Hormone Therapy in Menopause: True and False Alarms Concerns
Wednesday August 26, 2009
Menopause Hormone Therapy: Concerns Real and False Alarms - Part II: Cardiovascular
Jaime MD Urdinola.
Andes Medical Association - AK 9116 20 CS 326 - Bogotá DC Colombia
Jaime MD Urdinola.
Andes Medical Association - AK 9116 20 CS 326 - Bogotá DC Colombia
Symposium / Luncheon on Women's Health and Menopause - Medical Association of the Andes - Prime Boardroom Floor
Wednesday August 26, 2009
Summary
from 2 002-2 008 reports of the WHI (Women's Health Initiative = Initiative Women's Health) said the Menopausal Hormone Therapy (HT) significantly increased risk for developing breast cancer, cardiac events, Alzheimer's disease and stroke. These statements have alarmed the public and to health professionals, immediately causing a sharp decrease in the number of women who are taking prescribed or TH.
However, current data published in the articles on the WHI show that the findings reported in the press releases and interviews with principal investigators, were often distorted, oversimplified or wrong.
This second part of the review examines the findings on cardiovascular disease, most of which are weak or not statistically significant. On these complicated matters, therefore, physicians and the public should be very cautious in accepting the "findings of press releases" to determine on their part, doctors if they prescribe o las pacientes si toman la TH formulada. (Cancer J. 2009; 15:93-104) 1
However, current data published in the articles on the WHI show that the findings reported in the press releases and interviews with principal investigators, were often distorted, oversimplified or wrong.
This second part of the review examines the findings on cardiovascular disease, most of which are weak or not statistically significant. On these complicated matters, therefore, physicians and the public should be very cautious in accepting the "findings of press releases" to determine on their part, doctors if they prescribe o las pacientes si toman la TH formulada. (Cancer J. 2009; 15:93-104) 1
Introducción
La Enfermedad Cardiovascular (ECV) y especialmente la Enfermedad Coronaria (EC) son las principales causas de muerte en la mujer, no sólo en los países desarrollados sino también en Colombia.
Según datos del DANE ( Departamento Administrativo Nacional de Estadística) 2 ,
en el año 2 005 la tasa de mortalidad en mujeres mayores de 50 años por enfermedades cerebrovasculares was of 50.7 per 1 000 women and 67.1 per 1 000 women the rate of ischemic heart disease.
Of the 75 891 deaths that occurred that year in women, 25 441 = 33.5% were caused by CVD.
If we compare with deaths from breast cancer, a woman in Colombia is almost 14 times more likely to die from CVD than from breast cancer. In the U.S. the same proportion is 5 to 1.
It is therefore crucial to understand the role of TH in the possible development and progression of cardiovascular disease as well as it could provide protection against this entity HT. Recommendations
U.S. scientific societies on TH
Of the 75 891 deaths that occurred that year in women, 25 441 = 33.5% were caused by CVD.
If we compare with deaths from breast cancer, a woman in Colombia is almost 14 times more likely to die from CVD than from breast cancer. In the U.S. the same proportion is 5 to 1.
It is therefore crucial to understand the role of TH in the possible development and progression of cardiovascular disease as well as it could provide protection against this entity HT. Recommendations
U.S. scientific societies on TH
● 1992 - American College of Obstetricians and Gynecologists - Probable beneficial effects of estrogen on heart disease, "
● 1992 - American College of Physicians - " Women with Coronary Heart Disease or who have increased risk for it, could benefit from hormonal therapy "
● 1996 - American Heart Association - " Estrogen therapy seems promising as long-term protection against a heart attack "
These recommendations were based in various publications of the eighties, on the cardiovascular benefit obtained from taking HRT, reporting that the reduction of CHD with estrogen therapy (ET) could be 30%, consistent finding in 90% of the cohort, 63% of Case-control studies and one randomized, double-masked study to date 3.
In 1991 an editorial in the New England Journal of Medicine reported that the consensus of epidemiological studies on the reduction was 40-50%, compared to women not receiving HRT. In Study 2 000 Nurses reported that HT decreased the early development of primary CVD by about 40%.
It should be noted however that despite the plausible evidence obtained from observational studies that point on the cardiovascular benefit, this indication was never approved by any regulatory authorities of the globe.
And despite these data, the large randomized HERS 4 found a statistically significant increase in cardiac events in women with known CAD who had received HRT, but only during the first year of uso4 ("effect of thrombophilia?).
2 002 In the WHI study 9 reported that women taking combined HRT, but not women with ET, showed a slight increase in the relative risk of "cardiac events" (EC which included acute myocardial infarction requiring hospitalization or silent myocardial infarction), CVD death, angina or indications for bypass surgery. But as in the case of the HERS study, this increased risk occurred only among women during the first year of taking combined HT.
It should be noted however that despite the plausible evidence obtained from observational studies that point on the cardiovascular benefit, this indication was never approved by any regulatory authorities of the globe.
And despite these data, the large randomized HERS 4 found a statistically significant increase in cardiac events in women with known CAD who had received HRT, but only during the first year of uso4 ("effect of thrombophilia?).
2 002 In the WHI study 9 reported that women taking combined HRT, but not women with ET, showed a slight increase in the relative risk of "cardiac events" (EC which included acute myocardial infarction requiring hospitalization or silent myocardial infarction), CVD death, angina or indications for bypass surgery. But as in the case of the HERS study, this increased risk occurred only among women during the first year of taking combined HT.
2 007 In the WHI researchers reviewed the findings of 2 002, concluding that women who started HT during the first 10 years following menopause reduced their risk of CHD, while those who started HRT after this period slightly increase your risk 5.
-Observational Study - the Nurses 6 reached the same conclusions.
These data supported the theory of Opportunity for the Initiation of HT 7 although in July this year 2009 a new analysis of WHI study appears to rebut August, which could be discussed further in another symposium. KEEPS and ELITE studies currently underway, trying to test the theory. Why
TH increases cardiovascular risk only during the first year and only among women ancianas ?
Se sabe de datos obtenidos en primates, que el estrógeno administrado en forma continua mantiene saludables los vasos sanguíneos. También conocemos, que la TE después de un intervalo libre de hormonas no revierte el daño vascular. Los estudios HERS y Estrogen Prevention of Atherosclerosis Trial and Estrogen Replacement son consistentes con los datos obtenidos de animales.
Una de las explicaciones es que entre las mujeres sin ECV, la TH reduce la oxidación del colesterol LDL y produce dilatación en los vasos sanguíneos, inhibiendo de esta manera la aterosclerosis. Sin embargo, en las mujeres con ECV, la TH puede ser potencialmente dañina, causando que la placa stable atherosclerotic breaks induced by inflammation and in turn you have bleeding within the plaque, leading to block both phenomena critically affected coronary artery.
This analysis may explain why studies have enrolled older women younger, the Nurses Study, found that HRT provides a protective effect, because these women probably have less arterial atherosclerotic plaques.
But in the WHI study only 10% of the women were between 50 and 54 years of age, age at which TH can probably have a beneficial role. 70% of the women were between 60 to 79 years of age range in which we expect to find pre-formed plates 9. TH Although the latter age may be effective in reducing total cholesterol, LDL cholesterol and glucose as well as raise HDL cholesterol levels, these benefits do not result in a reduction in the incidence of stroke in elderly women, it which is consistent taking into account pre-existing atherosclerosis in this population.
The WHI is likely that atherosclerosis was present in the population, as well as the average age of 63 years, 70% of women were overweight and half of them were obese. About 50% were or had been smokers and 35% were treated for hypertension. Women with these risk factors were not excluded from the analysis of HT and cardiovascular events, although the WHI investigators had established that all women who were recruited were healthy, a prerequisite for participation in this course study of primary prevention . However, it is difficult to reconcile these statements with the records of this large number of women 10 .
What conclusions can you go?
What conclusions can you go?
- HT may have beneficial effects on the heart of women who start taking HRT early after menopause (around 50 years old), since estrogen promotes healthy blood vessels and may help delay the formation of atherosclerotic plaque
- HT may not have a protective effect in women who start HT use later in the decade of their 60
- HT is potentially risky for women who start during the decade of their 60's, at least during the first year of use, especially if they have EC
existing
Finally, you can share the opinion of the majority of cardiologists, there is no reason to prevent CVD only by TH, as there are other ways to reduce cardiovascular risk.
But something can be clear. It is time to cease calls to cite security concerns about the TH, based on the publication of the WHI study 2 002 9 because their findings have been superseded and its conclusions have been reinterpreted.
References
1 - Bluming AZ, Tavris C. Hormone Replacement Therapy: Real Concerns and False Alarms. J. Cancer 2009, 15: 93-104.
2 - DANE: Table of Deaths by Age and Sex Grouped Causes According List - Preliminary 2005 to 6187 ICD-10.
3 - Barrett-Connor E, Bush TL. Estrogen replacement and coronary heart disease. Cardiovasc Clin. 1989; 19:159-172.
4- Hulley S, Grady D, Bush T, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. JAMA. 1998; 280: 605-613.
5- Rossouw JE, Prentice RL, Manson JE, et al. Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA. 2007; 297: 1465 – 1477.
6- Grodstein F, Manson JE, Stampfer MJ. Hormone therapy and coronary heart disease: the role of time since menoapuse and aged at hormone initiation. J Womens Health. 2006; 15: 35 – 44.
7- Barrett-Connor E. Hormones and Heart Disease in Women: The Timing Hypothesis. Am J Epidemiol. 2007; 166: 506-510.
8- Prentice RL, Manson JE, Langer RD, et al. Benefits and risks of postmenopausal hormone therapy when it is initiated son after menopause. Am J Epidemiol. 2009;170:12–23.
9- Rossouw JE, Anderson GL, Prentice RL, et al. Writing Group for the Women’s Health Initiative investigators. Risks and benefits os estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Helath initiative Randomized Controlled Trial. JAMA. 2002; 288: 321 – 333.
10- Bhavnani BR, Strickler RC. Menopausal hormone therapy. J Obstet Gynaecol Can. 2005; 27: 137 – 162.
If you have any comments, questions or concerns, you can "click" in comments and send your message.
existing
Finally, you can share the opinion of the majority of cardiologists, there is no reason to prevent CVD only by TH, as there are other ways to reduce cardiovascular risk.
But something can be clear. It is time to cease calls to cite security concerns about the TH, based on the publication of the WHI study 2 002 9 because their findings have been superseded and its conclusions have been reinterpreted.
References
1 - Bluming AZ, Tavris C. Hormone Replacement Therapy: Real Concerns and False Alarms. J. Cancer 2009, 15: 93-104.
2 - DANE: Table of Deaths by Age and Sex Grouped Causes According List - Preliminary 2005 to 6187 ICD-10.
3 - Barrett-Connor E, Bush TL. Estrogen replacement and coronary heart disease. Cardiovasc Clin. 1989; 19:159-172.
4- Hulley S, Grady D, Bush T, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. JAMA. 1998; 280: 605-613.
5- Rossouw JE, Prentice RL, Manson JE, et al. Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA. 2007; 297: 1465 – 1477.
6- Grodstein F, Manson JE, Stampfer MJ. Hormone therapy and coronary heart disease: the role of time since menoapuse and aged at hormone initiation. J Womens Health. 2006; 15: 35 – 44.
7- Barrett-Connor E. Hormones and Heart Disease in Women: The Timing Hypothesis. Am J Epidemiol. 2007; 166: 506-510.
8- Prentice RL, Manson JE, Langer RD, et al. Benefits and risks of postmenopausal hormone therapy when it is initiated son after menopause. Am J Epidemiol. 2009;170:12–23.
9- Rossouw JE, Anderson GL, Prentice RL, et al. Writing Group for the Women’s Health Initiative investigators. Risks and benefits os estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Helath initiative Randomized Controlled Trial. JAMA. 2002; 288: 321 – 333.
10- Bhavnani BR, Strickler RC. Menopausal hormone therapy. J Obstet Gynaecol Can. 2005; 27: 137 – 162.
If you have any comments, questions or concerns, you can "click" in comments and send your message.
Or if you prefer, you can send your comments, questions or concerns e-mail jaimeurdinolamd@gmail.com
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