Abstract-Estrogens are important regulators of cardiovascular function. Some of estrogen's cardiovascular effects are mediated by a G-protein-coupled receptor mechanism, namely, G-protein-coupled estrogen receptor (GPER). Estradiol-mediated regulation of vascular cell programmed cell death reflects the balance of the opposing actions of GPER versus estrogen receptor α (ERα). However, the significance of these opposing actions on the regulation of vascular smooth muscle cell proliferation or migration in vitro is unclear, and the significance in vivo is unknown.To determine the effects of GPER activation in vitro, we studied rat aortic vascular smooth muscle cells maintained in primary culture. GPER was reintroduced using adenoviral gene transfer. Both estradiol and G1, a GPER agonist, inhibited both proliferation and cell migration effects that were blocked by the GPER antagonist, G15. To determine the importance of the GPER-ERα balance in regulating vascular remodeling in a rat model of carotid ligation, we studied the effects of upregulation of GPER expression versus downregulation of ERα. Reintroduction of GPER significantly attenuated the extent of medial hypertrophy and attenuated the extent of CD45 labeling. Downregulation of ERα expression comparably attenuated the extent of medial hypertrophy and inflammation after carotid ligation. These studies demonstrate that the balance between GPER and ERα regulates vascular remodeling. Receptor-specific modulation of estrogen's effects may be an important new approach in modifying vascular remodeling in both acute settings like vascular injury and perhaps in longer term regulation like in hypertension. Our initial focus on ERα (versus ER β , which is also expressed in rat aortic vascular smooth muscle cells [VSMCs]) was based on our demonstration that in isolated rat VSMCs, estradiol's (E2) antiapoptotic effects were mediated via ERα. 30 In contrast, E2 acting via GPER was proapoptotic. However, the in vivo implications of these receptor-specific opposing effects of estradiol on growth regulation have yet to be established.In these studies, we examined the process of vascular remodeling to understand how E2 regulates vascular growth via GPER versus ERα. Remodeling occurs subsequent to several vascular stressors including hypertension, 31 atherosclerosis, 32 and vascular injury 33 and can be associated with both adaptive responses (as in vascular injury) and maladaptive responses (as in hypertension and in vascular restenosis). The VSMC hypertrophy and hyperplasia that occurs in remodeling processes has been linked to a shift in the balance between proliferative and apoptotic mechanisms and a dedifferentiation of VSMCs from a contractile phenotype, as seen under normal conditions in situ, to a so-called synthetic phenotype, 34 as seen after vascular injury. This latter phenotype is characterized as having higher proliferative rates and greater migratory behavior. This synthetic phenotype is more similar to the phenotype of VSMCs maintained in primary culture, 35 th...