Newsletter: HRT and Heart Disease, Obesity, PCOS, Alternative Medicine

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May 2009 Newsletter

HRT and protection against Coronary Heart Disease

Oestrogen is one of several sex hormones secreted by a woman's endocrine glands, principally the ovaries, starting in puberty. its production falls off significantly when ovulation (egg release) stops. But oestrogen also has a profound effect on the heart and the brain, the blood vessels, the liver, the urinary tract and the digestive system. It keeps skin smooth and promotes cell growth that keeps bones strong and breasts firm. All those benefits cease at the menopause.

In the early 1970s, oestrogen was considered the fountain of youth, but by the middle of that decade, it had been identified as a cause of endometrial cancer. Then we added progestin to estrogen because it protected against endometrial cancer, and hormone therapy was terrific again.

Through the 1980s and '90s, people thought it would prevent all sorts of diseases, including colon cancer, even though there was a suspicion it might cause breast cancer.

In 2002, investigators of the Women's Health Initiative (WHI), the largest examination of menopausal women, abruptly stopped one part of the study three years ahead of schedule after finding that a routinely prescribed combination of two hormones, estrogen and progestin, was making many women more susceptible to heart attack, stroke, breast cancer and blood clots.

In 2002, 40 percent of menopausal women in the United States were taking HRT, mainly to protect them from heart disease.

When the results were released, the editor of the journal Menopause, gave some blunt advice: "If you're taking hormone therapy to protect your heart, get off the drugs now." and Millions of women did, including those whose primary motivation was to relieve the distressing symptoms -- from hot flashes and night sweats to reduced libido -- that afflict 80 percent of women entering menopause.

Within a year, U.S. prescriptions for HRT prescribing had plummeted and researchers in Australia, Britain and New Zealand had cancelled a major hormone therapy trial that was about to begin.

Finally, the WHI threw cold water on hormone therapy.

I doubt whether there is any other medications for which advice has swung back and forth so strongly and so often.

Once again scientists are sharply divided over whether, and to what degree, hormone therapy should be rehabilitated.

In the seven years since the WHI dropped its bombshell, their results have been endlessly analyzed, with many experts wondering how a just one randomized, controlled trial could have negated dozens of observational and epidemiological studies that showed estrogen reduced women's heart disease risk by as much as 50 percent.

"A misunderstanding of the WHI results has turned off so many women and their physicians from hormone therapy," laments Frederick Naftolin, director of reproductive biology research and co-director of menopause medicine at New York University School of Medicine. "And there may be a price to pay. Women may die prematurely from heart disease and suffer unnecessarily from fractures or diabetes because they or their doctors didn't want to consider estrogen."

Oestrogen researchers have become interested in a "timing hypothesis": that if hormones are prescribed promptly at menopause, they'll have the beneficial effect the WHI study seemed to disprove. These scientists fault the WHI for enrolling women who were many years past menopause, whereas the earlier observational studies that showed positive heart effects from hormone therapy used newly menopausal women. "The women in the earlier research took hormone therapy when they started experiencing symptoms of menopause," says S. Mitchell Harman, "In the U.S., that's at age 51, on average. But the women in WHI had an average age of 63 -- 12 years past the onset of menopause -- when they started taking these drugs."

But additional research and further shifts in the advice for women seem almost inevitable.⁰⁸⁰¹

Impact of obesity on women's health.

Those of us who live in developed countries are increasingly prone to obesity. We are all aware that this has an impact on our general health and reduces our lifespan.

Fertility and Sterility 2009

A recent Review in Fertility and Sterility⁰⁹⁰¹ has shown that obesity in women is associated with early puberty, aberrant menstrual patterns, decreased contraceptive efficacy, ovulatory disorders (infertility), an increased miscarriage rate, and worse assisted reproductive technology outcomes. Losing weight can ameliorate many of these problems.

PCOS and Long-Term Health

Metabolism. 2009

It has been known for sometime that PCOS is associated with heart disease, but there has been some uncertainty as to whether the PCOS is the significant factor or whether it is the obesity that frequently accompanies PCOS.

A recent study from Cincinnati⁰⁹⁰¹, found that increased coronary heart disease (CHD) risk factors cannot be exclusively attributed to their preponderant centripetal obesity. Identification of women with clinical features of PCOS should alert the clinician to potentially increased risk for CHD and prompt CHD risk factor testing.

Alternative Medicine For Uterine Fibroids

Cochrane Database Syst Rev. 2009

Herbal preparations for uterine fibroids.

Uterine fibroids are the most common non-malignant growths in women of childbearing age. They are associated with heavy menstrual bleeding and subfertility.

Herbal preparations are commonly used as alternatives to surgical procedures.

To assess the benefits and risks of herbal preparations for uterine fibroids, the authors searched following electronic databases: the Trials Registers of the Cochrane Menstrual Disorders and Subfertility Group and the Cochrane Complementary Medicine Field, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 3), MEDLINE, EMBASE, the Chinese Biomedical Database, the Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS), AMED, and LILACS.

They included two randomised trials (involved 150 women) with clear description of randomisation methods. The methodological risk of bias of the trials varied. There were variations in the tested herbal preparations, and the treatment duration was six months.

The outcomes available were not the primary outcomes selected for this review, such as symptom relief or the need for surgical treatment; trials mainly reported outcomes in terms of shrinkage of the fibroids.

Compared with mifepristone, Huoxue Sanjie decoction showed no significant difference in the disappearance of uterine fibroids, number of patients with shrinking of uterine fibroids or average volume of uterine fibroids, but less effective than mifepristone on reducing average size of uterus (mean difference 23.23 cm(3),95% confidence interval 17.85 to 28.61).

There was no significant difference between Nona Roguy herbal product and GnRH agonist in average volume of uterine fibroids or size of uterus.

No serious adverse effects from herbal preparations was reported. AUTHORS' CONCLUSIONS: Current evidence does not support or refute the use of herbal preparations for treatment of uterine fibroids due to insufficient studies of large sample and high quality. Further high quality trials evaluating clinically relevant outcomes are warranted.

Is it safe to induce labour as an outpatient?

Am J Perinatol. 2009

Induction of labour can be associated with uterine over activity which can reduce the blood supply to the placenta causing fetal distress. There is also a risk of uterine rupture. The concept of inducing labour outside of a consultant obstetric unit has been regarded as an anathema.

This has been challenged by a pilot study in California that found no adverse effects using oral misopristol.⁰⁹⁰¹

Maternal Mortality

We assume that childbirth has become risk free but this is sadly far from true. Over the last 100 years there has been a dramatic fall in the number of women dying of pregnancy - maternal mortality - related problems although this has been mainly in developed countries.

Clin Obstet Gynecol. 2009

Women continue to die from pregnancy-related causes at an alarming rate. Maternal mortality was first called a neglected epidemic in 1985, but to date, no significant improvements have been realized. Great disparity exists as lifetime risk of dying from pregnancy is

1 in 26 in Africa,
1 in 7300 in high-income areas.

The UN Millennium Development Goals call for a 75% reduction in maternal mortality by 2015, which will only be realized when priority setting, funding, and program implementation can create conditions for appropriate human resources, infrastructure, and patient education for high-quality obstetric care.

Women's Health

This is the personal website of David A Viniker MD FRCOG, Consultant Obstetrician and Gynaecologist at Whipps Cross University Hospital, London - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.

I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.

Newsletter April 2009