Brief report: Coronary heart disease events associated with hormone therapy in younger and older women. A meta-analysis

Estrogen and progestogen use in postmenopausal women: July 2008 position statement of The North American Menopause Society

OBJECTIVE

: To update for both clinicians and the lay public the evidence-based position statement published by The North American Menopause Society (NAMS) in March 2007 regarding its recommendations for menopausal hormone therapy (HT) for postmenopausal women, with consideration for the therapeutic benefit-risk ratio at various times through menopause and beyond.

DESIGN

: An Advisory Panel of clinicians and researchers expert in the field of women's health was enlisted to review the March 2007 NAMS position statement, evaluate new evidence through an evidence-based analysis, and reach consensus on recommendations. The Panel's recommendations were reviewed and approved by the NAMS Board of Trustees as an official NAMS position statement. The document was provided to other interested organizations to seek their endorsement.

RESULTS

: Current evidence supports a consensus regarding the role of HT in postmenopausal women, when potential therapeutic benefits and risks around the time of menopause are considered. This paper lists all these areas along with explanatory comments. Conclusions that vary from the 2007 position statement are highlighted. Addenda include a discussion of risk concepts, a new component not included in the 2007 paper, and a recommended list of areas for future HT research. A suggested reading list of key references is also provided.

CONCLUSIONS

: Recent data support the initiation of HT around the time of menopause to treat menopause-related symptoms; to treat or reduce the risk of certain disorders, such as osteoporosis or fractures in select postmenopausal women; or both. The benefit-risk ratio for menopausal HT is favorable close to menopause but decreases with aging and with time since menopause in previously untreated women.

[Hormone therapy in menopause: when not to use]

Menopause is defined as the permanent cessation of menses, as a result of the loss of ovarian follicular function or of surgical removal of ovaries. The mean age for occurrence of natural menopause is around 50 years. Estrogen deficiency has been associated with vasomotor symptoms, urogenital atrophy, and cognitive impairment, as well as increased risk of chronic degenerative diseases such as osteoporosis and Alzheimer's disease. Estrogen therapy remains the most effective treatment for the management of vasomotor symptoms and urogenital atrophy. Progesterone or progestins should be added to estrogen treatment in women with uterus, in order to antagonize the estrogen-induced endometrial proliferation. In turn, in specific clinical conditions hormone therapy is not recommended. In the present article, the authors critically focus these clinical conditions in which hormone therapy should not be used.

Could transdermal estradiol + progesterone be a safer postmenopausal HRT? A review

Hormone replacement therapy (HRT) in young postmenopausal women is a safe and effective tool to counteract climacteric symptoms and to prevent long-term degenerative diseases, such as osteoporotic fractures, cardiovascular disease, diabetes mellitus and possibly cognitive impairment. The different types of HRT offer to many extent comparable efficacies on symptoms control; however, the expert selection of specific compounds, doses or routes of administration can provide significant clinical advantages. This paper reviews the role of the non-oral route of administration of sex steroids in the clinical management of postmenopausal women. Non-orally administered estrogens, minimizing the hepatic induction of clotting factors and others proteins associated with the first-pass effect, are associated with potential advantages on the cardiovascular system. In particular, the risk of developing deep vein thrombosis or pulmonary thromboembolism is negligible in comparison to that associated with oral estrogens. In addition, recent indications suggest potential advantages for blood pressure control with non-oral estrogens. To the same extent, a growing literature suggests that the progestins used in association with estrogens may not be equivalent. Recent evidence indeed shows that natural progesterone displays a favorable action on the vessels and on the brain, while this might not be true for some synthetic progestins. Compelling indications also exist that differences might also be present for the risk of developing breast cancer, with recent trials indicating that the association of natural progesterone with estrogens confers less or even no risk of breast cancer as opposed to the use of other synthetic progestins. In conclusion, while all types of hormone replacement therapies are safe and effective and confer significant benefits in the long-term when initiated in young postmenopausal women, in specific clinical settings the choice of the transdermal route of administration of estrogens and the use of natural progesterone might offer significant benefits and added safety.

Need for research on estrogen receptor function: importance for postmenopausal hormone therapy and atherosclerosis

BACKGROUND

Cardiovascular disease is the leading cause of morbidity and mortality in men and women worldwide. Although rare in premenopausal women, its incidence rises sharply after menopause, indicating atheroprotective effects of endogenous estrogens.

OBJECTIVE

This review discusses the differential effects of estrogen receptor function on atherosclerosis progression in pre- and postmenopausal women, including aspects of gender differences in vascular physiology of estrogens and androgens.

METHODS

Recent advances in the understanding of the pathogenesis of atherosclerosis, estrogen receptor function, and hormone therapy are reviewed, with particular emphasis on clinical and molecular issues.

RESULTS

Whether hormone therapy can improve cardiovascular health in postmenopausal women remains controversial. Current evidence suggests that the vascular effects of estrogen are affected by the stage of reproductive life, the time since menopause, and the extent of subclinical atherosclerosis. The mechanisms of vascular responsiveness to sex steroids during different stages of atherosclerosis development remain poorly understood in women and men.

CONCLUSION

In view of the expected increase in the prevalence of atherosclerotic vascular disease worldwide due to population aging, research is needed to determine the vascular mechanism of endogenous and exogenous sex steroids in patients with atherosclerosis. Such research may help to define new strategies to improve cardiovascular health in women and possibly also in men.

Estrogen, inflammation, and platelet phenotype

BACKGROUND

Although exogenous estrogenic therapies increase the risk of thrombosis, the effects of estrogen on formed elements of blood are uncertain.

OBJECTIVE

This article examines the genomic and nongenomic actions of estrogen on platelet phenotype that may contribute to increased thrombotic risk.

METHODS

To determine aggregation, secretion, protein expression, and thrombin generation, platelets were collected from experimental animals of varying hormonal status and from women enrolled in the Kronos Early Estrogen Prevention Study.

RESULTS

Estrogen receptor beta predominates in circulating platelets. Estrogenic treatment in ovariectomized animals decreased platelet aggregation and adenosine triphosphate (ATP) secretion. However, acute exposure to 17beta-estradiol did not reverse decreases in platelet ATP secretion invoked by lipopolysaccharide. Thrombin generation was positively correlated to the number of circulating microvesicles expressing phosphatidylserine.

CONCLUSION

Assessing the effect of estrogen treatments on blood platelets may lead to new ways of identifying women at risk for adverse thrombotic events with such therapies.

Health related quality of life after combined hormone replacement therapy: randomised controlled trial

OBJECTIVE

To assess the effect of combined hormone replacement therapy (HRT) on health related quality of life.

DESIGN

Randomised placebo controlled double blind trial.

SETTING

General practices in United Kingdom (384), Australia (94), and New Zealand (24).

PARTICIPANTS

Postmenopausal women aged 50-69 at randomisation; 3721 women with a uterus were randomised to combined oestrogen and progestogen (n=1862) or placebo (n=1859). Data on health related quality of life at one year were available from 1043 and 1087 women, respectively.

INTERVENTIONS

Conjugated equine oestrogen 0.625 mg plus medroxyprogesterone acetate 2.5/5.0 mg or matched placebo orally daily for one year.

MAIN OUTCOME MEASURES

Health related quality of life and psychological wellbeing as measured by the women's health questionnaire. Changes in emotional and physical menopausal symptoms as measured by a symptoms questionnaire and depression by the Centre for Epidemiological Studies depression scale (CES-D). Overall health related quality of life and overall quality of life as measured by the European quality of life instrument (EuroQol) and visual analogue scale, respectively.

RESULTS

After one year small but significant improvements were observed in three of nine components of the women's health questionnaire for those taking combined HRT compared with those taking placebo: vasomotor symptoms (P<0.001), sexual functioning (P<0.001), and sleep problems (P<0.001). Significantly fewer women in the combined HRT group reported hot flushes (P<0.001), night sweats (P<0.001), aching joints and muscles (P=0.001), insomnia (P<0.001), and vaginal dryness (P<0.001) than in the placebo group, but greater proportions reported breast tenderness (P<0.001) or vaginal discharge (P<0.001). Hot flushes were experienced in the combined HRT and placebo groups by 30% and 29% at trial entry and 9% and 25% at one year, respectively. No significant differences in other menopausal symptoms, depression, or overall quality of life were observed at one year.

CONCLUSIONS

Combined HRT started many years after the menopause can improve health related quality of life.

TRIAL REGISTRATION

ISRCTN 63718836.

Can menopausal hormone therapy prevent coronary heart disease?

Observational studies show that women who take menopausal hormone therapy (MHT) have a greatly reduced risk of coronary heart disease (CHD). But in some large randomized controlled trials, MHT failed to decrease CHD and so has been deemed inappropriate for long-term prophylaxis against atherosclerosis or other chronic diseases associated with the menopause. Despite the apparent strength of this conclusion, several recent reports suggest that MHT could be atheroprotective when started close to the menopause, and effects of early discontinuation of MHT have never been studied in randomized trials. Here, we examine these reports and highlight existing uncertainty regarding the effects of long-term continuation versus early discontinuation of early-start MHT on atherosclerosis and CHD risk. We call for new research on this question, and an evidence-based review of existing recommendations for MHT.

Update on hormones, menopause, and heart disease: evaluating professional responses to the Women's Health Initiative

The Women's Health Initiative (WHI) randomized controlled clinical trials provided evidence that, contrary to the common wisdom and clinical practice of the day, estrogen and estrogen/progestin hormone therapies (HT) were not safe or effective interventions to prevent chronic illnesses, especially heart disease, among postmenopausal women. A recent criticism of WHI, the timing hypothesis, asserts that HT would be cardioprotective if started around the time of menopause. This article critiques the timing hypothesis. The hypothesis relies on rejecting traditional criteria for scientific evidence, overinterpreting weak evidence, underemphasizing harm, and valuing the metatheory that menopause is an estrogen deficiency disease.

Association between hormone replacement therapy and subsequent arterial and venous vascular events: a meta-analysis

AIMS

Randomized controlled trials (RCTs) have shown that the risk of stroke and venous thromboembolism (VTE) is increased with hormone replacement therapy (HRT); the effect on coronary heart disease (CHD) remains unclear.

METHODS AND RESULTS

RCTs of HRT were identified. Event rates for cerebrovascular disease [stroke, TIA (transient ischaemic attack)], CHD (myocardial infarction, unstable angina, sudden cardiac death), and VTE (pulmonary embolism, deep vein thrombosis) were analysed. Sensitivity analyses were performed by type of HRT (mono vs. dual) and subject age. 31 trials (44 113 subjects) were identified. HRT was associated with increases in stroke (odds ratio, OR, 1.32, 95% confidence intervals, CI, 1.14-1.53) and VTE (OR 2.05, 95% CI 1.44-2.92). In contrast, CHD events were not increased (OR 1.02, 95% CI 0.90-1.11). Ordinal analyses confirmed that stroke severity was increased with HRT (OR 1.31, 95% CI 1.12-1.54). Although most trials included older subjects, age did not significantly affect risk. The addition of progesterone to oestrogen doubled the risk of VTE.

CONCLUSION

HRT is associated with an increased risk of stroke, stroke severity, and VTE, but not of CHD events. Although most trials studied older patients, increased risk was not related to age. Combined HRT increases the risk of VTE compared with oestrogen monotherapy.

Rationale for low-dose systemic hormone replacement therapy and review of estradiol 0.5 mg/NETA 0.1 mg

The menopausal transition is associated with several symptoms, for which both non-pharmacological and pharmacological measures are available to provide relief. However, present knowledge indicates that the former is not highly effective, and that the latter, in terms of systemic oestrogen and progestogen-based hormone replacement therapy (HRT), although being effective (e.g. on vasomotor symptoms, bleeding control, bone mineral density, vaginal atrophy and quality of life), can be associated with some caveats. Amongst these are an increased risk for coronary heart disease, breast cancer, venous thromboembolism and stroke. In recent years, literature has indicated a dose dependency for HRT on some of the caveats, hence authorities (Food and Drug Administration, and the European Medicines Agency) and menopause societies (International Menopause Society and North American Menopause Society) now recommend that women deemed in need of HRT should receive the lowest possible dose without compromising the effect of symptom relief. Estradiol 0.5 mg/norethisterone acetate (NETA) 0.1 mg, despite being a lower dose than conventional hormones, is a compound, among a few other low-dose options, that can be used in such therapy. As a first-line oral option, it has demonstrated its effectiveness (which seems comparable to other compounds), with high tolerability and, apparently, no safety concerns, in a 6-month study. Further long-term clinical trials and observational studies are mandatory in order to capture any potential harm as well as to elucidate this compound's full potential. Following a thorough literature search using PubMed and MEDLINE from the earliest publication dates through to January 2008, including results from various types of clinical trials and statements on HRT, we review the rationale for these recommendations. We also review the effects and safety of a novel 'ultra-low-dose' oral continuous combined HRT tablet, estradiol 0.5 mg/NETA 0.1 mg.

Vascular actions of estrogens: functional implications

The impact of estrogen exposure in preventing or treating cardiovascular disease is controversial. But it is clear that estrogen has important effects on vascular physiology and pathophysiology, with potential therapeutic implications. Therefore, the goal of this review is to summarize, using an integrated approach, current knowledge of the vascular effects of estrogen, both in humans and in experimental animals. Aspects of estrogen synthesis and receptors, as well as general mechanisms of estrogenic action are reviewed with an emphasis on issues particularly relevant to the vascular system. Recent understanding of the impact of estrogen on mitochondrial function suggests that the longer lifespan of women compared with men may depend in part on the ability of estrogen to decrease production of reactive oxygen species in mitochondria. Mechanisms by which estrogen increases endothelial vasodilator function, promotes angiogenesis, and modulates autonomic function are summarized. Key aspects of the relevant pathophysiology of inflammation, atherosclerosis, stroke, migraine, and thrombosis are reviewed concerning current knowledge of estrogenic effects. A number of emerging concepts are addressed throughout. These include the importance of estrogenic formulation and route of administration and the impact of genetic polymorphisms, either in estrogen receptors or in enzymes responsible for estrogen metabolism, on responsiveness to hormone treatment. The importance of local metabolism of estrogenic precursors and the impact of timing for initiation of treatment and its duration are also considered. Although consensus opinions are emphasized, controversial views are presented to stimulate future research.

[Prevention of coronary heart disease by early postmenopausal hormone therapy: new supporting data]

The important controversy concerning the potential beneficial, neutral or unfavourable effect of estrogens or estrogen plus progestin on the risk of coronary heart disease in postmenopausal women is beginning to settle down. Reanalysis of large observational and randomized trials according to age and years since menopause and recent additional studies allow to positively state that postmenopausal hormone therapy - and particularly estrogens alone - is safe and effective. For instance, in the Women's Health Initiative study, provided hormone therapy is initiated within 10 years since menopause, a reduction of the risk of coronary heart disease by 12 to 52% according to the use of estrogen plus progestin or estrogen alone, respectively, is observed versus placebo use. Global mortality is also reduced by 30% with both hormone therapies. This favourable effect is not observed when treatment is initiated in older postmenopausal women. These important and reassuring data should encourage regulatory authorities to reassess clinical recommendations in that prospect.

Vascular effects of estrogen and progestins and risk of coronary artery disease: importance of timing of estrogen treatment

The effects of estrogen and progestins on the vascular wall have drawn major medical attention, and significant controversy over various studies has been developed. Several experimental and observational studies have shown cardioprotective effects; however, prospective randomized trials showed an increase in cardiovascular events in postmenopausal women on estrogen/ medroxyprogesterone acetate treatment. The most significant parameter for cardiovascular benefit of estrogen seems to be the interval since the onset of menopause. In the early postmenopausal years, estrogen has beneficial effects on the vascular wall by inhibition of atherosclerosis progression, whereas in the late postmenopause, adverse effects like upregulation of the plaque inflammatory processes and plaque instability may develop. The effects of progestins on the cardiovascular system are not as clear and may differ according to the choice of progestins that is used. The aim of this review is to summarize the effects of estrogen and progestins on the vascular wall and their clinical implications.

Hormone therapy and postural balance in elderly women

OBJECTIVE

Most fractures occur in elderly individuals without osteoporosis, and more than 90% of all hip fractures are associated with a fall. It is unclear whether hormone therapy (HT) can improve postural balance when initiated in elderly women and the effect of endogenous estradiol (E2) levels.

DESIGN

Forty healthy women (33 assessable), age 60 years or older, were recruited through advertising in the local media. They were randomly and blindly assigned to receive either estradiol patches (50 microg/24 h) combined with oral medroxyprogesterone acetate (2.5 mg/d) or placebo for 6 months. Postural balance was assessed as sway velocity using a force platform.

RESULTS

Low serum E2 levels were associated with greater impairment of sway velocity during the study in the placebo group. After 6 months sway velocity had improved (decreased) in the HT group by 4.3% from baseline and increased in the placebo group by 6.2%. The difference was not significant (1.30 cm/s, 95% CI: -3.0 to 0.4; P = 0.13). However, among women with low serum E2 levels at baseline (less than the median, 35 pmol/L), sway velocity improved in the HT group and deteriorated in the placebo group with a difference of 23% (2.9 cm/s, 95% CI: 0.6-5.1; P = 0.013). There were similar results after adjustment for baseline sway velocity (P = 0.003) and in the intention-to-treat analysis (P = 0.023). There was also a significant interaction between the study group and baseline serum E2 levels with regard to changes in sway velocity (P = 0.014).

CONCLUSIONS

In elderly women low endogenous serum E2 levels were associated with greater impairment of postural balance function during the study, whereas HT, as compared with placebo, improved postural balance in women with low serum E2 levels.

Postmenopausal hormones and coronary artery disease: potential benefits and risks

Various secondary prevention trials, including the Women's Health Initiative (WHI0, assessing the effects of hormone therapy (HT) on coronary artery disease (CAD) showed no benefit, and a trend towards early harm. However, in the WHI trial, there was a significant trend for decreasing CAD with time. The observational arms of WHI for both estrogen and estrogen/progestin suggested results which were similar to the cardioprotective effects reported in earlier observational studies. Women in these observational trials initiated hormones at a younger age and were generally healthier than women in the randomized trials. Hypotheses have been generated to explain the phenomenon of early harm, based on the induction of plaque instability in the older woman with existent significant atherosclerosis. A report of over 7000 early postmenopausal women initiating prospective trials on hormonal use did not find any evidence suggesting early harm. In the estrogen-only arm of the WHI trial, an analysis of the 50-59-year-old age group showed a near statistical decrease in coronary events: 63 (0.36-1.08), and a statistically significant reduction in a global coronary score, 0.66 (0.45-0.96). In a pooled analysis of 23 randomized clinical trials of hormonal therapy, those women within 10 years of menopause had a significant reduction in coronary events, 0.68 (0.48-0.96). Recent publications from WHI have shown a significant trend for reduced CAD and total mortality in younger women, as well as a reduced coronary calcium score when estrogen alone was given. In that neither aspirin nor statins have been shown to afford a statistical primary benefit for reducing CAD, the benefit of estrogen remains an attractive yet unproven possibility for younger women. In conclusion, while it is clear that HT has no place in the treatment of older women with CAD, emerging evidence strongly suggests a possible coronary benefit in younger healthy women.

Postmenopausal hormone therapy in clinical perspective

Although many of the risks and benefits of postmenopausal hormone therapy are known, only recently has the magnitude of these effects and their perspective to other therapies become more fully understood. Careful review of randomized controlled trials indicates that the risks of postmenopausal hormone therapy including breast cancer, stroke and venous thromboembolism are similar to other commonly used agents. Overall, these risks are rare (less than 1 event per 1,000 women) and even rarer when initiated in women less than 60 years of age or within 10 years of menopause. In addition, the literature indicates similar benefit of postmenopausal hormone therapy, in women who initiate hormone therapy in close proximity to menopause, to other medications used for the primary prevention of coronory heart disease in women.

Time since menopause influences the acute and chronic effect of estrogens on endothelial function

OBJECTIVE

We evaluated whether time since menopause influences the acute and chronic effect of Estradiol (E) on vascular endothelial function.

METHODS AND RESULTS

We studied flow-mediated dilatation (FMD) in 134 postmenopausal women (PMW) before and after acute and chronic E administration. At baseline FMD was inversely associated to time from menopause (r=-0.67, P<0.001) and age (r=-0.43, P<0.05), in exogenous estrogen naïve but not in previous users. Acute and chronic E improved endothelial function in all women. E administration improved FMD more in women within 5 years since menopause than in those with more than 5 years since menopause (76% and 74% versus 45% and 48%, acute and chronic E, respectively; P<0.05). Among women with more than 5 years since menopause acute and chronic E increased FMD more in previous E users than in nonusers (59% and 63% versus 31% and 38%, acute and chronic E, respectively; P<0.01). Multivariate analysis showed that time from menopause was a predictor of impaired FMD and of its improvement after acute and chronic E.

CONCLUSIONS

Time from menopause influences FMD in PMW. The acute and chronic effect of E on FMD is time dependent and is reduced by a longer time since menopause.

Main morbidities recorded in the women's international study of long duration oestrogen after menopause (WISDOM): a randomised controlled trial of hormone replacement therapy in postmenopausal women

OBJECTIVE

To assess the long term risks and benefits of hormone replacement therapy (combined hormone therapy versus placebo, and oestrogen alone versus combined hormone therapy).

DESIGN

Multicentre, randomised, placebo controlled, double blind trial.

SETTING

General practices in UK (384), Australia (91), and New Zealand (24).

PARTICIPANTS

Postmenopausal women aged 50-69 years at randomisation. At early closure of the trial, 56,583 had been screened, 8980 entered run-in, and 5692 (26% of target of 22,300) started treatment.

INTERVENTIONS

Oestrogen only therapy (conjugated equine oestrogens 0.625 mg orally daily) or combined hormone therapy (conjugated equine oestrogens plus medroxyprogesterone acetate 2.5/5.0 mg orally daily). Ten years of treatment planned.

PRIMARY OUTCOMES

major cardiovascular disease, osteoporotic fractures, and breast cancer.

SECONDARY OUTCOMES

other cancers, death from all causes, venous thromboembolism, cerebrovascular disease, dementia, and quality of life.

RESULTS

The trial was prematurely closed during recruitment, after a median follow-up of 11.9 months (interquartile range 7.1-19.6, total 6498 women years) in those enrolled, after the publication of early results from the women's health initiative study. The mean age of randomised women was 62.8 (SD 4.8) years. When combined hormone therapy (n=2196) was compared with placebo (n=2189), there was a significant increase in the number of major cardiovascular events (7 v 0, P=0.016) and venous thromboembolisms (22 v 3, hazard ratio 7.36 (95% CI 2.20 to 24.60)). There were no statistically significant differences in numbers of breast or other cancers (22 v 25, hazard ratio 0.88 (0.49 to 1.56)), cerebrovascular events (14 v 19, 0.73 (0.37 to 1.46)), fractures (40 v 58, 0.69 (0.46 to 1.03)), and overall deaths (8 v 5, 1.60 (0.52 to 4.89)). Comparison of combined hormone therapy (n=815) versus oestrogen therapy (n=826) outcomes revealed no significant differences.

CONCLUSIONS

Hormone replacement therapy increases cardiovascular and thromboembolic risk when started many years after the menopause. The results are consistent with the findings of the women's health initiative study and secondary prevention studies. Research is needed to assess the long term risks and benefits of starting hormone replacement therapy near the menopause, when the effect may be different.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN 63718836.

Estrogen effects on arteries vary with stage of reproductive life and extent of subclinical atherosclerosis progression

The past several years have been marked by confusion and controversy concerning whether estrogens are cardioprotective. The issue is of utmost public health importance because coronary heart disease (CHD) remains the leading cause of death among postmenopausal women. Fortunately, a unifying hypothesis has emerged that reproductive stage is a major determinant of the effect of estrogens on atherosclerosis progression, complications, and plaque vulnerability. PREMENOPAUSAL YEARS: Premenopausal atherosclerosis progression seems to be an important determinant of postmenopausal atherosclerosis and thus the risk for CHD. Clearly, plasma lipids/lipoproteins influence this progression; however, estradiol deficiency seems to be the major modulator. Both monkeys and women with premenopausal estrogen deficiency develop premature atherosclerosis, an effect that can be prevented in both species by estrogen-containing oral contraceptives. PERIMENOPAUSAL/EARLY POSTMENOPAUSAL YEARS: During this stage, there are robust estrogen benefits. Monkeys given estrogens immediately after surgical menopause have a 70% inhibition in coronary atherosclerosis progression. Estrogen treatment prevented progression of atherosclerosis of women in the Estrogen in the Prevention of Atherosclerosis Trial. A meta-analysis of women younger than 60 years given hormone therapy had reduced total mortality (relative risk = 0.61, 95% CI: 0.39-0.95). LATE POSTMENOPAUSAL YEARS: This stage is one in which there are no or possible deleterious estrogen effects. Monkeys lose CHD benefits of estrogens when treatment is delayed. The increase in CHD events associated with initiating hormone therapy 10 or more years after menopause seems to be related to up-regulation of the plaque inflammatory processes and plaque instability and may be down-regulated by statin pretreatment.

Hormone replacement therapy and risk for coronary heart disease

BACKGROUND

Hormone replacement therapy (HRT) has been suggested to prevent cardiovascular disease, while some intervention studies have shed doubt on this concept. Thus, uncertainty remains whether current HRT use is beneficial as to cardiovascular disease or may even be harmful.

OBJECTIVES

This research investigates the association of hormone replacement therapy, risk factors and lifestyle characteristics with the manifestation of coronary heart disease in current HRT users versus never users.

DESIGN

The coronary risk factors for atherosclerosis in women study (CORA-study) provide clinical and biochemical parameters and data on lifestyle in 200 consecutive pre- and postmenopausal women with incident coronary heart disease compared to 255 age-matched population-based controls, of which 87.9% were postmenopausal.

RESULTS

Significantly more controls than cases used currently HRT for a median of 9.5 years (32.9% versus 20.2%), while 50.0% of cases and 42.5% of controls had never used HRT (p<0.02). Compared to women who never used HRT, current users ate less meat and sausage, had a significantly lower BMI and waist-to-hip ratio and a lower prevalence of hypertension, insulin resistance and diabetes. However, current users among cases were often smokers and smoked significantly more cigarettes than never users. In a multivariate analysis the risk of current HRT users for coronary artery disease was 57% lower than the risk of never users (odds ratio 0.428, CI 0.206-0.860, p<0.02). Adjustment for conventional and dietary risk factors revealed neither current HRT use, nor HRT use combined with smoking as independent risk factors.

CONCLUSIONS

These data from the CORA-study are not compatible with an adverse impact of hormone replacement therapy on cardiovascular disease, rather support the notion of beneficial effects of HRT on weight, central adiposity, insulin sensitivity and blood pressure. Yet, the data do not support the presumption of a general healthy user effect in women on HRT either. Rather, in some women adverse lifestyle habits, especially intense smoking, appear to counteract possible beneficial effects of HRT.

HRT: a reappraisal of the risks and benefits

In 2002, when results of the Women's Health Initiative (WHI) randomised controlled trial of hormone replacement therapy (HRT) showed an increased occurrence of breast cancer and thromboembolism, up to two-thirds of women taking HRT stopped the therapy, often without medical consultation. Recent analyses of the WHI data and other randomised controlled trials suggest that, although there are potential side effects and risks involved in taking HRT, these may be reduced by: using lower HRT doses; minimising or eliminating systemic progestogens; using non-oral routes in some women; and initiating HRT in symptomatic women near menopause. When HRT is initiated near menopause for symptom control, there may be additional benefits (reduced fracture and cardiovascular risk) that outweigh the risks (which are not significantly raised in women under age 60 years). Older women with continuing symptoms should not be denied HRT if their therapy and risks are assessed on an individual basis and each patient is aware of the risks.

Hormonal therapy: does it increase or decrease cardiovascular risk?

The use of hormonal therapy (HT) has become one of the most controversial topics in the area of women's health. A particular area of confusion has been the issue of cardiovascular benefit versus cardiovascular risk for women using HT. Although years of observational data have suggested that women receiving HT have a lower incidence of coronary artery disease (CAD) and longer survival, several prospective, randomized controlled trials have brought this tenet into debate. This article provides a historical perspective on the role of HT and CAD. The Heart and Estrogen/Progestin Replacement Study (HERS) and the Women's Health Initiative (WHI) data are analyzed in conjunction with newer data. Finally, an explanation will be provided as to how early initiation of HT could afford cardiovascular protection and not contradict the HERS and WHI.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to state that controversy still remains in the use of hormonal therapy (HT) for menopause, explain that there are conflicting data from both prospective and observational studies, and recall that a new look at prospective data may indicate that HT has beneficial cardiovascular effects.

Carotid artery intima-media thickness after raloxifene treatment

BACKGROUND

Raloxifene, a selective estrogen receptor modulator (SERM), decreases total and low-density lipoprotein cholesterol (LDL-C) in postmenopausal women and inhibits increases in intima-media thickness (IMT) in animal models. We tested whether up to 8 years exposure to raloxifene had an effect on subclinical atherosclerosis in the 4-year Multiple Outcomes of Raloxifene Evaluation (MORE) trial and the follow-up study, the 4-year Continuing Outcomes Relevant to Evista (CORE) trial.

METHODS

A subsample of postmenopausal women with osteoporosis, who had completed the MORE and CORE trials and were on average 68 years of age and 19 years postmenopausal at randomization into MORE, participated in this substudy. Within 6 months of cessation of study drug in CORE, right common carotid artery IMT (CIMT) and carotid artery stiffness and arterial compliance were measured at one of two sites (San Diego and San Francisco) using high-resolution B-mode ultrasound. CIMT and arterial stiffness measures were compared between women who had received raloxifene vs. placebo; the primary analysis included only women who were >or=80% drug compliant and had used <or=6 months of lipid-lowering medication during CORE.

RESULTS

For the primary analysis dataset (n = 89), there was no significant difference in mean CIMT between the raloxifene and placebo groups (0.83 and 0.81 mm, respectively, p = 0.62). Carotid artery stiffness and compliance were not significantly different between treatment groups (p = 0.33 and 0.59, respectively).

CONCLUSIONS

These preliminary data suggest that in this self-selected group of elderly post-menopausal women with osteoporosis who were evaluated within 6 months of cessation of study medication, there were no differences between long-term raloxifene treatment and placebo groups in several measures of subclinical atherosclerosis.

Provider management of menopause after the findings of the Women's Health Initiative

OBJECTIVE

A survey was conducted to determine current provider behaviors and concerns related to menopause management.

DESIGN

All gynecology, internal medicine, and family medicine providers (both physicians and nurse practitioners) within a large Midwestern integrated health system were surveyed about current approaches to menopause management, frequency and reasons for hormone therapy (HT) use, approaches to HT discontinuation, treatments for symptom control, bone mineral density testing, and concerns related to menopause management. Descriptive statistics and chi-square tests were performed to examine frequencies and differences based on gender, specialty, and years in practice.

RESULTS

Overall the response rate was 58% with providers from owned clinics, with female providers being the most likely to respond (P < 0.001). Changes in menopause management included using lower dose hormones (74%), encouraging use for shorter time periods (73%), and using different modes of delivery (21%). Most providers (89%) initiate HT use in symptomatic patients, and only 12% initiate use to prevent symptoms. Patients were most likely to discuss HT with gynecologists (78% gynecologists vs 64% family medicine providers and 48% internal medicine providers, P = 0.015). Nearly two thirds of providers (64%) claimed to order bone mineral density testing frequently. Providers' concerns related to information on symptom management, alternative and over-the-counter medications, the risk/benefits of medications, patients' sexual concerns, and maintaining bone health.

CONCLUSIONS

We found that providers were responsive to current literature, shifting the agents and dosages they prescribe. Still they are faced with women reporting symptoms that interfere with their ability to function optimally and must continue to help women maintain healthy bones.

Unopposed estradiol therapy in postmenopausal women: results from two randomized trials

OBJECTIVE

To estimate the rates of endometrial hyperplasia, bleeding episodes, and interventions among menopausal women receiving unopposed oral estradiol or placebo therapy with ultrasound monitoring over 3 years.

METHODS

Two-hundred eighteen healthy women with intact uteri enrolled in the Estrogen in the Prevention of Atherosclerosis Trial (EPAT) or the Women's Estrogen-Progestin Lipid-Lowering Hormone Atherosclerosis Regression Trial (WELL-HART) were randomly assigned to either 1 mg of micronized 17beta-estradiol (n=96) or placebo (n=122) daily for up to 3 years in a double-blind fashion. Patients were followed with annual measurement of endometrial thickness using transvaginal ultrasonography. Logistic regression was used to identify predictors of uterine bleeding and endometrial biopsy.

RESULTS

Over the study periods, nine women (9.4% of patients, 95% confidence interval [CI] 3.6-15.2%) in the estradiol group developed hyperplasia. Eight of the nine cases (88.9%) of hyperplasia were simple without atypia. Women receiving estradiol were more likely than those receiving placebo to have at least one episode of uterine bleeding (67% versus 11% at 3 years, respectively, P<.001). Women in the estradiol group were also more likely to have an endometrial biopsy (48% versus 4% at 3 years, P<.001). Among women on estradiol, obesity (body mass index [BMI] greater than 30 kg/m(2)) significantly increased the odds of uterine bleeding compared with normal-weight patients (BMI 25 or less) (OR 3.7, 95% CI 1.2-11.8).

CONCLUSION

Short-term, unopposed estradiol therapy with gynecologic monitoring may be an option for the treatment of menopausal symptoms. Menopausal women choosing estradiol therapy, especially if obese, should anticipate uterine bleeding and the possibility of an endometrial biopsy.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, www.clinicaltrials.gov, NCT 00000559 and NCT 00115024.

LEVEL OF EVIDENCE

I.

The future of postmenopausal hormone therapy: It's time to move forward

There are good reasons why the use of postmenopausal hormone therapy is at a contemporary low level. But an analysis of these factors provides explanations that offer a basis for appropriate and renewed use. A more optimistic position is supported by an up-to-date appraisal of clinical studies.

Hormonal therapy is associated with a lower prevalence of breast arterial calcification on mammography

OBJECTIVE

To bring further understanding to the relationship between hormonal therapy (HT) and breast arterial calcification (BAC).

METHODS

Of women arriving for breast cancer screening mammography, 1995 consented to complete a survey and have their mammograms analyzed for the presence of BAC. The survey assessed HT use and major risk factors for CAD.

RESULTS

Of the 1919 women with complete data, there were 268 with BAC (14%). When categorized into three age groups, BAC was present in 40.7% of the women > or =65, 10.9% of those 55-64 and 3.0% of those <55. The > or =65 year-old group showed a nearly 50%-point lower prevalence of BAC among HT users compared with women who were not on HT (25.8% versus 74.2%, respectively, p=0.006). With age included as a continuous variable, past use of HT was significantly associated with a lower prevalence of BAC (p<0.03), while the presence of diabetes or a history of stroke were significantly associated with a higher prevalence of BAC (p<0.002).

CONCLUSIONS

Well-established cardiovascular risk factors (diabetes, stroke, and age) appear to be associated with a significantly higher incidence of BAC, while HT during the menopausal years appears to be associated with a significantly lower prevalence of BAC.

How to evaluate the risk-benefit ratio of the low-dose hormone replacement therapy?

Since the results of the women health initiative study showing an overall negative risk-benefit ratio with 0.625 mg of conjugated estrogens plus 2.5mg of medroxyprogesterone acetate, the use of the lowest effective dose of steroids in hormone replacement therapy (HRT) is recommended. A low-dose regimen appears to induce less side effects such as breast tenderness or leg pain than do higher dose preparations. The decrease in hot flashes with low-dose estrogens, range 60-70%, is less than the 80-90% reduction with standard dosing. But this mean that 60-70% of menopausal women do not need higher doses. The same applies to bone preservation which is dose dependent: the number of non-respondant women will be higher than with standard doses. However, randomized double-blind, placebo controls trials have defined positive effects on bone of low doses of HRT with adequate calcium and Vitamin D in elderly women. The use of bone densitometry and of biochemical markers of bone turnover is mandatory in women using low or ultra-low-dose preparations. In spite of the lack of trials conducted with low-dose HRT, this treatment seems to be safer: Beside the low-dose HRT, one must consider some other facts: In the future, it is conceivable that more comprehensive pharmacogenomic studies will lead to effective algorithms for individualizing the right dose of steroids to be used in HRT.

Tratamiento hormonal sustitutivo y enfermedades cardiovasculares

Despite biologically plausible mechanisms for cardiac protection and compelling evidence from observational studies suggesting that menopausal hormone therapy confers cardiovascular benefit, results of well-designed and conducted randomized clinical trials in healthy women and in women with established coronary heart disease displayed that menopausal hormone therapy failed to prevent clinical cardiovascular events and rather was associated with harms. Clinical trial of the SERM raloxifene also did not demonstrate a decrease in coronary events. It is unknown whether the earlier initiation of such therapies, i.e., at menopause, would result in favorable outcomes; or whether different hormonal preparations, lower doses, or alternate routes of administration would confer benefit. At present, proved coronary risk reduction strategies are requisite (albeit underutilized) for menopausal women; these include lifestyle and pharmacologic coronary preventive interventions. The baseline characteristics of menopausal women with coronary heart disease who were participants in cardiovascular outcome trials of menopausal hormone therapy or raloxifene were remarkably similar; globally, cardiovascular risk factors were not optimally controlled at entry into these trials, suggesting that more aggressive cardiovascular risk interventions are appropriate to achieve optimal target goals for menopausal women with documented coronary heart disease.

A new ‘publication bias’: the mode of publication

The editor of a medical journal may influence the opinion of his readers by a 'publication bias'. This can be through the choice of an editorial at the front of the journal, tutoring the article, the choice of an author from the Editorial Board and the organization of a press conference accompanying the publication. The publicity from which certain studies benefited in recent years has had a negative effect on doctors' prescriptions and comprehension of the published studies.