Article Impact Level: HIGH Data Quality: STRONG Summary of BMJ, 387, e078784. https://doi.org/10.1136/bmj-2023-078784 Dr. Therese Johansson et al.
Points
- The study evaluated cardiovascular risks associated with different menopausal hormone therapy (MHT) regimens in women aged 50-58, using Swedish national registries to assess risks of venous thromboembolism (VTE), ischemic heart disease (IHD), cerebral infarction (CI), and myocardial infarction (MI).
- Women were categorized into eight treatment groups to compare cardiovascular outcomes, including oral and transdermal therapies, tibolone, and non-initiators.
- Tibolone significantly increased the risk of cardiovascular disease (HR 1.52) and IHD. At the same time, oral estrogen-progestin therapies were linked to a higher risk of IHD and VTE, especially with continuous (HR 1.61) and sequential (HR 2.00) regimens.
- Among 24,089 cardiovascular events recorded, 43% were IHD, 17% were CI, and 18% were MI, highlighting the prevalence of heart-related risks associated with specific MHT regimens.
- The findings emphasize the need for personalized MHT prescriptions, carefully considering hormone combinations and administration routes, particularly for women at elevated risk of cardiovascular events.
Summary
This study aimed to assess the cardiovascular risks associated with contemporary menopausal hormone therapy (MHT) in women aged 50-58, focusing on the route of administration and combination of hormones. Using Swedish national registries, the study included 919,614 women without prior hormone therapy use in the past two years. Participants were assigned to one of eight treatment groups: oral combined continuous, oral combined sequential, oral unopposed estrogen, oral estrogen with local progestin, tibolone, transdermal combined, transdermal unopposed estrogen, or non-initiators of MHT. The primary outcomes were the risks of venous thromboembolism (VTE), ischaemic heart disease (IHD), cerebral infarction (CI), and myocardial infarction (MI), with hazard ratios (HR) and 95% confidence intervals (CI) used for estimation.
The results showed that 77,512 women initiated MHT, while 842,102 were non-initiators. Over the follow-up period, 24,089 women experienced a cardiovascular event, with 43% having an IHD event, 17% having a CI event, and 18% having an MI event. In intention-to-treat analyses, tibolone was associated with a significantly higher risk of cardiovascular disease (HR 1.52, 95% CI 1.11-2.08) than non-initiators. Tibolone and oral estrogen-progestin therapy were associated with increased risk of IHD (HR 1.46, 95% CI 1.00-2.14 for tibolone and HR 1.21, 95% CI 1.00-1.46 for estrogen-progestin therapy). Additionally, oral estrogen-progestin therapies, including continuous and sequential regimens, were associated with a higher risk of VTE (HR 1.61, 95% CI 1.35-1.92 for continuous therapy, and HR 2.00, 95% CI 1.61-2.49 for sequential therapy).
The findings of this study indicate that MHT regimens, particularly oral estrogen-progestin therapy and tibolone, have varying cardiovascular risks. Oral estrogen-progestin therapy increases the risk of heart disease and VTE, while tibolone elevates the risk of IHD, CI, and MI. These results underscore the need for careful consideration of hormone combination and administration routes when prescribing MHT, particularly for women at risk of cardiovascular events.
Link to the article: https://www.bmj.com/content/387/bmj-2023-078784
References Johansson, T., Karlsson, T., Bliuc, D., Schmitz, D., Ek, W. E., Skalkidou, A., Center, J. R., & Johansson, Å. (2024). Contemporary menopausal hormone therapy and risk of cardiovascular disease: Swedish nationwide register based emulated target trial. BMJ, 387, e078784. https://doi.org/10.1136/bmj-2023-078784
