Hormone replacement therapy and your heart

Long-term hormone replacement therapy used to be routinely prescribed for postmenopausal women to relieve hot flashes and other menopause symptoms. Hormone replacement therapy was also thought to reduce the risk of heart disease.

Before menopause, women have a lower risk of heart disease than men do. But as women age, and their estrogen levels decline after menopause, their risk of heart disease increases. In the 1980s and 1990s, experts advised older women to take estrogen and other hormones to keep their hearts healthy.

However, hormone replacement therapy — or hormone therapy, as it's now called — has had mixed results. Many of the hoped-for benefits failed to materialize for large numbers of women. The largest randomized, controlled trial to date actually found an insignificant increase in heart disease in postmenopausal women using hormone therapy.

Still, some data suggest that estrogen may decrease the risk of heart disease when taken early in postmenopausal years:

• In a recent Danish study, after 10 years of treatment, women receiving hormone replacement therapy early after menopause had a significantly reduced risk of mortality, heart failure or heart attack, without any apparent increase in risk of cancer or stroke.
• A randomized, controlled clinical trial — the Kronos Early Estrogen Prevention Study (KEEPS) — exploring estrogen use and heart disease in younger postmenopausal women was recently completed, with results expected soon.

Risks in perspective

If you're having a tough time with symptoms of menopause but worry about how hormone therapy will affect your heart, talk with your health care provider to put your personal risk into perspective. Consider these points:

• The risk of heart disease to an individual woman taking hormone therapy is very low. If you are in early menopause, have moderate to severe hot flashes and other menopausal symptoms, and are otherwise healthy, the benefits of hormone therapy likely outweigh any potential risks of heart disease.
• Your individual risk of developing heart disease depends on many factors, including family medical history, personal medical history and lifestyle practices. Talk to your doctor about your personal risks. If you're at low risk of heart disease, and your menopausal symptoms are significant, hormone therapy is a reasonable consideration.
• Risk differs for women with premature menopause or premature ovarian failure. If you stopped having periods before age 40 (premature menopause) or lost normal function of your ovaries before age 40 (premature ovarian failure), you have a different set of heart and blood vessel (cardiovascular) health risks compared with women who reach menopause near the average age of about 50. This includes a higher risk of coronary heart disease.

Hormone therapy risks may vary depending on whether estrogen is given alone or with a progestin, and depending on your current age and age at menopause, the dose and type of estrogen, and other health risks such as your family medical history and cancer risks.

Who should not take hormone therapy

If you've already had a heart attack, hormone therapy is not for you. If you already have heart disease or you have a history of blood clots, the risks of hormone therapy have been clearly shown to outweigh any potential benefits.

How to limit the risks

Talk with your doctor about these strategies to reduce the risks of hormone therapy:

• Try a form of hormone therapy that has limited systemic effects. Estrogen and progestin are available in many forms, including pills, skin patches, gels, vaginal creams, and slow-releasing suppositories or rings that you place in your vagina. Low-dose vaginal preparations of estrogen — which come in cream, tablet or ring form — can effectively treat vaginal symptoms while minimizing absorption into the body. Similarly, hormones delivered through skin patches aren't as extensively metabolized in the body and have less potential for unwanted side effects.
• Minimize the amount of medication you take. Use the lowest effective dose for the shortest amount of time needed to treat symptoms, unless you're younger than age 45 — in that case, you need enough estrogen for protection against long-term health effects of estrogen deficiency. If you have lasting menopausal symptoms that significantly impair your quality of life, your doctor may recommend longer term treatment.
• Make healthy lifestyle choices. Counter the risks of developing heart disease by making heart-healthy lifestyle choices. Don't smoke or use tobacco products. Get regular physical activity. Eat a healthy diet focusing on fruits, vegetables, whole grains and low-fat protein. Maintain a healthy weight. And get regular health screenings to check your blood pressure and cholesterol levels to detect early signs of heart disease.
• Seek regular follow-up care. See your health care provider regularly to ensure that the benefits of hormone therapy continue to outweigh the risks, and for cancer screenings such as mammograms and pelvic exams.

A balancing act

Women of all ages should take heart disease seriously. Among U.S. women, 1 in 3 deaths each year is due to heart and blood vessel disease.

Most healthy women who are within five years of menopause can safely take short-term hormone therapy for menopausal symptoms without significantly increasing the risk of heart disease. If you experience classic menopausal symptoms, including intolerable hot flashes, vaginal dryness or insomnia, talk to your doctor about how you can relieve troublesome symptoms without putting your health at risk.

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