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I am a mother aged 53. I am concerned to read that coronary heart disease is a major risk for me. Isn’t this a man’s disease?
Of the deaths from heart attacks each year, nearly half are in women. All forms of heart and blood vessel diseases added together claim twice as many women’s lives as do all forms of cancer. Although fewer women have heart disease than men at the age of 50, they have caught up by 65–70 years of age. The main difference between men and women as regards heart disease is not if they are going to get coronary disease, but when; the difference in its timing is about 10 years.
Coronary heart disease is therefore your – and other women’s – biggest problem too. It is becoming more of a woman’s disease as women tend to live longer; coronary disease is partly a problem of getting older, so more women will eventually develop it. The problem is going to increase as the population ages in general. More men and women are now surviving heart attacks, so they are likely to encounter heart problems later – an increased chance of angina or a further heart attack, unless they try to reduce their risks. Women are more vulnerable to the risks of cigarette smoking and high blood pressure but less so to that of cholesterol. Having diabetes sadly wipes out any advantages that women may have had over men (see above).
My father had heart disease and I am concerned that my daughter might develop heart disease also. I know that she smokes. How can I help her avoid heart disease?
Y our daughter may have an increased risk of heart disease if it runs in your family but one of the best ways to help prevent coronary heart disease is to get her to stop smoking. It is well known that there has been an increase in the numbers of young women smoking; their chances of heart disease in later life consequently are rising. If your daughter smokes, she should stop now. If she is thinking about starting, she should think again!
I have read that women’s natural hormones protect us from heart disease. Is this true?
To a degree they do, but if you smoke, have high blood pressure or have diabetes, women lose a lot of this protection. Following the menopause, the normal protection that oestrogen gives disappears anyway. Hormone replacement therapy (HRT; see below) unfortu ¬nately does not appear to help.
I have been taking the pill on and off since I was 18. I have just been through the menopause. Am I at any greater risk of heart disease because I have been using oral contraceptives?
Very few women on the pill (taking oral contraceptives) develop heart disease and the low hormone dose pills do not increase the coronary risk. So long as you do not smoke, the low dose pill may actually protect you against heart problems. In women under 35 years of age we do not know what the risk is from taking the pill, nor do we know about its long-term use (over 5 years), although it is unlikely you will be harmed. Cigarette smoking and also taking the pill is not a good combination and should be avoided at all costs. In general the low dose pills are safe, but smokers should preferably stop smoking, or use alternative contraception.
I have felt well since being on HRT but I am worried about its effect on my heart and the risk of breast cancer – what should I do?
There is no doubt that HRT helps with the distressing symptom of menopausal flushes and protects against thinning of the bones (osteoporosis). Initial enthusiasm regarding HRT and heart disease has been replaced with sound scientific evidence of a lack of benefit. Currently HRT is not recommended as a treatment to prevent heart disease developing or to benefit women who have heart disease already. If coronary disease has been diagnosed, other protective treatments should be used – for example statin therapy. Some studies have suggested HRT can actually increase the risk of heart disease, but this risk does not appear to be present if the cholesterol is normal or a statin is also being taken.
A very big study – The Million Women Study – has identified an increased risk of breast cancer if HRT is taken for 5 years or more. We are looking at 1 extra case of breast cancer in 166 women treated for 5 years or 1 extra case in 53 women treated for 10 years. There is no need to panic about these figures, but clearly women on HRT for many years should see their family doctor about discontinuing.
The HRT story is a sad journey from the belief of benefit to the proof of potential harm. There is no role for HRT in women who do not have menopausal symptoms (such as flushes). When flushes are a problem (this happens in 10–20% of women), the risks must be weighed against the benefit, and HRT used for as short a time as possible.
Most women are on combined medications of oestrogen and progestogen but, if they have had a hysterectomy (removal of the womb), they will be on oestrogen alone. All increase the breast cancer risk. With regard to the heart, we are not sure about oestrogen alone but, with all the information we have, HRT cannot be considered a treatment for heart disease.
Whether this advice will change when we know more about raloxifene (see next question) is debatable, but it is obviously important to continue research in this area and advise women on up¬to-date scientific facts.
I have read in the paper about a new drug called raloxifene – what advantage does this have?
Raloxifene is one of a class of drugs called Selective Estrogen (American spelling) Receptor Modulators,or SERMS. Tamoxifen is the one we already have but tamoxifen can sometimes, as a side effect, cause the uterus (womb) lining to overgrow and become troublesome. Raloxifene acts the same as tamoxifen in benefiting the heart and bones, avoids breast cancer risks and does not affect the womb. It is an important drug but like tamoxifen does not reduce hot flushes. It may be an important advance in HRT for women because it looks to have the major benefits without the major risks. A lot of research is taking place to determine how valuable it will be to the heart
– proof is not yet available, but early results do not show any harm.
Does HRT have any side effects?
All medication can give side effects and HRT is no exception. You may feel nauseous but it usually goes after 2 weeks or so – taking tablets after a meal can help this. Breast tenderness and swelling may occur and, again, wear off. If they are persistent, you may be given a different form of HRT to try.
Women worry about gaining weight whilst on HRT. The many research trials do not report weight gain but you should remember that everyone is an individual and if you gain weight, it is you that matters, not the statistics. It is probably due to eating more as you feel better on HRT! Watching your weight is important anyway, so at this time take note of what you are eating and make sure that you take plenty of exercise.
On average, women take 3 months to settle into their HRT therapy.
Does HRT raise blood pressure?
Very rarely. Your doctor or nurse will always check your blood pressure when HRT is prescribed. If you have high blood pressure, you can still take HRT because the chances of your control being upset are so small.
I have breast cancer which is now controlled, and I have also had a heart attack – will HRT help me?
t will not obviously help the heart and it could make the breast cancer worse, so it is not recommended. HRT is not an alternative to proven heart attack treatments.
What sort of HRT therapy is available?
The choice of therapy is best discussed with your doctor. There are two sorts: the first is oestrogen only and this type is for women who have had a hysterectomy (removal of the womb) – this is known as ‘unopposed oestrogen’. The second type is ‘combined’ HRT (containing oestrogen and progesterone) for women who still have a womb, because oestrogen alone in these women will cause excess stimulation of the lining of the womb.
I have been advised to go on HRT but I am resisting as I have read that it doubles your chances of getting blood clots in the legs – is this true?
Yes, this is true. Your normal risk of getting a dangerous blood clot is 1 in 10 000 and it increases to 2 in 10 000 on HRT. So the risk is very small and remains very small on HRT. The risk is higher in those over 60 years of age, but HRT is rarely started in this age group. Smoking and being overweight increase the risk. Talk to your doctor about this, if you think that you may be at risk.
I’m fit and active with no risk factors for heart disease – will I benefit from HRT?
f you have no risks for heart disease, HRT will not improve this as your risk is very low anyway, but you may benefit from HRT by avoiding osteoporosis (thin bones). This is more common in slim women. HRT also helps to relieve hot flushes. Check with your doctor about the possibility of having a bone density scan if you think you may be at risk for osteoporosis.
From the point of view of heart health, who will benefit most from taking HRT?
No one.
I have been taking HRT for 7 years and I think that it is wonderful – I now feel a new woman! However, my doctor says that I should stop it soon. How long should I continue taking HRT?
HRT is usually taken for hot flushes for up to 5 years. Bone benefits continue on beyond 10 years, but the breast cancer risk increases. So, at present, we recommend HRT is stopped.
I’m on HRT at the moment. Do I need regular check-ups?
It is very important that you attend for regular check-ups at first every 3 months and then 6-monthly, and follow your doctor’s instructions. For these check-ups, make a note of any queries or concerns that you might have and discuss them with your doctor.
I have been on oral HRT for some months and my doctor has arranged for me to have a lipid test. Why?
The doctor is checking to make sure that you are not at risk of heart disease, which is good medical practice. Up to the menopause, women usually have a raised high density lipoprotein level (HDL) (greater than 1.3) which helps protect them from coronary disease. This HDL gradually falls after the menopause unless HRT is taken. It is important that women should always have a ‘full lipid profile’taken (HDL as well as LDL) because a high total cholesterol may reflect good (HDL) rather than bad (LDL) cholesterol levels. Reducing your total cholesterol in this situation might reduce the protective HDL and be counter -productive.
A full lipid profile will also tell you about your triglycerides. Oral HRT can raise triglycerides, but HRT patches have no effect on triglyceride levels. A high triglyceride level is more of a risk in women than in men; the best means of lowering it is by weight loss and regular exercise, along with a low saturated fat diet. An underactive thyroid and too much alcohol can also be a cause.
I do find the advice on HRT confusing – can you clarify it for me?
I’ll try, but doctors find it confusing too!
• HRT definitely helps menopausal symptoms, e.g. hot flushes.
• It definitely helps prevent thin bones (osteoporosis).
• It does not protect against heart disease developing.
• In those with coronary disease, it does not benefit them, so it is not a treatment for heart disease.
• In those with heart disease, it still helps menopausal symptoms and osteoporosis.
• HRT increases the risk of breast cancer.
• Overall, HRT is indicated only if menopausal symptoms are severe and intolerable. It is then given for as short a time as possible and at as low a dose as possible.
I’m concerned that my wife is at risk of heart disease and I want her to take it seriously; she smokes and is rather well padded! However, her doctor does not seem to be bothering either. What should I tell her?
You should point out that women are just as vulnerable to coronary disease as men. Some women don’t recognise this and play down any symptoms of chest discomfort. They usually put their family first. Sometimes they might hide things from the doctor, which makes diagnosis difficult for both angina and a heart attack.
Your wife and every other woman should take heart disease seriously and her doctor, like all doctors, should recognise that women with a mixture of symptoms need taking seriously. Women may be reassured too easily because most women believe themselves to be less likely to have heart disease than men.
Post-menopausal women are at more risk and, even when the symptoms are not typical, these should be discussed and heart disease ruled in or out.
Women are just as likely as men to develop coronary disease if they smoke and just as likely to benefit if they stop. Keeping to a sensible weight and taking regular exercise are also important preventative measures. Tell her that heart disease is an equal opportunity killer and that she should do her best to avoid it for her sake and that of her family.
Send for the British Heart Foundation’s booklet Women and heart diseaseand present it to her!
Reference:
All questions are answered through articles indexed in www.PubMed.com and edited by: Dr G. Jackson in Heart Health 4th edition.
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