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Menopause
Figure 1: Coronary Artery Events in Hormone-treated Women
Unopposed estrogen use Estrogen and progestin
50–59 0.63 50–59 1.29
60–69 0.94 60–69 1.03
RH RH

Age (years)
70–79 1.13
Age (years)
70–79 1.48
Total 0.96 Total 1.23
0 1 10 0 1 10
Relative hazard of CHD (95% CI) Relative hazard of CHD (95% CI)
Unopposed estrogen use Estrogen and progestin
<10 0.48 <10
0.88
10-–20 0.96 10–20 1.23
RH RH
≤20 1.12 ≤20 1.66
Y
ears from menopause
Y
ears from menopause
Total 0.96 Total 1.23
0 1 10 0 1 10
Relative hazard of CHD (95% CI) Relative hazard of CHD (95% CI)
The figure shows estrogen (left side) and estrogen–progestogen (right side) risks of myocardial infarction or coronary-artery-related death according to age at treatment (top) and number of years
after menopause that treatment was started (bottom). Relative hazard (RH) corresponds to the relative rate of coronary artery events in hormone groups compared with placebo groups. The circles
are proportional to the number of events and size of the subgroup. Horizontal bars are 95% confidence intervals (CIs). CHD = coronary heart disease.
Prevention of Osteoporosis and Fractures treatment seemed to reduce the risk for dementia by 34%.
15
However,
Osteoporosis is associated with 1.5 million fractures per year in the US. Hip these studies may be affected by bias, as women with dementia may not
fracture is the most severe fracture, but is uncommon in women below 60 recall whether they took hormones. The WHI Memory Study (WHIMS)
years of age, who suffer less than one hip fracture per 1,000 women per involved only women above 65 years of age, and neither estrogen alone
year.
10
Hormone treatment can prevent osteoporosis, but most fractures are nor estrogen–progestogen prevented the mild impairment of memory.
16–18
due to trauma from a fall rather than osteoporosis.
11
Estrogen with or without In the estrogen trial, 28 estrogen patients and 19 placebo
progestogen reduces the likelihood of hip fracture by about one-quarter.
12,13
patients developed dementia, a 1.5-fold increase in risk for dementia
The WHI trials were the first to show a significant overall reduction in fractures (95% confidence interval [CI] 0.8–2.7).
17
With estrogen–progestin, the
with any kind of treatment in women who were not known to be at high risk dementia risk was 2.1-fold higher (95% CI 1.21–3.48) than with
for osteoporotic fracture. Nevertheless, the absolute effect of estrogen or placebo.
16
Thus, the best available evidence does not support a role
estrogen–progestogen on hip fracture incidence is small, involving less than for hormone treatment in the prevention of memory impairment
one hip fracture per 1,000 women per year. Hormone treatment for the or dementia.
prevention of osteoporosis is not warranted in women who are typically low-
risk and who are below 60 years of age. Non-prescription alternatives Coronary Heart Disease
including exercise and vitamin D have a better risk–benefit ratio. Cardiovascular disease is the leading cause of death in post-menopausal
women. CHD rates are lower in pre-menopausal women than in men of a
Memory Impairment and Senile Dementia comparable age, but the incidence rises after the menopause to
More than 33% of women above 65 years of age will develop dementia approximately three to five cases per 1,000 per year in low-risk women.
12,13
during their lifetime.
14
In a summary of epidemiological studies, hormone One mechanism for the pre-menopausal protective effect in women is the
56 US OBSTETRICS & GYNECOLOGY
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