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HRT No Savior for Women With Heart Problems

Particularly true for older women on hormone therapy, study finds

TUESDAY, July 2, 2002 (HealthDayNews) -- Estrogen replacement therapy doesn't prevent recurrent heart attacks and cardiovascular deaths in women with a history of heart disease.

That's the result of a new study that adds the much-needed perspective of time to an earlier report that reached the same conclusion.

"At least for older women with heart disease, we don't see any benefit for the use of estrogen plus progestin," says Dr. Stephen Hulley, an epidemiologist at the University of California, San Francisco, and a co-author of two papers on the new research. "Things might be different for women who are healthy, and who take [hormone therapy] during menopause."

When results from the widely awaited HERS study arrived in 1998, doctors were surprised to learn the combination of estrogen and a progestin did not prevent more heart attacks, strokes and other cardiac problems in older women with a history of such trouble. In fact, the study showed that for these women, the risk of heart complications increased during the first year or so of hormone replacement therapy (HRT) before dropping off in subsequent years.

At the time, experts advised post-menopausal women with heart trouble not to start HRT if they wanted to prevent additional problems, and suggested other treatments instead. However, since the roughly four-year-long HERS study also hinted that HRT might protect the heart in the long run, they told women already taking the hormones to prevent cardiac illness to be patient and await further study results.

The new study, called HERS II, found HRT offered no long-term heart protection, compared to placebo treatments, in more than 2,300 women from the original trial who agreed to stay in the project for nearly three more years.

What's more, they had a 50 percent higher risk of needing gall bladder surgery and were twice as likely to develop potentially dangerous blood clots in their legs and lungs than those not on hormones. The risk of clotting fell as the study progressed, but the odds of requiring gall bladder surgery rose, says the study, which appears in tomorrow's Journal of the American Medical Association.

Dr. Lori Mosca, author of the American Heart Association's 2001 guidelines reflecting the first HERS study, says the latest findings support the recommendation that women with heart disease not use HRT to prevent additional cardiac problems.

However, she acknowledges that for those with heart disease already on the drugs, what to do now might be confusing. "The answer lies with what they're taking [HRT] for," says Mosca, director of preventative cardiology at New York-Presbyterian Hospital in New York City.

"For women who have heart disease that are on HRT for established benefits such as menopausal symptoms or preventing thinning of the bones, there is no reason to discontinue it," she says. "However, if a woman with heart disease is on HRT for the purpose of preventing further heart disease, then she should consider other therapies that are known to prevent recurrent" heart attacks and strokes. These include statin drugs to lower cholesterol, aspirin, blood pressure medications, beta blockers and ACE inhibitors.

Experts say this time, they weren't caught off guard by the findings.

"We need to stop thinking of hormone replacement therapy as one-stop shopping for women's health," says Dr. Nieca Goldberg, a cardiologist at Lenox Hill Hospital in New York City and author of Women Are Not Small Men.

"It's beneficial in menopausal symptoms and osteoporosis prevention, but the data supporting it for reducing [heart disease] are still not here," Goldberg says.

The ongoing Women's Health Initiative is looking at whether HRT can prevent heart attacks and other cardiovascular trouble in 27,000 women, fewer than 10 percent of whom had a history of such problems when the study began. Neither the initial HERS study nor its follow-up addresses that question, Goldberg says.

HRT does lead to somewhat lower "bad" cholesterol and higher "good" cholesterol levels. Some researchers had expected these changes to result in less heart and vessel disease.

However, Dr. Jacques Rossouw, of the National Institutes of Health, says "it's starting to look very much like these apparently beneficial effects on blood [fats] are irrelevant."

Rossouw, who is directing the Women's Health Initiative for the National Heart, Lung, and Blood Institute, says women should still consider HRT to control symptoms of menopause like hot flashes, insomnia and vaginal dryness.

For now, the message to those with cardiovascular disease should be: "Don't start to prevent it and don't continue" if you're on it, he says.

The study was supported by Wyeth-Ayerst, maker of Premarin, the leading formulation of estrogen and the nation's most widely prescribed drug.

What To Do

To learn more about hormone replacement therapy (HRT) and what it's useful for, try the National Institute on Aging, or the National Women's Health Information Center.

For more on the Women's Health Initiative, visit the National Heart, Lung, and Blood Institute.

SOURCES: Lori Mosca, M.D., MPH, Ph.D., director, preventative cardiology, New York-Presbyterian Hospital, New York City; Nieca Goldberg, M.D., chief, Cardiac Rehabilitation and Prevention Center, Lenox Hill Hospital, and assistant clinical professor, medicine, New York University School of Medicine, New York City; Jacques Rossouw, M.D., acting director, Women's Health Initiative, National Heart, Lung, and Blood Institute, Bethesda, Md.; Stephen Hulley, M.D., M.P.H., professor and chair, department of epidemiology and biostatistics, University of California, San Francisco; July 3, 2002, Journal of the American Medical Association
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