IS HORMONAL THERAPY BENEFICIAL FOR THE HEART IN MENOPAUSE?
Cardiovascular disease is the main cause of death in the world and in women it is the leading cause of morbidity and mortality, surpassing cancer in Spain and representing 56% of all female deaths in Western European countries.
The woman suffers her own or acquired hormonal changes that cause a greater risk of thromboembolic disease. Some, exclusive to women, such as pregnancy and its possible complications, contraception, menopausal hormone therapy, assisted reproduction therapies, antitumor hormonal treatment (tamoxifen) and the postmenopausal state. Others are common for both sexes, such as personal history, age, family history, HTN, dyslipidemia, diabetes, chronic kidney disease and tobacco.
The cessation of ovarian estrogens worsens the effect of cardiovascular risk factors, and changes occur in abdominal fat, BP, lipid profile and blood glucose. Reason why cardiovascular disease is the main cause of morbidity and mortality after menopause. Furthermore, the appearance of a menopause at an early age before the age of 45 (early menopause) or early ovarian failure (before the age of 40) significantly increases these risks since for each year of menopause before the age of 45 there is an increase of 3 % cardiovascular risk.
BUT HOW DO HORMONES AFFECT CARDIOVASCULAR RISK?
Estrogens induce variations and increases in some of the proteins involved in hemostasis and coagulation factors. Estrogens are prothrombotic, but on the other hand, endogenous estrogens generate protection by positively affecting vascular tone, enhancing vasodilation and vascular compliance, and additionally generating an anti-inflammatory and antioxidant effect and improving the lipid profile.
Estrogens increase TGC (triglycerides) and HDL (good cholesterol) and metabolize LDL (bad cholesterol). And progestins (progesterone) increase total cholesterol and modify the activity of HDL and LDL, mainly observed with powerful progestins such as those used in oral contraception, and not in hormonal therapy that uses natural progestins with little lipid effect, rather it is beneficial. and help prevent atheroma plaques from forming.
Therefore, an ambiguity is created between the risks and benefits and doubt arises.
Is hormone therapy beneficial?
It is necessary to differentiate between the healthy woman without pathology and the woman with previous arterial or venous pathology, and between oral therapy versus transdermal therapy.
Oral Therapy is related to changes and increases in coagulation factors such as D-dimer, fibrinogen and thrombin and Transdermal Therapy is not. In the healthy population, a reduction in the risk of heart disease is evident at all ages after the start of hormonal therapy, but more marked between 50 and 59 years of age, and over 70 years of age it is not recommended due to increased risk. If started early the benefit is clear and there is no limit to the duration. In venous disease (deep vein thrombosis or pulmonary thromboembolism), the risk with hormone therapy increases with age and is usually associated with other classic cardiovascular risk factors. Oral hormone therapy is associated with a more marked increase in the first year, greater with combined therapy than with estrogen alone, with no clear risk with transdermal therapy. The risk with non-bioidentical (equine) hormone therapy is greater.
What's going on? in the population with previous cardiovascular disease.
In general, studies include patients over 60 years of age, because it is at this age when cardiovascular events begin to appear, which are less frequent between 50-60 years of age. Furthermore, starting therapy after age 60 or continuing it is not common.
We know that atheroma plaques are destabilized when estrogen is added, but we also know that estrogen "protects" plaque formation, so its use is considered a window of opportunity when it is early before plaque formation. atheroma, when its benefit is greater. The use of hormonal therapy can be considered in patients with HTN as long as they are not associated with other risk factors and in patients with previous episodes of angina pectoris, heart attack or stroke, only in young patients and if the pathophysiology is not atherosclerotic.
The risk of venous disease (deep vein thrombosis or pulmonary thromboembolism) is higher in patients with known pre-existing conditions. With a history of thrombosis, the risk increases 10 times and hormonal therapy should be avoided. In Thrombophilias, the risk with oral therapy can increase between 15 and 25% depending on the mutation, but the transdermal route can be considered as an option. On the other hand, obesity depends on BMI (body mass index), with less than 25 the risk is 5%, it rises to 10% with BMI between 25-30 and up to 20% with BMI over 30. But always transdermal is recommended. Tobacco causes an increase in hepatic metabolism of estrogens, which can reduce or cancel the effects and benefits of therapy (with oral therapy), but not with transdermal therapy.
In conclusion, cardiovascular disease is the main cause of morbidity and mortality after menopause. It seems that MHT exerts a protective effect against arterial thrombosis under 70 years of age. That this protection is greater in early onset and does not influence the time of use. In women with angina pectoris, infarction or previous stroke, it is necessary to assess whether it is of atheromatous etiology before indicating MHT. There is no contraindication in HTA if it is not associated with other risk factors. But hormone therapy should not be used as primary or secondary cardiovascular prevention. It is used to control menopause symptoms.
MHT is associated with an increased risk of venous thrombosis (Low Absolute Risk), transdermal and tibolone are not associated with this increased risk. In women with previous VTE, do not use MHT.
In thrombophilias, obese women and smokers, use transdermal.
It is also worth remembering that the choice of MHT and its route of administration will depend on the woman's profile and her risk factors, and may be used orally or transdermally depending on the case, and that there is an opportune time or window of opportunity to do so. indicate and that it is beneficial for that woman. All of this allows us an approach to evaluate the data and decide whether or not to recommend the use of hormonal therapy in menopause and its relationship with the cardiovascular system.
By Dr. Alejandro Sáez, specialist in the non-invasive cardiology unit, outpatient consultations and hospitalization at UICAR