Thread by @KarenMagraith

Myth: Menopausal hormone therapy (MHT) increases the risk of coronary heart disease. ❤️❤️

The question of whether MHT causes or protects from heart disease has been a subject of debate.

Here’s my take. 🧵
1/10

Prior to menopause women are relatively protected from heart disease, and this is related to the role of estrogen.
The menopause transition is associated with an increase in risk of heart disease which has been shown to be separate from the effects of chronological aging. 2/10

Observational studies found a reduction in heart disease for women taking MHT.
There is RCT evidence that estrogen has beneficial effects on cardiovascular risk factors, such as lipids and glucose metabolism. It also has effects on blood vessel function. 3/10

The Women’s Health Initiative RCTs reported an increase in heart disease in women taking oral conjugated equine estrogens with medroxyprogesterone acetate.
Why was there a difference between the observational data and the WHI? 4/10

The average age of women in the WHI was 63, and subsequent analyses found that there was no increase in risk for women aged 50-59 at the time of randomization. At long term follow-up there was a reduction in risk for younger women taking estrogen only. 5/10

In meta-analyses there’s evidence of a reduction in heart disease with MHT in younger women.

This supports the timing hypothesis, which proposes that healthy women close to menopause benefit from estrogen, whereas those who start estrogen many years after menopause don’t.
6/10

More research is needed to investigate MHT and heart disease, including exploring the effects of transdermal estrogen, and the role of progestogens. Transdermal estrogen may be safer than oral. Some synthetic progestogens may increase risk. 7/10

What recommendations can we give clinically?

1. For women with pre-existing heart disease, MHT is not recommended. Transdermal estrogen is preferred over oral for women who have risk factors for cardiovascular disease. 8/10

2. Women with premature ovarian insufficiency (under 40) or early menopause (40-45) have an increased risk of heart disease and MHT appears to reduce this risk. 9/10

3. For healthy women at the usual age of menopause (45-55) who wish to start MHT to treat symptoms, they can be reassured that MHT will not increase their risk of heart disease. Indeed, for some women it may provide cardioprotection. 10/10
❤️❤️❤️
#Menopause