Updated June 08, 2015.
By DrRich
Over the past several years, hormone replacement therapy (HRT) for menopausal women has all but died out. Extremely popular for years, HRT was stopped in its tracks in 2002 after major clinical trials (most prominently the Women's Health Initiative - WHI - study, and the Heart Estrogen/Progestin Replacement Study) showed that HRT not only failed to delay cardiovascular disease, but also led to an increased risk of cardiac events.
The consensus of expert opinion rapidly changed from "All women should get HRT," to "No women should get HRT."
In 2004, however, a meta-analysis of several randomized trials confused the picture by suggesting that, in women who were under the age of 60 when HRT was started, a reduction in mortality may have occurred with HRT.
And now, in a new analysis of data from the WHI study published this month in the New England Journal of Medicine, investigators report that women who started estrogen at an earlier age (under age 60) had a significantly reduced coronary artery calcium score than women of the same age who were treated with placebo. (A lower calcium score correlates with a lower risk of heart attack.)
This new finding has re-energized some proponents of HRT, who are now pronouncing HRT to be "cardio-protective" in younger post-menopausal women. They theorize that while HRT clearly increases cardiac risk in older women, the effect of HRT on the heart may be related to the age at which women begin taking it, and that women who begin taking HRT early in menopause can enjoy not only the known benefits of HRT, but also a reduced incidence of heart disease.
This theory, while plausible, is far from proven. Another theory that would equally fit all the available data is that HRT, while improving calcium scores, may have some other effect on blood vessels that makes plaque rupture (and thus heart attacks) more likely.
Furthermore, it is also being theorized that the sharp reduction in HRT usage over the past five explains the equally sharp reduction in breast cancer that has been seen over that time period.
DrRich comments:
Unfortunately, the HRT story just keeps getting more complicated. It seems evident that HRT is safer (from a cardiovascular standpoint) in younger women than in older women, but it is unknown a) whether that relative safety persists with long term use; b) whether that relative saftey translates to an overall reduction of risk, or simply to a lesser elevation of risk; and c) whether reinstituting HRT in large numbers of younger postmenopausal women would be associated with a rebound in the incidence of breast cancer.
The most judicious path at this time would be to limit HRT to younger postmenopausal women for short periods of time, and then only to treat severe menopausal symptoms; that is, NOT to use it chronically, or in the attempt to reduce heart disease. Plenty of other effective methods of cardiac risk reduction are available for women.
Sources:
Manson JE, Allison MA, Rossouw JE, et al. Estrogen therapy and coronary-artery calcification. New Engl J Med 2007; 356: 2591-2602.
By DrRich
Over the past several years, hormone replacement therapy (HRT) for menopausal women has all but died out. Extremely popular for years, HRT was stopped in its tracks in 2002 after major clinical trials (most prominently the Women's Health Initiative - WHI - study, and the Heart Estrogen/Progestin Replacement Study) showed that HRT not only failed to delay cardiovascular disease, but also led to an increased risk of cardiac events.
The consensus of expert opinion rapidly changed from "All women should get HRT," to "No women should get HRT."
In 2004, however, a meta-analysis of several randomized trials confused the picture by suggesting that, in women who were under the age of 60 when HRT was started, a reduction in mortality may have occurred with HRT.
And now, in a new analysis of data from the WHI study published this month in the New England Journal of Medicine, investigators report that women who started estrogen at an earlier age (under age 60) had a significantly reduced coronary artery calcium score than women of the same age who were treated with placebo. (A lower calcium score correlates with a lower risk of heart attack.)
This new finding has re-energized some proponents of HRT, who are now pronouncing HRT to be "cardio-protective" in younger post-menopausal women. They theorize that while HRT clearly increases cardiac risk in older women, the effect of HRT on the heart may be related to the age at which women begin taking it, and that women who begin taking HRT early in menopause can enjoy not only the known benefits of HRT, but also a reduced incidence of heart disease.
This theory, while plausible, is far from proven. Another theory that would equally fit all the available data is that HRT, while improving calcium scores, may have some other effect on blood vessels that makes plaque rupture (and thus heart attacks) more likely.
Furthermore, it is also being theorized that the sharp reduction in HRT usage over the past five explains the equally sharp reduction in breast cancer that has been seen over that time period.
DrRich comments:
Unfortunately, the HRT story just keeps getting more complicated. It seems evident that HRT is safer (from a cardiovascular standpoint) in younger women than in older women, but it is unknown a) whether that relative safety persists with long term use; b) whether that relative saftey translates to an overall reduction of risk, or simply to a lesser elevation of risk; and c) whether reinstituting HRT in large numbers of younger postmenopausal women would be associated with a rebound in the incidence of breast cancer.
The most judicious path at this time would be to limit HRT to younger postmenopausal women for short periods of time, and then only to treat severe menopausal symptoms; that is, NOT to use it chronically, or in the attempt to reduce heart disease. Plenty of other effective methods of cardiac risk reduction are available for women.
Sources:
Manson JE, Allison MA, Rossouw JE, et al. Estrogen therapy and coronary-artery calcification. New Engl J Med 2007; 356: 2591-2602.
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