Estrogen and your heart: Does it help or hurt?

Does estrogen have a different effect on the hearts (and minds) of younger versus older women?
Most likely. When estrogen is given to monkeys immediately after their ovaries are removed, there is a 50 percent to 70 percent decrease in the development of plaque in their coronary arteries, but there is no benefit if estrogen is given years later. Because WHI was begun on older women who were more than a decade past menopause, they were likely to already have plaque in their arteries, and estrogen’s inflammatory effect might have made this plaque “vulnerable.” This likely increased the risk that the plaque would rupture or that pieces would shear off and be carried to small arteries, block them, and cause a heart attack or stroke. 

When we put all these facts and theories together, estrogen’s effect on coronary heart disease is thought to be as follows: In our reproductive years, hormones protect our vessels from plaque formation. Once we become menopausal there is an early window of opportunity to reduce this plaque formation with estrogen. If hormone therapy is delayed and is started years after menopause when plaque has already formed, it may initially cause the plaque to erode or rupture, but years later there could be a benefit in that cholesterol levels are improved. In scientific terms, this is a triphasic effect: First good, then not good, then better. 

Are there new thoughts and recommendations regarding estrogen and hormone replacement in heart disease?
The official American Heart Association recommendation states that hormones should not be prescribed for the purpose of preventing heart disease. Currently The American College of Obstetricians and Gynecologists as well as the North American Menopause Society state that hormone replacement should not be initiated in women known to have coronary heart disease.  Two of the WHI investigators (Drs Phillip and Langer) recently published their own recommendation in the Journal of Fertility and Sterility. They stated that they believed “that based on all the data now available, the benefits of hormone therapy outweigh the risks.  Hormone therapy should be started at menopause in most women and failure to initiate treatment near menopause may foster damage to the vasculature [blood vessels], bone and other organs systems that cannot be repaired by initiating treatment later." They go on to say that blood vessels may experience paradoxical harm with delayed treatment and that we should consider forms of progestin other than Provera.

The current state of knowledge is still in flux. Obviously we have to continue to abide by all our other attempts to safeguard our hearts with appropriate behavioral changes and medications to treat high blood pressure and abnormal cholesterol. 

Many physicians feel that the WHI should not be considered the last or only word with regard to the many forms of estrogen and hormone replacement therapy available to women, especially to younger women who are just becoming menopausal and who are more likely to suffer from significant symptoms. A new National Institute of Health (NIH) sponsored study called ELITE (Early vs. Late Intervention Trial with Estradiol) has recently begun at the University of Southern California. Menopausal women will be given estradiol or a placebo and followed for two and a half years. They will have extensive checks of their arteries, heart function and cholesterol levels as well as mammograms, pelvic exams and mental function tests (all free of charge). The investigators want to find out if use of this estrogen in early or even late menopause has a clinically demonstrable protective effect on the vessels, hearts and minds of these women. Menopausal women can learn more about this study and enroll by going online at www.usc.edu/medicine/aru or calling the toll free number (866) 240-1489.

The results of the ElITE study will help us better counsel women on the possible cardiac benefits of early estrogen therapy.

Dr. Judith Reichman, the “Today” show's medical contributor on women's health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," which is now available in paperback. It is published by William Morrow, a division of HarperCollins .

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