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Postmenopausale Hormonersatztherapie und vaskuläres Risiko

Postmenopausal hormone replacement therapy and vascular risk

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Zusammenfassung

Die Ergebnisse großer randomisierter Interventionsstudien bestätigen die Vorstellung eines kardiovaskulären Schutzes durch Östrogene in der Postmenopause nicht, sondern weisen auf notwendige Vorsicht und allenfalls Möglichkeiten einer individualisierten Therapie mit geringem Risiko, aber auch möglichem kardiovaskulärem Vorteil hin. Das quantitativ wichtigste vaskuläre Risiko einer oralen Hormonersatztherapie (HRT) sind venöse Thrombosen und Thromboembolien (ca. 2 Fälle pro 1000 behandelter Frauen und Jahr), ischämische Schlaganfälle sind das zweithäufigste und folgenschwerste Risiko einer oralen HRT (ca. 1 Fall pro 1000 behandelter Frauen und Jahr). Im Gegensatz dazu wurde weder für die Östrogen-Monotherapie noch für die kombinierte HRT ein signifikanter Einfluss auf das Risiko für koronare Ereignisse gefunden. Allerdings wurden die kardiovaskuläre und Gesamtmortalität nicht beeinflusst. Das geringste Risiko für tiefe Beinvenenthrombosen, Lungenembolien und ischämische Schlaganfälle besteht bei Beginn einer oralen HRT in den ersten 10 Jahren nach der Menopause. Trotz der positiven Wirkungen auf konventionelle Risikofaktoren, wie LDL- bzw. HDL-Cholesterin, Lipoprotein(a), Insulinresistenz, die Entwicklung eines Diabetes mellitus Typ 2 und möglicherweise den Blutdruck, gibt es keinen formalen Beweis für eine Reduktion des Risikos für koronare Ereignisse, auch wenn dies bei Beginn einer HRT in den ersten 10 postmenopausalen Jahren möglich erscheint. Aussichtsreich scheinen transdermale Applikationsformen zu sein: Beobachtungsstudien ließen kein vaskuläres Risiko jedweder Art erkennen, vermutlich aufgrund der allenfalls schwachen Beeinflussung der Blutgerinnung, doch entsprechende randomisierte Endpunktstudien fehlen noch.

Abstract

The results of large randomized interventional trials have not confirmed the perception of cardiovascular protection of women by estrogens in the postmenopause but point to necessary caution and at best to an individualized treatment with low risk but possible cardiovascular benefits. Thrombosis and thromboembolism represent the quantitatively highest risk of an oral hormone replacement therapy (HRT). The risk doubles up by ca. 2 cases per 1000 women per year in treated women free of vascular disease on estrogen monotherapy or combined therapy. Ischemic stroke is the second most frequent and most serious risk of oral HRT. It rises by 1 case per 1000 treated women equally on oral mono-HRT or combined HRT per year. In contrast, a significant influence on the risk for coronary events was not found for either estrogen monotherapy or for combined HRT; however, cardiovascular and total mortality were not affected. The risk for deep vein thrombosis, pulmonary embolism and ischemic stroke is lowest when starting oral HRT during the first 10 years after the menopause. In spite of the positive effects of HRT on conventional risk factors, such as low density lipoprotein (LDL) cholesterol, lipoprotein(a), high density lipoprotein (HDL) cholesterol, insulin resistance and diabetes mellitus type 2 as well as possibly on blood pressure, there is no formal proof of an impact on the risk of coronary events, even if risk reduction seems possible by starting HRT during the first 10 postmenopausal years. Transdermal application forms appear promising, because observational studies revealed no vascular risk of any kind presumably on account of an at most weak influence on coagulation; however, suitable randomized endpoint trials are still lacking.

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Authors and Affiliations

  1. Präventive Medizin, Universitäres Herzzentrum Hamburg, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, O56, 22543, Hamburg, Deutschland

    Eberhard Windler

  2. Abteilung für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital, Bern, Schweiz

    Petra Stute

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  1. Eberhard Windler
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Correspondence to Eberhard Windler.

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Interessenkonflikt

E. Windler hat Honorarien für Vorträge und Beratung von den HRT-herstellenden Firmen Bayer HealthCare und Mylan Pharmaceuticals angenommen. P. Stute gibt an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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O. Ortmann, Regensburg

A. Schwenkhagen, Hamburg

K. Schaudig, Hamburg

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Windler, E., Stute, P. Postmenopausale Hormonersatztherapie und vaskuläres Risiko. Gynäkologe 50, 579–585 (2017). https://doi.org/10.1007/s00129-017-4104-5

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  • DOI: https://doi.org/10.1007/s00129-017-4104-5

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