Based on the Women’s Health Initiative (WHI), shouldn’t women on HRT be taking aspirin (if tolerated) to reduce their risk of heart attack or ischemic stroke?
—ROBERT E. GARNER, MD, JD, Chesterland, Ohio

The estrogen-only arm of the WHI actually showed protection against heart attacks and no increase in stroke among women aged 50-59 who took estrogen compared with placebo controls (JAMA. 2004;291:
1701-1712). High doses of oral estrogen protect against development of atherosclerosis, but they are thrombophilic and can cause vascular occlusion in older women with pre-existing vascular disease. Thus, aspirin may be beneficial in women older than 60 who are taking oral estrogen. Transdermal estradiol may be preferable to the oral form because the transdermal form does not have the thrombophilic effect that occurs with oral administration (Lancet. 2003;362:428-432).
—Daniel R. Mishell Jr, MD (119-6)