Women with heart disease should not start taking hormones to prevent heart attacks because so far there is not enough evidence that this treatment works, the American Heart Association says in a new policy statement.
Women still may want to take hormones after menopause to ease the symptoms of menopause or to help prevent the “brittle bones” disease called osteoporosis, the association says.
The guidelines, published in the July 24, 2001, issue of the AHA journal Circulation, summarize the evidence from several recent studies on the effects of replacing the hormones estrogen and progestin (a form of progesterone) in women after menopause.
Earlier research had indicated that women who used hormone-replacement therapy developed less heart disease than those who did not. In these studies, however, researchers simply looked at the health of women who had chosen to take or not to take hormones. Many factors, including the women’s education, habits and overall health, could have affected the results.
Newer studies, designed in a different way, so far have found no benefit from hormone therapy in preventing heart disease or avoiding heart attacks. These studies randomly assigned women with similar health histories to receive either hormones or a placebo. This type of study is considered the most accurate and least biased way to do medical research.
JoAnn Manson, M.D., a professor of medicine at Harvard Medical School who is one of the principal investigators n several major women’s health studies, including the Women’s Health Initiative, says she hopes the heart association’s statement gets wide circulation among physicians and patients.
“I think it’s important that physicians not expect and women not expect that these hormones will prevent heart disease, and that they understand that these hormones are not currently indicated for the express purpose of preventing heart disease,” says Dr. Manson, chief of preventive medicine at Brigham and Women’s Hospital in Boston.
On the other hand, she says, “there are still suitable candidates for hormone therapy,” which is known to help relieve menopause symptoms and prevent bone loss.
In an article in the July 5, 2001, issue of the New England Journal of Medicine, Dr. Manson and Kathryn A. Martin, M.D., a Harvard colleague, outline criteria for deciding who can benefit from taking hormones to treat menopause symptoms or prevent osteoporosis.
One reason to be cautious in using hormone therapy is that it carries risks as well as benefits. It may increase the risk of blood clots, gallbladder disease and, with long-term use, breast cancer. Use of estrogen alone, without progestin, may increase the risk of endometrial cancer.
One study among women with heart disease also found that they had 52 percent more heart attacks in their first year of using hormone therapy than women who received a placebo. At the end of four years, the average rate for the two groups was the same.
Therefore, the heart association says:
- Doctors should not offer hormone therapy to prevent heart attacks in patients with heart disease.
- Decisions on whether to continue hormone therapy for women who already receive it should be based on its benefits for helping menopause symptoms or preventing osteoporosis.
- If a woman receiving hormones has a heart attack or is otherwise forced to be immobile for a while, doctors should consider stopping the hormones to compensate for the increased risk of a blood clot during this period of inactivity.
- To minimize their risk of heart disease, women should quit smoking, eat a healthy diet and get regular exercise. Medicines that reduce cholesterol and blood pressure also can be effective and should be prescribed more often for women.
- Several studies are continuing to test the effects of hormone-replacement therapy for women who have heart disease or atherosclerosis (hardening of the arteries). Other long-term studies, including the Women’s Health Initiative, are examining whether hormones can help to prevent heart disease in healthy women.
Until the results of those studies are available, Dr. Manson offers these suggestions for deciding who should use hormone therapy:
- Avoid starting hormones unless the patient is bothered by menopause symptoms or is at increased risk for osteoporosis.
- Women who are taking hormones and doing well do not necessarily need to quit taking them.
- Hormone therapy can be used safely for up to five years to ease menopause symptoms. Because of their higher risk of heart attacks, women with heart disease should first consider other therapies first. These include several medications and soy products.
- Longer-term use of hormones may increase the risk of breast cancer. Such use may be considered for women with osteoporosis or a strong risk of osteoporosis who are at low risk for breast cancer. One option is to resume therapy (after menopause symptoms ease) only when tests show actual bone loss.
- Other strategies to prevent osteoporosis include exercise, adequate consumption of calcium and vitamin D, and certain drugs. Menopause symptoms may be eased by quitting smoking, increasing physical activity and eating a healthy diet.