Prof Peter Collins, Professor of Clinical Cardiology at Imperial College of London, UK

Peter Collins, Professor of Clinical Cardiology at Imperial College of London, UK, speaks with Cardio Debate about microvascular angina in postmenopausal women.

I’m Professor Peter Collins, Professor of Clinical Cardiology at Imperial College and the Royal Brompton and Harefield NHS Trust.

And I’ve been speaking on post-menopausal women and microvascular angina.

What are the main challenges in HRT? What are the indications?

The main challenges in HRT are really to identify patients who you feel will benefit from it, and the majority of patients that we treat in our clinic have menopausal symptoms.

We know that post-menopausal symptoms like hot flushes, tiredness, irritability and vaginal dryness are all improved significantly with hormone therapy. And basically if patients have cardiovascular disease or angina with those symptoms, then those are the patients who we feel may benefit from the addition of hormone therapy. And the key with treating these patients is really to identify the lowest dose that will control the symptoms and then, if needed, to up-titrate the dose of the hormone.

Now one of the issues with hormone therapy is that there are different oestrogens, there are different progestins, there are different routes of administration and there are different doses.

I’m not suggesting that cardiologists should treat women with hormone therapy for these post-menopausal symptoms. But it may be that if these women are identified as having symptoms then a gynecologist can be asked for help, and an opinion as to what forms of hormones may be applicable to those women, and in what doses and routes of administration.

In our clinic we favour the naturally occurring oestrogen which is 17-beta estradiol, and transdermal therapy will then avoid first liver pass, and that, we think, is more cardiovascularly favourable than giving oral HRT.

There is a slight increase of deep venous thrombosis risk in women who take hormonal therapy, and that’s about an increase of three women per 10,000 women treated in a year. So that’s a very small increase in risk, but that is the only established risk in younger women with regard to HRT.

Who should initiate and monitor HRT in women with microvascular angina?
It very much depends on the skills of the cardiovascular physician. If the cardiovascular physician is confident and knows enough about the area to be able to prescribe then that would be acceptable. But we really recommend that if that’s not the case then they get the help of an endocrinologist or a gynecologist, and we promote a team effort, so that these patients can be dually managed by the gynecologist, the endocrinologist and the cardiovascular physician.

What are the risks of treatment?
The risks of treatment, as I’ve already explained, are a slight increase in deep venous thrombosis risk, and again that’s about three per 10,000 women treated for a year. So it’s a very small risk, but it’s a real risk.

And women are often accepting of that risk because of the beneficial effects of the menopausal symptoms.

Menopausal symptoms can be very bad, and affect the general well being of the woman quite badly, and therefore that sort of morbidity is addressed by the HRT and they often say “Well, if there is a small risk, I’m prepared to accept that risk for the benefit that I’m getting with regard to the management of the symptoms.”