Professor Rodney Baber
University of Sydney / Royal North Shore Hospital
Although more common in men than in women cardiovascular disease (CVD) remains the leading cause of death for women globally. A beneficial effect of estrogen on surrogate markers of cardiovascular health has long been accepted and a large majority of observational studies have supported the proposition that exogenous estrogens may offer cardioprotective benefits to postmenopausal women.
Timing of initiation of hormone therapy and choice of regimen seem to be important.
Several systematic reviews and meta-analyses have reported similar benefits for younger postmenopausal women using MHT however, the results of the largest RCT, The Women’s Health Initiative (WHI) has been less positive, perhaps because of the age of women at recruitment.
Trials testing for a secondary protective effect of MHT on CVD, whilst demonstrating the expected beneficial changes in surrogate markers, have failed to show any reduction in subsequent cardiovascular adverse events.
Current evidence suggests that initiating MHT when women’s hearts are younger and their arteries are more susceptible to estrogen could decrease the risk of heart disease and all-cause mortality in later life. Initiating MHT >10 years after LMP does not appear to have any cardiovascular benefit and may be harmful.
MHT should not be used for primary or secondary prevention of CHD nor in women at very high risk of CVD. Treatment of severe vasomotor symptoms in women with mild to moderate CVD should be individualized considering age, years since menopause, risk factors and preferences. Transdermal body-identical MHT is to be preferred.