Bm. Psaty et al., A REVIEW OF THE ASSOCIATION OF ESTROGENS AND PROGESTINS WITH CARDIOVASCULAR-DISEASE IN POSTMENOPAUSAL WOMEN, Archives of internal medicine, 153(12), 1993, pp. 1421-1427
The purpose of this article was to review, with special attention to t
he hypothesized mechanisms of atherosclerosis and thrombosis, the lite
rature on the association of estrogens and progestins with cardiovascu
lar disease. The data sources included recent reviews and their citati
ons as well as literature searches of Medline. For coronary heart dise
ase, we relied on a recent meta-analysis; for the lipid effects of est
rogens and progestins, we refer to recent reviews and studies; for str
oke, we identified all cohort and case-control studies; and for the ef
fects of hormones on coagulation factors, we identified all relevant s
tudies. The lipid effects of estrogens in postmenopausal women probabl
y prevent atherosclerosis, and we would expect long duration o f use r
ather than current use to provide the greatest benefit. Few epidemiolo
gic studies have, however, assessed duration of estrogen use. High dos
es of estrogens are likely to be thrombogenic during current use, and
it is possible that even moderate doses may increase the risk of clott
ing among women who smoke or who have existing coronary atherosclerosi
s. Compared with the lipid effects of estrogens alone, the lipid effec
ts of combined therapy with progestins may increase atherosclerosis. T
he effect of progestins on coagulation factors is largely unknown, and
no epidemiologic study has assessed the risk of cardiovascular diseas
e associated with the use of combined hormone therapy in postmenopausa
l women. Cardiovascular risk or benefit associated with the use of pos
tmenopausal hormones may involve several competing mechanisms, includi
ng effects on prostaglandins and vascular tone as well as atherosclero
sis and thrombosis.