Heart disease is the number one killer of women. More women die of it than all types of cancer combined. Before menopause, 1 in 17 women get heart disease, but after menopause, 1 in 3 women get it. Researchers are just beginning to figure out how and why this happens. For all the information that follows, it's important to remember that they don't know a lot about long-term use. Also, almost all the studies are on oral estrogen. They don't know yet whether they apply to the patch or creams.
Coronary heart disease happens when fat, calcium, and other matter stick to the artery walls and clog up the artery that brings oxygen to the heart muscle. The artery wall stiffens up and handles less blood. Of course it's important not to smoke, to control diabetes, tame high blood pressure, reduce blood cholesterol, exercise, eat a low-fat diet with 5-9 servings of fruit and vegetables a day, but even among women who do all that, HRT can make big additional difference.
THE GOOD NEWS
HRT helps prevent heart disease because it stops the clog of fat from forming and it helps the artery wall stay flexible and open so the blood flows better and oxygen gets to the heart. HRT lowers postmenopausal women's risk of heart disease by 35% to 50%.
HRT works a number of ways. Estrogen keeps blood vessels open because it signals the artery walls to relax and expand and slows down the signal to tighten up and close the artery. It's also an antioxidant that helps protect the lining of arteries. It works so well on cholesterol that the National Cholesterol Education Program is recommending that ERT be considered as a therapy for high cholesterol in women, not just as a side benefit when managing menopause (total cholesterol should be under 200 mg/dL). HRT helps boost the good and lower some of the bad.
HDL (high-density lipoproteins)
HDL, good cholesterol, seems to be the most important factor for women and heart disease. The best HDL is over 35 mg/dL. Estrogen and estrogen with micronized progesterone (like Prometrium) boost HDL three times higher. But, estrogen with progestin (the synthetic version like Provera) is a lot less effective.
LDL (low-density lipoproteins)
LDL is bad cholesterol. It should be under 130 mg/dL. All kinds of hormone treatment that include estrogen lower LDL by 10% to 15%.
Blood pressure
The big trials using Premarin and Provera have found that HRT has no effect on blood pressure. One small study of transdermal estradiol (bioidentical estrogen in a patch) and intravaginal progesterone showed that blood pressure dropped at night. So it can't hurt and might help.
Insulin
There seems to be no significant effect on insulin, but there is an indication in one study that insulin might be twice as good when women were taking estrogen alone or estrogen with micronized progesterone.
THE BAD NEWS
Triglycerides
Triglycerides are another bad part of cholesterol, though doctors don't know exactly how they affect heart disease. They should be under 250 mg/dL. Estrogen taken alone increases triglycerides by 25%, but progestin and micronized progesterone both slow down the increase in triglycerides to 15%-20%. If your triglycerides are 400 mg/dL or higher before you take HRT, then estrogen could raise them to the risk level for pancreatitis. So get your triglycerides checked.
Fibrinogen
Fibrinogen in the blood helps form blood clots. Usually with menopause, fibrinogen increases, so it might be a good thing that HRT lowers it or keeps it at premenopausal levels. However, it's possible that the drop in fibrinogen, in some women, may create a problem (more precisely, a thromboembolic event). So anyone with clotting problems should be cautious.
The HERS study
A large study (Heart and Estrogen/progestin Replacement Study) was done of women who already had serious heart disease to see whether HRT improved already existing heart disease. Instead, there was a 50% increase in heart/artery events in the first year. The women improved after the second year, so something happened that first year before the good effects kicked in.
One author pointed out that they used progestin (Provera) not micronized progesterone and that might have made a difference. Another idea is that estrogen alone and estrogen with progestin and micronized progesterone cause a rapid increase in a chemical that causes inflammation (swelling) of the artery. But they also decrease another chemical, which evens up the risk over yime, which would fit the pattern of the study.
But one comment that struck me was that the average age in the HERS was 67 (40% were over 70). The DNA in arteries seems to shut down in women in their late 60s and early 70s, and estrogen can no longer do its job. Therefore, HRT for the heart benefits is probably most useful before 70.
If anyone wants this article with the footnotes and sources identified, just email me at trishm@excite.com.
Sources: Arteriosclerosis, Thrombosis, and Vascular Biology; The American College of Obstetricians and Gynecologists' Guide to Managing Menopause; Internal Medicine; European Heart Journal; European Journal of Obstetrics, Gynecology, and Reproductive Biology; Maturitas; Circulation; American Journal of Hematology; JAMA; Drugs and Aging; Annals of Internal Medicine; and Hypertension.
This content was written by staff of HysterSisters.com by non-medical professionals based on discussions, resources and input from other patients for the purpose of patient-to-patient support.
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