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Estrogen and Heart Disease: Alternatives to a Paradigm in Crisis—Reply

Estrogen and Heart Disease: Alternatives to a Paradigm in Crisis—Reply In reply Sullivan raises the issue of the contribution of nonestrogen-mediated mechanisms to cardioprotection among premenopausal women. The WHI hormone trials1,2 do not refute the hypothesis that estrogen protects premenopausal women against coronary heart disease (CHD) because oral administration of conjugated estrogens with or without progestin is physiologically different from endogenous reproductive hormone delivery. Rather, the trials establish that exogenous estrogen with progestin does not prevent CHD and that unopposed conjugated estrogens do not prevent CHD, except possibly among younger postmenopausal women. Differences in CHD risk between men and women may, in fact, be attributable to testosterone,3 not estrogen; the change in slope of CHD risk at menopause4 is not universally accepted. We did not discuss testosterone or other putative nonestrogen mechanisms, since these were not the focus of our trial. We appreciate Sullivan's endorsement of the need for a paradigm shift. In acknowledging the evolution in the way medical communities and the lay public view postmenopausal hormone therapy, it is important to consider all the effects of unopposed estrogen or combination estrogen with progestin, including effects on stroke, venous thrombosis, breast cancer, fracture, and cognitive function as well as CHD and vasomotor symptoms. Consistent with current guidelines, postmenopausal hormone therapy should not be used for CHD prevention because of concerns about global risk and the availability of safer and better prevention measures. Correspondence: Dr Hsia, Division of Cardiology, George Washington University, 2150 Pennsylvania Ave NW, Suite 4-414, Washington, DC 20037 (jhsia@mfa.gwu.edu). References 1. Hsia JLanger RDManson JE et al. Conjugated equine estrogens and the risk of coronary heart disease: the Women's Health Initiative. Arch Intern Med 2006;166357- 365PubMedGoogle ScholarCrossref 2. Manson JEHsia JJohnson KC et al. Estrogen plus progestin and risk of coronary heart disease. N Engl J Med 2003;349523- 534PubMedGoogle ScholarCrossref 3. Sutton-Tyrrell KWildman RPMatthews KA et al. Sex hormone-binding globulin and the free androgen index are related to cardiovascular risk factors in multiethnic premenopausal and perimenopausal women enrolled in the Study of Women Across the Nation (SWAN). Circulation 2005;1111242- 1249PubMedGoogle ScholarCrossref 4. Gordon TKannel WBHjortland MC et al. Menopause and coronary heart disease: the Framingham Study. Ann Intern Med 1978;89157- 161PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Estrogen and Heart Disease: Alternatives to a Paradigm in Crisis—Reply

Abstract

In reply Sullivan raises the issue of the contribution of nonestrogen-mediated mechanisms to cardioprotection among premenopausal women. The WHI hormone trials1,2 do not refute the hypothesis that estrogen protects premenopausal women against coronary heart disease (CHD) because oral administration of conjugated estrogens with or without progestin is physiologically different from endogenous reproductive hormone delivery. Rather, the trials establish that exogenous estrogen with progestin...
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Publisher
American Medical Association
Copyright
Copyright © 2006 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.166.19.2160-b
Publisher site
See Article on Publisher Site

Abstract

In reply Sullivan raises the issue of the contribution of nonestrogen-mediated mechanisms to cardioprotection among premenopausal women. The WHI hormone trials1,2 do not refute the hypothesis that estrogen protects premenopausal women against coronary heart disease (CHD) because oral administration of conjugated estrogens with or without progestin is physiologically different from endogenous reproductive hormone delivery. Rather, the trials establish that exogenous estrogen with progestin does not prevent CHD and that unopposed conjugated estrogens do not prevent CHD, except possibly among younger postmenopausal women. Differences in CHD risk between men and women may, in fact, be attributable to testosterone,3 not estrogen; the change in slope of CHD risk at menopause4 is not universally accepted. We did not discuss testosterone or other putative nonestrogen mechanisms, since these were not the focus of our trial. We appreciate Sullivan's endorsement of the need for a paradigm shift. In acknowledging the evolution in the way medical communities and the lay public view postmenopausal hormone therapy, it is important to consider all the effects of unopposed estrogen or combination estrogen with progestin, including effects on stroke, venous thrombosis, breast cancer, fracture, and cognitive function as well as CHD and vasomotor symptoms. Consistent with current guidelines, postmenopausal hormone therapy should not be used for CHD prevention because of concerns about global risk and the availability of safer and better prevention measures. Correspondence: Dr Hsia, Division of Cardiology, George Washington University, 2150 Pennsylvania Ave NW, Suite 4-414, Washington, DC 20037 (jhsia@mfa.gwu.edu). References 1. Hsia JLanger RDManson JE et al. Conjugated equine estrogens and the risk of coronary heart disease: the Women's Health Initiative. Arch Intern Med 2006;166357- 365PubMedGoogle ScholarCrossref 2. Manson JEHsia JJohnson KC et al. Estrogen plus progestin and risk of coronary heart disease. N Engl J Med 2003;349523- 534PubMedGoogle ScholarCrossref 3. Sutton-Tyrrell KWildman RPMatthews KA et al. Sex hormone-binding globulin and the free androgen index are related to cardiovascular risk factors in multiethnic premenopausal and perimenopausal women enrolled in the Study of Women Across the Nation (SWAN). Circulation 2005;1111242- 1249PubMedGoogle ScholarCrossref 4. Gordon TKannel WBHjortland MC et al. Menopause and coronary heart disease: the Framingham Study. Ann Intern Med 1978;89157- 161PubMedGoogle ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Oct 23, 2006

Keywords: heart diseases,estrogen

References