Postmenopausal hormone therapy. Is it useful for coronary prevention?

Contemporary interest in postmenopausal hormone therapy as a coronary preventive intervention in women derives from the increased prevalence of coronary disease in the postmenopausal years, the importance of estrogen status as a determinant of coronary risk for women, the less favorable outcomes of coronary events for women than for men, the biologically plausible mechanisms of estrogen benefit, and encouraging epidemiologic data suggesting that estrogen use may favorably affect coronary risk. Observational studies describe the greatest reduction in mortality risk with estrogen use in women at high risk for coronary disease or with documented coronary heart disease, with greater benefit currently accruing for those with angiographically severe rather than angiographically mild disease. Noncoronary risks of estrogen use warrant consideration; these include endometrial hyperplasia, breast cancer, and venous thromboembolism. Noncoronary benefits include a decrease in osteoporosis and osteoporotic fractures and in vasomotor symptoms of estrogen deficiency. Because about one of two U.S. women die from cardiovascular disease (heart disease and stroke), emphasis is warranted on available data, which suggest that the group of women likely to experience the greatest cardioprotection from hormone therapy are those with defined coronary disease or those at high risk for occurrence; the group of women least likely to benefit are those at increased risk for breast cancer.