International Journal of Epidemiology 2002;31:1278-1279
© International Epidemiological Association 2002
Book Review |
Hormone Replacement Therapy and Cardiovascular Disease. The Current Status of Research and Practice.
AR Genazzani. London UK, New York USA: The Parthenon Publishing Group, 2001, pp. 188, US$77.95 ISBN: 1 84214 038 8.
Reading this book taught me an important lesson—never include ‘current’ or ‘modern’ or ‘up to date’ or any words with a similar meaning in the title of a scientific book. With the large number of medical and health-related journals, information technology and media interest (particularly in women’s) health issues1 health research moves too fast for a book to be ‘current’ by the time it is launched.
This book brings together the presentations given during the Expert Workshop on Hormone Replacement Therapy and Cardiovascular Disease, organized by the International Menopause Society and held in October 2000. Since that time the results of the Women’s Health Initiative Study have been published,2 and resulted in a U-turn in thinking among many clinicians and researchers interested in this area. This was a large well conducted primary prevention trial which, far from finding that hormone replacement therapy (HRT) protected women from cardiovascular disease, was stopped early because of an increased risk of both cardiovascular disease and breast cancer in women who received the HRT.2
This book disappoints—it reads like a series of abstracts from a conference, with little editorial input and little critical appraisal of all of the relevant literature or even of some of the empirical data presented by the authors of the chapters. Chapter 1 begins with a description of secular trends in cardiovascular diseases in developed countries; the analysis is limited to women only. The authors conclude that these trends should be used, in different countries, to assess the likely public health impact of HRT. They assume that HRT will prevent cardiovascular disease despite the emerging evidence from trials, that had been published by October 2000, that this was unlikely.3–5 The failure to compare secular trends in women and men is a missed opportunity to look at the likely role of endogenous oestrogen in cardiovascular disease.6 Chapters 2–4 on cardiovascular ageing, lipid metabolism, diabetes and endothelial function are useful for someone with little knowledge in this area but more detailed critical reviews of current thinking are missing.
In the second section of the book (chapters 8–16) various aspects of ‘basic mechanisms of sex steroid action’ with respect to cardiovascular disease are presented. This is interesting and relevant background to the subject, but these chapters, largely presenting data from animal and in vivo studies, occupy one-third of the book. They often read like special pleading— the results of HERS4 must be wrong because, look! oestrogen does all these beneficial things in animals and test tubes. Nowhere in the book does anyone try to appraise why, given the potentially beneficial physiological actions of oestrogen, the trials of HRT in secondary prevention had failed to show any benefit.4,5
In chapter 17 on the cardiovascular effects of HRT it is stated that:
With one exception, major population-based trials have demonstrated that postmenopausal ERT or HRT users have a significantly reduced risk of CVD, myocardial infarction, stroke, mortality from CVD and all-cause mortality. Relative risk (RR) reductions ranged from 35 to 50% in these trials.
None of the citations accompanying this statement refer to trials—they are all observational studies, and the author failsto mention the importance of selection bias as an explanation for these results. With an emphasis on proxy indicators or intermediaries such as lipid profiles, inflammatory markers and homocysteine the chapter concludes that:
... a sound, internally consistent body of clinical, preclinical and observational data supports the beneficial effects of ERT and HRT on CVD in postmenopausal women.
Overall the book disappoints. Because of the time delays in producing a book it is impossible to be bang up-to-date, but from its title I expected this book to contain a more critical and balanced discussion of the evidence around HRT and cardiovascular disease in women up to 2000. I also expected more information on clinical practice. There is no presentation inthe book of research concerning women’s attitudes towards or experience of HRT use7 and no description of side effect profiles of the oestrogen and progestogen components of HRT and how these can be managed in clinical practice.
References
1 Bartlett C, Sterne J, Egger M. What is newsworthy? Longitudinal study of the reporting of medical research in two British newspapers. BMJ 2002;325:81–84.
2 Women’s Health Initiative writing group. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomised controlled trial. JAMA 2002;288:321–33.
3 Hemminki E, McPherson K. Impact of postmenopausal hormone therapy on cardiovascular events and cancer: pooled data from clinical trials. BMJ 1997;315:149–53.
4 Hulley S, Grady D, Bush T et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS). JAMA 1998;282:605–13.
5 Herrington DM, Reboussin DM, Brosnikan KB et al. Effects of estogen replacement on the progression of coronary-artery atherosclerosis. New Engl J Med 2000;343:522–29.
6 Lawlor DA, Ebrahim S, Davey Smith G. Sex matters: secular and geographical trends in sex differences in ischaemic heart disease mortality. BMJ 2001;323:541–45.
7 Newton KM, La Croix AZ, Buist DS et al. Women’s responses to a mailed hormone replacement therapy workbook. Menopause 2001;8: 361–67.[Medline]
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