[Role of hormone replacement therapy during menopause in the cardiovascular prevention]

Menopausal hormone replacement therapy is a physiological rather than a pharmacological approach. Large numbers of cohort studies have now clearly shown that relative coronary risk increases at the menopause in the absence of treatment, in particular regarding an early menopause, and decreases by approximately 50% with replacement therapy, provided the latter is based upon physiological estrogens (all studies on the other side of the Atlantic have involved equine conjugated estrogens). Micronized 17 beta estradiol and in the form of its valerate per os, and percutaneous or transdermal 17 beta estradiol are also available in France. There are beneficial effects on cholesterol fractions, and all the more so if the estrogen is given orally rather than percutaneously or transdermally: decrease in total cholesterol by decrease in the atherogenic fraction LDL-C and apoprotein B, increase in anti-atherogenic fraction HDL2-C and apoprotein A1. There is also a significant fall in lipoprotein (a), a particularly atherogenic lipoprotein if its plasma level exceeds 0.30 g/l and also thrombogenic because of decreased fibrinolysis. Increases in triglycerides are seen only when estrogens are taken orally.