New coals have been thrown onto the fire that fuels one of the hottest debates in women's health care: Whether hormone replacement therapy (HRT) prevents cardiovascular disease.

In an advisory to be released tomorrow by the American Heart Association (AHA), women are told not to turn to HRT for the sole purpose of cardiovascular protection. The report, appearing in the AHA journal, says there's not enough proof it works.

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Meanwhile, back at the laboratory, a new study shows even low doses of HRT reduce levels of LDL, or "bad" cholesterol, and increase levels of HDL, or "good" cholesterol. And that's good news for the heart.

So, what should a girl think?

"These studies are not so far apart as it would seem at first glance," says Dr. Lori Mosca, director of preventive cardiology at New York Presbyterian Hospital.

While the AHA cautions against using HRT specifically to prevent heart disease, she says it doesn't condemn the therapy completely.

"All we are saying is that for a sub-population of women who are at increased risk for clotting or heart attack, HRT may not be the appropriate choice," says Mosca. Other women could benefit from hormone therapy, even in relation to heart disease.

"So, if you view it in that way, the data are not inconsistent. They are very consistent," she says.

Protection

For primary protection from heart attack or stroke, the new AHA advisory says all women should first reduce risk factors such as high cholesterol and high blood pressure through diet and lifestyle changes, or with medications developed for these problems.

The advisory says the decision to use HRT should be based on health needs not related to the heart. Women on HRT who have heart disease should be re-evaluated since there aren't enough studies to say whether the therapy really prevents cardiovascular problems.

And on this point - the number of available studies - the debate really heats up.

"Hormone replacement therapy has already proven itself as having cardio-protective qualities in studies that the AHA has chosen to ignore," says Dr. Rogerio A. Lobo, lead author of the new HRT study.

Lobo adds, "I don't think they have taken a rational approach. And they also hold it to a higher-than-it-should-be standard - that the only truth is a randomised clinical trial -while discounting thousands of women in observational studies that have clearly, repeatedly shown heart-related benefits on HRT”.

He focused on 749 healthy menopausal women who received low doses of HRT for one year. At the start of the study, blood tests assessed lipid levels (cholesterol), lipid proteins, glucose tolerance and various clotting factors. Blood testing was repeated six months later and again at the end of the year.

The result: a 10 percent increase in "good" cholesterol, with a 7 percent decrease in "bad" cholesterol. Both changes could help prevent heart disease.

Mosca says, "It is good news that this new study found good effects on cholesterol using the lower doses of HRT, but I still don't think, at this time, we have the data to recommend that women take HRT solely for protection from heart disease."

What To Do

If you haven't already thrown up your hands in frustration, here are some guidelines from experts to help you make the HRT decision.

• If you have been diagnosed with heart disease, don't consider HRT your primary treatment.
• If you are healthy and have no menopausal symptoms and no other medical reasons to take HRT, think twice before taking HRT strictly for the prevention of cardiovascular disease.
• If you are healthy and have menopausal symptoms such as hot flashes, vaginal dryness, memory impairment or concern about osteoporosis, take cardiovascular protection out of the equation when it comes to HRT.

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