Hormones and the heart, (and other vascular things)!. Dr Heather Currie Associate Specialist Obstetrician & Gynaecologist MD Menopause Matters Ltd. Plan. CVD in women Menopause & CVD risk Menopause, HRT and other vascular things!. Demographics. 1850 Age of menopause - 45 yrs.
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Dr Heather Currie
Associate Specialist Obstetrician & Gynaecologist
MD Menopause Matters Ltd
Cumming G, Currie H et al. Menopause International 2007;13:79-83
At Every Age, More Women Die of Heart Disease Than Breast Cancer
Coronary Artery Disease
Mortality Rate per 100,000
National Center for Health Statistics. 1999:164-7.
Don’t know/ no answer
Mosca et al. Arch Fam Med 2000.
Different from those in men
Angina can be mistaken for indigestion or heartburn
MI symptoms can include overwhelming fatigue, shortness of breath, nausea, or indigestion
The Framingham Study
(per 1000 women)
n = 2873.
Kannel WB, et al. Ann Intern Med. 1976;85:447-52.
Obese population aged 15 and above
OECD Factbook 2005 www.sourceoecd.org/factbook
n = 371
n = 69
n = 75
n = 27
Chilvers CE, et al. Eur Heart J. 2003;24:2197-205.
Grady D, et al. JAMA. 2002;288:49-57.
Hulley S, et al. JAMA. 1998;280:605-13; Grady D, et al. JAMA. 2002;288:49-57; Blumenthal RS, et al. Am J Cardiol. 2000;85:1015-7.
CEE = conjugated equine estrogen; MPA = medroxyprogesterone acetate; HT = hormone therapy (estrogen alone [E-alone], estrogen plus a progestin [E+P]).
The Women's Health Initiative Study Group. Control Clin Trials. 1998;19:61-109.
10/15/2014 10:47:24 AM
CEE + MPA
CEE + MPA
E + P2
1Manson JE, et al. N Engl J Med. 2003;349:523-34; 2Grodstein F, et al. Ann Intern Med. 2000;133:933-41;
3Women's Health Initiative Steering Committee. JAMA. 2004;291:1701-12.
Note demographics of study population
60% > 60yrs
30% had BMI >30
Pre-existing heart disease
Drop out rate 75% (active and placebo)
Salpeter et al J Gen Int Med 2004;19:791-804
Plaque Area (% of placebo)
CEE + atherogenic diet
CEE + atherogenic diet
Healthy diet+ CEE
~ 6 Year Human Equivalent
1Clarkson TB, et al. J Clin Endocrinol Metab. 1998;83:721-6; 2Adams MR, et al. Arterioscler Thromb Vasc Biol. 1997;17:217-21; 3Clarkson TB, et al. J Clin Endocrinol Metab. 2001;86:41-47; 4Williams JK, et al. Arterioscler Thromb Vas Biol. 1995;15:827-36.
Benefits of Endogenous E2
Primary Benefits of HT
No Benefits of HT
Mikkola TS, et al. Ann Med. 2004;36:402-13.
RH = relative hazard.
*Mean BMI 28.5 kg/m2.
BMI data from Willett WC, et al. JAMA. 1995;273:461-5.
WHI data from Manson JE, et al. N Engl J Med. 2003;349:523-34.
Hodis and Mack. Menopause 2007; 14: 1-14
Lokkegaard et al Arch Neurol 2003;60:1379
Low doses may confer protection while higher doses may increase risk
Risks may be lower with transdermal
Birge ss Menopause 2006;13(5):719-20
Renoux et al, BMJ 2010; 340:83
UK GP Research Database
870,286 women with no prior stroke history aged 50 – 79 between 1987 and 2006 followed up for mean duration of 6.7 years
15710 cases of stroke
Low dose transdermal ET (50 micrograms) is not associated with increase in risk of stroke
High dose transdermal ET and oral estrogen, alone or combined with progestogen, are associated with increased risk.
Use of oral (ET or EPT) had a 28% increase in risk which translates into an absolute risk of 0.8 strokes per 1000 person years of use.
Use of HT at the menopause will have different effects from HT started 10 to 15 years later
No data to suggest change of indications for HT at the menopause
Increasing evidence that progestogen reduces estrogen benefit / adds to risks
Canonico et al BMJ 2008;336:1227-1231
HR = 0.79
95% CI = 0.67–0.93
Margolis KL, et al. Diabetologia. 2004;47:1175-87.