Issues of Hormone Replacement Therapy and Cardiovascular Disease
Issues of Hormone Replacement Therapy and Cardiovascular Disease
Based on epidemiologic studies demonstrating mainly positive biologic effects of estrogen on cardiovascular risk factors and outcomes, earlier recommendations decreed that most, if not all women should be treated with long-term postmenopausal hormone replacement. A review of recent controlled clinical trials demonstrates that previously held dictums might not prove accurate. For elderly women, the decision to begin hormone replacement therapy should not be based on an assumption of protection from cardiovascular diseases. A careful assessment of the risks and benefits, as well as acknowledgement of the outcomes for which hormone replacement therapy has unknown impact, is needed for any decision to begin, continue, or stop hormone replacement therapy.
Elderly women and their clinicians are faced with many questions regarding the use of postmenopausal hormone therapy, including: 1) Should older women, well past the period of menopausal symptoms, begin hormone replacement if they have or are at risk for cardiovascular disease (CVD)? and 2) Should older women who have been taking hormone replacement since the perimenopausal years continue hormone replacement therapy (HRT)? The answers are not yet clear, particularly when the potential reasons for use are to reduce the risks of CVD. To develop a response to these questions, existing data as well as biases must be examined. The definition of "elderly" is arbitrary, but for the purposes of this report a woman will be considered elderly if she is older than 65 years of age.
In earlier cycles in the history of HRT, it was popularly recommended that all women should take hormones. There was little understanding of the possibility of side effects and adverse outcomes. In fact, it was recommended that HRT be started before menopause and continued throughout life. HRT was promoted not only as an effective treatment to relieve menopausal symptoms but also as a potent preventive measure for weakening of the bones and muscles, heart trouble, hardening of the arteries, atrophy of the breasts, and wrinkling of the skin. Proponents were certain that many of the attributes of aging and chronic disease would be attenuated in women who took HRT throughout their postmenopausal years. Since CVD was considered to be a disease of middle-aged men, HRT would merely maintain the "female advantage" over CVD and large numbers of elderly women might never be expected to experience CVD. The reality, of course, is that elderly women are at increasing risk for CVD. More women than men actually die of CVD. Women experience an increase in risk approximately 10 years after CVD risk increases for men, and do not approach the same level of risk as men until over age 80, if ever. Yet, more women are alive at the highest risk years, resulting in a large number of surviving elderly women whose greatest ongoing risk for morbidity and mortality is CVD. Means to prevent or modify the health impact of CVD in elderly women are of great interest and deserve careful attention. HRT is one potential intervention strategy that will be examined in this report.
Based on epidemiologic studies demonstrating mainly positive biologic effects of estrogen on cardiovascular risk factors and outcomes, earlier recommendations decreed that most, if not all women should be treated with long-term postmenopausal hormone replacement. A review of recent controlled clinical trials demonstrates that previously held dictums might not prove accurate. For elderly women, the decision to begin hormone replacement therapy should not be based on an assumption of protection from cardiovascular diseases. A careful assessment of the risks and benefits, as well as acknowledgement of the outcomes for which hormone replacement therapy has unknown impact, is needed for any decision to begin, continue, or stop hormone replacement therapy.
Elderly women and their clinicians are faced with many questions regarding the use of postmenopausal hormone therapy, including: 1) Should older women, well past the period of menopausal symptoms, begin hormone replacement if they have or are at risk for cardiovascular disease (CVD)? and 2) Should older women who have been taking hormone replacement since the perimenopausal years continue hormone replacement therapy (HRT)? The answers are not yet clear, particularly when the potential reasons for use are to reduce the risks of CVD. To develop a response to these questions, existing data as well as biases must be examined. The definition of "elderly" is arbitrary, but for the purposes of this report a woman will be considered elderly if she is older than 65 years of age.
In earlier cycles in the history of HRT, it was popularly recommended that all women should take hormones. There was little understanding of the possibility of side effects and adverse outcomes. In fact, it was recommended that HRT be started before menopause and continued throughout life. HRT was promoted not only as an effective treatment to relieve menopausal symptoms but also as a potent preventive measure for weakening of the bones and muscles, heart trouble, hardening of the arteries, atrophy of the breasts, and wrinkling of the skin. Proponents were certain that many of the attributes of aging and chronic disease would be attenuated in women who took HRT throughout their postmenopausal years. Since CVD was considered to be a disease of middle-aged men, HRT would merely maintain the "female advantage" over CVD and large numbers of elderly women might never be expected to experience CVD. The reality, of course, is that elderly women are at increasing risk for CVD. More women than men actually die of CVD. Women experience an increase in risk approximately 10 years after CVD risk increases for men, and do not approach the same level of risk as men until over age 80, if ever. Yet, more women are alive at the highest risk years, resulting in a large number of surviving elderly women whose greatest ongoing risk for morbidity and mortality is CVD. Means to prevent or modify the health impact of CVD in elderly women are of great interest and deserve careful attention. HRT is one potential intervention strategy that will be examined in this report.
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