[CG] HRT and cardiovascular disease

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Abstract

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Cardiovascular disease is common; therefore we will inevitably see women with cardiovascular disease who wish to use hormone replacement therapy (HRT).

Until the late 1990s oestrogen was thought to protect against coronary heart disease (CHD).  However, an RCT, the Women’s Health Initiative (WHI) found an early, transient increase in coronary events in the combined HRT (oestrogen plus progestogen) arm.  However, the average age of participants in WHI was 63 years old, and more recent subgroup analyses of data from the WHI trials have questioned these results.  HRT use was stratified by age and time since menopause, and this analysis demonstrated more favourable results for all-cause mortality and myocardial infarction in women aged 50-59, and those starting HRT close to menopause (1).  The Danish Osteoporosis Prevention Study (DOPS) (2), an open label RCT, showed that HRT was associated with a reduction in cardiovascular disease in women of the same age group.

The NICE Guideline on Menopause (NG23) provides guidance on the use of HRT and the risk of cardiovascular risk, and this is summarized below.

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Last reviewed: 01 June 2019

Next review: 30 June 2024

Author(s): Dr. Jenifer Sassarini (Consultant Gynaecologist)

Approved By: Dr. R. Jamieson, Clinical Director

Related resources

NICE Guidance: NG23. Diagnosis and management of menopause. https://www.nice.org.uk/guidance/ng23/

BMS Consensus Statements – www.thebms.org.uk

Alternatives to HRT for the Management of Symptoms of the Menopause (SAC Opinion Paper 6). RCOG; 2010. http://www.rcog.org.uk/womens-health/clinicalguidance/alternatives-hrt-management-symptoms-menopause  

References
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  2. Schierbeck LL, Rejnmark L, Tofteng CL, et al. Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women: randomised trial. 2012 2012-10-09 22:32:25;345.
  3. Windler E, Stute P, Ortmann O, Mueck AO. Is postmenopausal hormone replacement therapy suitable after a cardio- or cerebrovascular event? Archives of Gynecology and Obstetrics. 2015;291(1):213-7.
  4. Shlipak MG, Angeja BG, Go AS, et al. Hormone Therapy and In-Hospital Survival After Myocardial Infarction in Postmenopausal Women. Circulation. 2001;104(19):2300-4.
  5. Tackett AH, Bailey AL, Foody JM, et al. Hormone replacement therapy among postmenopausal women presenting with acute myocardial infarction: Insights from the GUSTO-III trial. American Heart Journal. 2010 10//;160(4):678-84.
  6. Mikkola TS, Tuomikoski P, Lyytinen H, et al. Increased Cardiovascular Mortality Risk in Women Discontinuing Postmenopausal Hormone Therapy. J Clin Endocrinol Metab. 2015 Dec;100(12):4588-94. PubMed PMID: 26414962.
  7. Renoux C, Dell'aniello S, Garbe E, Suissa S. Transdermal and oral hormone replacement therapy and the risk of stroke: a nested case-control study. BMJ. 2010;340:c2519. PubMed PMID: 20525678.