[Menopause and cardiovascular risk]

Abstract

Estrogenic deficiency of menopause is not only responsible to the precocious occurrence of climateric troubles but exposes at increased risk of osteoporosis, metabolic troubles, and cardiovascular complications. We believed for a long time that the hormonal treatment prescription could prevent cardiovascular risk. Then, initial analysis of the great controlled study WHI and HERS causes unfavorable judgment of overall risk-benefit balance evaluation. However, the situation isn't so contrasted, and many arguments are in favor of vascular benefit with hormonal replacement therapy (HRT). Menopause and HRT influence the cardiovascular risk factors. The oral-estrogen taking conducts to significant decrease of LDL cholesterol rate, and significant increase of HDL and triglyceride plasma levels. Otherwise, there is a decrease of insulin-resistance and incidence of type 2 diabetes in substituted women. At least, oral estrogens seem to be responsible of deleterious effect pro-inflammatory and prothrombotic. The transdermal taking would limit these effects. During the precocious stage of atheromatous plaque formation, estradiol has a really protective function, with endothelial effect, limiting the induction and the activation of proinflammatory cells. On the contrary, when plaques are formed, giving estrogens could be harmful, because it could facilitate plaque rupture by pro-inflammatory effect. In 1998, then in 2002, the publication of the two main controlled study WHI and HERS removes the legitimacy of HRT in cardiovascular prevention terms, however, post-hoc analysis since published, have moderate the initial version: more and more convincing arguments suggest vascular benefit of HRT, if it begins just after menopause and probably before the existence of advanced atheromatous plaque, bringing the notion of the opportunity window. In contrary of oral taking, transdermal estrogens do not seem to be associated with a significant increase risk in the risk of thromboembolism or cerebrovascular events (stroke). At last, the choice of associated progestatif is essential, concerning the improvement of lipid profile among the human being or towards the prevention of atheroma among the animal, this hormones are able to attenuate or to stop benefits effects of estradiol. In practice, and according to AFSSAPS recommendations, the doctor will make a personalised and rigorous prescription of HRT, at minimal effective dose, associating healthy life style and dietetics measures, and after having given detailed information to the patient.