The past,the present and the future o oestrogen and progestogen therapy for cardiovascular disease in postmenopausal women

Abstract

The overwhelming body of evidence indicating that oestrogen or hormone replacement therapy may be beneficial as primary prevention in cardiovascular disease in women leads one to continue to actively counsel women who have or do not have cardiovascular risk factors that oestrogen will be indeed cardioprotective. A lack of significant data other than the HERS trial, which is the only prospective randomised trial of secondary intervention, leads one to be reluctant to intervene with oestrogen plus progestin in women who have had a cardiac event. Can oestrogen be used more than one year after the acute event is a question that can only be answered by future research. The data from the HERS trial would suggest that, if oestrogen is used, its effect on preventing subsequent cardiovascular events is low. The reason for this is that other agents used to prevent recurrent cardiovascular events such as statins have a greater efficacy. The use of other agents, most notably statins initially, with a later addition of oestrogen, should be considered. It should be remembered that oestrogen can have other positive effects on the skeleton and the central nervous system.

Markers of cardiovascular risk such as C-reactive protein, homocysteine, and lipids, can be useful in counselling women who are at increased risk for coronary heart disease. The measurement of C-reactive protein, homocysteine, and a lipid profile in postmenopausal women now appears to be useful and should be incorporated into the physician's evaluation. These results should be factored into a treatment plan.

The use of statins for prevention and active treatment after cardiovascular events in women is changing the prescribing habits of obstetricians and gynaecologists in the USA. Physicians treating and counselling older women now should be comfortable with including lipid altering agents in their armamentarium. The information on the selective oestrogen receptor modulator raloxifene and alternative therapies such as soy protein and isoflavones are limited and, at the present time, do not lend themselves to making definitive statements as to their efficacy in long-term cardiovascular prevention and/or treatment as secondary interventions.