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Women who take estrogen plus progestin after menopause boost their risk of heart attack most during the first year of therapy, a study reports today.
Yet, even during the first year, the heart attack risk posed by the hormones appears to be quite small, especially for newly menopausal women with a low overall risk of heart disease, says lead author JoAnn Manson of Harvard's Brigham and Women's Hospital.
A second study found that hormone replacement therapy doesn't worsen existing coronary-artery disease.
The studies in today's New England Journal of Medicine offer some new clues to help women and their doctors weigh the tangled risks and benefits of the controversial treatment.
They also cement a major shift in thinking about hormone therapy. Studies completed two decades ago seemed to suggest that taking hormones could extend estrogen's natural protection against heart attack well past menopause. Better studies in recent years have deflated that claim.
''The clear message is that these hormones should not be used to prevent heart disease, but they still have a role in the short-term treatment of menopausal symptoms,'' Manson says.
The new findings are based on an analysis of the Women's Health Initiative, a study in which more than 16,600 women were given either hormones or a placebo for nearly six years, and a study led by Howard Hodis of the University of Southern California of 226 women either on hormones or placebo who had at least one clogged coronary artery.
The researchers found:
* The risk of heart attack increases 81% for women on hormones in the first year, then drops to 24% within six years.
* All women who take hormones seem to have a higher heart attack risk, not just certain subgroups.
* Three years of treatment did not significantly affect the progression of coronary artery disease.
Researchers still haven't demonstrated, however, that hormones provide a significant benefit. And that makes a woman's decision to take hormones even tougher, even if her hot flashes, night sweats and sleep disturbances are severe, doctors say.
''The risk (of HRT) is very small. The benefit -- if any -- is also small. I don't think we have enough information right now to say which is smaller,'' says John Bailar, a clinical trials expert at the University of Chicago, who wrote an accompanying editorial. ''Based on the present evidence, if I were in the right sex and age group, I would not take hormone replacement therapy.
''But I'm not quite sure enough in my judgment to tell other people what to do.''
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