NONALCOHOLIC FATTY LIVER DISEASE IN MENOPAUSAL WOMEN

Doença hepática gordurosa não alcoólica em mulheres menopausadas

Gesira Soares de Assis FLORENTINO Helma Pinchemel COTRIM Consuelo Padilha VILAR André Vinícius de Assis FLORENTINO Geruza Maria Almeida GUIMARÃES Victorino Spinelli Toscano BARRETO About the authors

Abstracts

Context

Nonalcoholic Fatty Liver Disease (NAFLD) is common in postmenopausal women. It is associated with metabolic syndrome. However, the influence of hormone replacement therapy in NAFLD development in these women needs to be investigated. This study aimed to describe the clinical characteristics of NAFLD in postmenopausal women, and the relationship between hormone replacement therapy and this disease.

Methods

From April 2009 to April 2011, 292 postmenopausal women from National Health System from Northeast of Brazil were selected, and 251 were included in this study. Menopause was defined as the absence of menstruation for 12 consecutive months in otherwise healthy women. Criteria to NAFLD included: presence of steatosis on abdominal ultrasound; history of alcohol consumption less than 20 g/day and exclusion of other liver diseases. All women underwent a clinical evaluation. Standard univariate and multivariate analyses were performed to evaluate the results.

Results

The mean age was 56.5 ± 6.7 years. Hormone replacement therapy was referred by 21.1% (53) women and 78.9% (198) was not. Prevalence of NAFLD was 37.1% (93/251) in postmenopausal women, 26,4% (14/53) in the group with hormone replacement therapy and 39,9% (79/198) without hormone replacement therapy. Gamma-glutamyl transpeptidase (P = 0.001), alanine transaminase (P<0.01), ferritin (P<0.001) and insulin resistance (homeostatic model assessment of insulin resistance ≥3) (P<0.001) were higher in the group of women with NAFLD diagnosis who did not referred the use of hormone replacement therapy. Metabolic syndrome was also more frequent in women with NAFLD, who did not refer hormone replacement therapy.

Conclusion

In conclusion this data suggests elevated prevalence of NAFLD in postmenopausal women; negative association of hormone replacement therapy and NAFLD.

Fatty Liver; Hormone replacement therapy


Contexto

A doença hepática gordurosa não alcoólica (DHGNA) é comum em mulheres na pós-menopausa. Esta condição está associada à síndrome metabólica. No entanto, a influência da terapia de reposição hormonal no desenvolvimento da DHGNA nessas mulheres necessita ser investigada. Este estudo teve como objetivo descrever as características clínicas da DHGNA em mulheres na pós-menopausa e, a relação entre terapia de reposição hormonal e esta doença.

Métodos

De abril de 2009 a abril de 2011, 292 mulheres pós-menopausadas do Sistema Único de Saúde foram selecionados, e 251 foram incluídas neste estudo. A menopausa foi definida como a ausência de menstruação durante 12 meses consecutivos em mulheres saudáveis. Os critérios para diagnostico da DHGNA foram: presença de esteatose na ultra-som abdominal, história de consumo de álcool menor que 20 g/dia e exclusão de outras doenças hepáticas. Todas as mulheres foram submetidas a uma avaliação clínica. Para a obtenção dos resultados foram realizadas as análises uni e multivariada.

Resultados

A média de idade foi de 56,5 ± 6,7 anos. O uso de terapia de reposição hormonal foi referido por 21,1% (53) das mulheres e 78,9% (198) negaram seu uso. A prevalência de DHGNA foi de 37,1% (93/251) nas mulheres pós-menopausadas, sendo de 26,4% (14/53) no grupo em uso de terapia de reposição hormonal e 39,9% (79/198) no grupo sem uso desta terapia. A gama-glutamil transpeptidase (P = 0,001), alanina transaminase (P<0,01), ferritina (P<0,001) e resistência à insulina (obtida pelo modelo de avaliação homeostática de resistência à insulina ≥ 3) (P<0,001) foram maiores nas mulheres com DHGNA que não referiram o uso da terapia de reposição hormonal. A síndrome metabólica também foi mais frequente em mulheres com DHGNA, que não utilizaram a terapia de reposição hormonal.

Conclusão

Estes dados sugerem uma elevada prevalência de DHGNA em mulheres na pós-menopausa, e ainda apontam para uma associação negativa da terapia de reposição hormonal com a DHGNA.

Fígado gorduroso; Terapia de reposição hormonal


INTRODUCTION

Nonalcoholic fatty liver disease (NAFLD) is characterized by the focal or diffuse accumulation of fat in the liver parenchyma of patients who deny abusive alcohol consumption(1212. Karnikowski M, Córdova C, Oliveira RJ, Karnikowski MG, Nóbrega O deT. Non-alcoholic fatty liver disease and metabolic syndrome in Brazilian middle-aged and older adults. Sao Paulo Med J. 2007;125:333-7.). It prevalence ranges from 3% to 24% in the general population(33. Clark JM. The epidemiology of nonalcoholic fatty liver disease in adults. J Clin Gastroenterol .2006;40:S5-10.), and reaches 89.5% among severe obese patients(77. de Moura Almeida A, Cotrim HP, Barbosa DB, de Athayde LG, Santos AS, Bitencourt AG, de Freitas LA, Rios A, Alves E. Fatty liver disease in severe obese patients: diagnostic value of abdominal ultrasound. World J Gastroenterol. 2008;14:1415-8.). It increases with increasing age(2727. Yatsuji S, Hashimoto E, Tobari M, Tokushige K, Shiratori K. Influence of age and gender in Japanese patients with non-alcoholic steatohepatitis. Hepatol Res. 2007;37:1034-43.), and is more prevalent among men and non-Hispanic whites(33. Clark JM. The epidemiology of nonalcoholic fatty liver disease in adults. J Clin Gastroenterol .2006;40:S5-10.), and in individuals with hepatitis C virus(55. Coral G, de Mattos AA, de Mattos AZ, dos Santos DE. [Steatosis and non-alcoholic steatohepatitis in patients with chronic hepatitis due to hepatitis C virus infection]. Arq Gastroenterol. 2006;43:265-8.).

NAFLD is frequent in postmenopausal women (PMW) and it is usually associated with metabolic syndrome. The influence of hormone replacement therapy (HRT) in NAFLD development in these women has been discussed(33. Clark JM. The epidemiology of nonalcoholic fatty liver disease in adults. J Clin Gastroenterol .2006;40:S5-10.). In menopause occurs a decrease in the liver ability to oxidize fatty acids, and an increased on lipogenesis that causes excessive accumulation of hepatic fat and culminates with inflammation(2121. Suzuki A, Abdelmalek MF. Nonalcoholic fatty liver disease in women. Womens Health 2009;5:191-203.).

The estrogen deficiency causes body fat redistribution, with accumulation of visceral fat, which can influence the development and progression of NAFLD(1313. Lavoie JM, Pighon A. NAFLD, estrogens, and physical exercise: the Animal Model. J Nutr Metab. 2012;2012:914938.).

An experimental study with ovariectomized rats showed that the absence of estrogens could stimulate fat accumulation in the liver, and that ovariectomized rats subjected to an endurance program had decreased fat in the liver and abdomen(66. Corriveau P, Paquette A, Brochu M, Prud'homme D, Rabasa-Lhoret R, Lavoie JM. Resistance training prevents liver fat accumulation in ovariectomized rats. Maturitas 2008;59:259-67.). It was also observed lower levels of ALT in type 2 diabetics undergoing HRT for 6 months(1616. McKenzie J, Fisher BM, Jaap AJ, Stanley A, Paterson K, Sattar N. Effects of HRT on liver enzyme levels in women with type 2 diabetes: a randomized placebo-controlled trial. Clin Endocrinol. 2006;65:40-4.).

The present study describes the clinical characteristics of NAFLD in PMW, and investigates the relationship between HRT and this liver disease.

METHODS

Study design and population selection

In a sectional study, a total of 292 PMW coming from the National Health System from Northeast of Brazil, who reported the use of HRT(G1) or who denied the use (G2), were analyzed. The use of HRT was defined as the use of estrogen in hysterectomized PMW or estrogen associated with progesterone when the uterus was present, or also the use of tibolone, by oral or transdermal routes for more than 6 months.

The sample was calculated by the method of proportions according to Arkin and Colton(11. Arkin H, Colton R. Tables for statisticians. New York: Barnes & Noble, 1959.).

The indication for HRT use was made by the gynecologists who accompanied the PMW based on the clinical features and climacteric symptoms. The duration of menopause ranged from 1 to 5 years (101 women/40.2%), 6-10 years (70 women/27.9%) and above 10 years (80 women/31.9%). The use of HRT was confirmed by patients report during the interview.

From April 2009 to April 2011, 251 women were included and evaluated. This study was conducted in accordance with the Declaration of Helsinki an the Institutional Ethics Committee from the Federal University of Campina Grande approved the study under the number 20080212-040. Written informed consent was obtained before include the participants.

Clinical evaluation

All participants had a complete physical exam and answered a questionnaire that included demographic characteristics (age, marital status and family income) and physical activity level (example: participation in any kind of sport at least three times a week), history of obesity, dyslipidemia and diabetes; history of alcohol intake and other illicit drugs usage.

Laboratory evaluation included: viral hepatitis infection markers for B virus (HBsAg) and C virus (anti HCV), ALT, AST, GGT, ferritin, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, glucose, insulin, transferrin saturation. Levels of follicle-stimulating hormone higher than 50 mIU/mL were determined to confirm menopause in hysterectomized women without oophorectomy. PMW with antinuclear factor reagent 1/80 were tested for anti-liver-kidney microsomal antibody and anti-smooth muscle antibodies to rule out autoimmune hepatitis.

Menopause was defined in woman who has been amenorrhea (absence of any menstruation) for 12 or more months.

The metabolic syndrome (MS) was defined according to the National Cholesterol Education Program's Adult Treatment Panel III report(1414. Marfell-Jones M. International standards for anthropometric assessment. Rev. ed. Potchefstroom, South Africa: International Society for the Advancement of Kinanthropometry. 2006.). Abdominal ultrasound exam was performed in all patients by a single radiologist in the same institution, and steatosis was classified in grades I, II and III, with the grade I corresponding to the increase of the echogenicity of the liver parenchyma, II (hepatic hyperechogenicity associated with attenuation of the sound beam in posteriors planes) and III (the sum of the above plus the loss of definition in liver vascular structures and the diaphragm).

Insulin resistance was calculated using the Homeostatic Model Assessment for Insulin Resistance, and a value ≥3 was considered abnormal(1515. Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner RC. Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia 1985;28:412-9.).

The hepatic enzymes were considered elevated when their values were at least 1.5 times their normal maximal values and the ferritin when its greater than its normal maximal value (200 ng/mL).

Other liver diseases were excluded: B and C virus (HBsAg or anti HCV positive); autoimmune, metabolic; hepatotoxic drugs use; hysterectomy with functioning ovaries (defined as a follicle-stimulating hormone value less than 50 mIU/mL), diabetes and hypotiroidism.

NAFLD criteria

History of ethanol intake ≤20 g/day; hepatic steatosis on abdominal ultrasound; exclusion of drug use and other liver diseases (B and C hepatitis virus, hemochromatosis and autoimmune hepatitis).

Statistical Analysis

Data were processed and analyses were performed using Statistical Package for the Social Sciences software (SPSS Inc., Chicago, IL, USA, Release 17.0.1, 2008). Continuous variables were summarized with means and standard deviations while categorical variables were presented in frequencies and percentages. Comparisons between the means of two groups were performed using Student's t-test for independent samples. Chi-square and Fisher's exact tests were used to test associations between categorical variables. One-way analysis of variance was used to compare the means of the four groups. This was followed by the Bonferroni's post hoc test. Logistic regression analysis was used for the study of prognostic factors and to obtain the adjusted odds ratios and their exact 95% confidence interval. All comparisons performed were two-tailed, P values were calculated and significance level was set to equal or less than 0.05.

RESULTS

The mean age of the 251 participants was 56.5 ± 6.7 years. Further demographic data are shown in Table 1. Fifty-three (21.1%) women referred to use HRT (G1) and 198 (78.9%) did not (G2). The prevalence of NAFLD was 37.1% in all sample, and was lower in G1 – 26,4% (14/53) than in G2 – 39,9% (79/198).

TABLE 1.
Absolute and relative frequencies of demographic data from 251 patients

The time of menopause varied as follows: 101 women (40.2%) were in menopause between 1 and 5 years; 70 women (27.9%) between 6 and 10 years and 80 women (31.9%), above 10 years.

Regarding the HRT usage time, 22 women (41.5%) used HRT between 6 months and 2 years, 14 women (26.4%) between 2 and 4 years and 17 women (32.1%) over 4 years.

PMW from G2, with and without NAFLD diagnosis, had higher rates of overweight, obesity and insulin resistance when compared with G1. The frequency of MS in the entire group of PMW was 39.8% (100/251), being higher in patients with NAFLD without using HRT as shown in Table 2.

TABLE 2.
Analyzed variables according to the use of hormone replacement therapy associated to NAFLD status

ALT, GGT and ferritin levels were higher in G2 with NAFLD (Table 3). ALT and ferritin levels were higher in the PMW with grades II and III steatosis in G2 than in women with equal degrees of steatosis in G1 (Table 4). The use of HRT, type of hormone used, route of administration and the duration of HRT use, did not reveal an association with NAFLD according to our results (Table 5).

TABLE 3.
Frequencies of abnormal blood laboratory levels, according to the use of hormone replacement therapy associated to NAFLD diagnosis
TABLE 4.
Frequencies of abnormal blood laboratory tests, according to the degree of steatosis among the groups
TABLE 5.
Frequencies of variables related to hormone replacement therapy according to NAFLD diagnosis

The multivariate logistic regression model showed that prognostic factors for NAFLD were: presence of MS – Odds Ratio: 2.02 (CI-1.11-3.69), P = 0.02, homeostatic model assessment of insulin resistance ≥3 – Odds Ratio: 3.73(CI-1.63-8.53), P = 0.002 and obesity – Odds Ratio: 1.91 (CI-1.01-3.61), P = 0.046) (Table 6). Additionally, the multivariate analyses also showed that the patients from the G1 were younger than G2 (P = 0.021). Moreover the group G1 was composed of a higher number of women who were married (P = 0.003). The G2 had lower family income (P<0.001) and a lower level of education (P = 0.700), regardless of NAFLD diagnosis.

TABLE 6.
Multivariate analyses of associated factors to NAFLD development among postmenopausal women

DISCUSSION

There is not much information about the NAFLD and HRT in PMW. Some reports are experimental or include patients with chronic hepatitis C (CHC) and type 2 diabetes.

Although the present sample of PMW has revealed a higher frequency of NAFLD, it was lower among those who referred HRT use, similar to the findings described in another study(1111. Hamaguchi M, Kojima T, Ohbora A, Takeda N, Fukui M, Kato T. Aging is a risk factor of nonalcoholic fatty liver disease in premenopausal women. World J Gastroenterol. 2012;18:237-43.).

Despite some researchers find no differences between the effects of HRT on hepatic proteins sensitive to estrogen regarding different routes of administration(2020. Sitruk-Ware R, Plu-Bureau G, Menard J, Conard J, Kumar S, Thalabard JC, Tokay B, Bouchard P. Effects of oral and transvaginal ethinyl estradiol on hemostatic factors and hepatic proteins in a randomized, crossover study. J Clin Endocrinol Metab. 2007;92:2074-9.), there are reports that the oral route leads the liver tissue to a supra physiological concentration of these hormones by hepatic first-pass effect(1818. Rosa-e-Silva AC, Melo AS. A importância da via de administração na terapia hormonal do climatério. Femina 2010;38:279-85.), altering the lipid metabolism by decreasing hepatic lipase activity, which would not happen in transdermal route(2323. Walsh BW, Li H, Sacks FM. Effects of postmenopausal hormone replacement with oral and transdermal estrogen on high density lipoprotein metabolism. J Lipid Res. 1994;35:2083-93.).

NAFLD was also studied in premenopausal, postmenopausal and polycystic ovary syndrome women by Gutierrez-Grobe et al.(1010. Gutierrez-Grobe Y, Ponciano-Rodríguez G, Ramos MH, Uribe M, Méndez-Sánchez N. Prevalence of non alcoholic fatty liver disease in premenopausal, posmenopausal and polycystic ovary syndrome women: the role of estrogens. Ann Hepatol. 2010;9:402-9.) who observed higher index in polycystic ovary syndrome and postmenopausal than those premenopausal ones. The authors suggested that estrogens might have a protective effect against NAFLD in women and this drug protection against liver injury have also been suggested for others studies. One of them showed that physiological concentration of estrogen inhibits spontaneous secretion of pro-inflammatory cytokines such as interleukins (IL)-1, IL-6 and tumor necrosis factor alpha. However, after menopause and the decreased of ovarian hormone production these cytokines levels could increase(88. Di Martino V, Lebray P, Myers RP, Pannier E, Paradis V, Charlotte F, Moussalli J, Thabut D, Buffet C, Poynard T. Progression of liver fibrosis in women infected with hepatitis C: long-term benefit of estrogens exposure. Hepatology 2004;40:1426-33.). Villa et al.(2222. Villa E, Karampatou A, Cammà C, Di Leo A, Luongo M, Ferrari A, Petta S, Losi L, Taliani G, Trande P, Lei B, Graziosi A, Bernabucci V, Critelli R, Pazienza P, Rendina M, Antonelli A, Francavilla A. Early menopause is associated with lack of response to antiviral therapy in women with chronic hepatitis C. Gastroenterology 2011;140:818-29.) observed that the estrogens-deprived environment in PMW with chronic hepatitis C virus (CHC) had influence in progression to fibrosis. There are reports that estrogen inhibits the myofibroblastic transformation of rat stellate cells that are responsible for hyper secretion of collagen and fibrosis, pointing to a possible anti fibrotic effect of this drug(2626. Yasuda M, Shimizu I, Shiba M, Ito S. Suppressive effects of estradiol on dimethylnitrosamine-induced fibrosis of the liver in rats. Hepatology 1999;29:719-27.).

A hepatic anti fibrogenic effect of HRT has also been referred in menopausal patients using HRT with the diagnosis of chronic hepatitis C(44. Codes L, Asselah T, Cazals-Hatem D, Tubach F, Vidaud D, Paraná R, Bedossa P, Bedossa P, Valla D, Marcellin P. Liver fibrosis in women with chronic hepatitis C: evidence for the negative role of the menopause and steatosis and the potential benefit of hormone replacement therapy. Gut 2007;56:390-5.), and there are evidences of less hepatic injury during pregnancy in women with chronic hepatitis C(99. Gervais A, Bacq Y, Bernuau J, Martinot M, Auperin A, Boyer N, Kilani A, Erlinger S, Valla D, Marcellin P. Decrease in serum ALT and increase in serum HCV RNA during pregnancy in women with chronic hepatitis C. J Hepatol. 2000;32:293-9.), pointing to an antifibrogenic effect of endogenous estrogen. The relevance of HRT in patients with CHC was also evaluated by Codes et al.(44. Codes L, Asselah T, Cazals-Hatem D, Tubach F, Vidaud D, Paraná R, Bedossa P, Bedossa P, Valla D, Marcellin P. Liver fibrosis in women with chronic hepatitis C: evidence for the negative role of the menopause and steatosis and the potential benefit of hormone replacement therapy. Gut 2007;56:390-5.) who observed that steatosis was more common and severe in menopausal women. Moreover the presence of liver fibrosis was lower among the women who referred HRT use(44. Codes L, Asselah T, Cazals-Hatem D, Tubach F, Vidaud D, Paraná R, Bedossa P, Bedossa P, Valla D, Marcellin P. Liver fibrosis in women with chronic hepatitis C: evidence for the negative role of the menopause and steatosis and the potential benefit of hormone replacement therapy. Gut 2007;56:390-5.). Shimizu and Ito(1919. Shimizu I, Ito S. Protection of estrogens against the progression of chronic liver disease. Hepatol Res. 2007;37:239-47.) also evaluated patients with CHC and observed a beneficial effect of estradiol on the progression of chronic liver disease.

The study showed that the frequency of MS was lower in the HRT group when compared with the group without HRT. One possible hypothesis for these results could be the contribution of the HRT to the reduction of abdominal visceral fat. The group without NAFLD on HRT also had a higher proportion of women with a normal body mass index. These findings may suggest that HRT could promote weight reduction.

Menopause has been associated with higher risk of MS development, even after adjustment for confounders such as age, body mass index, family income, and lack of physical activity(1717. Park YW, Zhu S, Palaniappan L, Heshka S, Carnethon MR, Heymsfield SB. The metabolic syndrome: prevalence and associated risk factor findings in the US population from the Third National Health and Nutrition Examination Survey, 1988-1994. Arch Intern Med. 2003;163:427-36.). In this sample of menopausal women, NAFLD was associated with well-known risk factors such as: obesity, MS and IR in the multivariate analysis.

Hamaguchi et al.(1111. Hamaguchi M, Kojima T, Ohbora A, Takeda N, Fukui M, Kato T. Aging is a risk factor of nonalcoholic fatty liver disease in premenopausal women. World J Gastroenterol. 2012;18:237-43.) suggested that aging is a risk factor for NAFLD in premenopausal women, independent of weight gain or influence of MS. In addition, results from the authors showed higher frequency of NAFLD in PMW who did not use HRT when compared to premenopausal and postmenopausal women who referred HRT usage. The logistic model did not suggest that HRT could be a risk factor for NAFLD development.

Results of this investigation are in concordance with these data(1111. Hamaguchi M, Kojima T, Ohbora A, Takeda N, Fukui M, Kato T. Aging is a risk factor of nonalcoholic fatty liver disease in premenopausal women. World J Gastroenterol. 2012;18:237-43.) and also suggested that HRT it is not related to NAFLD development. The NAFLD prevalence is higher in women not on HRT.

The HRT use was higher in younger PMW (up to 50 years old) and was lower in single women. It is possible, that these women are being influenced by their partners to use this therapy to reduce distressing symptoms and improve sexual enjoyment(2525. Wren BG. The benefits of oestrogen following menopause: why hormone replacement therapy should be offered to postmenopausal women. Med J Aust. 2009;190:321-5.). These women may also be encouraged by their gynecologists, who aim to reduce the risk of diseases resulting from estrogens deprivation, such as osteoporosis fractures, type 2 diabetes, cardiovascular disease, and colorectal cancer(22. Canderelli R, Leccesse LA, Miller NL, Unruh Davidson J. Benefits of hormone replacement therapy in postmenopausal women. J Am Acad Nurse Pract. 2007;19:635-41.). Low rates of insulin resistance were observed in women using HRT, regardless of the diagnosis of NAFLD, and these findings may confirm the possible beneficial effect of this therapy describes before.

Significant alterations of ferritin e ALT levels in PMW with steatosis grades II e III on abdominal ultrasound were observed in women that not use HRT. These results may suggest a possible relation of HRT in a less liver injury, and they are in agreement with a study performed in Scotland, which suggested that HRT improved the results of liver-enzyme levels in women with type 2 diabetes(1616. McKenzie J, Fisher BM, Jaap AJ, Stanley A, Paterson K, Sattar N. Effects of HRT on liver enzyme levels in women with type 2 diabetes: a randomized placebo-controlled trial. Clin Endocrinol. 2006;65:40-4.). However, in both studies was not performed liver biopsy, that remains the gold standard for diagnosis and staging of hepatic fibrosis(2424. Wieckowska A, Feldstein AE. Diagnosis of nonalcoholic fatty liver disease: invasive versus noninvasive. Semin Liver Dis. 2008;28:386-95.).

In conclusion, this study showed elevated frequency of NAFLD in PMW; metabolic syndrome and insulin resistance index were significantly elevated in PMW who have not used HRT. These results suggest that HRT may have a potential benefit effect on NAFLD, and strongly emphasis the relevance to investigate the causal relationship between HRT and NAFLD throughout a prospective cohort with liver biopsy.

ACKNOWLEDGMENTS

We want to thank Cláudia Gadelha, Debora Leite, Gerson Bragagnoli, Manoel Florentino de Medeiros Neto and Paulo Schwingel for their collaboration during this investigation.

REFERENCES

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    Arkin H, Colton R. Tables for statisticians. New York: Barnes & Noble, 1959.
  • 2
    Canderelli R, Leccesse LA, Miller NL, Unruh Davidson J. Benefits of hormone replacement therapy in postmenopausal women. J Am Acad Nurse Pract. 2007;19:635-41.
  • 3
    Clark JM. The epidemiology of nonalcoholic fatty liver disease in adults. J Clin Gastroenterol .2006;40:S5-10.
  • 4
    Codes L, Asselah T, Cazals-Hatem D, Tubach F, Vidaud D, Paraná R, Bedossa P, Bedossa P, Valla D, Marcellin P. Liver fibrosis in women with chronic hepatitis C: evidence for the negative role of the menopause and steatosis and the potential benefit of hormone replacement therapy. Gut 2007;56:390-5.
  • 5
    Coral G, de Mattos AA, de Mattos AZ, dos Santos DE. [Steatosis and non-alcoholic steatohepatitis in patients with chronic hepatitis due to hepatitis C virus infection]. Arq Gastroenterol. 2006;43:265-8.
  • 6
    Corriveau P, Paquette A, Brochu M, Prud'homme D, Rabasa-Lhoret R, Lavoie JM. Resistance training prevents liver fat accumulation in ovariectomized rats. Maturitas 2008;59:259-67.
  • 7
    de Moura Almeida A, Cotrim HP, Barbosa DB, de Athayde LG, Santos AS, Bitencourt AG, de Freitas LA, Rios A, Alves E. Fatty liver disease in severe obese patients: diagnostic value of abdominal ultrasound. World J Gastroenterol. 2008;14:1415-8.
  • 8
    Di Martino V, Lebray P, Myers RP, Pannier E, Paradis V, Charlotte F, Moussalli J, Thabut D, Buffet C, Poynard T. Progression of liver fibrosis in women infected with hepatitis C: long-term benefit of estrogens exposure. Hepatology 2004;40:1426-33.
  • 9
    Gervais A, Bacq Y, Bernuau J, Martinot M, Auperin A, Boyer N, Kilani A, Erlinger S, Valla D, Marcellin P. Decrease in serum ALT and increase in serum HCV RNA during pregnancy in women with chronic hepatitis C. J Hepatol. 2000;32:293-9.
  • 10
    Gutierrez-Grobe Y, Ponciano-Rodríguez G, Ramos MH, Uribe M, Méndez-Sánchez N. Prevalence of non alcoholic fatty liver disease in premenopausal, posmenopausal and polycystic ovary syndrome women: the role of estrogens. Ann Hepatol. 2010;9:402-9.
  • 11
    Hamaguchi M, Kojima T, Ohbora A, Takeda N, Fukui M, Kato T. Aging is a risk factor of nonalcoholic fatty liver disease in premenopausal women. World J Gastroenterol. 2012;18:237-43.
  • 12
    Karnikowski M, Córdova C, Oliveira RJ, Karnikowski MG, Nóbrega O deT. Non-alcoholic fatty liver disease and metabolic syndrome in Brazilian middle-aged and older adults. Sao Paulo Med J. 2007;125:333-7.
  • 13
    Lavoie JM, Pighon A. NAFLD, estrogens, and physical exercise: the Animal Model. J Nutr Metab. 2012;2012:914938.
  • 14
    Marfell-Jones M. International standards for anthropometric assessment. Rev. ed. Potchefstroom, South Africa: International Society for the Advancement of Kinanthropometry. 2006.
  • 15
    Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner RC. Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia 1985;28:412-9.
  • 16
    McKenzie J, Fisher BM, Jaap AJ, Stanley A, Paterson K, Sattar N. Effects of HRT on liver enzyme levels in women with type 2 diabetes: a randomized placebo-controlled trial. Clin Endocrinol. 2006;65:40-4.
  • 17
    Park YW, Zhu S, Palaniappan L, Heshka S, Carnethon MR, Heymsfield SB. The metabolic syndrome: prevalence and associated risk factor findings in the US population from the Third National Health and Nutrition Examination Survey, 1988-1994. Arch Intern Med. 2003;163:427-36.
  • 18
    Rosa-e-Silva AC, Melo AS. A importância da via de administração na terapia hormonal do climatério. Femina 2010;38:279-85.
  • 19
    Shimizu I, Ito S. Protection of estrogens against the progression of chronic liver disease. Hepatol Res. 2007;37:239-47.
  • 20
    Sitruk-Ware R, Plu-Bureau G, Menard J, Conard J, Kumar S, Thalabard JC, Tokay B, Bouchard P. Effects of oral and transvaginal ethinyl estradiol on hemostatic factors and hepatic proteins in a randomized, crossover study. J Clin Endocrinol Metab. 2007;92:2074-9.
  • 21
    Suzuki A, Abdelmalek MF. Nonalcoholic fatty liver disease in women. Womens Health 2009;5:191-203.
  • 22
    Villa E, Karampatou A, Cammà C, Di Leo A, Luongo M, Ferrari A, Petta S, Losi L, Taliani G, Trande P, Lei B, Graziosi A, Bernabucci V, Critelli R, Pazienza P, Rendina M, Antonelli A, Francavilla A. Early menopause is associated with lack of response to antiviral therapy in women with chronic hepatitis C. Gastroenterology 2011;140:818-29.
  • 23
    Walsh BW, Li H, Sacks FM. Effects of postmenopausal hormone replacement with oral and transdermal estrogen on high density lipoprotein metabolism. J Lipid Res. 1994;35:2083-93.
  • 24
    Wieckowska A, Feldstein AE. Diagnosis of nonalcoholic fatty liver disease: invasive versus noninvasive. Semin Liver Dis. 2008;28:386-95.
  • 25
    Wren BG. The benefits of oestrogen following menopause: why hormone replacement therapy should be offered to postmenopausal women. Med J Aust. 2009;190:321-5.
  • 26
    Yasuda M, Shimizu I, Shiba M, Ito S. Suppressive effects of estradiol on dimethylnitrosamine-induced fibrosis of the liver in rats. Hepatology 1999;29:719-27.
  • 27
    Yatsuji S, Hashimoto E, Tobari M, Tokushige K, Shiratori K. Influence of age and gender in Japanese patients with non-alcoholic steatohepatitis. Hepatol Res. 2007;37:1034-43.

Publication Dates

  • Publication in this collection
    July-Sept 2013

History

  • Received
    18 Dec 2012
  • Accepted
    8 May 2013
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