I know this is the Fourth of July weekend and many of my patients and readers will be busy with family, barbecues and hopefully celebrating the independence of the fabulous country we live in. (And, of course, there are those wonderful sales!). But if you happen to be glancing at this website, I want to take this opportunity to indulge in a modicum of self-congratulation; a committee opinion from the American College of Obstetricians and Gynecologists was just released and it supports what I’ve been telling my patients for years; that hormone therapy does not increase coronary heart disease risk for healthy women who have recently become menopausal. What also makes this committee opinion novel is that it states that if a woman’s quality of life is diminished by menopausal symptoms past the age of 65, extended therapy may be considered. Let me repeat: The American College of Obstetricians and Gynecologists now recommends against routine discontinuation of systemic estrogen at age 65 for women who need HT to manage their vasomotor symptoms (hot flashes and night sweats).
So that’s the summary. And you can go back to your holiday celebrations. But if you want to read further here are some of the studies and facts that the committee used in its announcement:
Much of the controversy about the impact of hormone therapy (HT) on cardiovascular disease came out of the Women’ Health Initiative (WHI) and the Heart and Estrogen/progestin Study (HERS) which seemed to show an increase in heart attack and stroke in women who took hormone therapy. But more recent studies have cast doubt on some of the methodologies used. Many of the women who were in the those two studies were over the age of 63 when they started hormone therapy and already had underlying coronary heart disease, hence they had an underlying increased risk for developing heart attack and stroke, which perhaps was augmented by hormone therapy. But newer studies indicate that when hormone therapy is started at a younger age, in women aged 50 to 59, the opposite occurs. An important study used CT scans to examine the distribution of calcification (plaque) in the coronary arteries in 1064 women who were in that 50 to 59 year range. Those who took estrogen had calcium scores that were lower than women who took a placebo, moreover, those who stayed on estrogen for more than five years had a significant reduction of 40% in their calcification scores.
The committee also looked at other variables of hormone therapy that could affect cardiovascular disease. They stated that synthetic medroxyprogesterone acetate (Provera) causes constriction of blood vessels whereas natural progesterone causes the vessels to relax and therefore may have a positive effect on blood pressure. In addition, unlike synthetic progestins, natural progesterone causes little or no reduction in high density lipoprotein. (Remember, high density lipoprotein is the good cholesterol and works like a rotor router to protect vessels from plaque formation). The committee doesn’t go so far as to state that ET or HT improve cardiovascular outcomes, they simply state that the evidence is as yet insufficient. But they do say that recent evidence suggests that women in early menopause who are in good cardiovascular health are at low risk of adverse cardiovascular outcomes and should be considered candidates for estrogen therapy or combined estrogen and progesterone therapy for relief of their menopausal symptoms. And women over 65 should talk to their doctor. If their symptoms are persistent, it’s OK to consider continuing their hormone therapy.
My final summation: If you develop symptoms that make you miserable – start hormone therapy in the early years of menopause, there is no increased risk of CHD if you are healthy… and continuation beyond age 65 may be an appropriate option if your quality of life is significantly reduced by these symptoms. We still have to discuss risk- benefits (most specifically breast cancer risk…) There is no free lunch or hormone!