Menopause and hormone replacement therapy in the 21st century

There continues to be controversy regarding the use of menopausal therapy for women, with considerable evidence supporting the benefits of oestrogen for women,1 but with recent guidelines from the American Heart Association stating that hormone replacement therapy (HRT) and selective oestrogen-receptor modulators should not be used for the primary or secondary prevention of cardiovascular (CV) disease (CVD).2 Nevertheless, there is substantial data to support that premature menopause is associated with increased risk of coronary heart disease (CHD) and CVD events.3 The reason for this, however, remains uncertain, including the adverse effects of earlier loss of oestrogen on CHD risk factors or loss of other beneficial effects of oestrogen on the CV system. In their Heart paper, O'Keeffe and colleagues4 use data from the large United Kingdom Medical Research Counsel National Survey of Health and Development to examine the association between age at cessation of menstrual period and trajectory of CHD risk factors from ages 53–69 years in over 2500 women, where approximately 1670 had data available on blood pressure and body composition and approximately 1500 had data on lipids and glucose metabolism. These results did not demonstrate a clear impact of cessation of period on conventional CHD and CVD risk factors, therefore, suggesting that the reason for the increased CHD and CVD risk in these women with early menopause likely comes from other factors. Whether or not a woman enters menopause at age 50 or 53 years may not have a great deal of differential impact on her overall CV status by the time she reaches age 69. There is, however, no doubt that with the arrival of menopause, the progression of the insidious diseases of ageing, and of CV dysfunction, …