Sex, hormones and the heart Dr Louise Newson BSc(Hons) MBChB(Hons) MRCP FRCGP www.menopausedoctor.co.uk #IandA2017
Declaration I have had financial relationships (lecturer, writer, member of advisory boards and/or consultant) with Pfizer, Meda, Mylan, Besins, Replens, Regelle, Sylk and MonaLisa Touch
Case history Mrs Smith 51-year-old woman Worried about her heart Palpitations Occur at rest Worse at night time More tired than usual FH of CVD
Cardiologist referral Blood pressure Normal ECG Normal Echo Normal 24 Hour Tape Normal Exercise Test Normal
Further questioning More anxious Sleep not good Irritable at times Low mood at times Likely diagnosis: Anxiety Cardiologist suggested propranolol
Even further questioning reveals LMP 13 months ago Hot flushes around 8 a day Night sweats and poor sleep Urinary frequency and urgency Worsening migraines Vaginal dryness and irritation No libido
So what is the diagnosis?
Effect of oestrogen on body Physical shape Breasts Uterus / vagina / urethra Collagen Cardiovascular system Bones Brain Emotions
Hot flushes Not always benign Associated with: Increased risk of cardiovascular disease Adverse lipid profiles Raised systolic blood pressure Increased insulin resistance Increased inflammatory markers Worsening of endothelial function Lower bone density Increased risk depression Climacteric 2015: 4; 306-312
Heart disease and menopause The risk of CVD greatly increases after the menopause Increased body fat and reduced insulin sensitivity Increased type 2 diabetes Increased blood pressure Increased cholesterol levels and triglycerides Reduced levels of HDL-cholesterol Women with POI have greatly increased risk of CVD Risk of heart disease doubles in women with BSO and no HRT
Women s Health Initiative (WHI) Study Assess long term risks and benefits of HRT Average age 63 years High dose oral HRT Preliminary data leaked to press early
Danish Osteoporosis Prevention Study (DOPS) 1006 women aged 45-58 years, average 7 months post-menopause Randomised to oral HRT or no treatment Trial stopped after 10 years (observational follow-up for further 6 years) RR CHD 0.5 No increased risk of stroke, VTE or cancer (including breast cancer) with HRT Schierbeck et al BMJ 2012 345 e64094
ELITE study Early versus Late Treatment with Estradiol 643 postmenopausal women Studied for up to 6 years Randomised to HRT or placebo Women either <6 years or >10 years from menopause U/S carotid artery I/M thickness progression significantly reduced in women taking HRT early Hods et al Circulation 2014 130 A13283
HRT - impact on cardiovascular disease in post-menopausal women 19 trials 40,410 women HRT all age cohorts no protection for CVD / mortality HRT <10yrs postmenopause lower mortality RR 0.70 lower CHD RR 0.52 Boardman et al Cochrane Database Syst Rev 2015
HRT and Coronary Vessels
Hormone replacement therapy (HRT)
Type of HRT matters Transdermal oestrogen No VTE risk Can be used in women with migraines / diabetes Oral oestrogen can lower libido
Type of HRT matters Micronised (natural) progesterone Can improve cardiovascular risk / lipids Neutral effect on BP / may reduce BP No VTE risk Different effect on breast cancer risk MPA can negate cardioprotective effect of oestradiol
HRT and breast cancer The risk is lower than most people realise
Breast cancer Breast cancer is common Increased risk of breast cancer with: Increasing age Family history Obesity Alcohol Reduced exercise
Breast cancer and HRT No increased risk of breast cancer in women: Who only take oestrogen Who are young Appears to be lower risk with micronised progesterone and dydrogestone Any increased risk reduces after stopping HRT Modifiable risk factors need to be addressed No increased risk of death from breast cancer
Testosterone not just a male hormone!
Testosterone in women
Testosterone in women Reduces risk of cardiovascular disease Beneficial effect: Glucose metabolism Lipid profiles Lean body mass Muscle strength
Testosterone Reduced libido despite HRT Consider testosterone Mood, energy and concentration often improve Testim / Testogel Younger women Post TAH and BSO
HRT as primary prevention of CVD?
Heart disease and HRT - Summary Lower incidence of CVD in women taking HRT within ten years of their menopause CVD benefit of taking HRT is greatest the earlier a woman starts HRT Window of opportunity HRT can lower cholesterol HRT can reduce future risk of diabetes Manage any underlying cardiovascular risk factors (eg BP, cholesterol) HRT is not as dangerous as many people think
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