Page 6 - Island hospital Heartbeats_Winter2018

Menopausal hormone-replacement therapy

by Robert Prins MD, Ob/Gyn of disease and treatment of disease. Estrogen cles was just published in the Journal of the
Island Hospital Chief Medical Officer effectively prevents heart disease. Estrogen American Medical Association (JAMA) last
treatment of heart disease was a disaster, well- September. They concluded that for the entire
t has long been recognized after we attempted to prevent fur- study group there was not an increased car-
Iobserved that there ther heart attacks in males by using estrogen
is a distinct difference in therapy. The study was supposed to be com- diovascular or cancer risk during a cumulative
the occurrence of heart prised of “just post-menopausal” women follow up of 18 years.
disease between men and whose average age would be 45-55. These There were many more problems with this
women. Women appear to would be women who had waning estrogen study that biased its conclusions that I have
have heart attack symp- which needed to be replaced. The investiga- not detailed here. In all, the study was badly
toms 10 years on average tors, however, chose to select a broad spec- conceived, biased and its conclusions not war-
later than men. Documented heart attacks trum of menopausal women whose average ranted. Estrogen is safe and it is effective in
occur on average 20 years later. These differ- age was 63.5 with the oldest woman admitted preventing heart disease, reducing the risk of
ences disappear if a woman has her ovaries to the study being 79. This group of women, Alzheimer’s Disease, reducing the incidence of
removed before the menopause and is pre- on average 15 years post-menopausal, had colon cancer and preventing osteoporosis. Its
sumptive evidence that female hormones are already developed those plaques in their arter- effects of eliminating hot flashes and insom-
responsible. Studies in non-human primates ies. The effect of estrogen on them was the nia, promoting genital health and improving
have repeatedly shown the protective benefits same as in the males treated with estrogen for bowel and bladder function are also well rec-
of female hormones in the prevention of coro- heart attacks. ognized as the beneficial short-term effects of
nary-artery disease. Experiments on isolated HRT. Using post-menopausal estrogen
blood vessels have repeatedly demonstrated Since the original article many investiga- replacement is a very personal choice, but it is
that female hormones prevent fatty deposits tors outside of the study have reworked the an important choice that needs to be made
(plaques) and maintain the health of the lin- data of the smaller cohort of “just post-meno- with valid information.
ing of these blood vessels. Female hormones pausal” women in the study. They found the Island Hospital Chief Medical Officer Robert
appear to lower bad cholesterol (LDL) in the expected 35-50% decrease in heart disease so
blood and raise good cholesterol levels (HDL). well described in the cohort longitudinal stud- Prins MD, Ob/Gyn, practices at Fidalgo
Low LDL levels matched with high HDL lev- ies of the past. The most recent of these arti- Medical Associates at Island Hospital.
els have always been an indicator of a low risk
of heart disease. Finally, multiple large obser-
vational longitudinal studies (following a sin-
gle person over time) carried out over the last First baby of 2018 celebrated
50 years have repeatedly demonstrated a
35-50% reduction in heart disease. Island Hospital had
So wherein lies the controversy concerning to wait a few extra
estrogen replacement (hormone-replacement days to welcome the
therapy or HRT) in the menopause? In 1993 a
study was begun to test the above hypothesis first baby of 2018.
that estrogen therapy in the menopause would With much anticipa-
reduce the incidence of heart disease. More tion, a healthy baby
than 16,000 women were recruited for the girl was born Jan. 3
study, which was to continue until 2005 but at 6:35 p.m. to proud
was discontinued early in 2002. This study, a parents Taylor and
subset of the Women’s Health Initiative, was Josh Ratzel of Oak
randomized (patients were randomly assigned Harbor. Braelynn
to HRT or placebo), and double-blind (nei- Ratzel weighed in at
ther investigators nor the patients knew what 7 lbs., 5 ½ oz. and
medicine they were taking). The results pub- measured 20 inches.
lished with great fanfare received widespread Welcome to the world
media attention. The study concluded that
there appeared to be no protective benefit Braelynn!
with the use of HRT and was stopped early
because of a concern about the number of
breast cancer cases in the HRT group.
How do we reconcile these conflicting
pieces of information? The problem with the
study lies in the failure of its investigators to
recognize the difference between prevention
6 | Heartbeats | Winter 2018