Hormone Replacement Therapy

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Postmenopausal hormone replacement therapy has been suggested to reduce cardiovascular morbidity by up to 56% in healthy women who take estrogen compared to women who have never taken hormone replacement medications (56); however, these observations from small clinical trials may overestimate the actual cardiovascular benefits derived from hormone replacement therapy (Fig. 6). Theoretically, estrogen supplementation may reduce coronary events by improving cholesterol profiles, promoting endothelium-derived vasodilation, and by serving as an antioxidant (12,57-59). Despite these potential therapeutic benefits, the HERS trial failed to demonstrate the therapeutic efficacy of estrogen replacement therapy compared to placebo with respect to coronary heart disease, nonfatal myocardial infarction, or mortality at 5 yr follow-up (60). In fact,

Hormone Replacement Progress

Fig. 7. Gender differences in referral patterns for cardiac catheterization following diagnostic stress testing. Men are more likely to be referred for coronary angiography than women early after exercise nuclear stress testing. This was most pronounced in patients with a high pre- and posttest likelihood of coronary disease. High, Intermediate, Low, refers to likelihood of coronary artery disease; Pre-ETT LK CAD, pretest likelihood of coronary artery disease; Post-ETT LK CAD, posttest likelihood of coronary artery disease (64).

Fig. 7. Gender differences in referral patterns for cardiac catheterization following diagnostic stress testing. Men are more likely to be referred for coronary angiography than women early after exercise nuclear stress testing. This was most pronounced in patients with a high pre- and posttest likelihood of coronary disease. High, Intermediate, Low, refers to likelihood of coronary artery disease; Pre-ETT LK CAD, pretest likelihood of coronary artery disease; Post-ETT LK CAD, posttest likelihood of coronary artery disease (64).

hormone replacement therapy was associated with a three-fold increase in venous thromboembolic events, a 3- to 8-fold increase in lifetime risk of developing endometrial cancer, and an increase in gallbladder disease (60,61). The Estrogen Replacement and Atherosclerosis (ERA) Study utilized quantitative coronary angiography to confirm these findings. Women were treated with hormone replacement therapy or placebo and underwent cardiac catheterization. After 3 yr of follow-up the mean change in lumen diameter was not significantly different between treatment groups (62). These trials, therefore, form the basis for the current American Heart Association/American College of Cardiology (AHA/ACC) recommendation that hormone replacement therapy does not play a role in the primary prevention of coronary heart disease; however, for women who presently take estrogen compounds, there is no benefit to discontinue this therapy (63).

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