When the Women’s Health Initiative was proposed more than 20 years ago, there were studies that demonstrated that hormone replacement decreased the risk of heart disease. The purpose of the WHI was to determine if giving women hormone replacement after menopause would decrease their future risk of heart disease. It was shocking to us as physicians when the initial data demonstrated an increase in stokes, heart attacks, and cancer in women who took hormones vs. placebo. But, the fifteen year follow-up data demonstrated no increase in mortality for any cause in women who took hormones vs. those who took placebo.
How could these two data points be consistent? The answer is not totally clear, but now we think that timing might be a contributing factor. It is now believed that the effect of hormone therapy (HT) on heart disease depends on when a woman initiates therapy.
Starting HT younger than age 60, or within the first ten years of menopause, decreased coronary heart disease by 32-48%, and decreased all-cause mortality by 30-39%.
The reduction is mortality was due to decreased cancers and heart disease, which are the two leading causes of death in women. Younger postmenopausal women, those ages less than 60, had a greater reduction in cardiac mortality, 54-61% reduction, vs. those women over 60, whose reduction was less but still quite good, 26-43%. This benefit was independent of the type of progesterone that was prescribed.
Mortality related to cancers was decreased 23-43% will all hormonal regimes, and this was not dependent on whether hormones were started before or after age 60.
There was no increased risk of strokes if hormones were started HT in the first 10 years after the onset of menopause, although the risk of blood clots did increase with HT.
So, how does one decide what to do? Your risk factors have to be evaluated, but if you are generally healthy, the studies support the safety and benefit of HT.
Marilyn Jerome, MD
Foxhall OB-Gyn Associates
Menopause: The Journal of The North American Menopause Society. Volume 24, November 2017
Dr. Victor Henderson, MD, MS, NCMP. Early and late intervention on vascular disease ad related outcomes: further evidence from the Early Versus Late Intervention Trial With Estradiol