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Change in Recommendation Regarding Hormone Replacement Therapy for the Heart (dateline July 27, 2001)

Reversing its policy from a few years ago, the American Heart Association has announced that it no longer recommends that women be prescribed hormone replacement therapy (HRT) for the sole purpose of preventing heart disease. While past studies had suggested that HRT may protect the heart, new research casts doubt on those findings and reveals that HRT may even increase heart attack and stroke risk in women who already have heart disease. However, the American Heart Association emphasizes that healthy women who are taking HRT for non-cardiac benefits, such as the relief of menopausal symptoms or the prevention of osteoporosis, should continue doing so provided that they are fully aware of all the potential benefits and risks.

HRT consists of synthetic forms of the female hormone estrogen and often progesterone (called progestin), which are designed to replace the body’s depleting hormone levels at menopause. Physicians have long believed that estrogen decreases heart disease risk. Logically, HRT would help prevent heart disease in post-menopausal women because the loss of estrogen at menopause is associated with a higher risk of heart disease (thus, adding estrogen therapy would decrease heart disease risk). However, recent studies have actually shown an increase in heart attack and stroke risk in women with a history of heart attack or those already diagnosed with heart disease who use HRT for the first few years, although the risk is minimized with prolonged use.

Many experts now believe that many of the heart benefits observed in studies of women who took HRT were not produced by the HRT but by the women themselves. This may be because women who use HRT or who enroll in long-term studies of HRT tend to be healthier, thinner, non-smokers, and better educated than the general public. Thus, it is believed that these women may be at lower risk for heart disease in the first place. Further research is needed to confirm this belief.

The new recommendation by the American Heart Association, advising women not to take HRT just to prevent heart disease, may cause many women to rethink the therapy. According to Dr. JoAnn E. Manson, Chief of Preventive Medicine at the Harvard Brigham and Women’s Hospital, it is estimated that 20% of the 20 million American women who take HRT do so simply to protect against heart disease. Dr. Manson said that percentage used to be twice as high but fears about breast cancer risk and other potential dangers of HRT have caused many women to stop taking hormones. Cholesterol-lowering drugs may be appropriate alternatives to HRT for women who have heart disease.

However, there is little doubt that HRT can effectively alleviate bothersome menopausal symptoms, such as hot flashes, vaginal dryness, and sleep disturbances. According to Dr. Lori Mosca, lead author of the new American Heart Association guidelines, HRT should still be recommended to healthy women who need relief from menopausal symptoms. HRT has also been shown to prevent osteoporosis, a disease that can cause bones to fracture easily. Negative effects of estrogen therapy include bloating, nausea, and a possible increase in breast cancer and ovarian cancer risk with prolonged use (after five years and 10 years, respectively).

According to the American Heart Association, women who should be cautious about taking HRT include those with:

  • Active or chronic liver disease
  • Previous diagnosis of breast or uterine cancer, or breast cancer in a close family member
  • Active gallbladder disease
  • History of blood clots in the veins, especially in the legs or lungs
  • Advanced coronary disease
  • Severe obesity
  • Diabetes
  • Abnormally high blood pressure (hypertension)
  • History of stroke

While further research is needed to better understand the effect of HRT on the heart, experts say that cholesterol-lowering drugs and other therapies are much better options for lowering heart disease risk than HRT. The decision to use HRT should be made after weighing the non-cardiac benefits and potential risks of the therapy.

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