Note: hormone therapy (HT) may also be referred to as hormone replacement therapy (HRT).

Questions and Answers

The Jean Hailes Foundation answers your questions about the findings of the Women’s Health Initiative Estrogen plus Progestin Study, published in the New England Journal of Medicine August 7, 2003.

This is not a new study but a more detailed report on heart disease and hormone therapy expanding on the original results.

What does this further analysis from the women's health initiative study mean for Australian women?

These are important findings that repeat those published last year.

What is the significance of the analysis?

The analysis shows a small increase in risk of fatal and non-fatal heart attack in users of oral combined Hormone Therapy (HT), most of whom are many years past menopause, compared with non-users.

Should women be concerned about these findings?

The findings confirm that HT should not be used to prevent heart disease.

Are these findings relevant for all Australian women using HT?

This research was using a specific hormone therapy and this may not apply to other forms of therapy prescribed around the time of menopause for symptoms relief.

What is coronary heart disease?

Coronary Heart disease is one aspect of cardiovascular disease and involves the heart or major blood vessels (arteries) supplying the heart. In Australia it is the number one killer of both men and women overall. After midlife women’s risk of heart disease increases.

What causes coronary heart disease?

From early in life fatty, cholesterol deposits (plaques) gradually build up in the walls of arteries - a process exacerbated by many other risk factors for heart disease. Over time this eventually causes narrowing of the blood vessels causing reduced blood flow to the heart muscle. This can result in angina (chest pain and heart attacks

What are the major risk factors for coronary heart disease?

Family history (if the relative was under the age of 65 years when the cardiovascular disease developed) · High blood pressure · Elevated blood cholesterol · Cigarette smoking · Diabetes · Excess body weight, especially when abdominal (tummy) fat is increased · Inactivity

What is cholesterol?

Cholesterol is the term used to describe the small particles that the human body uses to carry fats around in the blood stream. Our diet contains cholesterol in animal products however we also make cholesterol from fat. The amount of cholesterol in our blood is not only determined by our diet (primarily our fat intake), but also by our family history via genetic influences. Therefore cholesterol levels may be high even in women with healthy diets and low body weight, emphasising the need to have a cholesterol level checked in everyone.

There are several types of cholesterol. The low-density cholesterol (LDL) has been labelled the bad type, as it tends to put cholesterol in unwanted areas, mainly in the wall of the blood vessel leading to cholesterol plaques. The high-density cholesterol (HDL) labelled the good type, tends to carry cholesterol away from the blood vessel walls back to the liver. The balance of these cholesterol types as well as the total cholesterol level in the blood is important.

What is high blood pressure?

Blood pressure increases with age and is classically provided as two values, the systolic or upper level (upper number) and the diastolic or lower level (lower number). Put simply, when the heart pumps, roughly every second it momentarily increases the pressure in the blood vessels (the higher systolic pressure). Then in the brief pause between the heartbeats the pressure falls again (the lower diastolic pressure). Ideally the blood pressure should be 120/80 or less most of the time. Blood pressure does fluctuate, however if higher levels occur consistently this leads to damage to the blood vessel walls and to the heart muscle itself, increasing the risk of cardiovascular disease, especially stroke.

How can I lower my cholesterol and blood pressure?

The first line treatment for these is lifestyle measures but treatment of high cholesterol and high blood pressure may require the use of medications. These medications are introduced if changes in diet and exercise are not sufficient to lower cholesterol or blood pressure, or levels are especially high. Treatment with blood pressure and cholesterol lowering medications have proved extremely effective in reducing cardiovascular disease in high risk individuals but they need to be taken consistently.

What are the symptoms of high cholesterol and high blood pressure?

There are often no symptoms from high blood pressure and cholesterol until a heart attack or stroke occurs. This is why it is so important for all women over the age of 40 to have blood pressure checks at least once a year and cholesterol checks as appropriate after discussion with your health practitioner.

How can I decrease my risk of coronary heart disease?

Apart from family history, most risk factors can be improved by modification of lifestyle and diet. Thus people can reduce their risk of coronary heart disease. Diet has many roles apart from the nutritional value. The foods we eat and perhaps more importantly, the foods we avoid have a far-reaching impact on our health and well-being.

The ideal nutritional intake for a woman at midlife which will assist in lowering heart disease risk, should be low in saturated fat (as found in animal fat), sugar and salt (as found in many fast foods), high in fibre (cereals, grains, rice, fruit and vegetables) and rich in calcium. Increased exercise is vital as is cessation of smoking, along with detection and treatment of diabetes.

Does HT have a role in the prevention of cardiovascular disease?

There are potentially both good and bad effects of oestrogen on the cardiovascular system.

Results from trials including the “Women’s Health Initiative” study (released in July 2002 and August 2003) indicated that oral combined HT (oestrogens plus progestins) caused a small increase in the risk of heart attacks and strokes.

It is important that you discuss the risks and benefits for you, in relation to heart disease and HT, with your health practitioner.

What should women do about using hormone therapy?

These studies once again remind us that any decision about HT is an individual one and should be made after each woman is informed about her individual risks, benefits, needs and concerns in consultation with her prescribing doctor.

Where to Now

• Combined oral oestrogen / progestin therapy is not recommended to prevent heart disease.

• Short-term use of combined oestrogen-progestin therapy (for the management of menopause symptoms that adversely impacts on one’s quality of life) is a reasonable option. But the benefits and risks need to be weighed up by each individual woman.

• Women who have prolonged symptoms may choose to continue oestrogen –progestin therapy after balancing the small risks of ongoing HT with quality of life issues on an individual basis.

• This study tells us nothing about the use of oestrogen-progestin for women who undergo an early menopause (before the age of 40). It is generally recommended that such women use HT until they approach the average age of menopause and then at that time re-evaluate their need for ongoing treatment in the light of their personal risk.

• It is important that all women using any form of HT should be reviewed at least annually by their prescribing health practitioner. Risks and benefits, and other alternatives can be discussed at this time for that individual woman.

Conclusion

The Jean Hailes Foundation concurs that the current information from American studies reconfirms that hormone therapy after menopause should primarily be used for symptomatic relief.

The Jean Hailes Foundation is committed to undertaking research in this area and to keeping up to date with new research findings and communicating these findings to women and their families.

The Jean Hailes Foundation’s aim is to assist women to become well informed so they can be active participants with their health professionals, in decision-making about issues that affect their health and well being.