Menopause and menopause: natural processes in women's lives
We physicians at Cardiopraxis also see menopausal and menopausal women who develop complaints during this particular time. With the drying up of estrogen production, so-called vasomotor complaints such as hot flashes or sweating can occur. But also sleep disturbances, depressive moods or sexual dysfunctions affect the quality of life. The expiry of female fertility is a normal aging process in a woman's life. Therefore, we understand hormone deficiency as a natural condition and basically not as a deficiency condition. But almost one in three women experience the discomfort to such an extent that it interferes with their daily lives. This is where therapy with estrogens would help. However, hormone therapy can have adverse effects if cardiovascular risk factors and pre-existing conditions are present; for example, it can increase the risk of ischemic stroke or thromboembolism. Consequently, a cardiovascular assessment is useful before starting hormone therapy to determine the individual risk for cardiovascular disease and possible contraindications as early as possible.
Hormone therapy: learning from the past-the Women's Health Initiative.
Hormone therapy is an effective measure for complaints and is now recommended again. This was not always the case. The past, especially the study results of the Women's Health Initiative (WHI) from 2002 and 2004, resulted in a great deal of uncertainty on the part of physicians, but also on the part of patients. Whereas until the 1990s hormone therapy was prescribed rather generously regardless of actual symptoms, age at initiation of therapy, and existing cardiovascular risk factors, a radical change occurred after the publication of the Women's Health Initiative (WHI) study results in 2002 and 2004. These results had established a high risk of cardiovascular disease and also of breast carcinoma under hormone therapy.
Women's Health Initiative: analyses and other studies put data in perspective
A more detailed analysis and numerous other studies put the WHI data into perspective in that the above risk increases were not equally applicable to all women, nor were they generally applicable to the preparations used today: Women were older (mean age was 63.3 years), and about 50% already had risk factors(obesity, nicotine abuse, arterial hypertension, hypercholesterolemia) and preexisting conditions (coronary artery disease) before starting therapy. In addition, only orally administered estrogens were used.
Safe hormone therapy for the cardiovascularly healthy woman.
For cardiovascularly healthy women who had started therapy around the age of 50, no relevant increase in risk was demonstrated in the further analysis of the Women's Health Initiative. For women under 60 years of age, there were even preventive effects with regard to the risk of myocardial infarction. The probability of suffering a stroke was not relevantly increased during this period. Accordingly, the best and safest time for hormone therapy is with the onset of menopause. In contrast, cardiovascular risks increase significantly beyond age 60 or more than 10 years after the onset of menopause.
Individualized hormone replacement therapy: with the lowest dose and only for as long as necessary
Modern hormone therapy involves the individualized use of preferably low-dose estrogens. These are combined with progestogens if the uterus is present, in order to prevent uncontrolled proliferation of the endometrium. Otherwise, the risk of endometrial carcinoma increases. After uterus removal, estrogen alone can also be substituted.
Application through the skin (transdermal) is preferred nowadays to avoid metabolization in the liver with potential activation of the coagulation system. Nevertheless, oral therapy (as a tablet) may be useful in some cases, e.g., for androgenization symptoms or for better bleeding control in cardiovascularly healthy and unaffected patients. In contrast to the usual hormone substitution, e.g. in case of hypothyroidism, we do not define target values here, because low estrogen and progesterone levels in this phase of life are physiological and do not express a deficiency. The goal is to treat hormone deficiency-related complaints with the lowest hormone dose and only for as long as necessary.
Control of vascular risk factors makes sense before starting therapy
It is well known that the risk of cardiovascular disease and corresponding risk factors increases with age. Even in menopausal and menopausal women, cardiovascular risk varies greatly, so we recommend individual control and treatment of possible vascular risk factors so that they do not constitute a contraindication to hormone replacement therapy.
Cardiovascular diseases and hormone replacement therapy
With regard to cardiovascular diseases, hormone replacement therapy can have positive but also negative effects. On risk factors such as hypercholesterolemia, diabetes and hypertension, hormone replacement therapy can have a positive effect: The risk of diabetes is significantly reduced, LDL ch olesterol (the "bad" cholesterol) is lowered, and elevated blood pressure is often reduced. Nevertheless, hormone replacement therapy is usually not sufficient to completely eliminate the risk factors, especially since a preventive approach is also clearly discouraged. The risk of coronary heart disease (CHD) and heart attacks is often the subject of controversy. According to the study results, however, combined therapy with estrogen and progestin has little or no effect on the risk of myocardial infarction if the therapy is started in the first 10 years after menopause, i.e., usually between the ages of 50 and 60.
Hormone replacement therapy unsuitable as prevention of coronary heart disease
Estrogen therapy alone, as may be considered for women after removal of the uterus, probably even reduces the risk of heart attack. In any case, it does not increase CHD risk. This is probably due to the beneficial effect of estrogens on risk factors. Nevertheless, hormone replacement therapy is unsuitable for the sole prevention of coronary heart disease because of the thromboembolic risk. In patients younger than 60 years (or within ten years of menopause) with healthy or mildly atherosclerotic coronary arteries, hormone therapy is safe. The situation is different in patients with advanced atherosclerosis. Here, pro-inflammatory (inflammatory) and plaque-destabilizing effects come to the fore, so that hormone replacement may have a negative effect. According to current guidelines, manifest coronary disease is therefore a contraindication for therapy.
Thromboembolic diseases and hormone replacement therapy
Thromboses are mainly triggered by increased clotting activity, e.g. by severe obesity or a genetic, i.e. inherited, predisposition to thromboses. Indications of this are either previous venous thromboses or pulmonary embolisms of one's own or close blood relatives who suffered a thromboembolic disease at a young age. Estrogens have thrombogenic effects; these vary depending on the dose and route of administration. In contrast, the thrombogenic effects of progestins appear to be of secondary importance. In the first 2 years of oral hormone replacement therapy, the risk of thrombosis is remarkably increased 3- to 4-fold. Transdermal application does not appear to be associated with an increased risk of thrombosis, presumably because of the lack of hepatic passage of estrogens and the resulting avoidance of activation of coagulation factors. In any case, evidence of an increased risk of thromboembolism should be investigated before hormone replacement therapy. In suspected cases, special coagulation diagnostics (thrombophilia diagnostics) should be performed. Consequently, a history of thromboembolic disease is a contraindication to hormone replacement therapy.
Cerebrovascular disease and hormone replacement therapy.
Strokes are the second most serious risk of oral hormone replacement therapy after thrombosis. The risk is very low in the first 10 years after menopause. Nevertheless, the risk factors of hypertension and diabetes should be well controlled before therapy. Smokers generally have a higher risk. The risk normalizes completely after hormone replacement therapy is discontinued. As with thrombosis, the risk of stroke can possibly be avoided by using transdermal therapy (patches, gels) according to current knowledge. However, no data from randomized intervention trials on stroke risk are available for transdermal hormone replacement therapy. Hormone replacement therapy should not be used in the presence of known cerebrovascular disease, such as stroke or transient ischemic attack.
Conclusion:
From a cardiological point of view, vascular risk factors such as high blood pressure, diabetes, high cholesterol and smoking do not preclude the use of hormone replacement therapy. However, they should be optimally controlled. In addition, smoking should be stopped and, if a tendency to thrombosis is suspected, this risk should be clarified in more detail. The risk of cardiovascular diseases such as thrombosis, stroke and myocardial infarction is lowest if hormone replacement therapy is started within the first 10 years of menopause and a low estrogen dose is used as a patch, gel or spray. Before starting therapy, possible cardiovascular and thromboembolic disease and breast carcinoma must be excluded. Under ongoing hormone therapy, annual gynecological check-ups are advisable in order to be able to detect any new contraindications in good time.
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