Post-Menopausal HRT May Prevent Heart Disease
Studies have reported conflicting results on the use of post-menopausal hormone replacement therapy (HRT) to prevent cardiovascular disease. A new study in the Dec. 19 issue of the Annals of Internal Medicine provides insight on the relation between HRT, including estrogens alone and with progestin.
A team of researchers from the Channing Laboratory, Brigham and Women’s Hospital, Harvard Medical School, and Harvard School of Public Health conducted a study to investigate duration, dose and type of post-menopausal HRT in the primary prevention of heart disease. Primary prevention entails taking steps to prevent a disease from developing in the first place, whereas secondary prevention involves slowing the progression of a disease that is already present. Their results indicate that post-menopausal HRT use appears to decrease the risk for major coronary events in women without previous heart disease. In other words, it may be useful in the primary prevention of heart disease.
One study, the Heart and Estrogen/progestin Replacement Study (HERS), found an increased risk for coronary events in previously diagnosed with heart disease during their first year of hormone therapy. Another study, known as the Women’s Health Initiative, recently reported an increased risk of coronary events in healthy post-menopausal women during their first two years of treatment.
The researchers analyzed data on 70,533 post-menopausal women who were followed as part of the Nurses’ Health Study from 1976 to 1996 and who had no known history of heart disease at study entry. Over the period of 20 years, the researchers identified 953 nonfatal myocardial infarctions (heart attacks), 305 coronary deaths and 767 strokes; 119 deaths were due to stroke.
They found that healthy post-menopausal women who took hormones had a 40 percent decrease in risk for major coronary events. Furthermore, the reduction in risk was similar for women taking low dose (0.3 milligrams) as well as the standard dose (0.625 milligrams) of oral estrogen. However, women who took daily doses of 0.625 milligrams or more and women who took estrogen in combination with progestin, each had a modest increase in risk of stroke compared to women who never took hormones.
“According to the data from this Nurses’ Health Study cohort, if 100,000 post-menopausal women 55 to 59 years of age were given hormone therapy, 55 fewer cases of cardiovascular disease per year would be expected. For estrogen alone, 60 fewer cases would be expected, and with combined therapy, 21 fewer cardiovascular disease events would be expected,” the authors reported.
The researchers did note some limitations of the study, however. First, the Nurses’ Health Study is an observational study, not a randomized clinical trial. That is, the researchers were unable to control which subjects would receive HRT and which would not. Without controlling the treatment and measuring the changes that result, researchers cannot reliably conclude that there is a cause-and-effect relationship. Second, all the subjects are registered nurses — a profession that has knowledge about and access to healthcare.
“The Nurses’ Health Study investigation of primary prevention indicates that hormone therapy may be associated with coronary benefits. … However, the risk for stroke appears to be increased with hormone use,” the authors concluded. “In addition, hormone therapy is related to increased risk for breast cancer. Clearly, alternatives should be considered that promote healthy aging and pose no risks, such as physical activity, a healthy diet and smoking cessation,” they added.
In an editorial accompanying the report, Deborah Grady, M.D., M.P.H., and Stephen Hulley, M.D., M.P.H., both from the University of California, San Francisco, wrote, “It is puzzling that hormone therapy would decrease risk for coronary heart disease but increase risk for ischemic stroke.”
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