Cardiovascular Risk in Climacteric Women: When to Begin the Hormone Treatment?

Abstract

Hormonal changes determine a greater vulnerability in the cardiovascular system and thus, when considering the cardiovascular health of a menopausal woman, personalized medicine is decidedly required to ensure she is an appropriate candidate for menopausal hormone therapy (MHT). Tailoring to the individual patient is important for establishing the optimal dose, the formulation, and the administration route, as well as for ascertaining the effects of MHT initiated prior to the onset of a cardiovascular disease (CVD), for assessing whether there is a special group of women whose risk for CVD may increase or diminish with the therapy, and for clarifying the differences among the research protocols according to the MHT administration route in relation to the cardiovascular system. Basic research studies clearly show that in early menopause estrogens promote increased vasodilation, a decrease in inflammatory factors, and a slowing down in the progression of atherosclerotic lesions. They also show that in late menopause estrogens produce the reverse effect, i.e., decreased vasodilation, an increase in inflammatory factors, and growing instability of the atherosclerotic plaque. Randomized clinical trials (RCTs), observational cohort studies, and meta-analyses show that estrogens used as a MHT may diminish CVDs and the causes of mortality in women younger than 60 years and with less than 10 years of menopause. The data on combined estrogen–progestogen therapy in the same population are suggestive of a similar tendency; however, some RCTs did not find a significant increase or decrease in CVDS. The DOPS study was the only long-term study to include women approaching menopause or going through it and have them begin MHT. It provided evidence that prevention benefits surpass the risks and confirmed the data accumulated in the last 50 years that MHT reduces CVDs and mortality when prescribed for women at the very beginning of postmenopause. They corroborate the findings that MHT, including tibolone and the combination of conjugated estrogens with a SERM (bazedoxifene), is the most effective treatment for the vasomotor symptoms associated with menopause. The benefits surpass the risks when therapy is initiated before age 60 in women with less than 10 years of menopause. They highlight the distinction between estrogen therapy and combined MHT, stress the difference in the risk of venous thromboembolism and ischemic stroke between the oral and the transdermal routes, and emphasize that treatments should be individualized and their dosages and duration should conform to their objectives and to safety issues. The MHT poses no danger for the cardiovascular system; on the contrary, if given to the right woman at the right time, it may reduce the risk of a CVD. This is what is known as the “window of opportunity.”