1. Skin, the carotid artery and intervertebral discs: making the connection Mark P. Brincat

2. Estrogen therapy Decreased skin thickness (reversed) Cerebral changes (Alzheimer’s decreased) CVS effects (including carotids) Genital organs (improved) Bone loss (stopped and reversed) Connective tissue: different effects Cartilage

3. Extracellular matrix Glycoaminoglycans (GAGs) Proteins –Collagen –Elastin

4. Skin collagen changes with age 120 115 110 105 100 2030405060 Age (years) Castelo-Branco C, et al. Maturitas 1992;15:113–19

5. 150 200 250 05 10 15 Treated (59) Untreated (148) Years since menopause Brincat M, et al. Br J Obstet Gynaecol 1985;92:256–9 Thigh collagen content (mg/mm 2 ) Thigh collagen with the number of years since the menopause

6. 024681012 Months of treatment Skin thickness (mm) * *** * p < 0.05 ***p < 0.001 n = 40 Brincat M, et al. Obstet Gynecol 1987;70:840–5 Skin thickness in women on 100 mg estradiol implants 1.05 1.00 0.95 0.90 0.85

7. HRT No HRT Pierard-Franchimont C, et al. 1999 Scatterplot of tensile strength of skin in menopausal women MD (mm) Biological elasticity (%) 90 80 70 60 50 40 30 20 10 0 1234567812345678

8. Effects of menopause on the skin Hot flushes, altered hot/cold sensation Dizzy spells, falling, fractures Skin collagen changes –Tensile properties of the skin –Wound healing Atrophic changes –Dry vulva, dry eyes –Hair –Incontinence –Dyspareunia –Psychosexual role of the skin, effect on relationships –Transdermal role Brincat MP. HRT and the Skin, 2001

9. The collagen family Collagen classTypesTissue distribution Fibril-formingIMost connective tissues IICartilage and vitreous humor IIIExtensible connective tissues, skin VLung XITissues containing collagen I Tissues containing collagen II Fibril-associatedIXTissues containing collagen II XIITissues containing collagen I XIVTissues containing collagen I XVIMany tissues Network-formingIVBasal laminae Anchoring filamentsVIIAttachments of basal laminae to underlying tissues Brincat MP. HRT and the Skin, 2001

10. Carotid artery wall thickness The vessel wall is made up of three main layers which are affected by estrogen replacement –The intima –The media –The adventitia The effects of estrogens are: –Intima thickness –Externa thickness –Media thickness

11. 24 25 26 27 28 29 30 31 32 33 34 Controls vs oral HRT p < 0.05 Controls vs implants p < 0.005 Oral HRT vs implants p = N.S. Carotid artery wall (media) thickness (mm) ** * * ** ControlsOral HRTImplants n = 51 n = 46 n = 32 Muscat Baron Y. Maturitas 1997;27:47–53 Effect of HRT on carotid artery wall in postmenopausal women (media) (mean ± SE)

12. 0.85 0.90 0.95 1.00 1.05 1.10 1.15 1.20 1.25 1.30 Controls vs. oral HRT p < 0.05 Controls vs. implants p < 0.05 Oral HRT vs. implants p = NS Carotid artery wall thickness (intima/media) (mm) * * Controls n = 51 Oral HRT n = 46 Implants n = 32 **** Muscat Baron Y. Maturitas 1997;27:47–53 Effect of HRT on carotid artery wall thickness in postmenopausal women (intima/media) (mean ± SE)

13. Normal intervertebral disc Collagen types II and IX – inner lamellae Collagen type I outer lamellae Collagen type II, IX, X Collagen types II and IV

14. Aged intervertebral disc Collagen types I, III, VI Early lesions collagens II & IX Advanced lesions collagens III & VI Significant decreases in glycoaminoglycans and elastin

15. Functions of intervertebral discs Intervertebral discs are responsible for 20% of the spinal column height Allow flexion and extension of the spine Also act as ‘shock absorbers’ of the spinal column This may have an impact on osteoporotic compression fracture

16. ** ** HRT/MENS vs MENO, CAL p < 0.05 D1 – D3 total length Muscat Baron Y, Brincat MP, et al. Hum Reprod 2005;20:3566–70 Total intervertebral disc height in different groups of women

17. ** ** p < 0.01 Effect of HRT on disc thickness in postmenopausal women taking corticosteroids

18. Bone density, skin and disc thickness in postmenopausal women on HRT

19. Intervertebral disc space in normal women plotted as a function of age (n = 464) * * ** *p < 0.05 vs. younger age groups ** p < 0.05 vs. younger age groups by Fisher test Gambacciani M, et al. Climacteric 2007;10:298–305 20–2526–3031–3536–4040–4546–5051–5556–6061–6565–7071–75>75 Age (years)

20. *p < 0.05 vs. other groups † p < 0.05 vs. preceding groups § p < 0.05 vs. preceding groups by Fisher test Gambacciani M, et al. Climacteric 2007;10:298–305 Intervertebral disc space in normal postmenopausal women (n = 312) plotted as a function of years since menopause † † * §

21. ** * Intervertebral disc space in 3 groups of age- matched (47 years; n = 39 in each group) pre-, peri- and postmenopausal women p < 0.001 by ANOVA p < 0.002 vs. premenopausal group ** p < 0.0001 vs. premenopausal and perimenopausal groups by Fisher test Gambacciani M, et al. Climacteric 2007;10:298–305

22. Scattergram of bone density index of femoral neck in menopausal women and skin biological elasticity Pierard-Franchimont C, et al. 2001 Bone mass density index Biological elasticity (%) 90 80 70 60 50 40 30 20 10 0 00.20.40.60.81

23. Ward's triangle density (g/cm 2 ) Skin thickness (mm) 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 0.50.60.70.80.91.01.11.21.3 Fractures, n = 129 Controls, n = 411 Sensitivity %Accuracy % Skin thickness91.739.2 Ward’s triangle100.050.9 Box Ward’s triangle91.759.1 Brincat MP, Galea R, 2001 Scattergram of Ward's triangle bone density vs. skin thickness

24. Conclusion Menopause has been shown to directly or indirectly increase symptoms and signs of aging in the skin Hormone replacement therapy (HRT) has a positive effect on skin connective tissue parameters, both directly and indirectly This is in keeping with the general improvement demonstrated in several connective tissue sites such as blood vessels, bone and cartilage as a result of HRT in postmenopausal women