Menopause International > Volume 14, Number 4 > Pp. 182-183

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Proceedings of the Annual Meeting of the British Menopause Society: Progress in...

Cardiovascular disease – the window of opportunity

John C Stevenson

National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, London, UK

Beneficial effects of estrogen on metabolic risk factors for coronary heart disease (CHD), as well as on arterial function and on surrogate clinical markers of CHD, have been widely demonstrated. Thus, hormone replacement therapy (HRT) should benefit CHD in postmenopausal women. Observational studies have consistently shown a benefit of HRT on CHD, although it has been noted that the biggest beneficial impact has been seen in those women who initiated HRT close to the menopause. Randomized studies of HRT have not shown any significant effect on CHD. However, most randomized trials using defined clinical events as outcomes have studied just one dose of one HRT regimen, a dose inappropriately high with the average starting age of the participants being in their mid-sixties. In contrast, the observational population studies that do show large benefits comprise women starting on HRT around the age of menopause, i.e. early fifties. In fact, it is the older women in the randomized trials who failed to show benefit, whereas there was evidence of benefit in the younger ones. Thus, the age of initiation of HRT seems to be important, with the biggest benefit being seen in women starting treatment below 60 years of age and within 10 years of onset of menopause.

This gives rise to the concept of a ‘window of opportunity’ for HRT to help prevent CHD around the menopause, and in the UK this is the usual time of initiation of HRT. Does this mean that older women cannot benefit? The optimal dose of estrogen at initiation may be highly dependent on the age of the individual. Older women need less estrogen than younger ones for almost any of its effects.

Inappropriately high doses of estrogen could cause cardiovascular harm due to transient disturbances in thrombogenesis and vascular remodelling. Indeed, a pilot study of low-dose HRT in older women did not show any cardiovascular harm. While the greatest CHD benefit may be seen by starting HRT in the early postmenopause, this does not exclude benefit in older women provided they are given appropriate low-dose therapy. HRT may prove useful for the primary prevention of CHD in women. This could be an important option, as agents that are effective for the primary prevention of CHD in men do not appear as effective in women.

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Stevenson, J. C Search for Related Content Social Bookmarking                      What's this?