Sex, hormones and the heart

Dr Louise Newson BSc(Hons) MBChB(Hons) MRCP FRCGPwww.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 studyEarly 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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