WOMEN AND CORONARY HEART DISEASE

I am a mother aged 53. I am concerned to read that coronary heart disease is a major risk for me. Isn't this a man's disease?

If the deaths from heart attacks each year, nearly half are in women. All forms of heart and blood vessel diseases added together claim twice as many women's lives as do all forms of cancer. Although fewer women have heart disease than men at the age of 50, they have caught up by 65-70 years of age. The main difference between men and women as regards heart disease is not if they are going to get coronary disease, but when; the difference in its timing is about 10 years.

Coronary heart disease is therefore your - and other women's -biggest problem too. It is becoming more of a woman's disease as women tend to live longer; coronary disease is partly a problem of getting older, so more women will eventually develop it. The problem is going to increase as the population ages in general. More men and women are now surviving heart attacks, so they are likely to encounter heart problems later - an increased chance of angina or a further heart attack, unless they try to reduce their risks. Women are more vulnerable to the risks of cigarette smoking and high blood pressure but less so to that of cholesterol. Having diabetes sadly wipes out any advantages that women may have had over men (see above).

My father had heart disease and I am concerned that my daughter might develop heart disease also. I know that she smokes. How can I help her avoid heart disease?

Tour daughter may have an increased risk of heart disease if it runs in your family but one of the best ways to help prevent coronary heart disease is to get her to stop smoking. It is well known that there has been an increase in the numbers of young women smoking; their chances of heart disease in later life consequently are rising. If your daughter smokes, she should stop now. If she is thinking about starting, she should think again!

I have read that women's natural hormones protect us from heart disease. Is this true?

No a degree they do, but if you smoke, have high blood pressure or have diabetes, women lose a lot of this protection. Following the menopause, the normal protection that estrogen gives disappears anyway. Hormone replacement therapy (HRT; see below) unfortunately does not appear to help.

I have been taking the pill on and off since I was 18. I have just been through the menopause. Am I at any greater risk of heart disease because I have been using oral contraceptives?

Very few women on the pill (taking oral contraceptives) develop heart disease and the low hormone dose pills do not increase the coronary risk. So long as you do not smoke, the low dose pill may actually protect you against heart problems. In women under 35 years of age we do not know what the risk is from taking the pill, nor do we know about its long-term use (over 5 years), although it is unlikely you will be harmed. Cigarette smoking and also taking the pill is not a good combination and should be avoided at all costs. In general the low dose pills are safe, but smokers should preferably stop smoking, or use alternative contraception.

I have felt well since being on HRT but I am worried about its effect on my heart and the risk of breast cancer - what should I do?

There is no doubt that HRT helps with the distressing symptom of menopausal flushes and protects against thinning of the bones (osteoporosis). Initial enthusiasm regarding HRT and heart disease has been replaced with sound scientific evidence of a lack of benefit. Currently HRT is not recommended as a treatment to prevent heart disease developing or to benefit women who have heart disease already. If coronary disease has been diagnosed, other protective treatments should be used - for example statin therapy. Some studies have suggested HRT can actually increase the risk of heart disease, but this risk does not appear to be present if the cholesterol is normal or a statin is also being taken.

A very big study - The Million Women Study - has identified an increased risk of breast cancer if HRT is taken for 5 years or more. We are looking at 1 extra case of breast cancer in 166 women treated for 5 years or 1 extra case in 53 women treated for 10 years. There is no need to panic about these figures, but clearly women on HRT for many years should see their family doctor about discontinuing.

The HRT story is a sad journey from the belief of benefit to the proof of potential harm. There is no role for HRT in women who do not have menopausal symptoms (such as flushes). When flushes are a problem (this happens in 10-20% of women), the risks must be weighed against the benefit, and HRT used for as short a time as possible.

Most women are on combined medications of oestrogen and progestogen but, if they have had a hysterectomy (removal of the womb), they will be on oestrogen alone. All increase the breast cancer risk. With regard to the heart, we are not sure about oestrogen alone but, with all the information we have, HRT cannot be considered a treatment for heart disease.

Whether this advice will change when we know more about raloxifene (see next question) is debatable, but it is obviously important to continue research in this area and advise women on up-to-date scientific facts.