Cardiovascular Disease – Conclusion

The WHI <<Women's Health Initiative Study>> concluded (and many individuals and organizations did as well) that hormone therapy is not a viable intervention for primary prevention of CHD (coronary heart disease).  We cannot quarrel with the conclusion that postmenopausal hormone therapy does not reduce or slow the progression of established coronary heart disease.  However, the WHI did not study the appropriate population in the appropriate time period to establish that hormone therapy does not exert a primary preventive effect on the risk of coronary heart disease.  <<Here Dr. Speroff is saying that it is becoming increasingly clear that hormones are not good treatment for women who have "established" heart disease.  In other words, once a woman develops atherosclerosis in her heart blood vessels, hormones will not "reduce or slow" this disease.  But he suggests that WHI didn't find the expected "good" effect of hormones because they studied older women (average age was 63), rather than younger women just entering menopause (around age ~50).  These younger women would probably have benefited from hormone therapy.>> 

The results of secondary prevention trials provide a reasonably solid basis not to recommend postmenopausal hormone therapy for women with existing atherosclerosis in the anticipation of preventing future cardiovascular events.  <<Again he advises against starting hormone therapy in women who have "existing atherosclerosis" (i.e. hardening of the arteries).>>  The results also indicate that there is no need to avoid the use of medroxyprogesterone acetate (Provera), because there has been no difference observed comparing women treated only with estrogen to those treated with estrogen and progestin.  <<He is saying that the research suggests that taking Provera doesn't increase your risk of getting heart disease.>>

The cardiovascular results over the last few years support an emerging theme.  The theme is: Healthy endothelium <<blood vessel lining>> is needed to respond to estrogen.  Experimental evidence in the monkey indicates that the beneficial effects of hormonal treatment are progressively diminished with increasing atherosclerosis.  In postmenopausal women, the vasodilatory effects of estrogen dissipate with increasing age.  By the time the endothelium is involves with atherosclerosis, it is too late for estrogen to exert a beneficial effect.  The clinical trial reports make an argument that the optimal approach to postmenopausal hormone therapy is to start treatment close to the menopause, avoiding a significant period of exposure to low estrogen levels prior to beginning therapy.  <<He repeats the overriding theme that younger women, just going into menopause, with health blood vessels (no atherosclerosis), will benefit from starting hormone therapy.  Older menopausal women who have already developed atherosclerosis (because their estrogen levels were deficient for so many years) will probably not benefit from beginning hormone therapy.>>  And there continues to be good reason (a combination of biologic data and uniform agreement in a large number of observational studies) to believe that hormone therapy can have a beneficial role in the primary prevention of coronary heart disease.  <<And finally Dr. Speroff says that the majority of medical research supports the idea that hormone therapy prevents heart disease when started in an early menopausal woman.>>