After the report that came out in 2002 from the Women’s Health Initiative (WHI) almost 80% of women who had been on Premarin and Provera stopped taking it. But as more and more women went through the menopausal change, had significant symptoms and the results of the WHI underwent interpretation and reanalysis, women and their physicians sought forms of hormone therapy (HT) that would potentially be safer and “cure” symptoms. In many instances, this involved the use of estradiol instead of Premarin (a type of estrogen that is “conjugated” and made from the urine of pregnant mares). The “new” estrogen that was often preferred was estradiol (the active estrogen that is produced by the ovary and works on the estrogen receptors in our body). It also was more acceptable, especially to vegetarians, because it is manufactured from a vegetable source. Estradiol is currently available as a pill, patch, cream or vaginal ring. And rather than use synthetic Provera, many physicians have switched to a natural progesterone which they prescribe with estrogen in order to protect the lining of the uterus in women who have not undergone hysterectomy. Has this change made a huge difference on the impact of hormone therapy on coronary heart disease mortality?
An attempt to answer this question was addressed in a recent article published in the Journal Obstetrics and Gynecology by the Department of Obstetrics and Gynecology at Helsinki University Hospital in Finland and the Nordic School of Public Health. The risk of coronary heart disease death in hormone therapy users in age-matched women were compared between the pre (1995-2001) and post ( 2002-2009) women’s WHI eras. They used a nationwide register on 290,272 women age 40 years or older who took hormone therapy. (I love the way Scandinavian countries have kept registers and medical data on their population.) The post-WHI group was given estrogen in the form of estradiol and when needed natural progesterone.
The researchers expected to find a higher coronary heart disease death risk in hormone therapy users during the pre-WHI era. But instead, the use of HT was accompanied by significant reductions in the risk of death resulting from coronary heart disease in both groups. They found that exposure to HT for one year or less was accompanied by a 29% reduction and an exposure of 1 to 8 years with the 43% reduction in the risk of coronary heart disease and death in the pre-WHI era. In the post-WHI era HT use of one year or less was associated with an 18% and an exposure of 1 to 8 years with a 54% reduction in coronary heart disease mortality. The differences are not significant. Discontinuation of HT was associated with an increased risk of cardiac death of 42% in the pre-women’s health initiative era and 31% in the post women’s health initiative era during the first post treatment year. This risk apparently vanished in further follow-up during both eras
Their conclusion was that the changes in HT use after the WHI when they were almost exclusively using estradiol and natural progesterone failed to affect coronary heart disease mortality in HT users in their nationwide study. Does this mean all women should consider hormone therapy for prevention of coronary heart disease mortality no matter what? And does the type of hormone make a difference? No … other studies have shown that hormone therapy is helpful in women who are not older than 60 and that estrogen is beneficial if a woman has healthy coronary arteries but it is probably not affective in she has atherosclerotic plaque which is far more likely to be present in the arteries of women older than 60.
So once more decision to use HT is not simple… Should we take hormones for our hearts at least initially and what it does HT do to our risk of breast cancer? (The answer is that long-term use does increase breast cancer risk). And what are the benefits of estradiol and natural progesterone versus previously prescribed forms of HT? Should hormones be taken orally or through patches, creams or vaginal inserts? How long is it safe and have positive impacts? At what age should we stop? There is no question that estrogen it is the out effective therapy for severe menopausal symptoms but it is contraindicated for some women going through the menopausal transition. All this has to be discussed with a physician who has thorough knowledge about the pros and cons of HT. There is now one more study to put into the discussion.