IS POSTMENOPAUZALE SUBSTITUTIE CARDIOPROTECTIEF?

From a review of recent data on cardiovascular disease in women it appears that hormone replacement therapy of postmenopausal women significantly lowers the cardiovascular risk and that oestrogen therapy can be proposed as one of the most efficacious forms of primary and secundary prevention of ischemic heart disease in women. This might come as a surprise considering the well known association between previous formulas of oral contraception and coronary artery disease and the still prevailing caution for use of hormonal contraception in women at increased cardiovascular risk. This paradox can be explained by the fundamental difference in pharmacological and biological effects between the combination of synthetic oestrogens and gestagens in the contraceptive pill and natural oestrogens as used in the menopause. The mechanism by which oestrogens lower the cardiovascular risk is only partially understood. The well documented beneficial effect of oestrogens on the profile of lipids alone cannot account for the large reduction of the risk. Direct effect of oestrogens on the vascular wall probably plays an even or more important role. In spite of its proven benefit, postmenopausal hormone replacement therapy is very slow in getting of the ground. The cyclic or continuous supplement with progesterone or one of its derivatives is necessary for the prevention of endometrial hyperplasy in those women who have their uterus in place. The need for regular desquamation of the endometrium and the menstrual-like bleeding is one of the major stumbling-blocks for wide scale acceptance of oestrogen therapy. It is furthermore not yet proven that the addition of progestagens will not to a certain extent counteract the positive effects of oestrogens, although recent data give evidence to the contrary.