No, Estrogen Supplementation Should Not Be Started in Menstruating Women with ACS
Estrogen therapy should not be initiated in any woman presenting with acute coronary syndrome, regardless of menopausal status, as this represents a Class III (Harm) recommendation for secondary prevention of coronary events. 1
Clear Guideline-Based Contraindication
The ACC/AHA guidelines explicitly state that hormone therapy with estrogen (with or without progestin) should not be given as new drugs for secondary prevention of coronary events to women after acute coronary syndrome. 1 This recommendation carries Level of Evidence A, representing the highest quality evidence from multiple randomized controlled trials. 1
Key Evidence Against Estrogen Initiation
The HERS trial demonstrated no beneficial effect of hormone therapy for secondary prevention of death and MI, and disturbingly showed an excess risk for death and MI early after hormone therapy initiation. 1
The Women's Health Initiative trials (both estrogen plus progestin and estrogen alone arms) were stopped early due to observed increased cardiovascular risk that outweighed potential benefits. 1
The Women's Estrogen for Stroke Trial (WEST) found higher risk of fatal stroke (HR 2.9; 95% CI 0.9-9.0) and worse functional outcomes after recurrent events in women taking estrogen. 2
Application to Premenopausal Women
While the guideline language specifically addresses postmenopausal women, the cardiovascular and cerebrovascular risks of exogenous estrogen apply regardless of the indication for its use. 2 A history of ACS represents an absolute contraindication that supersedes any potential benefits. 2
For premenopausal menstruating women with ACS:
Do not initiate estrogen supplementation for any indication related to cardiovascular protection. 1
If the patient is already on hormonal contraception containing estrogen, this should be reassessed and generally discontinued unless there are compelling non-cardiovascular reasons to continue, with careful risk-benefit analysis. 1
The presumed pathophysiological association between female sex hormones and certain ACS presentations (particularly spontaneous coronary artery dissection) further supports avoiding exogenous estrogen exposure. 1
Critical Clinical Pitfall to Avoid
Never assume that because a woman is premenopausal and menstruating that she would benefit from estrogen supplementation after ACS. The protective effect of endogenous estrogen in younger women is completely overridden by the presence of established coronary disease. 3, 4 Exogenous hormone therapy has fundamentally different effects than endogenous hormones, particularly in the setting of established atherosclerosis or acute coronary events. 4, 5
Alternative Contraception Considerations
If contraception is needed in a premenopausal woman post-ACS, preferred methods include non-hormonal options or progestin-only formulations with local delivery (such as levonorgestrel intrauterine devices), vasectomy for male partners, or tubal ligation once antiplatelet therapy is completed. 1