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Benefit/risk of estrogen therapy in cardiovascular disease: current knowledge and future challenges
1University of Connecticut School of Pharmacy, Hartford, USA.
Insights
Estrogen therapy may reduce coronary disease risk in postmenopausal women, particularly those with existing heart conditions. Further research is needed to confirm benefits and optimal usage, balancing risks like uterine cancer.
Area of Science:
- Cardiovascular Medicine
- Endocrinology
- Oncology
Background:
- Cardiovascular disease is the leading cause of death in US women, with heart attack incidence rising with age.
- Observational studies suggest estrogen therapy (ET) may reduce coronary disease risk in postmenopausal women, especially those with existing disease.
- ET demonstrates potential cardioprotective mechanisms, including lipid profile modification and vasodilatory effects.
Purpose of the Study:
- To review the evidence for estrogen therapy's cardioprotective effects in postmenopausal women.
- To discuss the optimal use of ET, including dosage, and combination with progesterone.
- To highlight ongoing clinical trials investigating ET for cardiovascular disease prevention.
Main Methods:
- Review of observational studies and preclinical findings on estrogen's effects on cardiovascular health.
- Discussion of potential benefits and risks of estrogen therapy, including effects on lipid profiles and cancer risk.
- Consideration of current clinical trials evaluating estrogen therapy in postmenopausal women.
Main Results:
- Estrogen may prevent low-density lipoprotein (LDL) cholesterol accumulation and increase high-density lipoprotein (HDL) cholesterol.
- Estrogen exhibits vasodilating properties and antioxidant effects, potentially improving cardiac performance.
- Long-term ET may increase uterine cancer risk, while progesterone addition may mitigate this but potentially reduce HDL benefits.
Conclusions:
- Estrogen therapy shows promise for reducing cardiovascular disease risk in postmenopausal women.
- The optimal regimen, including dosage and co-administration with progesterone, requires further investigation.
- Balancing the cardioprotective benefits of ET against risks like uterine cancer is crucial for clinical decision-making.
Abstract:
In the United States, cardiovascular disease represents the leading cause of death among women. A majority of the deaths are due to coronary disease. In addition, the incidence of heart attacks increases with age. Among those who are 65 years of age or older, the estimated heart attack rate is 374,000 per year for women, compared with 440,000 per year for men. In the past three decades, a number of observational studies have suggested that estrogen therapy can reduce the risk of coronary disease in postmenopausal women. This protective effect appears to be much greater in women who have existing coronary disease. These observational data point to the potential usefulness of estrogen therapy in preventing cardiovascular death among women. Although large, well-controlled, clinical trials are needed to confirm the benefit of estrogen therapy, several important findings strongly support the cardioprotective effect of estrogen therapy. For example, in monkeys estrogen prevents the accumulation of low-density lipoprotein (LDL) cholesterol (a known risk factor for heart disease) in coronary arteries, and estrogen has also been shown to increase high-density lipoprotein (HDL) cholesterol (a known cardioprotective factor). Estrogen also possesses a vasodilating property, which can improve cardiac performance in ischemic heart disease. In addition, recent studies have demonstrated that estrogens (especially equilin) exhibit a high antioxidant effect, which may also be related to cardioprotectivity. Although estrogen therapy has been observed to decrease the risk of coronary disease, long-term estrogen therapy has also been found to increase the risk of uterine carcinoma; the addition of progesterone to estrogen therapy may lessen this undesirable risk, however. On the other hand the addition of progesterone to estrogen therapy may decrease estrogen's beneficial effect on HDL cholesterol. What should be the present position on estrogen therapy in postmenopausal women? What is the best dosage regimen? Should it be used alone or in combination with a progesterone? These important issues are discussed, as are several current clinical trials addressing the issue of estrogen therapy in postmenopausal women.