Matthew Nudy, MD, on estrogen and the cardiovascular system

Cardiovascular disease is the leading cause of death among women in the United States and globally, and estrogen, both the body’s own and hormone therapy, influences the cardiovascular system in multiple, sometimes opposing ways, according to Matthew Nudy, MD, assistant professor of medicine and public health sciences in the division of cardiology at Penn State College of Medicine. Nudy spoke during the president’s symposium on estrogen and the cardiovascular system at The Menopause Society Annual Meeting, in a session titled “The Cardiovascular Consequences of Estrogen Avoidance.”

In a conversation with Contemporary OB/GYN, Nudy discussed how LDL cholesterol rises through the menopause transition, the role of coronary artery calcification in detecting subclinical disease, and the opportunities for OB/GYN clinicians to take part in cardiovascular risk assessment. He also addressed the evolving understanding of hormone therapy and cardiovascular risk, including evidence that younger menopausal women may derive benefit.

Contemporary OB/GYN: Tell us about your session, “The Cardiovascular Consequences of Estrogen Avoidance,” presented at TMS this year.

Matthew Nudy, MD: I was able to speak during the president’s symposium on estrogen and the cardiovascular system. I think some key points from the lecture are that estrogen, both endogenous estrogen and hormone therapy, has complex effects and associations with the cardiovascular system.

During the talk, I highlighted a few different areas of the cardiovascular system. First, we looked at cholesterol profiles and LDL cholesterol, including how LDL cholesterol increases through the menopause transition. We also reviewed some data on older oral conjugated equine estrogen and how, in a randomized trial, this formulation and dose of hormone therapy reduced LDL cholesterol, increased triglycerides, and reduced some other cardiovascular biomarkers, such as lipoprotein(a), or Lp(a).

We also spent some time looking at subclinical cardiovascular disease, including coronary artery calcification, which can be detected on a CT scan. We reviewed data showing that, in menopausal women, elevated coronary artery calcium is strongly associated with the development of cardiovascular disease. We also looked at randomized trial data on hormone therapy showing either beneficial or neutral effects on coronary artery calcification.

Contemporary OB/GYN: What would you like to highlight about the various crossover opportunities in care between ob-gyn and cardiovascular health?

Nudy: I definitely think there’s crossover. One of the key points is that the number one cause of death among women in the United States and globally is cardiovascular disease. So there is definitely a role for primary care, cardiology, and even OB/GYN providers to assess cardiovascular risk in patients.

Contemporary OB/GYN: What questions should ob-gyn clinicians be prepared for related to heart health, or what types of questions should they be asking their patients?

Nudy: I think it’s very important for women to receive a cardiovascular disease risk assessment. This typically involves a calculator. The calculator we’re using now is the PREVENT Calculator from the American Heart Association, which helps assess cardiovascular risk. Essentially, the patient’s demographics, blood pressure, lab values, and other information are entered into the calculator, which then estimates the 10-year risk of experiencing a cardiovascular event. We use this information to guide preventive therapies and potentially determine whether to initiate statin medications to reduce risk.

First and foremost, everybody should receive counseling on lifestyle therapies and modifications that can reduce the risk of heart disease. These include increasing physical activity and trying to follow a heart-healthy diet, such as the Mediterranean diet. If a patient smokes, counseling should focus on quitting smoking and tobacco use. If the patient is overweight or obese, weight loss may help. If the patient consumes a lot of alcohol, reducing alcohol consumption is another important step. There are certainly many lifestyle modifications and therapies that can be implemented to reduce cardiovascular risk.

Contemporary OB/GYN: What would you like to highlight about cardiovascular health and menopause specifically?

Nudy: I think there’s one important thing to highlight regarding the effects of hormone therapy used to treat moderate to severe vasomotor symptoms on cardiovascular disease. This is an area where the pendulum has swung back and forth over the years regarding whether there is risk or benefit.

There are observational data linking hormone therapy use to reduced cardiovascular disease risk, but we know that these data are of low methodological quality. There are biases in these studies, including healthy-user bias and selection bias.

We also have randomized trials, including the Women’s Health Initiative and the HERS trial, which found no cardiovascular benefit from oral conjugated equine estrogen, either alone or combined with medroxyprogesterone, on cardiovascular disease outcomes.

However, over the years, we’ve learned more about these trials. Specifically, younger menopausal women between the ages of 50 and 59, or women within 10 years of menopause onset, may actually derive cardiovascular benefits from hormone therapy.

So I think one of the key messages is that when younger menopausal women use hormone therapy to treat vasomotor symptoms, it appears to be safe from a cardiovascular standpoint and may even offer some benefit.