Estrogens for prevention of coronary heart disease. Putting the brakes on the bandwagon.

Abstract

Eighty-two percent of 1383 cardiologists, internists, family doctors, and general practitioners surveyed by the National Heart, Lung, and Blood Institute (NHLBI) reported that they prescribe hormone replacement therapy (HRT). Of those who prescribe it, 93% do so for relief of menopausal symptoms and 91% for osteoporosis. These are proven and accepted indications for estrogen replacement therapy. However, 41% also prescribe it for high blood cholesterol, and 66% prescribe it for coronary heart disease. These are not proven indications and should not be accepted as such until unequivocal clinical trial data are available. Why, then, have so many medical practitioners climbed aboard the HRT bandwagon? That bandwagon is clearly rolling, as anyone who reads newspapers or magazines, watches television, or talks to colleagues can attest. The bandwagon appears to be picking up in speed and volume. The putative benefits of HRT are being trumpeted to postmenopausal women, with only transient muting for reports of possible adverse effects. A short history of HRT is instructive. The use of postmenopausal estrogens first gathered momentum during the sixties under the banner of “feminine forever.” The promise to women that estrogens would hold back the ravages of time went unfulfilled, and instead they learned that they were being put at increased risk of endometrial cancer.1 Other disturbing news emerged: estrogens increased the risk of coronary heart disease (CHD) in men, and oral contraceptives increased the risk of CHD and stroke in middle-aged women.2 3 Result: from the midseventies onward, estrogen use declined precipitously.4 Better news started emerging in the eighties: estrogens prevented bone loss, and estrogen users appeared to be at lower risk of CHD.5 6 When it was demonstrated that concomitant administration of progestins removed the risk of endometrial cancer, the brakes were loosened and use of postmenopausal hormones has …