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April 12, 1999
News this month When members of the American College of Cardiology convened for an annual scientific session in March, one of the topics high on their agenda was a discussion of clinical trials studying the role of estrogen and heart disease. Millions of women take estrogen supplements (estrogen replacement therapy, ERT) to replace the hormones their bodies stop making at menopause. The supplements relieve symptoms like hot flashes and protect against thinning of bones. Previous research found that women taking them also suffered up to 60 percent fewer heart attacks. ERT in women without heart disease All subjects in the active treatment groups showed a significant elevation in HDL cholesterol (good cholesterol) compared to the placebo group. Those receiving estrogen alone increased their HDLs by more than twice as much as women who received the estrogen/progesterone formulation. Women with the greatest rise in HDL reduced their risk of heart disease by 25 percent, according to the investigators. Both active and placebo groups reduced their LDL cholesterol (bad cholesterol), but the placebo group showed a much smaller decrease. Investigators concluded the best treatment regimen would be an estrogen/progesterone therapy for postmenopausal women with a uterus and estrogen alone for women who have had hysterectomies. The trial did not answer whether these positive cholesterol findings translated into decreased risk of heart disease in postmenopausal women.
…the best treatment regimen would be an estrogen/progesterone therapy for postmenopausal women with a uterus and estrogen alone for women who have had hysterectomies.
ERT in women who already have heart disease Those who were randomly assigned to take a supplement containing estrogen and progestin suffered no fewer heart attacks over four years than the other women. In fact, the women taking the supplements actually suffered more heart attacks during the first year, but they had fewer later, so the effects balanced out over the four-year study. The study's lead author, Dr. Stephen Hulley, chairman of epidemiology and biostatistics at the University of California at San Francisco, cautioned the findings were directly applicable only to women who already had heart disease. The HERS recommendations for women with heart disease are to not start estrogen/progestin to prevent future heart attacks, but if women are already taking ERT, they should continue since there may be a long-term benefit. Women with heart disease should not start estrogen/progestin to prevent future heart attacks, but if they are already taking ERT, they should continue since there may be a long-term benefit.
ERT and statins offer women extra protection More research needed
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 Estrogen and Heart disease: what's a woman to do?
As the number of women entering menopause increases, I hear the question of whether estrogen replacement therapy (ERT) will help protect them against heart disease more often. It's an important question. Coronary heart disease (CHD) kills more women than any other disease--233,000 in the U.S. each year. Unfortunately, the current research provides no simple answer. Early observational studies, the two major clinical trials (PEPI and HERS) discussed at a recent session of the American College of Cardiology, as well as a few smaller recent studies, just don't give us conclusive evidence to guide us in advising our patients. It is important to look at a woman's medical history and weigh her particular risk factors for heart disease, breast and uterine cancer, thrombosis, phlebitis and osteoporosis.
Estrogen study results are mixed
The ideal ERT candidate The decision to continue or to stop ERT is complicated. Talk with your physician.
The ideal candidate, in my eyes, for ERT is a woman with a strong family history of heart disease but none or very little family history of breast or uterine cancer. If her family history includes risk of developing osteoporosis, that would certainly tip the balance in favor of ERT since it would not only help control her cholesterol, it would also protect her against fractures resulting from osteoporosis. Where the choice becomes unclear If a woman has high postmenopausal cholesterol and requires cholesterol- lowering therapy, I would first put that woman on statins to reduce the cholesterol. If her other risk factors indicate, I might combine that with ERT as well since there is some additional cholesterol-lowering benefit. At this point, however, I would not prescribe estrogen in lieu of statins. We need to learn more, and we should benefit from the results of a number of
major controlled clinical trials now underway. These results will not be available
for several years, so in the meantime, I would caution women the decision to
continue or to stop ERT is complicated. Talk with your physician about your health
profile and your family history, as well as other options available for the prevention and treatment of coronary heart disease. Dr. Gerber is a partner with Cardiology Associates of New Haven, 40 Temple Street, New Haven, CT. He is an attending physician at Yale-New Haven Hospital and an assistant clinical professor of medicine and cardiology at the Yale University School of Medicine. |
