Endocrinologist Association Encourages HRT in Younger Women

Sue Hughes

January 07, 2008

January 7, 2008 (Jacksonville, FL) - The American Association of Clinical Endocrinologists (AACE) has released a statement on hormone replacement therapy (HRT) and cardiovascular risk, emphasizing that HRT does not appear harmful in younger women in early menopause and may indeed be beneficial in this group [1]. "With this in mind, and given the powerful effects of estrogen therapy in relieving menopausal symptoms, we believe that physicians may safely counsel women to use estrogen for the relief of menopausal symptoms. Each patient should be evaluated for the severity of her symptoms, her age, and specific risk factors that might impact on her use of hormonal therapy," the statement concludes.

One of the authors of the statement, past AACE president Dr Rhoda Cobin (Mount Sinai School of Medicine, New York), told heartwire that a review of all the available evidence suggests that younger women who are close to menopause have less to fear from HRT than older women in terms of cardiovascular risk. "We think the data offer some reassurance to women close to the menopause, with the suggestion that estrogen supplementation may even protect against heart disease in these younger women. And even if it is not protective, it doesn't appear to be harmful so can probably be used safely to treat menopausal symptoms. There does appear to be a window of opportunity for use of estrogen."

She added: "After all the negative publicity from the HRT trials, physicians are now fearful of prescribing estrogen at all. But we believe there are advantages and disadvantages to such treatment and that cardiovascular risk in particular is not the same for everyone. Each woman should be considered individually, and many factors should be taken into account when thinking about prescribing HRT. These include age, time from menopause, other cardiovascular and thrombotic risks, and menopausal symptoms.

"The evidence is particularly reassuring for estrogen-only therapy, which has not been associated with increases of either cardiovascular disease or breast cancer in younger women. So for women who have had an early hysterectomy and therefore do not have to have progesterone, they should not be deprived of estrogen replacement therapy," Cobin commented.

The AACE statement notes that in animal studies, estrogen is effective in inhibiting progression of early-stage atherosclerosis but it is much less effective in inhibiting progression of more advanced atherosclerosis in older animals. After these observations, data from the major HRT studies were reexamined to determine the effect of treatment on cardiovascular risk when stratified by age or time from menopause.

The reevaluation of the Nurses' Health Study found that women beginning hormone therapy near menopause had a significantly reduced risk of CHD (RR=0.66 for estrogen alone; RR=0.72 for estrogen with progestin). A recent meta-analysis of 23 trials of HRT that compared results in younger women (younger than 60 or less than 10 years since menopause) vs older women showed that HRT significantly reduced CHD events in the former (OR 0.68) but not in the latter (OR 1.03). And in the Women’s Health Initiative (WHI) trial, when stratified by time since menopause, the hazard ratios for CHD were 0.76 in the women fewer than 10 years from the onset of menopause, 1.1 in those 10 to 19 years from onset of menopause, and 1.28 in those women more than 20 years from onset of menopause. By age, the hazard ratios for cardiovascular disease were 0.93 for ages 50 to 59, 0.98 for ages 60 to 69, and 1.26 for ages 70 to 79.

The AACE statement notes that further data on HRT in younger women will come from the Kronos Early Estrogen Prevention Study (KEEPS), which is evaluating five years of HRT vs placebo in 720 women aged 42 to 58 years within 36 months of final menstrual period. The end points will include prevention of progression of carotid intimal medial thickness and accrual of coronary calcium, but results will not be available for several years.

  1. American Association of Clinical Endocrinologists. AACE Analysis shows no excess cardiovascular risk from hormone replacement therapy for most patients [press release]. January 2, 2008. Available at: http://www.aace.com/newsroom/press/2008/index.php?r=20080102-1 .

The complete contents of Heartwire , a professional news service of WebMD, can be found at www.theheart.org, a Web site for cardiovascular healthcare professionals.

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