Hormone replacement therapy and cardiovascular disease revisited

John C Stevenson 

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

Correspondence: Dr John C Stevenson, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK. Email: j.stevenson{at}imperial.ac.uk

Controversy still rages about whether hormone replacement therapy(HRT) confers cardiovascular benefit or harm. There is a wealthof biological evidence that estrogen has a beneficial effect,supporting a large body of epidemiological evidence demonstratingreduction in coronary events with HRT. A large randomized placebo-controlledclinical trial of preventive strategies for coronary heart disease(CHD) in postmenopausal women, the Women’s Health Initiative(WHI), included HRT arms. The published preliminary findingsof this trial showed a significant increase in coronary events,stroke, venous thromboembolism and breast cancer with estrogen–progestogen,leading to the conclusion that HRT was unsafe to use other thanfor short-term relief of menopausal symptoms. But subsequentpublications of the more complete data from WHI have shown nosignificant increase in CHD, and a tendency to a reduction inthose initiating HRT below age 60 years. This is important becauseother therapeutic strategies for the primary prevention of CHD,such as aspirin and statins, are not of proven benefit in women,in contrast to men. Subsequent WHI findings have not shown aclear increase in breast cancer, and any potential increasefrom HRT is similar to that seen with many lifestyle factorsand other commonly used medications. The preliminary WHI resultsdo not reflect accurately true benefits and risks, and HRT shouldremain a potential preventive treatment for CHD.

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