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Although the risk of heart attack does not increase abruptly at the moment a woman reaches natural menopause, the rate of heart disease does rise sharply over the course of the decade after a woman reaches her fifties. A clear picture of the "cumulative, absolute risks" of the major causes of death for white women —between the ages of fifty and ninety-four— were spelled out in an editorial accompanying the Nurses' Health Study. There is a 31 percent absolute risk of dying of heart disease, a 2.8 percent risk of dying of breast cancer, a 2.8 percent risk of a hip fracture, and only a 0.7 percent risk of uterine cancer.

"Then why don't we read about women having heart attacks the way we do men?" someone will sensibly demand.

Perhaps because doctors pay less attention to women's symptoms of heart disease and treat them less aggressively than they do men. As a result, women often develop more advanced heart disease and are more likely to have fatal heart attacks than men. Two new studies involving tens of thousands of patients have recently shown irrefutable evidence of sex differences in the way heart conditions are treated. The unawareness of the general public simply reflects the prevailing attitude in the medical fraternity that heart disease is a man's disease.

"Women lag behind men in heart disease by about five to seven years," says Dr. Trudy Bush. "It really starts hitting women in their late fifties and sixties." By the age of sixty-seven they are just as likely to have a heart attack as their husbands, but more likely to die from it.

The most significant predictor of heart disease is the HDL level. Bad cholesterol levels normally increase in women for some ten to fifteen years following the cessation of periods. Again, dangerous changes in cholesterol count or blood pressure do not announce themselves with obvious symptoms, not until there is a medical catastrophe. "If your HDL level is low, and your LDL level is relatively higher—even if you're walking around with a total cholesterol count of 200—you're going to be in trouble," says Dr. Ramey. Estrogen replacement therapy decreases LDL (bad) cholesterol levels by about 15 percent and raises the HDL (good) cholesterol levels by the same amount.

Estrogen has a direct effect on the wall of the blood vessels. "Cholesterol uptake is the first change that occurs in the creation of the plaque that forms the basis for heart disease," explains Dr. Lindsay. "Estrogen appears to block that effect, resulting in open vessels and good blood flow." That explains why estrogen reduces heart disease.

The Nurses' Health Study, the first prospective study of women's health with a population of tens of thousands of women (almost exclusively white), has found striking results on the heart disease front. After ten years 48,000 of the subjects—who had no histories of cancer or heart disease when the study began—were evaluated. "Women who were taking estrogen, after menopause, had just half as many heart attacks and cardiovascular deaths as women who never used estrogen," reported Meir Stampfer, who led the study. An evaluation by Dr. Lee Goldman of Brigham and Women's Hospital in Boston concludes, "The benefits of estrogen outweigh the risks, substantially."