by

Helen Noble, M.D.

When we think " heart attack" what comes to mind? Often it is a picture of a middle-aged, type A, overweight man who smokes, suddenly clutching his chest, turning gray and perhaps collapsing. The reality is that women over 60 are victims in numbers equal to men, making coronary heart disease the number one cause of death in men and women in our society.

Women’s hormonal cycles of estrogen and progesterone appear to be protective until the time of menopause. Up until age 50 women experience heart attacks and angina at 1/10 the rate of men at the same age. After the ovaries cease to function, hormonal protection lapses and coronary heart disease assumes the same threat for women as men. A good third of coronary heart disease deaths in women are considered "premature" because they occur before age 65.

How can some of these deaths be prevented? First, our strategies in women parallel those in men: controlling diabetes and hypertension, smoking cessation, exercise, proper diet, cholesterol lowering medication, even daily use of aspirin and certain vitamins are all proven interventions. An additional prospect for women is to mimic the premenopausal state by taking estrogen (with progesterone if the uteruses is intact to prevent uterine cancer). Numerous large studies have looked at populations of women and found a 30-50% lower incidence of coronary heart disease and a lower mortality rate in women taking hormones.

A word of caution in needed here; the "HERS" study, published in 1998, showed that in a group of women with known coronary heart disease, starting hormone replacement therapy led to a slightly higher rate of adverse events during the first one to two years. After two years the rates for women taking hormones were slightly lower than those who didn't take hormones.

Hormone replacement is not for every woman. Possible advantages include relief of menopausal symptoms, protection from osteoporosis, maintenance of urinary and sexual function and protection of brain function. Disadvantages include a risk of blood clots, a slight increase in breast cancer risk after ten or more years of use and the possibility of unwelcome bleeding or side effects. The decision is an important one for every woman and should be discussed with her physician.

Helen Noble, M.D., is board-certified in Internal Medicine and practices in association with Internal Medicine Associates in Chestertown. She earned her medical degree from the Medical College of Wisconsin and completed her residency at the Washington Hospital Center.

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