholar] [CrossRef] [PubMed]
  152. da Cunha, T.R.; Giesen, J.A.S.; Rouver, W.N.; Costa, E.D.; Grando, M.D.; Lemos, V.S.; Bendhack, L.M.; dos Santos, R.L. Effects of progesterone treatment on endothelium-dependent coronary relaxation in ovariectomized rats. Life Sci. 2020, 247, 117391. [Google Scholar] [CrossRef] [PubMed]
  153. Dubey, R.K.; Jackson, E.K. Estrogen-induced cardiorenal protection: Potential cellular, biochemical, and molecular mechanisms. Am. J. Physiol. Renal Physiol. 2001, 280, F365–F388. [Google Scholar] [CrossRef]
  154. Wassmann, K.; Wassmann, S.; Nickenig, G. Progesterone antagonizes the vasoprotective effect of estrogen on antioxidant enzyme expression and function. Circ. Res. 2005, 97, 1046–1054. [Google Scholar] [CrossRef] [PubMed]
  155. Costa, R.M.; Alves-Lopes, R.; Alves, J.V.; Servian, C.P.; Mestriner, F.L.; Carneiro, F.S.; Lobato, N.d.S.; Tostes, R.C. Testosterone Contributes to Vascular Dysfunction in Young Mice Fed a High Fat Diet by Promoting Nuclear Factor E2-Related Factor 2 Downregulation and Oxidative Stress. Front. Physiol. 2022, 13, 837603. [Google Scholar] [CrossRef]
  156. Lu, Q.; Schnitzler, G.R.; Ueda, K.; Iyer, L.K.; Diomede, O.I.; Andrade, T.; Karas, R.H. ER Alpha Rapid Signaling Is Required for Estrogen Induced Proliferation and Migration of Vascular Endothelial Cells. PLoS ONE 2016, 11, e0152807. [Google Scholar] [CrossRef]
  157. Nikhil, K.; Sharan, S.; Wishard, R.; Palla, S.R.; Krishna Peddinti, R.; Roy, P. Pterostilbene carboxaldehyde thiosemicarbazone, a resveratrol derivative inhibits 17beta-Estradiol induced cell migration and proliferation in HUVECs. Steroids 2016, 108, 17–30. [Google Scholar] [CrossRef]
  158. Liu, H.; Tao, Y.; Chen, M.; Yu, J.; Li, W.-J.; Tao, L.; Li, Y.; Li, F. 17beta-Estradiol Promotes Angiogenesis of Rat Cardiac Microvascular Endothelial Cells In Vitro. Med. Sci. Monit. 2018, 24, 2489–2496. [Google Scholar] [CrossRef]
  159. Cai, J.; Hong, Y.; Weng, C.; Tan, C.; Imperato-McGinley, J.; Zhu, Y.S. Androgen stimulates endothelial cell proliferation via an androgen receptor/VEGF/cyclin A-mediated mechanism. Am. J. Physiol. Heart Circ. Physiol. 2011, 300, H1210–H1221. [Google Scholar] [CrossRef]
  160. Zhao, X.; Li, X.; Liu, P.; Li, P.; Xu, X.; Chen, Y.; Cheng, Y.; Zhu, D.; Fu, X. 17beta-estradiol promotes angiogenesis through non-genomic activation of Smad1 signaling in endometriosis. Vascul Pharmacol. 2022, 142, 106932. [Google Scholar] [CrossRef]
  161. Crews, J.K.; Khalil, R.A. Antagonistic effects of 17 beta-estradiol, progesterone, and testosterone on Ca2+ entry mechanisms of coronary vasoconstriction. Arterioscler. Thromb. Vasc. Biol. 1999, 19, 1034–1040. [Google Scholar] [CrossRef] [PubMed]
  162. Murphy, J.G.; Khalil, R.A. Decreased [Ca2+](i) during inhibition of coronary smooth muscle contraction by 17beta-estradiol, progesterone, and testosterone. J. Pharmacol. Exp. Ther. 1999, 291, 44–52. [Google Scholar] [CrossRef]
  163. English, K.M.; Jones, R.D.; Jones, T.H.; Morice, A.H.; Channer, K.S. Testosterone acts as a coronary vasodilator by a calcium antagonistic action. J. Endocrinol. Investig. 2002, 25, 455–458. [Google Scholar] [CrossRef] [PubMed]
  164. Hall, J.; Jones, R.D.; Jones, T.H.; Channer, K.S.; Peers, C. Selective inhibition of L-type Ca2+ channels in A7r5 cells by physiological levels of testosterone. Endocrinology 2006, 147, 2675–2680. [Google Scholar] [CrossRef]
  165. Kelly, D.M.; Jones, T.H. Testosterone: A vascular hormone in health and disease. J. Endocrinol. 2013, 217, R47–R71. [Google Scholar] [CrossRef]
  166. Mazzuca, M.Q.; Mata, K.M.; Li, W.; Rangan, S.S.; Khalil, R.A. Estrogen receptor subtypes mediate distinct microvascular dilation and reduction in [Ca2+]I in mesenteric microvessels of female rat. J. Pharmacol. Exp. Ther. 2015, 352, 291–304. [Google Scholar] [CrossRef]
  167. Pang, Y.; Thomas, P. Involvement of sarco/endoplasmic reticulum Ca2+-ATPase (SERCA) in mPRalpha (PAQR7)-mediated progesterone induction of vascular smooth muscle relaxation. Am. J. Physiol. Endocrinol. Metab. 2021, 320, E453–E466. [Google Scholar] [CrossRef] [PubMed]
  168. Prakash, Y.S.; Togaibayeva, A.A.; Kannan, M.S.; Miller, V.M.; Fitzpatrick, L.A.; Sieck, G.C. Estrogen increases Ca2+ efflux from female porcine coronary arterial smooth muscle. Am. J. Physiol. 1999, 276, H926–H934. [Google Scholar] [CrossRef]
  169. Cairrao, E.; Alvarez, E.; Santos-Silva, A.J.; Verde, I. Potassium channels are involved in testosterone-induced vasorelaxation of human umbilical artery. Naunyn Schmiedebergs Arch. Pharmacol. 2008, 376, 375–383. [Google Scholar] [CrossRef]
  170. Deenadayalu, V.; Puttabyatappa, Y.; Liu, A.T.; Stallone, J.N.; White, R.E. Testosterone-induced relaxation of coronary arteries: Activation of BKCa channels via the cGMP-dependent protein kinase. Am. J. Physiol. Heart Circ. Physiol. 2012, 302, H115–H123. [Google Scholar] [CrossRef]
  171. White, R.E.; Darkow, D.J.; Lang, J.L. Estrogen relaxes coronary arteries by opening BKCa channels through a cGMP-dependent mechanism. Circ. Res. 1995, 77, 936–942. [Google Scholar] [CrossRef] [PubMed]
  172. Seyrek, M.; Yildiz, O.; Ulusoy, H.B.; Yildirim, V. Testosterone relaxes isolated human radial artery by potassium channel opening action. J. Pharmacol. Sci. 2007, 103, 309–316. [Google Scholar] [CrossRef] [PubMed]
  173. Kanashiro, C.A.; Khalil, R.A. Gender-related distinctions in protein kinase C activity in rat vascular smooth muscle. Am. J. Physiol. Cell Physiol. 2001, 280, C34–C45. [Google Scholar] [CrossRef]
  174. Herkert, O.; Kuhl, H.; Busse, R.; Schini-Kerth, V.B. The progestin levonorgestrel induces endothelium-independent relaxation of rabbit jugular vein via inhibition of calcium entry and protein kinase C: Role of cyclic AMP. Br. J. Pharmacol. 2000, 130, 1911–1918. [Google Scholar] [CrossRef]
  175. Chrissobolis, S.; Budzyn, K.; Marley, P.D.; Sobey, C.G. Evidence that estrogen suppresses rho-kinase function in the cerebral circulation in vivo. Stroke 2004, 35, 2200–2205. [Google Scholar] [CrossRef] [PubMed]
  176. Li, H.; Cheng, Y.; Simoncini, T.; Xu, S. 17beta-Estradiol inhibits TNF-alpha-induced proliferation and migration of vascular smooth muscle cells via suppression of TRAIL. Gynecol. Endocrinol. 2016, 32, 581–586. [Google Scholar] [CrossRef]
  177. Cutini, P.H.; Massheimer, V.L. Role of progesterone on the regulation of vascular muscle cells proliferation, migration and apoptosis. Steroids 2010, 75, 355–361. [Google Scholar] [CrossRef]
  178. Hsu, S.-P.; Chen, T.-H.; Chou, Y.-P.; Chen, L.-C.; Kuo, C.-T.; Lee, T.-S.; Lin, J.-J.; Chang, N.-C.; Lee, W.-S. Extra-nuclear activation of progesterone receptor in regulating arterial smooth muscle cell migration. Atherosclerosis 2011, 217, 83–89. [Google Scholar] [CrossRef]
  179. Hu, W.-P.; Xie, L.; Hao, S.-Y.; Wu, Q.-H.; Xiang, G.-L.; Li, S.-Q.; Liu, D. Protective effects of progesterone on pulmonary artery smooth muscle cells stimulated with Interleukin 6 via blocking the shuttling and transcriptional function of STAT3. Int. Immunopharmacol. 2021, 102, 108379. [Google Scholar] [CrossRef]
  180. Somjen, D.; Kohen, F.; Jaffe, A.; Amir-Zaltsman, Y.; Knoll, E.; Stern, N. Effects of gonadal steroids and their antagonists on DNA synthesis in human vascular cells. Hypertension 1998, 32, 39–45. [Google Scholar] [CrossRef]
  181. Lopes, R.A.M.; Neves, K.B.; Pestana, C.R.; Queiroz, A.L.; Zanotto, C.Z.; Chignalia, A.Z.; Valim, Y.M.; Silveira, L.R.; Curti, C.; Tostes, R.C. Testosterone induces apoptosis in vascular smooth muscle cells via extrinsic apoptotic pathway with mitochondria-generated reactive oxygen species involvement. Am. J. Physiol. Heart Circ. Physiol. 2014, 306, H1485–H1494. [Google Scholar] [CrossRef] [PubMed]
  182. Mahmoodzadeh, S.; Dworatzek, E.; Fritschka, S.; Pham, T.H.; Regitz-Zagrosek, V. 17beta-Estradiol inhibits matrix metalloproteinase-2 transcription via MAP kinase in fibroblasts. Cardiovasc. Res. 2010, 85, 719–728. [Google Scholar] [CrossRef] [PubMed]
  183. Wingrove, C.S.; Garr, E.; Godsland, I.F.; Stevenson, J.C. 17beta-oestradiol enhances release of matrix metalloproteinase-2 from human vascular smooth muscle cells. Biochim. Biophys. Acta 1998, 1406, 169–174. [Google Scholar] [CrossRef] [PubMed]
  184. Dang, Y.; Li, W.; Tran, V.; Khalil, R.A. EMMPRIN-mediated induction of uterine and vascular matrix metalloproteinases during pregnancy and in response to estrogen and progesterone. Biochem. Pharmacol. 2013, 86, 734–747. [Google Scholar] [CrossRef]
  185. Pedram, A.; Razandi, M.; O’Mahony, F.; Lubahn, D.; Levin, E.R. Estrogen receptor-beta prevents cardiac fibrosis. Mol. Endocrinol. 2010, 24, 2152–2165. [Google Scholar] [CrossRef]
  186. Wang, H.; Zhao, Z.; Lin, M.; Groban, L. Activation of GPR30 inhibits cardiac fibroblast proliferation. Mol. Cell Biochem. 2015, 405, 135–148. [Google Scholar] [CrossRef]
  187. Hatakeyama, H.; Nishizawa, M.; Nakagawa, A.; Nakano, S.; Kigoshi, T.; Uchida, K. Testosterone inhibits tumor necrosis factor-alpha-induced vascular cell adhesion molecule-1 expression in human aortic endothelial cells. FEBS Lett. 2002, 530, 129–132. [Google Scholar] [CrossRef]
  188. Mauvais-Jarvis, F.; Klein, S.L.; Levin, E.R. Estradiol, Progesterone, Immunomodulation, and COVID-19 Outcomes. Endocrinology 2020, 161, bqaa127. [Google Scholar] [CrossRef]
  189. Annibalini, G.; Agostini, D.; Calcabrini, C.; Martinelli, C.; Colombo, E.; Guescini, M.; Tibollo, P.; Stocchi, V.; Sestili, P. Effects of sex hormones on inflammatory response in male and female vascular endothelial cells. J. Endocrinol. Investig. 2014, 37, 861–869. [Google Scholar] [CrossRef]
  190. Fedotcheva, T.A.; Fedotcheva, N.I.; Shimanovsky, N.L. Progesterone as an Anti-Inflammatory Drug and Immunomodulator: New Aspects in Hormonal Regulation of the Inflammation. Biomolecules 2022, 12, 1299. [Google Scholar] [CrossRef]
  191. Bordallo, J.; Cantabrana, B.; Suarez, L.; Sanchez, M. Testosterone inhibits cAMP-phosphodiesterases in heart extracts from rats and increases cAMP levels in isolated left atria. Pharmacology 2011, 87, 155–160. [Google Scholar] [CrossRef] [PubMed]
  192. Golden, K.L.; Marsh, J.D.; Jiang, Y. Testosterone regulates mRNA levels of calcium regulatory proteins in cardiac myocytes. Horm. Metab. Res. 2004, 36, 197–202. [Google Scholar] [PubMed]
  193. Furukawa, T.; Kurokawa, J. Non-genomic regulation of cardiac ion channels by sex hormones. Cardiovasc. Hematol. Disord. Drug Targets 2008, 8, 245–251. [Google Scholar] [CrossRef]
  194. Moshal, K.S.; Zhang, Z.; Roder, K.; Kim, T.Y.; Cooper, L.; Patedakis Litvinov, B.; Lu, Y.; Reddy, V.; Terentyev, D.; Choi, B.R.; et al. Progesterone modulates SERCA2a expression and function in rabbit cardiomyocytes. Am. J. Physiol. Cell Physiol. 2014, 307, C1050–C1057. [Google Scholar] [CrossRef]
  195. Chen, J.; Liu, Y.; Pan, D.; Xu, T.; Luo, Y.; Wu, W.; Wu, P.; Zhu, H.; Li, D. Estrogen inhibits endoplasmic reticulum stress and ameliorates myocardial ischemia/reperfusion injury in rats by upregulating SERCA2a. Cell Commun. Signal 2022, 20, 38. [Google Scholar] [CrossRef]
  196. Liang, S.; Sun, Y.-S.; Li, L.; Long, Y.; Wang, M.; Yang, H.-Z.; Li, C.-D.; Wang, Y.; Li, S.-S.; Chen, X.; et al. Progesterone Changes the Pregnancy-Induced Adaptation of Cardiomyocyte Kv2.1 Channels via MicroRNA-29b. Cardiovasc Ther 2022, 2022, 7145699. [Google Scholar]
  197. Feridooni, H.A.; MacDonald, J.K.; Ghimire, A.; Pyle, W.G.; Howlett, S.E. Acute exposure to progesterone attenuates cardiac contraction by modifying myofilament calcium sensitivity in the female mouse heart. Am. J. Physiol. Heart Circ. Physiol. 2016, 312, H46–H59. [Google Scholar] [CrossRef] [PubMed]
  198. Shen, T.; Ding, L.; Ruan, Y.; Qin, W.; Lin, Y.; Xi, C.; Lu, Y.; Dou, L.; Zhu, Y.; Cao, Y.; et al. SIRT1 functions as an important regulator of estrogen-mediated cardiomyocyte protection in angiotensin II-induced heart hypertrophy. Oxid. Med. Cell Longev. 2014, 2014, 713894. [Google Scholar] [CrossRef]
  199. Pedram, A.; Razandi, M.; Aitkenhead, M.; Levin, E.R. Estrogen inhibits cardiomyocyte hypertrophy in vitro. Antagonism of calcineurin-related hypertrophy through induction of MCIP1. J. Biol. Chem. 2005, 280, 26339–26348. [Google Scholar] [CrossRef]
  200. Altamirano, F.; Oyarce, C.; Silva, P.; Toyos, M.; Wilson, C.; Lavandero, S.; Uhlén, P.; Estrada, M. Testosterone induces cardiomyocyte hypertrophy through mammalian target of rapamycin complex 1 pathway. J. Endocrinol. 2009, 202, 299–307. [Google Scholar] [CrossRef]
  201. Duran, J.; Oyarce, C.; Pavez, M.; Valladares, D.; Basualto-Alarcon, C.; Lagos, D.; Barrientos, G.; Troncoso, M.F.; Ibarra, C.; Estrada, M. GSK-3beta/NFAT Signaling Is Involved in Testosterone-Induced Cardiac Myocyte Hypertrophy. PLoS ONE 2016, 11, e0168255. [Google Scholar] [CrossRef] [PubMed]
  202. Wilson, C.; Contreras-Ferrat, A.; Venegas, N.; Osorio-Fuentealba, C.; Pávez, M.; Montoya, K.; Durán, J.; Maass, R.; Lavandero, S.; Estrada, M. Testosterone increases GLUT4-dependent glucose uptake in cardiomyocytes. J. Cell Physiol. 2013, 228, 2399–2407. [Google Scholar] [CrossRef]
  203. Rattanasopa, C.; Phungphong, S.; Wattanapermpool, J.; Bupha-Intr, T. Significant role of estrogen in maintaining cardiac mitochondrial functions. J. Steroid Biochem. Mol. Biol. 2015, 147, 1–9. [Google Scholar] [CrossRef] [PubMed]
  204. Pingili, A.K.; Kara, M.; Khan, N.S.; Estes, A.M.; Lin, Z.; Li, W.; Gonzalez, F.J.; Malik, K.U. 6beta-hydroxytestosterone, a cytochrome P450 1B1 metabolite of testosterone, contributes to angiotensin II-induced hypertension and its pathogenesis in male mice. Hypertension 2015, 65, 1279–1287. [Google Scholar] [CrossRef]
  205. Cruz-Topete, D.; Dominic, P.; Stokes, K.Y. Uncovering sex-specific mechanisms of action of testosterone and redox balance. Redox Biol. 2020, 31, 101490. [Google Scholar] [CrossRef] [PubMed]
  206. Dai, Q.; Likes, C.E., 3rd; Luz, A.L.; Mao, L.; Yeh, J.S.; Wei, Z.; Kuchibhatla, M.; Ilkayeva, O.R.; Koves, T.R.; Price, T.M. A Mitochondrial Progesterone Receptor Increases Cardiac Beta-Oxidation and Remodeling. J. Endocr. Soc. 2019, 3, 446–467. [Google Scholar] [CrossRef]
  207. Lan, C.; Cao, N.; Chen, C.; Qu, S.; Fan, C.; Luo, H.; Zeng, A.; Yu, C.; Xue, Y.; Ren, H.; et al. Progesterone, via yes-associated protein, promotes cardiomyocyte proliferation and cardiac repair. Cell Prolif. 2020, 53, e12910. [Google Scholar] [CrossRef]
  208. Patten, R.D.; Pourati, I.; Aronovitz, M.J.; Baur, J.; Celestin, F.; Chen, X.; Michael, A.; Haq, S.; Nuedling, S.; Grohe, C.; et al. 17beta-estradiol reduces cardiomyocyte apoptosis in vivo and in vitro via activation of phospho-inositide-3 kinase/Akt signaling. Circ. Res. 2004, 95, 692–699. [Google Scholar] [CrossRef]
  209. Kruger-Genge, A.; Blocki, A.; Franke, R.P.; Jung, F. Vascular Endothelial Cell Biology: An Update. Int. J. Mol. Sci. 2019, 20, 4411. [Google Scholar] [CrossRef]
  210. Lv, Y.; Zhang, S.; Weng, X.; Huang, J.; Zhao, H.; Dai, X.; Bai, X.; Bao, X.; Zhao, C.; Zeng, M.; et al. Estrogen deficiency accelerates postmenopausal atherosclerosis by inducing endothelial cell ferroptosis through inhibiting NRF2/GPX4 pathway. FASEB J. 2023, 37, e22992. [Google Scholar] [CrossRef]
  211. Geraldes, P.; Sirois, M.G.; Bernatchez, P.N.; Tanguay, J.F. Estrogen regulation of endothelial and smooth muscle cell migration and proliferation: Role of p38 and p42/44 mitogen-activated protein kinase. Arterioscler. Thromb. Vasc. Biol. 2002, 22, 1585–1590. [Google Scholar] [CrossRef] [PubMed]
  212. Gilligan, D.M.; Badar, D.M.; Panza, J.A.; Quyyumi, A.A.; Cannon, R.O., 3rd. Acute vascular effects of estrogen in postmenopausal women. Circulation 1994, 90, 786–791. [Google Scholar] [CrossRef] [PubMed]
  213. Eckstein, N.; Nadler, E.; Barnea, O.; Shavit, G.; Ayalon, D. Acute effects of 17 beta-estradiol on the rat heart. Am. J. Obstet. Gynecol. 1994, 171, 844–848. [Google Scholar] [CrossRef]
  214. Kauser, K.; Rubanyi, G.M. Gender difference in endothelial dysfunction in the aorta of spontaneously hypertensive rats. Hypertension 1995, 25, 517–523. [Google Scholar] [CrossRef]
  215. Bernstein, S.R.; Kelleher, C.; Khalil, R.A. Gender-based research underscores sex differences in biological processes, clinical disorders and pharmacological interventions. Biochem. Pharmacol. 2023, 215, 115737. [Google Scholar] [CrossRef] [PubMed]
  216. Wilcox, J.N.; Subramanian, R.R.; Sundell, C.L.; Tracey, W.R.; Pollock, J.S.; Harrison, D.G.; Marsden, P.A. Expression of multiple isoforms of nitric oxide synthase in normal and atherosclerotic vessels. Arterioscler. Thromb. Vasc. Biol. 1997, 17, 2479–2488. [Google Scholar] [CrossRef]
  217. Forte, P.; Kneale, B.J.; Milne, E.; Chowienczyk, P.J.; Johnston, A.; Benjamin, N.; Ritter, J.M. Evidence for a difference in nitric oxide biosynthesis between healthy women and men. Hypertension 1998, 32, 730–734. [Google Scholar] [CrossRef]
  218. Kublickiene, K.; Svedas, E.; Landgren, B.M.; Crisby, M.; Nahar, N.; Nisell, H.; Poston, L. Small artery endothelial dysfunction in postmenopausal women: In vitro function, morphology, and modification by estrogen and selective estrogen receptor modulators. J. Clin. Endocrinol. Metab. 2005, 90, 6113–6122. [Google Scholar] [CrossRef]
  219. Thompson, L.P.; Pinkas, G.; Weiner, C.P. Chronic 17beta-estradiol replacement increases nitric oxide-mediated vasodilation of guinea pig coronary microcirculation. Circulation 2000, 102, 445–451. [Google Scholar] [CrossRef]
  220. Smith, A.M.; Jones, R.D.; Channer, K.S. The influence of sex hormones on pulmonary vascular reactivity: Possible vasodilator therapies for the treatment of pulmonary hypertension. Curr. Vasc. Pharmacol. 2006, 4, 9–15. [Google Scholar] [CrossRef]
  221. Geary, G.G.; Krause, D.N.; Duckles, S.P. Estrogen reduces mouse cerebral artery tone through endothelial NOS- and cyclooxygenase-dependent mechanisms. Am. J. Physiol. Heart Circ. Physiol. 2000, 279, H511–H519. [Google Scholar] [CrossRef] [PubMed]
  222. Sumi, D.; Hayashi, T.; Jayachandran, M.; Iguchi, A. Estrogen prevents destabilization of endothelial nitric oxide synthase mRNA induced by tumor necrosis factor alpha through estrogen receptor mediated system. Life Sci. 2001, 69, 1651–1660. [Google Scholar] [CrossRef] [PubMed]
  223. MacRitchie, A.N.; Jun, S.S.; Chen, Z.; German, Z.; Yuhanna, I.S.; Sherman, T.S.; Shaul, P.W. Estrogen upregulates endothelial nitric oxide synthase gene expression in fetal pulmonary artery endothelium. Circ. Res. 1997, 81, 355–362. [Google Scholar] [CrossRef]
  224. Knot, H.J.; Lounsbury, K.M.; Brayden, J.E.; Nelson, M.T. Gender differences in coronary artery diameter reflect changes in both endothelial Ca2+ and ecNOS activity. Am. J. Physiol. 1999, 276, H961–H969. [Google Scholar] [CrossRef]
  225. Asunción-Alvarez, D.; Palacios, J.; Ybañez-Julca, R.O.; Rodriguez-Silva, C.N.; Nwokocha, C.; Cifuentes, F.; Greensmith, D.J. Calcium signaling in endothelial and vascular smooth muscle cells: Sex differences and the influence of estrogens and androgens. Am. J. Physiol. Heart Circ. Physiol. 2024, 326, H950–H970. [Google Scholar] [CrossRef]
  226. Tran, Q.K.; VerMeer, M.; Burgard, M.A.; Hassan, A.B.; Giles, J. Hetero-oligomeric Complex between the G Protein-coupled Estrogen Receptor 1 and the Plasma Membrane Ca2+-ATPase 4b. J. Biol. Chem. 2015, 290, 13293–13307. [Google Scholar] [CrossRef] [PubMed]
  227. Russell, K.S.; Haynes, M.P.; Sinha, D.; Clerisme, E.; Bender, J.R. Human vascular endothelial cells contain membrane binding sites for estradiol, which mediate rapid intracellular signaling. Proc. Natl. Acad. Sci. USA 2000, 97, 5930–5935. [Google Scholar] [CrossRef]
  228. Hisamoto, K.; Ohmichi, M.; Kurachi, H.; Hayakawa, J.; Kanda, Y.; Nishio, Y.; Adachi, K.; Tasaka, K.; Miyoshi, E.; Fujiwara, N.; et al. Estrogen induces the Akt-dependent activation of endothelial nitric-oxide synthase in vascular endothelial cells. J. Biol. Chem. 2001, 276, 3459–3467. [Google Scholar] [CrossRef]
  229. Guo, X.; Razandi, M.; Pedram, A.; Kassab, G.; Levin, E.R. Estrogen induces vascular wall dilation: Mediation through kinase signaling to nitric oxide and estrogen receptors alpha and beta. J. Biol. Chem. 2005, 280, 19704–19710. [Google Scholar] [CrossRef]
  230. Browner, N.C.; Dey, N.B.; Bloch, K.D.; Lincoln, T.M. Regulation of cGMP-dependent protein kinase expression by soluble guanylyl cyclase in vascular smooth muscle cells. J. Biol. Chem. 2004, 279, 46631–46636. [Google Scholar] [CrossRef]
  231. Tan, E.; Gurjar, M.V.; Sharma, R.V.; Bhalla, R.C. Estrogen receptor-alpha gene transfer into bovine aortic endothelial cells induces eNOS gene expression and inhibits cell migration. Cardiovasc. Res. 1999, 43, 788–797. [Google Scholar] [CrossRef] [PubMed]
  232. Chen, Z.; Yuhanna, I.S.; Galcheva-Gargova, Z.; Karas, R.H.; Mendelsohn, M.E.; Shaul, P.W. Estrogen receptor alpha mediates the nongenomic activation of endothelial nitric oxide synthase by estrogen. J. Clin. Investig. 1999, 103, 401–406. [Google Scholar] [CrossRef] [PubMed]
  233. Darblade, B.; Pendaries, C.; Krust, A.; Dupont, S.; Fouque, M.J.; Rami, J.; Chambon, P.; Bayard, F.; Arnal, J.F. Estradiol alters nitric oxide production in the mouse aorta through the alpha-, but not beta-, estrogen receptor. Circ. Res. 2002, 90, 413–419. [Google Scholar] [CrossRef] [PubMed]
  234. Widder, J.; Pelzer, T.; von Poser-Klein, C.; Hu, K.; Jazbutyte, V.; Fritzemeier, K.-H.; Hegele-Hartung, C.; Neyses, L.; Bauersachs, J. Improvement of endothelial dysfunction by selective estrogen receptor-alpha stimulation in ovariectomized SHR. Hypertension 2003, 42, 991–996. [Google Scholar] [CrossRef] [PubMed]
  235. Kim, K.H.; Moriarty, K.; Bender, J.R. Vascular cell signaling by membrane estrogen receptors. Steroids 2008, 73, 864–869. [Google Scholar] [CrossRef]
  236. Chambliss, K.L.; Yuhanna, I.S.; Anderson, R.G.; Mendelsohn, M.E.; Shaul, P.W. ERbeta has nongenomic action in caveolae. Mol. Endocrinol. 2002, 16, 938–946. [Google Scholar]
  237. Park, J.S.; Lee, G.H.; Jin, S.W.; Pham, T.H.; Thai, T.N.; Kim, J.Y.; Kim, C.Y.; Han, E.H.; Hwang, Y.P.; Choi, C.Y.; et al. G protein-coupled estrogen receptor regulates the KLF2-dependent eNOS expression by activating of Ca2+ and EGFR signaling pathway in human endothelial cells. Biochem. Pharmacol. 2021, 192, 114721. [Google Scholar] [CrossRef]
  238. Brandes, R.P.; Mugge, A. Gender differences in the generation of superoxide anions in the rat aorta. Life Sci. 1997, 60, 391–396. [Google Scholar] [CrossRef]
  239. Yung, L.M.; Wong, W.T.; Tian, X.Y.; Leung, F.P.; Yung, L.H.; Chen, Z.Y.; Yao, X.; Lau, C.W.; Huang, Y. Inhibition of renin-angiotensin system reverses endothelial dysfunction and oxidative stress in estrogen deficient rats. PLoS ONE 2011, 6, e17437. [Google Scholar] [CrossRef]
  240. Hernández, I.; Delgado, J.L.; Díaz, J.; Quesada, T.; Teruel, M.J.G.; Llanos, M.C.; Carbonell, L.F. 17beta-estradiol prevents oxidative stress and decreases blood pressure in ovariectomized rats. Am. J. Physiol. Regul. Integr. Comp. Physiol. 2000, 279, R1599–R1605. [Google Scholar] [CrossRef]
  241. Barbacanne, M.; Rami, J.; Michel, J.; Souchard, J.; Philippe, M.; Besombes, J.; Bayard, F.; Arnal, J. Estradiol increases rat aorta endothelium-derived relaxing factor (EDRF) activity without changes in endothelial NO synthase gene expression: Possible role of decreased endothelium-derived superoxide anion production. Cardiovasc. Res. 1999, 41, 672–681. [Google Scholar] [CrossRef] [PubMed]
  242. Wagner, A.H.; Schroeter, M.R.; Hecker, M. 17beta-estradiol inhibition of NADPH oxidase expression in human endothelial cells. FASEB J. 2001, 15, 2121–2130. [Google Scholar] [CrossRef] [PubMed]
  243. Gragasin, F.S.; Xu, Y.; Arenas, I.A.; Kainth, N.; Davidge, S.T. Estrogen reduces angiotensin II-induced nitric oxide synthase and NAD(P)H oxidase expression in endothelial cells. Arterioscler. Thromb. Vasc. Biol. 2003, 23, 38–44. [Google Scholar] [CrossRef] [PubMed]
  244. Lv, Y.; Huang, Y.; Fan, H.; Zhao, Y.; Ma, L.; Lan, Y.; Li, C.; Chen, P.; Lou, Z.; Zhou, J. 17beta-Estradiol inhibits hydrogen peroxide-induced senescence and apoptosis in human umbilical vein endothelial cells by regulating the THBS1/TGF-beta/Smad axis. Mol. Cell. Endocrinol. 2024, 580, 112111. [Google Scholar] [CrossRef]
  245. Calkin, A.C.; Sudhir, K.; Honisett, S.; Williams, M.R.; Dawood, T.; Komesaroff, P.A. Rapid potentiation of endothelium-dependent vasodilation by estradiol in postmenopausal women is mediated via cyclooxygenase 2. J. Clin. Endocrinol Metab. 2002, 87, 5072–5075. [Google Scholar] [CrossRef]
  246. O’Sullivan, M.G.; Goodrich, J.A.; Adams, M.R. Increased prostacyclin synthesis by atherosclerotic arteries from estrogen-treated monkeys. Life Sci. 2001, 69, 395–401. [Google Scholar] [CrossRef]
  247. Egan, K.M.; Lawson, J.A.; Fries, S.; Koller, B.; Rader, D.J.; Smyth, E.M.; FitzGerald, G.A. COX-2-derived prostacyclin confers atheroprotection on female mice. Science 2004, 306, 1954–1957. [Google Scholar] [CrossRef]
  248. Jun, S.S.; Chen, Z.; Pace, M.C.; Shaul, P.W. Estrogen upregulates cyclooxygenase-1 gene expression in ovine fetal pulmonary artery endothelium. J. Clin. Investig. 1998, 102, 176–183. [Google Scholar] [CrossRef]
  249. Sherman, T.S.; Chambliss, K.L.; Gibson, L.L.; Pace, M.C.; Mendelsohn, M.E.; Pfister, S.L.; Shaul, P.W. Estrogen acutely activates prostacyclin synthesis in ovine fetal pulmonary artery endothelium. Am. J. Respir. Cell Mol. Biol. 2002, 26, 610–616. [Google Scholar] [CrossRef]
  250. Jiang, C.W.; Sarrel, P.M.; Lindsay, D.C.; Poole-Wilson, P.A.; Collins, P. Endothelium-independent relaxation of rabbit coronary artery by 17 beta-oestradiol in vitro. Br. J. Pharmacol. 1991, 104, 1033–1037. [Google Scholar] [CrossRef]
  251. Case, J.; Davison, C.A. Estrogen alters relative contributions of nitric oxide and cyclooxygenase products to endothelium-dependent vasodilation. J. Pharmacol. Exp. Ther. 1999, 291, 524–530. [Google Scholar] [CrossRef] [PubMed]
  252. Kahonen, M.; Tolvanen, J.P.; Sallinen, K.; Wu, X.; Porsti, I. Influence of gender on control of arterial tone in experimental hypertension. Am. J. Physiol. 1998, 275, H15–H22. [Google Scholar] [PubMed]
  253. Liu, M.Y.; Hattori, Y.; Fukao, M.; Sato, A.; Sakuma, I.; Kanno, M. Alterations in EDHF-mediated hyperpolarization and relaxation in mesenteric arteries of female rats in long-term deficiency of oestrogen and during oestrus cycle. Br. J. Pharmacol. 2001, 132, 1035–1046. [Google Scholar] [CrossRef] [PubMed]
  254. Sakuma, I.; Liu, M.; Sato, A.; Hayashi, T.; Iguchi, A.; Kitabatake, A.; Hattori, Y. Endothelium-dependent hyperpolarization and relaxation in mesenteric arteries of middle-aged rats: Influence of oestrogen. Br. J. Pharmacol. 2002, 135, 48–54. [Google Scholar] [CrossRef]
  255. SenthilKumar, G.; Katunaric, B.; Bordas-Murphy, H.; Young, M.; Doren, E.L.; Schulz, M.E.; Widlansky, M.E.; Freed, J.K. 17beta-Estradiol promotes sex-specific dysfunction in isolated human arterioles. Am. J. Physiol. Heart Circ. Physiol. 2023, 324, H330–H337. [Google Scholar] [CrossRef]
  256. Xu, X.; Yan, Q.; Liu, X.; Li, P.; Li, X.; Chen, Y.; Simoncini, T.; Liu, J.; Zhu, D.; Fu, X. 17beta-Estradiol nongenomically induces vascular endothelial H(2)S release by promoting phosphorylation of cystathionine gamma-lyase. J. Biol. Chem. 2019, 294, 15577–15592. [Google Scholar] [CrossRef]
  257. Wang, R. The gasotransmitter role of hydrogen sulfide. Antioxid. Redox Signal 2003, 5, 493–501. [Google Scholar] [CrossRef]
  258. Tschugguel, W.; Stonek, F.; Zhegu, Z.; Dietrich, W.; Schneeberger, C.; Stimpfl, T.; Waldhoer, T.; Vycudilik, W.; Huber, J.C. Estrogen increases endothelial carbon monoxide, heme oxygenase 2, and carbon monoxide-derived cGMP by a receptor-mediated system. J. Clin. Endocrinol. Metab. 2001, 86, 3833–3839. [Google Scholar] [CrossRef]
  259. Riddle, M.A.; Walker, B.R. Regulation of endothelial BK channels by heme oxygenase-derived carbon monoxide and caveolin-1. Am. J. Physiol. Cell Physiol. 2012, 303, C92–C101. [Google Scholar] [CrossRef]
  260. Hughes, J.M.; Riddle, M.A.; Paffett, M.L.; Gonzalez Bosc, L.V.; Walker, B.R. Novel role of endothelial BKCa channels in altered vasoreactivity following hypoxia. Am. J. Physiol. Heart Circ. Physiol. 2010, 299, H1439–H1450. [Google Scholar] [CrossRef]
  261. Naik, J.S.; Walker, B.R. Heme oxygenase-mediated vasodilation involves vascular smooth muscle cell hyperpolarization. Am. J. Physiol. Heart Circ. Physiol. 2003, 285, H220–H228. [Google Scholar] [CrossRef] [PubMed]
  262. Webb, C.M.; Ghatei, M.A.; McNeill, J.G.; Collins, P. 17beta-estradiol decreases endothelin-1 levels in the coronary circulation of postmenopausal women with coronary artery disease. Circulation 2000, 102, 1617–1622. [Google Scholar] [CrossRef]
  263. Akishita, M.; Kozaki, K.; Eto, M.; Yoshizumi, M.; Ishikawa, M.; Toba, K.; Orimo, H.; Ouchi, Y. Estrogen attenuates endothelin-1 production by bovine endothelial cells via estrogen receptor. Biochem. Biophys. Res. Commun. 1998, 251, 17–21. [Google Scholar] [CrossRef] [PubMed]
  264. David, F.L.; Carvalho, M.H.C.; Cobra, A.L.; Nigro, D.; Fortes, Z.B.; Rebouças, N.A.; Tostes, R.C. Ovarian hormones modulate endothelin-1 vascular reactivity and mRNA expression in DOCA-salt hypertensive rats. Hypertension 2001, 38, 692–696. [Google Scholar] [CrossRef]
  265. Ba, Z.F.; Lu, A.; Shimizu, T.; Szalay, L.; Schwacha, M.G.; Rue, L.W., 3rd; Bland, K.I.; Chaudry, I.H. 17beta-Estradiol modulates vasoconstriction induced by endothelin-1 following trauma-hemorrhage. Am. J. Physiol. Heart Circ. Physiol. 2007, 292, H245–H250. [Google Scholar] [CrossRef]
  266. Morey, A.K.; Razandi, M.; Pedram, A.; Hu, R.M.; Prins, B.A.; Levin, E.R. Oestrogen and progesterone inhibit the stimulated production of endothelin-1. Biochem. J. 1998, 330 Pt 3, 1097–1105. [Google Scholar] [CrossRef]
  267. Bilsel, A.S.; Moini, H.; Tetik, E.; Aksungar, F.; Kaynak, B.; Ozer, A. 17Beta-estradiol modulates endothelin-1 expression and release in human endothelial cells. Cardiovasc. Res. 2000, 46, 579–584. [Google Scholar] [CrossRef]
  268. Takeda-Matsubara, Y.; Nakagami, H.; Iwai, M.; Cui, T.-X.; Shiuchi, T.; Akishita, M.; Nahmias, C.; Ito, M.; Horiuchi, M. Estrogen activates phosphatases and antagonizes growth-promoting effect of angiotensin II. Hypertension 2002, 39, 41–45. [Google Scholar] [CrossRef] [PubMed]
  269. Dubey, R.K.; Gillespie, D.G.; Mi, Z.; Rosselli, M.; Keller, P.J.; Jackson, E.K. Estradiol inhibits smooth muscle cell growth in part by activating the cAMP-adenosine pathway. Hypertension 2000, 35, 262–266. [Google Scholar] [CrossRef]
  270. Teoh, J.P.; Li, X.; Simoncini, T.; Zhu, D.; Fu, X. Estrogen-Mediated Gaseous Signaling Molecules in Cardiovascular Disease. Trends Endocrinol. Metab. 2020, 31, 773–784. [Google Scholar] [CrossRef]
  271. Sivritas, D.; Becher, M.U.; Ebrahimian, T.; Arfa, O.; Rapp, S.; Bohner, A.; Mueller, C.F.; Umemura, T.; Wassmann, S.; Nickenig, G.; et al. Antiproliferative effect of estrogen in vascular smooth muscle cells is mediated by Kruppel-like factor-4 and manganese superoxide dismutase. Basic. Res. Cardiol. 2011, 106, 563–575. [Google Scholar] [CrossRef] [PubMed]
  272. Lee, C.-H.; Su, S.-C.; Chiang, C.-F.; Chien, C.-Y.; Hsu, C.-C.; Yu, T.-Y.; Huang, S.-M.; Shieh, Y.-S.; Kao, H.-W.; Tsai, C.-S.; et al. Estrogen modulates vascular smooth muscle cell function through downregulation of SIRT1. Oncotarget 2017, 8, 110039–110051. [Google Scholar] [CrossRef] [PubMed]
  273. Li, F.; Yu, X.; Szynkarski, C.K.; Meng, C.; Zhou, B.; Barhoumi, R.; White, R.E.; Heaps, C.L.; Stallone, J.N.; Han, G. Activation of GPER Induces Differentiation and Inhibition of Coronary Artery Smooth Muscle Cell Proliferation. PLoS ONE 2013, 8, e64771. [Google Scholar]
  274. Mueck, A.O.; Seeger, H. 2-Methoxyestradiol--biology and mechanism of action. Steroids 2010, 75, 625–631. [Google Scholar] [CrossRef] [PubMed]
  275. Tofovic, S.P.; Jones, T.J.; Bilan, V.P.; Jackson, E.K.; Petrusevska, G. Synergistic therapeutic effects of 2-methoxyestradiol with either sildenafil or bosentan on amelioration of monocrotaline-induced pulmonary hypertension and vascular remodeling. J. Cardiovasc. Pharmacol. 2010, 56, 475–483. [Google Scholar] [CrossRef]
  276. Perez-Cremades, D.; Mompeon, A.; Vidal-Gomez, X.; Hermenegildo, C.; Novella, S. miRNA as a New Regulatory Mechanism of Estrogen Vascular Action. Int. J. Mol. Sci. 2018, 19, 473. [Google Scholar] [CrossRef]
  277. Jiang, C.; Sarrel, P.M.; Poole-Wilson, P.A.; Collins, P. Acute effect of 17 beta-estradiol on rabbit coronary artery contractile responses to endothelin-1. Am. J. Physiol. 1992, 263, H271–H275. [Google Scholar] [CrossRef]
  278. Kakucs, R.; Varbiro, S.; Nadasy, G.L.; Monos, E.; Szekacs, B. Acute, nongenomic vasodilatory action of estradiol is attenuated by chronic estradiol treatment. Exp. Biol. Med. 2001, 226, 538–542. [Google Scholar] [CrossRef]
  279. Murphy, J.G.; Khalil, R.A. Gender-specific reduction in contractility and [Ca2+](i) in vascular smooth muscle cells of female rat. Am. J. Physiol. Cell Physiol. 2000, 278, C834–C844. [Google Scholar] [CrossRef]
  280. Johnson, B.D.; Zheng, W.; Korach, K.S.; Scheuer, T.; Catterall, W.A.; Rubanyi, G.M. Increased expression of the cardiac L-type calcium channel in estrogen receptor-deficient mice. J. Gen. Physiol. 1997, 110, 135–140. [Google Scholar] [CrossRef]
  281. Bowles, D.K. Gender influences coronary L-type Ca2+ current and adaptation to exercise training in miniature swine. J. Appl. Physiol. 2001, 91, 2503–2510. [Google Scholar] [CrossRef] [PubMed]
  282. Zhang, F.; Ram, J.L.; Standley, P.R.; Sowers, J.R. 17 beta-Estradiol attenuates voltage-dependent Ca2+ currents in A7r5 vascular smooth muscle cell line. Am. J. Physiol. 1994, 266, C975–C980. [Google Scholar] [CrossRef] [PubMed]
  283. Diaz-Zegarra, L.A.; Espejo, M.S.; Ibañez, A.M.; Rando, M.E.; Pagola, L.E.; De Giusti, V.C.; Aiello, E.A. Activation of G Protein-Coupled Estrogen Receptor (GPER) Negatively Modulates Cardiac Excitation-Contraction Coupling (ECC) through the PI3K/NOS/NO Pathway. Int. J. Mol. Sci. 2024, 25, 8993. [Google Scholar] [CrossRef] [PubMed]
  284. Dzobo, K.; Dandara, C. The Extracellular Matrix: Its Composition, Function, Remodeling, and Role in Tumorigenesis. Biomimetics 2023, 8, 146. [Google Scholar] [CrossRef] [PubMed]
  285. Zhang, L.; Li, C.; Yang, L.; Adzika, G.K.; Machuki, J.O.; Shi, M.; Sun, Q.; Sun, H. Estrogen Protects Vasomotor Functions in Rats During Catecholamine Stress. Front. Cardiovasc. Med. 2021, 8, 679240. [Google Scholar] [CrossRef]
  286. Zhao, M.Y.; Zhao, T.; Meng, Q.Y.; Zhao, L.; Li, X.C. Estrogen and estrogen receptor affects MMP2 and MMP9 expression through classical ER pathway and promotes migration of lower venous vascular smooth muscle cells. Eur. Rev. Med. Pharmacol. Sci. 2020, 24, 1460–1467. [Google Scholar]
  287. Ambhore, N.S.; Kalidhindi, R.S.R.; Pabelick, C.M.; Hawse, J.R.; Prakash, Y.S.; Sathish, V. Differential estrogen-receptor activation regulates extracellular matrix deposition in human airway smooth muscle remodeling via NF-kappaB pathway. FASEB J. 2019, 33, 13935–13950. [Google Scholar] [CrossRef]
  288. Medzikovic, L.; Aryan, L.; Eghbali, M. Connecting sex differences, estrogen signaling, and microRNAs in cardiac fibrosis. J. Mol. Med. 2019, 97, 1385–1398. [Google Scholar] [CrossRef]
  289. Xu, J.; Wang, F.; Li, Y.; Li, P.; Zhang, Y.; Xu, G.; Sun, K.; Huang, Y. Estrogen inhibits TGF‑beta1‑stimulated cardiac fibroblast differentiation and collagen synthesis by promoting Cdc42. Mol. Med. Rep. 2024, 30, 123. [Google Scholar] [CrossRef]
  290. Zhang, S.; Ma, J.; Wang, X.; Zhao, D.; Zhang, J.; Jiang, L.; Duan, W.; Wang, X.; Hong, Z.; Li, Z.; et al. GPR30 Alleviates Pressure Overload-Induced Myocardial Hypertrophy in Ovariectomized Mice by Regulating Autophagy. Int. J. Mol. Sci. 2023, 24, 904. [Google Scholar] [CrossRef]
  291. Wang, Y.; Xing, Y.; Liu, X.; Chen, L.; Zhang, G.; Li, Y. G-protein coupled receptor 30 attenuates myocardial hypertrophy by reducing oxidative stress and apoptosis in Ang II-treated mice. Peptides 2022, 157, 170878. [Google Scholar] [CrossRef] [PubMed]
  292. Barrett-Connor, E.; Bush, T.L. Estrogen and coronary heart disease in women. JAMA 1991, 265, 1861–1867. [Google Scholar] [CrossRef] [PubMed]
  293. Dubey, R.K.; Imthurn, B.; Zacharia, L.C.; Jackson, E.K. Hormone replacement therapy and cardiovascular disease: What went wrong and where do we go from here? Hypertension 2004, 44, 789–795. [Google Scholar] [CrossRef] [PubMed]
  294. O’Keefe, J.H., Jr.; Kim, S.C.; Hall, R.R.; Cochran, V.C.; Lawhorn, S.L.; McCallister, B.D. Estrogen replacement therapy after coronary angioplasty in women. J. Am. Coll. Cardiol. 1997, 29, 1–5. [Google Scholar] [CrossRef]
  295. Rossouw, J.E.; Anderson, G.L.; Prentice, R.L.; LaCroix, A.Z.; Kooperberg, C.; Stefanick, M.L.; Jackson, R.D.; Beresford, S.A.; Howard, B.V.; Johnson, K.C. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results From the Women’s Health Initiative randomized controlled trial. JAMA 2002, 288, 321–333. [Google Scholar]
  296. Hulley, S.; Grady, D.; Bush, T.; Furberg, C.; Herrington, D.; Riggs, B.; Vittinghoff, E. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. JAMA 1998, 280, 605–613. [Google Scholar] [CrossRef]
  297. Grady, D.; Herrington, D.; Bittner, V.; Blumenthal, R.; Davidson, M.; Hlatky, M.; Hsia, J.; Hulley, S.; Herd, A.; Khan, S.; et al. Cardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/progestin Replacement Study follow-up (HERS II). JAMA 2002, 288, 49–57. [Google Scholar] [CrossRef]
  298. Smith, N.L.; Heckbert, S.R.; Lemaitre, R.N.; Reiner, A.P.; Lumley, T.; Weiss, N.S.; Larson, E.B.; Rosendaal, F.R.; Psaty, B.M. Esterified estrogens and conjugated equine estrogens and the risk of venous thrombosis. JAMA 2004, 292, 1581–1587. [Google Scholar] [CrossRef]
  299. Cushman, M.; Kuller, L.H.; Prentice, R.; Rodabough, R.J.; Psaty, B.M.; Stafford, R.S.; Sidney, S.; Rosendaal, F.R. Estrogen plus progestin and risk of venous thrombosis. JAMA 2004, 292, 1573–1580. [Google Scholar] [CrossRef]
  300. Grodstein, F.; Manson, J.E.; Stampfer, M.J. Postmenopausal hormone use and secondary prevention of coronary events in the nurses’ health study. a prospective, observational study. Ann. Intern. Med. 2001, 135, 1–8. [Google Scholar] [CrossRef]
  301. Hendrix, S.L.; Wassertheil-Smoller, S.; Johnson, K.C.; Howard, B.V.; Kooperberg, C.; Rossouw, J.E.; Trevisan, M.; Aragaki, A.; Baird, A.E.; Bray, P.F.; et al. Effects of conjugated equine estrogen on stroke in the Women’s Health Initiative. Circulation 2006, 113, 2425–2434. [Google Scholar] [PubMed]
  302. Viscoli, C.M.; Brass, L.M.; Kernan, W.N.; Sarrel, P.M.; Suissa, S.; Horwitz, R.I. A clinical trial of estrogen-replacement therapy after ischemic stroke. N. Engl. J. Med. 2001, 345, 1243–1249. [Google Scholar] [CrossRef] [PubMed]
  303. Stefanick, M.L.; Legault, C.; Tracy, R.P.; Howard, G.; Kessler, C.M.; Lucas, D.L.; Bush, T.L. Distribution and correlates of plasma fibrinogen in middle-aged women. Initial findings of the Postmenopausal Estrogen/Progestin Interventions (PEPI) study. Arterioscler. Thromb. Vasc. Biol. 1995, 15, 2085–2093. [Google Scholar] [CrossRef] [PubMed]
  304. Simon, J.A.; Lin, F.; Vittinghoff, E.; Bittner, V. The relation of postmenopausal hormone therapy to serum uric acid and the risk of coronary heart disease events: The Heart and Estrogen-Progestin Replacement Study (HERS). Ann. Epidemiol. 2006, 16, 138–145. [Google Scholar] [CrossRef]
  305. Angerer, P.; Stork, S.; Kothny, W.; Schmitt, P.; von Schacky, C. Effect of oral postmenopausal hormone replacement on progression of atherosclerosis: A randomized, controlled trial. Arterioscler. Thromb. Vasc. Biol. 2001, 21, 262–268. [Google Scholar] [CrossRef]
  306. Herrington, D.M.; Howard, T.D.; Hawkins, G.A.; Reboussin, D.M.; Xu, J.; Zheng, S.L.; Brosnihan, K.B.; Meyers, D.A.; Bleecker, E.R. Estrogen-receptor polymorphisms and effects of estrogen replacement on high-density lipoprotein cholesterol in women with coronary disease. N. Engl. J. Med. 2002, 346, 967–974. [Google Scholar] [CrossRef]
  307. Vickers, M.R.; MacLennan, A.H.; Lawton, B.; Ford, D.; Martin, J.; Meredith, S.K.; DeStavola, B.L.; Rose, S.; Dowell, A.; Wilkes, H.C.; et al. Main morbidities recorded in the women’s international study of long duration oestrogen after menopause (WISDOM): A randomised controlled trial of hormone replacement therapy in postmenopausal women. BMJ 2007, 335, 239. [Google Scholar] [CrossRef]
  308. Waters, D.D.; Alderman, E.L.; Hsia, J.; Howard, B.V.; Cobb, F.R.; Rogers, W.J.; Ouyang, P.; Thompson, P.; Tardif, J.C.; Higginson, L.; et al. Effects of hormone replacement therapy and antioxidant vitamin supplements on coronary atherosclerosis in postmenopausal women: A randomized controlled trial. JAMA 2002, 288, 2432–2440. [Google Scholar] [CrossRef]
  309. Canonico, M.; Oger, E.; Plu-Bureau, G.; Conard, J.; Meyer, G.; Lévesque, H.; Trillot, N.; Barrellier, M.T.; Wahl, D.; Emmerich, J.; et al. Hormone therapy and venous thromboembolism among postmenopausal women: Impact of the route of estrogen administration and progestogens: The ESTHER study. Circulation 2007, 115, 840–845. [Google Scholar]
  310. Barrett-Connor, E.; Mosca, L.; Collins, P.; Geiger, M.J.; Grady, D.; Kornitzer, M.; McNabb, M.A.; Wenger, N.K. Effects of raloxifene on cardiovascular events and breast cancer in postmenopausal women. N. Engl. J. Med. 2006, 355, 125–137. [Google Scholar]
  311. Hwang, J.; Mack, W.J.; Xiang, M.; Sevanian, A.; Lobo, R.A.; Hodis, H.N. Long-term effect of estrogen replacement on plasma nitric oxide levels: Results from the estrogen in the prevention of atherosclerosis trial (EPAT). Atherosclerosis 2005, 181, 375–380. [Google Scholar] [CrossRef]
  312. Miller, V.M.; Black, D.M.; Brinton, E.A.; Budoff, M.J.; Cedars, M.I.; Hodis, H.N.; Lobo, R.A.; Manson, J.E.; Merriam, G.R.; Naftolin, F.; et al. Using basic science to design a clinical trial: Baseline characteristics of women enrolled in the Kronos Early Estrogen Prevention Study (KEEPS). J. Cardiovasc. Transl. Res. 2009, 2, 228–239. [Google Scholar] [CrossRef]
  313. Harman, S.M.; Black, D.M.; Naftolin, F.; Brinton, E.A.; Budoff, M.J.; Cedars, M.I.; Hopkins, P.N.; Lobo, R.A.; Manson, J.E.; Merriam, G.R.; et al. Arterial imaging outcomes and cardiovascular risk factors in recently menopausal women: A randomized trial. Ann. Intern. Med. 2014, 161, 249–260. [Google Scholar] [CrossRef] [PubMed]
  314. Kantarci, K.; Tosakulwong, N.B.; Lesnick, T.G.; Kara, F.; Kendall-Thomas, J.B.; Kapoor, E.M.; Fields, J.A.; James, T.T.; Lobo, R.A.; Manson, J.E.M.; et al. Cardiometabolic outcomes in Kronos Early Estrogen Prevention Study continuation: 14-year follow-up of a hormone therapy trial. Menopause 2024, 31, 10–17. [Google Scholar] [CrossRef]
  315. Hodis, H.N.; Mack, W.J.; Henderson, V.W.; Shoupe, D.; Budoff, M.J.; Hwang-Levine, J.; Li, Y.; Feng, M.; Dustin, L.; Kono, N.; et al. Vascular Effects of Early versus Late Postmenopausal Treatment with Estradiol. N. Engl. J. Med. 2016, 374, 1221–1231. [Google Scholar] [CrossRef] [PubMed]
  316. White, W.B.; Hanes, V.; Chauhan, V.; Pitt, B. Effects of a new hormone therapy, drospirenone and 17-beta-estradiol, in postmenopausal women with hypertension. Hypertension 2006, 48, 246–253. [Google Scholar] [CrossRef] [PubMed]
  317. Gordon, J.L.; Rubinow, D.R.; Watkins, L.; Hinderliter, A.L.; Caughey, M.C.; Girdler, S.S. The Effect of Perimenopausal Transdermal Estradiol and Micronized Progesterone on Markers of Risk for Arterial Disease. J. Clin. Endocrinol. Metab. 2020, 105, e2050–e2060. [Google Scholar] [CrossRef]
  318. Sathyapalan, T.; Aye, M.; Rigby, A.; Thatcher, N.; Dargham, S.; Kilpatrick, E.; Atkin, S. Soy isoflavones improve cardiovascular disease risk markers in women during the early menopause. Nutr. Metab. Cardiovasc. Dis. 2018, 28, 691–697. [Google Scholar] [CrossRef]
  319. Yuk, J.; Kim, G.S.; Byun, Y.S.; Yang, S.; Kim, M.; Yoon, S.; Seo, Y.; Kim, B.G. Effect of menopausal hormonal therapy on cardiovascular risks in Korean postmenopausal women: A nationwide cohort study. BJOG 2024, 131, 1306–1317. [Google Scholar] [CrossRef]
  320. Barrett-Connor, E.; Grady, D.; Sashegyi, A.; Anderson, P.W.; Cox, D.A.; Hoszowski, K.; Rautaharju, P.; Harper, K.D.; MORE Investigators (Multiple Outcomes of Raloxifene Evaluation). Raloxifene and cardiovascular events in osteoporotic postmenopausal women: Four-year results from the MORE (Multiple Outcomes of Raloxifene Evaluation) randomized trial. JAMA 2002, 287, 847–857. [Google Scholar] [CrossRef]
  321. Douglas, G.; Cruz, M.N.; Poston, L.; Gustafsson, J.A.; Kublickiene, K. Functional characterization and sex differences in small mesenteric arteries of the estrogen receptor-beta knockout mouse. Am. J. Physiol. Regul. Integr. Comp. Physiol. 2008, 294, R112–R120. [Google Scholar] [CrossRef] [PubMed]
  322. Dinh, Q.N.; Vinh, A.; Arumugam, T.V.; Drummond, G.R.; Sobey, C.G. G protein-coupled estrogen receptor 1: A novel target to treat cardiovascular disease in a sex-specific manner? Br. J. Pharmacol. 2021, 178, 3849–3863. [Google Scholar] [CrossRef] [PubMed]
  323. Teede, H.J.; Dalais, F.S.; Kotsopoulos, D.; Liang, Y.L.; Davis, S.; McGrath, B.P. Dietary soy has both beneficial and potentially adverse cardiovascular effects: A placebo-controlled study in men and postmenopausal women. J. Clin. Endocrinol. Metab. 2001, 86, 3053–3060. [Google Scholar] [CrossRef]
  324. Liu, Z.M.; Ho, S.C.; Chen, Y.M.; Woo, J. Effect of soy protein and isoflavones on blood pressure and endothelial cytokines: A 6-month randomized controlled trial among postmenopausal women. J. Hypertens. 2013, 31, 384–392. [Google Scholar] [CrossRef]
  325. Husain, D.; Khanna, K.; Puri, S.; Haghighizadeh, M. Supplementation of soy isoflavones improved sex hormones, blood pressure, and postmenopausal symptoms. J. Am. Coll. Nutr. 2015, 34, 42–48. [Google Scholar] [CrossRef]
  326. Liu, Z.M.; Ho, S.C.; Chen, Y.M.; Tomlinson, B.; Ho, S.; To, K.; Woo, J. Effect of whole soy and purified daidzein on ambulatory blood pressure and endothelial function--a 6-month double-blind, randomized controlled trial among Chinese postmenopausal women with prehypertension. Eur. J. Clin. Nutr. 2015, 69, 1161–1168. [Google Scholar] [CrossRef]
  327. Oliver-Williams, C.; Glisic, M.; Shahzad, S.; Brown, E.; Pellegrino Baena, C.; Chadni, M.; Chowdhury, R.; Franco, O.H.; Muka, T. The route of administration, timing, duration and dose of postmenopausal hormone therapy and cardiovascular outcomes in women: A systematic review. Hum. Reprod. Update 2019, 25, 257–271. [Google Scholar] [CrossRef] [PubMed]
  328. Pickar, J.H.; Yeh, I.T.; Wheeler, J.E.; Cunnane, M.F.; Speroff, L. Endometrial effects of lower doses of conjugated equine estrogens and medroxyprogesterone acetate: Two-year substudy results. Fertil. Steril. 2003, 80, 1234–1240. [Google Scholar] [CrossRef]
  329. Zhang, R.; Wang, H.; Cheng, X.; Fan, K.; Gao, T.; Qi, X.; Gao, S.; Zheng, G.; Dong, H. High estrogen induces trans-differentiation of vascular smooth muscle cells to a macrophage-like phenotype resulting in aortic inflammation via inhibiting VHL/HIF1a/KLF4 axis. Aging 2024, 16, 9876–9898. [Google Scholar] [CrossRef]
  330. Lewandowski, K.C.; Komorowski, J.; Mikhalidis, D.P.; Bienkiewicz, M.; Tan, B.K.; O’callaghan, C.J.; Lewinski, A.; Prelevic, G.; Randeva, H.S. Effects of hormone replacement therapy type and route of administration on plasma matrix metalloproteinases and their tissue inhibitors in postmenopausal women. J. Clin. Endocrinol. Metab. 2006, 91, 3123–3130. [Google Scholar] [CrossRef]
  331. Kaunitz, A.M.; Manson, J.E. Management of Menopausal Symptoms. Obstet. Gynecol. 2015, 126, 859–876. [Google Scholar] [CrossRef] [PubMed]
  332. Faubion, S.S.; Larkin, L.C.; Stuenkel, C.A.; Bachmann, G.A.; Chism, L.A.; Kagan, R.; Kaunitz, A.M.; Krychman, M.L.; Parish, S.J.; Partridge, A.H.; et al. Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer: Consensus recommendations from The North American Menopause Society and The International Society for the Study of Women’s Sexual Health. Menopause 2018, 25, 596–608. [Google Scholar] [CrossRef] [PubMed]
  333. Mikkola, T.S.; Tuomikoski, P.; Lyytinen, H.; Korhonen, P.; Hoti, F.; Vattulainen, P.; Gissler, M.; Ylikorkala, O. Vaginal estradiol use and the risk for cardiovascular mortality. Hum. Reprod. 2016, 31, 804–809. [Google Scholar] [CrossRef]
  334. Goodman, M.P. Are all estrogens created equal? A review of oral vs. transdermal therapy. J. Womens Health 2012, 21, 161–169. [Google Scholar] [CrossRef]
  335. Turgeon, J.L.; Carr, M.C.; Maki, P.M.; Mendelsohn, M.E.; Wise, P.M. Complex actions of sex steroids in adipose tissue, the cardiovascular system, and brain: Insights from basic science and clinical studies. Endocr. Rev. 2006, 27, 575–605. [Google Scholar] [CrossRef]
  336. Goldstajn, M.S.; Mikus, M.; Ferrari, F.A.; Bosco, M.; Uccella, S.; Noventa, M.; Torok, P.; Terzic, S.; Lagana, A.S.; Garzon, S. Effects of transdermal versus oral hormone replacement therapy in postmenopause: A systematic review. Arch. Gynecol. Obstet. 2023, 307, 1727–1745. [Google Scholar] [CrossRef] [PubMed]
  337. Ambikairajah, A.; Walsh, E.; Cherbuin, N. Lipid profile differences during menopause: A review with meta-analysis. Menopause 2019, 26, 1327–1333. [Google Scholar] [CrossRef]
  338. Canonico, M. Hormone therapy and hemostasis among postmenopausal women: A review. Menopause 2014, 21, 753–762. [Google Scholar] [CrossRef]
  339. Scarabin, P.Y. Progestogens and venous thromboembolism in menopausal women: An updated oral versus transdermal estrogen meta-analysis. Climacteric 2018, 21, 341–345. [Google Scholar] [CrossRef]
  340. Gouva, L.; Tsatsoulis, A. The role of estrogens in cardiovascular disease in the aftermath of clinical trials. Hormones 2004, 3, 171–183. [Google Scholar] [CrossRef]
  341. Ho, J.Y.-P.; Chen, M.-J.; Sheu, W.H.-H.; Yi, Y.-C.; Tsai, A.C.-W.; Guu, H.-F.; Ho, E.S.-C. Differential effects of oral conjugated equine estrogen and transdermal estrogen on atherosclerotic vascular disease risk markers and endothelial function in healthy postmenopausal women. Hum. Reprod. 2006, 21, 2715–2720. [Google Scholar] [CrossRef] [PubMed]
  342. Laliberte, F.; Dea, K.; Duh, M.S.; Kahler, K.H.; Rolli, M.; Lefebvre, P. Does the route of administration for estrogen hormone therapy impact the risk of venous thromboembolism? Estradiol transdermal system versus oral estrogen-only hormone therapy. Menopause 2018, 25, 1297–1305. [Google Scholar] [CrossRef]
  343. Donovitz, G.S. Low complication rates of testosterone and estradiol implants for androgen and estrogen replacement therapy in over 1 million procedures. Ther. Adv. Endocrinol. Metab. 2021, 12, 20420188211015238. [Google Scholar] [CrossRef]
  344. Glaser, R.; York, A.E.; Dimitrakakis, C. Beneficial effects of testosterone therapy in women measured by the validated Menopause Rating Scale (MRS). Maturitas 2011, 68, 355–361. [Google Scholar] [CrossRef] [PubMed]
  345. Renke, G.; Tostes, F. Cardiovascular Safety and Benefits of Testosterone Implant Therapy in Postmenopausal Women: Where Are We? Pharmaceuticals 2023, 16, 619. [Google Scholar] [CrossRef]
  346. Alevizaki, M.; Saltiki, K.; Cimponeriu, A.; Kanakakis, I.; Xita, N.; Alevizaki, C.C.; Georgiou, I.; Sarika, H.-L. Severity of cardiovascular disease in postmenopausal women: Associations with common estrogen receptor alpha polymorphic variants. Eur. J. Endocrinol. 2007, 156, 489–496. [Google Scholar] [CrossRef]
  347. Emre, A.; Sahin, S.; Erzik, C.; Nurkalem, Z.; Oz, D.; Cirakoglu, B.; Yesilcimen, K.; Ersek, B. Effect of hormone replacement therapy on plasma lipoproteins and apolipoproteins, endothelial function and myocardial perfusion in postmenopausal women with estrogen receptor-alpha IVS1-397 C/C genotype and established coronary artery disease. Cardiology 2006, 106, 44–50. [Google Scholar] [CrossRef] [PubMed]
  348. Ogueta, S.B.; Schwartz, S.D.; Yamashita, C.K.; Farber, D.B. Estrogen receptor in the human eye: Influence of gender and age on gene expression. Investig. Ophthalmol. Vis. Sci. 1999, 40, 1906–1911. [Google Scholar]
  349. Isola, J.V.V.; Ko, S.; Ocanas, S.R.; Stout, M.B. Role of Estrogen Receptor alpha in Aging and Chronic Disease. Adv. Geriatr. Med. Res. 2023, 5, e230005. [Google Scholar]
  350. Gurrala, R.; Kilanowski-Doroh, I.M.; Hutson, D.D.; Ogola, B.O.; Zimmerman, M.A.; Katakam, P.V.G.; Satou, R.; Mostany, R.; Lindsey, S.H. Alterations in the estrogen receptor profile of cardiovascular tissues during aging. Geroscience 2021, 43, 433–442. [Google Scholar] [CrossRef]
  351. Kim, K.H.; Young, B.D.; Bender, J.R. Endothelial estrogen receptor isoforms and cardiovascular disease. Mol. Cell Endocrinol. 2014, 389, 65–70. [Google Scholar] [CrossRef] [PubMed]
  352. Li, L.; Haynes, M.P.; Bender, J.R. Plasma membrane localization and function of the estrogen receptor alpha variant (ER46) in human endothelial cells. Proc. Natl. Acad. Sci. USA 2003, 100, 4807–4812. [Google Scholar] [CrossRef] [PubMed]
  353. Mangani, S.; Piperigkou, Z.; Koletsis, N.E.; Ioannou, P.; Karamanos, N.K. Estrogen receptors and extracellular matrix: The critical interplay in cancer development and progression. FEBS J. 2024, 292, 1558–1572. [Google Scholar] [CrossRef] [PubMed]
  354. Zhu, H.; Huang, Y.; Su, H.; Ma, Y.; Tao, Y.; Liao, D.J.; Liu, Y.; Feng, Z. Identification of a novel human estrogen receptor-alpha splice variant able to enhance malignant biological behaviors of breast cancer cells. Oncol. Lett. 2018, 15, 5339–5344. [Google Scholar]
  355. Pagano, M.T.; Ortona, E.; Dupuis, M.L. A Role for Estrogen Receptor alpha36 in Cancer Progression. Front Endocrinol 2020, 11, 506. [Google Scholar] [CrossRef]
  356. Costa, T.J.; Jiménez-Altayó, F.; Echem, C.; Akamine, E.H.; Tostes, R.; Vila, E.; Dantas, A.P.; de Carvalho, M.H.C. Late Onset of Estrogen Therapy Impairs Carotid Function of Senescent Females in Association with Altered Prostanoid Balance and Upregulation of the Variant ERalpha36. Cells 2019, 8, 1217. [Google Scholar] [CrossRef]
  357. Post, W.S.; Goldschmidt-Clermont, P.J.; Wilhide, C.C.; Heldman, A.W.; Sussman, M.S.; Ouyang, P.; Milliken, E.E.; Issa, J.P. Methylation of the estrogen receptor gene is associated with aging and atherosclerosis in the cardiovascular system. Cardiovasc. Res. 1999, 43, 985–991. [Google Scholar] [CrossRef]
  358. Somani, Y.B.; Pawelczyk, J.A.; De Souza, M.J.; Kris-Etherton, P.M.; Proctor, D.N. Aging women and their endothelium: Probing the relative role of estrogen on vasodilator function. Am. J. Physiol. Heart Circ. Physiol. 2019, 317, H395–H404. [Google Scholar] [CrossRef]
  359. Liu, P.Y.; Christian, R.C.; Ruan, M.; Miller, V.M.; Fitzpatrick, L.A. Correlating androgen and estrogen steroid receptor expression with coronary calcification and atherosclerosis in men without known coronary artery disease. J. Clin. Endocrinol. Metab. 2005, 90, 1041–1046. [Google Scholar] [CrossRef]
  360. Novensà, L.; Novella, S.; Medina, P.; Segarra, G.; Castillo, N.; Heras, M.; Hermenegildo, C.; Dantas, A.P. Aging negatively affects estrogens-mediated effects on nitric oxide bioavailability by shifting ERalpha/ERbeta balance in female mice. PLoS ONE 2011, 6, e25335. [Google Scholar] [CrossRef]
  361. Gavin, K.M.; Seals, D.R.; Silver, A.E.; Moreau, K.L. Vascular endothelial estrogen receptor alpha is modulated by estrogen status and related to endothelial function and endothelial nitric oxide synthase in healthy women. J. Clin. Endocrinol. Metab. 2009, 94, 3513–3520. [Google Scholar] [CrossRef] [PubMed]
  362. Pinna, C.; Cignarella, A.; Sanvito, P.; Pelosi, V.; Bolego, C. Prolonged ovarian hormone deprivation impairs the protective vascular actions of estrogen receptor alpha agonists. Hypertension 2008, 51, 1210–1217. [Google Scholar] [CrossRef]
  363. Kalesnykas, G.; Roschier, U.; Puolivali, J.; Wang, J.; Miettinen, R. The effect of aging on the subcellular distribution of estrogen receptor-alpha in the cholinergic neurons of transgenic and wild-type mice. Eur. J. Neurosci. 2005, 21, 1437–1442. [Google Scholar] [CrossRef]
  364. Wynne, F.L.; Payne, J.A.; Cain, A.E.; Reckelhoff, J.F.; Khalil, R.A. Age-related reduction in estrogen receptor-mediated mechanisms of vascular relaxation in female spontaneously hypertensive rats. Hypertension 2004, 43, 405–412. [Google Scholar] [CrossRef]
  365. Forabosco, A.; Criscuolo, M.; Coukos, G.; Uccelli, E.; Weinstein, R.; Spinato, S.; Botticelli, A.; Volpe, A. Efficacy of hormone replacement therapy in postmenopausal women with oral discomfort. Oral. Surg. Oral. Med. Oral. Pathol. 1992, 73, 570–574. [Google Scholar] [CrossRef] [PubMed]
  366. Leimola-Virtanen, R.; Salo, T.; Toikkanen, S.; Pulkkinen, J.; Syrjanen, S. Expression of estrogen receptor (ER) in oral mucosa and salivary glands. Maturitas 2000, 36, 131–137. [Google Scholar] [CrossRef]
  367. Parés, D.; Iglesias, M.; Pera, M.; Pascual, M.; Torner, A.; Baró, T.; Alonso, S.; Grande, L. Expression of estrogen and progesterone receptors in the anal canal of women according to age and menopause. Dis. Colon. Rectum 2010, 53, 1687–1691. [Google Scholar] [CrossRef]
  368. Dieudonne, M.N.; Leneveu, M.C.; Giudicelli, Y.; Pecquery, R. Evidence for functional estrogen receptors alpha and beta in human adipose cells: Regional specificities and regulation by estrogens. Am. J. Physiol. Cell Physiol. 2004, 286, C655–C661. [Google Scholar] [CrossRef] [PubMed]
  369. McInnes, K.J.; Andersson, T.C.; Šimonytė, K.; Söderström, I.; Mattsson, C.; Seckl, J.R.; Olsson, T. Association of 11beta-hydroxysteroid dehydrogenase type I expression and activity with estrogen receptor beta in adipose tissue from postmenopausal women. Menopause 2012, 19, 1347–1352. [Google Scholar] [CrossRef]
  370. Ahmed, F.; Kamble, P.G.; Hetty, S.; Fanni, G.; Vranic, M.; Sarsenbayeva, A.; Kristófi, R.; Almby, K.; Svensson, M.K.; Pereira, M.J.; et al. Role of Estrogen and Its Receptors in Adipose Tissue Glucose Metabolism in Pre- and Postmenopausal Women. J. Clin. Endocrinol. Metab. 2022, 107, e1879–e1889. [Google Scholar] [CrossRef]
  371. Park, Y.M.; Erickson, C.; Bessesen, D.; Van Pelt, R.E.; Cox-York, K. Age- and menopause-related differences in subcutaneous adipose tissue estrogen receptor mRNA expression. Steroids 2017, 121, 17–21. [Google Scholar] [CrossRef]
  372. Ishunina, T.A.; Kruijver, F.P.; Balesar, R.; Swaab, D.F. Differential expression of estrogen receptor alpha and beta immunoreactivity in the human supraoptic nucleus in relation to sex and aging. J. Clin. Endocrinol. Metab. 2000, 85, 3283–3291. [Google Scholar]
  373. Chen, G.D.; Oliver, R.H.; Leung, B.S.; Lin, L.Y.; Yeh, J. Estrogen receptor alpha and beta expression in the vaginal walls and uterosacral ligaments of premenopausal and postmenopausal women. Fertil. Steril. 1999, 71, 1099–1102. [Google Scholar] [CrossRef]
  374. Gebhart, J.B.; Rickard, D.J.; Barrett, T.J.; Lesnick, T.G.; Webb, M.J.; Podratz, K.C.; Spelsberg, T.C. Expression of estrogen receptor isoforms alpha and beta messenger RNA in vaginal tissue of premenopausal and postmenopausal women. Am. J. Obstet. Gynecol. 2001, 185, 1325–1330; discussion 1330–1331. [Google Scholar] [CrossRef] [PubMed]
  375. Sakaguchi, H.; Fujimoto, J.; Aoki, I.; Tamaya, T. Expression of estrogen receptor alpha and beta in myometrium of premenopausal and postmenopausal women. Steroids 2003, 68, 11–19. [Google Scholar] [CrossRef] [PubMed]
  376. Pelletier, G.; El-Alfy, M. Immunocytochemical localization of estrogen receptors alpha and beta in the human reproductive organs. J. Clin. Endocrinol. Metab. 2000, 85, 4835–4840. [Google Scholar] [PubMed]
  377. Hodis, H.N.; Mack, W.J.; Azen, S.P.; Lobo, R.A.; Shoupe, D.; Mahrer, P.R.; Faxon, D.P.; Cashin-Hemphill, L.; Sanmarco, M.E.; French, W.J.; et al. Hormone therapy and the progression of coronary-artery atherosclerosis in postmenopausal women. N. Engl. J. Med. 2003, 349, 535–545. [Google Scholar] [CrossRef]
  378. Carmel, S. Health and Well-Being in Late Life: Gender Differences Worldwide. Front. Med. 2019, 6, 218. [Google Scholar] [CrossRef]
  379. Chen, K.; Xu, M.; Lu, F.; He, Y. Development of Matrix Metalloproteinases-Mediated Extracellular Matrix Remodeling in Regenerative Medicine: A Mini Review. Tissue Eng. Regen. Med. 2023, 20, 661–670. [Google Scholar] [CrossRef]
  380. Wang, D.; Brady, T.; Santhanam, L.; Gerecht, S. The extracellular matrix mechanics in the vasculature. Nat. Cardiovasc. Res. 2023, 2, 718–732. [Google Scholar] [CrossRef]
  381. Cho, L.; Kaunitz, A.M.; Faubion, S.S.; Hayes, S.N.; Lau, E.S.; Pristera, N.; Scott, N.; Shifren, J.L.; Shufelt, C.L.; Stuenkel, C.A.; et al. Rethinking Menopausal Hormone Therapy: For Whom, What, When, and How Long? Circulation 2023, 147, 597–610. [Google Scholar] [CrossRef] [PubMed]
  382. Skouby, S.O.; Pan, K.; Thompson, J.R.; Komm, B.S.; Mirkin, S. Effects of conjugated estrogens/bazedoxifene on lipid and coagulation variables: A randomized placebo- and active-controlled trial. Menopause 2015, 22, 640–649. [Google Scholar] [CrossRef]
  383. Marko, K.I.; Simon, J.A. Clinical trials in menopause. Menopause 2018, 25, 217–230. [Google Scholar] [CrossRef] [PubMed]
  384. Nita, A.R.; Knock, G.A.; Heads, R.J. Signalling mechanisms in the cardiovascular protective effects of estrogen: With a focus on rapid/membrane signalling. Curr. Res. Physiol. 2021, 4, 103–118. [Google Scholar] [CrossRef] [PubMed]
  385. The NAMS 2017 Hormone Therapy Position Statement Advisory Panel. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause 2017, 24, 728–753. [Google Scholar] [CrossRef]
  386. Mehta, J.; Manson, J.E. Menopausal hormone therapy and hypertension: Minimizing risk. Menopause 2021, 28, 1201–1202. [Google Scholar] [CrossRef]
  387. Shimbo, D.; Wang, L.; Lamonte, M.J.; Allison, M.; Wellenius, G.A.; Bavry, A.A.; Martin, L.W.; Aragaki, A.; Newman, J.D.; Swica, Y.; et al. The effect of hormone therapy on mean blood pressure and visit-to-visit blood pressure variability in postmenopausal women: Results from the Women’s Health Initiative randomized controlled trials. J. Hypertens. 2014, 32, 2071–2081; discussion 2081. [Google Scholar] [CrossRef]
  388. Ettehad, D.; Emdin, C.A.; Kiran, A.; Anderson, S.G.; Callender, T.; Emberson, J.; Chalmers, J.; Rodgers, A.; Rahimi, K. Blood pressure lowering for prevention of cardiovascular disease and death: A systematic review and meta-analysis. Lancet 2016, 387, 957–967. [Google Scholar] [CrossRef]
  389. Herrington, D.M.; Espeland, M.A.; Crouse, J.R., 3rd; Robertson, J.; Riley, W.A.; McBurnie, M.A.; Burke, G.L. Estrogen replacement and brachial artery flow-mediated vasodilation in older women. Arterioscler. Thromb. Vasc. Biol. 2001, 21, 1955–1961. [Google Scholar] [CrossRef]
  390. Mikkola, T.S.; Clarkson, T.B. Estrogen replacement therapy, atherosclerosis, and vascular function. Cardiovasc. Res. 2002, 53, 605–619. [Google Scholar] [CrossRef]
  391. Mori, T.; Durand, J.; Chen, Y.; Thompson, J.A.; Bakir, S.; Oparil, S. Effects of short-term estrogen treatment on the neointimal response to balloon injury of rat carotid artery. Am. J. Cardiol. 2000, 85, 1276–1279. [Google Scholar] [CrossRef] [PubMed]
  392. Alvandi, Z.; Bischoff, J. Endothelial-Mesenchymal Transition in Cardiovascular Disease. Arterioscler. Thromb. Vasc. Biol. 2021, 41, 2357–2369. [Google Scholar] [CrossRef] [PubMed]
  393. Cho, L.; Davis, M.; Elgendy, I.; Epps, K.; Lindley, K.J.; Mehta, P.K.; Michos, E.D.; Minissian, M.; Pepine, C.; Vaccarino, V.; et al. Summary of Updated Recommendations for Primary Prevention of Cardiovascular Disease in Women: JACC State-of-the-Art Review. J. Am. Coll. Cardiol. 2020, 75, 2602–2618. [Google Scholar] [CrossRef]
  394. Abramenko, N.; Vellieux, F.; Tesařová, P.; Kejík, Z.; Kaplánek, R.; Lacina, L.; Dvořánková, B.; Rösel, D.; Brábek, J.; Tesař, A.; et al. Estrogen Receptor Modulators in Viral Infections Such as SARS-CoV-2: Therapeutic Consequences. Int. J. Mol. Sci. 2021, 22, 6551. [Google Scholar] [CrossRef]
  395. Randolph, J.F., Jr.; Zheng, H.; Sowers, M.R.; Crandall, C.; Crawford, S.; Gold, E.B.; Vuga, M. Change in follicle-stimulating hormone and estradiol across the menopausal transition: Effect of age at the final menstrual period. J. Clin. Endocrinol. Metab. 2011, 96, 746–754. [Google Scholar] [CrossRef]
  396. Ausmanas, M.K.; Tan, D.A.; Jaisamrarn, U.; Tian, X.W.; Holinka, C.F. Estradiol, FSH and LH profiles in nine ethnic groups of postmenopausal Asian women: The Pan-Asia Menopause (PAM) study. Climacteric 2007, 10, 427–437. [Google Scholar] [CrossRef]
  397. Kling, J.M.; Dowling, N.M.; Bimonte-Nelson, H.A.; Gleason, C.E.; Kantarci, K.; Manson, J.E.; Taylor, H.S.; Brinton, E.A.; Lobo, R.A.; Cedars, M.I.; et al. Impact of menopausal hormone formulations on pituitary-ovarian regulatory feedback. Am. J. Physiol. Regul. Integr. Comp. Physiol. 2019, 317, R912–R920. [Google Scholar] [CrossRef]
  398. Costa, R.; Tuomainen, T.P.; Virtanen, J.; Niskanen, L.; Bertone-Johnson, E. Associations of reproductive factors with postmenopausal follicle stimulating hormone. Womens Midlife Health 2022, 8, 8. [Google Scholar] [CrossRef] [PubMed]
  399. Kim, J.; Freeman, K.; Ayala, A.; Mullen, M.; Sun, Z.; Rhee, J.W. Cardiovascular Impact of Androgen Deprivation Therapy: From Basic Biology to Clinical Practice. Curr. Oncol. Rep. 2023, 25, 965–977. [Google Scholar] [CrossRef]
  400. Labrie, F. All sex steroids are made intracellularly in peripheral tissues by the mechanisms of intracrinology after menopause. J. Steroid Biochem. Mol. Biol. 2015, 145, 133–138. [Google Scholar] [CrossRef]
  401. Purohit, A.; Reed, M.J. Regulation of estrogen synthesis in postmenopausal women. Steroids 2002, 67, 979–983. [Google Scholar] [CrossRef] [PubMed]
  402. Murakami, H.; Harada, N.; Sasano, H. Aromatase in atherosclerotic lesions of human aorta. J. Steroid Biochem. Mol. Biol. 2001, 79, 67–74. [Google Scholar] [CrossRef]
  403. Ishunina, T.A.; Fischer, D.F.; Swaab, D.F. Estrogen receptor alpha and its splice variants in the hippocampus in aging and Alzheimer’s disease. Neurobiol. Aging 2007, 28, 1670–1681. [Google Scholar] [CrossRef] [PubMed]
  404. Pasquali, R.; Vicennati, V.; Bertazzo, D.; Casimirri, F.; Pascal, G.; Tortelli, O.; Labate, A.M.M. Determinants of sex hormone-binding globulin blood concentrations in premenopausal and postmenopausal women with different estrogen status. Virgilio-Menopause-Health Group. Metabolism 1997, 46, 5–9. [Google Scholar] [CrossRef]
  405. Stanczyk, F.Z.; Sriprasert, I.; Karim, R.; Hwang-Levine, J.; Mack, W.J.; Hodis, H.N. Concentrations of endogenous sex steroid hormones and SHBG in healthy postmenopausal women. J. Steroid Biochem. Mol. Biol. 2022, 223, 106080. [Google Scholar] [CrossRef] [PubMed]
  406. Karim, R.; Hodis, H.N.; Stanczyk, F.Z.; Lobo, R.A.; Mack, W.J. Relationship between serum levels of sex hormones and progression of subclinical atherosclerosis in postmenopausal women. J. Clin. Endocrinol. Metab. 2008, 93, 131–138. [Google Scholar] [CrossRef] [PubMed]
  407. Pieber, D.; Allport, V.C.; Hills, F.; Johnson, M.; Bennett, P.R. Interactions between progesterone receptor isoforms in myometrial cells in human labour. Mol. Hum. Reprod. 2001, 7, 875–879. [Google Scholar] [CrossRef]
  408. Leslie, K.K.; Stein, M.P.; Kumar, N.S.; Dai, D.; Stephens, J.; Wandinger-Ness, A.; Glueck, D.H. Progesterone receptor isoform identification and subcellular localization in endometrial cancer. Gynecol. Oncol. 2005, 96, 32–41. [Google Scholar] [CrossRef]
  409. Vazquez, F.; Rodriguez-Manzaneque, J.C.; Lydon, J.P.; Edwards, D.P.; O’Malley, B.W.; Iruela-Arispe, M.L. Progesterone regulates proliferation of endothelial cells. J. Biol. Chem. 1999, 274, 2185–2192. [Google Scholar] [CrossRef]
  410. Nisolle, M.; Gillerot, S.; Casanas-Roux, F.; Squifflet, J.; Berliere, M.; Donnez, J. Immunohistochemical study of the proliferation index, oestrogen receptors and progesterone receptors A and B in leiomyomata and normal myometrium during the menstrual cycle and under gonadotrophin-releasing hormone agonist therapy. Hum. Reprod. 1999, 14, 2844–2850. [Google Scholar] [CrossRef]
  411. Pedroza, D.A.; Subramani, R.; Lakshmanaswamy, R. Classical and Non-Classical Progesterone Signaling in Breast Cancers. Cancers 2020, 12, 2440. [Google Scholar] [CrossRef] [PubMed]
  412. Molinari, C.; Battaglia, A.; Grossini, E.; Mary, D.A.S.G.; Stoker, J.B.; Surico, N.; Vacca, G. The effect of progesterone on coronary blood flow in anaesthesized pigs. Exp. Physiol. 2001, 86, 101–108. [Google Scholar] [CrossRef] [PubMed]
  413. Rupnow, H.L.; Phernetton, T.M.; Shaw, C.E.; Modrick, M.L.; Bird, I.M.; Magness, R.R. Endothelial vasodilator production by uterine and systemic arteries. VII. Estrogen and progesterone effects on eNOS. Am. J. Physiol. Heart Circ. Physiol. 2001, 280, H1699–H1705. [Google Scholar] [CrossRef]
  414. Selles, J.; Polini, N.; Alvarez, C.; Massheimer, V. Progesterone and 17 beta-estradiol acutely stimulate nitric oxide synthase activity in rat aorta and inhibit platelet aggregation. Life Sci. 2001, 69, 815–827. [Google Scholar] [CrossRef]
  415. Thomas, P.; Pang, Y. Protective actions of progesterone in the cardiovascular system: Potential role of membrane progesterone receptors (mPRs) in mediating rapid effects. Steroids 2013, 78, 583–588. [Google Scholar] [CrossRef]
  416. Giesen, J.A.S.; Rouver, W.D.N.; Costa, E.D.; Lemos, V.S.; Dos Santos, R.L. Sex differences in progesterone-induced relaxation in the coronary bed from normotensive rats. J. Mol. Endocrinol. 2019, 64, 91–102. [Google Scholar] [CrossRef]
  417. Cox, M.W.; Fu, W.; Chai, H.; Paladugu, R.; Lin, P.H.; Lumsden, A.B.; Yao, Q.; Chen, C. Effects of progesterone and estrogen on endothelial dysfunction in porcine coronary arteries. J. Surg. Res. 2005, 124, 104–111. [Google Scholar] [CrossRef] [PubMed]
  418. Yuan, X.-H.; Fan, Y.-Y.; Yang, C.-R.; Gao, X.-R.; Zhang, L.-L.; Hu, Y.; Wang, Y.-Q.; Jun, H. Progesterone amplifies oxidative stress signal and promotes NO production via H2O2 in mouse kidney arterial endothelial cells. J. Steroid Biochem. Mol. Biol. 2015, 155, 104–111. [Google Scholar] [CrossRef]
  419. Faulkner, J.L.; Kennard, S.; Huby, A.C.; Antonova, G.; Lu, Q.; Jaffe, I.Z.; Patel, V.S.; Fulton, D.J.R.; Belin de Chantemèle, E.J. Progesterone Predisposes Females to Obesity-Associated Leptin-Mediated Endothelial Dysfunction via Upregulating Endothelial MR (Mineralocorticoid Receptor) Expression. Hypertension 2019, 74, 678–686. [Google Scholar] [CrossRef]
  420. Nickenig, G.; Strehlow, K.; Wassmann, S.; Bäumer, A.T.; Albory, K.; Sauer, H.; Böhm, M. Differential effects of estrogen and progesterone on AT(1) receptor gene expression in vascular smooth muscle cells. Circulation 2000, 102, 1828–1833. [Google Scholar] [CrossRef]
  421. Mueck, A.O.; Seeger, H. Progestogens and target tissues: Vascular systems. Maturitas 2009, 62, 356–361. [Google Scholar] [CrossRef]
  422. Prior, J.C. Progesterone for treatment of symptomatic menopausal women. Climacteric 2018, 21, 358–365. [Google Scholar] [CrossRef] [PubMed]
  423. Hitchcock, C.L.; Prior, J.C. Oral micronized progesterone for vasomotor symptoms--a placebo-controlled randomized trial in healthy postmenopausal women. Menopause 2012, 19, 886–893. [Google Scholar] [CrossRef]
  424. Casanova, G.; Spritzer, P.M. Effects of micronized progesterone added to non-oral estradiol on lipids and cardiovascular risk factors in early postmenopause: A clinical trial. Lipids Health Dis. 2012, 11, 133. [Google Scholar] [CrossRef] [PubMed]
  425. Kaemmle, L.M.; Stadler, A.; Janka, H.; von Wolff, M.; Stute, P. The impact of micronized progesterone on cardiovascular events—A systematic review. Climacteric 2022, 25, 327–336. [Google Scholar] [CrossRef]
  426. Lobo, R.A.; Kaunitz, A.M.; Santoro, N.; Bernick, B.; Graham, S.; Mirkin, S. Metabolic and cardiovascular effects of TX-001HR in menopausal women with vasomotor symptoms. Climacteric 2019, 22, 610–616. [Google Scholar] [CrossRef]
  427. Koh, K.K.; Jin, D.K.; Yang, S.H.; Lee, S.-K.; Hwang, H.Y.; Kang, M.H.; Kim, W.; Kim, D.S.; Choi, I.S.; Shin, E.K. Vascular effects of synthetic or natural progestagen combined with conjugated equine estrogen in healthy postmenopausal women. Circulation 2001, 103, 1961–1966. [Google Scholar] [CrossRef] [PubMed]
  428. Coksuer, H.; Koplay, M.; Oghan, F.; Coksuer, C.; Keskin, N.; Ozveren, O. Effects of estradiol-drospirenone hormone treatment on carotid artery intima-media thickness and vertigo/dizziness in postmenopausal women. Arch. Gynecol. Obstet. 2011, 283, 1045–1051. [Google Scholar] [CrossRef]
  429. Vitale, C.; Mammi, C.; Gambacciani, M.; Russo, N.; Spoletini, I.; Fini, M.; Volterrani, M.; Rosano, G.M. Effect of hormone replacement therapy with the anti-mineralocorticoid progestin Drospirenone compared to tibolone on endothelial function and central haemodynamics in post-menopausal women. Int. J. Cardiol. 2017, 227, 217–221. [Google Scholar] [CrossRef]
  430. Preston, R.A.; White, W.B.; Pitt, B.; Bakris, G.; Norris, P.M.; Hanes, V. Effects of drospirenone/17-beta estradiol on blood pressure and potassium balance in hypertensive postmenopausal women. Am. J. Hypertens. 2005, 18, 797–804. [Google Scholar] [CrossRef]
  431. Rizzo, M.R.; Leo, S.; De Franciscis, P.; Colacurci, N.; Paolisso, G. Short-term effects of low-dose estrogen/drospirenone vs low-dose estrogen/dydrogesterone on glycemic fluctuations in postmenopausal women with metabolic syndrome. Age 2014, 36, 265–274. [Google Scholar] [CrossRef] [PubMed]
  432. Sullivan, J.M.; Shala, B.A.; Miller, L.A.; Lerner, J.L.; McBrayer, J.D. Progestin enhances vasoconstrictor responses in postmenopausal women receiving estrogen replacement therapy. Menopause 2018, 25, 1180–1186. [Google Scholar] [CrossRef] [PubMed]
  433. Seeger, H.; Mueck, A.O.; Teichmann, A.T.; Lippert, T.H. Effect of sequential estrogen/progestin treatment on biochemical vasoactive markers in postmenopausal women comparing oral and transdermal application. Clin. Exp. Obstet. Gynecol. 2000, 27, 17–20. [Google Scholar]
  434. Viinikka, L.; Orpana, A.; Puolakka, J.; Pyorala, T.; Ylikorkala, O. Different effects of oral and transdermal hormonal replacement on prostacyclin and thromboxane A2. Obstet Gynecol 1997, 89, 104–107. [Google Scholar] [CrossRef]
  435. Clarkson, T.B.; Anthony, M.S.; Wagner, J.D. A comparison of tibolone and conjugated equine estrogens effects on coronary artery atherosclerosis and bone density of postmenopausal monkeys. J. Clin. Endocrinol. Metab. 2001, 86, 5396–5404. [Google Scholar] [CrossRef] [PubMed]
  436. Williams, J.K.; Anthony, M.S.; Honoré, E.K.; Herrington, D.M.; Morgan, T.M.; Register, T.C.; Clarkson, T.B. Regression of atherosclerosis in female monkeys. Arterioscler. Thromb. Vasc. Biol. 1995, 15, 827–836. [Google Scholar] [CrossRef]
  437. Azizian, H.; Khaksari, M.; Asadikaram, G.; Esmailidehaj, M.; Shahrokhi, N. Progesterone eliminates 17beta-estradiol-Mediated cardioprotection against diabetic cardiovascular dysfunction in ovariectomized rats. Biomed. J. 2021, 44, 461–470. [Google Scholar] [CrossRef]
  438. Levine, R.L.; Chen, S.J.; Durand, J.; Chen, Y.F.; Oparil, S. Medroxyprogesterone attenuates estrogen-mediated inhibition of neointima formation after balloon injury of the rat carotid artery. Circulation 1996, 94, 2221–2227. [Google Scholar] [CrossRef]
  439. Reckelhoff, J.F.; Yanes, L.L.; Iliescu, R.; Fortepiani, L.A.; Granger, J.P. Testosterone supplementation in aging men and women: Possible impact on cardiovascular-renal disease. Am. J. Physiol. Renal Physiol. 2005, 289, F941–F948. [Google Scholar] [CrossRef]
  440. Jiroutek, M.R.; Chen, M.H.; Johnston, C.C.; Longcope, C. Changes in reproductive hormones and sex hormone-binding globulin in a group of postmenopausal women measured over 10 years. Menopause 1998, 5, 90–94. [Google Scholar] [CrossRef]
  441. Gonzales, R.J.; Ansar, S.; Duckles, S.P.; Krause, D.N. Androgenic/estrogenic balance in the male rat cerebral circulation: Metabolic enzymes and sex steroid receptors. J. Cereb. Blood Flow. Metab. 2007, 27, 1841–1852. [Google Scholar] [CrossRef]
  442. Oh, H.; Wild, R.A.; Manson, J.E.; Bea, J.W.; Shadyab, A.H.; Pfeiffer, R.M.; Saquib, N.; Underland, L.; Anderson, G.L.; Xu, X.; et al. Obesity, Height, and Serum Androgen Metabolism among Postmenopausal Women in the Women’s Health Initiative Observational Study. Cancer Epidemiol. Biomarkers Prev. 2021, 30, 2018–2029. [Google Scholar] [CrossRef] [PubMed]
  443. Ng, M.K. New perspectives on Mars and Venus: Unravelling the role of androgens in gender differences in cardiovascular biology and disease. Heart Lung Circ. 2007, 16, 185–192. [Google Scholar] [CrossRef]
  444. Wynne, F.L.; Khalil, R.A. Testosterone and coronary vascular tone: Implications in coronary artery disease. J. Endocrinol. Investig. 2003, 26, 181–186. [Google Scholar] [CrossRef]
  445. Higashiura, K.; Mathur, R.S.; Halushka, P.V. Gender-related differences in androgen regulation of thromboxane A2 receptors in rat aortic smooth-muscle cells. J. Cardiovasc. Pharmacol. 1997, 29, 311–315. [Google Scholar] [CrossRef] [PubMed]
  446. Wang, J.; Fan, X.; Yang, M.; Song, M.; Wang, K.; Giovannucci, E.; Ma, H.; Jin, G.; Hu, Z.; Shen, H.; et al. Sex-specific associations of circulating testosterone levels with all-cause and cause-specific mortality. Eur. J. Endocrinol. 2021, 184, 723–732. [Google Scholar] [CrossRef] [PubMed]
  447. Ba, Z.F.; Wang, P.; Kuebler, J.F.; Rue, L.W.; 3rd Bland, K.I.; Chaudry, I.H. Flutamide induces relaxation in large and small blood vessels. Arch. Surg. 2002, 137, 1180–1186. [Google Scholar] [CrossRef]
  448. Horton, A.C.; Wilkinson, M.M.; Kilanowski-Doroh, I.; Dong, Z.; Liu, J.; Ogola, B.O.; Visniauskas, B.; Lindsey, S.H. Dihydrotestosterone induces arterial stiffening in female mice. Biol. Sex. Differ. 2024, 15, 9. [Google Scholar] [CrossRef]
  449. Sorva, R.; Kuusi, T.; Dunkel, L.; Taskinen, M.R. Effects of endogenous sex steroids on serum lipoproteins and postheparin plasma lipolytic enzymes. J. Clin. Endocrinol. Metab. 1988, 66, 408–413. [Google Scholar] [CrossRef]
  450. Mäkinen, J.I.; Perheentupa, A.; Irjala, K.; Pöllänen, P.; Mäkinen, J.; Huhtaniemi, I.; Raitakari, O.T. Endogenous testosterone and serum lipids in middle-aged men. Atherosclerosis 2008, 197, 688–693. [Google Scholar] [CrossRef]
  451. English, K.M.; Steeds, R.P.; Jones, T.H.; Diver, M.J.; Channer, K.S. Low-dose transdermal testosterone therapy improves angina threshold in men with chronic stable angina: A randomized, double-blind, placebo-controlled study. Circulation 2000, 102, 1906–1911. [Google Scholar] [CrossRef] [PubMed]
  452. Rosano, G.M.C.; Leonardo, F.; Pagnotta, P.; Pelliccia, F.; Panina, G.; Cerquetani, E.; della Monica, P.L.; Bonfigli, B.; Volpe, M.; Chierchia, S.L. Acute anti-ischemic effect of testosterone in men with coronary artery disease. Circulation 1999, 99, 1666–1670. [Google Scholar] [CrossRef] [PubMed]
  453. Sievers, C.; Klotsche, J.; Pieper, L.; Schneider, H.J.; März, W.; Wittchen, H.U.; Stalla, G.K.; Mantzoros, C. Low testosterone levels predict all-cause mortality and cardiovascular events in women: A prospective cohort study in German primary care patients. Eur. J. Endocrinol. 2010, 163, 699–708. [Google Scholar] [CrossRef] [PubMed]
  454. Khatibi, A.; Agardh, C.-D.; Shakir, Y.A.; Nerbrand, C.; Nyberg, P.; Lidfeldt, J.; Samsioe, G. Could androgens protect middle-aged women from cardiovascular events? A population-based study of Swedish women: The Women’s Health in the Lund Area (WHILA) Study. Climacteric 2007, 10, 386–392. [Google Scholar] [CrossRef] [PubMed]
  455. Montalcini, T.; Gorgone, G.; Gazzaruso, C.; Sesti, G.; Perticone, F.; Pujia, A. Endogenous testosterone and endothelial function in postmenopausal women. Coron. Artery Dis. 2007, 18, 9–13. [Google Scholar] [CrossRef]
  456. Chen, Y.-Q.; Zhou, H.-M.; Chen, F.-F.; Liu, Y.-P.; Han, L.; Song, M.; Wang, Z.-H.; Zhang, W.; Shang, Y.-Y.; Zhong, M. Testosterone ameliorates vascular aging via the Gas6/Axl signaling pathway. Aging 2020, 12, 16111–16125. [Google Scholar] [CrossRef] [PubMed]
  457. Son, B.K.; Kojima, T.; Ogawa, S.; Akishita, M. Testosterone inhibits aneurysm formation and vascular inflammation in male mice. J. Endocrinol. 2019, 241, 307–317. [Google Scholar] [CrossRef] [PubMed]
  458. Yue, P.; Chatterjee, K.; Beale, C.; Poole-Wilson, P.A.; Collins, P. Testosterone relaxes rabbit coronary arteries and aorta. Circulation 1995, 91, 1154–1160. [Google Scholar] [CrossRef]
  459. Costarella, C.E.; Stallone, J.N.; Rutecki, G.W.; Whittier, F.C. Testosterone causes direct relaxation of rat thoracic aorta. J. Pharmacol. Exp. Ther. 1996, 277, 34–39. [Google Scholar] [CrossRef]
  460. Chou, T.M.; Sudhir, K.; Hutchison, S.J.; Ko, E.; Amidon, T.M.; Collins, P.; Chatterjee, K. Testosterone induces dilation of canine coronary conductance and resistance arteries in vivo. Circulation 1996, 94, 2614–2619. [Google Scholar] [CrossRef]
  461. Honda, H.; Unemoto, T.; Kogo, H. Different mechanisms for testosterone-induced relaxation of aorta between normotensive and spontaneously hypertensive rats. Hypertension 1999, 34, 1232–1236. [Google Scholar] [CrossRef] [PubMed]
  462. Chen, Y.-Q.; Zhao, J.; Jin, C.-W.; Li, Y.-H.; Tang, M.-X.; Wang, Z.-H.; Zhang, W.; Zhang, Y.; Li, L.; Zhong, M. Testosterone delays vascular smooth muscle cell senescence and inhibits collagen synthesis via the Gas6/Axl signaling pathway. Age 2016, 38, 60. [Google Scholar] [CrossRef] [PubMed]
  463. Stone, T.; Cardozo, L.L.Y.; Oluwatade, T.N.; Leone, C.A.; Burgos, M.; Okifo, F.; Pal, L.; Reckelhoff, J.F.; Stachenfeld, N.S. Testosterone-associated blood pressure dysregulation in women with androgen excess polycystic ovary syndrome. Am. J. Physiol. Heart Circ. Physiol. 2023, 325, H232–H243. [Google Scholar] [CrossRef]
  464. Wild, S.; Pierpoint, T.; McKeigue, P.; Jacobs, H. Cardiovascular disease in women with polycystic ovary syndrome at long-term follow-up: A retrospective cohort study. Clin. Endocrinol. 2000, 52, 595–600. [Google Scholar] [CrossRef]
  465. Bianchi, V.E.; Bresciani, E.; Meanti, R.; Rizzi, L.; Omeljaniuk, R.J.; Torsello, A. The role of androgens in women’s health and wellbeing. Pharmacol. Res. 2021, 171, 105758. [Google Scholar] [CrossRef]
  466. Kloner, R.A.; Carson, C., 3rd; Dobs, A.; Kopecky, S.; Mohler, E.R., 3rd. Testosterone and Cardiovascular Disease. J. Am. Coll. Cardiol. 2016, 67, 545–557. [Google Scholar] [CrossRef] [PubMed]
  467. Snyder, P.J.; Bhasin, S.; Cunningham, G.R.; Matsumoto, A.M.; Stephens-Shields, A.J.; Cauley, J.A.; Gill, T.M.; Barrett-Connor, E.; Swerdloff, R.S.; Wang, C.; et al. Lessons From the Testosterone Trials. Endocr. Rev. 2018, 39, 369–386. [Google Scholar] [CrossRef]
  468. Hackett, G.I. Long Term Cardiovascular Safety of Testosterone Therapy: A Review of the TRAVERSE Study. World J. Mens Health 2025, 43, 282–290. [Google Scholar] [CrossRef]
  469. Ghowsi, M.; Sisakhtnezhad, S.; Wang, Y. Effect of testosterone on the mRNA expression of Wnt-2 and dickkopf1 (DKK1), collagen deposition and oxidative stress in the cardiac tissue in male rats. Cell. Mol. Biol. 2023, 69, 75–81. [Google Scholar] [CrossRef]
  470. Nácul, A.P.; Rezende, G.P.; Gomes, D.A.Y.; Maranhão, T.; Costa, L.O.B.F.; dos Reis, F.M.; Maciel, G.A.R.; Damásio, L.C.V.d.C.; Silva, A.C.J.d.S.R.e.; Lopes, V.M.; et al. Use of androgens at different stages of life: Climacterium. Rev. Bras. Ginecol. Obstet. 2022, 44, 83–88. [Google Scholar] [CrossRef]
  471. Vegunta, S.; Kling, J.M.; Kapoor, E. Androgen Therapy in Women. J. Womens Health 2020, 29, 57–64. [Google Scholar] [CrossRef] [PubMed]
  472. Eckenrode, H.E.; Carwie, J.C.; Curtis, L.M. Does Gender Affirming Hormone Therapy Increase the Risk of Kidney Disease? Semin. Nephrol. 2022, 42, 151284. [Google Scholar] [CrossRef] [PubMed]
  473. Nota, N.M.; Wiepjes, C.M.; de Blok, C.J.M.; Gooren, L.J.G.; Kreukels, B.P.C.; den Heijer, M. Occurrence of Acute Cardiovascular Events in Transgender Individuals Receiving Hormone Therapy. Circulation 2019, 139, 1461–1462. [Google Scholar] [CrossRef]
  474. Caceres, B.A.; Jackman, K.B.; Edmondson, D.; Bockting, W.O. Assessing gender identity differences in cardiovascular disease in US adults: An analysis of data from the 2014-2017 BRFSS. J. Behav. Med. 2020, 43, 329–338. [Google Scholar] [CrossRef] [PubMed]
  475. Karalexi, M.A.; Frisell, T.; Cnattingius, S.; Holmberg, D.; Holmberg, M.; Kollia, N.; Skalkidou, A.; Papadopoulos, F.C. Cardiovascular outcomes in transgender individuals in Sweden after initiation of gender-affirming hormone therapy. Eur. J. Prev. Cardiol. 2022, 29, 2017–2026. [Google Scholar] [CrossRef]
  476. Quinn, V.P.; Nash, R.; Hunkeler, E.; Contreras, R.; Cromwell, L.; Becerra-Culqui, T.A.; Getahun, D.; Giammattei, S.; Lash, T.L.; Millman, A.; et al. Cohort profile: Study of Transition, Outcomes and Gender (STRONG) to assess health status of transgender people. BMJ Open 2017, 7, e018121. [Google Scholar] [CrossRef]
  477. Panel, A. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause 2022, 29, 767–794. [Google Scholar]
  478. Manson, J.E.; Chlebowski, R.T.; Stefanick, M.L.; Aragaki, A.K.; Rossouw, J.E.; Prentice, R.L.; Anderson, G.L.; Howard, B.V.; Thomson, C.A.; Lacroix, A.Z.; et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women’s Health Initiative randomized trials. JAMA 2013, 310, 1353–1368. [Google Scholar] [CrossRef]
Figure 1. Changes in sex hormone synthesis in the postmenopausal period. In Pre-MW, cholesterol is transported into the mitochondria by steroidogenic acute regulatory protein and then converted by P450Scc (20,22-desmolase) into Δ5-3β-hydroxysteroid pregnenolone. In the ovary, pregnenolone is released into the cytosol, where it undergoes oxidation and isomerization by 3β-hydroxysteroid dehydrogenase (3β-HSD, Δ54 isomerase) into the ketosteroid progesterone (P4). P4 is converted mainly into androstenedione then estrone (E1). Androstenedione could also be transformed via 17β-HSD3,5 into testosterone (T), which is then converted by aromatase into E1. E1 is transformed by 17β-HSD1,7 into 17β-estradiol (E2) and reversibly by 17β-HSD2,4 mainly in adipose tissue from E2 to E1. E2 is metabolized mainly in the liver by catechol-o-methyl transferase (COMT) into 2-methoxy-E2. During pregnancy, E2 is metabolized in the placenta by 16α-hydroxylase into estriol (E3). Pregnenolone is also converted in the adrenal glands into androstenediol, which is then converted by 3β-HSD Δ5,4 isomerase into testosterone (T). T is transformed in the liver by 5α-reductase into dihydrotestosterone (DHT). Sex hormones are also synthesized de novo or through interconversion by aromatase and other enzymes in the uterus, breast, and other tissues so that each cell can make enough hormones for its metabolic needs. In Post-MW, a sharp decline in ovarian function leads to decreases in the release of P4, E2, and ovarian T precursors, but the adrenal glands continue to produce T, leading to a small, slow decline in circulating free T and relative increase in T/E2 ratio. Also, in Post-MW, ovarian production and circulating levels of both E2 and E1 are reduced, but aromatase and 17β-HSD2,4 activities are increased in adipose tissue, causing relative increases in the E1/E2 ratio. Dashed red lines indicate decrease. Thick red lines indicate increase.
Figure 1. Changes in sex hormone synthesis in the postmenopausal period. In Pre-MW, cholesterol is transported into the mitochondria by steroidogenic acute regulatory protein and then converted by P450Scc (20,22-desmolase) into Δ5-3β-hydroxysteroid pregnenolone. In the ovary, pregnenolone is released into the cytosol, where it undergoes oxidation and isomerization by 3β-hydroxysteroid dehydrogenase (3β-HSD, Δ54 isomerase) into the ketosteroid progesterone (P4). P4 is converted mainly into androstenedione then estrone (E1). Androstenedione could also be transformed via 17β-HSD3,5 into testosterone (T), which is then converted by aromatase into E1. E1 is transformed by 17β-HSD1,7 into 17β-estradiol (E2) and reversibly by 17β-HSD2,4 mainly in adipose tissue from E2 to E1. E2 is metabolized mainly in the liver by catechol-o-methyl transferase (COMT) into 2-methoxy-E2. During pregnancy, E2 is metabolized in the placenta by 16α-hydroxylase into estriol (E3). Pregnenolone is also converted in the adrenal glands into androstenediol, which is then converted by 3β-HSD Δ5,4 isomerase into testosterone (T). T is transformed in the liver by 5α-reductase into dihydrotestosterone (DHT). Sex hormones are also synthesized de novo or through interconversion by aromatase and other enzymes in the uterus, breast, and other tissues so that each cell can make enough hormones for its metabolic needs. In Post-MW, a sharp decline in ovarian function leads to decreases in the release of P4, E2, and ovarian T precursors, but the adrenal glands continue to produce T, leading to a small, slow decline in circulating free T and relative increase in T/E2 ratio. Also, in Post-MW, ovarian production and circulating levels of both E2 and E1 are reduced, but aromatase and 17β-HSD2,4 activities are increased in adipose tissue, causing relative increases in the E1/E2 ratio. Dashed red lines indicate decrease. Thick red lines indicate increase.
Ijms 26 05078 g001
Figure 2. Based on previously published reports, predictive estimates of changes in sex hormone levels and the incidence of CVD during menopause have been drawn. Throughout the menopausal transition, E2 levels experience a sharp decline, and E1 levels decrease more gradually, while FSH and LH levels rise, and free T levels decline slowly and modestly (A), but E1/E2 and T/E2 ratios are increased (B) [27,28]. Changes in sex hormone levels may contribute to the observed sex differences in the incidence of CVD. Prior to menopause, women experience a significantly lower incidence of HTN compared to men. However, as ovarian function declines during menopause and postmenopause, the prevalence of HTN increases, eventually matching and even surpassing that of men in older Post-MW (C) [1]. Women between 25 and 45 years old experience a higher incidence of stroke compared to men, and this trend persists after menopause. However, as age increases, the gender gap gradually narrows, with men eventually matching or surpassing women at very advanced ages (D) [1].
Figure 2. Based on previously published reports, predictive estimates of changes in sex hormone levels and the incidence of CVD during menopause have been drawn. Throughout the menopausal transition, E2 levels experience a sharp decline, and E1 levels decrease more gradually, while FSH and LH levels rise, and free T levels decline slowly and modestly (A), but E1/E2 and T/E2 ratios are increased (B) [27,28]. Changes in sex hormone levels may contribute to the observed sex differences in the incidence of CVD. Prior to menopause, women experience a significantly lower incidence of HTN compared to men. However, as ovarian function declines during menopause and postmenopause, the prevalence of HTN increases, eventually matching and even surpassing that of men in older Post-MW (C) [1]. Women between 25 and 45 years old experience a higher incidence of stroke compared to men, and this trend persists after menopause. However, as age increases, the gender gap gradually narrows, with men eventually matching or surpassing women at very advanced ages (D) [1].
Ijms 26 05078 g002
Figure 3. Changes in estrogen receptors (ERs) postmenopause. In Pre-MW, E2 binds to cytosolic/nuclear ERα and ERβ and membrane GPER to generate cardiovascular benefits. In Post-MW, ERs show differential expression of subtypes and variants, altered distribution, conformation changes, and decreased ligand binding, receptor sensitivity, and post-ER coupling mechanisms, leading to decreased cardiovascular benefits. ↓, decreased.
Figure 3. Changes in estrogen receptors (ERs) postmenopause. In Pre-MW, E2 binds to cytosolic/nuclear ERα and ERβ and membrane GPER to generate cardiovascular benefits. In Post-MW, ERs show differential expression of subtypes and variants, altered distribution, conformation changes, and decreased ligand binding, receptor sensitivity, and post-ER coupling mechanisms, leading to decreased cardiovascular benefits. ↓, decreased.
Ijms 26 05078 g003
Figure 4. Genomic and nongenomic estrogen (E2)/estrogen receptor (ER)-mediated pathways in endothelial cells (ECs), vascular smooth muscle cells (VSMC), and extracellular matrix (ECM). In ECs, E2 binds to cytosolic/nuclear ERα and ERβ to form ER homodimers or heterodimers and stimulate genomic pathways involving MAPK activation, gene transcription, EC growth, and eNOS expression. E2 also binds less abundant plasmalemmal ERα, ERβ, and GPER in ECs and activates phospholipase C (PLC) to produce inositol 1,4,5-triphosphate (IP3) and diacylglycerol (DAG). E2/ER activation increases cytosolic free Ca2+ concentration ([Ca2+]c) through initial IP3-induced Ca2+ release from the endoplasmic reticulum and sustained store-operated Ca2+ entry through store-operated channels (SOCs). E2 also inhibits plasma membrane Ca2+-ATPase (PMCA) activity in ECs, thus reducing Ca2+ extrusion and contributing to the prolongation of Ca2+ signal. The E2-induced increase in Ca2+ binds to calmodulin (CAM), and the Ca2+/CAM complex initiates translocation of eNOS away from caveolin. E2 also activates phosphatidylinositol 3-kinase (PI3K) to transform phosphatidylinositol-4,5-bisphosphate (PIP2) into phosphatidylinositol 3,4,5-trisphosphate (PIP3) and activate Akt. ER-mediated activation of MAPK/Akt causes phosphorylation and full activation of eNOS, which transforms L-arginine to L-citrulline and produces NO. NO diffuses into VSMC and activates guanylate cyclase (GC) to form cyclic guanosine monophosphate (cGMP), which activates protein kinase G (PKG). PKG decreases [Ca2+]c by stimulating plasmalemmal Ca2+ extrusion pump (PMCA) and sarcoplasmic reticulum (SR) Ca2+ uptake pump (SERCA). PKG also phosphorylates and inhibits myosin light-chain kinase (MLCK) and in turn decreases the actin–myosin myofilaments force sensitivity to [Ca2+]c, leading to VSM relaxation. E2 also inhibits NADPH and formation of O2•− and ONOO, thus promoting antioxidant effects that increase NO bioavailability. E2 also activates cyclooxygenases (COX) to produce prostacyclin (PGI2), which binds the prostanoid receptor (PR) in VSMC and activates adenylate cyclase (AC) to form cyclic adenosine monophosphate (cAMP), which activates protein kinase A (PKA). PKA decreases [Ca2+]c and myofilament force sensitivity to Ca2+ using the same mechanisms as cGMP/PKG, leading to VSM relaxation. E2 also increases endothelium-derived hyperpolarizing factor (EDHF), causing activation of VSM K+ channels, hyperpolarization, inhibition of Ca2+ influx through Ca2+ channels, and VSM relaxation. In VSMCs, E2 binds cytosolic/nuclear ERα and ERβ to activate genomic pathways and inhibit MAPK, gene transcription, and VSMC proliferation. Also, in VSMCs, vasoconstrictor agonists such as phenylephrine (Phe), ET-1, TXA2, or Ang II activate their specific receptors (R) to stimulate PLC and generate IP3 and DAG. IP3 stimulates Ca2+ release from the sarcoplasmic reticulum (SR). Agonists also stimulate Ca2+ entry through Ca2+ channels. Ca2+ binds CAM to activate myosin light-chain kinase (MLCK), causing MLC phosphorylation, actin–myosin interaction, and VSM contraction. DAG activates PKC to phosphorylate calponin (CaP) or activates MAPK kinase (MEK) and MAPK cascade, leading to phosphorylation of caldesmon (CaD) and increased myofilament sensitivity to [Ca2+]c. E2 binds less abundant plasmalemmal ERα, ERβ, and GPER to activate non-genomic pathways and inhibit agonist-activated mechanisms of VSM contraction, including Ca2+ channels, PKC, MAPK, and ROCK-mediated [Ca2+]c sensitization pathways. E2/ER also increases the proteolytic activity of MMP-2 and MMP-9, leading to breakdown of ECM proteins, changes in elastin/collagen ratio, and vascular remodeling. Dashed lines indicate inhibition. ↑, increase.
Figure 4. Genomic and nongenomic estrogen (E2)/estrogen receptor (ER)-mediated pathways in endothelial cells (ECs), vascular smooth muscle cells (VSMC), and extracellular matrix (ECM). In ECs, E2 binds to cytosolic/nuclear ERα and ERβ to form ER homodimers or heterodimers and stimulate genomic pathways involving MAPK activation, gene transcription, EC growth, and eNOS expression. E2 also binds less abundant plasmalemmal ERα, ERβ, and GPER in ECs and activates phospholipase C (PLC) to produce inositol 1,4,5-triphosphate (IP3) and diacylglycerol (DAG). E2/ER activation increases cytosolic free Ca2+ concentration ([Ca2+]c) through initial IP3-induced Ca2+ release from the endoplasmic reticulum and sustained store-operated Ca2+ entry through store-operated channels (SOCs). E2 also inhibits plasma membrane Ca2+-ATPase (PMCA) activity in ECs, thus reducing Ca2+ extrusion and contributing to the prolongation of Ca2+ signal. The E2-induced increase in Ca2+ binds to calmodulin (CAM), and the Ca2+/CAM complex initiates translocation of eNOS away from caveolin. E2 also activates phosphatidylinositol 3-kinase (PI3K) to transform phosphatidylinositol-4,5-bisphosphate (PIP2) into phosphatidylinositol 3,4,5-trisphosphate (PIP3) and activate Akt. ER-mediated activation of MAPK/Akt causes phosphorylation and full activation of eNOS, which transforms L-arginine to L-citrulline and produces NO. NO diffuses into VSMC and activates guanylate cyclase (GC) to form cyclic guanosine monophosphate (cGMP), which activates protein kinase G (PKG). PKG decreases [Ca2+]c by stimulating plasmalemmal Ca2+ extrusion pump (PMCA) and sarcoplasmic reticulum (SR) Ca2+ uptake pump (SERCA). PKG also phosphorylates and inhibits myosin light-chain kinase (MLCK) and in turn decreases the actin–myosin myofilaments force sensitivity to [Ca2+]c, leading to VSM relaxation. E2 also inhibits NADPH and formation of O2•− and ONOO, thus promoting antioxidant effects that increase NO bioavailability. E2 also activates cyclooxygenases (COX) to produce prostacyclin (PGI2), which binds the prostanoid receptor (PR) in VSMC and activates adenylate cyclase (AC) to form cyclic adenosine monophosphate (cAMP), which activates protein kinase A (PKA). PKA decreases [Ca2+]c and myofilament force sensitivity to Ca2+ using the same mechanisms as cGMP/PKG, leading to VSM relaxation. E2 also increases endothelium-derived hyperpolarizing factor (EDHF), causing activation of VSM K+ channels, hyperpolarization, inhibition of Ca2+ influx through Ca2+ channels, and VSM relaxation. In VSMCs, E2 binds cytosolic/nuclear ERα and ERβ to activate genomic pathways and inhibit MAPK, gene transcription, and VSMC proliferation. Also, in VSMCs, vasoconstrictor agonists such as phenylephrine (Phe), ET-1, TXA2, or Ang II activate their specific receptors (R) to stimulate PLC and generate IP3 and DAG. IP3 stimulates Ca2+ release from the sarcoplasmic reticulum (SR). Agonists also stimulate Ca2+ entry through Ca2+ channels. Ca2+ binds CAM to activate myosin light-chain kinase (MLCK), causing MLC phosphorylation, actin–myosin interaction, and VSM contraction. DAG activates PKC to phosphorylate calponin (CaP) or activates MAPK kinase (MEK) and MAPK cascade, leading to phosphorylation of caldesmon (CaD) and increased myofilament sensitivity to [Ca2+]c. E2 binds less abundant plasmalemmal ERα, ERβ, and GPER to activate non-genomic pathways and inhibit agonist-activated mechanisms of VSM contraction, including Ca2+ channels, PKC, MAPK, and ROCK-mediated [Ca2+]c sensitization pathways. E2/ER also increases the proteolytic activity of MMP-2 and MMP-9, leading to breakdown of ECM proteins, changes in elastin/collagen ratio, and vascular remodeling. Dashed lines indicate inhibition. ↑, increase.
Ijms 26 05078 g004
Figure 5. Factors contributing to the limited efficacy of MHT in managing CVD include inappropriate selection of MHT formulation, administration route, dosage, initiation timing, treatment duration, hormonal milieu, as well as the presence of underlying cardiovascular or other medical conditions (indicated in red). To enhance the cardiovascular benefits and overall effectiveness of MHT in reducing CVD risk, the use of natural estrogens, bioidentical hormones, or phytoestrogens, preferably via parenteral administration at lower doses initiated early in the menopausal transition for a limited period with an optimal hormone combination and in Post-MW with intact vascular health and no preexisting cardiovascular or systemic disorders (indicated in green) could be more advantageous.
Figure 5. Factors contributing to the limited efficacy of MHT in managing CVD include inappropriate selection of MHT formulation, administration route, dosage, initiation timing, treatment duration, hormonal milieu, as well as the presence of underlying cardiovascular or other medical conditions (indicated in red). To enhance the cardiovascular benefits and overall effectiveness of MHT in reducing CVD risk, the use of natural estrogens, bioidentical hormones, or phytoestrogens, preferably via parenteral administration at lower doses initiated early in the menopausal transition for a limited period with an optimal hormone combination and in Post-MW with intact vascular health and no preexisting cardiovascular or systemic disorders (indicated in green) could be more advantageous.
Ijms 26 05078 g005
Table 1. Effects of sex hormones on cardiovascular cells and biological processes.
Table 1. Effects of sex hormones on cardiovascular cells and biological processes.
Cell/ProcessE2P4TReferences
ECs
  Endothelium-dependent vascular relaxation+++/-[140,141,142,143,144,145,146]
  eNOS, NO+++/-[140,141,142,143,144,145,146]
  PGI2++ [147,148,149]
  EDHF+++[150,151,152]
  ROS production-++[153,154,155]
  Proliferation+ +[156,157,158,159]
  Migration+ [156,157,158]
  Angiogenesis+ [158,160]
VSMCs
  Endothelium-independent vascular relaxation+++[87,161,162]
  [Ca2+]c, L-type Ca2+ channel---[161,162,163,164,165,166]
  PMCA, SERCA++ [167,168]
  BKCa+ +[169,170,171]
  Kv, KATP +[169,172]
  PKC-- [173,174]
  ROCK- [175]
  Proliferation-+/-+/-[100,176,177,178,179,180]
  Migration-+/- [100,176,177,178]
  Apoptosis ++[177,181]
Fibroblasts
  MMP-2, MMP-9+/- [182,183,184]
  Fibrosis- [182,185,186]
Inflammation--+/-[112,187,188,189,190]
Atherogenesis- -[15,165]
Cardiomyocytes
  β-adrenergic receptor +[191,192]
  L-type Ca2+ channel- +[191,192,193]
  Delayed-rectifier K+ channel+ [193]
  SERCA2a++ [194,195]
  Kv2.1 channel + [196]
  Contractility--+[191,192,193,197]
  Hypertrophy- +[100,198,199,200,201]
  Glucose uptake +[202]
  ATP synthesis+ [203]
  ROS Production- +[203,204,205]
  β-oxidation, cell respiration + [206]
  Proliferation + [47,207]
  Apoptosis- [47,208]
BKCa, large-conductance Ca2+-activated K+ channel; KATP, ATP-sensitive K+ channel; Kv, voltage-sensitive K+ channel; PKC, protein kinase C; ROCK, rho-kinase; PMCA, plasma membrane Ca2+-ATPase; SERCA, sarcoplasmic/endoplasmic reticulum Ca2+-ATPase. +, stimulate; -, inhibit.
Table 2. Outcomes of representative MHT clinical trials in CVD (in chronological order).
Table 2. Outcomes of representative MHT clinical trials in CVD (in chronological order).
Clinical TrialCohort Size, Age, ConditionFollow-Up PeriodMHTOutcomeRef.
PEPI
RDBPC
875, 45–64 yr
healthy
3 yr (1991–1994)CEE 0.625 mg
CEE+MPA 2.5 mg Oral
CEE or CEE+progestin improves lipoproteins and lowers fibrinogen levels.[303]
HERS
RDBPC
2763,
44–79 yr
with CAD
4.1 yr (1993–1997)CEE 0.625 mg +MPA 2.5 mg
Oral
No overall reduction in cardiovascular events. High risk of CVD in first year.[296]
HERS II
RDBPC
Follow-up
2321,
44–79 yr
with CAD
6.8 (2.7 yr added to HERS) (1993–1999)CEE+MPA
Oral
MHT did not reduce risk of cardiovascular events in women with CAD.[297]
HERS-UA
(Uric Acid)
RDBPC
2763,
44–79 yr
4.1 yr (1993–1997)CEE+MPA
Oral
CEE+MPA lowered serum UA levels slightly, but neither baseline UA nor change in UA affected CHD risk.[304]
WHI
RDBPC
16,608, 50–79 yr healthy
10,739 healthy with prior hysterectomy
5.2 yr (1993–1998)CEE+MPA
Oral
CEE
Oral
Overall health risks exceeded benefits. Overall doubling of VTE events in CEE+MPA arm; 30% to 40% increased risk of stroke.[295]
WEST
RDBPC
664, ~71 yr (46–91 yr) with prior ischemic stroke2.8 yr
(1993- 1998)
E2
Oral
No reduction in mortality or recurrence of stroke. MHT should not be used for secondary prevention of cerebrovascular disease.[302]
PHOREA
RDBPC
321,
>55 yr (40–70 yr)
48 weeks (1995–1996)E2 1 mg + gestodene 0.025 mg OralDid not slow progression of subclinical atherosclerosis in Post-MW at increased risk.[305]
ERA
RDBPC
309, ~65.8 yr with CAD3.2 yr (1996–1999)CEE
CEE+MPA, Oral
Increased HDL and decreased LDL but no change in coronary atherosclerosis progression.[306]
WISDOM
RDBPC
5692,
50–69 yr
1 yr
(1999- 2002)
CEE
CEE+MPA, Oral
MHT increased CVD and VTE risk when started many years postmenopause.[307]
WAVE
RDBPC
423, >55 yr with coronary stenosis2.8 yr (1999–2002)CEE+MPA
Vitamin E, C
Oral
No cardiovascular benefit of MHT or vitamin C and E.[308]
ESTHER
case-control
271—case
610—control
45–70 yr
6 yr (1999–2006)Users of E2+
Progestogen
Oral versus Trans-dermal
Oral but not transdermal E2 increases VTE risk. Norpregnanes may be thrombogenic. Micronized P4 and pregnanes are safe with respect to thrombotic risk.[309]
RUTH
RDBPC
10,101,
~67.5 yr
5.6 yr (2000–2005)Raloxifene
daily
Oral
Did not affect risk of CVD. Benefits in reducing invasive breast cancer and vertebral fracture should be weighed against risk of VTE and stroke.[310]
EPAT
RDBPC
222,
~57 yr healthy
2 yr (2001–2003)E2
Oral
Slower progression of subclinical atherosclerosis.[311]
KEEPS
DBRCT
720, 42–58 yr, 6–36 months postmenopause5 yr (2005–2010)Oral CEE 0.45 mg/d or
Transdermal E2 50 μg weekly
+ Oral P4 200 mg/d 12 d/month
No effect on progression of carotid intima-thickness, atherosclerosis, or accrual of coronary calcium. No CAD benefits or adverse effects.[312,313,314]
ELITE
RDBPC
643, <6 versus ≥10 yr postmenopause2005–2012Oral E2 1 mg/d
± Vaginal P4 gel 4%
Less progression of carotid-intima thickness and subclinical atherosclerosis when MHT was initiated within 6 yr but not ≥ 10 yr postmenopause.[315]
DRSP+E2
RDBPC
750, 45–75 yr, with HTN8 weeks (~2006)DRSP 1–3 mg
+E2 1 mg
Oral
DRSP+E2 reduced BP in Post-MW with HTN. Decreased serum LDL-C. No increase in serum potassium.[316]
E2+Micro P4
RDBPC
172, 45–60 yr healthy1 yr (2010–2016)Transdermal E2 0.1 mg patch
+Micronized P4 200 mg/d oral 12 d/month
Lower diastolic BP and LDL-C. Improved cardiac autonomic baroreflex sensitivity. Prevented age-related decrease in brachial artery FMD (endothelium-dependent) and increase in stress reactivity score.[317]
Soy ± isoflavone
DBRCT
200, ~55 yr,
Healthy
6 months (2012)Oral 15 g/d soy ± 66 mg/d isoflavone
for 6 months
Beneficial effect on systolic BP with soy protein plus isoflavones versus soy protein without isoflavones.[318]
DBRCT, double-blind randomized clinical trial; DRSP, drospirenone; ELITE, Early versus Late Intervention Trial with Estradiol; EPAT, Estrogen in the Prevention of Atherosclerosis Trial; ERA, Estrogen Replacement and Atherosclerosis; ESTHER, EStrogen and THromboEmbolism Risk study; HERS, Heart and Estrogen/progestin Replacement Study; KEEPS, Kronos Early Estrogen Prevention Study; PEPI, Postmenopausal Estrogen/Progestin Interventions; PHOREA, Postmenopausal Hormone REplacement against Atherosclerosis; RDBPC, randomized double-blind placebo-controlled; RUTH, Raloxifene Use for The Heart; WAVE, Women’s Angiographic Vitamin and Estrogen trial; WEST, Women’s Estrogen for Stroke Trial; WHI, Women’s Health Initiative; WISDOM, Women’s International Study of long Duration Oestrogen after Menopause; yr, year.
Table 3. Changes in ER subtypes and levels in representative biological systems in Pre-MW versus Post-MW.
Table 3. Changes in ER subtypes and levels in representative biological systems in Pre-MW versus Post-MW.
SystemTissuePre-MWPost-MWFunction/SignificanceRef.
Eye/VisionRetina, retinal pigment epithelium, ciliary body, iris, and lens epitheliumERα↓ ERαAlterations in ER may be involved age-related macular degeneration, idiopathic full-thickness macular hole, glaucoma, cataract, and dry eye.[348]
Cardiovascular System Coronary artery
all layers, mainly VSMCs
ERβ > ERαNo change among MHT nonusers.
↓ ERα in MHT users.
Dominant role of ERβ in coronary arteries and in association with atherosclerosis and calcification. The association of ERβ and atherosclerotic severity is not linked to age. MHT may decrease ERα expression.[108,115]
Aorta
VSMCs
ERα ~30%
ERβ ~70%
ERα ~23%
ERβ 77%
(MHT user)
Relative abundance of ERβ mRNA supports E2/ERβ-mediated inhibition of VSMC proliferation/migration. ERβ levels may not correlate with age.[108]
Peripheral arterioles from discarded adipose tissueERβ and GPER in ECs and
ERα in adventitia
↓↓ ERβ
↓↓ GPER
Continuous E2 exposure in cis- and transgender females or Post-MW may suppress EC ERβ and GPER, causing oxidative stress, decreased FMD, and microvascular damage.[255]
Peripheral veinsERα in ECs
↓ in early versus late follicular phase of menstrual cycle
↓↓ ERαERα levels positively related to eNOS expression, ser1177 phosphorylation, and endothelium-dependent brachial artery FMD and are modulated by fluctuations in E2 status during menopausal cycle and age-related E2 deficiency in Post-MW.[361]
Digestive SystemBuccal mucosa, minor salivary, submandibular, and parotid glandsERs↓ ERsE2/ER-responsive tissues. MHT may be effective for menopausal mucosal diseases and oral discomfort.[365,366]
Anal canal hemorrhoid tissueERsNo changeNo differences in anal canal ERs in relation to menopausal status or age.[367]
Adipose TissueVisceral and subcutaneousERα>ERβ↓ ERα
↑ ERβ
↓ ERα/ERβ ratio may affect adipose tissue metabolism in Post-MW.[368,369,370,371]
Nervous SystemDorsolateral supraoptic nucleusERβ>ERα↑ ERα
↓↓ ERβ
↓ ERβ and ↑ ERα in Post-MW may activate arginine vasopressin neurons and increase incidence of HTN and CVD.[372]
Reproductive SystemVaginal wall and uterosacral ligamentsERα and ERβ↓ ERα
↓↓ ERβ
Decreased ER expression, particularly ERβ, may play a role in common symptoms of vaginal atrophy and dryness in Post-MW.[373,374]
MyometriumERβ/ERα ratio 0.6–1.5↓ ERα
↑ ERβ
ERβ:ERα ratio 2.5–7.6
Altered ERα and ERβ expression may be associated with pathological myometrium growth.[375]
OvariesERα in thecal cells, ERβ in granulosa cells, and ERα and ERβ in interstitial gland cells↓↓ ERβIn Pre-MW, high ERβ expression in granulosa cells may be associated with growth and development of follicles, which are reduced in Post-MW.[376]
↓, decreased; ↓↓, markedly decreased; ↑, increased.
Table 4. Guide for MHT use in Post-MW.
Table 4. Guide for MHT use in Post-MW.
Menopausal StageEarlyPerimenopauseLate
Age (years)40–5050–60>60
Years since menopauseWithin 1010–15>15
Smoking-++
Cardiovascular health
BMI18.5–25 (Normal)25–30 (Overweight)≥30 (Obese)
Physical activityActiveLimitedSedentary
BP (systolic/diastolic) mmHg<120/<80 Normal120–129/<80 Elevated≥130/≥80 HTN
10-year ASCVD risk<5%5–10%>10%
Pre-existing CVD--Congenital heart disease
ASCVD/CAD/PAD
Clotting disorders, VTE
MI, stroke/TIA
Other pre-existing conditions
Diabetes/metabolic syndrome-+++
Lipid profile
Hyperlipidemia
↑ HDL, ↓ LDL
-
↓ HDL, ↑ LDL
+
↓↓ HDL, ↑↑ LDL
++
Autoimmune disease-+++
Breast/uterine cancerLow riskHigh riskDetected
MHT riskLowIntermediateHigh
MHT guide
RouteOral/transdermalTransdermal preferredAvoid oral/transdermal
Topical preferred
Dose
To control menopausal and genitourinary symptoms
E2 1 mg/d oral
or 0.025–0.05 mg/d transdermal
+ Micronized P4 100–200 mg/d oral
E2 0.5 mg/d oral
or 0.025 mg/d transdermal (preferred)
+ Micronized P4 100 mg/d oral
Vaginal E2 at minimal effective dose
OtherTransdermal E2 reduces risk of VTE/strokeLifestyle adjustments.
Diet, exercise, lipid-lowering drugs (statins)
Consider non-hormonal treatment
ASCVD, atherosclerotic cardiovascular disease; MI, myocardial infarction; PAD, peripheral artery disease; TIA, transient ischemic attack (mini-stroke); VTE, venous thromboembolism. -, No; +, mild; ++, severe; ↑, increased; ↑↑, markedly increased; ↓, decreased; ↓↓ markedly decreased.
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Xia, W.; Khalil, R.A. Hormone Replacement Therapy and Cardiovascular Health in Postmenopausal Women. Int. J. Mol. Sci. 2025, 26, 5078. https://doi.org/10.3390/ijms26115078

AMA Style

Xia W, Khalil RA. Hormone Replacement Therapy and Cardiovascular Health in Postmenopausal Women. International Journal of Molecular Sciences. 2025; 26(11):5078. https://doi.org/10.3390/ijms26115078

Chicago/Turabian Style

Xia, Wenhan, and Raouf A. Khalil. 2025. "Hormone Replacement Therapy and Cardiovascular Health in Postmenopausal Women" International Journal of Molecular Sciences 26, no. 11: 5078. https://doi.org/10.3390/ijms26115078

APA Style

Xia, W., & Khalil, R. A. (2025). Hormone Replacement Therapy and Cardiovascular Health in Postmenopausal Women. International Journal of Molecular Sciences, 26(11), 5078. https://doi.org/10.3390/ijms26115078

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop