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Postmenopausal
Hormone Therapy and Cardiovascular Disease in Women
American Heart Association Article
The week of July 8, 2002, scientists at the National Heart, Lung, and Blood Institute announced that they had stopped a large study of postmenopausal hormone therapy (PHT) using a combination of estrogen plus progestin. This trial, called the Women’s Health Initiative (WHI), showed that estrogen plus progestin significantly increased the risk of invasive breast cancer and blood clots in the legs and lungs and did not protect women from heart disease and stroke.
In fact, the study showed that women taking this drug had a higher risk of heart attack and stroke. (The hormone formulation studied in this trial was CEE/MPA [brand name Prempro]. The medical name is oral conjugated equine estrogens [CEE] with oral medroxyprogestrone acetate [MPA].)
The week of March 1, 2004, the National Institutes of Health stopped the estrogen-only phase of the Women’s Health Initiative (WHI). The WHI found an increased risk of stroke and no reduction in the risk of heart disease in postmenopausal women who have had a hysterectomy. The estrogen-only arm used CEE [brand name Premarin].)
In February 2004 the American Heart Association updated its Guidelines for Cardiovascular Disease Prevention in Women with new recommendations for PHT. Combined hormone therapy is not recommended for the prevention of heart disease and stroke in postmenopausal women. The Guidelines recommended a conservative approach to the use of estrogen-alone hormone therapy until further research is available.
Since the recent data from the estrogen only arm of the WHI trial does not support the use of estrogen only to prevent cardiovascular disease, the American Heart Association reinforces its recommendation that hormone therapy not be used for cardiovascular prevention. Its use for other reasons should be cautiously considered with the advice of a physician. Hormones may relieve menopausal symptoms, but women and their healthcare providers should weigh the potential risks of therapy against the potential benefits for menopausal symptom control.
Many people have been confused and alarmed by the recent news about the WHI. To help you understand what it means, we’ve prepared a Q&A to provide some perspective. Before you make any decisions, though, it’s very important to consult your physician.
What if I’m taking or considering taking estrogen alone or estrogen plus progestin to prevent heart disease or stroke?
Estrogen alone and estrogen plus progestin should not be used to prevent heart disease or stroke.
Many established methods are available to lower heart disease risk in women. Lowering cholesterol and controlling blood pressure are two examples. If blood pressure and cholesterol aren’t controlled with lifestyle measures such as not smoking, getting regular physical activity and eating a heart-healthy diet, then drug therapy may be indicated. Certain medications, such as aspirin, statins, beta-blockers and ACE-inhibitors, also may benefit women who have cardiovascular disease or are at high risk of developing it.
What if I’m taking another type of hormone therapy to prevent heart disease or stroke?
Until there’s clear evidence that other forms of PHT not tested in recent clinical trials are beneficial, women should not use these therapies to prevent heart disease and stroke.
Newer estrogen therapies such as selective estrogen receptor modulators (SERMs) aren’t the same as PHT. They don’t treat menopausal symptoms and don’t seem to increase the risk of breast cancer — but they are effective in treating osteoporosis and preventing fractures. Studies are under way to find out if they lower the risk of heart disease. However, like estrogen plus progestin, these should not be used for this purpose until more research is available.
What if I’m taking hormone therapy for other reasons, such as relief of menopausal symptoms?
For many women, using estrogen alone or estrogen plus progestin for short-term relief of menopausal symptoms may be worth the small absolute increase in risk for heart disease, stroke or breast cancer. Because the risk of these complications rises the longer it is used, PHT should be used for the shortest time necessary. Women who’ve had premature menopause because their ovaries were surgically removed should consult their physician(s) about when to stop hormone therapy.
What if I’m taking hormone therapy to prevent osteoporosis?
Estrogen alone and estrogen plus progestin are effective for preventing osteoporosis and bone breaks, but these benefits may not outweigh the risk of breast cancer and cardiovascular disease. Other options should be considered.
Is more research under way to evaluate using other forms of hormone therapy to prevent and treat heart disease?
Yes. The WHI results show that postmenopausal hormone therapy didn’t work the way physicians assumed it would. This shows why research studies like the WHI are so important. It also makes scientists more intent than ever to discover new types of estrogens that might help prevent and treat heart diseases. It could be that in the future new and different estrogens or SERMs might help prevent and/or treat heart disease. Many different kinds of estrogens and SERMs are now being tested.
For more information about the Women’s Health Initiative study and the NHLBI’s “Facts About Postmenopausal Hormone Therapy,” go to nhlbi.nih.gov/whi/index.html.
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