Chapters Transcript Video Prevention & Hormone Replacement Click here to view presentation deck Back to Symposium Hi, good morning, everyone. Pleasure being here. I am uh an advanced cardiac imager, general cardiologist. Um Angelina Zoska. Nice to meet you. All right. So, um now that we've heard uh for Doctor Lynch, uh that are two about um women uh taking care of women um during pregnancy, we took them from pregnancy to now per menopause and menopause. And um my to day talk will fo focus on uh menopause and hormone replacement therapy. So, as we know, cardiovascular disease is a leading cause of death in women. Um their sex differences in the risk conferred uh by traditional risk factors. Women, addition, women additionally experience um unique risk factors through their lifetime that are influenced by hormones that are influenced by pregnancy as we just heard and of course, influenced by menopause. Today, I will specifically focus on a menopause and the risk factors that are associated uh as women enter their menopause. So I don't have any relevant disclosure to my today's presentation. So let's just dive in before we actually fully dive in into my presentation. Just wanted to clarify um the slide a little bit. So today, um I will in my, today's talk, I would like to discuss two terms that are often used is sex and gender. Sex is a biological, variable. Gender is uh can be broadly defined as a multi dimensional construct that encompasses gender identity and expression, as well as social and cultural expectation about the status characteristics, behavior as a as they're associated with a certain sex trait, sex and gender can shape um can influence cardiovascular disease um interchangeably and separately as well. In my today's presentation, I will be using female and male. Um um and as well as uh man and woman interchangeably, and I will focus on sex specifically as a biological determinant. And I know that this is a complex topic that will be uh requires its own presentation. But I thought it was worth mentioning uh uh in today's presentation. So, um life expectancy as we know is increasing in women and women actually now spend about 40% of their life in menopause. What is the definition of menopause as we all know uh that uh natural menopause is defined as permanent cessation of menstrual periods determined retrospectively after a woman has experienced 12 months of amenorrhea without any obvious physi uh pathologic or physiologic cause. It occurs at the median age now of 51.4 years and uh is a reflection of complete or near complete oval uh ovarian follicular depletion uh with resulting hypo hypoestrogenemia and high follicular hormone concentrations. What are some of men menopause? Facts and why is this important? Over 63 million of women in the US are over the age of 50 around 6000 of women enter menopause each year. Vasal motor symptoms are most common symptoms during menopause. And about 75% of women experience vasal motor symptoms, which is a high number. Uh visa motor symptoms are most common in black and African women and smokers. Um What have in terms of the cardio metabolic changes with me? What do we see? So, we know that estrogen in general reduces um oxidative stress. Uh it reduces endothelial dysfunction. It inhibits the activation of Ren ren and angio dense and all Doster system. It increases uh brain naic peptide levels. It also attenuates fibrosis and this is something we'll talk a little bit later. Uh Some of the changes will happen after menopause. There's loss of inhibition of these processes due to menopause and um uh and due to decline of estrogen in the body and this contributes to increased cardiovascular disease risk in women after they enter menopause. So, um why as a cardiologist do I care about menopause, why do I see patients and counsel them about uh hormone replacement therapy? Well, uh there are numerous adverse changes that happen uh to women after they enter menopause. Um and the specific study, um the study of women's health across the nation. This one study is a multi center loudin epidemiological study designed to examine the health of women during their middle age, uh middle years, um at different stage of menopause transition. The study reported that there's significantly higher blood pressure, systolic and diastolic after women enter menopause, there is increased in total cholesterol increase in LDL triglycerides. Um And they usually peak the the these increases, peak around perimenopause and an early post menopause stages. So we, as we see what this is what we call an accelerated cardio metabolic risk. So, um another interesting study is that we also know that the more vasomotor symptoms that uh women experience uh those with uh that will be associated with a higher increase in cardiovascular disease and cardiovascular mortality in women. Something to keep in mind as well in the US. Throughout the timeline. Starting in 19 forties, doctors fell differently about prescriptions, uh basically pres prescribing or not prescribing hormone replacement therapy and women, as you see, uh on the X AIS we have up and down. Uh from 19 forties, we had an increase in prescription decrease, then again, increase and now again, decrease. So why let's go over a couple of trials, key trials basically that influence this timeline. Um So this was um the trial um hers trial was published in 1998. Um This was a trial for secondary prevention with hormone replacement therapy in women uh with cardiovascular disease. So, basically the uh overall the outcome of this trial. Uh uh so, uh there was no significant difference between the groups in primary outcomes or actually in any secondary outcomes. So negative trial, then the next trial uh came out. Uh This was uh wh I trial was published in 1994. This trial looked at primary prevention for women um uh and tested the hypothesis whether putting them on hormone replacement therapy will prevent their cardiovascular disease and it did not prevent it. This was another negative trial. Subsequently, there were multiple other trials uh published in this meta analysis. Um 19 of them, uh it basically studied both primary and secondary prevention of cardiovascular disease in women. Um And they were all negative trials. There was no benefits of giving hormone replacement therapy to women uh to prevent cardiovascular disease. There was although there was an increased risk of pe stroke and venous thromboembolism. Um So now, as we know, none of the societies, um all of the societies that I mentioned there including Hah A and AC C do not recommend giving uh hormone replacement therapy for prevention of cardiovascular disease. But what are the FDA approval um indication for uh treatment um and giving hormone replacement therapy. So, uh the FDA approved for approved indication for hormone replacement therapy is vasal motor symptoms which are hot flashes and night sweats, osteoporosis, premature hypoestrogenism, Vallo vaginal atrophy. And uh um there are the different formulations uh that women can receive uh the hormone therapy, they're oral, they are transdermal formulation and they uh they, those are both systemic formulations and vaginal formulations are usually low dose um uh estrogen that can, that is minimally and only locally absorbed. Uh and it's not a systemic uh therapy. They um uh pills, patches, implants, creams and pesar as a cardio, you know, as a cardiologist. When I see patients in the clinic, uh I and I assess them uh any patient for cardiovascular risk but also when before starting a hormone replacement therapy, I will put them in buckets. Uh There's low risk patients, intermediate risk patients and high risk patients. So let's talk a little bit about the lowest risk patients. And um and those are the patients that um would be hormone replacement therapy can be used. Uh Those are the patients who entered recent menopause, uh less than 10 years being in menopause, those are normal weight patients, normal blood pressure, uh active female and 10 and 10 year a, a CBD risk of less than 5%. Um So if you're 10 years, um uh before 10 years in menopause, low risk, uh it's ok to use um hormone replacement therapy in those uh women, high risk patients uh recommended to avoid hormone, the uh uh replacement therapy. Uh with some exception uh with the shared decision making, but in general, I would avoid uh hormone replacement therapy and those are no one is CBD, no one cardi uh uh no one peripheral vascular disease uh having C ad already um no one venous thromboembolism or uh pulmonary embolism, no one strokes, tiasrmis clotting disorders, uh breast cancer, uh and A A CV D risk over 7.5%. And then there is inter intermediate category that's always, uh basically, this is where we use shared decision making. We um discuss whether, how beneficial would it be and what is the risk for the patient. So, those are the patients who are smokers, overweight diabetes, um sedentary lifestyle, um autoimmune diseases and um uh the A S CD, the risk of 5 to 7.4%. So this is the category where we would you share decision making in general. A A and AC C uh recommends to use hormone replacement therapy for uh in women, women who are in menopause for less than 10 years for the shortest period of time. So the shorter you can use, the faster you can get them off uh is ideal. Um So some of the patients that I mentioned in that intermediate category just to give you a little bit of data. Um For, for example, uh women with obesity in that intermediate category, um about 50% of women age 40 to 59 are obese. There is an increased risk of uh of venous thromboembolism. There's three fold and risk uh increased risk of venous thromboembolism with BM I 25 to 30 versus BM I less than 25 and there's six time increase in VTE and BM I over 30. So something to keep in mind, even though you're intermediate risk, you are very high risk. Now for uh venous thromboembolism, another influence that hormone replacement therapy uh has on uh blood pressure and we know as a cardiologist, even one millimeter per mercury increase in blood pressure is significant. Uh so uh the hormone replacement therapy increases in some studies, blood pressure by 0.8 to one a millimeter per mercury um and high risk patient that should not receive hormone replacement therapy. As I already mentioned, no one CBD. History of VTE any congenital heart disease, patients, history of ischemic stroke, and history of spontaneous cornea artery dissection. Uh This is a slide I attended this talk uh last year at the AC C and this was presented by Doctor Lau, one of their, one of the emerging data that we have on menopause. Uh Basically, I know it's a load of like there's a lot of things going on, but just to make it simple, there's 44 lines basically for uh uh first and there's different biomarkers that are listed there. So uh biomarkers that are usually predominantly women. Biomarkers are leptin biomarkers which are marked in red color, more male predominant biomarkers are biomarkers of fibrosis. So, those are outlined in the blue. Um What happens when a woman enters menopause? Third graph. Uh Third line, we see that a woman that enters menopause and the third line over there they are bio markers start to approach male looking biomarkers, meaning they have higher degree of fibro uh biomarkers and they have lower degrees of leptin and some more female predominant biomarkers. Interestingly, when we put women on hormone replacement therapy, their biomarkers resemble very close to those women who are premenopausal. Uh So this is just some emerging data. Uh Further studies would be necessary in this area to see if there's any targeted therapies that could be used. Obviously, at this point, we know that uh hormone replacement therapy does carry a high risk if not every woman should be on it. But this is just something to keep in mind. And this will be a topic in the future research to maybe study separate um uh uh the biomarkers and direct uh treatment potentially of, of those uh some take home points. Um Basically, once a woman enters menopause, uh she's at risk for uh accelerated, uh she's an accelerated risk of cardio vsc sorry, she, she's at risk of accelerating uh cardiovascular disease. Uh better understanding the mechanism that increases cardiovascular disease. Susceptibility in women and early menopause may enhance the prevention and management of cardiovascular disease in women, menopause, hormonal replacement therapy, increased risk of cardiovascular disease um in large RCTS but may be safe in women less than 60 years of age and less than 10 post menopause. Um menopause hormone replacement therapy is approved for vasal motor symptoms, pre premature hypoestrogenism, vagal vaginal atrophy and osteoporosis, not for CBD prevention. The importance of team approach and shared decision making is emphasized pretty much in any uh health care setting. Um So in this one as well, um these are my references and uh thank you very much for uh attending my talk today. Published November 1, 2024 Created by Related Presenters Angelina Zhyvotovska, MD Cardiology, Internal Medicine View full profile
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