Effects of estrogen as a cardiovascular drug - adapted from the American Journal of Cardiology 1996;

Author: Richard Sadovsky
Date: Nov 15, 1996

Recent reviews of the effect of estrogen on the cardiovascular system suggest that long-term estrogen replacement therapy after menopause may prevent cardiovascular disease in women who are at risk. Short-term effects of estrogen on coronary vascular reactivity may warrant its consideration as an anti-ischemic agent. Ginsburg and Douglas reviewed the use of estrogen by cardiologists.

Reasons for lack of interest in the use of estrogen for cardiovascular purposes include the following: (1) concern about side effects; (2) possibility of prothrombotic effects, and (3) confusion about how a reproductive hormone can also be a powerful cardiovascular agent.

Early studies demonstrating the relationship between low rates of coronary artery disease among premenopausal women and the tremendous increase in myocardial infarction associated with patients in surgical menopause first suggested the important role of estrogen. Postmenopausal women receiving estrogen therapy demonstrated a 50 percent reduction in cardiovascular events. This exceeds the degree of risk reduction observed in primary prevention trials using aspirin or cholesterol-lowering agents. Problems with estrogen included increased rates of endometrial cancer and an increased risk of breast cancer. While retaining the beneficial effects, these problems can be eliminated by concomitant use of progestin. Retrospective studies have also shown an increased survival rate in women at risk for heart disease who also receive estrogen therapy.

The reduction in cardiovascular disease associated with estrogen therapy is related to the favorable effects on lipids and lipoproteins and the estrogen-receptor regulation of genes inhibiting endothelial effects on vascular tone. Estrogen has also been shown to be an antioxidant, a stimulator of prostacyclin production, and a potent inhibitor of platelet aggregation.

The remaining undefined risk of estrogen use is breast cancer. For most women, morbidity risks from cardiovascular disease far outweigh those from breast cancer, but patients with a personal or family history of breast cancer should not be treated with estrogen. Periodic screening for endometrial hyperplasia is performed at the discretion of the woman and her physician.

The authors conclude that estrogen should be considered a first-line agent for reducing low-density lipoprotein cholesterol and raising high-density cholesterol levels in women. Every postmenopausal woman should be educated about the value and risks of hormone replacement therapy. Appropriate dosages would be daily use of estrogen (e.g., 0.625 mg of conjugated estrogen) and daily use of a progestin (e.g., 2.5 mg of medroxyprogesterone acetate). If a hysterectomy has been performed, there is no need for a progestin.

Ginsburg GS, Douglas PS. Why cardiologists should be interested in estrogen. Am J Cardiol 1996;78:559-61.

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